Opinion
7:20-CV-00064-D
07-31-2021
Whitlee J. Williams, Plaintiff, v. Kilolo Kijakazi, [1] Acting Commissioner of Social Security, Defendant.
MEMORANDUM & RECOMMENDATION
ROBERT T. NUMBERS, II, UNITED STATES MAGISTRATE JUDGE
Plaintiff Whitlee Williams challenges Administrative Law Judge (“ALJ”) Joseph Booth, III's denial of her application for social security income. Williams claims that ALJ Booth erred in (1) evaluating her conditions under the Listing of Impairments and (2) considering the medical opinion evidence. Both Williams and Defendant Kilolo Kijakazi, Acting Commissioner of Social Security, have moved for judgment on the pleadings in their favor. D.E. 25, 30.
After reviewing the parties' arguments, the undersigned has determined that ALJ Booth erred in his determination. ALJ Booth failed to examine relevant evidence in assessing whether Williams's mental health conditions met or equaled the Listing of Impairments. And ALJ Booth's reasons to accord little weight to the treating provider's opinions lack support in the record. The undersigned thus recommends that the court grant Williams's motion, deny the Acting Commissioner's motion, and remand this matter to the Acting Commissioner for further consideration.
The court has referred this matter to the undersigned for entry of a Memorandum and Recommendation. 28 U.S.C. § 636(b). D.E. 32.
I. Background
In December 2013, Williams applied for disability benefits and supplemental security income. In both applications, she alleged a disability that began that month. After the Social Security Administration denied her claim at the initial level and upon reconsideration, Williams appeared before an ALJ for a hearing to determine whether she was entitled to benefits. The ALJ determined Williams had no right to benefits because she was not disabled. Tr. at 1253-1263.
After unsuccessfully seeking review by the Appeals Council, Williams filed a complaint with this court. See Williams v. Berryhill, No. 7:18-CV-00087-BO (filed May 22, 2018 E.D. N.C. ). Upon a motion to remand filed by the Commissioner, which Williams did not oppose, the court remanded the matter for further consideration. D.E. 40, Order (Mar. 14, 2019).
Williams appeared at a hearing before ALJ Booth to determine her entitlement to benefits. ALJ Booth determined that Williams had no right to benefits because she was not disabled. Tr. at 1183-97.
ALJ Booth found that Williams's obesity, headaches, pseudoseizures, vertigo, somatoform disorder, depressive disorder, anxiety disorder, and sleep disturbance were severe impairments. Tr. at 1186. ALJ Booth also found that Williams's impairments, either alone or in combination, did not meet or equal a Listing impairment. Id.
ALJ Booth then determined that Williams had the RFC to perform light work with other limitations. Tr. at 1187-88. She can frequently climb ramps and stairs and she can occasionally climb step-ladders up to four feet in height. Id. Williams cannot climb higher ladders or ropes or scaffolds of any height. Id. And she can frequently stoop, kneel, crouch, and crawl. Id.
Williams can have occasional exposure to vibration, atmospheric conditions, and moving, mechanical parts. Id. She may have exposure to moderate noise, but no exposure to high, exposed places. Id.
Williams may have occasional interactions with supervisors, coworkers, and the public. Id. She is limited to unskilled work, with no production rate pace work on assembly lines. Id. Williams may have occasional changes in the work setting and the manner and method of performing the assigned work. Id. She cannot operate motorized vehicles or heavy machinery required as part of her assigned work. Id.
ALJ Booth concluded that Williams could not perform her past relevant work a CNA. Tr. at 1195. But considering her age, education, work experience, and RFC, ALJ Booth found that jobs existed in significant numbers in the national economy that Williams could perform. Tr. at 1196. These jobs include housekeeper, plastic battery inspector, and electrical equipment inspector. Id. Thus, ALJ Booth found that Williams was not disabled. Tr. at 1196-97.
After unsuccessfully seeking review by the Appeals Council, Williams commenced this action in April 2020. D.E. 1.
