Ault v. SSA CV-10-553-JL 1/10/12

UNITED STATES DISTRICT COURT DISTRICT OF NEW HAMPSHIRE

Stephanie V . Ault v. Civil N o . 10-cv-553-JL Opinion N o .

Michael J. Astrue, Commissioner, Social Security Administration

MEMORANDUM ORDER

This is an appeal from the denial of a claimant’s

application for Social Security Disability Benefits. See

(g). The claimant, Stephanie Ault, contends that the

administrative law judge (“ALJ”) incorrectly found that although

Ault was severely impaired by degenerative joint disease in her

left knee and left femoral neuropathy, Admin. R. 14; 1 see

(a),(c), she retained the residual functional

capacity2 (“RFC”) to perform light work, Admin. R. 1 5 ; see

(b), and that she remained capable of performing

her past work as a receptionist at a laboratory, nail technician,

1 The court will reference the administrative record (“Admin. R.”) to the extent that it recites facts contained in or directly quotes documents from the record. C f . Lalime v . Astrue, N o . 08- cv-196-PB,

, at *1 (D.N.H. Apr. 1 4 , 2009). 2 “Residual Functional Capacity” is defined as “an assessment of an individual’s ability to do sustained work-related physical and mental activities in a work setting on a regular and continuing basis. A ‘regular and continuing basis’ means 8 hours a day, for 5 days a week, or an equivalent work schedule.” SSR 96-8p,

, at *1 (July 2 , 1996). and customer service representative. Admin. R. 1 7 ; see

(a)(4)(iv). Ault contends that the ALJ committed

reversible error at steps two through five of the five step

disability analysis.3 Specifically, Ault alleges that the ALJ:

(1) failed to properly analyze Ault’s impairments at Step 2 and erroneously concluded that her pancreatitis, migraine headaches, myofascial pain, and depression were not severe,4 Admin. R. 1 4 ; C l . B r . 8-13,

3 The social security regulations set forth a five step procedure to determine if a claimant is disabled.

(a)(4). The claimant bears the burden in the first four steps to show that: (1) she is not engaged in substantial gainful activity; (2) she has a severe impairment; (3) the impairment meets or equals a specific impairment listed in the Social Security regulations; or (4) the impairment prevents or prevented her from performing past relevant work. At Step 5 of the analysis, it is the Commissioner’s burden to establish that jobs exist in the national economy given the claimant’s impairments, age, education, and work experience. See

4 Ault also contends that the ALJ erred in failing to mention the effects of hypothyroidism, asthma, and the side-effects of her medications. Admin. R. 14-15. The court finds no error as none of these impairments were mentioned in Ault’s “Disability Report,” and were only briefly mentioned during the hearing.

. Indeed, asthma was only mentioned in response to a question about a list of medications, but not discussed as an impairment.

at 3 5 . Hypothyroidism and side- effects from medication were mentioned almost as an afterthought in response to prompting by her attorney and even then, Ault stated that due to hypothyroidism “and some of the other medications I’m o n , I could be tired. I find myself dozing off sometimes, and sometimes it can be while I am driving, and sometimes it’s at work.”

at 3 6 . Although a claimant’s burden at Step 2 is de minimis, see LaBonte v . Astrue, N o . 09- 358-P-S,

, at *2 (D. M e . May 1 8 , 2010), mere mention of an impairment without further development does not satisfy this burden. See

Ault hardly demonstrates that these impairments significantly limit her “ability to do basic work activities.”

(c). The court finds no

2 (2) failed to determine that her left knee injury and left femoral neuropathy qualified as a listed impairment in 20 C.F.R. Part 4 0 4 , Subpart P, Append ix 1 , see Admin. R. 1 5 ; C l . B r . 13-14; see generally

(a)(4)(iii),(d), 404.1525, 404.1526,

(3) improperly assigned greater weight to the opinion of a non-examining physician, and did not grant controlling weight to a treating physician’s functional assessment, C l . B r . 17-19, see generally

, 404.1527(d); SSR 96-2p,

(July 2 , 1996), and

(4) failed at Step 4 to take into account Ault’s allegations of disabling depression, migraine headaches, pancreatitis, hypothyroidism, neck pain, and asthma when determining her RFC.5 See C l . B r . 14-17.

