                                PUBLISHED

                  UNITED STATES COURT OF APPEALS
                      FOR THE FOURTH CIRCUIT


                               No. 13-1702


NORA COLLINS, widow of Johnnie Collins,

                Petitioner,

           v.

POND CREEK MINING COMPANY; DIRECTOR, OFFICE OF WORKERS'
COMPENSATION PROGRAMS, UNITED STATES DEPARTMENT OF LABOR,

                Respondents.



On Petition for Review of an Order of the Benefits Review Board.
(12-0230 BLA)


Argued:   March 20, 2014                     Decided:   May 1, 2014


Before WILKINSON, KING, and FLOYD, Circuit Judges.


Reversed and remanded by published opinion.      Judge Wilkinson
wrote the opinion, in which Judge King and Judge Floyd joined.


ARGUED: Leonard Joseph Stayton, Inez, Kentucky, for Petitioner.
Rita Ann Roppolo, UNITED STATES DEPARTMENT OF LABOR, Washington,
D.C., for Respondent Director, Office of Workers' Compensation
Programs, United States Department of Labor. Kathy Lynn Snyder,
JACKSON KELLY, PLLC, Morgantown, West Virginia, for Respondent
Pond Creek Mining Company.       ON BRIEF: M. Patricia Smith,
Solicitor of Labor, Rae Ellen Frank James, Associate Solicitor,
Gary K. Stearman, Counsel for Appellate Litigation, Office of
the Solicitor, UNITED STATES DEPARTMENT OF LABOR, Washington,
D.C., for Respondent Director, Office of Workers' Compensation
Programs, United States Department of Labor.
WILKINSON, Circuit Judge:

     This case is the latest chapter in a long-running dispute

between    Nora    Collins   (“Mrs.        Collins”)      and   Pond       Creek   Mining

Company     (“Pond      Creek”)    regarding        her    claim       to    survivor’s

benefits under the Black Lung Benefits Act, 30 U.S.C. §§ 901-945

(the “Act”). Mrs. Collins petitions for review of an April 2013

decision    of    the   Benefits        Review   Board    (“BRB”)      affirming      the

denial of benefits by an Administrative Law Judge (“ALJ”). She

challenges the ALJ’s ruling that she failed to prove that her

husband’s       pneumoconiosis     hastened      his     death.      For    the    reasons

that follow, we reverse the BRB’s decision and remand for an

award of benefits.



                                           I.

                                           A.

     Johnnie Collins (“Mr. Collins”) worked in various mining-

industry jobs for more than thirty-six years between 1943 and

1983, including at Pond Creek for the last eleven. He was also a

regular smoker during this time, though he later quit. When he

stopped working for Pond Creek in 1983, Mr. Collins filed a

claim for lifetime benefits under the Act.

     Five    years      later,    ALJ    Lawrence      ruled    in    his    favor.   See

Collins v. Pond Creek Coal Co., No. 85-BLA-5349 (Feb. 25, 1988).

Under     the     Act’s    implementing          regulations,          a     miner    has

                                            2
pneumoconiosis if he meets one of two conditions. He must either

have   “clinical           pneumoconiosis”           (a    particular       set    of    diseases

recognized by the medical community) or “legal pneumoconiosis”

(a   broader        category        that   includes            any   chronic      lung    disease

arising out of coal mine employment). See 20 C.F.R.

§ 718.201(a); Barber v. Director, OWCP, 43 F.3d 899, 901 (4th

Cir. 1995). The ALJ determined that although the x-rays did not

show Mr. Collins to have clinical pneumoconiosis, the miner did

have     a        chronic      respiratory            condition         known      as     Chronic

Obstructive             Pulmonary    Disease         (“COPD”).         Moreover,        the     best

evidence          indicated       that     his    work         in    the    coal      mines     had

contributed to this condition. As a result, he was afflicted

with pneumoconiosis for purposes of the Act. Determining that

the pneumoconiosis had totally disabled Mr. Collins, the ALJ

ruled him entitled to benefits. Pond Creek did not appeal, and

the mining company provided Mr. Collins the required payments

until his death in 1997.

