Evelyn Balsavage, widow of ANTHONY BALSAVAGE v. DIRECTOR, OFFICE OF WORKERS’ COMPENSATION PROGRAMS (United States Department of…

PRECEDENTIAL
Filed June 28, 2002
UNITED STATES COURT OF APPEALS
FOR THE THIRD CIRCUIT
No. 01-2091
EVELYN BALSAVAGE, widow of ANTHONY BALSAVAGE,
Claimant/Petitioner
v.
DIRECTOR, OFFICE OF
WORKERS’ COMPENSATION PROGRAMS
(United States Department of Labor),
Party-in-Interest/Respondent.
Appeal from an Order of the Benefits Review Board
(United States Department of Labor)
(No. 00-0630 BLA)
Argued: January 15, 2002
Before: ALITO, ROTH, Circuit Judges, and
SCHWARZER,* Senior District Judge
(Filed: June 28, 2002)
_________________________________________________________________
* The Honorable William W Schwarzer, Senior United States District
Judge for the Northern District of California, sitting by designation.
HELEN M. KOSCHOFF, ESQUIRE
(Argued)
303 Greco Lane
Warburton, PA 17888
Attorney for Claimant/Petitioner
Evelyn Balsavage, widow of
Anthony Balsavage
JEFFREY S. GOLDBERG,
ATTORNEY (Argued)
HOWARD M. RADZELY,
Acting Solicitor of Labor
DONALD S. SHIRE,
Associate Solicitor
PATRICIA M. NECE, Counsel
for Appellate Litigation
U.S. Department of Labor
Office of the Solicitor
Suite N-2117
Frances Perkins Building
200 Constitution Avenue, N.W.
Washington, D.C. 20210

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Attorneys for Party-in-Interest/
Respondent Director, Office of
Workers’ Compensation Programs
(United States Department of Labor)
OPINION OF THE COURT
SCHWARZER, Senior District Judge:
Evelyn Balsavage petitions for review of a final order of
the Benefits Review Board, United States Department of
Labor, affirming a final decision of the Administrative Law
Judge ("ALJ") denying survivor’s benefits to appellant,
pursuant to 33 U.S.C. S 921(b)(3), as incorporated into the
Black Lung Benefits Act, 30 U.S.C. SS 901-945. Mrs.
Balsavage is the widow of Anthony Balsavage ("the Miner"),
who died at the age of 73 on November 10, 1998. We must
decide whether the ALJ’s decision is supported by
substantial evidence. We have jurisdiction under 33 U.S.C.
2
S 921(c), as incorporated by 30 U.S.C. S 932(a), and grant
the petition.
FACTUAL AND PROCEDURAL BACKGROUND
In 1991, Dr. Edward W. Cubler diagnosed the Miner with
pneumoconiosis1 Category II, severe obstructive lung
disease, moderately severe emphysema, low blood oxygen
levels at rest, and severe wheezes and rales over all lung
fields. The Miner could "walk about 50 yards before
[getting] winded" and could "not make a flight of stairs
because of his shortness of breath." Dr. Cubler concluded
that the Miner had a "severe impairment . . . preventing
him from performing his last coal mine job," and certified
him totally disabled. Later that year, Dr. Richard F.
Feudale, who treated the Miner from 1963 to 1991,
examined him and diagnosed pneumoconiosis, severe
obstructive lung disease, bilateral pulmonary emphysema,
and other respiratory symptoms. Neither physician noted
any cardiac dysfunction.
Seven years later, on September 24, 1998, the Miner was
admitted to Ashland Regional Medical Center, suffering
from "shortness of breath and syncope" and other cardiac
and respiratory symptoms. The principal diagnosis, by
attending physician Dr. Houssam Abdul-Al, was "acute
congestive heart failure"; other diagnoses were"new onset
atrial fibrillation; chronic obstructive pulmonary disease;
coronary artery disease; emphysema; pleural effusion; [and]
mitral insufficiency." Chest x-rays showed "moderate left
_________________________________________________________________
1. Pneumoconiosis, also known as black lung disease or anthracosis, is
a chronic dust disease of the lung and its sequelae, including respiratory
and pulmonary impairments, arising out of coal mine employment.
"Pneumoconiosis" includes both clinical and legal pneumoconiosis,

