Sito v. Commissioner of Social Security
Sito v. Commissioner of Social Security
Opinion of the Court
MEMORANDUM OPINION AND ORDER
Introduction
Before me
Facts
A. Background facts and decision of the Administrative Law Judge (“ALJ”)
Sito who was 48 years old at the time of the administrative hearing,
The ALJ, whose decision became the final decision of the Commissioner, found that Sito had the following severe impairments: depression/dysthymie disorder (20
After concluding that the relevant impairments did not meet or equal a listing, the ALJ made the following finding regarding Sito’s residual functional capacity (“RFC”):
After careful consideration of the entire record, the undersigned finds that, through the date last insured, the claimant had the residual functional capacity to perform a full range of work at all exertional levels but with the following non-exertional limitations: no climbing ladders and the like and no exposure to obvious hazards. The claimant could also: understand, carry out and remember simple instructions where the pace of productivity is not dictated by an external source over which the claimant has no control such as an assembly line or conveyor belt; make judgments on simple work, and respond appropriately to usual work situations and changes in a routine work setting that is repetitive from day to day with few and expected changes; and respond appropriately to supervision, the general public and coworkers.16
Based on that residual functional capacity, the ALJ found Sito capable of her past relevant work as a small parts assembler and, therefore, not under a disability.
Based on an answer to a hypothetical question posed to the vocational expert at the hearing setting forth the residual functional capacity finding quoted above, the ALJ determined that a significant number of jobs existed locally and nationally that Sito could perform.
B. Issues on judicial review
Sito asks for reversal of the Commissioner’s decision on the ground that it does not have the support of substantial evidence in the administrative record. Specifically, Sito presents the following issues for judicial review:
• Whether the final agency decision is not supported by substantial evidence because there were two separate administrative hearings but no explanation for if or why plaintiffs case may have been reassigned to a different ALJ after the first hearing. Thereby, the agency decision erred by failing to address plaintiffs testimony at the first hearing and the agency also violated plaintiffs constitutional due process rights.20
• Whether the ALJ found at Step 2 that plaintiffs . physical impairments were non-medially determinable impairments. This finding lacks the support of substantial evidence because the ALJ failed to properly consider plaintiffs physical impairments.21 v
• Whether the ALJ found at Step 3 that plaintiff has the RFC to perform a full range of work at all exertional levels with some non-exertional limitations. This finding lacks support of substantial evidence because the ALJ failed to properly consider the opinion evidence of record and failed to consider the combined effects of plaintiffs severe mental impairment and non-medieally determinable physical impairments.22
*638 • Whether the ALJ found at Step 3 that plaintiffs statements concerning the intensity, persistence and limiting effects of her symptoms are not entirely credible. This finding lacks support of substantial evidence because the reasons given by the ALJ for the credibility assessment are not supported by the evidence of the record.23
• Whether the ALJ found at Step 4 that, through the date last insured, plaintiff was capable of performing past relevant work as a small parts assembler and at Step 5 that plaintiff was capable of making a successful adjustment to other work that existed in significant numbers in the national economy. These findings lack the support of substantial evidence because the ALJ relied on responses to an incomplete hypothetical question, plaintiffs past work and the jobs identified by the YE are inconsistent with the ALJ’s RFC determination, and the ALJ’s errors at the previous steps make the Steps 4 and 5 findings inherently unsupported by substantial evidence.24
• Whether the Appeals Council erred as a matter of law in failing to consider new and material evidence.25
For the reasons that follow, I will conclude that the ALJ’s finding of no disability is not supported by substantial evidence and, therefore, must be reversed and remanded.
Analysis
A. Standards of review
1. Substantial evidence
The Sixth Circuit in Buxton v. Halter reemphasized the standard of review applicable to decisions of the ALJs in disability cases:
Congress has provided for federal court review of Social Security administrative decisions. 42 U.S.C. § 405(g). However, the scope of review is limited under 42 U.S.C. § 405(g): “The findings of the Secretary as to any fact, if supported by substantial evidence, shall be conclusive.... ” In other words, on review of the Commissioner’s decision that claimant is not totally disabled within the meaning of the Social Security Act, the only issue reviewable by this court is whether the decision is supported by substantial evidence. Substantial evidence is “ ‘more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.’ ”
The findings of the Commissioner are not subject to reversal merely because there exists in the record substantial evidence to support a different conclusion. This is so because there is a “zone of choice” within which the Commissioner can act, without the fear of court interference.26
Viewed in the context of a jury trial, all that is necessary to affirm is that reasonable minds could reach different conclusions on the evidence. If such is the case, the Commissioner survives “a directed verdict” and wins.