       Shortly after Mr. Collins died, Mrs. Collins applied for

survivor’s          benefits      pursuant       to       30   U.S.C.      § 922(a)(2).         Pond

Creek opposed an award to the widow and asked for a hearing

before       an    ALJ.     ALJ   Morgan     ruled        in    2001    that    the      1988    ALJ

Decision was not entitled to collateral estoppel on the issue of

whether           Mr.     Collins        suffered         from       pneumoconiosis.            Upon

reweighing the evidence, he concluded that Mr. Collins did not

                                                 3
suffer     from      pneumoconiosis.                 After     several        additional

administrative rulings, Mrs. Collins petitioned this court for

review.

      We vacated the ALJ’s denial of benefits. See Collins v.

Pond Creek Mining Co., 468 F.3d 213 (4th Cir. 2006). We held

that the doctrine of collateral estoppel did indeed apply to the

holding of the 1988 ALJ Decision that Mr. Collins suffered from

pneumoconiosis      due     to    coal        dust    exposure.      Furthermore,      we

rejected ALJ Morgan’s alternate holding, affirmed by the BRB,

that even if Mr. Collins had suffered from pneumoconiosis, Mrs.

Collins had failed to establish that Mr. Collins’s death was due

to the disease. See Collins, 468 F.3d at 223-24. We remanded for

further proceedings to determine if pneumoconiosis contributed

to Mr. Collins’s death.

      In the nearly eight years since our decision, this matter

has continued to bounce back and forth in the administrative

process.   There     have    been          three     different      decisions    by   two

different ALJs and three decisions by the BRB. Most recently,

ALJ   Lesniak     determined          in   2012      that    Mrs.   Collins     was   not

entitled to survivor’s benefits. He found that the physicians’

opinions   relied    upon        by    Mrs.       Collins    were    not   sufficiently

reasoned or documented to support a finding that Mr. Collins’s

pneumoconiosis      caused       his       death.     The    ALJ    also   refused    to

consider   as   supportive        of       Mrs.    Collins    the    opinions    of   two

                                              4
doctors for Pond Creek who found that Mr. Collins’s death was in

fact   hastened      by   COPD,    although          they   believed      the   COPD   was

caused by smoking, not pneumoconiosis. The BRB affirmed this

ruling in 2013, echoing the analysis advanced by the ALJ. Mrs.

Collins has petitioned this court for review.

                                             B.

       The arguments of the parties center on the proper weight to

be accorded the various medical opinions in the case. A brief

review of these opinions is thus necessary.

       Dr.    Maan      Younes,        a     board     certified       internist       and

pulmonologist, was Mr. Collins’s treating physician for the last

three years of his life. During that period, Dr. Younes often

stated in his treatment notes that Mr. Collins suffered from

COPD   and    pneumoconiosis.          In    Mr.   Collins’s      death    certificate,

completed less than a week after he died, Dr. Younes stated that

his    patient    had     died    of       “cardiac    arrest”     due    to    or   as   a

consequence of “respiratory failure,” and that “coal workers’

pneumoconiosis” had contributed to the death. J.A. at 194.

       Expanding on the earlier form less than two months later,

Dr. Younes explained in a letter to the Department of Labor that

Mr. Collins had severe coal workers’ pneumoconiosis and COPD

when he died, requiring hospitalization once or twice a month.

