KIMBERLY A. JOLSON, Magistrate Judge.
Plaintiff, Mary Estrada, brings this action under 42 U.S.C. § 405(g) seeking review of a final decision of the Commissioner of Social Security ("Commissioner") denying her application for Supplemental Security Income ("SSI"). For the reasons set forth below, it is
Plaintiff filed her application for SSI on February 11, 2015, alleging that she was disabled beginning September 1, 2006. (Doc. 7, Tr. 193). She later amended her onset date to February 10, 2015. (Tr. 222). After her application was denied initially and on reconsideration, the Administrative Law Judge (the "ALJ") held a hearing on October 11, 2017. (Tr. 48-96). On February 9, 2018, the ALJ issued a decision denying Plaintiff's application for benefits. (Tr. 17-37). The Appeals Council denied Plaintiff's request for review, making the ALJ's decision the final decision of the Commissioner. (Tr. 1-6).
Plaintiff filed the instant case seeking a review of the Commissioner's decision on August 27, 2018 (Doc. 1), and the Commissioner filed the administrative record on November 19, 2018 (Doc. 7). Plaintiff filed her Statement of Errors (Doc. 8), and Defendant filed an Opposition (Doc. 9), and no reply was filed. Thus, this matter is now ripe for consideration.
Relevant here, Plaintiff testified about her mental health and abilities. She testified that being around new people or in new places makes her anxious, and her anxiety causes her to pick at her skin. (Tr. 66-67). She does not drive to new places, and she leaves the house only for doctors' appointments and grocery shopping. (Tr. 67-68). When Plaintiff goes to the store, her daughter accompanies her, prepares the grocery list, and marks off items on the list as they shop. (Tr. 68). Plaintiff's daughter also assists Plaintiff with scheduling doctors' appointments and other paperwork. (Tr. 69). Plaintiff testified that, at a previous job, she struggled with the required paperwork. (Tr. 68-69).
Plaintiff additionally testified about her memory. She told the ALJ that, at times, she forgets to eat, bathe, or take her medications. (Tr. 72-73). When doing households chores, she sometimes leaves the oven on, leaves clothes in the washing machine or dryer, or forgets about dishes in the sink. (Tr. 73). Plaintiff testified that she takes Cymbalta and Zyprexa for her depression and anxiety. (Tr. 69).
Dr. Michael A. Lace, Psy.D., a non-examining medical expert, also testified at the administrative hearing. He indicated that Plaintiff has a condition described as "borderline intellectual functioning" as well as depressive and anxiety disorders not otherwise specified. (Tr. 76). Dr. Lace further testified that while Plaintiff may have some challenges with reading, she would be capable of reading simple sentences. Dr. Lace also explained his opinion regarding the notations in the record from a state agency examiner and social worker regarding Plaintiff's limitations. Dr. Lace stated that within the confines of simple, routine, repetitive tasks, there would be no need for additional assistance based on his evaluation of the record as a whole. (Tr. 77-78). Dr. Lace concluded that Plaintiff should be limited to simple, routine, repetitive tasks where there is only occasional contact with coworkers, the general public, and supervisors and no high production quotas or fast pace. (Tr. 78).
As noted, Plaintiff's Statement of Errors concerns her mental health, and it follows that the Court examines only the same. The ALJ usefully summarized the relevant records:
(Tr. 29-31).
In a review dated July 15, 2015, state agency psychologist Joseph Edwards, Ph.D. assessed Plaintiff's mental abilities after he had reviewed Plaintiff's medical records through that date. Dr. Edwards gave the consultative examiners' opinions "great weight" and concluded that Plaintiff was "not significantly limited" in certain mental arenas and "moderately limited" in others. (Tr. 107, 110-11)). For instance, Dr. Edwards found that Plaintiff's ability to remember locations and work-like procedures was "not significantly limited," but her abilities to carry-out detailed instructions, perform activities within a regular schedule, and sustain an ordinary routine without special supervision were "moderately limited." (Tr. 110; see also Tr. 111 (assessing additional limitations)). Another state reviewer came to the same conclusions when Plaintiff's claim was reconsidered. (Tr. 126, 128-29).
The ALJ found that Plaintiff had not engaged in substantial gainful employment since February 11, 2015, the application date. (Tr. 19). The ALJ determined that Plaintiff suffered from the following severe impairments: degenerative disc disease of the lumbar spine; osteoarthritis of the left hip; degenerative joint disease of the feet; asthma; chronic obstructive pulmonary disease; migraines; obstructive sleep apnea; obesity; affective disorder; anxiety; and borderline intellectual functioning. (Id.). The ALJ, however, found that none of Plaintiff's impairments, either singly or in combination, met or medically equaled a listed impairment. (Tr. 21).
As to Plaintiff's residual functional capacity ("RFC"), the ALJ opined:
(Tr. 25).
