PER CURIAM. Richard Crum is a former coal miner who suffers from a respiratory malady that completely disables him. He contends that he developed it from working in coal mines. His former employer, Robert Coal Company (or, the Company), agrees that he has a totally disabling lung condition—but it disagrees on the cause. The Company believes Crum’s

longstanding smoking habit caused his affliction. This case arose because Crum sought and received benefits under a federal program for miners who develop black lung disease as a consequence of their occupation. The Company challenged Crum’s benefits, but Crum prevailed

at the agency level. The Company appeals the final decision of the agency. For the reasons below, we AFFIRM the Board’s decision.

Case No. 17-3947, Robert Coal Co. v. Dir., OWCP

I.

Congress passed the Black Lung Benefits Act (the Act) to provide benefits to coal miners

who, through their trade, become totally disabled due to pneumoconiosis—the technical term for black lung disease. 30 U.S.C. § 901(a) (2012); Brandywine Explosives & Supply v. Dir., OWCP, 790 F.3d 657, 661 (6th Cir. 2015). The Act empowers the Secretary of Labor to issue regulations to effectuate its provisions. 30 U.S.C. § 936(a). The regulations provide detailed requirements that a miner must satisfy to be eligible for benefits. Under the regulations, a miner must prove four things by a preponderance of the evidence: “(1) he has pneumoconiosis; (2) his pneumoconiosis arose at least in part out of his coal mine employment; (3) he is totally disabled;

and (4) the total disability is due to pneumoconiosis[.]” Greene v. King James Coal Mining, Inc., 575 F.3d 628, 634 (6th Cir. 2009) (citing 20 C.F.R. §§ 718.202–204 (2000) and Adams v. Dir., OWCP, 886 F.2d 818, 820 (6th Cir. 1989)).

Although the Act itself simply refers to “pneumoconiosis,” the regulations provide two different definitions for the term: one “clinical,” the other “legal.” As we have explained:

“Clinical pneumoconiosis” refers to certain lung diseases that the medical community recognizes to be caused by exposure to coal dust—in the words of the applicable regulation, diseases “characterized by permanent deposition of substantial amounts of particulate matter in the lungs and the fibrotic reaction of the lung tissue to that deposition caused by dust exposure in coal mine employment.” 20 C.F.R. § 718.201(a)(1). “Legal pneumoconiosis” is a broader and less definite term that refers to any chronic lung disease that was caused in this instance by exposure to coal dust. 20 C.F.R. § 718.201(a)(2).

Cent. Ohio Coal Co. v. Dir., OWCP, 762 F.3d 483, 486 (6th Cir. 2014). As its name suggests, “legal pneumoconiosis” is not a medical term, but a legal fiction “designed to facilitate the remedial purposes of the Black Lung Benefits Act.” Sunny Ridge Mining Co. v. Keathley, 773 F.3d

734, 738 (6th Cir. 2014). A chronic lung disease constitutes legal pneumoconiosis only if it is

“significantly related to, or substantially aggravated by, dust exposure in coal mine employment.”

Case No. 17-3947, Robert Coal Co. v. Dir., OWCP

20 C.F.R. § 718.201(b) (2018). A miner may receive benefits if he suffers from either clinical or legal pneumoconiosis. Id. § 718.201(a).

II.

Around 1973, at about age 19, Crum became both a cigarette smoker and a coal miner. His coal-mine employment was sporadic and he worked for various companies including Robert Coal.

All told, he spent 8.62 years working in coal mines, eventually putting in his last day in 1983. His smoking habit lasted much longer. Although the evidence of Crum’s smoking history varies widely, Crum seems to have smoked around half of a pack each day until the year 2000, at which point he cut back a bit. Ultimately, the ALJ found that by 2015, Crum had accumulated “at least

10 pack-years1 of smoking and continue[d] to smoke several cigarettes per day.”

Crum filed for benefits in September 2010—27 years after his last stint in the mines. The District Director issued a proposed decision and award of benefits to Crum, which led the Company to request a hearing before an ALJ. The ALJ held a hearing in November 2014, and in June 2015 he issued a decision granting Crum benefits. The Company appealed, but a panel of the Benefits Review Board affirmed the ALJ’s decision the following May. When the Review

Board subsequently denied the Company’s motion for reconsideration on July 12, 2017, the decision became final and the Company filed the instant appeal.