I will review the findings of the ALJ at issue here consistent with that deferential standard.
2. Treating physician rule and good reasons requirement
The regulations of the Social Security Administration require the Commissioner to give more weight to opinions of treating sources than to those of non-treating sources under appropriate circumstances.
Generally, we give more weight to opinions from your treating sources, since these sources are likely to be the medical professionals most able to provide a detailed, longitudinal picture of your medical impairment(s) and may bring a unique perspective to the medical evidence that cannot be obtained from objective medical findings alone or from reports of individual examinations, such as consultative examinations or brief hospitalizations.29
If such opinions are “well-supported by medically acceptable clinical and laboratory diagnostic techniques” and “not inconsistent with the other substantial evidence in [the] case record,” then they must receive “controlling” weight.
The ALJ has the ultimate responsibility for determining whether a claimant is disabled.
The regulation does cover treating source opinions as to a claimant’s exer-tional limitations and work-related capacity in light of those limitations.
In Wilson v. Commissioner of Social Security,
*640 • State that the opinion is not supported by medically acceptable clinical and laboratory techniques or is inconsistent with other evidence in the case record.
• Identify evidence supporting such finding.
• Explain the application of the factors listed in 20 C.F.R. § 404.1527(d)(2) to determine the weight that should be given to the treating source’s opinion.40
The court went on to hold that the failure to articulate good reasons for discounting the treating source’s opinion is not harmless error.
The Sixth Circuit in Gayheart v. Commissioner of Social Security
As explained in Gayheart, the ALJ must first consider if the treating source’s opinion should receive controlling weight.
The court in Gayheart cautioned against collapsing these two distinct analyses into
But the ALJ did not provide “good reasons” for why Dr. Onady’s opinions fail to meet either prong of this test.
To be sure, the ALJ discusses the frequency and nature of Dr. Onady’s treatment relationship with Gayheart, as well as alleged internal inconsistencies between the doctor’s opinions and portions of her reports. But these factors are properly applied only after the ALJ has determined that a treating-source opinion will not be given controlling weight.59
In a nutshell, the Wilson/Gayheart line of cases interpreting the Commissioner’s regulations recognizes a rebuttable presumption that a treating source’s opinion should receive controlling weight.
The failure of an ALJ to follow the procedural rules for assigning weight to the opinions of treating sources and the giving of good reason for the weight assigned denotes a lack of substantial evidence even if the decision of the ALJ may be justified based on the record.
Given the significant implications of a failure to properly articulate (ie., remand) mandated by the Wilson decision, an ALJ should structure the decision to remove any doubt as to the weight given the treating source’s opinion and the reasons for assigning such weight. In a single paragraph the ALJ should state what weight he or she assigns to the treating source’s opinion and then discuss the evidence of record supporting that assignment. Where the treating source’s opinion does not receive controlling weight, the decision must justify the assignment given in light of the factors set out in §§ 1527(d)(1)-(6).
• the failure to mention and consider the opinion of a treating source,66
• the rejection or discounting of the weight of a treating source without assigning weight,67
• the failure to explain how the opinion of a source properly considered as a treating source is weighed lie., treating v. examining),68
• the elevation of the opinion of a non-examining source over that of a treating source if the nonexamining source has not reviewed the opinion of the treating source,69
• the rejection of the opinion of a treating source because it conflicts with the opinion of another medical source without an explanation of the reason therefor,70 and
• the rejection of the opinion of a treating source for inconsistency with other evidence in the record without an explanation of why “the treating physician’s conclusion gets the short end of the stick.”71
The Sixth Circuit in Blakley
In Cole v. Astrue,
B. Application of standards
The Commissioner’s decision in this case occurred after a second ALJ held a second hearing on the claimant’s application.
Sito here raises several issues on review, of which two will be individually addressed below.
1. Due process
Sito asserts that due process, as expressed in the agency’s HALLEX manual,
In that regard, I observe that there has been some confusion as to whether this case represents a “reopening” of the earlier hearing or a “reassignment” of an undecided case to a new ALJ.
