Hale v. Comm'r of Soc. Sec.
Hale v. Comm'r of Soc. Sec.
Opinion of the Court
This Social Security disability benefits appeal is before the undersigned for disposition based upon the parties' full consent. Doc. 7. At issue is whether the Administrative Law Judge ("ALJ") erred in finding Plaintiff not "disabled" and therefore unentitled to Disability Insurance Benefits ("DIB") and/or Supplemental Security Income ("SSI").
I.
A. Procedural History
Plaintiff filed for DIB and SSI alleging a disability onset date of October 17, 2006. PageID 221-31. Plaintiff suffers from a number of impairments including, among others, chronic back pain, obesity, diabetes, and depression. PageID 1027.
After initial denial of her claims, Plaintiff received a hearing before ALJ Maria Hodges on October 12, 2011. PageID 66-107. The ALJ issued a written decision on October 26, 2011 finding Plaintiff not disabled. PageID 40-56. Plaintiff subsequently appealed ALJ Hodges's decision and the undersigned reversed her non-disability finding as unsupported by substantial evidence, and remanded the case for further proceedings. Hale v. Comm'r of Soc. Sec. , No. 3:13-CV-195,
On remand, Plaintiff received a hearing before ALJ Elizabeth Motta on March 23, 2015. PageID 1059-92. ALJ Motta issued a decision on July 31, 2015 finding Plaintiff not disabled. PageID 1023-48. Specifically, the ALJ found:
1. The claimant met the insured status requirements of the Social Security Act through December 31, 2012.
2. The claimant has not engaged in substantial gainful activity since October 17, 2006, the alleged disability onset date ( 20 CFR 404.1571, et seq., and 416.971, et seq. ).
3. The claimant has the following severe impairments: degenerative disc disease of the lumbar spine, obesity, diabetes mellitus with nephropathy, depressive disorder, personality disorder with dependent features, borderline intellectual functioning versus learning disorder ( 20 CFR 404.1520(c) and 416.920(c) ).
4. The claimant does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in20 CFR Part 404, Subpart P, Appendix 1( 20 CFR 404.1520(d), 404.1525, 404.1526, 416.920(d), 416.925 and 416.926 ).
5. The claimant has the residual functional capacity ["RFC"] to perform light work [
6. The claimant is unable to perform past relevant work ( 20 CFR 404.1565 and 416.965 ).
7. The claimant was born on July 22, 1967. At age 47 she is classified as a "younger individual" for Social Security purposes ( 20 CFR 404.1563 and 416.963 ).
8. The claimant has a high-school education ( 20 CFR 404.1564 and 416.964 ).
9. The claimant does not have "transferable" work skills within the meaning of the Social Security Act ( 20 CFR 404.1568 and 416.968 ).
10. Considering the claimant's age, education, work experience and residual functional capacity, there are jobs that exist in significant numbers in the national economy that the claimant can perform ( 20 CFR 404.1569, 404.1569(a), 416.969, and 416.969(a) ).
11. The claimant was not "disabled," as defined in the Social Security Act, from October 17, 2006, through the date of this decision ( 20 CFR 404.1520(g) and 416.920(g) ).
PageID 1023-48.
Plaintiff did not seek Appeals Council review of ALJ Motta's decision. See
B. Evidence of Record
The evidence of record is adequately summarized in the ALJ's decision (PageID 1027-45), Plaintiff's Statement of Errors (doc. 8), the Commissioner's memorandum in opposition (doc. 10), and Plaintiff's reply (doc. 11). The undersigned incorporates all of the foregoing and sets forth the facts relevant to this Decision herein.
II.
A. Standard of Review
The Court's inquiry on a Social Security appeal is to determine (1) whether the ALJ's non-disability finding is supported by substantial evidence, and (2) whether the ALJ employed the correct legal criteria.
Substantial evidence is "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales,
The second judicial inquiry-reviewing the correctness of the ALJ's legal analysis-may result in reversal even if the ALJ's decision is supported by substantial evidence in the record. Rabbers v. Comm'r of Soc. Sec. ,
B. "Disability" Defined
To be eligible for disability benefits, a claimant must be under a "disability" as defined by the Social Security Act.
Administrative regulations require a five-step sequential evaluation for disability determinations.
1. Has the claimant engaged in substantial gainful activity?
2. Does the claimant suffer from one or more severe impairments?
3. Do the claimant's severe impairments, alone or in combination, meet or equal the criteria of an impairment set forth in the Commissioner's Listing of Impairments (the "Listings"), 20 C.F.R. Subpart P, Appendix 1?
4. Considering the claimant's RFC, can he or she perform his or her past relevant work?
5. Assuming the claimant can no longer perform his or her past relevant work-and also considering the claimant's age, education, past work experience, and RFC-do significant numbers of other jobs exist in the national economy which the claimant can perform?
III.
