Childhood Coffins Due to Cuts in Foreign Aid

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Nicholas Kristof, NY Times, 9/20/25: Trump’s Most Lethal Policy

Reporting from Uganda, Mr. Kristof reports on the devastating and worsening impact related to the cuts of foreign aid –without apparent cost savings. He details three particular avoidable deaths and outlines the larger problem. Here’s an excerpt:

The Trump administration has claimed that no one has died because of its cuts to humanitarian aid…Yet what I find here in desperate villages in southwestern Uganda is that not only are aid cuts killing children every day, but that the death toll is accelerating.

Stockpiles of food and medicine are running out here. Village health workers who used to provide inexpensive preventive care have been laid off. Public health initiatives like deworming and vitamin A distribution have collapsed. Immunizations are being missed. Contraception is harder to get. Ordinary people are growing weaker, hungrier and more fragile. So as months pass, the crisis is not easing but growing increasingly lethal — and because children are particularly vulnerable, they are often the first to starve and the first to die… credible estimates by experts suggest that the child death toll may be in the hundreds of thousands this year alone — and likely an even higher number next year.

A June 3 State Department memo, headed “sensitive but unclassified,” saying that the shutdown of the U.S. Agency for International Development will cost taxpayers $6.4 billion over two years… the money is necessary to manage “litigation, claims, residual payments and closeout activities.”..

A recent study published in The Lancet estimated that the cuts will cost the lives of about 690,000 children under the age of 5 in 2025, and 829,000 next year. The study estimated that some 3.1 million children under age 5 would die during Trump’s second term because of his cuts in humanitarian assistance...

PEPFAR, founded by President George W. Bush with the strong backing of America’s evangelical Christians. It turned the tide of AIDS and has saved 26 million lives — but the Trump administration has withheld some of its funding…About 65 percent of PEPFAR awards have been canceled…

Yet it’s also true that there are hints that the Trump administration is beginning to find some footing on aid. It has begun to place new orders for R.U.T.F. and has plans to move these stockpiles. It is preparing to hand over its food aid stockpiles to U.N. agencies to distribute to those in need. And it announced this month that PEPFAR will distribute lenacapavir, an important new drug that prevents AIDS transmission, in at least eight countries next year. These are real and positive steps; they just don’t make up for the larger pattern of chaos and cutbacks…

Related blog posts:

Huntingdon Lake, Sandy Springs GA

High Frequency of Asymptomatic Perianal Crohn’s Disease at Diagnosis

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M Antaya et al. AJG; DOI: 10.14309/ajg.0000000000003733 (ahead of print); The impact of integrating pelvic MRI at diagnosis on early detection of perianal Crohn’s disease in pediatrics

Methods: “Patients [n=139] were prospectively enrolled into the Edmonton Pediatric Inflammatory Bowel Disease Clinic (EPIC) registry (baseline pelvic MR since 2018). A retrospective review (2018-2023) was performed.”

Key findings:

  • Nearly 1 in 3 (31%) newly diagnosed pediatric CD patients had perianal CD identified on pelvic MRI
  • Overall, 19% (n=27/139) had subclinical perianal disease (MR+/ asymptomatic (ASx)).
  • For patients who were both asymptomatic and had a normal perianal exam (n=86/139, 62%), their subclinical perianal disease rate was similar at 20% (n=17/86)
  • One in ten pediatric CD patients needed perianal surgery within the first 6 years post-diagnosis
  • MR+/ASx also had higher rates and faster time to perianal surgery than MR-/ASx (p=0.02)
  • Perianal side branch fistula was a predictor of surgery (OR 107.6, [95% CI 16.9-2178] p<0.0001)
  • In this study from Canada, 78% (n=108/139) were receiving biologic therapy at one year following diagnosis. However, only 51% (n=71/139) received biologic therapy as initial maintenance therapy

In their discussion, the authors indicate that pelvic MRI “enables identification of patients who may benefit from earlier biologic therapy (particularly anti-TNF) and closer monitoring despite being asymptomatic, given they have an increased risk of perianal surgery.” They note potential concerns for cost-effectiveness but note routine MRI may reduce future hospitalizations and surgery.