II. Analysis
A. Standard for Review of the Acting Commissioner's Final Decision
When a social security claimant appeals a final decision of the Acting Commissioner, the district court's review is limited to determining whether, based on the entire administrative record, there is substantial evidence to support the Acting Commissioner's findings. 42 U.S.C. § 405(g); Richardson v. Perales, 402 U.S. 389, 401 (1971). Substantial evidence is defined as “evidence which a reasoning mind would accept as sufficient to support a particular conclusion.” Shively v. Heckler, 739 F.2d 987, 989 (4th Cir. 1984) (quoting Laws v. Celebrezze, 368 F.2d 640, 642 (4th Cir. 1966)). The court must affirm the Acting Commissioner's decision if it is supported by substantial evidence. Smith v. Chater, 99 F.3d 635, 638 (4th Cir. 1996).
B. Standard for Evaluating Disability
In making a disability determination, the ALJ engages in a five-step evaluation process. 20 C.F.R. § 404.1520; see Johnson v. Barnhart, 434 F.3d 650 (4th Cir. 2005). The ALJ must consider the factors in order. At step one, if the claimant is engaged in substantial gainful activity, the claim is denied. At step two, the claim is denied if the claimant does not have a severe impairment or combination of impairments significantly limiting him or her from performing basic work activities. At step three, the claimant's impairment is compared to those in the Listing of Impairments. See 20 C.F.R. Part 404, Subpart P, App. 1. If the impairment is listed in the Listing of Impairments or if it is equivalent to a listed impairment, disability is presumed. But if the claimant's impairment does not meet or equal a listed impairment, the ALJ assesses the claimant's RFC to determine, at step four, whether he can perform his past work despite his impairments. If the claimant cannot perform past relevant work, the analysis moves on to step five: establishing whether the claimant, based on his age, work experience, and RFC can perform other substantial gainful work. The burden of proof is on the claimant for the first four steps of this inquiry, but shifts to the Acting Commissioner at the fifth step. Pass v. Chater, 65 F.3d 1200, 1203 (4th Cir. 1995).
C. Medical Background
Williams has a history of mental and physical impairments, including major depressive disorder, anxiety disorder, somatoform disorder, psuedoseizure, sleep disturbance, and headaches. Tr. at 1186.
In August 2013, she saw Dr. Alfred DeMaria, a neurologist at Wilmington Health, for migraines. Tr. at 338. Williams reported that she had ten migraines a month. Id. Three months later, Williams sought treatment in the emergency department of New Hanover Regional Medical Center for a seizure episode. Tr. at 563. Dr. John Tsend, the attending physician, assessed pseudoseizure. Tr. at 568.
In March 2014, Howard Grotsky, Ed.D., evaluated Williams. Tr. at 391-92. He noted that Williams had much anger and the potential for explosive behavior. Tr. at 392. He concluded that she had a somatization disorder. Id.
The next month, Williams provided a statement claiming that she had worsening depression with suicidal ideations. Tr. at 393. She also stated that she had racing thoughts and a high level of stress. Id.
Two months later, Williams returned to the emergency department at NHRMC for a seizure which caused rigidity, jerking, and breath-holding. Tr. at 602. Williams began treatment with Carla Savinon, FNP, at MedNorth the next day. Tr. at 653-58. Williams reported hopelessness and loss of interest in activities. Tr. at 655. Savinon assessed Williams with major depressive disorder, migraine headaches, and recurrent seizures. Tr. at 657.
Williams again sought emergency treatment at NHRMC the next month for depression. Tr. at 686-89. Providers hospitalized her at RHA-The Harbor, a psychiatric facility, for three days because she had suicidal thoughts. Tr. at 623, 704-08.
Courtney Tindal evaluated Williams at A Helping Hand two months later. Tr. at 613-29. Her symptoms included depressed mood, inappropriate guilt, feelings of hopelessness, fatigue, loss of interest, and suicidal ideations. Tr. at 620.
In February 2015, Williams saw Susan Marshall, FNP, at MedNorth. Tr. at 955-59. Marshall noted that Williams was complaint with her medications but continued to experience major depression, recurrent migraines, and seizures. Tr. at 955.
The next month, providers admitted Williams to UNC Hospital for three days to evaluate her seizures. Tr. at 733-816. Although she experienced two events while being monitored, there was no EEG correlation. Tr. at 738. So providers assessed psychogenic non-epileptic spells. Id.
Dr. Megan Ardvison, a neurologist, found that Williams would benefit from in-patient psychiatric treatment because of her persistent depression, despite medication therapy, and physical manifestations of her mental state. Tr. at 770. Dr. Rish Peterson, a psychiatrist, evaluated Williams while she was a patient at UNC. Tr. at 753-54. Dr. Peterson believed Williams's depression was more severe than at first believed and that she presented an elevated risk of danger to herself and others. Tr. at 754.