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which include, but are not limited to "anthracosilicosis, anthracosis,
anthrosilicosis . . ., [and] any chronic restrictive or obstructive
pulmonary disease arising out of coal mine employment." 20 C.F.R.
S 718.201(a)(1)-(2); see also The Merck Manual 622 (17th ed. 1999)
(defining the disease as a nodular deposition of dust in the lungs as a
result of long-term exposure to bituminous or anthracitic coal dust in
coal mining).
The Director does not contest the existence of pneumoconiosis.
3
ventricular enlargement increased from previous study with
recent changes indicating mild congestive heart failure
superimposed on chronic obstructive pulmonary disease."
EKGs revealed "atrial fibrillation with rapid ventricular
response, left axis deviation, [and] left bundle branch
block." He was discharged in stable condition on September
28.
On November 10, 1998, the Miner suffered a "cardio-
pulmonary arrest" after "coughing and gagging prior to
arrest," according to the emergency care registration form.
He died within minutes of admission to the hospital. 2
Three physicians made written submissions in support of
Mrs. Balsavage’s claim, two of them treating physicians,
and one also testified on deposition. All concluded that
pneumoconiosis hastened or contributed to the Miner’s
death.
Dr. Raymond J. Kraynak served as the Miner’s treating
physician for roughly sixteen months, seeing him every one
to two months until about six weeks before his death.3 On
January 11, 1999, Dr. Kraynak wrote a one-page letter to
the Department of Labor stating, "I do not have any records
concerning the circumstances of his death and [am] unable
to give you an updated report." Six months later, on July
27, 1999, Dr. Kraynak wrote to Mrs. Balsavage’s attorney
stating, "[i]t is clear from my taking care of Mr. Balsavage
and from his complaints for some time, that coal workers’
pneumoconiosis was a substantial and causative factor in
[his] death." In deposition testimony on October 8, 1999,
Dr. Kraynak testified that, after having reviewed the Miner’s
medical records, in his opinion the Miner’s death was "due
_________________________________________________________________
2. The death certificate listed as immediate causes acute respiratory
arrest, chronic obstructive pulmonary disease, and anthrasilicosis. It
was signed by a registered nurse and deputy coroner, not a physician or
the person holding the office of coroner. There was no autopsy, x-ray,
biopsy evidence, or other contemporaneous medical examination. Under
these circumstances, the death certificate has no probative value. See
Lango v. Director, OWCP, 104 F.3d 573, 578 (3d Cir. 1997); cf. Mancia v.
Director, OWCP, 130 F.3d 579, 587 (3d Cir. 1997).
3. Dr. Kraynak had replaced Dr. Feudale, who had treated the Miner for
the preceding twenty-eight years.

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4
to acute respiratory arrest as well as anthracosilicosis
which caused the arrest." He added that the Miner"had
some cardiac difficulties due to his anthracosilicosis." On
cross-examination, during which he was asked whether
pneumoconiosis could have caused the Miner’s coronary
artery disease or atrial fibrillation, he explained that it
could be indirectly responsible by requiring "the heart . . .
to pump blood through a diseased lung," lowering blood
oxygen and "aggravat[ing] the conductive mechanism of the
heart." Two weeks later, on October 15, 1999, Dr. Kraynak
wrote to Mrs. Balsavage’s attorney in response to the
opinion letter Dr. Samuel V. Spagnolo gave the Director,
stating:
From my review of all the records, my personal care of
Mr. Balsavage during his lifetime, as well as
interviewing the widow in this matter, it is still my
opinion that Mr. Balsavage’s death was due to coal
workers’ pneumoconiosis, contracted during his
employment in the anthracite coal industry. . . . He
definitely would have survived longer if he did not have
coal workers pneumonoconiosis.
On August 18, 1999, Dr. Abdul-Al, who had treated the
Miner from September 24 until his death seven weeks later,
reported that he "saw [the Miner] at the hospital . . . when
he had cardiopulmonary arrest and had unsuccessful
resuscitation [i.e. death]." He concluded that he had
"diffuse fibrotic pulmonary disease due to anthrasilicosis
and pneumoconiosis and because of his condition his heart
was getting progressively worse. . . . I do believe that the
number one cause of his death is the anthrasilicosis which
was the reason he developed cardiac disease."
On September 29, 1999, Dr. John P. Simelaro, after
reviewing twenty documents from the Miner’s medical
records,4 opined that the Miner’s"anthracosilicosis" caused
_________________________________________________________________
4. These documents included (a) Dr. Cubler’s report of February 11,
1991; (b) the accompanying pulmonary function study; (c) the
accompanying blood gas study; (d) the accompanying chest x-ray
readings; (e) the July 23, 1991, pulmonary function study; (f) Dr.
Feudale’s August 27, 1991, report; (g) the Ashland Regional Medical
Center records; (h) the death certificate; (i) Dr. Kraynak’s January 11,
1999, report; (j) Dr. Kraynak’s July 27, 1999, report; (k) Dr. Abdul-Al’s
medical records; (l) Dr. Abdul-Al’s August 18, 1999, report; and several
administrative filings and documents.
5
fibrosis in his lungs, interfering with oxygen uptake to the
myocardium, which led to "cardiac dysfunction[as
evidenced by his] dysrhythmia [and] atrial fibrillation." This,
in turn, caused "a 20% reduction in cardiac output." He
concluded there was diffuse airway destruction from the

