Opinion
C. A. 6:20-cv-02907-CMC-KFM
06-30-2021
Cynthia Joy Owens, Plaintiff, v. Andrew M. Saul, Commissioner of Social Security, Defendant.
REPORT OF MAGISTRATE JUDGE
KEVIN F. MCDONALD UNITED STATES MAGISTRATE JUDGE
This case is before the court for a report and recommendation pursuant to Local Civil Rule 73.02(B)(2)(a) (D.S.C.), concerning the disposition of Social Security cases in this District, and Title 28, United States Code, Section 636(b)(1)(B). The plaintiff brought this action pursuant to Section 205(g) of the Social Security Act, as amended (42 U.S.C. 405(g)) to obtain judicial review of a final decision of the Commissioner of Social Security denying her claim for disability insurance benefits under Title II of the Social Security Act.
A report and recommendation is being filed in this case, in which one or both parties declined to consent to disposition by the magistrate judge.
The ALJ’s decision records the date as December 8, 2016 (Tr. 10).
ADMINISTRATIVE PROCEEDINGS
The plaintiff filed an application for disability insurance benefits (“DIB”) on December 15, 2016,2 alleging that she became unable to work on March 30, 2016 (Tr. 200-01). The application was denied initially (Tr. 92-109) and on reconsideration (Tr. 110-25) by the Social Security Administration. On July 31,2017, the plaintiff requested a hearing (Tr. 139). On March 27, 2019, a video administrative hearing was held at which the plaintiff, represented by counsel, and Heather Mueller, an impartial vocational expert, appeared and testified before the ALJ, who was located in Chicago, Illinois (Tr. 57-91). On June 12, 2019, the ALJ considered the case de novo and found that the plaintiff was not under a disability as defined in the Social Security Act, as amended (Tr. 10-25). The ALJ’s finding became the final decision of the Commissioner of Social Security when the Appeals Council denied the plaintiff’s request for review on June 10, 2020 (Tr. 1-3). The plaintiff then filed this action for judicial review (doc. 1).
In making the determination that the plaintiff is not entitled to benefits, the Commissioner has adopted the following findings of the ALJ:
(1) The claimant meets the insured status requirements of the Social Security Act through December 30, 2022.
(2) The claimant has not engaged in substantial gainful activity since March 30, 2016, the alleged onset date (20 C.F.R. § 404.1571 et seq.).
(3) The claimant has the following severe impairments: degenerative disc disease, chronic obstructive pulmonary disease (“COPD”), peripheral artery disease, and lupus/fibromyalgia/inflammatory arthritis (20 C.F.R. § 404.1520(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 in 20 C.F.R. Part 404, Subpart P, Appendix 1 (20 C.F.R. §§ 404.1520(d), 404.1525 and 404.1526).
(5) After careful consideration of the entire record, the undersigned finds that the claimant has the residual functional capacity to perform light work as defined in 20 C.F.R. § 404.1567(b) where the claimant lifts or carries 20 pounds occasionally and 10 pounds frequently, stands or walks for six of eight hours during the workday, and sits for six of eight hours during the workday. The claimant can frequently reach, finger, and handle bilaterally. The claimant can have no concentrated exposure to noxious fumes, odors, or respiratory irritants.
(6) The claimant is capable of performing past relevant work as a systems analyst. This work does not require the performance of work-related activities precluded by the claimant’s residual functional capacity (20 C.F.R. § 404.1565).
(7) The claimant has not been under a disability, as defined in the Social Security Act, from March 30, 2016, through the date of this decision (20 C.F.R. § 404.1520(f)).
The ALJ’s decision included an alternative finding that “considering the claimant’s age, education, work experience, and residual functional capacity, there are other jobs that exist in significant numbers in the national economy that the claimant also can perform (20 C.F.R. §§ 404.1569, 404.1569a)” (Tr. 19).
The only issues before the court are whether proper legal standards were applied and whether the final decision of the Commissioner is supported by substantial evidence.
APPLICABLE LAW
Under 42 U.S.C. § 423(d)(1)(A), (d)(5), as well as pursuant to the regulations formulated by the Commissioner, the plaintiff has the burden of proving disability, which is defined as an “inability to do 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.” 20 C.F.R. § 404.1505(a).
