Joseph R. Shelton v. Garden Creek Pocahontas Company (Board decision, June 24, 2025)

BRB final decision. The Benefits Review Board affirmed the administrative law judge's award of black lung benefits. Under 20 C.F.R. § 802.406, a Board decision becomes final 60 days after issuance unless a timely petition for judicial review or a timely request for Board reconsideration is filed. A party may request Board reconsideration within 30 days under 20 C.F.R. § 802.407.

Plain-English summary

Joseph Shelton pursued black lung benefits in a subsequent claim after an earlier denial. The administrative law judge found complicated pneumoconiosis arising from coal mine work and awarded benefits under the irrebuttable Section 411(c)(3) presumption. Garden Creek Pocahontas challenged the judge's x-ray analysis and argued that other medical evidence undercut the finding. The Board upheld her decision to give greater weight to newer positive x-rays and found that the other evidence did not outweigh them. It affirmed the benefits award.

Decision snapshot

• Authority: Irrebuttable complicated-pneumoconiosis presumption under 30 U.S.C. § 921(c)(3) and 20 C.F.R. § 718.304.
• Outcome: The administrative law judge's black lung benefits award was affirmed.
• Key point: The judge could credit recent positive x-rays after weighing all relevant evidence for and against complicated pneumoconiosis.

Full text (DOL BRB public release)

U.S. Department of Labor
Benefits Review Board
200 Constitution Ave. NW
Washington, DC 20210-0001

BRB No. 24-0229 BLA

JOSEPH R. SHELTON
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Claimant-Respondent
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v. )
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NOT-PUBLISHED
GARDEN CREEK POCAHONTAS
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COMPANY
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) DATE ISSUED: 06/24/2025
Self-Insured Employer-
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Petitioner
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DIRECTOR, OFFICE OF WORKERS’
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COMPENSATION PROGRAMS, UNITED
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STATES DEPARTMENT OF LABOR
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Party-in-Interest
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DECISION and ORDER
Appeal of the Decision and Order Granting Benefits of Dierdra M. Howard, Administrative Law Judge, United States Department of Labor.

John R. Sigmond (Penn, Stuart & Eskridge), Bristol, Virginia, for Employer.

Before: GRESH, Chief Administrative Appeals Judge, ROLFE and JONES, Administrative Appeals Judges.

PER CURIAM:
Employer appeals Administrative Law Judge (ALJ) Dierdra M. Howard’s Decision and Order Granting Benefits (2021-BLA-06041) rendered on a claim filed pursuant to the Black Lung Benefits Act, as amended, 30 U.S.C. §§901-944 (2018) (Act). This case involves a subsequent claim filed on December 30, 2019.1

The ALJ credited Claimant with 14.5 years of coal mine employment. She found he established complicated pneumoconiosis pursuant to 20 C.F.R. §718.304(a), thereby invoking the irrebuttable presumption of total disability due to pneumoconiosis at Section 411(c)(3) of the Act. 30 U.S.C. §921(c)(3). She also determined that Claimant’s complicated pneumoconiosis arose out of his coal mine employment and therefore awarded benefits. 20 C.F.R. §718.203(b).

On appeal, Employer argues the ALJ erred in finding Claimant established complicated pneumoconiosis.2 Neither Claimant nor the Acting Director, Office of Workers’ Compensation Programs, has filed a response.

The Benefits Review Board’s scope of review is defined by statute. We must affirm the ALJ’s Decision and Order if it is rational, supported by substantial evidence, and in

1 Claimant filed a prior claim on September 22, 2003, which the district director

denied for failure to establish any element of entitlement. Director’s Exhibits 1, 3; see also Decision and Order at 2-3 (the ALJ indicated the previous claim was not before her and she thus assumed Claimant failed to establish any element of entitlement in the prior claim). When a miner files a claim for benefits more than one year after the denial of a previous claim becomes final, the ALJ must also deny the subsequent claim unless she finds that “one of the applicable conditions of entitlement . . . has changed since the date upon which the order denying the prior claim became final.” 20 C.F.R. §725.309(c); White v. New White Coal Co., 23 BLR 1-1, 1-3 (2004). The “applicable conditions of entitlement” are “those conditions upon which the prior denial was based.” 20 C.F.R. §725.309(c)(3). Because the district director denied Claimant’s prior claim for failing to establish any element of entitlement, he had to submit new evidence establishing any element to obtain review of his current claim on the merits. See 20 C.F.R. §725.309(c)(3), (4); White, 23 BLR at 1-3; Decision and Order at 2-3.
2 We affirm, as unchallenged on appeal, the ALJ’s finding that Claimant established