He died at home, one day after he insisted on being released

from    the      hospital        after       his      condition     had     temporarily

                                              5
stabilized.      Dr.     Younes    added       that         “Mr.    Collins         had     Severe

Respiratory Disability from his Coal Workers’ Pneumoconiosis and

there is no question that his severe Pneumoconiosis is a major

contributing factor to his death.” J.A. at 162. Dr. Younes then

stated the evidence for pneumoconiosis: Mr. Collins’s decades of

work in the coal mines, the content of his chest x-rays, and his

severe pulmonary disease.           Hospital records from just nine days

before    Mr.    Collins’s      death     noted         the       severity      of     his       lung

condition,       described         his         history             of        coal         workers’

pneumoconiosis,        and    recommended          that       doctors         not     administer

aggressive      cardiac      treatment     because           of    the       severity       of   his

pulmonary problems.

     Following      Mr.      Collins’s        death,        the    Department          of    Labor

asked    Dr.    Dominic      Gaziano,     a       board      certified         internist         and

pulmonologist,      to    review    the       miner’s        file       in    early    1998      and

answer a questionnaire regarding the circumstances of his death.

He filled out the form provided to him, indicating that although

the miner did not die from pneumoconiosis, he was disabled by it

and that the disease played a role in Mr. Collins’s death.                                       Dr.

Gaziano further stated in the comments section of the form that

Mr. Collins “died as a result of cardio-pulmonary failure in a

background of severe heart and lung diseases. I believe C.W.P.

[coal    workers’      pneumoconiosis]            was   a    significant            contributing

factor in his death.” J.A. at 195.

                                              6
       For its part, Pond Creek asked seven medical experts to

examine Mr. Collins’s medical records. Each of the seven doctors

found that Mr. Collins did not have pneumoconiosis. Six of the

seven reported that Mr. Collins had severe pulmonary disease due

to    smoking,      with     at   least    five    of    those    doctors     explicitly

classifying the pulmonary disease as COPD. Four of the doctors -

- Dr. Gregory Fino, Dr. George Zaldivar, Dr. A. Dahhan, and Dr.

Samuel   Spagnolo       –-    stated      that    the    death   was   due    purely    to

cardiac causes.

       Representative of the opinions is that of Dr. Fino, a board

certified internist and pulmonologist. Dr. Fino reported that

Mr. Collins’s x-rays did not show signs of pneumoconiosis, and

that his totally-disabling COPD was caused by cigarette smoking,

not his work in the mines. Dr. Fino further argued that Mr.

Collins’s death was due to heart disease, and that even if he

had been afflicted with pneumoconiosis, the lung disease would

not    have       exacerbated     the     particular       cardiac     condition     that

caused      the     death.    Dr.   Fino     thus       found    not   only   that     Mr.

Collins’s COPD was unrelated to coal dust exposure, but also

that the COPD did not hasten his death.

       Of particular note were the opinions of Dr. Thomas Jarboe

and   Dr.     W.K.C.    Morgan,     both    of    whom    Pond    Creek     enlisted    to

evaluate Mr. Collins’s file. Dr. Jarboe stated that Mr. Collins

was totally disabled by COPD, though the COPD was caused by

                                             7
smoking and not exposure to coal mine dust. He then concluded

that Mr. Collins died from a “combination” of his COPD and his

cardiac disease. Dr. Morgan also stated that Mr. Collins’s COPD

was due to smoking. He believed that the miner’s death was due

to a heart arrhythmia, and that the arrhythmia was exacerbated

by an oxygen deficiency known as hypoxemia, which was caused by

COPD.   Both     doctors       thus    agreed          that    Mr.   Collins’s      COPD

contributed to his death.



                                         II.

      Under the Act, we evaluate whether an ALJ’s decision that

has   been   affirmed     by    the    BRB       was    supported      by    substantial

evidence and in accordance with the law. See Collins v. Pond

Creek   Mining     Co.,    468        F.3d       213,    217    (4th        Cir.   2006).

“Substantial evidence consists of sufficient relevant evidence

to convince a reasonable mind that the evidence is adequate to

support a conclusion.” Scott v. Mason Coal Co., 289 F.3d 263,

267 (4th Cir. 2002). We review the ALJ’s and BRB’s conclusions

of law de novo. Id.

