What are the WPS (Wisconsin Physician Services) payor guidelines for common pain interventions and how can virtual visits be conducted in rural areas?

WPS Payor Guidelines for Pain Interventions and Virtual Visits in Rural Areas

Based on the most recent evidence, common interventional procedures for chronic spine pain are not recommended as they show little to no benefit compared to sham procedures while carrying risks of harm. 1

WPS Payor Guidelines for Pain Interventions

Strong Recommendations Against Common Pain Interventions

The 2025 BMJ clinical practice guidelines provide strong recommendations against the following interventional procedures for chronic spine pain:

For Chronic Axial Spine Pain:

• Epidural injections of local anesthetic, steroids, or their combination 1
• Joint radiofrequency ablation with or without joint-targeted injection of local anesthetic plus steroid 1
• Joint-targeted injection of local anesthetic, steroids, or their combination 1
• Intramuscular injection of local anesthetic with or without steroids 1

For Chronic Radicular Spine Pain:

• Dorsal root ganglion radiofrequency with or without epidural injection of local anesthetic or local anesthetic plus steroids 1
• Epidural injection of local anesthetic, steroids, or their combination 1

Evidence Quality and Rationale

• Moderate certainty evidence shows that epidural injections and joint-targeted steroid injections have little to no effect on pain relief compared to sham procedures 1
• Despite the rapid growth in use of interventional procedures for chronic spine pain (271% increase in lumbar epidural steroid injections between 1994-2001), the supporting evidence is uncertain 1
• An analysis of 17 review articles on epidural steroid injections found inconsistent conclusions, with positive results three times more likely when authored by an interventionalist versus a non-interventionalist 1

Cost Considerations

• In the US, average costs are substantial: over $1,000 for a single epidural steroid injection (up to $5,000) and approximately $6,000 for radiofrequency ablation 1
• These procedures typically require repeat administration (every 2-3 months for injections, every 6 months for nerve ablation procedures) 1

Virtual Visits in Rural Areas

Implementation Models for Telemedicine in Pain Management

Three primary models for telemedicine in pain management have been identified:

• Standard visits without on-site support (17% of studies) 2
• Standard visits with on-site support (38% of studies) 2
• Structured/integrated pain management programs (46% of studies) 2

Benefits of Virtual Visits

• Increased access and decreased barriers to care reported in 38% of studies 2
• Positive patient satisfaction reported in 42% of studies 2
• Positive pain-related outcomes reported in 38% of studies 2

Practical Considerations for Rural Implementation

• Videoconferencing can be an effective substitute for in-person care for movement-based and psychologically informed pain management interventions 3
• Virtual delivery of acceptance and commitment therapy showed no statistically significant difference in outcomes compared to in-person delivery 3
• Virtual visits can help address the high prevalence of chronic pain (approximately 20% of the worldwide population) 4

Challenges in Rural Settings

• Limited research exists specifically on virtual pain management in rural settings, with only one non-inferiority randomized trial meeting eligibility criteria in a systematic review 3
• Technology access and literacy may present barriers in rural populations 4, 2
• Patient preferences should be assessed when implementing virtual care models 3

Ethical Considerations

• Virtual reality (VR) interventions show promise as "nonpharmacological analgesics" but require careful consideration of patient vulnerabilities 4
• Technology developers must be aware of ethical risks that may be present in virtual interventions for chronic pain 4

Future Research Needs

• Further comparative and adequately powered studies are needed to assess the impact of movement-based and psychologically informed pain management delivered via videoconferencing 3
• Research should focus on understanding patient preferences for virtual interventions within rural settings 3, 2
• Studies should examine whether there are differences in treatment effects based on subtypes of chronic spine pain 1