BD04-D4B

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PART IV

ADMINISTRATIVE PROCESSING OF CLAIMS,

POWERS AND DUTIES OF THE ADMINISTRATIVE LAW JUDGE

D. EVALUATION AND WEIGHING OF EVIDENCE

4. MEDICAL REPORTS

b. Reasoned Opinion

A reasoned opinion is one in which the administrative law judge finds the underlying documentation adequate to support the physician's conclusions. Fields v. Island Creek Coal Co., 10 BLR 1-19 (1987); Fuller v. Gibraltar Coal Corp., 6 BLR 1-1291 (1984). Whether a medical report is sufficiently documented and reasoned is for the administrative law judge as the fact-finder to decide. See Clark v. Karst-Robbins Coal Co., 12 BLR 1-149 (1989)(en banc); Lucostic v. United States Steel Corp., 8 BLR 1-46 (1985); Peskie v. United States Steel Corp., 8 BLR 1-126 (1985). The mere fact that an opinion is asserted to be based upon medical studies cannot, by itself, establish that it is documented and reasoned. To make that determination, the administrative law judge must examine the validity of the reasoning of a medical opinion in light of the studies conducted and the objective indications upon which the medical opinion or conclusion is based. An administrative law judge, however, may not assert expertise over that of the doctor in evaluating the medical report. See Fuller, supra; see also Part IV. D.2.a. of the Desk Book.

CASE LISTINGS

[adjudicator erred in finding adequately documented medical opinion unreasoned where physician had treated miner for respiratory problem for 20 years] Estep v. Director, OWCP, 6 BLR 1-84 (1983).

[Fourth Circuit found medical report not addressing qualifying blood gas study neither documented nor reasoned] Beavan v. Bethlehem Mines Corp., 741 F.2d 689, 6 BLR 2-101 (4th Cir. 1984).

[fact-finder may reject as unreasoned and undocumented report that does not indicate what factors were relied on by physician, extent of disability and what ventilatory studies were performed, if any] Parsons v. Director, OWCP, 6 BLR 1-272, 1-276 (1983).

[adjudicator's finding that report diagnosing total disability not reasoned because x-ray reread as negative, ventilatory study non-qualifying and physical examination noted lungs "clear" affirmed] White v. Director, OWCP, 6 BLR 1-368 (1983).

[adjudicator reasonably rejected medical opinion as unreasoned for lack of adequate documentation] Minton v. Director, OWCP, 6 BLR 1-670 (1983).

[fact-finder's rejection of medical report as unreasoned affirmed where physician did not discuss physical condition on examination and did not explain how documentation supported diagnosis of disability] Duke v. Director, OWCP, 6 BLR 1-673 (1983).

[fact-finder's rejection of "yes" check mark to causation question on DOL form as unreasoned affirmed as physician failed to explain diagnosis and was also unaware of claimant's employment history] Crosson v. Director, OWCP, 6 BLR 1-809 (1984).

[adjudicator improperly discredited medical report as unreasoned as diagnosed no respiratory disability was inconsistent with objective data] Bogan v. Consolidation Coal Co., 6 BLR 1-1000 (1984).

[adjudicator may find medical report diagnosing totally disabling respiratory impairment unreasoned where physician's findings were the same as those made by other physicians who did not diagnose a disabling impairment, and where the diagnosis depended solely on a positive x-ray] Newsome v. Director, OWCP, 6 BLR 1-1104 (1984).

[unsupported medical conclusion is not a reasoned diagnosis] Fuller v. Gibraltar Corp., 6 BLR 1-1291 (1984).

[adjudicator properly discredited medical opinions as unreasoned because doctor failed to explain change in his conclusions and also did not explain how documentation supported diagnosis] Hopton v. United States Steel Corp., 7 BLR 1-12 (1984).

[fact-finder who rejected medical report because doctor failed to explain how he could distinguish between disability caused by coal mining and smoking, effectively found that medical opinion was not reasoned] Gilliam v. G & O Coal Co., 7 BLR 1-59 (1984).

[if medical report found unreasoned under Part 410, Subpart D, it cannot be found reasoned under Part 727] Luther v. Director, OWCP, 7 BLR 1-117 (1984).

[adjudicator must consider entire report and may not independently evaluate objective data as to whether it supports physician's conclusions in determining whether report is reasoned] Hess v. Clinchfield Coal Co., 7 BLR 1-295 (1984).