My take: In patients who will receive early biologic therapy, it is not likely that routine MRI will result in any cost savings. However, in settings without significant resource constraints, understanding the extent of disease is still desirable for later comparison.

Related blog posts:

“Tasty & Healthy” Whole Food Diet For Crohn’s Disease

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Y Frutkoff et al. Gastroenterology 2025 (Article in Press). Open Access! Whole Food Diet Induces Remission in Children and Young Adults With Mild to Moderate Crohn’s Disease and Is More Tolerable Than Exclusive Enteral Nutrition: A Randomized Controlled Trial

Yesterday’s post (“A Practical Guide to Diet and IBD” (2025)) provided a summary of data on a multitude of diets for inflammatory bowel disease. Today’s post describes a study on a new diet, called the Tasty & Healthy diet.

Background: Tasty & Healthy (T&H) is a whole food diet for Crohn’s disease (CD) that excludes processed food, gluten, red meat, and dairy, without requiring formula or mandatory ingredients.

Tasty & Healthy (T&H) is an exclusive whole food diet, first published in a charity cookbook in 2014… The T&H diet was developed to reduce proinflammatory dietary exposures by excluding gluten, animal fat (ie, red meat and dairy, except for plain yogurt), as well as all processed food (anything that comes in a package except for those with 1 unprocessed ingredient.” (see details and supportive references in Supplementary Appendix 1).

Methods: TASTI-MM was a clinician-blinded, randomized controlled trial comparing tolerability and effectiveness of T&H (n=41) vs exclusive enteral nutrition (EEN, n=42). The intention to treat analysis included 83 patients (mean age 14.5 yrs, range 7-25 yrs).

Key findings:

  • 88% tolerated T&H vs 52% for EEN. 59% of the patients in the EEN arm did not complete the 8-week follow-up period, compared with only 15% in the T&H arm
  • Calprotectin, C-reactive protein, and erythrocyte sedimentation rate decreased significantly in both groups, with no between-group differences
  • Symptomatic remission was achieved in 56% of the T&H group vs 38% of the EEN group
  •  Calprotectin <250 μg/g was achieved in 34% T&H vs 33% of the EEN group
  • Microbiome α-diversity improved in the T&H arm and declined in the EEN arm, showing superior species richness at both week 4 and week 8. Species associated with bowel inflammation, such as Ruminococcus gnavus, decreased in T&H and increased in EEN (q < .001)

Discussion Points:

“In multiple studies CDED has been found to induce symptomatic remission in 62%–77% of patients with mild to moderate uncomplicated CD, including biologic remission in a subset of patients. Although conceptually similar to CDED in the exclusion of proinflammatory food
groups, the T&H diet differs in structure—requiring no formula and no mandatory components, thus offering greater dietary flexibility.”

“The T&H diet was tested across multiple international centers, while still achieving similar outcomes compared with EEN. The use of any exclusion diet requires guidance of a dietitian to ensure balanced nutrition, and this becomes even more important in diets when formula is not needed. Other exclusive whole food diets studied in the RCT setting are the Specific Carbohydrate Diet and Mediterranean diet, which were effective in inducing symptomatic remission, but demonstrated insufficient biologic remission rates.”

“In the past, dietary interventions have not been as widely adopted in adults as in children…Although EEN use has been hampered by the thought that adults will not tolerate nutritional interventions, the advent of whole food diets has changed that notion…In this study, we found that not only were the included adults adherent to the T&H diet, it was as effective as in children and treatment response was not associated with age.”

Related article: Plotkin L, Aharoni Y, Fenster D, et al. Tasty & Healthy is a
dietary approach for inducing and maintaining remission in Crohn’s disease: a prospective case series. United European Gastroenterol J 2021;9:521 (PO431).

