Tinnitus Treatment

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 noiseinduced 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 intensity and persistence leads to disruption of daily life. While many patients habituate to tinnitus, others may seek medical care if the tinnitus becomes too disruptive.


Description of Procedure or Service
A variety of non-pharmacologic treatments are being evaluated to improve the subjective symptoms of tinnitus.These approaches include psychological coping therapies, sound therapies, combined psychological and sound therapies, repetitive transcranial magnetic stimulation, electrical and electromagnetic stimulation, and transmeatal laser irradiation.
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 noiseinduced 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 intensity and 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 in some patients' unpleasant response to the noise is due to a spreading of the signal and an abnormal conditioned reflex in the extra-auditory limbic and autonomic nervous systems.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 is set at a level such that the tinnitus can still be detected.This strategy is thought to enhance extinction of the subconscious conditioned reflexes connecting the auditory system with the limbic and autonomic nervous systems by increasing the neuronal activity within the auditory system.Treatment may also include the use of hearing aids to increase external auditory stimulation.The Heidelberg model uses an intensive program of active and receptive music therapy, relaxation with habituation to the tinnitus sound, and stress mapping with a therapist.
Sound therapy is a treatment approach that is based on evidence of auditory cortex reorganization (cortical remapping) with tinnitus, hearing loss, and sound/frequency training.One type of sound therapy uses an ear-worn device (Neuromonics ® Tinnitus Treatment, Neuromonics, Australia) prerecorded with selected relaxation audio and other sounds spectrally adapted to the individual patient's Tinnitus Treatment hearing thresholds.This is achieved by boosting the amplitude of those frequencies at which 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 uses music with the frequency of the tinnitus removed (notched music) to promote reorganization of sound processing in the auditory cortex.One theory behind notched music is that tinnitus is triggered by injury to inner ear hair cell population, resulting in both a loss of excitatory stimulation of the represented auditory cortex and loss of inhibition on the adjoining frequency areas.It is proposed that this loss of inhibition leads to hyperactivity and overrepresentation at the edge of the damaged frequency areas and that removing the frequencies overrepresented at the audiometric edge will result in reorganization of the brain.
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, electrical stimulation, and transcranial magnetic stimulation have also been evaluated.
The Neuromonics ® Tinnitus Treatment has been cleared for marketing as a tinnitus masker through the 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." This policy does not address surgical (e.g., cochlear or brainstem implants) or pharmacologic treatment of tinnitus, e.g., the use of amitriptyline or other tricyclic antidepressants.

Policy
BCBSNC will provide coverage for tinnitus treatment when it is determined to be medically necessary because the medical criteria and guidelines shown below are met.

Benefits Application
This medical policy relates only to the services or supplies described herein.Please refer to the Member's Benefit Booklet for availability of benefits.Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this medical policy.

When tinnitus treatment is covered
Psychological coping therapy may be considered medically necessary for persistent and bothersome tinnitus.

When tinnitus treatment is not covered
Treatment of tinnitus with any of the following therapies is considered investigational: • tinnitus maskers, customized sound therapy • combined psychological and sound therapy (eg, tinnitus retraining therapy) • transcranial magnetic stimulation, • transcranial direct current stimulation • electrical transcutaneous electrical stimulation of the ear, electromagnetic energy