      In order for Mrs. Collins to prevail under the Act, she

must show that (1) she was the surviving spouse of a miner who

suffered from pneumoconiosis, (2) the miner’s pneumoconiosis was

due at least in part to coal mining employment, and (3) the

miner’s death was due to pneumoconiosis. See U.S. Steel Mining

                                             8
Co. v. Director, OWCP, 187 F.3d 384, 388 (4th Cir. 1999) (citing

relevant regulations). Our previous decision in this case held

that the miner had pneumoconiosis due at least in part to his

exposure to coal dust. See Collins, 468 F.3d at 223. The parties

thus agree that the sole issue before this court is the last of

the three prongs: whether Mr. Collins’s pneumoconiosis caused

his death. A coal miner’s death is “due to” pneumoconiosis if

the    disease      was   a    “substantially        contributing       cause”       of    the

death. See Bill Branch Coal Corp. v. Sparks, 213 F.3d 186, 190

(4th    Cir.    2000)      (quoting     20    C.F.R.      §   718.205).      Moreover,       a

claimant can prove causation by establishing that pneumoconiosis

“actually hastened the miner’s death.” Id. (quoting Shuff v.

Cedar Coal Co., 967 F.2d 977, 979-80 (4th Cir.1992)).

       Pond    Creek      argues    that     the    ALJ   correctly     held    that       the

opinions       of   Dr.    Younes     and    Dr.     Gaziano    were       neither    well-

reasoned nor well-documented. As a result, those opinions could

not support a finding that Mr. Collins’s pneumoconiosis hastened

his death. Furthermore, the mining company argues, the ALJ was

also correct in refusing to credit the opinions of Dr. Jarboe

and Dr. Morgan as supportive of Mrs. Collins’s claim. Because

these    experts       found     that   Mr.        Collins    did    not     suffer       from

pneumoconiosis, but instead suffered from COPD due to cigarette

smoking, their views could not provide support for a finding

that    Mr.     Collins’s       pneumoconiosis            hastened     his     death.      We

                                              9
disagree      with    Pond      Creek   and    find    that    the   ALJ’s     decision

misapplied our case law and was not supported by substantial

evidence.

       Our previous decision in this dispute drives our present

holding. There, we singled out two critical considerations for

an ALJ when evaluating medical evidence. First, we emphasized

the   importance       of    the   miner’s      treating      physician’s      opinion,

noting       that,    in    a    similar      case,    “[w]e    were      particularly

concerned with the ALJ’s wholesale rejection of the diagnosing

physician’s causation opinion and corresponding overreliance on

the   non-diagnosing         physicians’       contrary    views.”     Collins,    468

F.3d at 224; see also 20 C.F.R. § 718.104(d) (instructing ALJs

to    give    added    consideration       to    the   opinions      of    a   treating

physician, and in particular to focus on the nature and duration

of the doctor-patient relationship and the frequency and extent

of treatment).

       Second, we noted that “even a poorly documented” causation

opinion that properly diagnoses pneumoconiosis should carry more

weight than those opinions that have denied the presence of the

disease. Collins, 468 F.3d at 224 (quoting Scott, 289 F.3d at

270). For instance, in Toler v. Eastern Associated Coal Co., 43

F.3d 109 (4th Cir. 1995), we stated:

       [A]n ALJ who has found (or has assumed arguendo) that
       a claimant suffers from pneumoconiosis and has total
       pulmonary disability may not credit a medical opinion

                                           10
        that the former did not cause the latter unless the
        ALJ can and does identify specific and persuasive
        reasons for concluding that the doctor's judgment on
        the question of disability causation does not rest
        upon her disagreement with the ALJ's finding as to
        either or both of the predicates in the causal chain.

Id. at 116. Toler further advises that the opinions of those

doctors who did not properly diagnose pneumoconiosis can carry,

at most, “little weight.” Id.