My take: This “Tasty & Healthy” Diet appears to be an effective option for induction of remission for mild to moderate Crohn’s disease. Extended studies will be needed to help determine whether it could be used for longer duration in those with a response. Also, whoever labelled this diet initially clearly understands marketing as it sounds a lot better than EEN or CDED.

Related blog posts:

Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition

“A Practical Guide to Diet and IBD” (2025)

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EJ Figueroa et al. Am J Gastroenterol 2025;120:1941–1945. A Practical Guide to Diet and IBD

Background: “A growing body of evidence suggests that dietary intake may play a role in the pathogenesis and perpetuation of IBD-associated inflammation. Human and animal-based studies have identified various dietary components, such as meat and artificial
food additives, associated with intestinal inflammation.”

“Despite the interest of patients in dietary therapy, robust data surrounding the potential harms and benefits are limited (1). Patients often attribute symptoms of IBD to their dietary intake and will avoid foods they perceive as triggers. Overly restrictive diets can lead to decreased food-related quality of life, malnutrition, or micronutrient deficiencies.”

Key points:

  • “For patients seeking general guidance, we recommend avoiding ultra-processed foods, artificial thickeners, and sweeteners and trying to adhere to a predominantly plant-based diet focusing on fruits and vegetables, with moderate amounts of lean proteins, and for patients with UC, reduced amounts of red meat.”
  • For Crohn’s disease: “the highest quality evidence supporting dietary management of IBD is for EEN and PEN in mild-to-moderate CD.”
  • “For patients seeking specific guidance, …there is good evidence for the use of EEN and
    PEN with CDED for induction of remission in Crohn’s disease…short-duration use of EEN/PEN can be offered to patients with medically refractory disease who require a bridge to their next advanced therapy.”
  • For Crohn’s disease: “Dietary strategies using whole food alone can improve gastrointestinal symptoms but have not definitively demonstrated successful control of inflammation. Their use is generally recommended for patients with mild-to-moderate symptoms.”
  • For Ulcerative Colitis: “There remains insufficient evidence to support the use of dietary approaches in the management of UC, but some evidence suggests a diet high in fiber and low in fat may be of benefit.”

Table 1 provides a good summary:

Other points:

Formula for EEN: “A Cochrane meta-analysis found no difference in efficacy between polymeric or elemental EEN formulations…Because of lower cost and better palatability, polymeric formulas are most often used in clinical practice.”

SCD Diet vs Mediterranean:”Iin a randomized superiority trial that compared 6 weeks of the SCD with a Mediterranean diet in adults with Crohn’s disease with mild-to-moderate symptoms, the SCD was not found to be superior to the Mediterranean diet (14). After 6 weeks of therapy, less than half the participants (46.5% on SCD and 43.5% on the
Mediterranean diet) were in clinical remission, and neither diet resulted in normalization of C-reactive protein concentration for most patients.”

My take: This article provides a good summary of the current evidence supporting the role of dietary treatment for IBD. In patients interested in specific diets, the assistance of a nutritionist/dietician is very important.

Related blog posts:

Pediatric Guidelines for Ulcerative Colitis (Part 2: Acute Severe Colitis)

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With regard to yesterday’s post (Pediatric Guidelines for Ulcerative Colitis (Part 1)), the use of combination therapy with thiopurines is frequently avoided in the pediatric population in the U.S. due to safety concerns (eg. low risk of lymphoma). Anti-TNF monotherapy with pTDM appears to be a more common practice in the U.S. (Related blog post: Can Therapeutic Drug Monitoring with Monotherapy Achieve Similar Results to Combination IBD Therapy?). These pediatric guidelines with regard to combination therapy are similar to recent ACG guidelines for adults (D Rubin et al. The American Journal of Gastroenterology 120(6):p 1187-1224, June 2025. Open Access! ACG Clinical Guideline Update: Ulcerative Colitis in Adults).

