MICHAEL J. NEWMAN, Magistrate Judge.
This is a Social Security disability benefits appeal. 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").
Plaintiff filed for DIB and SSI alleging a disability onset date of August 8, 2012. PageID 266-79. Plaintiff claims disability as a result of a number of alleged impairments including, inter alia, degenerative disc disease of the cervical and lumbar spine, posttraumatic stress disorder ("PTSD"), and depression. PageID 70. After initial denial of her applications, Plaintiff received a hearing before ALJ Irma Flottman on January 22, 2015. PageID 84-131. The ALJ issued a written decision on April 24, 2015 finding Plaintiff not disabled. PageID 68-79. Thereafter, the Appeals Council denied Plaintiff's request for review, making the ALJ's non-disability finding the final administrative decision of the Commissioner. PageID 57-59. See Casey v. Sec'y of Health & Human Servs., 987 F.2d 1230, 1233 (6th Cir. 1993). Plaintiff then filed this timely appeal. Cook v. Comm'r of Soc. Sec., 480 F.3d 432, 435 (6th Cir. 2007).
The evidence of record is adequately summarized in the ALJ's decision (PageID 71-77), Plaintiff's Statement of Errors (doc. 6), the Commissioner's memorandum in opposition (doc. 7), and Plaintiff's reply (doc. 8). The undersigned incorporates all of the foregoing and sets forth the facts relevant to this appeal herein.
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. 42 U.S.C. § 405(g); Bowen v. Comm'r of Soc. Sec., 478 F.3d 742,745-46 (6th Cir. 2007). In performing this review, the Court must consider the record as a whole. Hephner v. Mathews, 574 F.2d 359, 362 (6th Cir. 1978).
Substantial evidence is "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 401 (1971). When substantial evidence supports the ALJ's denial of benefits, that finding must be affirmed, even if substantial evidence also exists in the record upon which the ALJ could have found Plaintiff disabled. Buxton v. Halter, 246 F.3d 762, 772 (6th Cir. 2001). Thus, the ALJ has a "`zone of choice' within which he [or she] can act without the fear of court interference." Id. at 773.
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., 582 F.3d 647, 651 (6th Cir. 2009). "[A] decision of the Commissioner will not be upheld where the [Social Security Administration] fails to follow its own regulations and where that error prejudices a claimant on the merits or deprives the claimant of a substantial right." Bowen, 478 F.3d at 746.
To be eligible for disability benefits, a claimant must be under a "disability" as defined by the Social Security Act. 42 U.S.C. § 423(d)(1)(A). Narrowed to its statutory meaning, a "disability" includes physical and/or mental impairments that are both "medically determinable" and severe enough to prevent a claimant from (1) performing his or her past job and (2) engaging in "substantial gainful activity" that is available in the regional or national economies. Id.
Administrative regulations require a five-step sequential evaluation for disability determinations. 20 C.F.R. § 404.1520(a)(4). Although a dispositive finding at any step ends the ALJ's review, see Colvin v. Barnhart, 475 F.3d 727, 730 (6th Cir. 2007), the complete sequential review poses five questions:
20 C.F.R. § 404.1520(a)(4); see also Miller v. Comm'r of Soc. Sec., 181 F.Supp.2d 816, 818 (S.D. Ohio 2001). A claimant bears the ultimate burden of establishing disability under the Social Security Act's definition. Key v. Comm'r of Soc. Sec., 109 F.3d 270, 274 (6th Cir. 1997).
In her Statement of Errors, Plaintiff argues that the ALJ erred by improperly weighing opinion evidence. Doc. 6 at PageID 662-70. The undersigned concludes that the ALJ erred in weighing the opinion of the medical sources offering opinions concerning Plaintiff's mental health limitations, including treating clinical psychologist Kristin Rodzinka, Ph.D. The undersigned does not reach the merits as to whether the ALJ also erred in weighing opinions concerning Plaintiff's physical limitations but, nevertheless, on remand, the ALJ should reassess and reweigh all opinion evidence anew.