       Notwithstanding Toler, the ALJ found that he could not give

any    weight    to    the     opinions      of       Dr.    Younes      or    Dr.   Gaziano,

believing himself constrained by our decision in Sparks, 213

F.3d     186.    In    that     case,       we    found      a    doctor’s       explanation

insufficient where he had merely written on a death certificate

“[c]oal workers pneumoconiosis, simple” in the blank asking for

“[o]ther       significant      conditions            contributing        to    death,”     and

noted        without     explanation             on     an       autopsy       report       that

pneumoconiosis was present at the time of death. Id. at 192. We

found that the doctor “provided no explanation of how, or if,

Mr. Sparks’s pneumoconiosis hastened his death.” Id. Absent any

treatment records or justification, the doctor simply provided

an    “insufficient,”         “bald    conclusion”           devoid      of    the   necessary

reasoning. Id.

       The    ALJ     described       the   opinions         of    Dr.     Younes     and   Dr.

Gaziano as “similarly conclusory,” J.A. at 777, but such a view

ignores the significant differences between the explanation and


                                             11
documentation in Sparks and in this case. Here, Mr. Collins had

been found to be totally disabled by pneumoconiosis nearly ten

years before his death, and had been in and out of the hospital

regularly due to his severe COPD in the years prior to his

death. His treating physician Dr. Younes had compiled copious

treatment   notes    during      the   three      years    he    was    Mr.   Collins’s

doctor, which show both the seriousness of the miner’s pulmonary

condition and the toll it had taken on his body. In his letter

to the Department of Labor, Dr. Younes laid out the details of

Mr.   Collins’s     final     weeks         and   months,        demonstrating        his

intricate   understanding        of    his    patient’s         worsening     state    of

health. Meanwhile, Dr. Gaziano stated that his opinion was based

on a review of the case file, which at the time included Mr.

Collins’s treatment history, death certificate, and additional

hospital records.

      Unlike in Sparks, where a doctor with no significant ties

to    the   patient       decreed      in     a    few     cryptic          words    that

pneumoconiosis      had   been    a    contributing        cause       of   death,    Dr.

Younes’s    explanatory     letter      relied      upon    a    lengthy      treatment

history and his first-hand observations of the damage the coal-

dust-triggered pulmonary disability inflicted upon his patient.

The ALJ was mistaken to equate these two fundamentally different

situations so as to find that Sparks applied.



                                         12
       Unconstrained      by        the     mistaken    analogy        to   Sparks,      an

evaluation of the opinions of Dr. Younes and Dr. Gaziano shows

that    they    provide      sufficient           evidence    that      Mr.     Collins’s

pneumoconiosis hastened his death. It is true that Dr. Gaziano

could have explained in more detail the exact manner in which

Mr. Collins’s pneumoconiosis contributed to his respiratory and

cardiac failure. But the opinions, and certainly that of Dr.

Younes,      were   not   poorly          documented.    Whatever       their     alleged

deficiencies, our decisions in Collins and Scott counsel that

the physicians’ explanations were adequate and entitled to more

weight than those physicians for Pond Creek who mistakenly found

no presence of the disease at all. Indeed, as the Director has

noted, if the opinions were insufficient as a matter of law to

prove death causation, as the ALJ claimed, there would have been

no reason for us to remand this case for a finding of death

causation in our 2006 decision. See Br. of Director, Office of

Workers’     Compensation       Programs,         at   25-26.    The    ALJ     erred    in

according      no   weight     to    the     opinions    of     Dr.    Younes    and    Dr.

Gaziano.

       Furthermore, we note that Dr. Younes and Dr. Gaziano were

not    the   only    doctors        whose    opinions    provide       support     for    a

finding that Mr. Collins’s COPD hastened his death. Dr. Jarboe

and Dr. Morgan also both explained the connection between Mr.

