### In the 

# United States Court of Appeals
For the Seventh Circuit

____________________ No. 18-2097

C ONSOLIDATION C OAL C OMPANY , Petitioner

,

v.

D IRECTOR , O FFICE OF W ORKERS ’ C OMPENSATION P ROGRAMS , U NITED S TATES D EPARTMENT OF L ABOR , Respondent

.

____________________

Petition for Review of an Order of the Benefits Review Board. No. 17-BLA-0351.

____________________

A RGUED N OVEMBER 29, 2018

— D ECIDED D ECEMBER 21, 2018

____________________

Before F LAUM , R IPPLE , and M ANION , Circuit Judges

.
F LAUM , Circuit Judge . Ralph Ross worked as a coal miner for approximately thirty years. He smoked cigare tt es for almost as long but was able to quit after his fi rst heart a tt ack. Ross continued to work as a co al miner even though he suffered another heart a tt ack and had di ffi culty breathing at work. Approximately six years after Ross stopped working in the coal mines, his breathin g problems became severe.2 No. 18-2097

On January 19, 2012, Ross fi led a claim for bene fi ts under the Black Lung Bene fi ts Act, 30 U.S.C. § 901 et seq. At fi rst, the administrative law judge (“ALJ” ) denied Ross’s claim. Ross petitioned the United States Department of Labor’s Bene fi tsReview Board (the “Board”) for review, and the Board vacated and remanded the ALJ’s decision for further consideration. On remand, the ALJ granted Ross’s claim. Ross’s formeremployer, petitioner Consolidation Coal Company (the “Employer”), petitioned the Board for review, and the Board affi rmed the ALJ’s subsequent de cision. Then the Employer
fi led this appeal. We enforce the decision of the Board.

I. Background

A. Statutory and Regulatory Framework
Congress passed the Black Lung Bene fi ts Act (the “Act”) in light of the “signi fi cant number” of coal miners who became “totally disabled” from wo rking in coal mines. 30 U.S.C. § 901(a). Under the Act, coal mi ners may receive modest monetary and medical bene fi ts to treat their pulmonary impairments. See id. To establish eligibility for such bene fi ts, a coalminer must show: (1) he has pneumoconiosis, (2) the pneumoconiosis arose out of coal mi ne employment, (3) he is totally disabled, and (4) the pneu moconiosis contributes to the total disability. 20 C.F.R. § 725.202(d).
The Act and its implementing regulations de fi ne pneumoconiosis as “a chronic dust dise ase of the lung and its sequelae, including respiratory and pulmonary impairments, arising out of coal mine employment.” 30 U.S.C. § 902(b); 20 C.F.R. § 718.201(a). And the regulations de fi ne two subcategories of pneumoconiosis: “Clinical pneumoconiosis” refers to “those diseases recognized by the medical community asNo. 18-20973

pneumoconioses, i.e., the conditions characterized by permanent deposition of substantial amounts of particulate ma tt er in the lungs and the fi brotic reaction of the lung tissue to thatdeposition caused by dust exposure in coal mine employment.” 20 C.F.R. § 718.201(a)(1). “Legal pneumoconiosis” refers to “any chronic lung disease or impairment and its sequelae arising out of coal mine employment. This de fi nition includes, but is not limited to, any chronic restrictive or obstructive pulmonary disease arising out of coal mine employment.” Id. § 718.201(a)(2).
To establish a respiratory or pulmonary impairment that is “totally disabl[ing]” and quali fi es him for bene fi ts under the Act, a miner must show that the impairment prevents him from performing his usual coal mine work and from engaging in gainful employment that requires similar skills to his coal mining job and that is near his home. Id. § 718.204(b)(1)(i)–(ii).Additionally, the coal miner must satisfy certain medical criteria. Id. § 718.204(b)(2). “In absence of contrary probative evidence,” evidence that meets any of the standards outlined in § 718.204(b)(2)(i)–(iv) “shall estab lish a miner’s total disability.” Id. Under subparagraph (i), pulmonary function tests “showing values equal to or le ss than those listed in [certain tables in] Appendix B to this part for ... the FEV 1 test” qualify “if, in addition, such tests also reveal the values ... equal to or less than those listed in ... Appendix B for this part, for ... the FVC test, or ... the MVV test, or ... [a] percentage of 55 or less when the results of the FEV 1 test are divided by the results of the FVC test (FEV 1 /FVC equal to or less than 55%).” Under subparagraph (ii), arterial blood gas tests that “show the values listed in Appendix C to this part” qualify. Under subparagraph (iii), medical evidence showing the miner su ff ers from4 No. 18-2097

“cor pulmonale with right-sided congestive heart failure” quali fi es. And subparagraph (iv) provides:
Where total disability cannot be shown under paragraphs (b)(2)(i), (ii), or (iii) of this section, or where pulmonary function tests and/or blood gas studies are medically contraindicated, totaldisability may nevertheless be found if a physician exercising reasoned medical judgment,based on medically acceptable clinical and laboratory diagnostic techniques, concludes that a miner’s respiratory or pulmonary condition prevents or prevented the miner from engaging in employment as described in paragraph (b)(1) of this section.
Congress intended for the Act to serve a remedial purpose and for doubts “[i]n the absence of de fi nitive medical conclusion[s]” to be resolved in the miner’s favor. S. Rep. No. 92-743, at 2315. Accordingly, the Act includes a rebu tt able presumption that a miner may invoke if the miner can establish that he has spent at least fi fteen years working in a coal mine and establish pursuant to § 718.204 that he su ff ers from a totally disabling respiratory or pulmonary impairment. 1 See 30 U.S.C. § 921(c)(4); 20 C.F.R. § 718.305. If the miner can make that showing, the miner is presumed to be totally disabled by

1 Congress originally added the fifteen-year presumption in 1972, see Pub. L. No. 92–303, § 4(c) (1972); bu t in 1981, Congress limited its applicability to claims filed before January 1, 1982, see Pub. L. No. 97–119,§ 202(b)(1) (1981). Then, in 2010, Congress made the fifteen-year presumption available for claims filed after January 1, 2005 that were still pending on or after March 23, 2010. See Keene v. Consolidation Coal Co. , 645 F.3d 844, 847 (7th Cir. 2011).No. 18-20975

pneumoconiosis. 20 C.F.R. § 718.305(c)(1). Th e miner’s employer may rebut that presumption either by disproving the existence of legal and clinical pneumoconiosis, or by ruling out pneumoconiosis as a partia l cause of the miner’s disability. Id. § 718.305(d)(1).