The Court's review "is limited to determining whether the Commissioner's decision is supported by substantial evidence and was made pursuant to proper legal standards." Winn v. Comm'r of Soc. Sec., 615 F. App'x 315, 320 (6th Cir. 2015); see 42 U.S.C. § 405(g). "[S]ubstantial evidence is defined as `more than a scintilla of evidence but less than a preponderance; it is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.'" Rogers v. Comm'r of Soc. Sec., 486 F.3d 234, 241 (6th Cir. 2007) (quoting Cutlip v. Sec'y of Health & Human Servs., 25 F.3d 284, 286 (6th Cir. 1994)). The Commissioner's findings of fact must also be based upon the record as a whole. Harris v. Heckler, 756 F.2d 431, 435 (6th Cir. 1985). To this end, the Court must "take into account whatever in the record fairly detracts from [the] weight" of the Commissioner's decision. Rhodes v. Comm'r of Soc. Sec., No. 2:13-cv-1147, 2015 WL 4881574, at *2 (S.D. Ohio Aug. 17, 2015).
Plaintiff raises one error to the Court. (Doc. 8). She argues that the ALJ reversibly erred in evaluating the opinion and mental health evidence. Specifically, Plaintiff asserts that the ALJ impermissibly relied on the opinion of Michael A. Lace, Psy.D., a non-examining medical expert, who testified at the administrative hearing. (Id. at 6-7). And, Plaintiff argues, the ALJ instead should have preferred the opinions of the consultative examiners (Drs. Meyer and Sours), the state agency reviewers who gave those opinions "great weight," and the opinion of Plaintiff's treating social worker. (Id.).
Under the Regulations, an administrative law judge is charged with evaluating all of the medical evidence and resolving any conflicts that might appear. 20 C.F.R. § 416.927. In doing so, the ALJ will give each opinion the weight deemed appropriate based on factors such as whether the physician examined or treated the claimant, whether the opinion is supported by medical signs and laboratory findings, and whether the opinion is consistent with the entire record. 20 C.F.R. § 416.927(c). Typically, the opinion of a source who has examined the claimant is entitled to greater weight than the opinion of a non-examining source. 20 C.F.R. § 416.927(c)(1). But the ALJ may reject an opinion that is inconsistent with the record. 20 C.F.R. § 416.927(c)(4); Gant v. Comm'r of Soc. Sec., 372 F. App'x 582, 585 (6th Cir. 2010).
Here, the ALJ heard testimony from Dr. Lace, an independent psychologist who had reviewed the evidentiary record and had listened to Plaintiff's testimony during the administrative hearing. (Tr. 76). Dr. Lace testified that Plaintiff's medical records supported that she experienced borderline intellectual functioning, depression, and anxiety. (Tr. 76-77). But Dr. Lace testified that some evidence, such Plaintiff's GAF score of 60, suggested symptoms that were "well within normal limits." (Tr. 77). And, although the state agency consultants noted "mild to moderate limitations in certain records," Dr. Lace opined that Plaintiff's "mental status exams were actually within normal limits." (Tr. 77 (relying on Tr. 577-582, 593-596, 600-680)). Relatedly, Dr. Lace testified that the findings of the October 2014 consultative examination may be problematic because Plaintiff did not have her glasses and thus could not read during the test. (Tr. 76).
Ultimately, Dr. Lace concluded that the "general tone of the record would be of moderate limitations in most categories." (Tr. 77). Dr. Lace then proceeded to testify that Plaintiff's impairments did not meet or medical equal any Listing. (Id.). Dr. Lace also explained the work limitations Plaintiff would need. (Tr. 78). In particular, Dr. Lace opined that Plaintiff should be limited to simple, routine, repetitive tasks; where there is only occasional contact with coworkers, the general public, and supervisors; with no high production quotas and no fast pace. (Id.).
In response to Plaintiff's attorney's questioning, Dr. Lace was clear that he partially disagreed with the consultative examiners and Plaintiff's social worker:
(Tr. 81).
When considering the opinion evidence, the ALJ gave great—but not dispositive—weight to Dr. Lace's opinion. (Tr. 33). The ALJ determined that Dr. Lace's opinion was valuable because Dr. Lace "had the opportunity to review the entirety of the evidence of record," and Plaintiff's lawyer had the opportunity to question Dr. Lace in order "to elicit clear and complete information[.]" (Id.). In contrast, the ALJ discounted the state agency consultants' opinions, in part, because they examined Plaintiff only once and did not have the benefit of the entire record. (Id.).
Plaintiff contends this was error. Specifically, Plaintiff asserts that the ALJ's reliance on Dr. Lace's opinion was improper and that the ALJ should have afforded the consultative examiners' and state agency reviewers' opinions greater weight than Dr. Lace's. (Doc. 8 at 11 (arguing for greater weight for the October 2014 opinion of Floyd Sours, MA, and the July 2015 opinion of Dr. Steven J. Meyer, Ph.D.). Plaintiff also relies on the records of her social worker, Lindsey Cornett, to argue that more mental limitations were required in the RFC. (Id.).