To facilitate a uniform and efficient processing of disability claims, the Social Security Act has by regulation reduced the statutory definition of “disability” to a series of five sequential questions. An examiner must consider whether the claimant (1) is engaged in substantial gainful activity, (2) has a severe impairment, (3) has an impairment that meets or medically equals an impairment contained in the Listing of Impairments found at 20 C.F.R. Pt. 404, Subpt. P, App. 1, (4) can perform his past relevant work, and (5) can perform other work. Id. § 404.1520. If an individual is found disabled or not disabled at any step, further inquiry is unnecessary. Id. § 404.1520(a)(4).
A claimant must make a prima facie case of disability by showing he is unable to return to his past relevant work because of his impairments. Grant v. Schweiker, 699 F.2d 189, 191 (4th Cir. 1983). Once an individual has established a prima facie case of disability, the burden shifts to the Commissioner to establish that the plaintiff can perform alternative work and that such work exists in the national economy. Id. (citing 42 U.S.C. § 423(d)(2)(A)). The Commissioner may carry this burden by obtaining testimony from a vocational expert. Id. at 191-92.
Pursuant to 42 U.S.C. § 405(g), the court may review the Commissioner’s denial of benefits. However, this review is limited to considering whether the Commissioner’s findings “are supported by substantial evidence and were reached through application of the correct legal standard.” Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996). “Substantial evidence” means “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion; it consists of more than a mere scintilla of evidence but may be somewhat less than a preponderance.” Id. In reviewing the evidence, the court may not “undertake to re-weigh conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the [Commissioner].” Id. Consequently, even if the court disagrees with Commissioner’s decision, the court must uphold it if it is supported by substantial evidence. Blalock v. Richardson, 483 F.2d 773, 775 (4th Cir. 1972).
ANALYSIS
The plaintiff argues that the ALJ erred by (1) failing to properly assess medical source opinions by treating providers (doc. 16 at 12-18); (2) failing to appropriately evaluate the plaintiff’s mental health disorders (id. at 18-19); and (3) failing to support his conclusions with substantial evidence (id. at 19-20). The Commissioner asserts that the ALJ’s decision is supported by substantial evidence and should be affirmed (doc. 17 at 12-22). For the reasons set forth in more detail below, it is recommended that the decision of the Commissioner be reversed and remanded for administrative action consistent with this recommendation, pursuant to sentence four of 42 U.S.C. § 405(g).
Medical Source Statements
As noted, the plaintiff argues that the ALJ failed to appropriately evaluate opinion evidence, including an opinion by the plaintiff’s treating psychiatrist, Melanie Teasley, M.D. (doc. 16 at 15-17). The regulations require that all medical opinions in a case be considered. 20 C.F.R. § 404.1527(b). The regulations further direct ALJs to accord controlling weight to a treating physician’s opinion that is well-supported by medically-acceptable clinical and laboratory diagnostic techniques and that is not inconsistent with the other substantial evidence of record. Id. § 404.1527(c)(2). If a treating physician’s opinion is not given controlling weight, the ALJ must proceed to weigh the treating physician’s opinion, along with all the other medical opinions of record, based upon the following non-exclusive list of factors: (1) the examining relationship; (2) the length of the treatment relationship and the frequency of the examinations; (3) the nature and extent of the treatment relationship; (4) the evidence with which the physician supports his opinion; (5) the consistency of the opinion; and (6) whether the physician is a specialist in the area in which he is rendering an opinion. Id. § 404.1527(c)(1)-(5); see also Johnson v. Barnhart, 434 F.3d 650, 654 (4th Cir. 2005). However, “[w]hile an ALJ is not required to set forth a detailed factor-by-factor analysis in order to discount a medical opinion from a treating physician, it must nonetheless be apparent from the ALJ’s decision that he meaningfully considered each of the factors before deciding how much weight to give the opinion.” Dowling v. Comm’r of Soc. Sec. Admin., 986 F.3d 377, 385 (4th Cir. 2021) (emphasis in original).
These regulations apply for applications filed before March 27, 2017. See 20 C.F.R. § 404.1527. For applications filed on or after March 27, 2017, a new regulatory framework for considering and articulating the value of medical opinions has been established. See id. § 404.1520c; see also 82 Fed. Reg. 5844-01, 2017 WL 168819 (revisions to medical evidence rules dated Jan. 18, 2017, and effective for claims filed after Mar. 27, 2017). Here, the plaintiff’s DIB application was filed before March 27, 2017; thus, the opinions have been analyzed under the old rules.