B. Factual Background
Ross spent thirteen years wo rking underground in the mine and at least seventeen years working on the surface of the mine. Throughout his career, the dust from the mine was inescapable. After a day’s work, his clothes were “too nasty” to take inside his home, so he would shower at work, change into di ff erent clothes, and leave his work clothes hanging inhis garage. Cleaning his work clothes required using the laundromat’s special washer for coal miner’s clothes, and even then, it took two wash cycles to remove the dust and grease from the coal mine.
Starting at the age of twen ty and for approximately the next thirty years, Ross smoked between one-half to two packs of cigare tt es per day, though sometimes he would begin smoking a cigare tt e, but would be too busy with work to fi nish it, so he’d extinguish it and go back to work. He quit smoking in 1989 after su ff ering his fi rst heart a tt ack. Unfortunately, Ross had another serious heart a tt ack in 1995, and he suspects he had a third heart a tt ack in 1998.
Ross had breathing problems while working in the coal mines. He struggled to carry his tools while climbing the stairs and he often had to take breaks to catch his breath. Andyet, Ross kept working. That is, he kept working until his employer “let [him] go” in 2000 because he “got blinded in the right eye.” At that time, Ross said he felt he could still do his6 No. 18-2097

job from a cardiac standpoint and that from a pulmonary standpoint, he “was trying.” Si nce his coal mining career ended, Ross has not held steady employment. To stay busy, Ross volunteered by cu tt ing fi rewood with a chainsaw, mowing lawns with a riding lawnmower, and pu tt ing up hay with a square baler.
Ross said his breathing problems became severe in 2006 or 2007. He has testi fi ed that since that time, he cannot walk around his house and yard like he used to, and it takes him longer to complete daily tasks, namely feeding his animals and mowing the lawn. Although he takes medication for his breathing problems, he can only perform fi fteen to twenty minutes of work before he has to sit down to take a break for thirty- fi ve to forty minutes. Ross uses an oxygen monitor to make sure his oxygen does not fall so low as to risk stroke ordeath. When his oxygen levels get too low, Ross uses supplemental oxygen.

C. Procedural Background

1. The ALJ’s First Decision
On January 19, 2012, Ross fi led a claim for bene fi ts under the Act. The District Director awarded Ross bene fi ts in October 2012; the Employer requested a hearing before the O ffi ce of Administrative Law Judges. In preparation for that hearing, the Director of the O ffi ce of Workers’ Compensation Programs in the United States Department of Labor (the “Director”), Ross, and the Employer gathered medical evidence to present to the ALJ. The hearing occurred on October 23, 2013; Ross and his wife both testi fi ed. After the hearing, Ross andNo. 18-20977

the Employer submi tt ed briefs and the ALJ issued a decision denying bene fi ts on September 8, 2014.
The ALJ determined that Ross had over fi fteen years of qualifying coal mine employme nt, and in turn, focused on whether Ross was entitled to invoke the fi fteen-year presumption by establishing a totally disabling respiratory or pulmonary impairment using qualifying medical evidence. Beginning with the pulmonary function tests, the ALJ noted that the parties submi tt ed three such exams for Ross. Dr. Tazbaz, on behalf of the Department of Labor, performed the fi rst exam on Ross on February 13, 2012, and that exam produced qualifying values prebronchodila tor. Dr. Tuteur, on behalf of the Employer, performed two more exams on Ross on June 28, 2012, and those exams produced nonqualifying values prebronchodilator and postbronchodilator. Since the ALJ found the more recent results to be the best indicator of Ross’s pulmonary condition, the ALJ concluded that the pulmonary function testing, standing alone, did not support a fi nding of total disability under 20 C.F.R. § 718.204(b)(2)(i).
Then, the ALJ discussed the blood gas studies: Ross underwent four such studies, two at rest and two after exercise. In both “after exercise” studies, Ross’s PCO 2 increased and his PO 2 decreased, thereby producing qualifying values. The ALJ noted that Dr. Tazbaz conclude d that these studies showed that Ross had a “pulmonary limi tation to exercise with hypoxemia that requires oxygen,” and that Dr. Tuteur indicated that the “after exercise” qualifying result was abnormal, but a

re fl ection of a development of oxygen gas exchange impairment after exercise. The ALJ foun d that the blood gas studies, standing alone, supported a fi nding of total disability under § 718.204(b)(2)(ii).8 No. 18-2097

Next, the ALJ brie fl y noted that there was no evidence that Ross had cor pulmonale with right-sided congestive heart failure, so total disability could no t be supported on that basis. See id. § 718.204(b)(2)(iii).
Finally, the ALJ considered the medical opinion evidenceof three doctors. First, Dr. Tazbaz opined that Ross was “severely impaired with desaturatio n on exercise test” and “cannot do his activities in last year of employment.” He diagnosed Ross with chronic obstructive pulmonary disease, coalworkers’ pneumoconiosis, coronary artery disease, and hypoxemia with exercise. He opined that the cause of these conditions was exposure to coal mine dust and cigare tt e smoke.Second, Dr. Tuteur indicated that Ross had a “minimal obstructive abnormality and some air trapping,” but he opined that this was “not clinically me aningful and ... is [in] no wayassociated with any disability or reduced function.” Dr. Tuteur explained that Ross’s hypoxemia and blood gas results were “most likely ... due to a ri ght to left intracardiac shunt unrelated to the inhalation of coal mine dust, but consistent with complications of the coro nary artery disease, myocardial infarctions, surgical treatment and their sequelae.” 2 And Dr. Tuteur opined that there was no evidence to support legal orclinical coal workers’ pneumoconiosis or any coal-mine-dustrelated pulmonary process. Finally, Dr. Selby reviewed Ross’s medical records and submi tt ed a report of his fi ndings. In that report, dated March 18, 2013, Dr. Selby opined that Ross was

2 The ALJ also noted that Dr. Tuteur testified at a deposition that even when Ross received 100% oxygen during an exam, Ross’s hypoxemia was not corrected, which Dr. Tuteur interpreted as an indication that: (1) Ross’s blood never gets to his lungs because it is shunted away, and (2) the cause of Ross’s hypoxemia was not a pulmonary condition.No. 18-20979

not totally disabled from a pulmonary or respiratory standpoint. Dr. Selby also testi fi ed at a deposition on September 10, 2013: In his opinion, Ross’s mi nor pulmonary impairment was due to his extensive cigare tt e smoking and prior history of histoplasmosis or tubercul osis. He explained that Ross’s post-exercise levels demonstrated serious hypoxia, which “might cause some limitation.” But Dr. Selby testi fi ed that the cause of Ross’s drop in oxygen was not pulmonary in nature because his pulmonary function tests were normal, which “is virtually 100 percent predictive ofno lung disease.” He testifi ed that the evidence is “exa ctly to the contrary” of a fi nding of total disability due to a pulmonary condition.
The ALJ summarized the medical opinion evidence, in relevant part, as follows:
All three physicians are board-certi fi ed in pulmonary and internal medicine, and only one physician, Dr. Tazbaz, opined that [Ross] was totally disabled from a pulmonary standpoint. Dr. Tuteur opined that [Ross] was totally disabled from a cardiac standpoint, and Dr. Selby did not fi nd that [Ross] was totally disabled at all. With regard to the issue of total disability,Drs. Selby and Tuteur’s opinions were well reasoned, documented, and supported by the totality of the medical evidence. Dr. Tazbaz’s very minimal opinion did not consider [Ross’s] other testing and medical evidence, or [Ross’s] severecardiac issues as ... potential causes of his impairment. Greater weight may be accorded anopinion supported by more extensive documentation over an opinion supported by limited10 No. 18-2097

medical data.... Accordingly, I fi nd Dr. Tazbaz’s opinion is entitled to less weight and it is not

su ffi ciently documented. A doctor’s opinion that is both reasoned and documented and issupported by objective medical tests and consistent with all the documentation in the record,is entitled to greater probative weight.... Therefore, based on the abovementioned discussion, I
fi nd that the medical opinion evidence, standing alone, does not support a fi nding of total disability. [ See id. § 718.204(b)(2)(iv).]
Then, the ALJ considered all the probative evidence andfound that the preponderance of the evidence did not establish that Ross had a totally disabling respiratory or pulmonary impairment. As a result, the ALJ concluded that Ross was not entitled to invoke the fi fteen-year presumption. Ultimately, the ALJ denied Ross’s claim for bene fi ts. 3