The Commissioner asserts that the ALJ’s findings are supported by

substantial evidence in the record, and moves for an order

affirming his decision. This court has subject-matter

jurisdiction under

(federal question) and

(g) (Social Security). After a review of the

administrative record, the court concludes that although the ALJ

properly determined Ault’s severe impairments at Step 2 , he did

not account for these impairments when fashioning Ault’s RFC at

Step 4 . The court also finds error in the ALJ’s treatment of an

error. C f . Lacroix v . Barnhart,

0 0 , 115 (D. Mass. 2005). 5 Ault also inexplicably contends there was error at Step 5 . C l . B r . 17-19. The ALJ determined that Ault was not disabled at Step 4 , Admin. R. 1 7 , and therefore did not reach Step 5 . The court will not address this claim of error.

3 opinion rendered by Ault’s treating physician. The court grants

Ault’s motion, denies the Commissioner’s motion, and remands for

further proceedings.

I. APPLICABLE LEGAL STANDARD

The court’s review under Section 405(g) is “limited to

determining whether the ALJ deployed the proper legal standards

and found facts upon the proper quantum of evidence.” Nguyen v .

Chater,

1 , 35 (1st Cir. 1999); see Simmons v . Astrue,

9 1 , 399 (D.N.H. 2010). If the ALJ’s factual

findings are supported by substantial evidence in the record,

they are conclusive, even if the Court does not agree with the

ALJ’s decision and other evidence supports a contrary conclusion.

See Tsarelka v . Sec’y of Health & Human Servs.,

(1st Cir. 1988). Substantial evidence is “such relevant evidence

as a reasonable mind might accept as adequate to support a

conclusion.” Richardson v . Perales,

(1971)

(quotations omitted). The ALJ is responsible for determining

issues of credibility, resolving conflicting evidence, and

drawing inferences from the evidence in the record. See

Rodriguez v . Sec’y of Health & Human Servs.,

1 8 , 222

(1st Cir. 1981); Pires v . Astrue,

5 , 21 (D.

Mass. 2008) (“resolution of conflicts in the evidence or

4 questions of credibility is outside the court’s purview, and thus

where the record supports more than one outcome, the ALJ’s view

prevails”). The ALJ’s findings are not conclusive, however, if

they were “derived by ignoring evidence, misapplying the law, or

judging matters entrusted to experts.” Nguyen, 172 F.3d at 3 5 .

If the ALJ made a legal or factual error, the decision may be

reversed and remanded to consider new, material evidence, or to

apply the correct legal standard. Manso-Pizarro v . Sec’y of

Health & Human Servs.,

5 , 1 6 , 19 (1st Cir. 1996); see

(g).

II. BACKGROUND

Pursuant to this court’s local rules, the parties filed a

Joint Statement of Material Facts (document number 1 3 ) , which is

part of the record reviewed by the court. See LR 9.1(d). This

court will briefly recount the key facts and otherwise

incorporates the parties’ joint statement by reference.

Ault filed a request for benefits in August 2007 alleging an

onset of disability that month due t o , inter alia, knee pain,

nerve damage in her leg, neck pain, pancreatic pain, migraines,

and depression. See Admin. R. 31-42, 1 2 4 , 149-61. She was 35

5 years old at the date of filing,

at 1 1 1 , and taking numerous

prescription medications for her afflictions.6 Id. at 173-175.

Ault’s extensive medical records indicate many of her

alleged impairments significantly pre-date her disability filing,

and that she had been seeing numerous medical providers for many

years before her alleged onset date. Medical tests conducted in

November 2004 indicate that Ault suffered from “pancreas

divisum,”7 see id. at 576, and records from March and June 2005

indicate that she had a history of “recurrent pancreatitis.”8

Id. at 218-19, 343. Over the course of the next three years,

Ault would have numerous doctor’s office visits and

hospitalizations to address her gastro-intestinal issues. See,

e.g., id. at 218-19, 379-80, 383-84, 396-98, 409, 439, 5 1 7 , 596-

9 7 , 6 8 8 , 719-20, 1066-67, 1078, 1118.

In addition, Ault sustained injuries to her knee, upper

back, and neck in a motor vehicle accident in April 2005. Admin.

