KENDALL J. NEWMAN, Magistrate Judge.
Plaintiff seeks judicial review of a final decision by the Commissioner of Social Security denying plaintiff's application for Title II Disability Insurance Benefits.
After considering the parties' written briefing, the record, and the applicable law, the court recommends DENYING the Commissioner's motion for summary judgment, GRANTING plaintiff's motion for summary judgment, and REMANDING this case for further proceedings.
On June 24, 2015, plaintiff applied for Title II Disability Insurance Benefits alleging disability beginning March 6, 2012. (Administrative Transcript ("AT") 194-200.) Plaintiff claimed to suffer from general pain and soreness partially due to a prior surgery, hearing loss, depression, and anxiety. (AT 219.) Plaintiff's application was denied initially and again upon reconsideration. (AT 111-15, 117-21.) Plaintiff, aided by an attorney, sought review of these denials with an ALJ. (AT 124-25.) At a June 27, 2017 hearing, the ALJ received testimony from plaintiff about his conditions, as well as testimony from a vocational expert regarding plaintiff's ability to work. (AT 41-72.)
On January 12, 2018, the ALJ issued a decision finding that plaintiff was not disabled for the relevant period. (AT 15-40.) At step one, the ALJ concluded plaintiff had not engaged in substantial gainful activity since March 6, 2012. (AT 23.) At step two, the ALJ found plaintiff had the following severe impairments: bilateral carpal tunnel syndrome and major joint dysfunction. (
Based on these conclusions, the ALJ found plaintiff had the residual functional capacity ("RFC") to perform medium work,
(AT 29, cleaned up.) In reaching this conclusion, the ALJ stated he considered all symptoms and opinion evidence, as per the applicable regulations. (
On November 16, 2018, the Appeals Council denied plaintiff's request for review. (AT 1-8.) Plaintiff then timely filed this action requesting judicial review of the Commissioner's final decision, and the parties filed cross-motions for summary judgment. (ECF Nos. 1, 16, 17, 18.)
The Court reviews the Commissioner's decision de novo, and should reverse "only if the ALJ's decision was not supported by substantial evidence in the record as a whole or if the ALJ applied the wrong legal standard."
Plaintiff primarily alleges the ALJ erred by not adequately assessing plaintiff's mental impairments. Plaintiff also disputes the ALJ's finding that plaintiff can perform medium work and the rejection of his subjective-symptom testimony. (ECF No. 16.) The Commissioner counters each of plaintiff's arguments, contending that substantial evidence supports the ALJ's analysis and conclusion. (ECF No. 17.) Thus, the Commissioner maintains the opinion should be affirmed. (
Because plaintiff's argument that the ALJ improperly assessed plaintiff's mental impairments requires remand, the court focuses on that issue.
An impairment or combination of impairments may be found "not severe only if the evidence establishes a slight abnormality that has no more than a minimal effect on an individual's ability to work."
In disability benefits cases, courts "`distinguish among the opinions of three types of physicians: (1) those who treat the claimant (treating physicians); (2) those who examine but do not treat the claimant (examining physicians); and (3) those who neither examine nor treat the claimant (nonexamining physicians).'"
Plaintiff asserts that the ALJ erred in evaluating his mental impairment because the ALJ: (1) improperly discounted the examining opinions of Drs. Boyd and Kalman; (2) improperly discounted the opinions of plaintiff's treating sources; and (3) improperly relied on lay evidence of plaintiff's daily activities.
Plaintiff first contends that the ALJ erred in discounting the opinions of Drs. Boyd and Kalman. (ECF No. 16 at 32, 35.)
Dr. Boyd, an examining source, opined that plaintiff suffered from severe depression and anxiety. (AT 1762). Tests performed by Dr. Boyd indicated that plaintiff was depressed, disorganized, isolated, anxious, and withdrawn. (AT. 1760.) Dr. Boyd also had plaintiff perform basic cognitive exercises—remembering a simple address and counting sevens and threes sequentially. (AT 1759.) As a result of those tests, Dr. Boyd judged plaintiff's attention span and short-term memory to be intact. (
The ALJ provided the following rationale for discounting Dr. Boyd's opinions: "Dr. Boyd's extreme opinion is not consistent with the claimant's performance on mental tasks with Dr. Boyd as well as Dr. Kalman. On both examinations, the claimant only had mild difficulty with mental tasks. . . . In addition, Dr. Boyd himself stated that the claimant appeared to be stable psychiatrically." (AT 27.) Thus, the ALJ gave little weight to Dr. Boyd's opinion because of (1) plaintiff's performance on basic cognitive testing, and (2) Dr. Boyd himself opined that plaintiff was "stable psychiatrically."
