CurrentBlue Cross Blue Shield - MassachusettsPolicy 267

Nonpharmacologic Treatments for Tinnitus (Coverage Criteria)

This policy governs coverage determinations for nonpharmacologic, non-surgical treatments for persistent and bothersome tinnitus for Blue Cross Blue Shield Massachusetts members.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyNonpharmacologic Treatments for Tinnitus (Coverage Criteria)

Policy CodePolicy 267

Change TypeNo material clinical or coverage changes in this revision.

Effective Date

Next Review Date

Key ActionObtain precertification/preauthorization when the service is performed inpatient; outpatient prior authorization is not required for most products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

MEDICALLY NECESSARYpsychological coping therapy

INVESTIGATIONALinvestigational therapies

PRECERT REQUIREDinpatient auth

PRIOR AUTH NOT REQoutpatient auth

NO CPT CODEScoding

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Coverage Criteria for Nonpharmacologic Tinnitus Treatments

Medically Necessary

Psychological coping therapies are considered medically necessary for patients meeting clinical need

Psychological coping therapy including cognitive-behavioral therapy, self-help cognitive-behavioral therapy, tinnitus coping therapy, acceptance and commitment therapy, and psychophysiological treatment may be considered MEDICALLY NECESSARY for persistent and bothersome tinnitus.

Typically requires 4 to 6 one-hour visits over an 18-month period (descriptive).

Investigational / Not Proven

The following nonpharmacologic treatments are considered investigational for tinnitus

Investigational therapies list: Biofeedback; 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; transmeatal laser irradiation are considered INVESTIGATIONAL.

Evidence summaries indicate insufficient evidence of net health benefit for these modalities.

This policy addresses nonpharmacologic, non‑surgical management of persistent and bothersome tinnitus and does not govern surgical or pharmacologic interventions. Specifically, it does not address surgical treatments such as cochlear or brainstem implants, nor pharmacologic treatments including use of amitriptyline or other tricyclic antidepressants, or injection of botulinum toxin.

A review of the referenced sections identified no explicit statements listing additional coverage exclusions beyond those noted in the policy text.

The referenced sections do not contain explicit language designating any of the discussed nonpharmacologic therapies as universally not medically necessary outside the policy’s stated investigational determinations.

Coding and Reporting

CPT CodesCPT

No codes listed

Provider Actions, Authorization & Billing

Prior Authorization

Precertification Required for Inpatient Services

For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.

Inpatient: precertification/preauthorization required for all products when performed inpatient.

Prior Authorization

Outpatient Prior Authorization

For outpatient services described in this policy, prior authorization is generally not required for most products. Specifically, Commercial Managed Care (HMO and POS), Commercial PPO and Indemnity, Medicare HMO Blue SM, and Medicare PPO Blue SM do not require prior authorization for outpatient procedures described in this policy.

Outpatient: prior authorization not required for most products (Commercial HMO/POS, Commercial PPO/Indemnity, Medicare HMO Blue SM, Medicare PPO Blue SM).

Background

Tinnitus is the perception of sound in the absence of an external stimulus and commonly occurs in association with hearing impairment. It may be subjective (most common) or objective. Many management approaches are supportive; the policy focuses on persistent, bothersome tinnitus for which nonpharmacologic therapies are being considered.

Definitions

Tinnitus — concise definition

DefinitionPerception of any sound in the ear in the absence of an external stimulus; presents as a malfunction in auditory signal processing.

Subjective vs ObjectiveSubjective tinnitus is the more common type and is often self-limited; objective tinnitus is rare and may be heard by an observer (eg, via stethoscope).

Common associationsFrequently associated with hearing impairment (eg, noise-induced or age-related).

Causes of objective tinnitusMay include middle ear or skull-based tumors, vascular abnormalities, and metabolic derangements.

Clinical impactMost patients habituate, but a subset experience persistent, bothersome tinnitus that disrupts daily life and may seek care.

Tinnitus masking and retraining therapy — definitions

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyNonpharmacologic Treatments for Tinnitus (Coverage Criteria)

Policy CodePolicy 267

Change TypeNo material clinical or coverage changes in this revision.

Effective Date

Next Review Date

Key ActionObtain precertification/preauthorization when the service is performed inpatient; outpatient prior authorization is not required for most products.

SourceLink

On This Page

Billing Rule

Coding and Reporting Guidance

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable. Inclusion or exclusion of a code in policy materials does not guarantee member coverage or provider reimbursement; verify benefits in effect at the time of service.

Report services using current CPT, HCPCS, revenue, and ICD-10 diagnosis codes and appropriate modifiers.
There are no specific CPT codes listed for these services in this policy.

Step Therapy

No step therapy requirements are specified in the referenced sections of this policy.

Step therapy: none specified.

Note

Literature & Guideline References Note

This portion of the document contains references and does not specify additional provider documentation or authorization requirements. See the References section for clinical guidelines and historical CMS NCD notes.

References include clinical practice guidelines and a retired CMS NCD for tinnitus masking.

Masking therapyUse of ear-worn devices that produce a broadband continuous external noise intended to drown out or mask the tinnitus.

Retraining therapy (tinnitus habituation therapy)Sound is set at a level so the tinnitus is still detectable; aims to habituate subcortical and cortical responses and extinguish conditioned reflexes linking auditory and limbic/autonomic systems.

Sound therapy approachesIncludes frequency-specific approaches such as Neuromonics (spectrally adapted relaxation audio), auditory tone discrimination training, and notched music to promote cortical reorganization.

Adjuncts and modelsMay include hearing aids to increase external stimulation and programs like the Heidelberg model (music therapy, relaxation, stress mapping).

Other investigated modalitiesElectrical stimulation of the external ear, transcranial magnetic stimulation, and transmeatal low-power laser irradiation have also been evaluated.