2. The First Petition for Review
Ross petitioned the Board to review the ALJ’s decision. The Director fi led a response, asking the Board to vacate the denial of bene fi ts and to remand the case for further consideration. The Employer also fi led a response, and it moved to strike the Director’s brief as violating 20 C.F.R. § 802.212(b),which limits the Board’s consideration of arguments in response briefs to those that respond to arguments raised in the

3 The ALJ also found that Ross did not establish the existence of complicated pneumoconiosis such that he would be entitled to invoke the irrebuttable presumption under 30 U.S.C. § 921(c)(3) and 20 C.F.R. § 718.304(a). Those findings are not at issue on appeal.No. 18-209711

petitioner’s brief or that support the decision below; the Board denied the motion.
As for the merits of the appe al, the Board determined that the ALJ erred in several ways: combining the analysis of totaldisability and disability causation, which are meant to be distinct inquiries; characterizing Dr. Tazbaz’s opinion as not considering Ross’s severe cardiac issu es as potential causes of the impairment when in fact Dr. Ta zbaz considered Ross’s aortic valve replacement and triple bypass surgery, questioned thecongestive heart failure diagnosis, performed an electrocardiogram that produced normal sinus rhythm, and diagnosed Ross with coronary artery disease; considering Dr. Tazbaz’s opinion to not be “su ffi ciently documented” when Dr. Tazbaz relied on results from a physical examination, chest x-ray, pulmonary function study, blood gas study, echocardiogram (ECG), and Ross’s smoking, work , and surgery histories; and not explaining why Drs. Tuteur ’s and Selby’s opinions were be tt er supported, especially in light of the fact that Ross’s treatment records did not show a shunt despite extensive cardiac testing, Dr. Tuteur did not include the complete results of Ross’s blood gas study cond ucted with 100% oxygen, and neither doctor conducted an EC G. Due to these errors, the Board vacated the ALJ’s fi ndings that Ross did not establishtotal disability under 20 C.F.R. § 718.204(b)(2)(iv), that the totality of the evidence did not establish total disability under § 718.204(b)(2), and that Ross did not invoke the fi fteen-year presumption under 30 U.S.C. § 921(c)(4). As such, the Board remanded the case to the ALJ fo r further consideration of the relevant evidence.
The Employer moved for reconsideration of the Board’s decision, arguing that the Board erred in denying the motion12 No. 18-2097

to strike the Director’s brief and that the Board exceeded its scope of review by engaging in a de novo review of the case, improperly adopting the Director’s position, and usurping the ALJ’s fact- fi nding authority. The Board denied the Employer’s motion.

3. The ALJ’s Second Decision
Back before the ALJ, the Employer moved for leave to submit supplemental medical opinions. The ALJ granted that motion and it admi tt ed the Employer’s submission of supplemental medical opinions from Drs. Tuteur and Selby. After further brie fi ng, Ross submi tt ed Dr. Tazbaz’s supplemental opinion and additional treatment records, and the Employer submi tt ed second supplemental opinions by Drs. Tuteur and Selby. The ALJ issued its second decision on March 7, 2017. The ALJ incorporated the fi ndings from his fi rst decision under 20 C.F.R. § 718.204(b)(iv), and then outlined, in detail, the supplemental medical opinion evidence.
In Dr. Tuteur’s March 18, 2016 supplemental opinion, he included the complete results of the blood gas study that was conducted on June 28, 2012, on wh ich Dr. Tuteur heavily relied in reaching his fi rst opinion that a right-to-left shunt caused Ross’s hypoxemia. In this speci fi c exam, Ross received100% oxygen and still experienced hypoxemia. In the supplemental opinion, Dr. Tuteur found that it was unequivocally clear that Ross was totally and permanently disabled from engaging in work as a coal miner and that the disability is due to the demonstrated pathophysiology where Ross becomes hypoxemic with exercise. But Dr. Tuteur con fi rmed that thephysiologic presence of a right-to-left shunt was well-documented in the pulmonary function test he performed on Ross in 2012. He acknowledged that performing a bubble study atNo. 18-209713

the time of an echocardiogram is a less sensitive method of

con fi rming the presence of a right- to-left shunt, and that this test was not done. Nevertheless, Dr. Tuteur still concludedwith reasonable medical certainty that because Ross has advanced chronic coronary artery disease and very mild chronic obstructive pulmonary disease, the exercise-induced oxygendesaturation was a result of a right-to-left shunt. He emphasized that Ross does not have a meaningful impairment ofventilatory function, nor does he have a meaningful impairment of oxygen gas exchange due to a primary pulmonary process. He also stated that the cardiac disease is in no way related to, aggravated by, or caused by inhalation of coal mine dust or the development of coal workers’ pneumoconiosis.
Dr. Selby submi tt ed his supplemental opinion on May 13,2016. He explained that the 100% oxygen test Dr. Tuteur performed showed incontrovertible proof of the presence of a shunt and that the decreased PO 2 was not due to lung disease. Citing a New England Journal of Medicine article from 1984 describing the use of di ffusing capacity as a predictor of arterial oxygen desaturation during exercise in patients with chronic obstructive pulmonary disease, Dr. Selby explained that the study showed that if a patient had a di ffusion capacity above 55% of predicted, virtua lly 100% of the time the exercise blood gases would show no desaturation of oxygen. He noted that Ross had a normal di ffusion capacity when corrected for alveolar volume, but that even the obtained raw value was further support that the oxygen drop could not be caused by pulmonary disease an d that another source must be the cause. Finally, Dr. Selby disagreed with Dr. Tuteur’sdiagnosis of a minimal obstructive ventilatory defect. He reiterated his earlier opinion that Ross’s condition is not a total14 No. 18-2097

and permanent disability, and that Ross does not have clinical or legal pneumoconiosis.
Dr. Tazbaz based his August 3, 2016 supplemental opinion on his fi rst opinion and a review of additional medical opinions and treatment records. He observed that x-rays and a CT scan from 2012 established pneumoconiosis radiologically. Dr. Tazbaz diagnosed Ross with clinical pneumoconiosis caused by inhalation of coal mine dust, chronic obstructive pulmonary disease caused by coal mine dust and cigare tt e smoking, and total disability due to pneumoconiosis and chronic obstructive pulmonary disease. He further opinedthat Ross’s obesity and aging added to his disability. Regarding the study Dr. Selby cited, Dr. Tazbaz observed that thestudy did not address the subset of patients who had combined chronic obstructive pulmonary disease, coal workers’ pneumoconiosis, obesity, and aging as risk factors for oxygen desaturation, and that those pa tients (including Ross) are more likely to desaturate with all of those factors combined. Next, Dr. Tazbaz noted that Ross’s stress test from August 2, 2013 did not show cardiac ischemia, which would mean that the bypass from Ross’s coron ary artery bypass graft surgery was functioning well, and that the oxygen desaturation could not be a tt ributed to heart disease. Similarly, an echocardiogram performed on February 1, 2012 showed normal heart function and therefore, Ross did not have heart failure. Based on this medical evidence, Dr. Tazbaz opined that Ross’s heart disease had been treated surgically and was not causing any major issues from a cardiac st andpoint. And Dr. Tazbaz maintained that the test of choice to determine the presence of a shunt is an echocardiogram with a bubble study, which was not done here.No. 18-209715