In March 2015, Williams began mental health treatment with therapist Ann Simmonds at MedNorth. Tr. at 949, 953-54. Williams's depressive episodes sometimes lasted up to two weeks. Tr. at 954. She had a depressed mood, flat affect, and slow movement. Id. One month later, Simmonds performed a psychological evaluation. Tr. at 949-52. She had symptoms of depression and anxiety, including low energy, difficulty concentrating, and feelings of hopelessness. Tr. at 953. The next week, Simmons noted Williams's sleepiness and slow movement. Tr. at 947.
Williams also began seeing Dr. Saka Salami, a psychiatrist at MedNorth, later that month. Tr. at 945. Dr. Salami assess major depressive disorder, severe and recurrent, without psychotic features. Id.
In May 2015, Dr. Salami noted Williams's depressed mood and low motivation. Tr. at 936. One month later, Simmonds observed that Williams appeared sleepy and tearful. Tr. at 934. Williams claimed that her emptions were “all over the place” and she was annoyed, wanted to flee, and her emotions would sometimes “go nuts.” Id. She reported suicidal ideations over the previous few days when she saw Dr. Salami in August 2015. Tr. at 932. And she noted Williams presented with an irritable mood and constricted affect one month later. Tr. at 930. Simmonds remarked that Williams had a constricted affect and depressed mood later that month. Tr. at 928.
Simmonds issued a statement about Williams's condition in October 2015. Tr. at 961. Williams continued to experience recurrent and severe major depressive disorder with anxiety, migraines, and seizures. Id. Noting Williams's history of in-patient psychiatric treatment for depression, Simmonds stated that Williams had marked restrictions in activities of daily living and social functioning. Id. Simmonds also found that Williams had difficulty with concentration and motivation. Id.
Dr. Salami also issued an opinion statement at that time. Tr. at 963. He noted Williams's major depressive disorder diagnosis. Id. Dr. Salami held that she had marked limitations in activities of daily living and extreme limitations in social functioning. Id. Dr. Salami found that Williams's had extreme difficulty with understanding, remembering, and following detailed instructions, working with others, getting along with coworkers, and maintaining concentration and attention. Id. And he concluded that Williams's had marked limitations understanding, remembering, and following short and simple instructions and accepting supervision. Id.
Around this same time, Savinon completed a report on the effects of Williams's limitations. Tr. at 964. Because of her impairments, Williams had marked limitations in activities of daily living and social functioning. Id.
In November 2015, Dr. Salami observed that Williams had a dysphoric and defeated mood. Tr. at 1178. Later that month, Simmons remarked that Williams appeared sleepy with a flat affect and depressed mood. Tr. at 1167. And Simmonds noted her flat affect and depressed mood the next month. Tr. at 1175. Williams expressed a lack of control, paranoia, and guilt about being unable to care for her child. Tr. at 1169, 1175.
Williams visited the NHRMC emergency department in January 2016 for suicidal ideation. Tr. at 990. Providers admitted Williams for psychiatric treatment for 11 days. Tr. at 984-1017. At admission, Williams had major depressive disorder with anxious features. Tr. at 1011. Her symptoms included low energy, poor sleep, anhedonia, anxiety, and asociality. Tr. at 922.
The next month, Simmonds noted Williams's sad affect and depressed mood. Tr. at 1157. One month later, Williams reported that she panicked easily and was fearful in traffic. Tr. at 1151. Simmonds remarked that Williams cried a lot and was agitated. Tr. at 1147. And in May, Williams became upset and refused to talk to anyone. Tr. at 1125.
Three months later, Williams reported poor sleep. Tr. at 1111. She cried at a therapy session later that month, and displayed a depressed mood, flat affect, and stuttered speech. Tr. at 1102. Williams claimed she cried a lot, was tired, and was emotionally drained the next month. Tr. at 1026.
In October 2016, Williams went to the emergency department at NHRMC after having a seizure. Tr. at 1025-26. Williams saw Dr. DeMaria later that month for her seizures, dizziness, and headaches. Tr. at 1039-43. Dr. DeMaria prepared a statement that Williams needed a home health aide to help her drive and assist with activities of daily living. Tr. at 1032.
