85027
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Documentation of response to any treatments given, including validated outcome measures where applicable (fatigue scales, SF-36, CIS-fatigue, etc.) and any adverse events.
- Mental status examination to identify abnormalities in mood, intellectual function, memory and personality; if psychiatric/neurologic/cognitive disorder is suspected, obtain an appropriate psychiatric, psychological, or neurological evaluation: "Evidence of psychiatric, neurologic or cognitive disorder requires that an appropriate psychiatric, psychological, or neurological evaluation be done."
- Documentation that the patient meets clinical case definition criteria (e.g., CDC/Fukuda criteria): "Patients with CFS must have clinically evaluated, unexplained, persistent, or relapsing fatigue plus four or more specifically defined associated symptoms."
Key Coverage Criteria
- Evaluation of members suspected of having chronic fatigue syndrome (CFS).
- Aetna considers the following as medically necessary exclusionary tests to be used for the evaluation of members suspected of having chronic fatigue syndrome (CFS) as recommended by the National Institutes of Health. The selection of studies depends on the specific characteristics of a given case:
- Anti-nuclear antibodies (ANA)
- Blood and serum chemistries (blood urea nitrogen, calcium, creatinine, glucose, serum electrolytes)
- Complete blood count (CBC) with differential cell count
- Erythrocyte sedimentation rate (ESR)
3 Active Policies
AETNA-CPB-0369 — Chronic Fatigue Syndrome
AETNA-CPB-0511 — Eating Disorders
ANTHEM-CG-MED-61 — CG-MED-61 Preoperative Testing for Low Risk Invasive Procedures and Surgeries
Related Codes
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