Opinion ID: 3010322
Heading Depth: 1
Heading Rank: 2

Heading: the proceedings before the alj

Text: Josephine Mancia, and Armand Mancia (the miner's first cousin), testified before the ALJ. Josephine also offered the deposition testimony of Dr. Charles M. Manganiello, and a letter from Dr. Manganiello, dated August 26, 1991, in support of her claims. The Director's evidence consisted primarily of a report of Dr. Leon Candor whom the Director had retained to render an opinion as to the cause of Mancia's death. The Director also offered two documents that had been written by Dr. Manganiello in an attempt to support Dr. Candor's conclusion, and impeach the contrary conclusion of Dr. Manganiello.
Josephine Mancia testified that her husband had been awarded black lung benefits in 1984 and that his health seemed to worsen on a daily basis prior to his death. He could not breathe well and required assistance doing things around the house. She also testified that he was so short of breath that his bed was moved to the first floor as he could not climb stairs, and he was unable to walk very far before complaining of shortness of breath. Hearing Transcript, at 8-9. Mancia saw Dr. Manganiello for his breathing problems, and was also under the treatment of another physician for an unrelated skin condition. Id. at 10.2 Josephine testified that her husband never complained of any chest or heart pain and he was never treated for a heart condition. Id. Josephine further testified that Angelo complained that he could not breathe well about one week before he died. Id. at 11. She returned home from a bus trip to Atlantic City, and found him dead in their car. The motor was not running. Id. at 12. Armand Mancia, testified that he and Angelo were very close and that they spent a lot of time fishing at a lake in the summertime. Id. at 14. The cottage where they stayed was about 200 to 250 feet from a lake. In the year before _________________________________________________________________ 2. That condition was cancer, and all the parties and witnesses agree that that condition is not implicated in Angelo's death. 4 he died, Angelo had to stop about half-way to the lake to catch his breath. Angelo was able to fish only because the boat was powered by a motor, and Armand did all of the casting. According to Armand, Angelo never complained about chest pain or heart problems, nor did he ever tell Armand he was taking any medication for any heart condition. Armand testified that during the last years of Angelo's life he (Angelo) kept slowing up, that breathing was a major problem, and that Angelo could not tolerate any physical exertion of any kind because of his problem breathing. Id. at 17.
Dr. Manganiello's deposition testimony established that he had been a licensed physician for 15 years, practicing general medicine in a region where coal mining was once the prevalent industry. Approximately 10% of his patients are former coal miners, and he sees those patients primarily for anthracosilicosis and anthracosilicosis-related problems. He is, however, neither board-certified nor boardeligible in cardiology, occupational medicine, pulmonary medicine nor internal medicine. Deposition Transcript, at 7- 9. Dr. Manganiello first began treating Angelo Mancia in 1978, primarily for his underlying pneumoconiosis. He saw him at least three times a year thereafter. Mancia's medications consisted of bronchodilator therapy and respiratory treatments, as well as oxygen therapy as needed. Id. at 13. Dr. Manganiello testified he agreed to sign Mancia's death certificate at the coroner's request. Id. at 14. That death certificate states that the immediate cause of death was cardiopulmonary arrest with underlying causes of anthracosilicosis3 with emphysema. _________________________________________________________________ 3. The statutory definition of pneumoconiosis includes anthracosilicosis. 20 C.F.R. SS 718.201 & 727.202. The statutory definition of pneumoconiosis (i.e. any lung disease that is significantly related to, or substantially aggravated by, dust exposure in coal mine employment) is much broader than the medical definition, which only encompasses lung diseases caused by fibrotic reaction of lung tissue to inhaled dust. Labelle Processing Co. v. Swarrow, 72 F.3d 308, 312 (3d Cir. 1996). 