Later that month, Simmonds noted William had a sad mood and affect, crying for ten minutes of her therapy session. Tr. at 1074, 1076, Racing thoughts triggered Williams's seizures. Tr. at 1074. In December, Dr. Salami observed Williams's unhappy mood and tearful affect. Tr. at 1065.
In April 2017, Simmonds prepared a Patient Treatment Plan. Tr. at 2111-12. Simmonds remarked that Williams continued to experience significant functional impairments from her major depressive disorder with anxious distress. Tr. at 2111. The next month, Dr. Salami observed that Williams was feeling down and angry. Tr. at 2093. And four months later, she was emotional and tearful. Tr. at 2087. In October, Williams returned to the emergency department for seizure-like activity. Tr. at 1897. At a visit to MedNorth a few days later, Dr. Mayra Galeano remarked that Williams presented as despondent and despairing. Tr. at 2085.
Dr. Salami noted that Williams became easily frustrated and agitated when he saw her in January 2018. Tr. at 2072. She reported visual hallucinations and creating things in her own head. Id. The next month, Dr. Salami noted Williams's was feeling depressed and had general relationship difficulty with others. Tr. at 2070.
In April 2018, Williams saw Dr. DeMaria again for continued headaches, insomnia, and “spells.” Tr. at 1536-40. Dr. DeMaria indicated he would submit social work referrals for help with driving and home health care. Tr. at 1539. When she saw Simmonds a few days later, Williams displayed a dysthymic mood and abnormal affect. Tr. a 1667. Testing scores revealed moderately severe depression and severe anxiety. Id. The next month, Dr. Salami noted that Williams worried constantly and displayed a dysphoric mood and restricted affect. Tr. at 1662.
Simmonds remarked that Williams experienced persistent symptoms and dysthymic mood at a follow-up session in June 2018. Tr. at 1652. A week later, Simmonds noted Williams's persistent anxiety symptoms because of meeting people. Tr. at 1650.
Williams contacted MedNorth several days later requesting to see Simmonds because of depression. Tr. at 1648. Later that day, Williams saw Simmonds and Dr. Salami, who prescribed sedative medication. Tr. at 1646. Dr. Salami noted that Williams was down and depressed, with increased anxiety and panic-like feeling when he saw her several days later. Tr. at 1643. And later that month, Simmonds observed that Williams cried a lot during her therapy session. Tr. at 1642.
At therapy sessions with Simmonds in July 2018, Williams cried and had an abnormal affect and dysthymic mood. Tr. at 1640. And later that month, therapist Tracy Cercone remarked that Williams had a recent anger outburst against her husband. Tr. at 1642.
Williams continued mental health treatment at MedNorth in 2019. In February, Simmonds noted a change in Williams's mood as well as a dull affect and slurred speech. Tr. at 1601. The next day, Dr. Naomi Fleck remarked that she had anxiety, depression, feelings of hopelessness, sleep disturbance, and loss of interest in activities. Tr. at 1598.
Later that month, Williams returned to the emergency department at NHRMC for twitching. Tr. at 1999. Providers assessed pseudoseizure. Tr. at 2003. A week later, Simmons noted Williams had a dysthymic mood and abnormal affect. Tr. at 1594. Dr. Maya Overstreet, another MedNorth provider, remarked that Williams was experiencing hopelessness and loss of interest in activities. Tr. at 1589.
In July 2019, Williams told Dr. Salami that she had anger problems and that “things got out of hand” with law enforcement about to be called. Tr. at 2047. Two months later, she was tired, with a restricted affect and depressed mood. Tr. at 2064.
That month, Dr. Salmi completed a second statement again noting Williams's anxiety disorder, major depressive disorder, seizure disorder, and migraine headaches. Tr. at 2063. She continued to have marked limitations in activities of daily living and extreme limitations in social functioning. Id. Her abilities to get along with others and interact appropriately were extremely impaired and her ability to accept supervision and understand, remember, and follow both short and detailed instructions were markedly restricted. Id.
Two months later, providers admitted Williams for psychiatric partial-hospitalization treatment at Delta Behavioral Health. Tr. at 2113-82. She received treatment there over 11 days. Id. Brandy Alcorn, a licensed psychologist, performed an assessment that noted increased suicidal ideation as well as previous, but not current, homicidal ideation. Tr. at 2114. Williams's symptoms included lack of interest, no energy, hopelessness, poor concentration, and difficulty making decisions. Id. And she had trouble getting along with others, concentrating for more than ten minutes, and finding solutions to problems in daily life. Tr. at 2130-31.