R. 357-358. After months of treatment by medical providers and

6 As of March 2010, Ault was taking twenty-four prescription medications. Id. at 209.

7 divisum is “a developmental anomaly in which the ‘Pancreas pancreas is divided into two separate structures, each with its own duct.” Dorland’s Illustrated Medical Dictionary, 1387 (31st ed. 2007).

8 “Recurrent” or “chronic pancreatitis” is an “inflammation of the pancreas . . . . with chronic abdominal pain.” Dorland’s Illustrated Medical Dictionary, 1388 (31st ed. 2007). 6 physical therapy, see id. at 389-92, 449, 4 5 0 , 526-29, 536-39,

549, 556, Ault had surgery on her left quad tendon in March 2006,

id. at 239, and, in July 2006, her left knee. Id. at 284-85. By

September, 2006, a treating physician noted that Ault was still

hampered by significant pain and disability. Id. at 655. Ault’s

medical records indicate that she continued to experience post

surgical knee pain. See, e.g., id. at 489-90, 6 0 7 , 675, 6 9 7 ,

731, 751-52, 934. She was often observed to have an unsteady

gait. See, e.g., id. at 655, 675, 723, 776, 1186, 1188, 1191.

Ault also often sought medical care for neck pain and

migraines thought to arise from her neck injury. See, e.g., id.

at 221-22, 565, 589, 609-10, 653, 705-08, 7 3 1 , 737-38, 9 9 0 , 1014,

1033, 1049, 1051, 1056-57, 1095-97, 1100-02, 1114, 1138-39, 1157,

1192. In October 2009, December 2009, and February 2010, Ault,

upon the advice of treating physician D r . Leslie Dionne, M D ,

consulted with Foundation Neurology. Id. at 1191-92, 1193, 1229.

Ault was found to suffer from “[m]igraine headaches, poorly

controlled. Chronic neck and upper back pain. Insomnia with

fragmented sleep.” Id. at 1229. A November 2009 MRI ordered by

Foundation Neurology, however, revealed no abnormalities. Id. at

1196. During her October 2009 visit, Physician’s Assistant

Sharon Lockwood noted that “[i]t is going to be difficult to

treat [Ault] because she has tried so many different medications

7 in the past, which have not been helpful or have caused side

effects.” Id. at 1192. In March, 2010, Nurse Lockwood stated

that Ault’s

[h]eadaches occur four times per week. She has tried multiple preventative and rescue medications for her headaches in the past. They have been ineffective or have caused side effects. We have continued to try various medications and non medicinal [sic] treatments. She also sees pain specialists. So far, headaches continue to be poorly controlled.

Id. at 1258.

Although some of Ault’s regular providers opined that her

headaches, neck, and knee pain were limiting,9 id. at 800-03,

988, 1145, 1231, an agency consulting physician, D r . Lewis J.

Goldfine, concluded that Ault was capable of a wide range of

light work. Id. at 1 7 , 915-22. D r . Goldfine’s report, however,

was not detailed and contained little reference to the medical

records he used to formulate his opinion. Id. at 915-22. The

ALJ decided to adopt D r . Goldfine’s opinion, however, stating

only that it was “supported by the medical evidence in the file

9 treating physician, D r . Dionne, wrote three separate A over the course of 18 months stating that Ault’s letters conditions limited her to only part-time work. Id. at 9 8 8 , 1145, 1231. Although Physician’s Assistant Ronald Carson opined that Ault was capable of “gainful employment on a sustained basis,” he also imposed restrictions that would make full-time employment unsustainable, namely, that Ault would need to take “unscheduled breaks to relieve pain or discomfort” and would be absent three or more times per month from work. Id. at 803.

8 and is not inconsistent with the other substantial evidence in

the record.” Id. at 1 7 .

As such, the ALJ found that Ault has the residual functional

capacity to perform light work, see

(b),

“except she can lift and carry 20 pounds occasionally and 10

pounds frequently; sit for 2 hours at a time and up to 6 hours in

an 8 hour work period; stand or walk for 45 minutes at a time and

up to 3 hours in an 8 hour work period.” Admin. R. 1 5 . The ALJ

thus concluded that Ault was capable of performing her past work

as a lab receptionist, nail technician, and customer service representative.10

at 1 7 . This appeal followed.11

III. ANALYSIS

A five-step process is used to evaluate an application for

social security benefits.