After reviewing Dr. Tazbaz’s supplemental opinion and the results of the stress test and echocardiogram, Dr. Tuteur submi tt ed a second supplemental opinion. He con fi rmed that his previous opinion was unchanged, and he added that there was no meaningful obstructiv e ventilatory abnormality, meaning that there was no ch ronic obstructive pulmonary disease. He again con fi rmed that the echocardiogram did not use a bubble study to determine whether a shunt was present;he noted that the echocardiogram “did demonstrate low normal left ventricular ejection fraction,” but that no comment was made regarding an assessmen t of diastolic dysfunction, which is “a particularly important factor especially in the face of sub-optimally controlled hype rtension.” He also remarked that “[n]o comment was made on the state of function of theaortic valve replacement.” Finally, Dr. Tuteur refuted Dr. Tazbaz’s conclusion that Ross has clinical pneumoconiosis, explaining that the x-rays were mo stly negative and that the diagnosis was uncon fi rmed by CT scan. He also disagreed with Dr. Tazbaz’s diagnosis of lega l pneumoconiosis because he concluded there was clinically no meaningful air fl ow obstruction by pulmonary function testing.
Dr. Selby also submi tt ed a second supplemental opinionafter reviewing the stress test, the echocardiogram, Dr. Tazbaz’s supplemental opinion, and Dr. Tuteur’s second supplemental opinion. Dr. Selby agreed with Dr. Tazbaz that there was no signi fi cant reversibility in Ross’s FEV l /FVC ratio, but Dr. Selby stated that the normal ratio indicates that there is no permanent obstruction. Dr. Selby also agreed with Dr. Tazbaz that the article and study he cited did not separate all possible comorbidities like coal workers’ pneumoconiosis or obesity. But, he stated that obesity does not directly a ff ect di ffusion16 No. 18-2097

capacity and that aging is already adjusted for in the predicted values. Notwithstanding the absence of a bubble study, Dr. Selby defended his opinion that a shunt could be the only cause of exercise hypoxia when there is no congestive heart failure. In the end, he still concluded that Ross did not have coal workers’ pneumoconiosis and that Ross’s exercise was not signi fi cantly limited by pulmonary disease.
Based on the further developed record of medical opinion evidence, the ALJ concluded that Dr. Tazbaz’s opinion was “well-documented” and “support ed by the underlying objective tests and various work, smoking and medical histories.” Next, the ALJ found that “Dr. Tuteur now opines that [Ross]

su ff ers from a totally disabling impairment which is respiratory or pulmonary in nature an d this conclusion is supportedby his interpretation of the blood gas study values on exercise.” 4 Finally, the ALJ faulted Dr. Selby for not discussing the signi fi cance of the exercise blood gas studies that yielded qualifying results, and for no t addressing whether Ross is

4 Comparing the plain language of Dr. Tuteur’s supplemental opinions and this part of the ALJ’s deci sion might suggest tension—Dr. Tuteur makes clear he thinks the cause of Ross’s total and permanent disability isa cardiac impairment (the shunt), not a respiratory or pulmonary impairment. However, relying on the results of the exams Dr. Tuteur performed on Ross and Dr. Tuteur’s observation that those exams produced qualifying results constitute substantial ev idence to support the ALJ’s finding here. See Midland Coal Co. v. Dir., Office of Workers’ Comp. Programs , 358F.3d 486, 493 (7th Cir. 2004) (to decide if total disability has been established, “an ALJ must consider all relevant evidence on the issue of disability including medical opinions which are phrased in terms of total disability or provide a medical assessment of physical abilities or exertional limitations which lead to that conclusion” (quoting Poole v. Freeman United Coal Mining Co. , 897 F.2d 888, 894 (7th Cir. 1990))).No. 18-209717

able to perform his usual coal mine work despite the qualifying blood gas results. As such, the ALJ found Dr. Selby’s opinions not well-reasoned and the ALJ accorded them “li tt le weight.”
The ALJ decided that the be tt er-reasoned opinions on total disability were those of Drs. Tazbaz and Tuteur. And the ALJ found that the preponderance ofthe medical opinions established total disability under 20 C.F.R. § 718.204(b)(2)(iv). Next, the ALJ considered all the evidence and found that the preponderance of the evidence established that Ross su ff ers from a totally disabling pulmonary impairment and cannot return to his previous coal mine employment. Id. § 718.204(b)(1). Because the partie s did not dispute that Ross
satis fi ed the requisite number of years of coal mine employment, the ALJ then concluded that Ross established conditions su ffi cient to invoke the rebu tt able presumption of total disability due to pneumoconiosis under 30 U.S.C. § 921(c)(4) and 20 C.F.R. § 718.305.

As for rebu tt ing the presumption, the ALJ explained thatthe only medical opinion evidence that could support the Employer’s a tt empt to disprove the existence of legal pneumoconiosis were those of Drs. Tute ur and Selby. However: the ALJfound Dr. Tuteur’s statements about Ross’s obstructive impairments inconsistent; the ALJ faulted Dr. Tuteur for not addressing how he eliminated Ross’s signi fi cant coal dust exposure and a tt ributed the impairment to Ross’s smoking historyexclusively; and the ALJ took issue with Dr. Tuteur’s conclusion that Ross did not have chronic obstructive pulmonarydisease despite the several years of treatment records diagnosing Ross with that disease an d a CT scan interpretation by18 No. 18-2097

a board-certi fi ed B-reader diagnosing Ross with mild to moderate centrilobular emphysema. Si milarly, the ALJ found that Dr. Selby’s opinion did not adeq uately consider Ross’s medical and treatment records regarding chronic obstructive pulmonary disease and emphysema, nor did it su ffi ciently address Ross’s approximately thirty -year exposure to coal dust. And the ALJ noted that Dr. Selby’s view that Ross’s decrease in oxygen was not pulmonary because pulmonary function tests are “virtually 100 percent predictive of no lung disease”was contrary to the Act’s implementing regulations that permit miners to establish a totally disabling respiratory impairment by blood gas studies. Finally, the ALJ credited Dr. Tazbaz’s quali fi cation of the utility of Dr. Selby’s citation to the di ffusing capacity study as it did not consider all of Ross’s comorbidities.
Since the ALJ accorded the two relevant medical opinions li tt le weight, he concluded that there was insu ffi cient evidence to disprove the presumed existence of legal pneumoconiosis. And because the Employer cannot rebut the presumption of clinical pneumoconiosis without rebu tt ing the presumption of legal pneumoconios is, the ALJ reasoned that he “need not” decide whether the Employer rebu tt ed the existence of clinical pneumoconiosis. See 30 U.S.C. § 921(c)(4); 20 C.F.R. § 718.305(d)(1)(i). Simil arly, because the ALJ held “there [wa]s no reasoned medi cal opinion or other competent evidence excluding pneumoconiosis as a causative factor in [Ross]’s total disability,” the Employer also could not meet its burden of proving that pneumoconiosis played no part in Ross’s disability. 20 C.F.R. § 718.305(d)(1)(ii). Therefore, the ALJ decided Ross was entitled to bene fi ts under the Act.No. 18-209719

4. The Second Petition for Review
The Employer petitioned the Board to review the ALJ’s second decision. Renewing its argument from its motion forreconsideration, the Employer argued that the Board exceeded its scope of review by accepting the Director’s arguments and vacating the ALJ’s init ial decision on that basis. The Employer also asserted thatthe Board directed the ALJ to
fi nd on remand that Ross is totally disabled, in violation of the Administrative Procedures Act (“APA”) and due process. The Employer also took issue with the ALJ’s weighing of the medical opinion evidence on the issue of total disability, arguing this led to an erroneous fi nding that Ross invoked the fi fteenyear presumption. Lastly, the Employer argued that the ALJ erred in fi nding that it could not rebut the presumption.
The Board “decline[d] to consider” the Employer’s argument that the Board exceeded its scope of review because the Board had considered and rejected the same argument in the Employer’s motion for reconsideration. Additionally, theBoard dismissed the Employer’s argument that the Board directed the ALJ to make certain fi ndings on remand because the plain language of the Board’s opinion stated that the ALJshould reconsider relevant evidence. And given that the Employer had an opportunity to submit supplemental opinions from Drs. Selby and Tuteur, as well as to fi le briefs to advocate for its position, the Board foun d no basis for the Employer’sassertion that the Board had violated the Employer’s due process rights.