14.5 years of coal mine employment. See Skrack v. Island Creek Coal Co., 6 BLR 1-710, 1-711 (1983); Decision and Order at 9.

2 accordance with applicable law.3 33 U.S.C. §921(b)(3), as incorporated by 30 U.S.C.
§932(a); O’Keeffe v. Smith, Hinchman & Grylls Assocs., Inc., 380 U.S. 359 (1965).

Invocation of the Section 411(c)(3) Presumption - Complicated Pneumoconiosis

Section 411(c)(3) of the Act, 30 U.S.C. §921(c)(3), provides an irrebuttable presumption that a miner is totally disabled due to pneumoconiosis if he suffers from a chronic dust disease of the lung which: (a) when diagnosed by x-ray, yields one or more large opacities greater than one centimeter in diameter that would be classified as Category A, B, or C; (b) when diagnosed by biopsy or autopsy, yields massive lesions in the lung; or (c) when diagnosed by other means, is a condition that would yield results equivalent to (a) or (b). See 20 C.F.R. §718.304. In determining whether a claimant has invoked the irrebuttable presumption, the ALJ must weigh all evidence relevant to the presence or absence of complicated pneumoconiosis. See Westmoreland Coal Co. v. Cox, 602 F.3d 276, 283 (4th Cir. 2010); E. Assoc. Coal Corp. v. Director, OWCP [Scarbro], 220 F.3d 250, 255-56 (4th Cir. 2000); Melnick v. Consolidation Coal Co., 16 BLR 1-31, 1-33-34 (1991) (en banc). The ALJ found Claimant established the presence of complicated pneumoconiosis based on the x-ray evidence and when weighing the evidence as a whole.4 20 C.F.R. §718.304; Decision and Order at 17, 39-40.

X-Ray Evidence - 20 C.F.R. §718.304(a)

The ALJ considered twelve interpretations of four x-rays dated May 21, 2020, February 12, 2021, March 10, 2022, and March 23, 2022. Decision and Order at 12-17; Director’s Exhibits 13, 19, 20; Claimant’s Exhibits 1-4; Employer’s Exhibits 1, 3-5. She noted Dr. Forehand is solely a B reader while the other four interpreting physicians are dually-qualified as Board-certified radiologists and B readers; thus, she accorded the x-ray interpretations from the dually-qualified readers more weight. Decision and Order at 12.

In all of Dr. Adcock’s readings, he marked the International Labour Organization (ILO) x-ray form as entirely negative for pneumoconiosis but noted the presence of “end-

3 The Board will apply the law of the United States Court of Appeals for the Fourth

Circuit because Claimant performed his last coal mine employment in Virginia. See Shupe v. Director, OWCP, 12 BLR 1-200, 1-202 (1989) (en banc); Hearing Transcript at 10.
4 The ALJ found the computed tomography scan evidence, medical opinion evidence, and Claimant’s treatment records do not affirmatively support a finding of complicated pneumoconiosis, but do not undermine the positive x-ray evidence. 20 C.F.R.
§718.304(c); Decision and Order at 21, 37, 39-40. As the ALJ indicates, there is no pathology evidence of record. 20 C.F.R. §718.304(b); Decision and Order at 17.

3 stage unilateral left pleuro-parenchymal fibrosis with acquired minihemi-thorax” and provided multiple differential diagnoses.5 Employer’s Exhibits 1-5. The ALJ accorded his opinions less weight as he is the only reader to “repeatedly” find the absence of even simple clinical pneumoconiosis. Decision and Order at 13. She also accorded his opinions less weight for the reasons she gave when addressing the individual x-rays, addressed below.