(a)(4). The

applicant bears the burden through the first four steps to show

10 The ALJ also placed restrictions on Ault’s ability to use her left foot, climb ladders, stairs, ramps, and scaffolding, and crawl, stoop, kneel, and crouch.

at 1 5 . 11 The Decision Review Board, see generally

, did not complete its review of the ALJ’s denial in a timely fashion, Admin. R. 1 , rendering the ALJ’s order a final decision of the Commissioner appealable to this court. See

.

9 that she is disabled.12 Freeman v . Barnhart,

(1st Cir. 2001). At the fifth step, the Commissioner bears the

burden of showing that a claimant has the residual functional

capacity to perform other work that may exist in the national

economy. Id.; see also

(a)(4)(v); Heggarty

v . Sullivan,

9 0 , 995 (1st Cir. 1991). The ALJ’s

conclusions at steps four and five are informed by his assessment

of a claimant’s RFC, which is a description of the kind of work

that the claimant is able to perform despite her impairments.

(a)(4), 404.1545.

Ault alleged that she suffered from disabling pain due t o ,

inter alia, knee pain, leg pain, migraine headaches,

pancreatitis, and neck pain. See Admin. R. 31-33, 124. The ALJ

found at Step 2 that Ault was severely impaired by “degenerative

joint disease of the left knee and left femoral neuropathy.”

at 1 4 . He concluded, however, that:

I find [Ault’s] pancreatitis causes only intermittent symptoms and therefore causes only mild limitations in her ability to perform work related functions. I find that her complaints of migraine headaches and myofascial pain are based solely upon subjective complaints as diagnostic techniques have failed to

12 The Social Security Act defines disability as the “inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.”

(d)(1)(A).

10 determine an etiology for these subjective complaints. . . . I find no diagnostic evidence to support the claimant’s allegations of chronic myofascial pain. Therefore I find that the claimant’s depression, pancreatitis[,] migraine headaches and cervical myofascial pain impairments are not severe within the meaning of the regulations. However, any limitations caused by these impairments will be considered in conjunction with her other impairments when determining the claimant’s residual functional capacity.

Admin. R. 14 (citations omitted). Although the ALJ promised at

Step 2 that Ault’s non-severe impairments would be factored into

his RFC analysis, it is unclear from his order whether he

actually did s o . The ALJ, when discussing Ault’s RFC at Step 4 ,

mentioned Ault’s testimony that she is often fatigued,

uncomfortable, and in pain.13 See Admin. R. 15-16. He

discounted these complaints, however, ruling only that “the

claimant’s statements concerning the intensity, persistence and

limiting effects of these symptoms are not credible to the extent

they are inconsistent with the above residual functional

capacity.”

at 1 6 . He explained his credibility decision in

terms of her knee pain only,

concluding that:

[b]ased upon a thorough review of all of the evidence of record, the undersigned is persuaded that the claimant has knee impairments that could reasonably be expected to produce some of the symptoms she alleges. However, to the extent that the claimant alleges impairment so severe as to preclude the performance of

13 The ALJ never specifies the source of her pain, so it i unclear whether he is discussing pain due to her knee issues,

11 all sustained work activity, the undersigned does not find her fully credible.

Ault alleges it was error not to conclude that these

impairments were severe at Step 2 , and that the ALJ failed to

properly consider the functional effects of these impairments at

Step 4 . The court reverses the ALJ’s decision because there is

no indication that these issues were sufficiently accounted for

when formulating Ault’s RFC at Step 4.14 See, e.g., Resendes v .

14 The court finds there was no error at Step 2 even though the record could support a different result. Pires,

1 . “To meet the severity requirement, the claimant must show that an impairment or combination of impairments amounts to more than a slight abnormality and has more than a minimal effect on an individual's ability to work.” Treadwell v . Comm’r, N o . 1:09-cv-00534-JAW,

, at *2 (D. M e . Oct. 2 9 , 2010) (quotations omitted). See McDonald v . Sec'y of Health & Human Servs.,

(1st Cir. 1986); SSR 85-28,

, at *3 (1985). “This burden is a de minimis burden, designed to do no more than screen out groundless claims.” Treadwell,

at * 2 . Only medical evidence may be used to support a finding that an impairment or combination of impairments is severe, as a claimant’s “statements alone are not enough to establish that there is a physical or mental impairment.”