The Board determined that th e ALJ’s crediting of Dr. Tazbaz’s opinion, discrediting of Dr. Selby’s opinion, and fi ndingthat Dr. Tuteur diagnosed Ross with a totally disabling pulmonary condition was supported by the evidence. The Board20 No. 18-2097

a ffi rmed the ALJ’s fi nding that the preponderance of the medical evidence established total disability under 20 C.F.R. § 718.204(b)(2)(iv), that weighing the evidence established total disability under § 718.204(b)(2 ), and that Ross invoked the presumption under 30 U.S.C. § 921(c)(4). And because only Drs. Tuteur’s and Selby’s opinions that the shunt caused Ross’s impairment provided rebu tt al evidence, and the ALJ did not fi nd those opinions to be su ffi ciently reasoned or documented, the Board held that the ALJ permissibly discredited those opinions and rationally concluded that the Employer did not carry its burden of disproving the establishment of legal pneumoconiosis or that pneumoconiosis caused, to some extent, Ross’s respiratory or pulmonary total disability.
The Employer fi led this appeal, seeking to strike the Director’s response brief and to reinstate the ALJ’s fi rst decision denying Ross bene fi ts under the Act.

II. Discussion
On a petition for review from a decision by the Board, we look at the ALJ’s decision and consider the entire record, but we do not reassess the facts or substitute our judgment for that of the ALJ. Dalton v. O ffi ce of Workers’ Comp. Programs , 738 F.3d 779, 783 (7th Cir. 2013) (citing Amax Coal Co. v. Beasley

, 957 F.2d 324, 327 (7th Cir. 1992)). Our review of the Board’s decision is limited to whether the Board exceeded its scope of review and whether it commi tt ed an error of law. Id. (citing Old Ben Coal Co. v. Prewi tt , 755 F.2d 588, 590 (7th Cir. 1985)). The Board’s scope of review is statutorily de fi ned: the Board

must a ffi rm an ALJ’s decision if it is rational, supported byNo. 18-209721

substantial evidence, and in accordance with applicable law. Id. (citing 33 U.S.C. § 921(b)(3); 20 C.F.R. § 802.301).

A. The Director’s Response Brief
The Employer maintains that the Board should havegranted its motion to strike the Director’s response brief because 20 C.F.R. § 802.212(b) provides that the Board may not consider arguments in response briefs unless the arguments respond to issues raised in the pe titioner’s brief or support the decision below, and the Direct or’s response brief contained arguments that Ross had not raised in his petition for review from the Board and that the parties had not presented to theALJ. Additionally, the Employer argues that the Board violated the APA and due process by considering the Director’s brief on the basis that the brie f responded to “general allegations of error” in Ross’s petition for review.
According to the Employer, the Director’s brief criticized the ALJ’s analysis of the medical opinion evidence “in great detail,” while Ross’s brief only argued that because the opinions of Drs. Tuteur and Selby “fail[ed] to recognize the uncontradicted [blood gas] testing results as evidence of pulmonary disability,” the ALJ erred in fi nding those opinions to be wellrationalized. The Employer insists that the only area of “agreement” between Ross’s brief and the Director’s brief is their shared reliance on Bounds v. Marfork Coal Company, BRB No. 13-0522, 2014 WL 3897749 (Ben. Rev. Bd. July 29, 2014) (“ Bounds II”). Even then, the Employer argues that Ross and the Director relied on Bounds II for di ff erent propositions.

Ross admits that the Director ’s response brief was “more artfully stated” than his brief, bu t he does not concede that the22 No. 18-2097

Director advanced new arguments, in violation of the regulation. Similarly, the Director claims it addressed “more fully”the same arguments Ross made in his brief. The Director further defends its brief by noting that there is no statutory or regulatory rule that the response brief may only parrot an opening brief. To the contrary, in Harris v. Todd Paci fi c Shipyards Corp. , the Board interpreted “response” to include arguments in agreement with the opening brief. 28 BRBS 254, 1994 WL 661158, at *3 n.4 (Ben. Rev. Bd. Oct. 25, 1994) (per curiam) (citing 20 C.F.R. § 802.212(b)). 5
In his petition to the Board, Ross challenged the ALJ’s decision that the medical evidence was insu ffi cient to show a totally disabling pulmonary condition. Ross criticized the ALJ’s jump from acknowledging that Dr. Tazbaz concluded that Ross had a “pulmonary limitation to exercise with hypoxemia that requires oxygen” and that two blood gas tests produced qualifying results, to nevert heless concluding that the preponderance of the evidence established that Ross was not totally disabled on a pulmonary basis. To make that jump, Ross

5 In its reply brief, the Employer argues that Harris is “contrary to the regulation.” We disagree. Harris ’s application of the regulation was wellreasoned. The Board in Harris denied the employers’ motions to strike because “[c]ontrary to employers’ conten tions, a party may ‘respond’ to the petitioner’s brief by agreeing with th e arguments made therein, as the Director has done in the instant cases.” 1994 WL 661158, at *3 n.4. Section 802.212(b) does not define “response,” and there is nothing in the regulation or in the plain meaning of the term “response” to suggest that a response cannot take the form of an agreement, as Harris held. Additionally, there is no indication of how si milar or different a “response” mustbe from the previous assertion or question, so there is support for the notion that the Director could file a brief agreeing with the arguments in thepetitioner’s brief either by merely reiterating those arguments or by recasting those arguments in a new light.No. 18-209723

insisted, the ALJ must have credited Dr. Selby’s statement that “[Ross’s] drop in [oxygen] was not pulmonary in nature.” This was error “as a ma tt er of black lung law” and well-se tt led Board precedent, Ross contended, citing Bounds II for the proposition that the Board had previously rejected a similar argument that blood gas studies were cardiac-related and not pulmonary in nature.