May 21, 2020 X-Ray

Drs. Forehand and Ramakrishnan read the May 21, 2020 x-ray as positive for simple clinical pneumoconiosis. Director’s Exhibit 13 at 7; Claimant’s Exhibit 4. Dr. Ramakrishnan also noted coalescence of opacities. Claimant’s Exhibit 4. Dr. Crum interpreted the x-ray as positive for both simple and complicated pneumoconiosis, Category A, and noted coalescence. Claimant’s Exhibit 2 at 1-2. Both Drs. Adcock and Simone noted fibrosis in Claimant’s left lung and indicated the x-ray was negative for pneumoconiosis.6 Director’s Exhibit 20 at 3; Employer’s Exhibit 1. The ALJ found the entirely negative readings of Drs. Adcock and Simone were less persuasive and not well- reasoned when compared to the three consistent readings of Drs. Forehand, Ramakrishnan, and Crum, who all found at least simple pneumoconiosis. Decision and Order at 13-14. She also noted that while both Drs. Adcock and Simone observed “extensive” fibrosis, neither indicated any small or large opacites on the ILO form. Id. at 14. Weighing the readings together, she found the x-ray supported a finding of simple, but not complicated, pneumoconiosis. Id. at 14.

February 12, 2021 X-Ray

Dr. Crum read the February 12, 2021 x-ray as positive for simple and complicated pneumoconiosis, Category A, and noted coalescence. Director’s Exhibit 19 at 2-3. Dr. Adcock read the x-ray as negative for pneumoconiosis. Employer’s Exhibit 3. The ALJ accorded less weight to Dr. Adcock’s reading as unpersuasive, for her previously discussed

5 Differential diagnoses included “pulmonary artery or vein interruption,
gastroesophageal reflux, ventilator injury, idiopathic pulmonary fibrosis, pleuroparenchymal fibroelastosis, S/P median sternotomy.” Employer’s Exhibit 1; see also Employer’s Exhibits 2-5 (substantially the same but also noting an infusion catheter).
6 Dr. Simone noted “extensive upper lobe fibrosis present, presumably secondary to

the cardiac surgery” and “no evidence of rounded opacities that would suggest coal workers
[sic] pneumoconiosis. No large opacities are present.” Director’s Exhibit 20 at 2.

4 reasons. Decision and Order at 13, 15. She concluded this x-ray “leans in favor” of a finding of complicated pneumoconiosis.7 Id. at 15.

March 10 and March 23, 2022 X-Rays

Two x-rays were performed in March 2022. Dr. Ramakrishnan read both x-rays as positive for complicated pneumoconiosis, Category A. 8 Claimant’s Exhibits 1, 3. On the other hand, Dr. Adcock again determined both x-rays were negative for pneumoconiosis. Employer’s Exhibits 2, 4, 5. The ALJ found the probative value of Dr. Adcock’s interpretations was limited for the reasons previously discussed and, contrary to the other physicians’ opinions that described the abnormalities as bilateral, Dr. Adcock noted unilateral changes, which she found also undermined the credibility of his readings. Decision and Order at 16. Thus, she accorded greater weight to Dr. Ramakrishnan’s positive x-ray readings over Dr. Adcock’s negative readings to find the March 10, 2022 and March 23, 2022 x-rays support a finding of complicated pneumoconiosis. Decision and Order at 15-17.

Weighing the x-ray evidence together, and according more weight to the more recent evidence, the ALJ found the x-ray evidence supports a finding of complicated pneumoconiosis. Decision and Order at 17. She was particularly persuaded by the progression of the disease demonstrated in Dr. Ramakrishnan’s readings. Id.

Employer argues the ALJ erroneously presumed Claimant had complicated pneumoconiosis based on the x-ray evidence and then shifted the burden, requiring Employer to exclude pneumoconiosis. Employer’s Brief at 4-5. Specifically, it contends the ALJ held Employer’s readers to a different standard and mischaracterized the consistency of Dr. Ramakrishnan’s and Dr. Crum’s readings. We disagree.

