01/14/2026    Robert Kornfeld, DPM

The Quest for Non-Covered Services

Many podiatrists are working hard to find as many
non-covered services as possible to add into their
practice to improve income over the abysmal
insurance payments. And I completely understand
that. Surviving on what insurance is willing to
pay is a huge challenge. To that end, we have
lasers, shockwave, regenerative medicine injection
procedures, peptides and supplements to name a few
that have become very popular as an adjunct to
covered services. And there is no doubt all of
these modalities can be extremely helpful when
used on the right patient at the right time.

The trap many are falling into is recommending
these treatments without fully understanding the
mechanism of action. Again, I have no problem with
improving your practice’s bottom line. This is how
we make a living and we all have a right to make a
really good one. But we have an obligation to our
patients to recommend treatments in a prudent way.

What we all know is that these treatments and
protocols are designed to stimulate innate healing
pathways. In order to see clinical improvement, we
need a responsive immune system since it is the
immune system that governs repair pathways. When
we apply these treatments to patients with a
burdened immune system (not only specifically
immunocompromised, but burdened by refined carbs,
poor eating habits, alcohol, poor sleep, lack of
hydration, chronic stress, food sensitivities,
oxidative stress, chronic nsaid use, SNPs,
medications, comorbidities, etc.) outcomes are
unpredictable and often fail. Or they work, but
only for a short period of time.

And what we wind up believing is that these
treatments are not reliable or they don't work.
That could not be further from the truth. All of
these treatments represent tremendous progress in
how we can heal our patients. But WHO we are using
it on and WHEN is left out of the equation and the
meta-analysis statistics.

Being a great surgeon is wonderful. But in the
same way, operating on someone who does not have
efficient reparative capabilities can lead to
post-surgical sequelae. Since 1987, I began my
shift to a holistic/functional medicine paradigm.
It was not long before I saw the amazing power in
finding underlying mechanisms of pathology and
addressing them prior to treating the presenting
pathology. I have worked with many brilliant MDs
and DOs through the past 38+ years and I have
greatly benefitted, as have my patients and I
continue to learn so much from them.

Functional medicine is likely now the fastest
growing sub-specialty in medicine. That paradigm
includes lifestyle medicine and patient
optimization and naturally feeds into the
utilization of regenerative medicine therapies.
When you “optimize” your patient, meaning you have
lifted as many underlying causes/burdens as you
can, the use of all of these progressive and smart
therapies lead to far better and more reliable
outcomes.

I strongly believe in order to move podiatry into
the 21st century, a functional medicine education
is a must. If we are to survive as a profession,
we need to treat PATIENTS, who happen to have a
foot problem, and not just attack the foot problem
with little regard for why that patient crossed
the morbidity threshold.

I invite dialogue on this subject. It’s a really
important conversation for this profession to
participate in.

Robert Kornfeld, DPM, New York, NY

Other messages in this thread:

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01/19/2026    Robert Kornfeld, DPM

The Quest for Non-Covered Services (Allen Jacobs, DPM)

I did invite conversation on this subject and Dr.
Jacobs responded with a post that curiously both
lauds and dismisses functional medicine at the
same time. However, his post is not
“conversational”, but rather more opinionated.
Conversation invites inquiry. Inquiry elucidates
things in an educational way. But when someone has
strong opinions on something they have never
studied or applied to their practice, that is
called bias. His positive comments here are erased
by this bias.

Dr. Jacobs dismisses functional medicine because
of the cost. Something he brought up a few times.
He also states that insurance does not pay for it
as if insurance companies have the right to decide
the standard of care, which, unfortunately, they
do but only when you are in an insurance-dependent
business. Let me comment first on this. The “cost”
of care for someone covered by insurance is not
inexpensive. There are premiums, co-pays,
deductibles, non-covered services and rejected
claims that they must pay for. These are real
monthly costs for the patient.
Dr. Jacobs makes it seem like the people who can’t
afford direct-pay medicine get medical care for
free. They don’t. Additionally, don’t be so
haughty to decide who will be willing to pay for
these services. You would be shocked at how many
blue collar workers I have treated over the past
25 years that found value in what I do and somehow
found a way to pay for it. Especially when the
traditional medicine-insurance based care failed
them after seeing many doctors.