Collins’s COPD and his death. Dr. Jarboe stated that the miner

                                             13
died due to a combination of severe respiratory problems brought

on by COPD and heart disease. Dr. Morgan, meanwhile, determined

that Mr. Collins had died from an arrhythmia, which was worsened

by his hypoxemia, which was in turn caused by his COPD. Both

doctors     agreed    that   the   COPD    hastened        Mr.    Collins’s    death,

though both believed that it was caused by his cigarette smoking

and not his work in the mines.

      Our    ruling     in   Collins       that      the    1988     ALJ   decision

established that Mr. Collins’s COPD was caused in part by his

pneumoconiosis renders the opinions of Dr. Jarboe and Dr. Morgan

incorrect     regarding      the    presence         of     pneumoconiosis.      But

crucially, although Dr. Jarboe and Dr. Morgan disagreed with Dr.

Younes and Dr. Gaziano about what caused Mr. Collins’s COPD,

their opinions are in accord that the COPD hastened the miner’s

death.      Under our decision in Toler, these opinions, which did

not find the presence of pneumoconiosis, can be accorded only

lesser weight. Still, the weight they do carry acts to support

the   findings   of    Dr.   Younes    and     Dr.   Gaziano       regarding    death

causation. All four doctors agree that Mr. Collins had COPD and

that it hastened his death. And crucially, we have earlier held

that his COPD qualified as pneumoconiosis. See Collins, 468 F.3d

at 224 (noting that due to the 1988 ALJ Decision’s finding that

Mr. Collins’s COPD was caused in part by his work in the coal

mines,       “Mrs.     Collins        established           the      presence      of

                                          14
pneumoconiosis”). Thus, contrary to Pond Creek’s arguments and

the ALJ’s ruling below, Dr. Jarboe and Dr. Morgan provide at

least some additional support for a finding that Mr. Collins’s

pneumoconiosis hastened his death.

     In fact, the ALJ confirmed multiple times in his opinion

that Mr. Collins’s COPD was a cause of his death. See J.A. at

776-77. After our 2006 decision, there is no dispute that the

miner was totally disabled by pneumoconiosis. The ALJ argued,

however, that “it is not a foregone conclusion that this same

pulmonary impairment caused miner’s death; in fact, many of the

physicians in the present case opined that miner’s death was

purely cardiac, despite his respiratory failure.” J.A. at 777.

     This reasoning is flawed in two ways. First, there is no

support in the record that Mr. Collins suffered from a different

pulmonary impairment beyond the COPD that we have already held

to be pneumoconiosis. The ALJ’s observation that some doctors

opined that Mr. Collins’s death was purely cardiac in nature

provides no support for the presence of a second respiratory

problem   that   may   have   contributed   to   his   death.   Second,   the

relationship     between   severe   pulmonary    impairment     and   cardiac

functioning is well known. The body is an integrated organism. A

part can drag down the whole. The ALJ was right to dismiss the

possibility of a purely cardiac death, stating that “there is no

disputing that miner suffered from, and died of, respiratory

                                     15
failure.” J.A. at 777. It is only by relying on this rejected

explanation of an exclusively cardiac event that it is possible

to avoid the finding of death causation mandated by the record.



                                     III.

       Unlike after our previous decision in this case, no factual

issues remain to be determined by an ALJ. Mrs. Collins was 62

years old when she first filed her claim. She is now 78. We

hold, better late than never, that she has satisfied the test

for survivor’s benefits: she is the surviving spouse of a miner

whose death was hastened by pneumoconiosis due at least in part

to coal mine employment. The ravages of her husband’s long years

in the mines should yield at least the legacy of provision for

his    surviving    spouse.    No     further   factual   development   is

necessary. We reverse the BRB’s order and remand with directions

to    award   benefits   without    further   administrative   proceedings.

See Scott v. Mason Coal Co., 289 F.3d 263, 270 (4th Cir. 2002).



                                                    REVERSED AND REMANDED




                                      16