The ALJ gave partial weight to Dr. Kalman's opinion. As the ALJ noted, Dr. Kalman found that plaintiff had a "decreased ability to maintain attention, concentration, and memory" and could only "carry out simple one and two-step job instructions." (AT 27.) The ALJ gave these findings little weight because they were not consistent with Dr. Boyd's finding that plaintiff could perform serial numbers and remember a simple address. (
The undersigned finds no basis for the ALJ to discount the opinion of Dr. Boyd due to Dr. Boyd opining that plaintiff "appear[ed] to be stable psychiatrically." (AT 1764, 27.) Stable, in this context, means unchanging. Dr. Boyd, who opined that plaintiff suffered from severe depression and anxiety (AT 1762), was therefore stating that the level of plaintiff's depression and anxiety—which he identified as severe—was unchanging.
The second rationale the ALJ used in discounting both Dr. Boyd's and Dr. Kalman's opinions—plaintiff's cognitive functioning tests—is overbroad. While plaintiff's ability to concentrate is an alleged symptom of his depression and anxiety, his performance on these tests does not negate the remainder of Drs. Boyd's and Kalman's findings. Based on results from these cognitive-memory tests, the ALJ summarily discounted Dr. Boyd's findings that have no relation to plaintiff's cognitive abilities. For example, the ALJ used these tests to discount Dr. Boyd's findings that: plaintiff's objective MMPI-2 scores were in the range associated with "fatigue weariness or boredom" and indicated that plaintiff was "depressed, disorganized, isolated, anxious, and withdrawn" (AT 1760); there "was an abundant volume of data supporting problems with anxiety"; objective testing showed that plaintiff was "in the severely depressed range" and the "severely anxious range" (AT 1762); and Dr. Boyd's conclusion that plaintiff was disabled from the date he had a panic attack at work (March 6, 2012) to the present. (AT 1767). Furthermore, plaintiff's performance on these tests should have no relation to plaintiff's allegation of frequent panic attacks, one of the primary reasons Dr. Boyd found plaintiff unable to return to work. (
Regarding the ALJ's use of Dr. Boyd's testing to discount the same tests that Dr. Kalman performed, at best these two results present conflicting and ambiguous evidence. However, these "conflicting" tests do not clearly establish the nonseverity of plaintiff's alleged mental impairments.
Accordingly, the ALJ erred by improperly discounting the opinions of examining Drs. Boyd and Kalman.
Next, plaintiff asserts that the ALJ erred in rejecting the opinions of his treating sources, partially expressed through GAF scores,
It is not an error for an ALJ to disregard a claimant's GAF score, as the Commissioner has determined the GAF scale does not directly correlate with the Social Security Administration's mental disorders listing.
As an initial matter, the ALJ's rationale for discounting GAF scores because they are "merely a snapshot of an individual's condition at the time of the assessment," is without merit. While this may be true in a case involving a small number of GAF scores, the ALJ's statement directly follows citation to 48 separate GAF scores within the record. These scores, and the records underlying them, do not represent a mere snapshot, but perhaps a more complete picture of plaintiff's alleged impairments.
Furthermore, the ALJ's rejection of the usefulness of these scores was an improper basis for rejecting the majority of the treating sources plaintiff saw for his mental impairments. Attacking the usefulness of GAF scores, generally, does not amount to a specific and legitimate reason necessary for rejecting the opinions of treating sources.
Accordingly, the ALJ erred by failing to provide specific and legitimate reasons for rejecting the plaintiff's treating sources.
Finally, plaintiff contends the ALJ erred by relying on inaccurate and irrelevant representations regarding plaintiff's daily activities. (ECF 16 at 37.) A claimant's daily activities can be probative to determine the severity of his or her mental impairments.
Here, while some of the activities that the ALJ cites appear slightly incongruent from the record, e.g., the ALJ states that plaintiff homeschools his son when the hearing transcript states that his son was "doing a home study" (AT 51), on remand plaintiff can further develop his case regarding any alleged inconsistency or inaccuracy.
For the reasons stated above, the ALJ erred in weighing medical evidence regarding plaintiff's mental impairments, and this matter should therefore be remanded.
Regarding the remedy sought, the court recognizes plaintiff's general request to remand for benefits.
Finally, this remand will require the ALJ to fully reassess plaintiff's RFC in light of the medical record. Thus, as to plaintiff's other arguments, the court is confident that the ALJ can adequately address plaintiff's contentions concerning step three, (ECF No. 16 at 38-41), plaintiff's ability to perform medium work (
Accordingly, IT IS HEREBY RECOMMENDED that:
These findings and recommendations are submitted to the United States District Judge assigned to the case, pursuant to the provisions of 28 U.S.C. § 636(b)(1). Within