————

A Assa et al. JPGN 2025; 81:816–85. Open Access! Management of paediatric ulcerative colitis, part 2: Acute severe colitis—An updated evidence-based consensus guideline from the European Society of Paediatric Gastroenterology, Hepatology and Nutrition and the European Crohn’s and Colitis Organization

Comprehensive review (69 pages!) of all the topics related to acute severe colitis are covered. Topics include associated enteric infections (C diff, CMV), toxic megacolon, antibiotics, pain management, VTE, surgery, and pouchitis.

Some of the recommendations:

  • All mesalamine preparations (oral and rectal) should be discontinued upon admission to exclude mesalamine intolerance, especially when mesalamine has been commenced during the preceding few weeks; (re-) introduction should be considered after significant improvement in the clinical condition [EL5, adults EL5] (*100% agreement).
  • Regular diet should be continued in most ASC cases [not in toxic megacolon]. Enteral nutrition may be used if oral feeding is not tolerated or in malnourished children [EL4, adults EL1] (*100% agreement).
  • Pharmacological thromboprophylaxis for reducing the risk of VTE should be considered in all inpatient children with ASC (Figure 1) [EL5, adults EL2] (*100% agreement).
  • Intravenous methylprednisolone 1 mg/kg/day (up to 40 mg/day) once daily is the first-line treatment in ASC and should be promptly started [EL2, adults EL1]. A higher dose of 1.5 mg/kg/day (up to 60 mg/day) can be used at the clinician’s discretion (e.g., in patients on oral corticosteroids at admission and/or with a more severe spectrum of ASC) [EL4, adults EL4] (*100% agreement).
  • Intravenous methylprednisolone should not be extended beyond 7–10 days of total course, since it carries no additional benefit and increases toxicity. In corticosteroid-refractory patients in whom second-line therapy is initiated, there is no need for corticosteroid tapering if corticosteroids are given as an isolated short course (up to 10 days) (*100% agreement).
  • A PUCAI > 45 on the 3rd day of IVCS treatment should dictate planning for second-line therapy between Days 3–5 [EL2, adults EL2] (*100% agreement).
  • Second-line therapy should be initiated on the 5th day of IVCS treatment in children with a PUCAI ≥ 65 [EL2, adults EL2] (*100% agreement).
  • Infliximab is recommended as the preferred second-line medical therapy for anti-TNF naive children failing IVCS [EL3, adults EL1] (*100% agreement).
  • To reduce unnecessary immunosuppression, corticosteroids (when ineffective) should be rapidly weaned following introduction of second-line therapy or decision to proceed to colectomy (stopped if in use ≤10 days and reduced to prednisone ≤0.2 mg/kg or equivalent to 10 mg adult dose with gradual tapering thereafter if >10 days) [EL5, adults EL5] (*100% agreement).
  • Third-line sequential rescue therapies (CNIs after infliximab, infliximab after CNI or a JAK inhibitor after either) may be considered in stable patients, in specialised centres and in those whose corticosteroids were weaned off or nearly weaned off as stated above [EL5, adults EL2] (*100% agreement).

Related blog posts:

Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Pediatric Guidelines for Ulcerative Colitis (Part 1)

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E Wine et al. JPGN 2025;81:765–815. Open Access! Management of paediatric ulcerative colitis, part 1: Ambulatory care—An updated evidence-based consensus guideline from the European Society of Paediatric Gastroenterology, Hepatology and Nutrition and the European Crohn’s and Colitis Organisation

This is the first of two highly-detailed papers. (This is a 50 page report.) it has extensive/comprehensive recommendations and information on all aspects of UC management, except acute severe colitis which is covered tomorrow.