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anthracosilicosis, increasing "overall cardiopulmonary
compromise," "leading to cardiac failure and eventually
death . . . in this case."
In opposition to Mrs. Balsavage’s case, the Director
offered the medical report of Dr. Spagnolo, dated September
25, 1999, which was based on a review of documents from
the Miner’s medical records.5 Dr. Spagnolo’s letter states
that
[his] chronic left heart disease had worsened just prior
to his cardiac arrest and evidence of left heart failure
was present. He [sic] heart disease was unrelated to
his pneumoconiosis and emphysema. Increasing
respiratory symptoms prior to his death were the result
of left heart failure. His terminal event was cardiac
arrest caused by his acute and chronic coronary artery
disease. . . . [T]he medical records do not provide
objective, reliable or reproducible evidence that
pneumoconiosis contributed in any way to [the Miner’s]
death. He would have died at the same time even if he
had no other underlying medical conditions including
pneumoconiosis.
The ALJ rejected the Miner’s three physicians’ proffered
evidence and instead accepted Dr. Spagnolo’s opinion that
the Miner’s death was precipitated by left heart disease and
not hastened by pneumoconiosis. He found that the three
physicians’ testimony did not persuasively establish that
the Miner’s pneumoconiosis even hastened the Miner’s
death.
_________________________________________________________________
5. These eleven documents included items (a)-(i), listed in the preceding
footnote, but excluded items (j), (k), and (l) as well as Dr. Simelaro’s
report.
6
SCOPE OF REVIEW
We review the Board’s decision to determine whether the
Board adhered to its statutory scope of review. Kertesz v.
Crescent Hills Coal Co., 788 F.2d 158, 162 (3d Cir. 1986).
The Board was required to accept the ALJ’s findings of fact
if supported by substantial evidence. 33 U.S.C.S 921(b)(3),
as incorporated by 30 U.S.C. S 932(a). Thus, we must
" ‘independently review the record and decide whether the
ALJ’s findings are supported by substantial evidence.’ "
Lango v. Director, OWCP, 104 F.3d 573, 576 (3d Cir. 1997)
(quoting Kowalchick v. Director, OWCP, 893 F.2d 615, 619
(3d Cir. 1990)). Substantial evidence is "more than a mere
scintilla. It means such relevant evidence as a reasonable
mind might accept as adequate to support a conclusion."
Richardson v. Perales, 402 U.S. 389, 401 (1971) (quoting
Consol. Edison Co. v. NLRB, 305 U.S. 197, 229 (1938)). If
substantial evidence exists, we must affirm the ALJ’s
interpretation of the evidence even if we "might have
interpreted the evidence differently in the first instance."