Until March 27, 2017, "the Commissioner's regulations [which apply to this appeal] establish[ed] a hierarchy of acceptable medical source opinions[.]" Snell v. Comm'r of Soc. Sec., No. 3:12-cv-119, 2013 WL 372032, at *9 (S.D. Ohio Jan. 30, 2013). In descending order, these medical source opinions are: (1) treaters; (2) examiners; and (3) record reviewers. Id. Under the regulations in effect prior to March 27, 2017, the opinions of treaters are entitled to the greatest deference because they "are likely to be . . . most able to provide a detailed, longitudinal picture of [a claimant's] medical impairment(s) and may bring a unique perspective to the medical evidence that cannot be obtained from the objective medical findings alone or from reports of individual examinations[.]" 20 C.F.R. § 404.1527(c)(2).
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., 549 F. App'x 377, 384 (6th Cir. 2013). Even if a treater's opinion is not entitled to controlling weight, "the ALJ must still determine how much weight is appropriate by considering a number of factors, including the length of the treatment relationship and the frequency of examination, the nature and extent of the treatment relationship, supportability of the opinion, consistency of the opinion with the record as a whole, and any specialization of the treating physician." Blakley v. Comm'r of Soc. Sec., 581 F.3d 399, 406 (6th Cir. 2009); see also 20 C.F.R. § 404.1527(c).
After treaters, "[n]ext in the hierarchy are examining physicians and psychologists, who often see and examine claimants only once." Snell, 2013 WL 372032, at *9. Record reviewers are afforded the least deference and these "non-examining physicians' opinions are on the lowest rung of the hierarchy of medical source opinions." Id. Put simply, "[t]he regulations provide progressively more rigorous tests for weighing opinions as the ties between the source of the opinion and the individual [claimant] become weaker." Id. (citing SSR 96-6p, 1996 WL 374180, at *2 (July 2, 1996)). In the absence of a controlling treating source opinion, an ALJ must "evaluate all medical opinions" with regard to the factors set forth in 20 C.F.R. § 404.1527(c), i.e., length of treatment history; consistency of the opinion with other evidence; supportability; and specialty or expertise in the medical field related to the individual's impairment(s). Walton v. Comm'r of Soc. Sec., No. 97-2030, 1999 WL 506979, at *2 (6th Cir. June 7, 1999).
In this case, Dr. Rodzinka, "[a]fter comprehensive assessment[,]" found "it . . . clear that [Plaintiff] is struggling with military sexual trauma (MST) related PTSD, including symptoms related to re-experiencing, avoidance, altered mood and beliefs, and trauma related arousal symptoms (e.g., sleep disturbance, anxiety)." PageID 604. According to Dr. Rodzinka, Plaintiff's "PTSD has impacted her functioning, including in areas such as employment and social functioning, as evidenced by severe anxiety and panic attacks resulting in an inability to attend work, social withdrawal from friends and family, and avoidance of formerly valued activities." Id. In other words, Plaintiff would experience problems attending work regularly
In assessing acceptable medical source evidence, the ALJ gave only "partial weight" to Dr. Rodzinka's opinion. PageID 76. Specifically, the ALJ stated that:
Id. The Court finds error in the ALJ's assessment of Dr. Rodzinka's opinion.
Initially, the Court notes that, despite the fact that Dr. Rodzinka is a treating clinical psychologist, the ALJ never specifically mentioned the concept of controlling weight or specifically declined to afford this treater's opinion controlling weight. PageID 88; see also Wilson v. Comm'r of Soc. Sec., 378 F.3d 541, 544 (6th Cir. 2004) (stating that the regulations are designed to "ensure[ ] that the ALJ applies the treating physician rule and permits meaningful review of the ALJ's application of the rule"). Nowhere does the ALJ specifically analyze whether Dr. Rodzinka's conclusions are "well supported by medically acceptable clinical and laboratory diagnostic techniques and . . . not inconsistent with other substantial evidence in the case record." See 20 C.F.R. § 404.1527(c). As noted by this Court on numerous occasions, such failure is reversible error because it "deprives the Court of the opportunity to meaningfully review whether [the ALJ] undertook the `two-step inquiry' required when analyzing treating source opinions." See, e.g., Marks v. Colvin, 201 F.Supp.3d 870, 882 (S.D. Ohio 2016).