In Bounds II , the miner’s claim for bene fi ts was before the Board for a second time. 2014 WL 3897749, at *1. On remand,the ALJ had found that the pulmonary function study evidence did not establish total respiratory disability, but that the blood gas study and the me dical opinion evidence did; because the ALJ determined that the employer did not rebut the presumption, the ALJ awarded the miner bene fi ts. Id. at*2. On appeal, the employer challenged the ALJ’s total disability fi nding by asserting that the blood gas study evidence
was insu ffi cient to establish total respiratory disability because the results re fl ected a hypertensive cardiovascular response to exercise, not a total respiratory impairment. Id. at *4. After noting that the ALJ ba sed his total disability conclusion on the blood gas study evid ence, and that the employer’s experts did not dispute that the blood gas studies revealed a disabling condition, only that the blood gas studies revealeda pulmonary condition (because they believed the studies revealed a cardiac disease), the Board rejected the employer’s argument that the blood gas study evidence was insu ffi cient to establish a totally disabling respiratory impairment. Id.
The Director’s brief, in relevant part, cited Bounds II after stating that “the Director agr ees with [Ross]’s assertion that the ALJ erred by con fl ating the issue of total disability with the issue of cause of disability when determining whether the24 No. 18-2097

evidence was su ffi cient to establish invocation of the [30 U.S.C. § 921](c)(4) presumpt ion.” The brief further states: “As [Ross] notes, the Board has recognized that a physician’s statement that qualifying [blood gas] results are due to nonpulmonary causes is not releva nt to the disability inquiry.... Instead, any such opinions sh ould be addressed when evaluating the cause of disability.” The Director maintained that the ALJ’s error was not harmless because the ALJ did not “critically analyze the medical opinion evidence in fi nding no disability,” which means that ev en if the presumption was invoked, the Board had no basis to conclude that the ALJ’s credibility fi ndings would support a fi nding that the Employer could rebut that presumption.
What distinguishes Ross’s brief from the Director’s is that the Director characterized the ALJ’ s errors in this case and in Bounds II as a con fl ation of two distinct inquiries. Ross did not use that language, but when Ro ss included a block quotation from Bounds II in his petition for review that explained the Board’s reason for rejecting that employer’s challenge to the

su ffi ciency of the miner’s qualifying blood gas studies, Ross was making the same point as th e Director: the cause of qualifying blood gas results is not relevant to the ALJ’s inquiryinto whether the miner has a totally disabling pulmonary condition, it is only relevant to the ALJ’s inquiry into disability causation. Neither this distinction nor the di ff ering levels of quality or detail between the two briefs are enough to remove the Director’s brief from the realm of a “response” under the regulations. 20 C.F.R. § 802.212(b); see Harris , 1994 WL 661158,
at *3 n.4.
Finally, we are not persuaded by the Employer’s argument that the Board’s denial of the motion to strike violatedNo. 18-209725

the APA and due process. In re aching its conclusion on the motion to strike, the Board reas oned that because Ross challenged the ALJ’s weighing of medical opinion evidence and
fi nding that he did not have a totally disabling pulmonary impairment, the Board could consid er the arguments in the Director’s brief that responded to those “general allegations of error on that issue.” The Board cited 20 C.F.R. § 802.212(b) and Barnes v. Director

, O ffi ce of Workers’ Compensation Programs , BRB No. 93-0584, 1995 WL 80211 (Ben. Rev. Bd. Feb. 15,1995) (en banc) to support its reasoning. The Employer interprets Barnes as providing the Director with standing to argue any issue it believes the ALJ decided erroneously so long as a party appeals the ALJ’s decision and alleges the ALJ erred in declining to award bene fi ts. As such, the Employer contends that Barnes undermines the APA and due process. 6

However, this case does not raise the concerns the Employer has about Barnes . Si tt ing en banc, the Board in Barnes decided that it could consider arguments from the Director’sbrief because they “respond[ed] to claimant’s general allegation that the [ALJ] erred in failing to award bene fi ts.” 1995 WL 80211, at *2. Notably, the Board had previously held that the claimant did not raise any argum ents about the ALJ’s decision with su ffi cient speci fi city to invoke the Board’s review, and therefore, the Board refused to consider the Director’s brief as

6 The Employer’s argument concerning an APA violation is undeveloped; the Employer does not identify which provision of the APA it believes was violated. As such, this argument is waived. See Shumaker v. Colvin , 632 F. App’x. 861, 867 (7th Cir. 2015) (undeveloped arguments on appeal are waived). We will consider the Employer’s related, and more developed, argument that the Board violated due process by denying the motion to strike.26 No. 18-2097

nonresponsive. Id. Unlike the claimant in Barnes , however, Ross raised several speci fi c issues in his petition for review and the Director’s response brief only expounded on those points. This was all in keeping with 20 C.F.R. § 802.212(b).
Moreover, there was no due process violation because, as Ross and the Director point out, the Employer had the opportunity to argue its case twice before the ALJ and twice beforethe Board, including the chance to submit supplemental medical opinion evidence. Thus, we enforce the Board’s denial of the Employer’s motion to strike the Director’s response brief.

B. The ALJ’s First Decision
The Employer challenges the Board’s decision to vacate the ALJ’s fi rst decision and to remand the claim. Speci fi cally, the Employer argues that the Board blindly adopted the Director’s legal arguments and factual fi ndings, and that the Board forced the ALJ to do the same on remand. As such, the Employer argues that the Board exceeded its scope of review and that its decision was contrary to law.
Returning to the portion of th e Director’s brief that argues the ALJ erred by con fl ating two distinct inquiries, the Employer now seeks to undermine this argument as relying on

con fl icting Board precedent. As we discussed above, the Director cited Bounds IIto support its point that the total disability inquiry is distinct from th e disability causation inquiry.
But Bounds II was not the only decision the Director cited for that proposition; the Director also cited Street v. Dominion Coal Corp. , BRB No. 13-0116, 2013 WL 6408512 (Ben. Rev. Bd. Nov. 27, 2013) (per curiam) (“ Street II ”). The Employer incorrectly argues that Bounds II reached a contrary result to Street II . Fo-No. 18-209727

cusing on a di ff erent part of the Bounds IIdecision, the Employer now argues that the Board in Bounds II a ffi rmed the ALJ’s consideration of the cause of the impairment before the invocation of the fi fteen-year presumption. This misstates the relevant holding of Bounds II

. The employer in Bounds II argued that the ALJ relieved the miner of the burden of establis hing a totally disabling respiratory impairment because the ALJ focused on the cause of the claimant’s impairment. 2014 WL 3897749, at *5. But as theBoard explained, it was the doctors who “premised their diagnoses regarding a pulmonary impairment on their determinations of the cause of claimant’s hypoxia.” Id. Because the ALJ permissibly found one doctor more quali fi ed than the others and credited that doctor’s opinion over the others, theBoard rejected the employer’s argument that the ALJ improperly combined his analysis of th e issues of total disability and disability causation. Id.
Read that way, Bounds II does not con fl ict with Street II . In Street II , the ALJ decided that one doctor’s opinion that the claimant “did not retain the respiratory capacity to perform his regular coal mine employment” was su ffi cient to establish total respiratory disability because the blood gas study results supported this opinion. 2013 WL 6408512, at *2. The ALJ rejected a second doctor’s contrary opinion, which was based on the conclusion that the cl aimant’s disabling hypoxemia was due to nonpulmonary factor s, because the ALJ found the conclusion to be speculative. Id. at *2–3. In a ffi rming the ALJ’s decision, the Board explained th at the medical opinion that pneumoconiosis did not cause the disabling hypoxemia “does28 No. 18-2097