The Supreme Court has stated that the “fundamental requirement of due process is the opportunity to be heard ‘at a meaningful time and in a meaningful manner.’ ”
Examining that rubric in the present situation, Sito, as noted, claims that she was denied due process because the record in this case does not indicate why no decision issued after the first hearing and because the ALJ’s decision after the second hearing does not affirmatively reflect that the evidence of the first hearing was considered. In support she cites to provisions of the Hearings, Appeals and Litigation Law Manual (“HALLEX”) that address how an ALJ at a second hearing is to consider evidence obtained in the first hearing.
In that regard, I note first that the Sixth Circuit has characterized HAL-LEX as a source of “guiding principles, procedural guidance and information” to ALJs and agency staff.
Similarly, Sito’s argument that it was error for the ALJ here to not explicitly discuss unspecified portions of the prior record is also unpersuasive. As the Sixth Circuit observed in Simons v. Barnhart,
Moreover, as the Commissioner notes here, Sito was represented at all stages of the administrative proceeding in this case and her counsel made no objections to the rehearing or notice of rehearing, or requests for additional explanations or reasons.
2. Step 2
Sito argues that it was error for the ALJ to find her foot, back, and neck problems, as well as her fibromyalgia and diverticulitis are non-medically determinable impairments found after her date of last insured.
The Commissioner responds by noting that even if it was error not to find these conditions to be severe impairments at Step Two, any error is harmless because the ALJ did find other conditions to be severe impairments, and proceeded to analyze all of Sito’s physical and mental impairments—severe and non-severe—in the balance of the opinion.
The key issue in this regard concerns the treatment of the opinions and diagnoses of Robert Kanney, M.D., Sito’s treating physician. He lists fibromyalgia as one of Sito’s diagnosis in his answers to a functional capacity questionnaire completed in January 2012, wherein he also notes that he had been treating Sito for “7-10 years.”
The ALJ, however, did not mention this diagnosis by Dr. Kanney, but referenced Sito’s own reporting of a fibromyalgia diagnosis to Dr. Christina Feser, D.O.,
Just as significant, the ALJ dismissed the self-reported diagnosis of fibromyalgia by stating that a diagnosis of fibromyalgia may not be based solely on the conclusion of a physician who himself received a report of a history of fibromyalgia from the patient, but must be supported by evidence that the physician has reviewed the patient’s medical history and conducted a physical examination which produced findings that the patient “has at least 11 positive trigger points” supportive of a diagnosis of fibromyalgia.
Yet, however broadly true this may be as to the conclusion of Dr. Feser, who actually did conduct a physical examination of Sito but merely heard about a prior diagnosis of fibromyalgia, the ALJ’s remarks are far less probative of Dr. Kan-ney, who had, as noted, a multi-year treating relationship with Sito and who recorded a fibromyalgia diagnosis which was not attributed to self-reporting by Sito.
I note in this regard that my own review of the medical records here shows that there appears to be both a lack of clarity and certainty as to when and how Sito came to be diagnosed with fibromyalgia. On April 7, 2005 Dr. Tauseef G. Sayed, M.D., submitted a request to the Ohio Bureau of Workers’ Compensation for -authorization to have Sito undergo four weeks of physical therapy for what Dr. Sayed diagnosed as “myalgia.”
Dr. Sayed’s 2005 “myalgia” diagnosis appears to have been reported by Sito in 2006 as a diagnosis of “fibromyalgia” as she gave her medical history to Barbara Florke, a Clinical Nurse Specialist at Mau-mee Valley Guidance Center.-
Moreover, although the ALJ here stated that to support a diagnosis of fibromyalgia a patient’s physical examination “must” show eleven positive trigger points,
Here, although the ALJ did directly cite to SSR 12-2P in discussing Sito’s fibromyalgia,
Further, and as noted above, the ALJ gave little weight to the functional opinion of Dr. Kanney,
As has also been noted, the opinions of Dr. Kanney themselves are not themselves entirely consistent or clear as to the length of the treatment relationship, the diagnoses given or the symptoms recorded, and there are gaps in the record as to supporting treatment notes. But, these opinions do represent the views of a physician who treated Sito for a considerable period of time, and who has recorded functional limitations that are more restrictive than those in the RFC. As such, it is critical that Dr. Kanney’s opinions be properly weighed and fully analyzed in accordance with the treating physician rubric—something which was not done here.
