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DESCRIPTIONA variety of non-pharmacological treatments are being evaluated to improve the subjective symptoms of tinnitus. These approaches include use of tinnitus maskers, electrical stimulation, transmeatal laser irradiation, electromagnetic energy, tinnitus-retraining therapy, cognitive and behavioral therapies, transcranial magnetic stimulation, transcutaneous electrical stimulation, sound therapy, and botulinum toxin A injections.
Tinnitus describes the perception of any sound in the ear in the absence of an external stimulus and presents a malfunction in the processing of auditory signals. A hearing impairment, often noise-induced or related to aging, is commonly associated with tinnitus. Clinically, tinnitus is subdivided into subjective and objective; the latter describes the minority of cases in which an external stimulus is potentially heard by an observer, for example by placing a stethoscope over the patient’s external ear. Common causes of objective tinnitus include middle ear and skull-based tumors, vascular abnormalities and metabolic derangements. In the majority of cases, tinnitus is subjective and frequently self-limited. In a small subset of patients with subjective tinnitus, its persistence leads to disruption of daily life. While many patients habituate to tinnitus, others may seek medical care if the tinnitus becomes too disruptive.
Many treatments are supportive in nature, as currently, there is no cure. One treatment, called tinnitus masking therapy, has focused on use of devices worn in the ear that produce a broad band of continuous external noise that drowns out or masks the tinnitus. Psychological therapies may also be provided to improve coping skills, typically requiring 4 to 6 one-hour visits over an 18-month period. Tinnitus-retraining therapy, also referred to as tinnitus habituation therapy, is based on the theories of a researcher named Jastreboff. Jastreboff proposes that tinnitus itself is related to the normal background electrical activity in auditory nerve cells, but the key factor is the subject’s unpleasant perception of the noise, which is governed by an abnormal conditioned response in the extra-auditory limbic system. The goal of tinnitus retraining therapy is to retrain the subcortical and cortical centers involved in processing the tinnitus signals and habituate the subcortical and cortical response to the auditory neural activity. In contrast to tinnitus masking, the auditory stimulus is not intended to drown out or mask the tinnitus, but set at a level such that the tinnitus can still be detected. This strategy is thought to enhance habituation to the tinnitus by increasing the neuronal activity within the auditory system. Treatment may also include the use of hearing aids to increase external auditory stimulation.
Sound therapy is a treatment approach that is based on evidence of auditory cortex reorganization (cortical re-mapping) with tinnitus, hearing loss, and sound/frequency training. One type of sound therapy uses an ear-worn device (Neuromonics® Tinnitus Treatment, Neuromonics, Australia) pre-recorded with selected relaxation audio and other sounds spectrally adapted to the individual patient’s hearing thresholds. This is achieved by boosting the amplitude of those frequencies where an audiogram has shown the patient to have a reduced hearing threshold. Also being evaluated is auditory tone discrimination training at or around the tinnitus frequency. Another type of sound therapy that is being investigated utilizes music with the frequency of the tinnitus removed (notched music) to promote reorganization of sound processing in the auditory cortex.
Transcutaneous electrical stimulation (TENS) to the external ear has also been investigated and is based on the observation that the electrical stimulation of the cochlea associated with a cochlear implant may be associated with a reduction in tinnitus. Transmeatal low-power laser irradiation, electromagnetic energy, transcranial magnetic stimulation, and botulinum toxin A injections have also been evaluated.
The Neuromonics® Tinnitus Treatment has been cleared for marketing as a tinnitus masker through the U.S. Food and Drug Administration’s (FDA) 510(k) process and is “intended to provide relief from the disturbance of tinnitus, while using the system, and with regular use (over several months) may provide relief to the patient whilst not using the system.” FDA Product Code: KLW
POLICYTreatment of tinnitus with tinnitus maskers, electrical stimulation, transmeatal laser irradiation, electromagnetic energy, tinnitus-retraining therapy, tinnitus coping therapy, transcranial magnetic stimulation, transcutaneous electrical stimulation, sound therapy, or botulinum toxin A injections is considered investigational.
Note: This policy does not address pharmacologic treatment of tinnitus, e.g., the use of amitriptyline or other tricyclic antidepressants.
POLICY EXCEPTIONSFederal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY11/2001: Approved by Medical Policy Advisory Committee (MPAC)
2/13/2002: Investigational definition added
5/8/2002: Type of Service and Place of Service deleted
11/3/2004: Code Reference section completed
9/6/2006: Policy reviewed, policy section clarified
9/13/2006: Policy updated. Updates approved per Medical Policy Advisory Committee (MPAC), ICD9 diagnosis code 388.3 deleted from policy
4/27/2009: Policy reviewed, no changes
05/28/2010: Policy description updated regarding treatment approaches. For clarity purposes, the policy statement was updated to add tinnitus coping therapy, transcutaneous electrical stimulation, and sound therapy as investigational treatment approaches. Intent of policy statement unchanged. FEP verbiage added to the Policy Exceptions section.
07/29/2011: Policy reviewed; no changes.
07/17/2012: Policy reviewed; no changes.
08/14/2013: Policy reviewed; no changes.
07/14/2014: Policy reviewed; description updated regarding devices. Policy statement unchanged.
SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.39
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.