In her Statement of Errors, Plaintiff argues that the ALJ erred by improperly: (1) weighing the opinions of primary care physician James W. Thompson, D.O. and her treating psychiatrist Douglas Lehrer, M.D.; (2) explaining the weight accorded to non-treating medical sources; (3) assessing the extent of her daily activities; and (4) relying significantly on her alleged noncompliance with treatment recommendations in assessing her credibility. The undersigned finds error in the ALJ's weighing of medical source opinions and, therefore, does not address the merits of each of Plaintiff's alleged errors.
"[T]he Commissioner's regulations establish a hierarchy of acceptable medical source opinions[.]" Snell v. Comm'r of Soc. Sec. , No. 3:12-cv-119,
A treater's opinion must be given "controlling weight" if "well-supported by medically acceptable clinical and laboratory diagnostic techniques and ... not inconsistent with the other substantial evidence in [the] case record." LaRiccia v. Comm'r of Soc. Sec. ,
After treaters, "[n]ext in the hierarchy are examining physicians and psychologists, who often see and examine claimants only once." Snell ,
A. Dr. Lehrer
Before addressing the merits of the ALJ's assessment of Dr. Lehrer's *793opinion, the Court notes that in setting forth Plaintiff's RFC in this case, ALJ Motta cited no opinion from any medical source concerning limitations arising from Plaintiff's mental impairments. See PageID 1043. Instead, the ALJ's entire evaluation of opinion evidence related to Plaintiff's mental impairments was confined to the analysis at Step Two when determining whether such impairments were severe or non-severe. See
"While the ALJ must consider all of the relevant evidence in determining a claimant's RFC, the RFC is ultimately a medical question that must find at least some support in the medical evidence of record." Casey v. Astrue ,
Assuming the ALJ's analysis of mental health opinions at Step Two can be sufficiently attributed to the RFC determination at Step Four, the undersigned finds that the ALJ failed to appropriately weigh the opinion of treating psychiatrist Dr. Lehrer, who opined in April 2011, that Plaintiff is "markedly limited"
The undersigned concludes that the ALJ's statement regarding the lack of clinical findings fails to satisfy the requirements of the treating physician analysis set forth in
Further, insofar as the ALJ may have concluded that the record was devoid of any clinical findings,
In light of these clinical findings, the ALJ's conclusions-that Dr. Lehrer's opinion must be (1) based on "uncritical acceptance of [Plaintiff's] subjective complaints[,]" and (2) "entirely speculative and lacking any logical foundation in the medical record"-are also unsupported by the record. See supra ; see also PageID 971 (noting that Plaintiff not only reports "symptoms[,]" but also "displays symptoms of depression that include social withdrawal, lack of motivation, fatigue, over eating, remembering [and] concentrating").
With regard to the purportedly inconsistent "other substantial evidence in the case record" undermining Dr. Lehrer's opinion, it is not entirely clear what evidence the ALJ is referencing in this regard. See PageID 1033. Insofar as the ALJ relied on the opinions of "[o]ther mental health professionals" who purportedly "presented much less pessimistic assessments of the claimant's mental functioning capabilities," see PageID 1032, such reliance-in declining controlling weight to Dr. Lehrer's opinion-is error. See Gayheart ,
Insofar as the inconsistent substantial evidence is a medical record wherein Plaintiff represented working 129 hours per month (an average of 30 hours per week) at one point, the ALJ failed to acknowledge that such work was not on a full-time basis, and that the same note reflects Plaintiff's intent to quit such part-time job because she "hurt," the job increased her anxiety, and because her anxiety medication "knocks her out." PageID 1662-63. Accordingly, such evidence does not suggest Plaintiff's ability to work "on a sustained basis , which is how functional limitations of mental impairments are to be assessed." Gayheart ,
Finally, the only other portion of the record referenced by the ALJ in rejecting Dr. Lehrer's opinion was Plaintiff's "own statements made to other mental health professionals[;]" namely, unidentified statements made to Nancy Schmidtgoessling, Ph.D. and Gordon Harris, Ph.D. PageID 1033. Insofar as the ALJ may be referencing Plaintiff's daily activities as described by Drs. Schmidtgoessling and Harris, the undersigned sees little in such descriptions of Plaintiff's daily activities suggesting that Plaintiff is able to work "on a sustained basis [.]" Gayheart ,
Based upon all of the foregoing, the ALJ's analysis regarding the weight accorded Dr. Lehrer's opinion is unsupported by substantial evidence. Reversal is mandated.
B. Dr. Thompson
With regard to Plaintiff's physical limitations in this case, the record contains opinions from two treating physicians; namely, Dr. Thompson and Douglas Ross, D.O. See PageID 607-09, 998. On appeal, Plaintiff challenges the ALJ's assessment of Dr. Thompson's opinion and does not challenge the ALJ's assessment of Dr. Ross's opinion. PageID 1040.