Initially, although Employer is correct that Dr. Ramakrishnan read the May 21, 2020 x-ray as consistent with simple pneumoconiosis, profusion 1/1, and Dr. Crum read the same x-ray as profusion 2/3, with a large opacity, it fails to explain how this alleged inconsistency could make any difference in the outcome, especially considering the ALJ found this x-ray does not support a finding of complicated pneumoconiosis. See Shinseki

7 She indicated that while Dr. Crum commented there was “likely” a Category A opacity, she found his use of the word did not detract from a finding of complicated pneumoconiosis, as he clearly marked Category A on the x-ray form. Decision and Order at 14.
8 In his reading of the March 10, 2022 x-ray, Dr. Ramakrishnan noted that the x-ray

should be compared with previous imaging to rule out neoplasm. Claimant’s Exhibit 3.

5 v. Sanders, 556 U.S. 396, 413 (2009) (appellant must explain how the “error to which [it] points could have made any difference”); Employer’s Brief at 5-7.

Similarly, we reject Employer’s argument that the ALJ irrationally credited Dr.
Ramakrishnan’s x-ray readings because the ALJ failed to consider the alleged disparity in the shape and profusion of the opacities Dr. Ramakrishnan identified in his two March 2022 readings. Employer’s Brief at 6-7. The ALJ was not required to further evaluate Dr. Ramakrishnan’s positive readings because they contained differing numerical classifications (i.e., 2/3 profusion and then 3/2 profusion) and Employer has not explained how such findings are disparate.9 20 C.F.R. §718.102(a); Claimant’s Exhibits 1, 3. Further, Employer fails to explain how this alleged error undermines the ALJ’s reliance on Dr. Ramakrishnan’s repeated finding of complicated pneumoconiosis. See Shinseki, 556 U.S. at 413; Employer’s Brief at 7. The ALJ acted within her discretion in crediting Dr. Ramakrishnan’s x-ray readings as she found his observation of coalescence credible because it was twice corroborated by Dr. Crum and supported the finding that Claimant’s disease progressed from simple to complicated pneumoconiosis over time. 10 See Harman

9 The International Labour Organization (ILO) x-ray form allows a radiologist to

identify if there are any parenchymal abnormalities consistent with pneumoconiosis. 20 C.F.R. §718.102(d) (standards for classifying x-rays, incorporating by reference Guidelines for the Use of the ILO International Classification of Radiographs of
Pneumoconioses) (ILO Guidelines).
If the radiologist indicates there are such
abnormalities, the radiologist should identify the profusion, affected zones of the lung, and shape and size of any opacities. ILO Guidelines 3-6 (revised ed. 2022). The profusion of opacities refers to the concentration of small opacities in affected zones of the lung and includes four categories ranging from 0 to 3 representing increasing profusion. Id. at 3-4. A radiologist may identify that an alternative category was seriously considered through use of an “an oblique stroke, i.e. 0/ , 1/ , 2/ , 3/.” Id. at 4. Thus, a radiologist who indicates a profusion of 2/3 is stating that the profusion is 2, but the radiologist seriously considered a profusion of 3. See id.
10 As Employer notes, while the ALJ cited Dr. Ramakrishnan’s “repeated” identification of coalescence of small opacities up until 2022, he provided only one reading of coalescence prior to identifying a Category A opacity. Decision and Order at 17; Claimant’s Exhibits 1, 3, 4. However, Employer has not explained how this misstatement undermined the ALJ’s findings given Dr. Ramakrishnan’s notation of coalescence on the May 21, 2020 x-ray and his repeated diagnosis of a Category A opacity in subsequent readings, as well as Dr. Crum’s identification of coalescence and large opacities on the May 21, 2020 and February 12, 2021 x-rays. See Shinseki v. Sanders, 556 U.S. 396, 413 (2009); Grizzle v. Pickands Mather & Co., 994 F.2d 1093, 1096 (4th Cir. 1993) (ALJ has 6
Mining Co. v. Director, OWCP [Looney], 678 F.3d 305, 310 (4th Cir. 2012); Island Creek Coal Co. v. Compton, 211 F.3d 203, 211 (4th Cir. 2000); Adkins v. Director, OWCP, 958 F.2d 49, 52 (4th Cir. 1992); Decision and Order at 14, 16-17; Director’s Exhibit 19 at 2-3; Claimant’s Exhibits 2 at 1-2; 4 at 1-2.