This treatment started one day before her hearing before ALJ Booth. But it is unclear if Williams presented evidence relating to this care to ALJ Booth.
In February 2017, Williams had her first hearing on her disability claim. Tr. at 46. She testified that she needed someone with her because of suicidal thoughts. Tr. at 50. She claimed to experience migraine headaches twice a week. Tr. at 52. Her medications made her sleepy. Tr. at 53.
At her second hearing, Williams stated that she performed household chores for a few minutes at a time before stopping. Tr. at 1231. She spendt her days at home. Tr. at 1233. Williams does not drive, has conflict with others, cries a lot, has a short temper, and overreacts because of her own frustration. Tr. at 1231, 1234-35. Williams stated that stress triggered her seizures and she had detailed suicidal ideations. Tr. at 1220, 1236.
D. Listing 12.04
Williams contends that ALJ Booth erred by finding that her impairments did not meet or medically equal the requirements of Listing 12.04 (depressive, bipolar, and related disorders). The Acting Commissioner maintains that the evidentiary record supports ALJ Booth's finding. The undersigned concludes that ALJ Booth improperly analyzed Williams's impairments at step three because the he failed to evaluate all the relevant evidence.
1. Overview of Listing of Impairments
The Listing of Impairments details impairments that are “severe enough to prevent an individual from doing any gainful activity.” 20 C.F.R. § 416.925(a). If a claimant's impairments meet all the criteria of a particular listing, id. § 416.925(c)(3), or are medically equivalent to a listing, id. § 416.926, the claimant is considered disabled, id. § 416.920(d). “The Secretary explicitly has set the medical criteria defining the listed impairments at a higher level of severity than the statutory standard [for disability more generally]. The listings define impairments that would prevent an adult, regardless of his age, education, or work experience, from performing any gainful activity, not just ‘substantial gainful activity.'” Sullivan v. Zebley, 493 U.S. 521, 532 (1990); see also Bowen v. Yuckert, 482 U.S. 137, 153 (1987) (stating that the listings are designed to weed out only those claimants “whose medical impairments are so severe that it is likely they would be disabled regardless of their vocational background”).
The claimant has the burden of proving that his or her impairments meet or medically equal a listed impairment. Hall v. Harris, 658 F.2d 260, 264 (4th Cir. 1981); see also Hancock v. Astrue, 667 F.3d 470, 476 (4th Cir. 2012). As a result, a claimant must present medical findings equal in severity to all the criteria for that listing: “[a]n impairment that manifests only some of those criteria, no matter how severely, does not qualify.” Sullivan, 493 U.S. at 530-31; see also 20 C.F.R. § 416.925(c)(3). A diagnosis of a particular condition, by itself, cannot establish that a claimant satisfies a listing's criteria. 20 C.F.R. § 416.925(d); see also Mecimore v. Astrue, No. 5:10-CV-64, 2010 WL 7281096, at *5 (W.D. N.C. Dec. 10, 2010) (“Diagnosis of a particular condition or recognition of certain symptoms do not establish disability.”).
An ALJ need not explicitly identify and discuss every possible listing that may apply to a particular claimant. Instead, the ALJ must provide a coherent basis for his step three determination, particularly where the “medical record includes a fair amount of evidence” that a claimant's impairment meets a disability listing. Radford v. Colvin, 734 F.3d 288, 295 (4th Cir. 2013). When the evidence exists but is rejected without discussion, the “insufficient legal analysis makes it impossible for a reviewing court to evaluate whether substantial evidence supports the ALJ's findings.” Id. (citing Cook v. Heckler, 783 F.2d 1168, 1173 (4th Cir. 1986)). In reviewing the ALJ's analysis, it is possible that even “[a] cursory explanation” at step three may prove “satisfactory so long as the decision as a whole demonstrates that the ALJ considered the relevant evidence of record and there is substantial evidence to support the conclusion.” Meador v. Colvin, No. 7:13-CV-214, 2015 WL 1477894, at *3 (W.D. Va. Mar. 27, 2015) (citing Smith v. Astrue, 457 Fed.Appx. 326, 328 (4th Cir. 2011)). Still, the ALJ's decision must include “a sufficient discussion of the evidence and explanation of its reasoning such that meaningful judicial review is possible.” Id.