5 Dr. Manganiello was confronted with Dr. Candor's conclusion that Mancia died of a heart attack. Candor based that conclusion partly upon Dr. Manganiello's entry on the death certificate. Manganiello answered as follows: No where (sic) in my death certificate or in my opinions do I feel that I have ever expressed a myocardial infarction as his cause of death. I'm not sure where [Candor] extrapolated that type of information. And I'm not sure from where he draws his conclusion. Mr. Mancia never had any symptoms related to his heart. And again, the reason for me stating that Mr. Mancia died of a cardiopulmonary arrest is because his heart stopped. Why his heart stopped, in my opinion, was because of his underlying lung condition. The patient had difficulty breathing. He had difficulty oxygenating his heart on the basis of his breathing; and his heart stopped; not because his heart developed a clot, or he damaged his heart. He had no symptoms referable to that. And nowhere could I state that he died of a myocardial infarction.4 And I don't believe that anyone could make that statement. So I am not sure where he extrapolated that information. Id. at 20-21. Dr. Manganiello was also asked about Dr. Candor's reliance on an April 11, 1991 note written by Dr. Manganiello. As we discuss below, that note is at the heart of the ALJ's rejection of Dr. Manganiello's medical opinion as to the cause of Mancia's death. In that note, Dr. Manganiello wrote that Mancia had suffered a heart attack which was a direct result of his severe anthracosilicosis with emphysema. When asked about that note, Manganiello stated I believe there was one report that I had made, trying to embellish or trying to explain a cardiopulmonary arrest. And I do believe that that report has been mistaken and misunderstood. I totally negate that _________________________________________________________________ 4. Dr. Manganiello explained that a cardiopulmonary arrest is absolutely not the same as a myocardial infarction. The latter is a heart attack, but the heart does not necessarily stop, and unlike a pulmonary arrest where the heart stops, many patients survive a myocardial infarction. Deposition Testimony, at 26-7. 6 report. I do not refer to that in any of my thoughts or any of my opinions in terms of his cardiopulmonary arrest. And again, I believe his heart stopped on the basis of his underlying lung deterioration, and problems relating to his underlying anthracosilicosis. Id. at 21. On cross-examination, the following exchange occurred in response to a question about Manganiello's treatment of diseases related to pneumoconiosis: Q: Dr., in your testimony this morning, you have talked about treating Mr. Mancia for his pneumoconiosis and related diseases. What are those related diseases? A: The pneumoconiosis basically; the underlying infections and problems that he would incur as a result of his severe lung disease. Recurrent episodes of bronchitis. Problems such as cor pulmonale, or buildup of some right-sided heart failure, on the basis of severe underlying lung disease; and problems of that nature. But all related to his lung disease. Id. at 22. Manganiello admitted that his reports did not mention the presence of cor pulmonale and explained that it was not mentioned because it was basically [an] office concern[ ], which was not necessary to note in a report. Id. at 22-23. You could see that the man had some edema of his legs; some swelling in his abdomen from time to time. He required some diuretic therapy from time to time for the treatment of that problem. Id. at 23. Dr. Manganiello further explained that he didn't think it was necessary to order objective tests to confirm the presence of cor pulmonale because it can be diagnosed clinically, and because there is really no treatment for the condition once it is diagnosed. Id. I really don't feel that it was necessary to do that. I believe that a clinical diagnosis can be just as well treated in the office, without any of those studies. Id. at 23. 7
Josephine Mancia also introduced a letter from Dr. Manganiello, dated August 26, 1991, and addressed TO WHOM IT MAY CONCERN. It reads: Mr. Angelo Mancia was under my care for anthracosilicosis. I never treated Mr. Mancia for heart disease or coronary artery disease for that matter. The death certificate states cardiopulmonary arrest secondary to anthracosilicosis and there has never been a statement that his death was related to a myocardial infarction. It is therefore my opinion that Mr. Mancia's untimely death was a direct result of his anthracosilicosis.