Additionally, we see no error in the ALJ’s according less weight to the negative readings of Drs. Simone and Adcock. The ALJ permissibly discredited Dr. Simone’s reading for failing to explain how he could differentiate Claimant’s fibrosis from pneumoconiosis or determine it was secondary to cardiac surgery. See Milburn Colliery Co. v. Hicks, 138 F.3d 524, 528 (4th Cir. 1998); Sterling Smokeless Coal Co. v. Akers, 131 F.3d 438, 441 (4th Cir. 1997); see also Kertesz v. Director, OWCP, 788 F.2d 158, 163 (3d Cir. 1986) (ALJ is not bound to accept the opinion of any expert, but may weigh the evidence and draw his or her own inferences); Decision and Order at 14; Director’s Exhibit 20 at 2-3. She was also within her discretion to find Dr. Simone’s assertion that rounded opacities are required to diagnose clinical pneumoconiosis to be unpersuasive. See 20 C.F.R. §718.102(d) (standards for classifying x-rays, incorporating by reference Guidelines for the Use of the ILO International Classification of Radiographs of Pneumoconioses (ILO Guidelines)); ILO Guidelines 5 (revised ed. 2022) (ILO classification system specifically provides that small opacities of pneumoconiosis may be classified as round (p, q, r) or irregular (s, t, u)); see also Scarbro, 220 F.3d at 257-58 (complicated pneumoconiosis is established by the application of “congressionally-defined criteria;” when medical and legal standards for the disease diverge, the standard established by Congress applies); Decision and Order at 14.

The ALJ similarly acted within her discretion in finding Dr. Adcock’s opinion unpersuasive as he was the only physician to repeatedly find the absence of even simple clinical pneumoconiosis and the presence of unilateral fibrosis, in contrast to the other physicians’ notations of bilateral changes. See Hicks, 138 F.3d at 528; Akers, 131 F.3d at 441; Dempsey v. Sewell Coal Corp., 23 BLR 1-47, 1-65 (2004) (en banc); Decision and Order at 13. Further, she permissibly found that while Dr. Adcock’s readings included multiple differential diagnoses regarding the fibrosis he acknowledged, he failed to mention pneumoconiosis or indicate the presence of any opacities (whether small or large) on the ILO form. See 20 C.F.R. §718.102; Mingo Logan Coal Co. v. Owens, 724 F.3d 550, 558 (4th Cir. 2013); Decision and Order at 14; Employer’s Brief at 5, 8; Employer’s Exhibits 1, 3-5.

exclusive power to make credibility determinations and resolve inconsistencies in the evidence); Decision and Order at 7; Employer’s Brief at 6-7.

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 Thus, the ALJ properly performed both a qualitative and quantitative analysis of the conflicting x-ray readings and explained her basis for resolving the conflicts in the x-ray evidence. See Sea “B” Mining Co. v. Addison, 831 F.3d 244, 256 (4th Cir. 2016); Adkins, 958 F.2d at 52-53; Decision and Order at 13-17.

Moreover, considering the x-ray evidence as a whole, the ALJ permissibly took recency into account to find the three more recent x-rays which supported a finding of complicated pneumoconiosis were more probative than the oldest x-ray from May 21, 2020, which demonstrated only simple clinical pneumoconiosis. See Adkins, 958 F.2d at 52 (A “later test or exam” is a “more reliable indicator of a miner’s condition than an earlier one” when “a miner’s condition has worsened” given the progressive nature of pneumoconiosis.); Decision and Order at 17.

Employer’s arguments regarding the x-ray evidence amount to a request to reweigh the evidence, which we are not empowered to do. Anderson v. Valley Camp of Utah, Inc., 12 BLR 1-111, 1-113 (1989). Because it is supported by substantial evidence, we affirm the ALJ’s conclusion that the weight of the x-ray evidence establishes complicated pneumoconiosis at 20 C.F.R. §718.304(a). See Scarbro, 220 F.3d at 255-56; Compton, 211 F.3d at 211.