Dr. Jacobs also refers to functional medicine as
being “unproven” with a “lack of large-scale
studies”. Both of these statements could not be
further from the truth. Dr. Jacobs obviously has
not delved into the literature in this field and
puts a bias out there that is based on a non-
reality. In fact, and this is where functional
medicine gets criticized as not being evidence-
based, RCTs do not work for most things we do.
Why? Because functional medicine addresses
underlying causes. It is not single agent/modality
based. To that end, a typical protocol has many
parts to it. Each, on its own, cannot be shown to
heal pathology. It is a PATIENT-SPECIFIC approach
with a combination of therapies that get the job
done.

That is why, from a clinical point of view, meta-
analysis is how we evaluate what we do. This, in
addition to the untold thousands of studies on
nutrition, vitamins, mineral, hormones, enzymes,
neurotransmitters, the microbiome, immune system
activity, stress, lack of sleep, lack of adequate
hydration, etc., etc., gives us a strong
scientific base to work with. But as I said,
functional medicine is patient-specific and
therefore generic therapies are unreliable.

Dr. Jacobs gives examples of conditions treated
via “functional medicine” and speaks about some
simple “functional medicine principles” that can
be applied to up code your E&M encounter.
Functional medicine is not about upcoding. It is
not about making generic recommendations. It is
about understanding each patient’s unique
epigenetics, genetics, medical history, family
history, review of systems and prior therapies so
we can create a logical and pointed approach to
the patient in front of us. What is good for one
patient does not necessarily work on another. Our
responsibility as doctors is to meet each patient
where they are and treat them as the unique beings
that they are.

There is no question that not everyone can
“afford” direct-pay services and that is
unfortunate. Not everyone can afford their
deductible as well. And even though functional
medicine has been around for well over 30 years,
it still faces challenges because too few doctors
are practicing it compared to the total population
of doctors in the country. As such, it does not
have the numbers needed to make it a mainstream
part of our approach to patient care. But all
change must start somewhere. Dr. Jacobs’ dismissal
of this amazing paradigm keeps the bias and lack
of inquiry going and makes medicine less
effective. He cannot deny that in spite of all of
the “approved” protocols in traditional medicine,
morbidity has never been higher in our society.
What this proves is that traditional medicine is
aching for a partner. And functional medicine is
that partner.

Finally, he brings up the fact that I have a
course on functional medicine. I did not put in a
disclaimer in my first post because I was not
trying to solicit students with a cheap form of
advertising. It is my passion for the paradigm and
my frustration with this profession that keeps me
bringing it to PM News subscribers. As Dr. Jacobs
stated, I have been discussing this topic on this
forum for many years, decades before I had a
course. My intention was to keep the focus on
functional medicine. Not to put in a disclaimer
that would alert people to the fact that I have a
course on this subject. You brought it up, Dr.
Jacobs, not me. And I deeply resent your implying
that my intentions were self-serving.

In summary, I can say this. I do not know a single
functional medicine doctor that is unhappy in
practice. And I know many. We help our patients in
a profound way and the results of our efforts are
extremely gratifying. Needless to say, I have all
of the traditional training that all podiatrists
have. And in comparison to the way I practice now,
I have become a much more effective and happier
doctor. My healing skills have grown
astronomically through this paradigm. And I have
very happy patients as well.

Robert Kornfeld, DPM, New York, NY

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01/17/2026    Allen M. Jacobs, DPM

The Quest for Non-Covered Services (Robert Kornfeld, DPM)

Dr. Kornfeld has asked to open a discussion on
functional medicine. The basic tenet of functional
medicine is to address the etiology of a disorder
rather than address only the symptoms. It is a
holistic approach. This is a principle that
generally is appropriate in our daily practice. No
reasonable person can reasonably argue a contrary
position. It calls for individually unique
programs for each patient.

