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