20 C.F.R. §718.304(c) – Other Medical Evidence Computed Tomography (CT) Scans

The ALJ next considered eleven interpretations of six CT scans dated August 22, 2019, June 3, 2020, October 23, 2020, January 12, 2021, June 29, 2021, and June 29, 2022. Decision and Order at 18-22; Claimant’s Exhibits 5-10; Employer’s Exhibits 9-14.

The August 22, 2019 CT scan was read by Drs. Vijay Ramakrishnan11 and Adcock.
Claimant’s Exhibit 5; Employer’s Exhibit 10. Dr. Ramakrishnan read the CT scan as showing moderate to severe bilateral pulmonary fibrosis with “no significant airway obstruction or significant space-occupying masses.” Claimant’s Exhibit 5. Dr. Adcock identified no opacities “typical of coal workers pneumoconiosis” and, similar to his x-ray readings, diagnosed “severe unilateral left pulmonary fibrosis” with differential diagnoses of pleuro-parenchymal fibroelastosis, pulmonary vein occlusion, ventilatory injury, gastroesophageal reflux disease, atypical idiopathic pulmonary fibrosis, and radiation pneumonitis. Employer’s Exhibit 10 at 2.

11 Dr. M. R. Ramakrishnan interpreted the x-rays discussed above, while Dr. Vijay

Ramakrishnan interpreted the CT scans.

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 Drs. Ramakrishnan and Adcock also read the June 3, 2020 CT scan. Claimant’s Exhibit 6; Employer’s Exhibit 11. Dr. Ramakrishnan observed stable pulmonary fibrosis with bilateral fibrotic changes and “[n]o suspicious interval changes.” Claimant’s Exhibit

6. Dr. Adcock noted “no change.” Employer’s Exhibit 11. On the October 23, 2020 CT
   scan, Dr. Ramakrishnan observed stable fibrotic changes and “no new space-occupying lesions,” while Dr. Adcock again noted, “no change.” Claimant’s Exhibit 7; Employer’s Exhibit 12.

   Drs. Rao and Adcock read the January 12, 2021 CT scan. Dr. Rao noted bilateral
   chronic fibrotic changes with no new consolidation, pleural, or pericardial effusion, while Dr. Adcock’s interpretations remained the same. Claimant’s Exhibit 8; Employer’s Exhibit 13.

   Dr. Ramakrishnan read the June 29, 2021 CT scan and observed stable bilateral
   

   chronic fibrosis with no new consolidation, pleural, or pericardial effusion. Claimant’s Exhibit 9. Dr. Adcock’s interpretation remained largely the same as he noted “severe unilateral left pulmonary fibrosis with diffuse pleural reaction . . . not consistent with coal workers’ pneumoconiosis.” Employer’s Exhibit 14 at 2. Finally, only Dr. Ramakrishnan read the June 29, 2022 CT scan. He observed stable moderate to severe chronic interstitial fibrosis with “no new consolidation, pleural, or pericardial effusion.” Claimant’s Exhibit 10.

   The ALJ noted that the CT scan evidence documents abnormalities but does not
   specifically address their etiology or document a mass greater than one centimeter; thus, it does not support a finding of complicated pneumoconiosis. Decision and Order at 21. But she found it significant that all but one of the CT scans predate the x-ray evidence demonstrating complicated pneumoconiosis. Id. Thus, she determined the CT scan evidence does not weigh against a finding of complicated pneumoconiosis. Id.

   Employer asserts the ALJ erred in finding the CT scans do not undercut her
   conclusion that the x-ray evidence establishes complicated pneumoconiosis. Employer’s Brief at 7-9. We disagree.