[adjudicator not required to reject medical report as unreasoned because later positive x-ray evidence not available when he wrote his reports] York v. Director, OWCP, 7 BLR 1-641 (1985).

[judicial deference to qualified medical professional does not abrogate fact-finder's duty to determine credibility of physician's opinion to determine whether the medical opinion is documented and reasoned] Sykes v. Itmann Coal Co., 7 BLR 1-820 (1985).

[if adjudicator finds medical report sufficient to invoke interim presumption, s/he also finds it reasoned by inference] Pulliam v. Drummond Coal Co., 7 BLR 1-846, 1-851 (1985); Adamson v. Director, OWCP, 7 BLR 1-229 (1984); Laird v. Alabama By-Products Corp., 6 BLR 1-1146 (1984)(Smith, J., dissenting on other grounds).

[fact that doctor examined miner only once does not per se render the report unreasoned or undocumented] Pulliam v. Drummond Coal Co., 7 BLR 1-846, 1-850 (1985).

[adjudicator properly rejected medical report as unreasoned where physician failed to explain how findings supported diagnosis, even though DOL form did not require rationale] Oggero v. Director, OWCP, 7 BLR 1-860 (1985).

[Eighth Circuit held that medical report that fails to explain conclusion reached, especially with contrary clinical evidence, not based on reasoned medical judgment] Phillips v. Director, OWCP, 768 F.2d 982, 8 BLR 2-16 (8th Cir. 1985).

[physician can properly determine that claimant has no respiratory impairment or is not totally disabled even though clinical studies have qualifying results] Hoffman v. B & G Construction Co., 8 BLR 1-65 (1985); Bogan v. Consolidation Coal Co., 6 BLR 1-1000 (1984).

[adjudicator properly rejected medical report as inadequately reasoned where unclear whether documentation supported pre-printed conclusions] Hall v. Director, OWCP, 8 BLR 1-193 (1985).

[letter supplementing documented medical opinion may be read together with it and the whole credited as reasoned] Hunley v. Director, OWCP, 8 BLR 1-323 (1985).

DIGESTS

A finding that a medical report is not reasoned or documented for purposes of invocation does not necessarily indicate that the report cannot support the establishment of rebuttal under one of the appropriate subsections. Luketich v. Director, OWCP, 8 BLR 1-477, 1-480 n.3 (1986).

Where a non-examining physician clearly outlines the findings in an examining physician's report which support the non-examining physician's opinion, it is irrational to find that opinion is unreasoned. Lattimer v. Peabody Coal Co., 8 BLR 1-509 (1986).

A physician's opinion on etiology which consists of responding "no" to questions set forth on a standardized medical report form is sufficiently reasoned under Section 718.202(a)(4). Perry v. Director, OWCP, 9 BLR 1-1 (1986).

Physician's conclusion that claimant's disability is unrelated to coal mine employment is adequately supported by symptoms, physical exam, and work and smoking histories and is therefore a reasoned and documented opinion on which the administrative law judge could properly rely. Gee v. W. G. Moore and Sons, 9 BLR 1-4 (1986).

Physician's report may not be discredited as undocumented and unreasoned simply because it is based on an x-ray interpretation which is outweighed by the other x-ray interpretations of record. Fitch v. Director, OWCP, 9 BLR 1-45, 1-47 n.2 (1986).

The administrative law judge erred by crediting a medical opinion that failed to properly explain "why decedent miner was more likely disabled due to pneumoconiosis versus another disease." Brazzalle v. Director, OWCP, 803 F.2d 934, 9 BLR 2-133 (8th Cir. 1986).

The administrative law judge could rationally find physician's opinion unreasoned given: (1) inconsistencies in physician's testimony; and (2) another physician's evaluation of the miner's condition. Brazzalle v. Director, OWCP, 803 F.2d 934, 9 BLR 2-133 (8th Cir. 1986).

Administrative law judge could properly discredit physician's opinion regarding causation, due to its equivocal nature. Justice v. Island Creek Coal Co., 11 BLR 1-91 (1988).

Administrative law judge properly discredited doctor's report as unreasoned, since doctor failed to explain how his findings support his diagnosis. Tackett v. Cargo Mining Co., 12 BLR 1-11 (1988)(en banc), aff'd sub nom. Director, OWCP v. Cargo Mining Co., Nos.88-3531, 88-3578 (6th Cir. May 11, 1989)(unpub.).

An administrative law judge may reject an opinion where he finds that the doctor failed to adequately explain his diagnosis. Clark v. Karst-Robbins Coal Co., 12 BLR 1-149 (1989)(en banc).