not show that claimant does not have a totally disabling respiratory impairment pursuant to Section 718.204(b)(2)(iv).” Id. at *3.
Consequently, both Bounds II and Street IIsupport the Director’s argument that the total disability inquiry is distinct from the disability causation inquiry. In any event, the Board need not have relied on these cases in adopting the Director’s argument that the ALJ erred by con fl ating the two because, as the Board stated in its opinion, the Director’s argument is consistent with the relevant stat utory and regulatory framework, to which we now turn.
The Employer asserts that the Act’s unambiguous statutory language and its implementing regulations require the ALJ to determine if a miner ha d a respiratory or pulmonary impairment before invoking the presumption. Focusing onthe use of “respiratory” and “pulmonary” to modify “impairment,” the Employer argues that such language reveals Congress’s intent to limit the invo cation of the presumption to only respiratory and pulmonary impairments. Furthermore,the Employer asserts that the statutory and regulatory framework presumes that a miner’s respiratory or pulmonary impairment is pneumoconiosis and it limits the rebu tt al standard to establishing that the miner does not have pneumoconiosis or that the respiratory or pulmonary impairment did not arise out of coal mine employ ment. 30 U.S.C. § 921(c)(4); 20 C.F.R. § 718.305(d)(1).
Although we agree with the Employer that ALJs must fi nd that a totally disabling respi ratory or pulmonary impairmentexists before the presumption may be invoked, it does not follow that the ALJ may discount evidence that otherwise shows a totally disabling respiratory or pulmonary impairment ( i.e.No. 18-209729

through blood gas results) simp ly because a physician opines that the cause of the impairment is cardiac-based. It is clear from the Act, the regulations, and Board precedent that an ALJ must decide whether a totally disabling respiratory or pulmonary disability exists before invoking the presumption, but that in doing so, the ALJ should not let medical opinion evidence about the cause of such respiratory or pulmonary impairment a ff ect the analysis.
As for the Employer’s argum ent that the Board blindly adopted the Director’s factual fi ndings, we hold that theBoard acted within its scope of review and appropriately vacated and remanded the ALJ’s decision as not supported by substantial evidence in the reco rd. By noting that the ALJ mischaracterized an opinion and impr operly discounted an opinion because the ALJ misapprehen ded the factual record, the Board is not usurping the ALJ’s fact fi nding role. Rather, the Board is ful fi lling its own role of ensuring the ALJ’s fi ndings of fact and conclusions of law are set aside if they are not supported by substantial evidence or in accordance with law. See 20 C.F.R. § 802.301(a).
The Employer’s related theory that the Board forced the ALJ to blindly adopt the Director’s factual fi ndings also does not prevail. In its opinion, the Board simply instructed the ALJ on remand to “further consider[]” the evidence. We do not read the Board’s opinion as coercing the ALJ to reach a certain result. Rather, the Board pointed out evidence that the ALJ should acknowledge, but that the ALJ was still free to weigh as the ALJ saw fi t. Furthermore, a signi fi cant portion of theALJ’s decision on remand involved supplemental medical evidence to which the Board di d not have access. Thus, the Board could not have controlled the ALJ’s fi ndings on remand30 No. 18-2097

and the ALJ’s ultimate decision on remand could not have been preordained.
The Board did not exceed its scope of review by vacating and remanding the ALJ’s decision.

C. Finding of Total Disability Established on Remand
The Employer also argues that the ALJ’s fi ndings on remand as to the total disability inquiry were not supported by substantial evidence and were contrary to law.
Starting with Dr. Tazbaz’s opinion, the Employer assigns error to the ALJ’s fi nding, “[u]pon further re fl ection,” that Dr. Tazbaz’s opinion was well-documented and well-reasoned. The Employer concedes that “[s]uch fi nding would be appropriate” if the ALJ had not merely copied such fi ndings from the Board (which had blindly adopted the same fi ndings from the Director’s brief, accordin g to the Employer). As notedabove, however, we do not view the ALJ as thoughtlessly following the Board’s directive. Base d on the ALJ’s decision, it is clear that the ALJ considered th e relevant evidence (including a wealth of supplemental medical opinion evidence), made credibility determinations, and weighed di ff ering opinions in order to reach his independent conclusion.
The Employer also argues that the ALJ’s crediting of Dr. Tazbaz’s opinion was not support ed by the evidence because Dr. Tazbaz did not address: (1) how Ross’s chronic obstructive pulmonary disease and coal wo rkers’ pneumoconiosis wouldcause oxygen desaturation with exercise; (2) why the pulmonary function test he performed on Ross produced qualifying results but the testing Dr. Tuteur performed on Ross four months later did not; or (3) what evidence or medical research existed to undermine Drs. Tuteur ’s and Selby’s opinions. But,No. 18-209731

the Employer’s fi rst argument is premis ed on importing the causation analysis into the disability analysis, in violation of statutory and regulatory language. Dr. Tazbaz did not need to explain why chronic obstruct ive pulmonary disease or coal workers’ pneumoconiosis would cause Ross’s desaturation with exercise in order for the ALJ to be able to rely on his opinion as evidence of a totally disabling pulmonary impairment; the ALJ may rely on Dr. Tazbaz ’s conclusion that Ross produced qualifying blood gas results as evidence of total disability, even if Dr. Tazbaz believes the cause of the results is nonpulmonary. See Midland Coal Co. , 358 F.3d at 493. As to the second and third arguments, the record shows that Dr. Tazbaz discussed the other doctors’ opinions enough to support the ALJ’s fi nding that Dr. Tazbaz’s opin ion was credible. The statutory and regulatory framework do not require Dr. Tazbaz to respond to every con fl icting data point with a counterpoint orresolution; that Dr. Tazbaz considered Ross’s full medical record before making a medical judgment as to Ross’s diagnoses

was su ffi cient. Next, the Employer challenges the ALJ’s fi nding on remand that Dr. Tuteur deemed Ross to have a totally disabling pulmonary impairment. According to the Employer, it was just the opposite: Dr. Tuteur fo und Ross’s cardiac condition to be the cause of the disability. And the Employer argues that the ALJ’s decision should be va cated because ALJs are not allowed to mischaracterize a physic ian’s opinion or to substitute their own fi ndings for that of a physician’s. Again, the Employer seeks to use the doctor’s opinion that a cause of an impairment is nonpulmonary to remove evidence of a totally disabling pulmonary impairment from the ALJ’s considera-32 No. 18-2097

tion. To do so is improper un der the statute and the regulations; the ALJ reached an appropriate fi nding as to Dr. Tuteur’s opinion of a totally di sabling pulmonary impairment.
Lastly, the Employer disputes the ALJ’s decision to accordDr. Selby’s opinion that Ross did not have a pulmonary disability li tt le weight, emphasizing that Dr. Selby’s opinion was supported by Dr. Tuteur’s testing in 2012 and by Dr. Selby’s review of all the materials. Notwithstanding the parts of the record that support Dr. Selby’ s opinion, the ALJ may nevertheless decide that, on balance, Dr. Selby’s opinion was notwell-reasoned because Dr. Selby did not discuss the qualifying blood gas studies or why Ross would be capable of performing his usual coal mine employment.
In general, the Employer’s theo ry that someth ing must beamiss because the ALJ changed his mind on remand is particularly unpersuasive here because the parties submi tt ed fi ve additional medical opinions af ter the Board’s second decision. Those supplemental medica l opinions presented new information for the ALJ to consider, which ultimately altered the ALJ’s credibility determinations. For the fi rst time on remand, the doctors were able to consider the complete results of the 100% blood gas study, which formed the basis of Dr. Tuteur’s conclusion that a sh unt caused Ross’s hypoxemia. Relevant here, Dr. Tazbaz cast doubt on Dr. Tuteur’s use ofthe blood gas study to identify a shunt given that the preferred way to determine the presence of a shunt is an echocardiogram with a bubble study, which Dr. Tuteur did not perform. Moreover, Dr. Tazbaz noted that Ross’s treatment records relating to his coronary artery bypass graft surgery showed that his heart and the bypass were functioningNo. 18-209733

