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Date Printed: August 18, 2017: 07:58 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-92502-11

Original Effective Date: 09/15/03

Reviewed: 03/23/17

Revised: 04/15/17

Subject: Treatment of Tinnitus

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Tinnitus is described as any sound emanating from the head not attributable to an external sound. There may be hissing, buzzing, and squealing, whining, clicking, or popping noises. Tinnitus may be unilateral, bilateral, transient, or continuous. Tinnitus is not a disease, but a symptom of some underlying condition, usually in the ear, the auditory nerve, or the brain.

Tinnitus is classified as subjective or objective. Subjective tinnitus is more common, and is audible to the patient. Subjective tinnitus may be due to peripheral or central auditory problems, a metabolic abnormality, or anxiety/depression. Its persistence leads to disruption of daily life. Objective tinnitus, is less common, and refers to noises that can be heard by an examiner by placing his/her ear or stethoscope against the patient’s ear. Objective tinnitus may be due to a vascular or neuromuscular condition, a tumor within the head, neck, or brain, or a structural defect in the ear (usually the inner ear).

Causes of tinnitus may include:

Treatment of tinnitus is supportive in nature; there is no cure. Treatment of tinnitus has focused on counseling or use of tinnitus maskers that produce a broad band of continuous external noise that diverts attention or masks the tinnitus. Transcutaneous electrical stimulation 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 and electromagnetic energy have also been evaluated. The treatment of tinnitus depends on the severity of the condition. If the patient’s activities of daily living are not affected by tinnitus, the condition may be managed with the following life style changes (may lessen the severity of tinnitus):

Also, medications may help to manage persistent tinnitus (e.g., anticonvulsant agents [Tegretol, Dilantin] may diminish tinnitus by suppressing hyperactivity within the auditory system; antianxiety agents [Valium] may help the patient manage stress related to tinnitus).

Tinnitus masking instruments (e.g., maskers, sound generators, combination of hearing aid and tinnitus masker) has been used for alleviating symptoms associated with tinnitus. Tinnitus masking instruments are as small as hearing aids and can be worn the same as a hearing aid. Maskers introduce an external, pleasant, low-volume sound (e.g., soft music, sounds of a rain forest or a water fall) that reduces perception of the tinnitus. There are specialty devices manufactured by hearing aid manufacturers that can be “tuned” to help mask the sound of tinnitus.

Tinnitus-retraining therapy (TRT) also referred to, as tinnitus habituation therapy is another treatment option for tinnitus. Tinnitus retraining focuses counseling and behavioral retraining on the associations induced by tinnitus perception. Specifically, the goal is not to eliminate the tinnitus itself, but to retain the subcortical and cortical centers involved in processing the tinnitus signals. TRT combines masking with education and counseling. The counseling may require 4 to 6 one-hour visits over an 18-month period. As part of the overall therapy, maskers are used to induce habituation to the tinnitus. In contrast to the typical use of maskers, in retraining therapy, the masker is not intended to drown out or mask the tinnitus, but is set at a level such that the tinnitus can still be detected. This strategy is thought to enhance habituation by increasing the neuronal activity within the auditory system such that the tinnitus is difficult to detect. Transcutaneous electrical stimulation to the external ear has been investigated as a treatment option for the treatment of tinnitus. Transcutaneous electrical stimulation involves stimulation of the nerve endings in the external ear by an external probe to suppress the tinnitus.

Several tinnitus instruments, such as maskers are approved by the Food and Drug Administration (FDA) (e.g., Neuromonics Tinnitus Treatment, Unitron Tinnitus Masker, Levo System).

POSITION STATEMENT:

Psychological coping therapy meets the definition of medical necessity for persistent and bothersome tinnitus.

Treatment of tinnitus including, but limited to tinnitus maskers, transcutaneous electrical stimulation of the ear, combined psychological and sound therapy (e.g., tinnitus-retraining therapy), transmeatal laser irradiation, transcranial magnetic stimulation, transcutaneous electrical stimulation, electromagnetic energy treatment, and sound therapy is considered experimental or investigational, as there is insufficient evidence to show improved health outcomes in members with tinnitus treated with these treatments and therapies.

BILLING/CODING INFORMATION:

There is no specific CPT or HCPCS code for tinnitus treatment, tinnitus retraining therapy, or tinnitus maskers.

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

No National Coverage Determinations (NCD) and/or Local Coverage Determination (LCD) was found at the time of the last guideline reviewed date.

DEFINITIONS:

None applicable.

RELATED GUIDELINES:

None applicable.