Policy Guidelines
For individuals who have persistent, bothersome tinnitus who receive psychological coping therapy, the evidence includes randomized controlled trials (RCTs) and meta-analyses of RCTs.Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity.These therapies are intended to reduce tinnitus impairment and improve health-related quality of life.Metaanalyses of a variety of cognitive and behavioral therapies have found improvement in global tinnitus severity and quality of life, even when tinnitus loudness is not affected.Other RCTs have reported that a self-help/Internet-based approach to cognitive and behavioral therapy or acceptance and commitment therapy may also improve coping skills.The evidence is sufficient to determine that the technology results in a meaningful improvement in health outcomes.
For individuals who have tinnitus who receive sound therapy, the evidence includes RCTs and a systematic review of RCTs.Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity.The evidence on tinnitus masking includes a number of RCTs and a systematic review of RCTs.The RCTs have medium-to-high risk of bias and do not show efficacy of masking therapy.Research on customized sound therapy appears to be at an early stage.For example, the studies described use of very different approaches for sound therapy, and it is not yet clear whether therapy is more effective when the training frequency is the same or adjacent to the tinnitus pitch.A 2016 trial, double-blinded and adequately powered, found no benefit of notched music on the primary outcome measures of tinnitus perception and tinnitus distress, although the subcomponent score of tinnitus loudness was reported to be reduced.A benefit on tinnitus loudness but not tinnitus perception or tinnitus distress is of uncertain clinical significance, may be spurious, and would need corroboration in additional studies.The evidence is insufficient to determine the effects of the technology on health outcomes.
For individuals who have tinnitus who receive combined psychological and sound therapy (eg, tinnitus retraining therapy), the evidence includes RCTs.Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity.The evidence on tinnitus retraining therapy consists of a number of small randomized or quasi-randomized controlled trials.Together, the literature does not show a consistent improvement in the primary outcome measure (Tinnitus Handicap Inventory [THI]) when tinnitus retraining therapy is compared with active or sham controls.For Heidelberg neuromusic therapy, 1 trial has used an investigator-blinded RCT design and showed positive short-term results following treatment.However, the durability of treatment is also unknown.A large, multicenter RCT trial using an intensive, multidisciplinary intervention showed improvement in outcomes.However, it is uncertain whether the multiple intensive interventions used in this trial could be replicated outside of the investigational setting.The evidence is insufficient to determine the effects of the technology on health outcomes.
For individuals who have tinnitus who receive transcranial magnetic stimulation, the evidence includes a number of small-to moderate-sized RCTs and systematic reviews.Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity.Results from these studies are mixed, with some trials reporting a statistically significant effect of repetitive transcranial magnetic stimulation on tinnitus severity and others reporting no significant difference.Larger controlled trials with longer follow-up are needed for this common condition.The evidence is insufficient to determine the effects of the technology on health outcomes.
For individuals who have tinnitus who receive electrical or electromagnetic stimulation, the evidence includes a number of sham-controlled RCTs.Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity.The available evidence does not currently support use of these treatments.A 2015 sham-controlled study that was adequately powered found no benefit of transcranial direct current stimulation.Studies have not shown a benefit for direct current electrical stimulation of the ear.The evidence on electromagnetic energy includes a small RCT, which found no benefit for the treatment of tinnitus.The evidence is insufficient to determine the effects of the technology on health outcomes.

Tinnitus Treatment
For individuals who have tinnitus who receive transmeatal laser irradiation, the evidence includes RCTs and crossover trials.Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity.The evidence for transmeatal laser irradiation includes a number of double-blind RCTs, most of which showed no efficacy of this treatment.The evidence is insufficient to determine the effects of the technology on health outcomes.

Billing/Coding/Physician Documentation Information
This policy may apply to the following codes.Inclusion of a code in this section does not guarantee that it will be reimbursed.For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com.They are listed in the Category Search on the Medical Policy search page.

Applicable codes: 92625
There is no specific CPT code for psychological coping therapy.The CPT codes used may include evaluation and management codes or possibly 96152 or an unlisted code depending on the type of service and provider.
There are no specific CPT codes for electrical stimulation or tinnitus-retraining therapy.The CPT codes used may include evaluation and management CPT codes or possibly the physical medicine and rehabilitation code ( 97014) or speech therapy ( 92507).As tinnitus-retraining therapy in part involves counseling, an individual psychotherapy CPT code may be used (code range 90832-90838).Tinnitus-retraining therapy may also be billed as physical or speech therapy.
There is no specific CPT code for low-level laser therapy.However, providers may elect to use CPT code 97026, because the laser emits light in the infrared spectrum.
As described in the literature, electrical stimulation is an office-based procedure, but if selfadministered by the patient, the device could possibly be described by HCPCS code E0720.

Tinnitus-masking devices represent a piece of durable medical equipment.
There is currently no specific HCPCS code describing these devices.
BCBSNC may request medical records for determination of medical necessity.When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.Medical policy is not an authorization, certification, explanation of benefits or a contract.Benefits and eligibility are determined before medical guidelines and payment guidelines are applied.Benefits are determined by the group contract and subscriber certificate that is in effect at the time services are rendered.This document is solely provided for informational purposes only and is based on research of current medical literature and review of common medical practices in the treatment and diagnosis of disease.Medical practices and knowledge are constantly changing and BCBSNC reserves the right to review and revise its medical policies periodically.

Scientific Background and Reference Sources
Tinnitus Treatment Description section revised to include electromagnetic energy, transcranial magnetic stimulation and botulinum toxin A injections.Under Policy and When Not Covered sections, added electromagnetic energy, transcranial magnetic stimulation and botulinum toxin A injections as investigational.Policy guidelines, reference sources, key words and terms and definitions added.Notice given 10/16/06.Effective date 12/18/06.(pmo) 7/14/08 Specialty Matched Consultant Advisory Panel review 6/2008.Reference sources added.No change to Policy statement.(sk) 10/14/14 Reference added.Specialty Matched Consultant Advisory Panel review 9/30/14.No change to Policy guidelines.(sk) Reference added.Policy Guidelines updated.Psychological coping therapy may be considered medically necessary for persistent and bothersome tinnitus added to the covered policy statement.Combined psychological and sound therapy added to the investigational policy statement.(sk) 9/29/17 Specialty Matched Consultant Advisory Panel review 8/30/2017.(sk)