Here are some of the recommendations:

  • Thiopurines are recommended for maintaining remission in children who, despite optimal 5-ASA treatment, are corticosteroid-dependent or have frequent relapses (≥2 relapses per year) or in 5-ASA-intolerant patients; thiopurines should be considered following discharge from ASC episodes (EL4, adults EL3) (Agreement 100%).
  • Infliximab should be considered, preferably in combination with an IMM, as the first-line biologic agent in chronically active or corticosteroid-dependent UC, uncontrolled by 5-ASA, and in most cases also thiopurines, for both induction and maintenance of remission [EL1, adults EL1] (Agreement 96%).

It is worth noting that anti-TNF monotherapy with pTDM is common practice in the U.S. due to concerns about the safety of combined therapy with a thiopurine (Related blog post: Can Therapeutic Drug Monitoring with Monotherapy Achieve Similar Results to Combination IBD Therapy?). These pediatric guidelines with regard to combination therapy are similar to recent ACG guidelines for adults (D Rubin et al. The American Journal of Gastroenterology 120(6):p 1187-1224, June 2025. Open Access! ACG Clinical Guideline Update: Ulcerative Colitis in Adults).

  • Infliximab is recommended to be used preferably in combination with an IMM (with the most evidence in UC being for thiopurines) to reduce the likelihood of developing antibodies to infliximab (ATIs) and in thiopurine-naïve patients, to enhance effectiveness. Methotrexate may also be used to mitigate ATIs. For immunogenicity prevention, lower doses of azathioprine (1–1.5 mg/kg) may be used. Data on methotrexate dose in this setting are scarce, but low total doses of 7.5–12.5 mg weekly are reported. Proactive TDM is recommended, particularly when infliximab is prescribed as monotherapy (Agreement 96%).
  • In most cases, higher doses of infliximab (e.g., 10 mg/kg/dose at Weeks 0, 2 and 6, followed by 10 mg/kg every 4–8 weeks for maintenance) are required to provide the best chance of reaching the desired clinical and endoscopic outcome. The dose can be subsequently reduced, guided by TDM. Lower dosing (5 mg/kg) can be used in less severe cases. In cases in which IV infliximab treatment is switched to subcutaneous injections, the recommended dosing schedule (established only for >40 kg) is 120 mg every 2 weeks. See Table 2 for dosing details (Agreement 100%).
  • Proactive TDM is recommended for both infliximab and adalimumab, particularly at the end of induction (before the 4th infliximab infusion and after 3 adalimumab injections) [EL4] (Agreement 100%).

Cancer Surveillance:

  • 1. Children with UC aged 12 years and over with a disease duration of greater than 8 years should be considered for surveillance for CRC and dysplasia [EL4, Adults EL1] (Agreement 96%).
  • 2. Children with UC and PSC should be considered for surveillance for CRC and dysplasia starting at age 12, regardless of disease duration [EL4, Adults EL3] (Agreement 100%).

My take: The referenced paper in today’s post and tomorrow’s are essentially updated published book chapters with specific management recommendations. There are likely some practice variations but overall the recommendations will help garner support for current practices like optimizing infliximab dosing and using proactive TDM.

Related blog posts:

Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition

Tuberculosis: #1 Infectious Disease Killer

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Followup on previous blog post (Mary Suhr: Coding Update 2025) -there is a new CPT code for the PENFS procedure in 2026: 64567. This procedure has FDA approval for children/adolescents (8-21 years) with functional abdominal pain associated with irritable bowel syndrome; in addition, it has an indication for functional dyspepsia.

—–

From NPR 9/11/25: TB is the #1 killer among infectious diseases. A new study says its toll could mount

An excerpt:

While it may seem like a disease from the past, this airborne illness kills more people than any other infectious disease worldwide, roughly 1.2 million a year. That number could increase dramatically because of the Trump administration’s cuts to foreign assistance, according to a new study…

As many as 10 million additional people could get TB, and 2.2 million could die by 2030 in high-burden countries under the worst-case funding scenario over the next five years, researchers report in the journal PLOS Global Public Health. 