Administrative law judge reasonably discredited a medical report after concluding that an underlying premise upon which the physician relied, i.e., that claimant had childhood pneumonia, was incorrect. Clark v. Karst-Robbins Coal Co., 12 BLR 1-149 (1989)(en banc).

Administrative law judge reasonably accorded diminished weight to medical opinions after noting that these non-examining physicians were not fully apprised of the qualifying blood gas studies. Clark v. Karst-Robbins Coal Co., 12 BLR 1-149 (1989) (en banc).

Death certificate is unreliable where there is nothing in the record indicating that person signing the death certificate (the coroner) possessed any relevant qualification or personal knowledge from which to assess the cause of death. Administrative law judge erred in accepting the death certificate at face value without considering the underlying basis for coroner's conclusions as to cause of death. Addison v. Director, OWCP, 11 BLR 1-68 (1988); cf. Smith v. Camco Mining, Inc., 13 BLR 1-17 (1989).

The Board rejected claimant's contention that the physician's checking of the "no" box on the Department of Labor physical examination Form 988 cannot support Section 727.203(b)(3) rebuttal under Warman v. Pittsburg and Midway Mining Coal Co., 829 F.2d 257, 11 BLR 2-62 (6th Cir. 1988). Hall v. Director, OWCP, 12 BLR 1-133 (1989), modified on recon., 14 BLR 1-1 (1989).

An x-ray report in and of itself does not qualify as a medical report under Section 718.202(a)(4) and cannot be considered a reasoned medical opinion. Pettry v. Director, OWCP, 14 BLR 1-98 (1990)(en banc); Anderson v. Valley Camp of Utah, Inc., 12 BLR 1-111 (1989).

To comply with the quality standards contained in 20 C.F.R. §718.104, a medical report does not have to be in writing, but rather, it is sufficient if the opinion is well-reasoned and well-documented. Gorzalka v. Big Horn Coal Co., 16 BLR 1-48 (1990).

Before finding the medical reports of record sufficient to establish the existence of pneumoconiosis at Section 718.202(a)(4), the administrative law judge must determine if the reports are reasoned and documented. Trumbo v. Reading Anthracite Co., 17 BLR 1-85 (1993).

Where a physician explained that both pneumoconiosis and cigarette smoke are known to cause the type of airflow limitation detected in the miner’s lungs, and stated that the miner’s totally disabling respiratory impairment was due to both twenty-five years of coal dust exposure and twenty-nine years of smoking, substantial evidence supported the administrative law judge’s finding that the physician gave a well-reasoned opinion that the miner was totally disabled due to pneumoconiosis pursuant to revised 20 C.F.R. §718.204(c). Gross v. Dominion Coal Corp., 23 BLR 1-8 (2003).

The administrative law judge permissibly accorded less weight to a physician’s opinion that the miner’s disability was due solely to smoking where the administrative law judge found that the physician either overlooked or downplayed medical data that was inconsistent with the physician’s conclusions, and did not persuasively explain his opinion. Gross v. Dominion Coal Corp., 23 BLR 1-8 (2003).

It is within an administrative law judge’s discretion to accord little weight to a physician’s opinion as unreasoned because the physician’s credentials are not in the record, he did not provide any rationale for his diagnosis of pneumoconiosis, and the pulmonary function study he relied on was invalidated by two specialists. Webber v. Peabody Coal Co., 23 BLR 1-123 (2006) (en banc) (Boggs, J., concurring), aff’d on recon., BLR (2007)(en banc).

Applying Greene v. King James Coal Mining, Inc., 575 F.3d 628, BLR (6th Cir. 2009), the Board held that the administrative law judge erred in concluding that the claimants had not received complete pulmonary evaluations because the physicians’ reports did not provide a detailed explanation for their findings. Because the physicians had performed all of the necessary tests and their reports addressed the requisite elements of entitlement, the Board agreed with the Director that, pursuant to Greene, the Director had satisfied his obligation to provide a complete pulmonary evaluation under the Act and therefore, vacated the administrative law judge’s Orders of Remand issued pursuant to 20 C.F.R. §725.456(e). R.G.B., et. al. v. Southern Ohio Coal Co., et. al., BLR , BRB Nos. 08-0491 BLA, 08-0521 BLA, 08-0463 BLA, 08-0464 BLA, 08-0465 BLA (Aug. 28, 2009) (en banc).

11/09


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