2. Listing 12.04
To meet Listing 12.04 the claimant must establish that an impairment satisfies two sets of criteria:
A. Medical documentation of one or more of the following:
1. Depressive disorder, characterized by five or more of the following:
depressed mood; diminished interest in almost all activities; appetite disturbance with change in weight; sleep disturbance; observable psychomotor agitation or retardation; decreased energy; feelings of guilt or worthlessness; difficulty concentrating or thinking; or thoughts of death or suicide.
2. Bipolar disorder, characterized by three or more of the following:
pressured speech; flight of ideas; inflated self-esteem; decreased need for sleep; distractibility; involvement in activities that have a high probability of painful consequences that are not recognized; or increase in goal-directed activity or psychomotor agitation.
AND
B. Extreme limitation of one, or marked limitation of two, of the following areas of mental functioning:
1. Understand, remember, or apply information.
2. Interact with others.
3. Concentrate, persist, or maintain pace.
4. Adapt or manage oneself.Id.
Instead of Paragraph B, a claimant may also establish disability under Listing 12.04 by showing she satisfies the Paragraph C criteria. But Williams does not contend that she meets or equals the criteria for paragraph C.
Williams argues, and the Acting Commissioner does not dispute, that the evidence shows sufficient occurrences of the Paragraph A criteria. It reveals instances in which Williams displayed loss of interest, depressed mood, sleep disturbance, decreased energy, feelings of guilt, difficulty concentrating, and suicidal thoughts. So the undersigned concludes that Williams satisfies Paragraph A of Listing 12.04.
ALJ Booth discussed the Paragraph B criteria when he analyzed Listings 12.04. Tr. at 1186-87. He found that Williams had mild limitations in adapting or managing herself. Tr. At 1187. And Williams has moderate limitations in interacting with others, understanding, remembering, or applying information, and concentrating, persisting, or maintaining pace. Id.
Williams argues that ALJ Booth erred in examining the severity of her mental health impairments at step three. She claims that she has at least marked limitations in adapting or managing herself and interacting with others.
The Paragraph B analysis omitted reference to relevant evidence, which forecloses meaningful review. So the undersigned cannot find that substantial evidence supports ALJ Booth's Paragraph B findings.
The Appeals Council directive remarked that the prior decision failed to mention two of Williams's in-patient hospitalizations. Tr. at 1299. The lack of discussion made it unclear how the ALJ evaluated her depression, which was serious enough to result in two hospitalizations at that time. Tr. at 1300. So the Appeals Council remanded the claim with specific instructions that the ALJ further evaluate Williams's mental impairments, with specific findings and appropriate rationale for the Paragraph B functional areas. Tr. at 1301.
Despite these instructions, ALJ Booth's decision discloses no examination of Williams's 2014 or 2019 hospitalizations for mental health conditions. So a reviewing court cannot be certain whether ALJ Booth overlooked this evidence or considered it but found it immaterial to his analysis. Although an ALJ need not discuss every piece of evidence, the lack of discussion again renders the evaluation of her mental health impairments deficient.
ALJ Booth referenced Williams's 2016 hospitalization, which the previous decision had omitted. Tr. at 1190.
Yet Williams's mental health conditions were serious enough to require hospitalization, as the Appeals Council observed. So to comply with the remand order, ALJ Booth needed to discuss that evidence as part of his evaluation of the severity of her mental impairments on the Paragraph B functional domains. Having failed to do so constitutes error and warrant remand.
The Acting Commissioner focuses her argument on several generally unremarkable mental status examination findings. But these do not undermine the fact that Williams's mental health impairments have been acute enough to require hospitalization three times. Nor do unremarkable mental status examination findings overcome ALJ Booth's failure to evaluate the effect of Williams's hospitalizations on the Paragraph B criteria as the Appeals Council directed.
In sum, Williams's conditions meet Paragraph A of Listing 12.04. But ALJ Booth's evaluation of the Paragraph B criteria failed to examine all of her hospitalizations in accordance with the Appeals Council's order. And he erred in failing to explain how this evidence affected his analysis of Paragraph B's four functional domains.
Given this error at step three, the undersigned recommends that the court grant Williams's argument on this issue.