My take: I recently finished, Everything is Tuberculosis by John Green, which is a good read. So this article caught my attention. Even before the funding cuts, more effort was needed to stop the scourge of TB. Currently TB kills more than a million people per year; in some historic periods, it has killed as many as one in seven people.

Thanks to Anna Kelly for recommending the book to me.

Related blog posts:

Mary Suhr: Coding Update 2025

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Mary Suhr, a coding expert, provided our group with an excellent update on coding and the changes needed in documentation. I have taken some notes and shared some of her slides. There may be inadvertent omissions and mistakes in my notes.

  • In 2025, billing/coding relies entirely on medical decision-making OR time codes.  While documenting a comprehensive history and an exam are important for patient care and good practice, they are not important in billing/coding.
  • Medical decision-making (MDM) consists of three areas: diagnosis, review of data, and risks of treatment.  Data includes points for each lab reviewed/ordered and each radiology test.  If you order/review CBC/d, CRP, and CMP, this would be up to 3 points in this category.
  • With the changes in requirements in coding, the RVUs were increased for both outpatient and inpatient codes.  This reflects the increased difficulty in selecting some codes.  For example, the change in requirements, some 99214 codes several years ago will now qualify for 99213 codes.  It is much more difficult to use a 99215 code based on medical decision-making and the time spent is up to 40 minutes to use this code
  • Followup visits who are not doing well generally would NOT be a low level visit if documented appropriately
Coding for F/u visits
See slide below regarding split/shared services below.
If APP spends the majority of the time, then the time codes can be billed by the APP
or the MD can bill based on medical decision-making (but not time code).
  • Discontinuing a prescription medication can be counted as prescription drug management if documentation explains the potential benefits/risks of this
  • Newer codes that may be useful:
  • G2211 –>long-term longitudinal care code
  • 99451 –>interprofessional consultation (if patient consented). If an ED physician calls for consultation, documentation could allow for this code as long as the patient is not seen before or after within 7 days
  • 98016 –>audio (telephone) consult code for established patients. This could be used to check in to see if the patient needs an office visit
  • New ICD-10 codes for IBD with fistulas, BMI codes and eating disorders
  • If a patient is seen in ED and leaves ED, recommended to use ED codes, not office-based outpatient codes
  • For inpatients, HAL management is generally a high risk medication/treatment for coding-billing purposes
  • Document defensively.  Increasingly, insurance companies are trying to downcode visits.  Recommend resisting this and document why the initial codes were selected
  • Except for Medicaid, can use modifier 25 and bill if patient seen in clinic by one provider and in the hospital by another provider, if each was involved in patient care

Explaining Prior Authorization to Patients/Families

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Ron Lieber, NY Times 9/14/25: A Message From Your Doctor About the Prior Authorization Process

This article recommends that physicians consider a proactive role in explaining the prior authorization process. Here is his suggested handout:

Often, insurance companies require us to ask their permission for coverage before prescribing a drug or doing a test or procedure. They say they do this to make sure that we are suggesting medically appropriate, cost-effective care — on behalf of you or your employer. In fact, this is always our goal, but they don’t always think we’re accomplishing it.

To try to get this authorization ahead of time, we document our logic in the format they require, and they may reject it. Often we find out about rejections well before any surgery, but sometimes we don’t.

The prior authorization process can be as baffling to us as it may be to you, and we find it intensely frustrating. Please keep in mind that we are at the mercy of dozens of insurance companies, and their rules and requirements can change constantly. Your doctor may not be able to predict the odds of a prior authorization rejection, and musing over the possibility before it happens probably isn’t a productive use of our time together in the exam room.

If you have any concerns once you know what we’re recommending, reach out to our billing specialist or the department that helps with this. They too may not be able to tell you much ahead of time, but they will play a role in helping us with any appeal that is necessary if our request for prior authorization fails in full or in part.