The Director's evidence in opposition to the widow's claim consisted of a two-page report of Dr. Leon Candor,5 and the aforementioned April 11, 1991 note from Dr. Manganiello. Dr. Candor never examined the miner. His report was based entirely upon his examination of certain medical records and the results of tests that Dr. Manganiello and other physicians had performed over the years. The Director also introduced the death certificate into evidence. Dr. Manganiello's April 11, 1991 note is addressed TO WHOM IT MAY CONCERN. The entirety of that note is as follows: In my opinion Mr. Angelo Mancia (sic) heart attack was a direct result of his severe anthracosilicosis with emphysema which hastened or progressed his underlying coronary artery disease. Dr. Candor's report details the various medical records he reviewed. They include x-rays and the results of tests that had been performed on Mancia during his lifetime. Based upon his review of those records, Dr. Candor concluded: _________________________________________________________________ 5. The Director's Brief states that Dr. Candor is a Board-certified internist. Director's Br. at 5. However, the ALJ's Decision recites that Dr. Candor is Board-eligible in pulmonary medicine. ALJ's Decision at 3. 8 1. As noted in Dr. Manganiello's letter of 4/11/91, the immediate cause of Mr. Mancia's death on 8/5/90 was an acute myocardial infarction with resultant cardiopulmonary arrest. The myocardial infarction (heart attack) was caused by underlying coronary artery disease. 2. The patient's coronary artery disease with resultant myocardial infarction were casually unrelated to pneumoconiosis. 3. Despite Dr. Manganiello's statement in his letter of 4/11/91, I know of no scientific evidence which indicates that anthracosilicosis or emphysema hasten the progress of coronary artery disease. 4. The normal arterial oxygen tension at rest and during exercise makes it most unlikely that the patient's chronic lung disease had any effect upon cardiac rhythm and function. 5. The available information provides no evidence that Mr. Mancia's chronic lung disease was a substantially contributing cause to his death caused by acute myocardial infarction or hastened his death.
The ALJ focused on two aspects of Manganiello's testimony and letters in denying the widow's claim. The ALJ was clearly troubled by Manganiello's assertion that Mancia suffered from cor pulmonale. The ALJ noted that Manganiello's letters did not mention cor pulmonale but that Manganiello did, nevertheless, testify at his deposition that the miner suffered from cor pulmonale. ALJ's Decision at 3. The ALJ rejected Dr. Manganiello's explanation of the apparent contradiction. The ALJ concluded that Manganiello simply assumed that black lung disease played a part in the miner's death, and found that Manganiello's opinion was not well-reasoned, not supported by objective means and not based on competent medical evidence. The ALJ concluded that Dr. Manganiello responded disingenuously that the condition `. . . basically were office concerns; not . . . things that I felt needed justification in 9 these types of letters.' . . He stated that he did not believe that objective testing was necessary. ALJ's Decision at 3. The ALJ was also troubled by Manganiello's April 11, 1991 note and the doctor's repudiation of it. The ALJ was not convinced by Dr. Manganiello's explanation that he over embellished [him]self a bit in the note. Deposition Transcript, at 28. The ALJ wrote: Thus, after writing a note containing a premise Dr. Manganiello pulls the rug out by withdrawing the premise of a heart attack. By withdrawing the letter of April 11, 1991 the doctor inferentially, at least, concedes being less than candid. ALJ's Decision, at 3. The ALJ relied upon Dr. Candor's conclusion that Mancia died of a myocardial infarction unrelated to his chronic lung disease, and he (the ALJ) concluded that Manganiello's testimony to the contrary was merely an assumption that the miner's lung disease played a role in his death. When one views Dr. Manganiello's rationale as expressed at his deposition it amounted to nothing more that the doctor assumed that the progressive subjective breathing symptoms were attributable to Black Lung, and that, therefore, when the miner was found dead that Black Lung must have contributed to his death. . . . The most reasonable observation to make is that Dr. Manganiello merely assumed that Black Lung played a part in death. His opinion is not well-reasoned or supported by an objective means and is not found to be based on competent medical evidence 20 C.F.R. 718.205(c)(1)(2). Id. Thus, the ALJ ruled that there is no credible basis to conclude that coal worker's pneumoconiosis played any part in the miner's death. Id. at 4. The Director now argues that the ALJ weighed Manganiello's opinion that pneumoconiosis played a part in the miner's death and Candor's opinion to the contrary and simply made a credibility determination that we ought not overturn. 10 The Board affirmed the ALJ's decision ruling that the ALJ properly exercised his discretion as a fact-finder and discredited the only medical opinion that could support claimant's burden. BRB's Decision at 4.