E. Medical Opinion Evidence
Williams argues that ALJ Booth erred considering the opinions of Dr. Salami. The Acting Commissioner asserts that ALJ Booth properly evaluated Dr. Salami's findings. The undersigned cannot find that the records supports ALJ Booth's evaluation of the medical opinion evidence.
“Medical opinions are statements from physicians and psychologists or other acceptable medical sources that reflect judgments about the nature and severity of [a claimant's] impairment(s), including [the claimant's] symptoms, diagnosis and prognosis, what [the claimant] can still do despite impairment(s), and [the claimant's] physical or mental restrictions.” 20 C.F.R. §§ 404.1527(a)(2), 416.927(a)(2). An ALJ must consider all medical opinions in a case in determining whether a claimant is disabled. See Id. §§ 404.1527(c), 416.927(c); Nicholson v. Comm'r of Soc. Sec., 600 F.Supp.2d 740, 752 (W.D. Va. 2009) (“Pursuant to 20 C.F.R. §§ 404.1527(b), 416.927(b), an ALJ must consider all medical opinions when determining the disability status of a claimant.”).
Opinions of treating physicians and psychologists on the nature and severity of impairments must be given controlling weight if they are well supported by medically acceptable clinical and laboratory diagnostic techniques and are not inconsistent with the other substantial evidence in the record. 20 C.F.R. §§ 404.1527(c)(2), 416.927(c)(2); see Craig v. Chater, 76 F.3d 585, 590 (4th Cir. 1996); Ward v. Chater, 924 F.Supp. 53, 55-56 (W.D. Va. 1996); SSR 96-2p, 1996 WL 374188 (July 2, 1996). Otherwise, the opinions are to be given significantly less weight. Craig, 76 F.3d at 590. In determining the weight to be ascribed to an opinion, the ALJ should consider the length and nature of the treating relationship, the supportability of the opinions, their consistency with the record, any specialization of the source of the opinions, and other factors that tend to support or contradict the opinions. 20 C.F.R. §§ 404.1527(c)(2)-(6), 416.927(c)(2)-(6).
The ALJ's “decision must contain specific reasons for the weight given to the treating source's medical opinion, supported by the evidence in the case record, and must be sufficiently specific to make clear to any subsequent reviewers the weight the [ALJ] gave to the treating source's medical opinion and the reasons for that weight.” SSR 96-2p, 1996 WL 374188, at *5; see also 20 C.F.R. §§ 404.1527(c)(2), 416.927(c)(2); Ashmore v. Colvin, No. 0:11-2865-TMC, 2013 WL 837643, at *2 (D.S.C. Mar. 6, 2013) (“In doing so [i.e., giving less weight to the testimony of a treating physician], the ALJ must explain what weight is given to a treating physician's opinion and give specific reasons for his decision to discount the opinion.”).
Opinions from “other sources” who do not qualify as “acceptable medical sources” cannot be given controlling weight, but are evaluated under the same factors used to weigh the assessments of physicians and psychologists. SSR 06-3p, 2006 WL 2329939, at *2, 4 (Aug. 9, 2006); see also 20 C.F.R. §§ 404.1513(d)(1), 416.913(d)(1) (identifying “other sources”). An ALJ must explain the weight given opinions of “other sources” and the reasons for the weight given. SSR 06-3p, 2006 WL 2329939, at *6; Napier v. Astrue, No. TJS-12-1096, 2013 WL 1856469, at *2 (D. Md. May 1, 2013).
Similarly, evaluations from sources who neither treat nor examine a claimant are considered under the same basic standards as evaluations of medical opinions from treating providers whose assessments are not given controlling weight. See 20 C.F.R. §§ 404.1527(c), (e), 416.927(c), (e). The ALJ must explain the weight given to these opinions. Id.; Casey v. Colvin, No. 4:14-CV-00004, 2015 WL 1810173, at *3 (W.D. Va. Mar. 12, 2015), adopted by, 2015 WL 1810173, at *1 (Apr. 21, 2015); Napier, 2013 WL 1856469, at *2.
More weight is generally given to the opinion of a treating source over the opinion of a non-treating examining source. Similarly, the opinion of an examining source is typically given more weight than the opinion of a non-examining source. See 20 C.F.R. §§ 404.1527(c)(1), (2), 416.927(c)(1), (2). Under appropriate circumstances, however, the opinions of a non-treating examining source or a non-examining source may be given more weight than those of a treating source. See, e.g., Mastro v. Apfel, 270 F.3d 171, 178 (4th Cir. 2001) (affirming ALJ's attribution of greater weight to the opinions of a non-treating examining physician than to those of a treating physician); SSR 96-6p, 1996 WL 374180, at *3 (July 2, 1996) (“In appropriate circumstances, opinions from State agency medical and psychological consultants and other program physicians and psychologists may be entitled to greater weight than the opinions of treating or examining sources.”).