OTHER:

Other names used to report tinnitus treatment:

Note: The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

REFERENCES:

  1. American Academy of Audioloy. Audiologic Guidelines for the Diagnosis & Management of Tinnitus Patients, 10/18/00.
  2. American Academy of Otolaryngology. Head and Neck Surgery-Tinnitus, 04/08.
  3. American Tinnitus Association – About Tinnitus, Tinnitus Treatment Options, 2007.
  4. Barbara Tabachnick Sanders, American Tinnitus Association (ATA). There Is Something You Can Do About Tinnitus.
  5. Blue Cross Blue Shield Association Medical PolicyTreatment of Tinnitus 8.01.39, 02/17.
  6. Centers for Medicare and Medicaid Services Medicare National Coverage Determination (NCD) for Tinnitus Masking (50.6), Publication Number 100-3. Accessed 03/29/11.
  7. Department of Health & Human Services Food and Drug Administration – 510(k) Summary Neuromonics Tinnitus Treatment, 01/28/05.
  8. Folmer RL, Theodoroff SM, Casiana L et al. Repetitive Transcranial Magnetic Stimulation Treatment for Chronic Tinnitus: A Randomized Clinical Trial. JMA Otolaryngology Head Neck Surgery 2015; 141(8): 716-722.
  9. Hoare DJ, Kowalkowski VL, Kang S et al. Systematic review and meta-analyses of randomized controlled trials examining tinnitus management. Laryngoscope 2011; 121 (7):1555-1564.
  10. Kaldo V, Cars S, Rahnert M et al. Use of a self-help book with weekly therapist contact to reduce tinnitus distress: a randomized controlled trial. Journal of Psychosomatic Research 2007; 63(2): 195-202.
  11. Kleinjung T, Eichhammer P, Langguth B et al. Long-Term Effects of Repetitive Transcranial Magnetic Stimulation (rTMS) in Patients with Chronic Tinnitus. Otolaryngology Head and Neck Surgery 2005; 132(4): 566-9.
  12. Kleinjung T, Steffens T, Sand P et al. Which tinnitus patients benefit from transcranial magnetic stimulation? Otolaryngology Head Neck Surgery 2007; 137(4): 589-595.
  13. Mielczarek M, Olszewski J. Direct current stimulation of the ear in tinnitus treatment: a double-blind placebo-controlled study. European Archives of Otorhinolaryngology 2014; 271(6): 1815-1822.
  14. Rossi S, De Capua A, Ulivelli M et al. Effects of repetitive transcranial magnetic stimulation on chronic tinnitus: a randomised, crossover, double blind, placebo controlled study. Journal of Neurology, Neurosurgery & Psychiatry 2007; 78(8): 857-863.
  15. Song JJ, Vanneste S, Van de Heyning P et al. Transcranial direct current stimulation in tinnitus patients: a systemic review and meta-analysis. (Meta-Analysis). Scientific World Journal 2012; 2012: 427941.
  16. Stein A, Wunderlich R, Lau P et al. Clinical trial on tonal tinnitus with tailor-made notched music training. BMC Neurology 2016; 16:38.
  17. Stidham KR, Solomon PH, Roberson JB. Evaluation of Botulinum Toxin A in Treatment of Tinnitus. Otolaryngology Head and Neck Surgery 2005; 132(6): 883-9.
  18. Tunkel DE, Bauer CA, Sun GH et al. Clinical practice guideline: tinnitus. Otolaryngology-Head and Neck Surgery 2014; 151(2 Suppl): S1-S40.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 03/23/17.

GUIDELINE UPDATE INFORMATION:

09/15/03

New Medical Coverage Guideline.

07/15/04

Scheduled review. Added transmeatal irradiation as an investigational treatment for tinnitus.

01/01/05

HCPCS update. Added 92625.

06/15/05

Scheduled review, no change in coverage statement.

07/15/06

Scheduled review. Maintain coverage statement (investigational). Revised description section; added information regarding: transcranial magnetic stimulation and botulinum toxin A injections, tinnitus retraining and counseling. Updated references. Deleted related Internet links. Revised when services are not covered; added transcranial magnetic stimulation and botulinum toxin A injections, tinnitus retraining and counseling.

07/15/07

Scheduled review; no change in coverage statement; reformatted guideline, and update references.

05/15/08

Scheduled review. No change in position statement, and update references.

06/15/09

Annual review; maintain position statement, and update references.

03/15/10

Code update, deleted code 92625, and updated references.

06/15/11

Annual review; maintain experimental or investigational position statement. Added tinnitus coping therapy, transcutaneous electrical stimulation and sound therapy to position statement. Updated references.

01/15/13

Annual review; no change to position statement (revised for clarity). Added information regarding the FDA use of the Neuromonics Tinnitus treatment to the description section. Revised ICD-9 diagnoses codes medical necessity statement. Updated references.

05/11/14

Revision: Program Exceptions section updated.

11/01/15

Revision: ICD-9 Codes deleted.

04/15/17

Added psychological coping and combined psychological and sound therapy. Deleted tinnitus coping therapy and botulinum toxin A injections.

Date Printed: August 18, 2017: 07:58 PM