   The ALJ accurately indicated that CT scans need not be weighed more heavily than
   the x-ray evidence. See Consolidation Coal Co. v. Director, OWCP [Stein], 294 F.3d 885, 890-93 (7th Cir. 2002) (in the absence of controlling statutory language or guidance from the Department of Labor, an ALJ’s weighing of CT scan evidence may be accorded deference, unless it is irrational or unlawful); Anderson, 12 BLR at 1-113; Decision and Order at 18, 21; Claimant’s Exhibit 10. Further, contrary to Employer’s argument, the ALJ permissibly found the absence of a specific diagnosis of pneumoconiosis or a large opacity on the CT scans does not weigh against a finding of complicated pneumoconiosis,

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   particularly when Drs. Ramakrishnan and Rao performed their readings for the purpose of treatment. See Looney, 678 F.3d at 316-17; Marra v. Consolidation Coal Co., 7 BLR 1- 216, 1-218-19 (1984) (ALJ has discretion to determine the weight to accord diagnostic testing that is silent on the existence of pneumoconiosis); Decision and Order at 21; Employer’s Brief at 8.

   Moreover, the ALJ permissibly found the CT scans do not warrant as much weight
   as the x-ray evidence, as all but the June 29, 2022 CT scan, which does not specifically exclude a large opacity,12 predates the x-ray evidence that supports a finding of complicated pneumoconiosis. Decision and Order at 21; see Adkins, 958 F.2d at 52; Thorn v. Itmann Coal Co., 3 F.3d 713, 718-19 (4th Cir. 1993) (irrational to credit evidence solely based on recency when it purportedly demonstrates the miner’s condition improved); Kincaid v. Island Creek Coal Co., 26 BLR 143, 1-49-52 (2023). Thus, even if the ALJ had credited Dr. Adcock’s readings of no pneumoconiosis or large opacities in the earlier CT scans, Employer has failed to explain why the ALJ was required to accord such evidence greater weight than the more recent x-ray evidence. See Shinseki, 556 U.S. at 413.

   We therefore affirm the ALJ’s conclusion that the CT scan evidence weighs neither
   

   for nor against the finding of complicated pneumoconiosis but corroborates the presence of fibrosis. 20 C.F.R. §718.304(c); Decision and Order at 21-22.

   Medical Opinions

   The ALJ next considered the four medical opinions of record. Decision and Order
   at 22-37; Director’s Exhibit 13; Claimant’s Exhibit 11; Employer’s Exhibits 2, 7-9. Drs. Forehand’s, Sargent’s, and Rosenberg’s opinions are silent as to the presence of complicated pneumoconiosis.13 Dr. Adcock concluded the disease was absent, opining the precise etiology of the “significant lesion” involving the left lung and pleura that he found was unknown, but opined Claimant likely has a rare manifestation of predominantly

   12 Only Dr. Ramakrishnan read the most recent CT scan, and the ALJ accurately
   noted he did not specify, as he had in his prior CT scan readings, a failure to observe “significant space-occupying masses.” Decision and Order at 21; Claimant’s Exhibits 5, 7, 10.
   13 Dr. Forehand diagnosed simple clinical and legal pneumoconiosis. Director’s
   Exhibit 13 at 5. Dr. Sargent diagnosed a moderate restrictive impairment and could not exclude an “atypical presentation” of simple clinical pneumoconiosis. Claimant’s Exhibit 11 at 2. Dr. Rosenberg diagnosed bronchitis and predominantly unilateral fibrotic lung disease. Employer’s Exhibits 2 at 8; 8 at 16.

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   unilateral pleuroparenchymal fibroelastosis.14 Director’s Exhibit 13 at 5; Claimant’s Exhibit 11; Employer’s Exhibits 2, 7-9. The ALJ accorded little weight to Dr. Adcock’s opinion and concluded that the medical opinion evidence does not “independently” support a finding that Claimant suffers from complicated pneumoconiosis. Decision and Order at 37.

   Employer argues the ALJ erred in finding the medical opinions do not undercut her
   finding that the x-ray evidence establishes complicated pneumoconiosis. Employer’s Brief at 7-10. We disagree. The ALJ permissibly found the reports of Drs. Forehand, Sargent,15 and Rosenberg do not specifically address the issue of complicated pneumoconiosis and therefore do not undercut a finding of complicated pneumoconiosis. See Marra, 7 BLR at 1-218-19; Decision and Order at 24, 26, 37; Director’s Exhibit 13; Claimant’s Exhibit 11; Employer’s Exhibits 2, 7-9.