Insurance companies like paper mail. Check yours every day, in case they issue denials that way. Download your insurance company’s app and sign up for push notifications for any changes, especially if they offer alerts specifically for changes in prior authorization. Opt in to email notifications, and check your spam.

You might hear from the insurance company before we do.

We think we are pretty good at navigating this deeply suboptimal system, but we can’t do it without you. Please, become intimately familiar with your insurance plan and what it covers — whether prior authorization is required or not.

Engage a human resources specialist at your employer, if you have one, to help communicate with the insurance company during the prior authorization process if you think you might need help. Call the insurer on your own to ask whether your medicine or procedures require permission and whether the insurance company is missing information it needs.

Patients can sometimes get better information faster than we can, if only because we may be trying to help hundreds of patients at once.

There is an appeal process, which may differ by insurer. Contact a billing specialist with whatever information you have from your insurance company, though we may hear about it before you do and start the process on our own.

Sometimes, the problem is a relatively simple one, resulting from confusion over the byzantine process of submitting medical codes, or some similar snafu. But often, a doctor will have to do what’s known as a peer review with someone from the insurance company. We find this burdensome, since the “peer” on the line with us may not have the same level of expertise as we do. That prolongs the call, adds to our overall operating expenses and keeps us from spending more time with you, the patient.

We’ll give any appeal our best shot, but it may take time to schedule any peer review.

We dislike having to give you a document like this that might produce anxiety. Still, it’s better that you be aware of how things might go than be desperately trying to reach us or learn about the prior authorization process after getting a mysterious and indecipherable rejection letter in the mail.

If things don’t go our way at first, we will have your back and argue fiercely to get you coverage for the care you need.

Our industry has a structural problem. We can provide you information and over-communicate, but the incentive systems are what they are.

Insurance companies may sometimes deny permission for care in order to make more money. Employers (and individuals) don’t want premiums to rise. Some patients demand that we throw everything we doctors have at every health condition. Regulators are in the middle of all of it, ordering up paperwork. And doctors are not infallible.

We wish we could fix all of that. But for now, we can be plain-spoken with you about how prior authorization works and try to make the system that we have just a bit more tolerable.

Related posts:

Wheat Field with Cyprus, Vincent van Gogh at the Metropolitan Museum of Art (NYC)

Trisomy 21 and Associated Biliary Anomalies

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M Joseph et al. JPGN 2025;81:743–747. Duct tales: Biliary anomalies found at endoscopic retrograde cholangiopancreatography in trisomy 21 pediatric patients

Methods: A single-center, retrospective chart review was conducted to identify pediatric patients (n=12) with T21 who underwent ERCP.

Patient characteristics:

  • Six patients (50%) had a history of duodenal atresia with subsequent surgical repair during the neonatal period
  • Four patients (33.3%) had chronic or acute recurrent pancreatitis, and two patients (16.7%) had biliary pancreatitis
  • Five patients (41.7%) had a biliary stricture that required stenting
  • Choledocholithiasis was present in 7 of the 12 patients (58.3%)

Key findings:

  • Eight patients (66.7%) were found to have an abnormal location of the major papilla. This included three patients’ papillae which were in the blind duodenal pouch created after duodenal atresia surgery (Figure 1B) and two patients had their papilla in the proximal duodenum/bulb (Figure 1D)
  • Two patients (16.7%) had unsuccessful ERCP either due to difficult cannulation or inability to find the major papilla
Figure 1: Biliary anatomic variations in Trisomy 21. Shown are drawings that represent variations of the location of the major papilla.(A) Normal; (B) normal location but with a long common channel; (C) pylorus; (D) postsurgical pre‐anastomotic location; and (E) postanastomotic location with choledochal cyst. Illustrations by Dr. Robert E. Kramer.

My take: In patients with trisomy 21, ERCP may be quite challenging due to anatomic variations and stricturing. In some patients in this cohort, a front-viewing scope was helpful.