All told, Plaintiff's mental health records are inconsistent. Namely, her GAF scores ranged significantly, from 45 to 60. And although she reported psychiatric symptoms, her examinations tended to show a normal mood and affect, normal behavior, and normal judgment and thought content. (See, e.g., Tr. 708 ("Psychiatric: She has a normal mood and affect. Her behavior is normal. Judgment and thought content normal."); Tr. 712 (same); Tr. 717 (same); Tr. 726 (same)). And, as noted, Dr. Lace and the state agency reviewers came to different conclusions. So the ALJ had to choose between differing opinions. In doing so, the ALJ noted that there was additional evidence submitted after the state agency reviewers' last review in November 2015. (Tr. 32-33). For instance, the state agency reviewers did not review treatment records from Plaintiff's biweekly, outpatient psychotherapy sessions beginning in July 2015 through August 2017. (See Tr. 33). In contrast, Dr. Lace had the opportunity to review the entire record, including two years of mental health notes and opinion evidence from Plaintiff's treating social worker. Consequently, it was not improper for the ALJ to find Dr. Lace's opinion more useful than the consultative examiners' and state agency reviewers' opinions. See Werner v. Comm'r of Soc. Sec., No. 1:12-CV-143, 2013 WL 1137502, at *6 (N.D. Ohio Mar. 18, 2013) ("[T]here are instances where it may be appropriate for the ALJ to look more favorably upon the opinion of a non-examining source, such as a medical expert, especially when the medical expert has access to the claimant's complete medical record and observed the claimant at trial.").
Additionally, the ALJ properly considered Ms. Cornett's opinion. As a social worker, Ms. Cornett is not an acceptable medical source under the relevant regulations. See 20 C.F.R. § 416.913(a), (d)(1) (explaining that social worker is not an acceptable medical source and is, instead, an "other source").
(Tr. 34).
Said plainly, the ALJ noted that Ms. Cornett's own mental status examinations and psychiatric assessments did not support the opined serious limitations with respect to performing unskilled work. (Tr. 34). On July 29, 2015, Ms. Cornett noted that many of Plaintiff's mental health attributes were "not remarkable," including her appearance, posture, general body movements, quality of speech, perceptions, hallucinations, intellectual functioning (Tr. 603-04). And later records from Allwell Behavioral Health Services showed unremarkable mental examinations. Progress notes from March 2017, for instance, suggested that Plaintiff was doing "as well as ever." (Tr. 678). And a record dated December 7, 2016, from Allwell Behavioral Health Services reported, among other things: regular speech rate, rhythm, and volume; clear and linear thought processes; no overt delusions, but auditory hallucinations; intact judgment and insight; orientation to time/place/person; no apparent memory impairment; attention and concentration within normal limits; appropriate to age language and knowledge fund; and blunted mood and affect. (Tr. 668). Given these and similar records, the ALJ's ultimate conclusion has support, and the Undersigned cannot conclude that the ALJ improperly assigned Ms. Cornett's opinion little weight.
Ultimately, Plaintiff asks this Court to re-weigh the evidence relating to her impairments and decide the outcome of this case differently. This request is impermissible under the substantial evidence standard of review. The Court may not undertake a de novo review of the Commissioner's decision or re-weigh the evidence of record. Bradley v. Sec'y of Health and Human Serv., 862 F.2d 1224, 1228 (6th Cir. 1988); Young v. Sec'y of Health and Human Servs., 787 F.2d 1064, 1066 (6th Cir. 1986); Smith v. Chater, 99 F.3d 780, 782 (6th Cir. 1996). Even if this Court would have decided the case differently, it must give deference to the Commissioner and affirm his findings if substantial evidence supports them. Id. Because substantial evidence supports the ALJ's analysis and conclusion, the Undersigned recommends affirming.
Based on the foregoing, it is
If any party objects to this Report and Recommendation, that party may, within fourteen (14) days of the date of this Report, file and serve on all parties written objections to those specific proposed finding or recommendations to which objection is made, together with supporting authority for the objection(s). A District Judge of this Court shall make a de novo determination of those portions of the Report or specific proposed findings or recommendations to which objection is made. Upon proper objection, a District Judge of this Court may accept, reject, or modify, in whole or in part, the findings or recommendations made herein, may receive further evidence or may recommit this matter to the Magistrate Judge with instructions. 28 U.S.C. § 636(b)(1).
The parties are specifically advised that failure to object to the Report and Recommendation will result in a waiver of the right to have the district judge review the Report and Recommendation de novo, and also operates as a waiver of the right to appeal the decision of the District Court adopting the Report and Recommendation. See Thomas v. Arn, 474 U.S. 140 (1985); United States v. Walters, 638 F.2d 947 (6th Cir. 1981).
IT IS SO ORDERED.