The Court also notes that, while the ALJ purportedly gave Dr. Rodzinka's opinion "partial weight," i.e., some weight, it is not clear what portion of her opinion was credited, and which portion was discredited. See Sanders v. Comm'r of Soc. Sec., No. 1:13-CV-481, 2014 WL 3899288, at *13 (S.D. Ohio Aug. 11, 2014) (finding error where the ALJ gave some weight to an opinion "without explaining which portion . . . he was crediting"); Baskin v. Colvin, No. 3:11-0948, 2013 WL 1149597, at *17 (M.D. Tenn. Mar. 19, 2013), report and recommendation adopted, No. 3:11-CV-0948, 2013 WL 1405962 (M.D. Tenn. Apr. 8, 2013) (finding error where the ALJ "did not explain which portions of their opinions he credited and which portions he discounted").
In fact, in analyzing Dr. Rodzinka's opinion, the ALJ focused on Plaintiff's ability to have a relationship with a boyfriend "within the past several years" and her relationship with a roommate. PageID 76. The ALJ apparently pointed to these relationships in an effort to undermine the severity of Plaintiff's ability to socially interact with others. PageID 76. However, the ALJ appears to have accepted the fact that Plaintiff was limited in her ability to socially interact by finding her unable have contact with the public, but able to occasionally have contact with co-workers and supervisors. PageID 72-73. The ALJ pointed to nothing in the record questioning Dr. Rodzinka's opinion regarding Plaintiff's inability to regularly attend work. See PageID 76. Thus, the ALJ's failure to explain the rejection of Dr. Rodzinka's opinion concerning Plaintiff's "inability to attend work" amounts to a lack of substantial evidence supporting such rejection.
Accordingly, based upon all of the foregoing, the ALJ's non-disability finding is unsupported by substantial evidence and should be reversed.
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 an award of benefits. The Court has authority to affirm, modify or reverse the Commissioner's decision "with or without remanding the cause for rehearing." 42 U.S.C. § 405(g); Melkonyan v. Sullivan, 501 U.S. 89, 100 (1991). Generally, benefits may be awarded immediately "only if all essential factual issues have been resolved and the record adequately establishes a plaintiff's entitlement to benefits." Faucher v. Sec'y of Health & Human Servs., 17 F.3d 171, 176 (6th Cir. 1994); see also Abbott v. Sullivan, 905 F.2d 918, 927 (6th Cir. 1990); Varley v. Sec'y of Health & Human Servs., 820 F.2d 777, 782 (6th Cir. 1987). Here, the undersigned finds that evidence of disability is not overwhelming and that a remand for further proceedings is proper.
Pursuant to Fed. R. Civ. P. 72(b), any party may serve and file specific, written objections to the proposed findings and recommendations within
Any objections filed shall specify the portions of the Report and Recommendation objected to, and shall be accompanied by a memorandum of law in support of the objections. If the Report and Recommendation is based, in whole or in part, upon matters occurring of record at an oral hearing, the objecting party shall promptly arrange for the transcription of the record, or such portions of it as all parties may agree upon or the Magistrate Judge deems sufficient, unless the assigned District Judge otherwise directs.
A party may respond to another party's objections within
Failure to make objections in accordance with this procedure may forfeit rights on appeal. See Thomas v. Arn, 474 U.S. 140, 153-55 (1985); United States v. Walters, 638 F.2d 947, 949-50 (6th Cir. 1981).