In June 2011, Dr. Thompson concluded that, because of her impairments, Plaintiff was limited to standing 15 minutes at a time; sitting for 30 minutes at a time; lifting 10 pounds occasionally and 5 pounds frequently; no stooping; and working a total of 1 hour per day. PageID 998. In weighing Dr. Thompson's opinion, ALJ Motta found that such opinion could not "be given controlling or deferential weight." PageID 1041. In that regard, the ALJ found Dr. Thompson's "conclusions are entirely unsupported by medically acceptable clinical and laboratory diagnostic techniques"
Contrary to the ALJ's conclusion, however, there are numerous clinical and imaging findings of record that lend support to Dr. Thompson's opinion. See PageID 457, 479, 493, 516, 613, 618, 628, 642 (noting "[m]arked tenderness in the right lumbar parapinal area, moderate tenderness in the lumbar facet joints, moderate tenderness in the right S1 joint ... [and] pain elicited with active lumbar flexion"); 637-38 (noting tenderness at L4, L5 and sacrum); 988 (noting MRI findings of "[s]table shallow central disc protrusion at L4-L5" and "[f]acet arthropathy at L4-L5 and L5-S1" at MRI); 989 (noting MRI findings of "[m]ild degenerative changes of the right hip and pubic symphysis"); 1015-17 (noting "wide-based" gait, tenderness in the right S1 joint, and muscle spasm in the bilateral lumbar spine); 1341 (noting tenderness); 1348, 1353, 1357, 1361, 1366, 1370, 1375, 1379, 1383, 1387, 1393, 1400-01, 1405-06, 1411, 1416-17, 1419-20, 1423-24, 1429, 1432-33, 1436, 1440, 1443, 1446, 1449-50 (noting morbid obesity,
The Court also notes that, in rejecting Dr. Thompson's opinion, the ALJ instead gave "significant weight" to the opinions of four non-examining, record-reviewing physicians: (1) Eli Perencevich, D.O., who offered an assessment on August 21, 2007; (2) Gerald Klyop, M.D., who offered an assessment on August 11, 2009; (3) Diane Manos, M.D., who offered an opinion on June 2, 2010; and (4) Leon Hughes, M.D., who offered an assessment on October 28, 2010. PageID 409-16, 447-54, 805-12, 888, 1040. In giving these opinions "substantial weight," the ALJ found that these opinions are "not inconsistent with any compelling evidence in the case record and are found to represent a credible estimation of the claimant's actual basic functional capabilities." PageID 1042. Unfortunately, this conclusory assessment of the record-reviewers' opinions is not significantly different than the previous ALJ's analysis-a deficient analysis that the Court found amounted to reversible error. See Hale ,
Based upon the foregoing, the undersigned concludes that the ALJ's analysis of the weight accorded the opinions of Drs. Thompson, Perencvich, Klyop, Manos and Hughes are unsupported by substantial evidence. Reversal is also appropriate on this basis.
IV.
When, as here, the ALJ's non-disability determination is unsupported by substantial evidence, the Court must determine whether to reverse and remand the matter for rehearing or to reverse and order the award of benefits. The Court has authority to affirm, modify or reverse the Commissioner's decision "with or without remanding the cause for rehearing."
While the Court acknowledges Plaintiff's concern that this case was previously remanded, see Hale ,
V.
For the foregoing reasons, IT IS ORDERED THAT : (1) the Commissioner's non-disability finding is unsupported by substantial evidence, and REVERSED ; (2) this matter is REMANDED to the Commissioner under the Fourth Sentence of
IT IS SO ORDERED.
"The Commissioner's regulations governing the evaluation of disability for DIB and SSI are identical ... and are found at
Hereafter, citations to the electronically-filed administrative record will refer only to the PageID number.
The Social Security Administration ("SSA") classifies jobs as sedentary, light, medium, heavy, and very heavy depending on the physical exertion requirements.
In essence, "opinions of a treating source ... must be analyzed under a two-step process, with care being taken not to conflate the steps." Cadle v. Comm'r of Soc. Sec. , No. 5:12-cv-3071,
The Court notes that Dr. Lehrer's opinion was co-signed by Plaintiff's treating licensed professional counselor Jacqueline Rust, L.P.C. PageID 973. In addition to "medical source opinions," opinions from "other sources" can be used to establish the severity of a claimant's impairment and establish how impairments affect a claimant's ability to work.
"Moderate" functional limitations are "non-disabling," see Sims v. Comm'r of Soc. Sec. ,
With regard to clinical findings, the Sixth Circuit has "acknowledged the difficulty inherent in proving psychological disabilities." Keeton v. Comm'r of Soc. Sec. ,
Notably, the Court in its previous decision in 2014 concluded otherwise, noting that the record is "replete with clinical signs and findings supporting the existence of back pain including, but not limited to, marked to moderate tenderness in the lumbar spine area, reduced range of motion, antalgic gait, spinal tenderness, swelling in Plaintiff's legs, wide-based gait, tenderness to palpitation, muscle spasm, and pain to pressure of Plaintiff's spine." Hale ,
Obesity itself "can cause limitation of function." SSR 01-1P,
Reference
- Full Case Name
- Susan HALE v. COMMISSIONER OF SOCIAL SECURITY
- Cited By
- 5 cases
- Status
- Published