(a); SSR 85-28,

at * 4 ; Treadwell,

at * 2 ; LaBonte,

at * 2 .

In this case, the ALJ specifically cited objective medical tests that support his conclusion that these impairments were not severe, Admin. R. 1 4 , and indeed there is additional record support for his finding.

at 6 4 2 , 685, 7 3 1 , 813-14, 8 4 8 , 9 4 1 , 943, 963, 9 7 4 , 1011, 1146, 1150, 1196, 1235-1237. The record, however, also includes numerous reports of hospitalizations, physician visits for, and diagnosis o f , myofascial pain, chronic migraines, and chronic pancreatitis, albeit some of which was based on self-reports by Ault. See

at 5 1 7 , 719-20, 737-38,

12 Astrue,

(D. Mass. 2011); Guyton v .

Apfel,

(D. Mass. 1998).

Concluding that an impairment is not severe does not relieve

the ALJ of the duty to discuss whether such limitations affect a

claimant’s RFC at Step 4 . C f . Treadwell,

at * 3 .

An ALJ must factor into his or her RFC analysis the effects, if

any, of non-severe impairments on a claimant’s functional

abilities.

(e). It is possible for an ALJ

to conclude that a non-severe impairment does not hinder a

claimant’s “ability to perform his past relevant work at Step 4 ,

but, if s o , [the ALJ] must say so in his opinion, and explain how

he reached that conclusion.” Guber v . Astrue, N o . 1:10-cv-172-

JAW,

, at * 2 (D. M e . Mar. 3 0 , 2011).

The court cannot discern whether the ALJ in fact considered

Ault’s non-severe impairments at Step 4 despite the notation at

Step 2 that these impairments would be taken into account. As

such, the ALJ’s treatment of these issues was erroneous. See

1100-01, 1118, 1157, 1178, 1191-93, 1229, 1258. On this record, the court might have drawn a different severity conclusion than the ALJ. “To be sure, the resolution of conflicts in evidence and the determination of credibility are for the Commissioner, not for the doctors or the courts,” Reeves v . Barnhart,

5 4 , 156 (D. Mass. 2003), and thus the court cannot conclude that the ALJ committed reversible error at Step 2 . C f . Frustaglia v . Sec’y of Health & Human Servs.,

9 2 , 195 (1st Cir. 1987).

13 Resendes

(“it is not sufficient for the

adjudicator to make a single, conclusory statement that the

individual’s allegations have been considered” (quotations and

brackets omitted)). The ALJ referenced only Ault’s knee pain,

essentially ignoring mountains of medical evidence showing that

she regularly, and for many years, complained, inter alia of

migraines, neck pain, and pancreatitis to many medical

providers.15 This is not the case where minor complaints were

not addressed in detail. C f . Fifield v . Astrue, N o . 08-30078-

KPN,

, at *9 (D. Mass. Mar. 1 9 , 2009) (ALJ not

required to discuss every piece of contradictory evidence).

Rather, there are many observations by Ault’s regular providers

that she suffered from acute “recurrent” or “chronic”

pancreatitis, see, e.g., Admin. R. 3 9 7 , 1118, 1078, intense

headaches or migraines multiple times per week that are “poorly

controlled,” id. at 1191, 1229, and “chronic” neck pain. Id. at

1192, 1231-32. An ALJ is not required to conclude that these

non-severe impairments were disabling, but given the breadth of

the medical evidence chronicling Ault’s attempts to remedy her

15 It is true that Ault’s doctors diagnosed her with chronic pancreatitis, chronic migraines, and persistent neck pain based on her subjective reports, however, at Step 4 , unlike Step 2 , an ALJ must “look further” at the record and determine whether those complaints are credible and compromise her ability to work. Guyton,

; see Pires,

.

14 pain, at the very least these afflictions should be discussed at

Step 4 . Even if the ALJ decides that these impairments “would

not affect the [claimant’s] ability to perform [her] past

relevant work at Step 4 , . . . he must say so in his opinion, and

explain how he reached that conclusion.” Guber

,

at * 2 .

The ALJ’s analysis of whether Ault’s allegations of pain

were credible was likewise incomplete. Assessment of a

claimant’s credibility is the exclusive province of the ALJ, who

observes the claimant, evaluates her demeanor, and considers how

her testimony “fit[s] in with the rest of the evidence.”

