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 types. In the majority of cases, tinnitus is subjective and frequently self-limited. 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.
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.
Cognitive Behavior Therapy (CBT) for the treatment of tinnitus related distress may be considered medically necessary if the medical appropriateness criteria are met (See Medical Appropriateness below)
Treatment of tinnitus, including but not limited to, the following is considered investigational:
Combined psychological and sound therapy (e.g. tinnitus retraining therapy)
Transcranial magnetic stimulation
Transcutaneous electrical stimulation
Transmeatal laser irradiation
Cognitive Behavior Therapy (CBT) for the treatment of tinnitus related distress may be considered medically appropriate if ALL of the following apply:
Tinnitus is persistent (6 months or more)
Tinnitus is bothersome (causing distress, affected quality of life and/or functional health status)
Any specific products referenced in this policy are just examples and are intended for illustrative purposes 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. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits, or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
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.
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). Clinical practice guideline: tinnitus. Retrieved February 28, 2017 from http://www.entnet.org.
BlueCross BlueShield Association. Evidence Positioning System. (3:2019). Treatment of tinnitus (8.01.39). Retrieved April 5, 2019 from https://www.evidencepositioningsystem.com/. (47 articles and/or guidelines reviewed)
Folmer, R.L., Theodoroff, S.M., Casiana, L., Shi, Y., Griest, S., & Vachhani, J. (2015). Repetitive transcranial magnetic stimulation treatment for chronic tinnitus: a randomized clinical trial. JAMA Otolaryngology-Head and Neck Surgery, 141 (8), 716-722. Abstract retrieved March 2, 2018 from PubMed database.
Henry, J.A., McMillan, G., Dann, S., Bennett, K., Griest, S., Theodoroff, S., et al. (2017). Tinnitus management: randomized controlled trial comparing extended-wear hearing aids, conventional hearing aids, and combination instruments. Journal of the American Academy of Audiology, 28 (6), 546-561. Abstract retrieved March 2, 2018 from PubMed database.
Piccirillo, J. F. (2016). Transcranial magnetic stimulation for chronic tinnitus. JAMA, 315 (5), 506-507. (Level 2 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)
Soleimani, R., Jalali, M.M., & Hasandokht, T. (2016). Therapeutic impact of repetitive transcranial magnetic stimulation (rTMS) on tinnitus: a systematic review and meta-analysis. European Archives of Oto-Rhino-Laryngology, 273 (7), 1663-1675. Abstract retrieved March 2, 2018 from PubMed database.
Stein, A., Wunderlich, R., Lau, P., Engell, A., Wolbrink, A.,Shaykevich, A., et al. (2016). Clinical trial on tonal tinnitus with tailor-made notched music training. BMC Neurology, 16, 38. (Level 2 evidence)
Tugumia, D., Samelli, A., Matas, C., Magliaro, F., and Rabelo, C. (2016). Auditory training program in subjects with tinnitus. CoDAS, 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 Program™). 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). 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: 5/9/2019
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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