III.

We review the Benefits Review Board’s legal conclusions de novo and we must affirm its decision “if the Board has not committed any legal error or exceeded its statutory scope of review of the ALJ’s factual determinations[.]” Morrison v. Tenn. Consol. Coal Co., 644 F.3d 473, 477–

78 (6th Cir. 2011) (quoting Jonida Trucking, Inc. v. Hunt, 124 F.3d 739, 742 (6th Cir. 1997)). Our Case No. 17-3947, Robert Coal Co. v. Dir., OWCP review therefore focuses on “whether the ALJ—not the Board—had substantial evidence upon which to base his . . . decision.” Id. (quoting Jonida Trucking, 124 F.3d at 742). Evidence is substantial if “a reasonable mind might accept [it] as adequate to support a conclusion.” Big

Branch Res., Inc. v. Ogle, 737 F.3d 1063, 1068–69 (6th Cir. 2013) (quoting Kolesar v. Youghiogheny & Ohio Coal Co., 760 F.2d 728, 729 (6th Cir. 1985)).

IV. Over the course of Crum’s pursuit of benefits, he routinely underwent three procedures

often used by doctors to diagnose respiratory problems: x-rays, pulmonary function tests (PFTs), and arterial blood gas studies (ABGs). All three of the procedures are permissible forms of objective medical evidence under the regulations, but they measure different things. See 20 C.F.R.

§ 718.202(a)(1), (4). X-rays are used to identify specific obstructions in the lungs, while PFTs and ABGs measure lungs’ performance. The Merck Manual of Diagnosis and Therapy 521–25, 528, 532–33 (Mark H. Beers, M.D., et al. eds., 17th ed. 1999). Specifically, a PFT measures how well a person can exhale—thereby revealing the severity of airway obstruction—while an ABG measures how well gases are being exchanged between the lungs and blood. Id. at 522–23, 528.

PFTs and ABGs produce numeric values (e.g., an FEV1/FVC ratio of 55), and by comparing those numbers to tables promulgated by the Department of Labor, one can determine whether a person is “totally disabled.” 20 C.F.R. § 718.204(b)(2). When a PFT or ABG suggests a person is totally

disabled, the test is said to be “qualifying.” See Crockett Colleries, Inc. v. Barrett, 478 F.3d 350, 356–57 (6th Cir. 2007). In contrast, x-rays are pictorial and must therefore be interpreted by experts, called “B-readers.” See 20 C.F.R. § 718.102(e). A B-reader can study an x-ray, determine the types of obstructions and then, with varying confidence, conclude whether a person has clinical pneumoconiosis. Id. § 718.102(e)(2)(iii).

Case No. 17-3947, Robert Coal Co. v. Dir., OWCP

All told, Crum underwent five x-rays, four PFTs, and four ABGs. Every PFT Crum

underwent was qualifying, but only half of the ABGs were. Even so, all the doctors—and consequently the ALJ—concluded that Crum’s respiratory condition is totally disabling and no one disputes this on appeal. The x-ray results were also mixed. Every B-reader who looked at

Crum’s first three x-rays read them as negative for clinical pneumoconiosis. Dr. Alexander was the first B-reader to read Crum’s final two x-rays (both taken in 2012) and he read them as positive for clinical pneumoconiosis. But when another B-reader, Dr. Tarver, reviewed them, he read them as negative for clinical pneumoconiosis.

Section 718.202 allows an ALJ to find the existence of pneumoconiosis by relying on x- rays, biopsies or autopsies, a presumption, or a determination made by a physician. 20 C.F.R.

§ 718.202. The ALJ in this case relied on the fourth option: physicians’ reports. There are

requirements for these types of physicians’ findings. The physician must have reached the determination by “exercising sound medical judgment,” and any finding of pneumoconiosis “must be based on objective medical evidence such as blood-gas studies, electrocardiograms, pulmonary function studies, physical performance tests, physical examination, and medical and work histories. Such a finding must be supported by a reasoned medical opinion.” Id. § 718.202(a)(4).