Frustaglia,

. The ALJ’s credibility determination

is entitled to deference if it is supported by substantial

evidence.

In determining the credibility of a claimant’s

subjective testimony, however, the ALJ must consider the entire

record, including objective medical evidence, the claimant’s

statements, information provided by physicians and other

witnesses, and any other relevant evidence. SSR N o . 96-7p,

, at *2 (July 2 , 1996). When an ALJ has directly

observed the claimant, he is “not free to accept or reject that

individual’s subjective complaints solely on the basis of such

personal observations. Rather, . . . the determination rationale

is to contain a thorough discussion and analysis of the objective

15 medical and nonmedical evidence, including the individual’s

subjective complaints and the adjudicator’s personal

observations.” Avery v . Sec’y of Health & Human Servs.,

9 , 29 (1st Cir. 1986).

A claimant’s subjective complaints of pain will be deemed

credible only if they are consistent with objective medical

evidence and other evidence in the record.

(a). An ALJ, however, cannot base credibility findings

solely on the absence of objective medical evidence, rather, “the

absence of objective medical evidence supporting an individual’s

statements about the intensity and persistence of pain . . . is

only one factor that the adjudicator must consider in assessing

an individual’s credibility and must be considered in the context

of all the evidence.” SSR N o . 96-7p,

, at * 6 ; see

Pires,

(“mandate to take evidence besides

objective medical findings into account has been solidly

established in the case law of this and other circuits”).

Courts admonish administrative law judges to be particularly

careful when assessing subjective complaints of pain. “Where a

claimant’s complaints of pain are a significant factor limiting

[her] ability to work, and those complaints are not fully

supported by the medical evidence in the record, the

Administrative Law Judge must look further,” Guyton,

2d at 166, and inquire into the impact of these subjective

complaints on daily functionality. See Avery,

.

In Avery, the court of appeals directed that when evaluating a

claimant’s subjective complaints of pain and other symptoms, the

ALJ should consider a variety of factors. See

It is true

that an ALJ need not address every Avery factor16 in his opinion

so long as proper inquiry is made during the administrative

hearing. See, e.g., Resendes,

n . 1 6 .

Where an ALJ concludes that subjective evidence of pain is not

credible, however, he “must make specific findings as to the

relevant evidence he considered in determining to disbelieve the

[claimant]. DaRosa v . Sec’y of Health & Human Servs.,

4 , 26 (1st Cir. 1986). Satisfactory inquiry into the Avery

factors alone does not relieve an ALJ of his obligation to

explain a credibility determination. Guyton,

. Indeed, failure “to provide the requisite findings to

support [a] credibility determination” provides a basis for

remand.

see, e.g., Resendes,

.

16 These factors include: “ 1 . [t]he nature, location, onset, duration, frequency, radiation, and intensity of any pain; 2 . [p]recipitating and aggravating factors (e.g., movement, activity, environmental conditions); 3 . [t]ype, dosage, effectiveness, and adverse side-effects of any pain medication; 4 . [t]reatment, other than medication, for relief of pain; 5 . [f]unctional restrictions; and 6. [t]he claimant’s daily activities.” Avery,

.

17 Here, the ALJ’s analysis of Ault’s subjective complaints of

pain other than knee pain was extremely limited and arguably non-

existent. Admin. R. 15-17. There was no indication, other than

a passing notation at Step 2 , that these complaints were taken

into account,

, and such analysis is clearly

insufficient. See, e.g., Guyton

. This is

not the case where a claimant makes vague allegations of pain

that have limited record support. Rather, extensive medical

records indicate that Ault was treated for many years for neck

pain, migraines, and pancreatitis. Although the ALJ is not

required to accept this as proof of disability, c f . Fifield,

, at *8-*9, the ALJ, in this case, needed to support his

determination with specific or sufficient findings. Compare

Frustaglia

(“Although more express findings,

regarding head pain and credibility, than those given here are

preferable, we have examined the entire record and their adequacy

is supported by substantial evidence”) with Guyton

(although ALJ made appropriate Avery inquiry during the

administrative hearing, the case was remanded because “the

decision insufficiently explains the credibility determination”).

