BlueCross BlueShield of Tennessee Medical Policy Manual

Treatment of Tinnitus

DESCRIPTION

Tinnitus describes the perception of any sound in the ear in the absence of an external stimulus. Hearing impairment, often noise-induced or related to aging, is commonly associated with tinnitus. Clinically tinnitus is subdivided into subjective and objective. In the majority of cases, tinnitus is subjective and frequently self-limited. Many treatments are supportive in nature, as currently there is no cure. Common causes of objective tinnitus include middle ear and skull-based tumors, vascular abnormalities, and metabolic derangements.

The American Academy of Otolaryngology defines ‘persistent’ tinnitus as six months or longer in duration and ‘bothersome’ as causing individual distress, affected quality of life and/or functional health status.

A variety of nonpharmacologic treatments are being evaluated to improve the subjective symptoms of tinnitus. These approaches include use of tinnitus maskers (e.g. Neuromonics® Tinnitus Treatment) electrical stimulation, transmeatal laser irradiation, electromagnetic energy, tinnitus-retraining therapy, cognitive and behavioral therapies, transcranial magnetic stimulation, transcutaneous electrical stimulation, and sound therapy. Tinnitus retraining, also referred to as tinnitus habituation therapy, is another proposed treatment option. Tinnitus retraining focuses on the associations induced by tinnitus perception. 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. Many treatments are supportive in nature, as currently, there is no cure.

Cognitive behavioral therapy (CBT), originally developed for treatment of depression and anxiety, has been shown to be effective in the treatment of tinnitus related distress. CBT teaches skills to identify negative thoughts that result in distress and how restructure them. Current literature indicates that cognitive behavior therapy can improve coping skills and quality of life while decrease tinnitus-associated distress and annoyance.

Note: This policy does not address surgical (e.g. cochlear or brainstem implants); pharmacologic treatment of tinnitus (e.g. use of amitriptyline or other tricyclic antidepressants), or injection of botulinum toxin.

POLICY

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

ADDITIONAL INFORMATION  

Current evidence is insufficient to show improved health outcomes in patients treated with tinnitus maskers, electrical stimulation, transmeatal laser irradiation, electromagnetic energy, tinnitus-retraining therapy, sound therapy, transcranial magnetic stimulation, or transcutaneous electrical stimulation. Therefore, these treatments are considered investigational.

SOURCES

Agency for Healthcare Research and Quality (2013, August) Comparative Effectiveness Review; Number 122: Evaluation and Treatment of Tinnitus: Comparative Effectiveness. Retrieved December 5, 2016 from: http://www.ahrq.gov.

American Academy of Otolaryngology. (2014, October). Clinical practice guideline: tinnitus. Retrieved February 28, 2017 from http://www.entnet.org.

Bauer, C. A., & Brozoski, T. J. (2011). Effect of tinnitus retraining therapy on the loudness and annoyance of tinnitus: A controlled trial. Ear and Hearing, 32 (2), 145-155. (Level 3 evidence - Independent study)

BlueCross BlueShield Association. Medical Policy Reference Manual. (3:2016). Treatment of tinnitus (8.01.39). Retrieved February 28, 2017 from BlueWeb. (38 articles and/or guidelines reviewed)

Fioretti, A., Eibenstein, A., & Fusetti, M. (2011). New trends in tinnitus management. The Open Neurology Journal, 5, 12-17. (Level 1 evidence)

Goebel, G., Kahl, M., Arnold, W., and Fichter, M. (2006, December) 15-year prospective follow-up study of behavioral therapy in a large sample of inpatients with chronic tinnitus. Acta Otolaryngolic; (556):70-9. Abstract retrieved February 28, 2017 from PubMed database.

Hesser, H., Weise, C., Westin, V., and Andersson, G. (2011, June) A systematic review and meta-analysis of randomized controlled trials of cognitive-behavioral therapy for tinnitus distress. Clinical Psychology Review;31(4):545-53. Abstract retrieved February 28, 2017 from PubMed database.

Lehner, A., Schecklmann, M., Langrebe, M., Kreuzer, P. M., Poeppl, T. B., Frank, E., et al. (2012). Predictors for rTMS response in chronic tinnitus. Frontiers in Systems Neuroscience, 6 (11), 1-10. (Level 3 evidence)

Okhovat, A., Berjis, N., Okhovat, H., Malekpour, A., & Abtahi, H. (2011). Low-level laser for treatment of tinnitus: A self-controlled clinical trial. Journal of Research in Medical Sciences, 16 (1), 33-38. (Level 3 evidence)

Phillips, J., and  McFerran, D. (2010) Tinnitus Retraining Therapy (TRT) for tinnitus. Cochrane Database of Systematic Reviews, Issue 3. Art. No.: CD007330. DOI: 10.1002/14651858.

Piccirillo, J. F., (2016). Transcranial magnetic stimulation for chronic tinnitus. JAMA, 315 (5), 506-507. (Level 2 evidence)

Seidman, M. D., Standring, R. T., & Dornhoffer, J. L. (2010). Tinnitus: Current understanding and contemporary management. Current Opinion in Otolaryngology & Head and Neck Surgery, 18 (5), 363-368. (Level 1 evidence)

Shim, H. J., Kwak, M. Y., An, Y. H., Kim, D. H., Kim, Y. J., & Kim H. J. (2015). Feasibility and safety of transcutaneous vagus nerve stimulation paired with notched music therapy for the treatment of chronic tinnitus. Journal of Audiology & Otology, 19 (3), 159-167. (Level 3 evidence)

Tugumia, D., Samelli, A., Matas, C., Magliaro, F., and Rabelo, C. (2016) Auditory training program in subjects with tinnitus CoDAS 2016; 28(1):27-33. (Level 2 evidence)

U. S. Food and Drug Administration. (2007, July). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K070599 (Tinnitus Masker Device). Retrieved July 19, 2011 from: http://www.accessdata.fda.gov

U. S. Food and Drug Administration. (2008, March). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K080955 (Zen ProgramTM). Retrieved June 21, 2012 from http://www.accessdata.fda.gov.

U. S. Food and Drug Administration. (2011, December). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K112752 (ANM T30® Tinnitus Therapy System). Retrieved June 21, 2012 from http://www.accessdata.fda.gov

Zenner, H.,  Vonthein, R., Zenner, B., Leuchtweis, R., Plontke S., Torka, W, (2013, April) Standardized tinnitus-specific individual cognitive-behavioral therapy: a controlled outcome study with 286 tinnitus patients. Hearing Research; 298:117-25. Retrieved February 28, 2017 from PubMed database.

ORIGINAL EFFECTIVE DATE:  12/1/2002

MOST RECENT REVIEW DATE:  7/8/2017

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