The ALJ first considered whether Crum has clinical pneumoconiosis by reviewing the reports of the five doctors who saw him. Dr. Ammisetty made no findings about clinical pneumoconiosis so the ALJ gave little weight to his opinion on the issue. Drs. Gallai and Klayton diagnosed Crum with clinical pneumoconiosis, but the ALJ pointed out that both of them simply

relied on positive x-ray readings made by others, so they were entitled to little weight. In contrast, the other two doctors—Rosenberg and Jarboe—went beyond the x-rays in reaching their conclusions that Crum does not have clinical pneumoconiosis. The ALJ therefore gave Dr.

Case No. 17-3947, Robert Coal Co. v. Dir., OWCP

Rosenberg’s and Dr. Jarboe’s opinions full probative weight and found that Crum does not have clinical pneumoconiosis. No one challenges this finding on appeal.

The ALJ next turned to legal pneumoconiosis. Here, he reached the opposite conclusion.

After reviewing all the doctors’ reports and depositions, the ALJ assigned full probative weight to portions of the reports of Drs. Ammisetty, Gallai, and Klayton, while giving little weight to Dr.

Rosenberg’s and Dr. Jarboe’s opinions. Consequently, the ALJ found that Crum has legal pneumoconiosis.

V. The Company argues that the ALJ erred in finding Crum had legal pneumoconiosis because the conclusions of Drs. Ammisetty, Klayton, and Gallai were not based on any scientifically reliable methodology. According to the Company, none of the doctors’ opinions used objective medical evidence to connect Crum’s coal exposure as a cause of his condition and are thus not

“competent evidence” under 20 C.F.R. § 718.203(c).

The Director2 does not precisely disagree. At the outset of her response brief, the Director confined her argument to two legal issues: (1) whether an ALJ may credit doctors’ opinions when they are unable to apportion causation between coal-mine work and smoking, and (2) whether an

ALJ may discredit doctors’ opinions because they are premised on beliefs contrary to the Act’s preamble. Neither issue, however, addresses the initial question: whether there was any evidence

that coal-mine work in any way caused Crum’s condition to begin with. Even so, the Director avers that while a medical opinion can be credited only if it is “reasoned and documented,” the decision to credit a medical opinion that lacks an articulate rationale is a credibility matter left to the ALJ’s discretion. In support of this proposition, the Director relies on two of our prior Case No. 17-3947, Robert Coal Co. v. Dir., OWCP decisions: Wolf Creek Collieries v. Director, OWCP, 298 F.3d 511 (6th Cir. 2002) and Peabody

Coal Co. v. Groves, 277 F.3d 829 (6th Cir. 2002). Some clarification of these and other precedents is in order.

Thirty-five years ago, we vacated a judgment of the Benefits Review Board and remanded the case to the Board for further proceedings after somewhat irregular agency proceedings. See

Dir., OWCP v. Rowe, 710 F.2d 251, 256 (6th Cir. 1983). The claimant miner was examined by two doctors. Both diagnosed him with pneumoconiosis, but only one concluded that he was totally disabled; the other doctor did not mention his level of disability one way or another. Id. at 253–

54. The ALJ found that the miner was totally disabled based solely on the doctor who did not

opine on the miner’s disability and failed to even mention the other doctor or his report. On appeal, the Board recognized that the ALJ’s opinion was insufficient, but instead of remanding the case, the Board affirmed the award of benefits because the unmentioned doctor’s report “was a documented and reasoned medical opinion” in satisfaction of the relevant regulation. Id. at 254.

We vacated the Board’s judgment because “the proper course for the Board [was] to remand the case to the ALJ[.]” Id. at 255. We explained that the “determination as to whether [the unmentioned doctor’s] report was sufficiently documented and reasoned is essentially a credibility matter. As such, it is for the factfinder to decide.” Id. We then went on:

[T]he mere fact that an opinion is asserted to be based upon medical studies cannot by itself establish as a matter of law that it is documented and reasoned. Rather, that determination requires the factfinder to 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. Of course, the factfinder should also consider any contrary test results or diagnosis in reaching a decision as to whether a statutory presumption applies and ultimately whether the claimant is totally disabled.