properly and that his heart disease had been treated surgically, so it could not be the caus e of any major issues for Ross. In their second supplemental opinions, neither Dr. Tuteur nor Dr. Selby could refute the utility of a bubble study to con fi rm the presence of a shunt, nor did they explain how, in spite of Ross’s positive cardiac-related medical history, Drs. Tuteurand Selby nevertheless believed Ross’s impairment was cardiac-based and not pulmonary-based.
We hold that the ALJ’s decision to accord more weight to Drs. Tazbaz’s and Tuteur’s opinions—because he considered those opinions be tt er-reasoned than Dr. Selby’s and foundthem supported by the medical evidence—was rational, supported by substantial evidence, and in accordance with applicable law. In turn, we conclude that the Board appropriately

a ffi rmed the ALJ’s decision that Ross proved by a preponderance of the evidence that he was totally disabled under 20 C.F.R. § 718.204(b)(2)(iv), that the evidence was su ffi cient to establish total disability pursuant to 20 C.F.R. § 718.204(b)(2), and that Ross invoked the fi fteen-year presumption under 30 U.S.C. § 921(c)(4).

D. Finding that Presumption Was Not Rebu tt ed on Remand
After invoking the fi fteen-year presumption on remand, the ALJ addressed whether the Employer rebu tt ed it. Employers face an “uphill ba tt le” in a tt empting to rebut the presumption. R & H Steel Bldgs., Inc. v. Dir., O ffi ce of Workers’ Comp. Programs , 146 F.3d 514, 518 (7th Cir. 1998). But, the Employer34 No. 18-2097

advances several theories as to why the ALJ’s decision that it did not rebut the presumption should be vacated.
First, the Employer argues that because the ALJ only considered whether the Employer could rebut legal pneumoconiosis, the ALJ failed to revi ew all the medical evidence, which was contrary to law. Th is argument misses the mark. While the ALJ was required to review all medical evidence before determining if a total disability existed, the Employer does not cite any authority to support the notion that the ALJmay not decide that the employer cannot rebut the presumption because the employer cannot rebut one of the requisite elements. See 20 C.F.R. § 718.305(d)(1)(i).
Next, the Employer objects that the invocation of the presumption yields only a presumption of clinical pneumoconiosis. But, this argument contravenes the statutory and regulatory framework. Section 921(c)(4) speci fi cally provides that the fi fteen-year presumption is triggered when a miner is disabled or has died from “pneumoconiosis,” and both the statutory and the regulatory de fi nitions of pneumoconiosis are broad: “a chronic dust disease of the lung and its sequelae, including respiratory and pulmonary impairments, arising out of coal mine employment.” 30 U.S.C. § 902(b); 20 C.F.R. § 718.201(a). And as noted above, the regulation further speci fi es that this broad de fi nition includes “clinical” and “legal” pneumoconiosis. 20 C.F.R. § 718.201(a). There is no suggestion that Congress sought to limit the application of the presumption to only clinical pneumo coniosis. In fact, there is persuasive authority from other courts of appeals that have considered this precise issue and he ld that the plain language of§§ 902(b) and 921(c)(4) leads to the conclusion that the presumption applies to both clin ical and legal pneumoconiosis.No. 18-209735

See Consolidation Coal Co. v. Dir., O ffi ce of Workers’ Comp. Programs , 864 F.3d 1142, 1147 (10th Cir. 2017); Barber v. Dir., O ffi ce of Workers’ Comp. Programs , 43 F.3d 899, 901 (4th Cir. 1995).
The Employer argues that research concerning the fi fteenyear presumption showed that the likelihood of a miner developing clinically signi fi cant legal pneumoconiosis was only 14.2% for smoking miners and 7.7% for nonsmoking miners with “high exposure” to coal mi ne dust over varying lengths of time. See Regulations Implementing the Federal Coal Mine Health and Safety Act of 1969, as Amended, 65 Fed. Reg. 79920-01, 79940-01 (Dec. 20, 2000). And the Employer argues that this data revealed that ev en if the “high exposure” miners worked in the mines for over fi fteen years, 85.8% of them would not develop legal pneumoconiosis, and yet 88% of them did develop clinical pneumoconiosis. The Employer thus argues there is insu ffi cient evidence to support a presumption that a miner with chronic obstructive pulmonary disease and at least fi fteen years of coal mine employment has legal pneumoconiosis. Given that the law requires a logicalconnection between the proven fact and the presumed conclusion, the Employer reasons that the fi fteen-year presumption does not apply to legal pneumoconiosis. See Mullins Coal Co. v. Dir., O ffi ce of Workers’ Comp. Programs , 484 U.S. 135, 137, 158–59 (1987) (recognizing the “need for a logical connectionbetween the proven fact and the presumed conclusion” in reference to the interim presumption of eligibility for black lung bene fi ts claims fi led between July 1, 1973, and April 1, 1980).
In response, the Director points to an opinion from theTenth Circuit that considered and rejected the same argument:36 No. 18-2097

We fail to see how this study sheds light on Congress’ intent as to the fi fteen-year presumption. But in any event, the stud y is inapposite. It refl ects the incidence of respiratory impairment among all miners, healthy or unhealthy. The fi fteen-year presumption requires a claimant to demonstrate that he is totally disabled due to a respiratory condition, § 921(c)(4), and thus miners who successfully invoke the presumption have already shown that they fall within the class of miners with signi fi cant pulmonary dysfunction.

Consolidation Coal , 864 F.3d at 1148 n.2. We agree with the Tenth Circuit that the presumption is reasonable for legalpneumoconiosis. And we do not conclude that the presumption only applies to clinical pneumoconiosis.
Finally, the Employer argues that the ALJ’s interpretation of the rebu tt al requirements was erroneous and should be vacated. The parties devote pages to analyzing, criticizing, anddistinguishing the medical opinion evidence. But, in considering whether there is support for the Employer’s a tt empt to rebut the presumption, the medical opinion evidence may be simpli fi ed as a disagreement between three quali fi ed physicians as to the cause of Ross’s qu alifying test results. We may not reweigh the medical opinion evidence. It was rational for the ALJ to discredit the opinions of Drs. Tuteur and Selby to the extent they concluded that Ross did not su ff er from a pulmonary impairment because those opinions did not explain how they eliminated Ross’s thirty years of coal mine dust exposure as a potential cause of his pulmonary impairment, or how they concluded Ross does not have chronic obstructiveNo. 18-209737

pulmonary disease given the years of medical treatment records documenting the condition and the CT scan reading of mild to moderate emphysema. Similarly, it was rational for the ALJ to reject Drs. Tuteur’s and Selby’s opinions that a shunt was the sole cause of Ross’s disability given that those doctors did not diagnose pneumoconiosis and they did notaddress contrary medical evidence of record, namely Dr. Tazbaz’s normal cardiac test resu lts and Ross’s extensive cardiac treatment records that lacked any mention of a shunt.
Substantial evidence supports the ALJ’s decision to give li tt le weight to the disability causation opinions of Drs. Tuteurand Selby. Given that those were the only opinions the Employer could rely on to support its e ff ort to rebut the presumption, and the ALJ reasonably discredited them, we hold that the Board appropriately a ffi rmed the ALJ’s fi nding that the Employer did not rebut the presumption.

III. Conclusion
For the foregoing reasons, we E NFORCE the Board’s decision affirming the ALJ’s determin ation that Ross is entitled to benefits under the Act.