Anne Paxton
October 2025—Complementary and integrative medicine (CIM) has become gradually more popular and is accepted by a small but significant group of patients in tandem with traditional medicine. CIM providers often advocate a mix of conventional tests with special test panels that may include tens to hundreds of tests that conventional providers wouldn’t order. For those who lead laboratory stewardship efforts, it can be a challenge.
CIM is an umbrella term that includes a variety of related and overlapping practices, consisting of but not limited to integrative medicine, functional medicine, naturopathy, and chiropractic care.
CIM is commonly used to refer to “health care practices that traditionally haven’t been part of conventional medicine,” says Michael Astion, MD, PhD, professor of laboratory medicine and pathology, University of Washington. “When I started practicing, complementary and integrative medicine were considered pretty far out there. Now, there is an increasing number of patients who want CIM as part of their health care along with conventional medicine.”
Dr. Astion has a unique window into some of the challenges CIM testing presents. He is the creator and co-founder of PLUGS, the Patient-centered Laboratory Utilization Guidance Services, which has a nationwide membership. At the University of Washington and Seattle Children’s Hospital, laboratory stewardship has been an active part of laboratory medicine practice since the 1990s, he says. The UW reference laboratories, which he directed in the 1990s and in early 2000, were “slightly more expensive per test than other competing labs. But we didn’t promote overtesting,” he says, “and we could show that if our laboratory faculty could help you order the correct tests in the correct quantity, your overall bill would be the same as or less than that of our competitors. That’s the kind of stewardship we have consistently practiced.”
In addition, they have always had to manage unusual orders, he says, including those from CIM practitioners, “so we developed policies and procedures to manage this type of testing.”
In 2013, it was a natural evolution to form PLUGS, a laboratory stewardship collaborative. Its mission is to improve test access, ordering, retrieval, interpretation, and reimbursement.
Though CIM raises lab test stewardship questions, Dr. Astion says, putting it into perspective is important. “The vast majority of the laboratory testing industry is driven by older people with chronic diseases. That’s 60 or 70 percent of testing,” he says. CIM makes up “a very small percentage of the pie.”
The Institute for Functional Medicine defines functional medicine as a “systems biology-based approach that focuses on identifying and addressing the root cause of disease.” CIM tends to emphasize the search for particular hidden causes of a patient’s condition, Dr. Astion says, among them stealth infections, gut imbalances, toxins, nutritional deficiencies, inflammation, and mitochondrial and other cellular problems, which opens the path to all manner of large test panels.
The many nonstandard tests used in CIM include comprehensive stool analysis, organic acid panels, nutrition panels, genetic risk panels, alternative approaches to allergy panels, expanded testing for metals and other environmental toxins, unconventional testing for microbial pathogens, adrenal stress panels, and salivary hormone panels.
Traditional medicine has two main characteristics, Dr. Astion notes.
“First, evidence is primary, and evidence is evaluated using rigorous scientific grading systems that have long been part of scientific medical practice. Second, where the evidence is weaker, there’s still a standard of care based on the available evidence and expert consensus.” The standard of care has both a legal and medical definition, he says.
By contrast, functional and integrative medicine is more “based on experience and belief,” Dr. Astion says, though “any of the special tests they use that are evidence based—and this is a very small fraction of their special tests—eventually come over into the conventional test menu.”
CIM practitioners sometimes use conventional, evidence-based tests, he adds. “It’s just that they apply them in much larger panels than we do, and the use of these huge panels is not evidence based.” Allergy testing is an example. “Under most insurance company policies and most PLUGS members’ practices, an evidence-based test for food allergy might include a panel of between 11 and 20 allergens. But in CIM, it’s not unusual for them to do 250 allergens or more,” he says. “Each of the allergens in the panel is an actual test, but the immense size of the panel leads to overdiagnosis of allergy because of the profound difficulty of distinguishing allergic sensitization from allergic disease.”
PLUGS members usually take a different path. “We wouldn’t in general run a big bird allergy panel as part of some super-large general allergy panel. We would do a focused panel based on a patient’s history,” Dr. Astion says, “and this focused approach is used in nearly every area of medicine, including nutrition and exposure to environmental toxins.”
Thus, a PLUGS member’s cardiac panel will have fewer lipid-related elements than one offered by a reference laboratory known for CIM testing to assess cardiovascular disease risk, he says. Within that broader CIM panel, “there are some tests that we don’t currently consider tests at all, that we have never run.”
Insurers pose barriers, he notes. “If you look at all of Aetna’s laboratory testing policies, you’ll see that almost all the extra testing, for which there is weak or no evidence, is restricted. Or look at EviCore or Avalon, the two big lab benefits management companies that service the insurance industry. All the excess testing is blocked, and there’s a numerical limit on how many tests you can have for a particular allergy.”