Here, the ALJ’s credibility determination focuses

exclusively on whether Ault’s allegations of knee pain only were

credible. Admin. R. 16-17. The decision at Step 4 lacks any

18 mention of Ault’s subjective complaints of migraines, neck pain,

or pancreatitis. The ALJ’s analysis stands in stark contrast to

that in Fifield,

, at * 8 , where the ALJ “made

specific findings as to relevant evidence when deciding to

disbelieve” the claimant.

(quotations, italics, and brackets

omitted). An ALJ is not required to accept these allegations of

pain, but at the very least, he must “provide the requisite

findings to support [his] credibility determination.” Guyton,

; c f . Dalis v . Barnhart, N o . Civ. A . 02-10627-

DPW,

, at *10-*11 (D. Mass. Jun. 2 4 ,

2003)(finding that claimant’s headache pain was not credible

supported by specific findings by A L J ) . Because such support was

absent, the court remands the case for further findings. See

Guyton,

; c f . Guber

, at * 2 .

Finally, because the issue may arise on remand, the court

briefly addresses the ALJ’s treatment of a series of letters in

August 2008, August 2009, and February 2010 written by Ault’s

treating physician, D r . Dionne, limiting Ault to part-time

employment. Admin. R. 9 8 8 , 1145, 1231. In her February letter,

virtually identical to the two prior letters, D r . Dionne states:

This letter serves to document that you carry the diagnosis of cervical myofascial pain (neck pain) and recurrent headaches on that basis, chronic left leg pain and weakness due to nerve damage after surgery and right knee pain which has also become chronic. These diagnoses have limited you to working part time. It

19 would not be appropriate at this time to look for full time employment. I recommend continuing your part-time status 16 hours per week.

Id. at 1231. The ALJ merely noted the existence of this letter,

stating that “[s]uch recommendation is not sufficient as a

statement of functional capacity.” Id. at 1 7 .

The decision that a claimant is disabled is reserved to the

Commissioner. See

(e)(1); SSR 96-5p,

, at *2 (July 2 , 1996). As such, “[a] statement by a

medical source that [a claimant is] ‘disabled’ or unable to work”

does not compel a finding that the claimant is disabled.

(e)(1). Still, an ALJ is prohibited from

disregarding relevant medical source opinions. See SSR 96-5p,

, at * 5 . Indeed, an ALJ is required to give

controlling weight to the opinion of a treating physician “if it

is well-supported by medically acceptable clinical and laboratory

diagnostic techniques and is not inconsistent with the other

substantial evidence in the case record.” Lopes v . Barnhart,

(D. Mass. 2005) (quotations and brackets

omitted); see generally SSR N o . 96-2p,

, at * 1 .

Where an ALJ’s functional assessment is at odds with a medical

source opinion, he must adequately explain his reasons for

disregarding that opinion. See

(d); SSR 96-

20 8 p ,

, at * 7 ; Marshall v . Astrue, N o . 08-cv-147-JD,

, at *3 (D.N.H. Dec. 2 2 , 2008).

Here, D r . Dionne’s letter indicates that she believed, based

on her diagnosis of Ault’s various illnesses, that Ault was

functionally restricted from working on “a regular and continuing

basis.” See generally SSR 96-8p,

, at * 1 .

Although the form of that opinion may be a basis for giving it

less weight, disregarding it completely because it “is not

sufficient as a statement of functional capacity” does not

address the clear fact that the ALJ’s decision is in conflict

with the opinion of Ault’s treating source. C f . Monroe v .

Barnhart,

(D. Mass. 2007) (ALJ must

give sufficient explanation for adopting contrary view of

disability). On remand, the ALJ should fully explain his reasons

for disregarding D r . Dionne’s opinion.

IV. CONCLUSION

Pursuant to sentence four of

(g), Ault’s

motion to reverse and remand the Commissioner’s decision17 is

granted. The Commissioner’s motion to affirm the decision18 is

17 Document n o . 11. 18 Document n o . 1 2 .

21 denied. The Clerk of Court is directed to enter judgment in

accordance with this order and close the case.

SO ORDERED.

Joseph N_._ _Laplante ____ ___ lited States District Judge

Dated: January 10, 2012

cc: Janine Gawryl, Esq. Gretchen Leah Witt, Esq.

22