Id. at 255 (footnote omitted).

Case No. 17-3947, Robert Coal Co. v. Dir., OWCP

The portion of our holding in Rowe about credibility determinations has been regularly cited since then, whether directly or through a chain of reliant citations. See, e.g., Ogle, 737 F.3d

at 1073; Tenn. Consol. Coal Co. v. Crisp, 866 F.2d 179, 184–85 (6th Cir. 1989); Moseley v. Peabody Coal Co., 769 F.2d 357, 360 (6th Cir. 1985). Both Wolf Creek Colleries and Groves relied on the passage from Rowe. See Wolf Creek Colleries, 298 F.3d at 522; Groves, 277 F.3d at

836. We have applied the Rowe holding to differing facts and through varied phrasing. See, e.g., Advent Mining LLC v. Davis, 697 F. App’x 862, 865 (6th Cir. 2017); Williams v. Eastover Mining

Co., 335 F. App’x 577, 579–80 (6th Cir. 2009); Johnson Coal Co. v. Smith, 306 F. App’x 223, 224

(6th Cir. 2009); Cumberland River Coal Co. v. Caudill, 207 F. App’x 529, 532 (6th Cir. 2006).

As a result, the operation of the rule itself can be easily misconstrued. The Rowe holding therefore bears clarifying.

Our review, first and foremost, is rooted in the laws that bind us—namely, the Act and its attendant regulations. On the matter of evidence, the regulation is clear: if a determination of legal pneumoconiosis is based on a physician’s finding, the physician’s finding “must be based on objective medical evidence such as blood-gas studies, electrocardiograms, pulmonary function studies, physical performance tests, physical examination, and medical and work histories” and it

“must be supported by a reasoned medical opinion.” 20 C.F.R. § 718.202(a)(4). On causation, the standard is “competent evidence.” Id. § 718.203(c). Of course, sometimes two qualified

physicians will look at the same objective medical evidence and arrive at different conclusions. In these cases, the ALJ will have to make credibility determinations and we defer to those

determinations on review. See Crisp, 866 F.2d at 184–85. But under the terms of § 718.202(a)(4), for instance, an ALJ cannot base a finding of legal pneumoconiosis solely on a physician’s finding that is not itself based on objective medical evidence and supported by a reasoned medical opinion.

Case No. 17-3947, Robert Coal Co. v. Dir., OWCP

Accord Littlepage v. Dir., OWCP, 890 F.2d 416 (6th Cir. 1989) (Table) (“A physician’s opinion must be documented and reasoned to constitute substantial evidence in support of a finding.”)

(citing Rowe, 710 F.2d at 255); Dir., OWCP v. Congleton, 743 F.2d 428, 430 (6th Cir. 1984)

(recognizing that the reviewing court need not defer to the ALJ’s determination when “the evidence presented was simply too vague and conflicting to support the decision” as explained by

the ALJ). If an ALJ does so, his decision is not based on substantial evidence, contradicts the requirements of the regulations, and warrants a remand, not deference.

This is fully consistent with Rowe and its progeny. The refrain of the cases has been that the sufficiency of a physician’s documentation or reasoning is a credibility matter left to the ALJ.

This is a separate question from whether the physician began with the minimum raw materials demanded by § 718.202(a)(4), § 718.203(c), or any other provision. An ALJ’s decision must be supported by substantial evidence and the regulations define what is required. The regulations cannot be bypassed simply because an ALJ credited a physician’s demonstrably unsupported opinion. With this clarification in mind, we evaluate the ALJ’s findings and the doctors’ opinions that undergird them.

Crum saw Dr. Ammisetty first. At the time of the examination, Crum had received one x- ray, two ABGs, and one PFT. Dr. Ammisetty reviewed the results of the tests and personally

examined Crum. He diagnosed Crum with severe chronic obstructive pulmonary disease (COPD), bronchial asthma, cor pulmonale, and legal pneumoconiosis. Ultimately, the ALJ found that the COPD diagnosis was well-reasoned and documented, but the bronchial asthma and legal pneumoconiosis diagnoses were not. The ALJ pointed out that Dr. Ammisetty’s formal diagnosis of legal pneumoconiosis was apparently based on nothing more than Crum’s symptoms and thus found it not well-reasoned. Similarly, the ALJ found that the bronchial asthma diagnosis was Case No. 17-3947, Robert Coal Co. v. Dir., OWCP based only on Crum’s reported history and was therefore unreasoned and entitled to little weight.