Many practitioners of functional or integrative
medicine are direct pay. As a result, a
significant portion of the population may not be
able to avail themselves of functional medicine
benefits due to the cost of some therapies such as
supplement therapies or testing protocols which
are out of pocket. There are often high expenses
associated with functional medicine, as many of
these services are not covered by insurance. In
addition, there is a distinct lack of large-scale
rigorous studies to support the scientific basis
for some of these therapies (as there are for
other therapies cited by Dr. Kornfeld such as
laser therapies, peptides, regenerative medicine
therapies, shock wave therapies).

Unproven does not equal ineffective or
unnecessary-it means that insurance carriers will
not cover many of these procedures or supplements.
Yes we all understand that the inclusion in or
lack of insurance coverage has no real therapy
credibility meaning, we understand that. However,
it creates a practical issue for many patients.
And for us.

Some basic functional medicine principles however
may be incorporated at no cost to the patient,
while providing the practitioner to up-code to a
99213 if for no other reason than time devoted to
consultation and patient education.

Example: the overweight patient with plantar
fasciitis. Typically, plantar fasciitis is a
"reactive" problem. It does not occur in a vacuum.
3 injections and then a fasciotomy is treatment of
the symptoms. Advising weight loss, alteration in
footwear, control of pronation, recommendations
for proper external factor changes, management of
equinus, go to the etiology rather than simple
treatment of symptoms. It is not true functional
medicine, but it is closer than not.

Example: the treatment of diabetic neuropathy in
the patient taking metformin. Adjunctive
analgesics (eg: TCAs, SNRIs, gabapentinoids) treat
the symptoms. However, we know that metformin is
associated with increased risk and intensity of
diabetic neuropathy. Why? It is the effect of
metformin on intrinsic factor, lowering folic acid
and B12 quantitative or functional levels,
resulting in elevation of homocyteine levels and
lowering NO levels and decreasing neural blood
flow. These effects may be reversed by the
provision of L-methyl folate and cyanocobalamin to
our patients, improving nerve health and treating
the etiology of the neuropathy. Problem: cost of
the supplements needed.

In treating diabetic neuropathy, we can
incorporate some basic functional or integrative
medical principles at no cost to the patient but
allowing an increased E/M coding for time. For
example, discussing life-style changes with the
patient, encouraging weight loss, discussing
better diabetes control, encouraging exercise,
speaking to stress reduction, and so on.

Example: xerosis cutis of the foot. Prescribing
creams and lotions is helpful and may be remittive
for symptoms. However this skin condition may be
secondary to a wide range of problems, such as
thyroid disease, deficiency of vitamins A, B3, D,
Fe, diabetic peripheral autonomic neuropathy, we
can go on and on. Do you stop with the topical
prescription, or do you seek the underlying
disease process? The former is not wrong, it is
the "standard of care". The latter approach makes
practice interesting and rewarding. Again, true
functional or integrative medicine investigates at
a deeper level. But something is better than
nothing.

It is called being a doctor. Looking at the entire
patient, not just a foot or a symptom.
Like many of you, I understand that true
functional medicine explores deeper than these
examples. However, many of our patients simply
cannot afford the expensive testing and
supplements and long-term commitment required for
true functional medicine.

Dr. Kornfeld has discussed the potential benefits
of direct pay and functional medicine in our
profession for quite some time. He brings many
valid thoughts and questions to this forum. If I
am not mistaken, he apparently has an
instructional course on the subject, a potential
COI that should be stated if true. The basic
approach of treating the underlying
pathophysiology rather than only reactive symptoms
is clinically sound. All practitioners should
follow his directives and seek out cause not just
effect, in everything that we do.

Allen M. Jacobs, DPM, St. Louis, MO