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Old Ben Coal Co. v. Battram, 7 F.3d 1273, 1278 (7th Cir.
1993).
DISCUSSION
To be entitled to benefits, Mrs. Balsavage must prove that
"[t]he miner’s death was due to pneumoconiosis." 20 C.F.R.
S 718.205(a)(3). "[D]eath will be considered to be due to
pneumoconiosis . . . [w]here pneumoconiosis was a
substantially contributing cause or factor leading to the
miner’s death or where the death was caused
by complications of pneumoconiosis." 20 C.F.R.
S 718.205(c)(2). Pneumoconiosis is a "substantially
contributing cause of a miner’s death "if it hastens the
miner’s death." 20 C.F.R. S 718.205(c)(5)."Even if
pneumoconiosis hastened by only a few days a miner’s
death from other causes, there is a basis to award
benefits." Lango, 104 F.3d at 576.
The ALJ has broad discretion to determine the weight
accorded each doctor’s opinion. Director, OWCP v.
Mangifest, 826 F.2d 1318, 1326 (3d Cir. 1987)."ALJ is not
bound to accept the opinion or theory of any medical
7
expert, but may weigh the medical evidence and draw its
own inferences." Mancia, 130 F.3d at 588. However, as the
ALJ recognized, "the opinion of a miner’s treating physician
play[s] a major role in the determination of eligibility for
black lung benefits.’ " Id. at 590-91 (quoting Schaaf v.
Matthews, 574 F.2d 157, 160 (3d Cir. 1978)); but see
Lango, 104 F.3d at 577 (noting that there is some question
about the extent of reliance to be given a treating
physician’s opinion where there is conflicting evidence).
The Miner’s treating physicians’ testimony established
without qualification that in their opinion his
pneumoconiosis hastened or contributed to his death. The
ALJ rejected Dr. Kraynak’s entire opinion simply because of
his testimony on cross-examination that pneumoconiosis
"could" cause coronary artery disease and atrial fibrillation.6
The ALJ found this testimony "somewhat qualified,"
concluding, "[t]his is a factor which detracts from the
probative weight I will accord Dr. Kraynak’s conclusions."
But Dr. Kraynak’s statements must be viewed in context--
both as responses on cross-examination to general
questions and against the backdrop of his repeated
assertions that pneumoconiosis contributed to the Miner’s
death. They do not "qualify" his previously expressed and
his subsequently reiterated opinion. They are at most
peripheral, and it was error for the ALJ to reject that
opinion on that basis. Cf. Mancia, 130 F.3d at 589 (finding
error in ALJ’s rejection of a treating physician’s medical
opinion as merely an "assumption").
The ALJ also rejected Dr. Abdul-Al’s opinion because"it
is not clear that [he] examined the Miner on his last day
_________________________________________________________________

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6. Specifically, Dr. Kraynak was asked whether coronary artery disease
"would not be due to lowered blood oxygen from pneumoconiosis." He
implied that the question contained a sophistry, explaining, "It wouldn’t
be due to lowered oxygen. Coronary artery disease could be precipitated
by the heart having to pump blood through a diseased lung. It’s more
stressful on the heart." Similarly, when asked,"And that [atrial
fibrillation] would not be caused by pneumoconiosis, would it?" the
doctor replied, "No, not directly. Indirectly again the heart has to strain
itself to pump blood through a diseased lung and then we have lowered
blood oxygen. That could give rise and aggravate the conductive
mechanism of the heart giving rise to atrial fibrillation."
8
while [he was] alive." It is clear, however, from Dr. Abdul-
Al’s report that he saw the Miner in the hospital"when he
had cardiopulmonary arrest and had unsuccessful
resuscitation," at or about the time of his death. That he
may not have examined him on his last day does not
warrant rejection of his opinion as a treating physician
during the seven weeks of the Miner’s terminal illness.
Finally, the ALJ rejected the opinions of Dr. Simelaro, a
consulting physician, because they "do not persuasively
focus on the cardiac factors." The import of this statement
is obscure. As noted above, Dr. Simelaro’s report focuses
specifically on how anthracosilicosis caused fibrosis in the
Miner’s lungs leading to "cardiac dysfunction as is noted by
his dysrhythmia, atrial fibrillation." His report was based
on review of the Miner’s full medical file. He reiterated his
opinion that the Miner’s death was due to heart failure as
a result of lung failure due to pneumoconiosis after
reviewing Dr. Spagnolo’s opinion.
Physicians’ reasoning, consideration of records, and
credentials are relevant to an ALJ’s determination. Sterling
Smokeless Coal Co. v. Akers, 131 F.3d 438, 441 (4th Cir.
1997). "The ALJ may disregard a medical opinion that does
not adequately explain the basis for its conclusion." Lango,
104 F.3d at 578 (internal quotations and citations omitted).
In addition, he "should reject as insufficiently reasoned any
medical opinion that reaches a conclusion contrary to
objective clinical evidence without explanation." Kertesz,
788 F.2d at 163; cf. Mancia, 130 F.3d at 589 (ALJ could not
reject a reasoned assessment as an assumption).
Here, the ALJ did not reject these physicians’ opinions as
inadequately explained, insufficiently reasoned, or contrary
to clinical evidence. Rather, he simply failed to address
them. His rejection of this evidence was based on
peripheral quibbles at best and is not supported by
substantial evidence. See Mancia, 130 F.3d at 593 ("The
ALJ was not free to selectively credit testimony merely
because it supports a particular conclusion while ignoring
all evidence contrary to that conclusion.").
The ALJ instead deferred to Dr. Spagnolo’s conclusions
partly on the basis of his strong credentials. That Dr.