The COPD diagnosis, however, was well-reasoned, according to the ALJ. He explained that Dr.

Ammisetty’s finding was based on “both objective medical evidence as well as [Crum’s] smoking and coal dust history[.]” And because COPD can fall within the definition of legal pneumoconiosis, the ALJ gave that portion of the report full probative weight.

Crum saw Dr. Gallai a little more than a year after the Ammisetty exam. In the interim, Crum had received two more x-rays (both negative for clinical pneumoconiosis), another ABG

(non-qualifying), and another PFT (qualifying). On the day Dr. Gallai examined him, Crum also

underwent another ABG, PFT, and x-ray. Dr. Gallai diagnosed Crum with hypoxia, bronchitis, and COPD. Hypoxia is not necessarily a chronic lung disease, so the ALJ found it inadequate to

constitute legal pneumoconiosis under § 718.201(a)(2). And the ALJ determined that the bronchitis diagnosis was based only on Crum’s reported history and symptoms, so it did not pass muster under § 718.202(a)(4). The ALJ found, however, that the COPD diagnosis was based on

Crum’s reported symptoms, work and smoking histories, an x-ray, an ABG, and a PFT.

Accordingly, the ALJ found this portion of the report well-reasoned and documented and gave it full probative weight.

A month after the Gallai exam, Crum saw Dr. Klayton. He underwent three final tests that day: an x-ray, an ABG, and a PFT. Dr. Klayton formally diagnosed Crum with legal pneumoconiosis, but the constituent conditions of the diagnosis were COPD and hypoxemia.

Ultimately, the ALJ gave Dr. Klayton’s opinion full probative weight based on the COPD finding.

As the foregoing attests, there was substantial evidence to support a finding that Crum has

COPD. And there is no question that COPD can constitute legal pneumoconiosis. When coal- mine employment contributed “at least in part” to a miner’s COPD, then the COPD is properly

- 10 - Case No. 17-3947, Robert Coal Co. v. Dir., OWCP considered pneumoconiosis. See Arch on the Green, Inc. v. Groves, 761 F.3d 594, 597–98 (2014). But the regulations require the factfinder to make this additional causal connection between coal mining and the COPD, and that inquiry is governed by § 718.203. The ALJ made such a finding, albeit in a roundabout fashion. After finding that Crum had adequately proven that he suffers from legal pneumoconiosis under § 718.202(a)(4), the ALJ declined to make an additional causation finding. He explained: The Act and the regulations provide for a rebuttable presumption that pneumoconiosis arose out of coal mine employment if a miner with pneumoconiosis was employed in the mines for ten or more years. 30 U.S.C. § 921(c)(1); § 718.203(b). In Kiser v. L & J Equipment Co., 23 B.L.R. 1-246, 1-259 n. 18 (2006), the Board cited to Anderson v. Director, OWCP, 455 F. 3d 1102 (10th Cir. 2006) and Henley v. Cowan & Co., 21 B.L.R. 1-147, 1-151 (1999) and agreed with the Director’s position that, if an ALJ finds the existence of legal pneumoconiosis, then he or she need not separately determine the etiology of the disease at § 718.203 because the findings at § 718.202(a)(4) will necessarily subsume that inquiry. Therefore, because I have found that Claimant has established legal pneumoconiosis, a separate finding, under § 718.203, is unnecessary in this case. We disagree with the ALJ: a causation finding under the strictures of § 718.203 is necessary because § 718.202(a)(4) does not address causation, it simply defines the types of evidence necessary to find the existence of pneumoconiosis.^[3] Nevertheless, the ALJ made causation findings while discussing § 718.202(a)(4). We therefore analyze those findings to determine whether they constitute “competent evidence” under § 718.203(c).