Recently, the Fourth Circuit Court of Appeals reiterated the treating physician rule, explaining that it “requires that ALJs give ‘controlling weight’ to a treating physician’s opinion on the nature and severity of the [plaintiff’s] impairment if that opinion is (1) ‘well-supported by medically acceptable clinical and laboratory diagnostic techniques’ and (2) ‘not inconsistent with the other substantial evidence’ in the record.” Arakas v. Comm’r, Soc. Sec. Admin., 983 F.3d 83, 106 (4th Cir. 2020). The court went on to note that a treating physician opinion “must be given controlling weight unless it is based on medically unacceptable clinical or laboratory diagnostic techniques or is contradicted by the other substantial evidence in the record.” Id. at 107 (emphasis in original) (citations omitted).
The record contains a medical source statement by Dr. Teasley dated April 17, 2017, and an undated medical source statement (Tr. 521-25, 528-32). In both medical source statements, Dr. Teasley opined that the plaintiff had no limitations in understanding and memory, but did have limitations in other areas of mental functioning. Dr. Teasley opined in the dated medical source statement that the plaintiff had social interaction limitations because the plaintiff avoids being with people, but the undated statement noted “unknown” with respect to this area of limitation. Dr. Teasley also opined that the plaintiff was limited in sustained concentration and persistence, noting that the plaintiff could not read or watch television. The plaintiff also had a limitation in adaptation (including adapting to changes in the work setting, being aware of hazards, using public transportation, setting realistic goals, and making independent plans). Dr. Teasley noted that she could not provide an opinion regarding the plaintiff’s ability to do work-related activities; however, she noted that the plaintiff’s fibromyalgia and possible SLE (systemic lupus erythematosus) affected her ability to sit and caused pain in at least the plaintiff’s back, knees, and shoulders. Dr. Teasley indicated that the plaintiff was limited by a combination of her mental and physical impairments. Dr. Teasley further indicated that the plaintiff had not obtained sustained improvement as of the date of the opinion. She also noted a guarded prognosis, indicating that the plaintiff had a poor ability to sustaining employment, but that the plaintiff could manage her own funds if benefits were granted (Tr. 521-25, 528-32).
The ALJ considered Dr. Teasley's opinion and assigned it little weight, noting:
As for the mental opinion evidence, the state psychological consultants found the [plaintiff] is limited to unskilled work (Exhibit 1A, Exhibit 3A). Dr. Lewis Lazarus Ph.D. [opined] that the [plaintiff] has significant difficulties with mental persistence and attention (Exhibit 7F). Dr. Melanie Teanly M.D. found the [plaintiff] is limited in concentration, avoids being around people, and is limited in adaptation (Exhibit 8F). Their opinions are contradicted by the [plaintiff’s] self-report that she has no problems getting along with others and of improvement with medication (exhibit 6E, 13F/1). Their opinions are contradicted by mental status examinations that showed the [plaintiff] was fully oriented, average intelligence, and a fair mood (Exhibit 13F/4-6, Exhibit 14F/2, 4, Exhibit 8F/2). Therefore, their opinions are granted little weight.(Tr. 14).
It appears that this is a typo in the ALJ’s decision, as the ALJ references Dr. Teasley’s opinion (Tr. 14 (citing Tr. 521-32)).