Conclusion
For the reasons stated, I find that the Commissioner’s decision to deny benefits is not supported by substantial evidence and is therefore reversed. The matter is remanded for further proceedings consistent with this opinion.
. ECF # 32. The parties have consented to my exercise of jurisdiction.
. ECF # 1.
. ECF #11.
. ECF #12.
. ECF # 7.
. ECF # 13.
. ECF # 26 (Commissioner's brief); ECF # 20 (Sito’s brief).
. ECF # 26-1 (Commissioner’s charts); ECF # 21 at 3-7 (Sito’s charts).
. ECF # 21 at 1-2 (Sito’s fact sheet).
. ECF # 30.
. ECF #21 at 1.
. Id.
. ECF # 12, Transcript ("Tr.”) at 33.
. ECF #21 at 1.
. Tr. at 15.
. Id. at 19.
. Id. at 21.
. Id. at 22.
. Id. at 23.
. ECF # 20 at 1.
. Id.
. Id.
. Id.
. Id. at 1-2.
. Id.
. Buxton v. Halter, 246 F.3d 762, 772 (6th Cir. 2001) (citations omitted).
. LeMaster v. Sec'y of Health & Human Servs., 802 F.2d 839, 840 (6th Cir. 1986); Tucker v. Comm’r of Soc. Sec., No. 3:06-CV-403, 2008 WL 399573, at *6 (S.D. Ohio Feb. 12, 2008).
. Rogers v. Comm’r of Soc. Sec., 486 F.3d 234, 241 (6th Cir. 2007).
. 20 C.F.R. § 404.1527(d)(2).
. Id.
. Schuler v. Comm’r of Soc. Sec., 109 Fed.Appx. 97, 101 (6th Cir. 2004).
. Id.
. Swain v. Comm’r of Soc. Sec., 297 F.Supp.2d 986, 991 (N.D. Ohio 2003), citing Green-Younger v. Barnhart, 335 F.3d 99, 106-07 (2d Cir. 2003).
. Garner v. Heckler, 745 F.2d 383, 391 (6th Cir. 1984).
. Heston v. Comm’r of Soc. Sec., 245 F.3d 528, 536 (6th Cir. 2001).
. Id. at 535.
. Wilson v. Comm’r of Soc. Sec., 378 F.3d 541 (6th Cir. 2004).
. Id. at 544.
. Id., citing and quoting 20 C.F.R. § 404.1527(d)(2).
. Id. at 546.
. Id.
. Id.
. Id.
. Id.
. Gayheart v. Comm’r of Soc. Sec., 710 F.3d 365 (6th Cir. 2013).
. Id. at 375-76.
. Rogers v. Comm’r of Soc. Sec., 486 F.3d 234, 242 (6th Cir. 2007).
. Blakley v. Comm’r of Soc. Sec., 581 F.3d 399, 406-07 (6th Cir. 2009).
. Hensley v. Astrue, 573 F.3d 263, 266 (6th Cir. 2009).
. Gayheart, 710 F.3d at 376.
. Id.
. Id.
. Rogers, 486 F.3d at 242.
. Gayheart, 710 F.3d at 376.
. Id.
. Id.
. Id.
. Id.
. Id.
. Rogers, 486 F.3d 234 at 242.
. Blakley, 581 F.3d at 406-07.
. Hensley, 573 F.3d at 266-67.
. Friend v. Comm'r of Soc. Sec., 375 Fed.Appx. 543, 551-52 (6th Cir. 2010).
. Blakley, 581 F.3d at 407.
. Wooten v. Astrue, No. 1:09-CV-981, 2010 WL 184147, at *8 (N.D. Ohio Jan. 14, 2010).
. Blakley, 581 F.3d at 407-08.
. Id. at 408.
. Id.
. Id. at 409.
. Hensley, 573 F.3d at 266-67.
. Friend, 375 Fed.Appx. at 551-52.
.Blakley, 581 F.3d 399.
. Id. at 409-10.
. Id. at 410.
. Cole v. Astrue, 661 F.3d 931 (6th Cir. 2011).
. Id. at 940.
. Tr. at 29-81.
. Id. at 80.
. Id. at 54-55.