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9
Spagnolo’s credentials may be more distinguished than
those of Mrs. Balsavage’s physicians, however, does little to
resolve the question whether substantial evidence supports
the ALJ’s conclusion.
The ALJ stated that he was "more persuaded . . . by Dr.
Spagnolo’s analysis . . . to explain that the miner’s death
was caused . . . by cardiac arrest caused by his acute and
chronic coronary artery disease . . . . [His] report appears
more comprehensively to address the cardiac factors" that
led to the Miner’s death. The issue in this case, however, is
not whether the coronary heart disease from which the
Miner suffered caused his death but, rather, whether his
pneumoconiosis (which is not disputed) contributed to or
hastened his death, if "by only a few days." Lango, 104 F.3d
at 576. Dr. Spagnolo states that "[t]hese medical records do
not provide objective, reliable or reproducible evidence that
pneumoconiosis contributed in any way to Mr. Balsavage’s
death." But in reaching that conclusion, Dr. Spagnolo did
not consider the reports of the three physicians who opined
that pneumoconiosis was a contributing cause of death,
and he did not address the reasoning on which those
opinions were based. Nor did the ALJ in reaching his
conclusion discuss the evidence on this central issue. Thus,
the ALJ’s decision rejecting Mrs. Balsavage’s claim is not
supported by substantial evidence.
CONCLUSION
Because the ALJ’s decision failed to consider and address
Mrs. Balsavage’s evidence on the central issue whether
pneumoconiosis contributed to or hastened the Miner’s
death, it is not supported by substantial evidence. We
therefore GRANT the petition and REVERSE the Board’s
order. But because we cannot say that the record cannot
support conflicting inferences and supports only one
conclusion, we REMAND for the ALJ to make findings of
fact. See Kowalchick v. Director, OWCP, 893 F.2d 615, 624
(3rd Cir. 1990).
10
ROTH, Circuit Judge, dissenting:
I respectfully dissent. The ALJ, when confronted with
conflicting medical opinions, chose to follow that of Dr.
Samuel V. Spagnolo, the physician who, the ALJ found,
gave the more thorough and well documented analysis and
who had the superior credentials. Dr. Spagnolo determined
that the Miner’s heart disease was unrelated to his
pneumoconiosis and that pneumoconiosis did not
contribute in any way to the Miner’s death. When there is
a conflict in medical opinions, it is entirely appropriate for
the ALJ to choose to follow the opinion of the physician
with the more thorough analysis and the superior

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credentials. See, e.g., Sterling Smokeless Coal Co. v. Akers,
131 F.3d 438, 441 (4th Cir. 1997); Peabody Coal Co. v.
Helms, 901 F.2d 571, 573 (7th Cir. 1990).
The majority faults Dr. Spagnolo for not considering the
reports of the three other physicians who opined that
pneumoconiosis did contribute to the Miner’s death.
Medical diagnosis and opinions as to medical causation
are, however, based on the objective facts, observations,
and test results entered in the medical records. A physician
is well justified in basing a medical opinion on the objective
facts of the medical records and not on an explanation of
the deficiencies of the opinions of other, less qualified
physicians. Dr. Spagnolo thoroughly reviewed all the
pertinent medical records. For that reason, I find no
weakness in Dr. Spagnolo’s opinion based on the fact that
he does not attempt to explain away the opinions of his less
qualified colleagues.
A True Copy:
Teste:
Clerk of the United States Court of Appeals
for the Third Circuit
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