The plaintiff argues that the ALJ’s decision violates the treating physician rule because it does not evaluate Dr. Teasley’s opinion in accordance with the appropriate factors. The undersigned agrees. For example, it is not apparent from the “ALJ’s decision that he meaningfully considered each of the factors before deciding how much weight to give [Dr. Teasley’s] opinion.” Dowling, 986 F.3d at 385. Beyond citing to a function report and seven pages of medical records (out of 521 pages of medical records), there is no indication that the ALJ considered the majority of the factors under 20 C.F.R. § 404.1527(c) (see Tr. 14). Indeed, two factors that were omitted, relating to Dr. Teasley’s status as a treating provider and Dr. Teasley’s specialty of psychiatry, appear to favor the plaintiff, as Dr. Teasley was the plaintiff’s treating psychiatrist. 20 C.F.R. § 404.1527(c). In attempting to distinguish this matter from Arakas, the Commissioner argues that the remaining factors support the ALJ’s decision because the plaintiff had treated less than a month with Dr. Teasley when Dr. Teasley completed the opinion (doc. 17 at 15). However, this argument by the Commissioner does not appear in the ALJ’s decision; thus, it is a post hoc rationalization, which cannot be considered in undertaking substantial evidence review. See Moseley v. Berryhill, C/A No. 6:18-cv-01389-BHH-KFM, 2019 WL 2107917, at *10 (D.S.C. Apr. 22, 2019), R&R adopted by 2019 WL 2106181 (D.S.C. May 14, 2019) (“[G]eneral principles of administrative law preclude the Commissioner’s lawyers from advancing grounds in support of the agency’s decision that were not given by the ALJ.” (quoting Golembiewski v. Barnhart, 322 F.3d 912, 916 (7th Cir.2003))).
The plaintiff also argues that the ALJ’s decision erred in its consideration of other opinion evidence; however, because the undersigned finds that the ALJ’s error with respect to Dr. Teasley’s opinion is sufficient to warrant remand of this action, this report and recommendation will only address the analysis of Dr. Teasley’s opinion.
Nonetheless, a review of the record evidence indicates that the ALJ’s evaluation of the supportability and consistency of Dr. Teasley’s opinion relies upon a few cherry-picked pages of the record evidence; thus, it is not supported by substantial evidence. For example, Dr. Teasley’s treatment notes dated March 21, 2017, include abnormal examination findings, including passive suicidal/homicidal ideation with no plan; a depressed mood/affect; slow, soft speech; memory that was at times impaired, and poor to moderate judgment (T r. 529). Likewise, examination findings on April 17, 2017, indicate that although the plaintiff had no suicidal ideation on that day, the plaintiff had a depressed/anxious mood/affect; had trouble with concentration because she could not read and retain television or books; needed frequent refocusing; had a diminished memory; and adequate judgment (Tr. 522). The ALJ’s decision omits discussion of these abnormal examination findings, which are consistent with Dr. Teasley’s opinion that the plaintiff’s impairments would limit her ability to concentrate, be around people, and in adaptation (including adapting to changes in the work setting, being aware of hazards, using public transportation, setting realistic goals, and making independent plans).
Additionally, as noted by the plaintiff, the ALJ’s decision misconstrues the plaintiff’s function report, in finding that it was inconsistent with Dr. Teasley’s opinion (Tr. 14 (citing Tr. 248-55)) Indeed, although the plaintiff did not check the box on the form that her impairments caused “difficulty getting along with others,” her function report notes that the plaintiff gets anxious when leaving the house, avoids social events, and that she only spends time with her daughter twice a month (Tr. 248-55). Moreover, although not mentioned in the ALJ’s decision, the plaintiff also noted in her function report that she was unable to understand, complete tasks, concentrate, and follow instructions (Tr. 248-55). These assertions are consistent with Dr. Teasley’s opinion; thus, the ALJ’s reliance on one checkbox item to find Dr. Teasley’s opinion inconsistent with the function report appears to be in error.
Likewise, notes from the plaintiff’s other providers are consistent with Dr. Teasley’s opinion, although the ALJ’s evaluation of Dr. Teasley’s opinion makes only a passing reference to seven pages in the record. For example, the ALJ’s decision references four of six treatment records by Michael D. Wilcox, M.D., Ph.D., and notes that the plaintiff was fully oriented, had average intelligence, and a fair mood (Tr. 14 (citing Tr. 725, 728-30)). However, the ALJ’s analysis omits abnormal examination findings during those visits (as well as omits two treatment visits) including only fair concentration, a dysphoric or fair mood/affect, and moderate panic/anxiety (T r. 725-30). Likewise, the ALJ’s decision references two treatment visits with Katherine West, L.M.F.T., but omits mention of the remaining sixteen treatment visits the plaintiff had with Ms. West (compare Tr. 14 (citing Tr. 733, 735) with Tr. 732-86 (containing all of Ms. West’s treatment of the plaintiff)). Additionally, during the two treatment visits cited by the ALJ’s decision, the plaintiff is noted as having a disorganized though process, with a sad/depressed mood, and as drowsy (Tr. 732-37). These abnormal examination findings appear in conflict with the ALJ’s description of the plaintiff as “fully oriented, average intelligence, and a fair mood” (Tr. 14).