“The test panels that are evidence based will usually get reimbursed,” he says.
For cardiovascular disease testing, the medical necessity policies of the large insurance companies will allow a certain number of tests. “They’ll disallow the extra, unusual testing,” and pay for the evidence-based part of it, he says, “which is often a small fraction of the special CIM test.”
At Seattle Children’s Hospital, if a patient’s family member comes in with an order from, say, a naturopath for a 250-allergen food panel to be performed at a CIM-focused reference laboratory, they are told the specimen cannot be collected. “We have a policy that we can’t do that. We don’t say this is wrong; we’re just saying this is a different kind of medicine—‘that laboratory is not on our reference lab list, which is determined under CLIA by our medical director, and we don’t send that out from here.’”
But there are rare situations in which the UW or Seattle Children’s laboratory might agree to the request, Dr. Astion says. If a patient is very ill, perhaps with cancer, and they’re also going to a CIM provider, “you might want to send out some of the CIM testing. Sometimes you let it go through just because you want to keep the patient in your system, and you don’t want them to avoid treatment. So you might send a couple of those out if they are low-risk tests.”
In a 2024 webinar on CIM testing and lab stewardship, Dr. Astion offered a risk matrix for determining whether to perform CIM panel testing when scientific evidence for it is weak. Food as medicine is the general approach of many CIM providers, and the treatments they prescribe in response to certain test results are low risk, involving only modest changes in diet, rest, exercise, or stress reduction.
Treating with supplements or a more restrictive diet or a “medium” versus a “light” detox, for example, might pose a medium level of risk. “It would be where we would start to put the stewardship interventions in the way to restrict it,” though not to judge the providers who place the orders, he adds. “We’re saying that’s just a different kind of medicine.”
The higher-risk treatments might be chelation therapy to remove evoked metals, intravenous antibiotics for stealth infection, megadose supplements, or a “heavy” detox. But the highest risk, Dr. Astion says, would be advice to the patient to avoid conventional therapy for cancer or another serious illness while being treated with unconventional therapies.
In the 2024 webinar, Dr. Astion listed the questions CIM raises for lab test stewardship programs:
- What are evidentiary standards for putting the panel testing on a menu?
- If a patient is receiving care for chronic disease in your organization, should you send out low-risk CIM testing to minimize blood draw and maximize patient satisfaction?
- What should be done for patients who are relatively well and present with a kit for CIM testing that they want your laboratory to send out?
- When CIM testing is sent out, who pays for the CIM testing when the insurer does not cover it?
- What should be done when patients want to discuss results on special tests ordered by their CIM provider? “Our experience,” Dr. Astion says, “is that most conventional providers will not comment on the special tests ordered by CIM practitioners, which are not part of conventional practice. They usually refer the patient back to their CIM provider for interpretation. If the test result is particularly concerning to the conventional practitioner—for example, it appears to be leading to a false diagnosis—the provider may make their concerns known to the patient.”
PLUGS has a membership now of more than 100 laboratories, diagnostic companies, and payers.
It’s been “a place where people can regularly network and share their learnings and pass them across the member network,” Dr. Astion says. Achieving what he describes as “alignment” is the aim: “The patient doesn’t experience financial toxicity and is covered for medically necessary tests. Labs are fairly reimbursed. Insurance companies aren’t ripped off by fraud, waste, and abuse.”
The organization has regularly hosted in Seattle the largest laboratory stewardship meeting in the U.S., and occasionally regional meetings too, including four recently in the Midwest and one at the University of California at Los Angeles, focused more on payer-related issues. “PLUGS is a great example of a totally grassroots problem and solution, and people have taken to it. Everyone is interested in stewardship,” Dr. Astion says.
PLUGS offers “tips, tricks, policies and procedures, educational material, and access to experts,” he says.
The emphasis is a bit heavier on genetic testing than on other testing, but no area of testing is excluded.
To date, no functional, integrative, or complementary or alternative medicine laboratories are PLUGS members, Dr. Astion says, though they too are not excluded. Of the various laboratory testing options, he uses a restaurant analogy, even with patients: “There are dishes available at restaurant B that aren’t available at restaurant A because they’re simply not on the menu.”
CIM is a different kind of medical practice with its own beliefs, experiences, and laboratory testing needs, he notes. “Twenty years ago, there were very few patients pressuring the conventional systems for CIM-type tests. Now, almost every practitioner faces it with some set of patients.”
Anne Paxton is a writer and attorney in Seattle.