Opinions from medical sources on issues reserved to the Acting Commissioner, such as disability, deserve no special weight. See 20 C.F.R. §§ 404.1527(d), 416.927(d); SSR 96-5p, 1996 WL 374183, at *2, 5 (July 2, 1996). But the ALJ must still evaluate these opinions and give them appropriate weight. SSR 96-5p, 1996 WL 374183, at *3 (“[O]pinions from any medical source on issues reserved to the Commissioner must never be ignored. The adjudicator must evaluate all evidence in the case record that may have a bearing on the determination or decision of disability, including opinions from medical sources about issues reserved to the Commissioner.”).
“In most cases, the ALJ's failure to consider a physician's opinion (particularly a treating physician) or to discuss the weight given to that opinion will require remand.” Love-Moore v. Colvin, No. 7:12-CV-104-D, 2013 WL 5350870, at *2 (E.D. N.C. Sept. 24, 2013) (citations omitted). But “[i]n some cases, the failure of an ALJ to explicitly state the weight given to a medical opinion constitutes harmless error, so long as the weight given to the opinion is discernible from the decision and any grounds for discounting it are reasonably articulated.” Bryant v. Colvin, No. 5:11-CV-648-D, 2013 WL 3455736, at *5 (E.D. N.C. July 9, 2013) (internal quotation marks and citations omitted).
In October 2015, Dr. Salami found that Williams had marked limitations in activities of daily living and extreme limitations in social functioning. Four years later, Dr. Salami again found that Williams had marked limitations in activities of daily living and extreme limitations in social functioning.
ALJ Booth gave little weight to these assessments, finding that they conflicted with the longitudinal record. Tr. at 1194. The mostly benign mental status examination findings did not support his opinion. Tr. at 1191. And his findings suggested an individual needing in-patient psychiatric treatment. Id.
But as Williams notes, she was, in fact, hospitalized to mental health symptoms within a few months of Dr. Salami's assessments. So the evidence appears to confirm both the severity of Williams's condition and the degree of limitation Dr. Salami found. And while ALJ Booth noted that Williams also treated her conditions with medication and out-patient counseling during the relevant period, this treatment proved not entirely adequate given her three hospitalizations.
Dr. Salami is a specialist in psychiatry and has had a treatment relationship with Williams over sever years. Additionally, his conclusions track those of Simmonds and Savinon, who both found marked limitations in activities of daily living and social functioning.
ALJ Booth noted that the record showed periods of increased depressive symptoms, he observed that “the balance of the mental status examinations are unremarkable across the whole record.” Tr. at 1191. But the instances when Williams displayed generally normal status examination findings fail to discredit Dr. Salami's assessments.
Dr. Salami and Simmons both consistently noted Williams's sad, depressed mood and constricted, flat affect. That other mental status examination findings were generally normal does not negate the presence of some, even if few, indications of impaired psychological functioning. And the fact that Williams's mental health conditions required three hospitalization would seem to significantly overshadow the import of presenting with some normal mental status examination findings.
The overall evidence does not support ALJ Booth's reasons to accord Dr. Salami's opinions little weight. So this issue, too, supports remand.
III. Conclusion
For these reasons, the undersigned recommends that the court grant Williams's Motion for Judgment on the Pleadings (D.E. 25), deny Kijakazi's Motion for Judgment on the Pleadings (D.E. 30), and remand this matter to the Acting Commissioner for further consideration.
The Clerk of Court must serve a copy of this Memorandum and Recommendation (“M&R”) on each party who has appeared in this action. Any party may file a written objection to the M&R within 14 days from the date the Clerk serves it on them. The objection must specifically note the portion of the M&R that the party objects to and the reasons for their objection. Any other party may respond to the objection within 14 days from the date the objecting party serves it on them. The district judge will review the objection and make their own determination about the matter that is the subject of the objection. If a party does not file a timely written objection, the party will have forfeited their ability to have the M&R (or a later decision based on the M&R) reviewed by the Court of Appeals.