Further, the remainder of Ms. West’s records are consistent with Dr. Teasley’s opinion, but the ALJ’s decision does not reference them. For example, when the plaintiff presented to Ms. West for treatment on September 29, October 6, and October 20, 2017, she had a sad/depressed mood, poor insight, and hopeless/helpless thought content (Tr. 777-86). From March 30, 2018, to June 15, 2018, despite the plaintiff’s compliance with medication, Ms. West noted that the plaintiff was disheveled, had intermittent eye contact, unusual mannerism, slow/slurred speech, sad/depressed/labile mood, tangential disorganized thought processes, hopeless/helpless thought content, paranoia/suspicious, poor insight, impaired judgment, and drowsiness (Tr. 756-73). From July 11,2018, through January 16, 2019, Ms. West noted that the plaintiff had a sad/depressed mood, tangential disorganized thought processes, and occasional drowsiness (Tr. 732-55). These examination findings, along with notations by Ms. West that the plaintiff needed to continue intervention targeting specific problems, is consistent with Dr. Teasley’s opinion that the plaintiff would struggle with concentration, in interacting with others, and in adaptation.
Moreover, Dr. Teasley’s opinions are also consistent with records from consultative examiners, including Dr. Lazarus and Dora Anguelova, M.D., Ph.D., P.A. For example, after examination, Dr. Lazarus opined that the plaintiff would have the “most significant difficulties with respect to mental persistence and [ ] attention” (Tr. 519). Dr. Anguelova also noted that the plaintiff had memory loss affecting her ability to speak (Tr. 801-02). The examination findings from the plaintiff’s treating and non-treating examining providers, as well as the plaintiff’s ongoing treatment for major depressive disorder and anxiety disorder with panic attacks, appear to undercut the ALJ’s conclusion that Dr. Teasley’s opinion was only entitled to little weight because it was “contradicted by substantial evidence in the record,” Arakas, 983 F.3d at 107, as required when discounting an opinion by a treating physician.
As such, although the ALJ retains the authority to weigh medical opinions -and is not required to discuss every factor set forth in the regulations (so long as the decision reflects meaningful consideration of the factors) - it is legally insufficient for the ALJ’s decision to overlook portions of an opinion and record evidence in partially disregarding medical opinions provided by treating providers, such as Dr. Teasley. “A necessary predicate to engaging in substantial evidence review is a record” that adequately explains the ALJ’s findings and reasoning. Dowell v. Colvin, C/A No. 1:12-cv-1006, 2015 WL 1524767, at *4 (M.D.N.C. Apr. 2, 2015) (requiring that the ALJ “build a logical bridge between the evidence and his conclusions”) (citing Radford v. Colvin, 734 F.3d 288, 295 (4th Cir. 2013)). Accordingly, this case should be remanded so that the ALJ may properly weigh Dr. Teasley’s medical opinion under the applicable standards and explain the reasons for the weight given to Dr. Teasley’s opinion.
Remaining Allegations of Error
In light of the court’s recommendation that this matter be remanded for further consideration as discussed above, the court need not specifically address the plaintiff’s remaining allegations of error as the ALJ will be able to reconsider and re-evaluate the evidence as part of the reconsideration of this claim. Hancock v. Barnhart, 206 F.Supp. 2d 757, 763-64 n.3 (W.D. Va. 2002) (on remand, the ALJ’s prior decision has no preclusive effect as it is vacated and the new hearing is conducted de novo); see Boone v. Barnhart, 353 F.3d 203, 211 n.19 (3d Cir. 2003) (remanding on other grounds and declining to address claimant’s additional arguments). As such, on remand, the ALJ is to also take into consideration the plaintiff’s remaining allegations of error.
CONCLUSION AND RECOMMENDATION
As such, based upon the foregoing, this court recommends that the Commissioner’s decision be reversed under sentence four of 42 U.S.C. § 405(g), with a remand of the cause to the Commissioner for further proceedings as discussed above.
IT IS SO RECOMMENDED.