   Additionally, the ALJ reasonably discredited Dr. Adcock’s opinion based on her
   findings regarding the doctor’s entirely negative interpretations of the x-ray and CT scan evidence, which his medical opinion primarily relies upon. See Looney, 678 F.3d at 316- 17; Compton, 211 F.3d at 212 (medical opinion based on a discredited x-ray is not probative evidence); Akers, 131 F.3d at 441; Decision and Order at 28. Further, the ALJ rationally found Dr. Adcock’s opinion was unpersuasive as the doctor implied that a finding of pneumoconiosis requires evidence of rounded opacities, which is contrary to the regulatory definition of the disease.16 20 C.F.R. §718.102; ILO Guidelines; Decision and

   14 After indicating that congenital causes were unlikely, Dr. Adcock provided
   differential diagnoses including the following acquired conditions: “phrenic nerve palsy, fibrothorax, atypical idiopathic pulmonary fibrosis, ventilator injury, pleuroparenchymal fibroelastosis, posttraumatic hemothorax, and other rare conditions[].” Employer’s Exhibit 9 at 2.
   15 The ALJ accurately noted that Drs. Forehand’s and Sargent’s opinions also
   predate the evidence that supports a finding of complicated pneumoconiosis and therefore do not undercut a finding of complicated pneumoconiosis. Decision and Order at 24, 26.
   16 Additionally, the ALJ acted within her discretion in finding, as unpersuasive, Dr.

Adcock’s opinion that Claimant could potentially have a “rare manifestation of predominantly unilateral pleuroparenchymal fibroelastosis” but not an “atypical” presentation of pneumoconiosis. See Westmoreland Coal Co. v. Cochran, 718 F.3d 319, 324 (4th Cir. 2013); Knizner v. Bethlehem Mines Corp., 8 BLR 1-5, 1-7 (1985); Decision and Order at 29. As the ALJ also noted, while Dr. Adcock noted no small or large opacities “typical” of pneumoconiosis, he noted “a stable but significant lesion” involving the left lung; thus, she did not find his opinion persuasively excludes complicated pneumoconiosis.
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Order at 28; Employer’s Exhibit 9 at 2. We therefore affirm, as supported by substantial evidence, the ALJ’s according little weight to Dr. Adcock’s opinion on the issue of complicated pneumoconiosis. See Compton, 211 F.3d at 211; Decision and Order at 29.

Therefore, we affirm the ALJ’s determination that the medical opinion evidence neither supports nor undermines a finding of complicated pneumoconiosis.17 20 C.F.R.
§718.304(a), (c); Decision and Order at 24, 26, 29, 37. We further affirm her determination that the “other evidence” under 20 C.F.R. §718.304(c) does not outweigh the x-ray evidence and therefore Claimant established complicated pneumoconiosis based on the evidence as a whole, thus invoking the irrebuttable presumption of total disability due to pneumoconiosis.18 20 C.F.R. §718.304; Decision and Order at 39-40. In addition, we affirm, as unchallenged on appeal, the ALJ’s finding that Claimant’s complicated pneumoconiosis arose out of his coal mine employment. See Skrack v. Island Creek Coal Co., 6 BLR 1-710, 1-711 (1983); 20 C.F.R. §718.203(b); Decision and Order at 40.

Decision and Order at 29; Employer’s Exhibit 9 at 3. Employer does not challenge these findings. See Skrack, 6 BLR at 1-711.
17 We also affirm, as unchallenged on appeal, the ALJ’s determination to accord limited probative value to Claimant’s treatment record evidence. See Skrack, 6 BLR at 1- 711; Decision and Order at 39.
18 Because we affirm the ALJ’s finding that Claimant established complicated pneumoconiosis, we need not address Employer’s argument that the ALJ erred in her findings regarding simple clinical pneumoconiosis and legal pneumoconiosis. See Larioni v. Director, OWCP, 6 BLR 1-1276, 1-1278 (1984); Employer’s Brief at 11-12.

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Accordingly, we affirm the ALJ’s Decision and Order Granting Benefits.

SO ORDERED.

DANIEL T. GRESH, Chief
Administrative Appeals Judge

JONATHAN ROLFE
Administrative Appeals Judge

MELISSA LIN JONES
Administrative Appeals Judge