. HALLEX is the acronym for the Hearing, Appeals, Litigation and Law (LEX) Manual, and consists of both a procedural guideline and substantive material. Kostyo v. Colvin, No. 3:14-CV-1238, 2015 WL 4067260, at *7 fn. 3 (N.D. Ohio July 2, 2015).
. EOF # 20 at 14-15.
. See, EOF #29 at 1.
. Id. at 1-3.
. Mathews v. Eldridge, 424 U.S. 319, 333, 96 S.Ct. 893, 47 L.Ed.2d 18 (1976)(quoting Armstrong v. Manzo, 380 U.S. 545, 552, 85 S.Ct. 1187, 14 L.Ed.2d 62 (1965)).
. Flatford v. Chater, 93 F.3d 1296, 1304 (6th Cir. 1996).
. Id. at 1306.
. ECF # 20 at 15.
. Bowie v. Commissioner of Social Security, 539 F.3d 395,397 (6th Cir. 2008)(quoting HALLEX § 1-1-001)).
. Kostyo, 2015 WL 4067260, at *7 (quoting Dukes v. Comm’r of Soc. Sec., No. 1:10-CV-436, 2011 WL 4374557, at *9 (W.D. Mich.
.Given the split in the circuits outlined above, and the dicta in Bowie also quoted above, Caudill concluded, and Magistrate Judge White in Kostyo agreed, that the mere failure to follow specific procedures in the HALLEX manual is itself not grounds for reversal absent a convincing showing of prejudice to the plaintiff. See, Kostyo, 2015 WL 4067260 at *7 fn. 4.
. Simons v. Barnhart, 114 Fed.Appx. 727 (6th Cir. 2004).
. Id. at 733 (quoting Craig v. Apfel, 212 F.3d 433, 436 (8th Cir. 2000)).
. See, e.g., Rogers, 486 F.3d at 242-43.
. See, ECF # 26 at 7 (citing transcript).
. McMurtry v. Astrue, 749 F.Supp.2d 875, 882 (E.D.Wis. 2010) (citation omitted).
. ECF #20 at 16-17.
. Id. at 16.
. Id. at 17.
. ECF # 26 at 8-9.
. Tr. at 436; but see, id. at. 650 where Dr. Kanney two years later states that he has been treating Sito for "over twenty years.”
. Id. at 16 (citing id. at 626-31).
. Id. at 20. The failure of the ALJ to identify a source as a “treating source” is a ground for remand. Blakley, 581 F.3d at 408.
. Id. at 16.
. Id. at 437.
. The two-page supporting document sent to the BWC by Dr. Sayed contains a body diagram reflecting moderate pain on a scale of 3-6 in Sito’s shoulders and shooting pain on a scale of 7-8 in her neck and 9-10 in her ankles. Id. at 346.
. See, http://howshealth/myaIgia
. Id. at 362.
. Id. at 16.
. 2012 WL 3104869
. Id. at *2.
. Id. at *3. See also, Foster v. Colvin, No. 3:14-CV-66, 2015 WL 66553 at ** 7-8 (S.D. Ohio Jan. 5, 2015)(extensive discussion of the two diagnostic criteria contained in SSR 12-2P, reversing a decision of an ALJ that failed to consider the non-trigger point tests of SSR 12-2P).
. Id. at *3.
. Tr. at 16.
. Foster, 2015 WL 66553 at *8.
. Tr. at 20.
. Id. at 436. It must be noted that Dr. Kanney did not include a diagnosis of "fibro-myalgia” on his 2013 functional capacity questionnaire, although he did list "pain” and "fatigue” as her symptoms. Tr. at 623. A later functional capacity questionnaire is discussed below.
. See, Wilson, 378 F.3d at 545.
. Id. at 545-46. I note also that on June 2, 2014, or the day before the ALJ's current opinion issued, Dr. Kanney submitted another functional capacity report for the record. Tr. at 647. That opinion also does not specifically list fibromyalgia as a diagnosis, and, unlike prior reports, left blank the space for listing symptoms (Tr. at 648), but does state that Sito has had the functional limitations expressed since 2001. Tr. at 650.
. Blakley, 581 F.3d at 408.
. See, Foster, 2015 WL 66553 at** 7-8.
Reference
- Full Case Name
- Denise R. SITO v. COMMISSIONER OF SOCIAL SECURITY
- Cited By
- 5 cases
- Status
- Published