MARK J. DINSMORE, Magistrate Judge.
Plaintiff Tonya L. Booker requests judicial review of the final decision of the Commissioner of the Social Security Administration ("Commissioner") denying her application for Social Security Disability Insurance ("DIB") under Title II of the Social Security Act ("the Act"). See 42 U.S.C. §§ 416(i), 423(d).
Booker filed her application for SSI on May 7, 2013, alleging January 28, 2011 as the onset date of disability. [
To determine whether a claimant is disabled, the ALJ employs a five-step sequential analysis: (1) if the claimant is engaged in substantial gainful activity, he is not disabled; (2) if the claimant does not have a "severe" impairment, or one that significantly limits his ability to perform basic work activities, he is not disabled; (3) if the claimant's impairment or combination of impairments meets or medically equals any impairment appearing in the Listing of Impairments, 20 C.F.R. pt. 404, subpt. P, App. 1, the claimant is disabled; (4) if the claimant is not found to be disabled at step three and he is able to perform his past relevant work, he is not disabled; and (5) if the claimant is not found to be disabled at step three and either cannot perform his past relevant work or has no past relevant work but can perform certain other available work, he is not disabled. 20 C.F.R. § 404.1520. Before proceeding from step three to step four, the ALJ must assess the claimant's residual functional capacity (RFC), identifying the claimant's functional limitations and assessing the claimant's remaining capacity for work related activities. S.S.R. 96-8p, 1996 WL 374184.
The ALJ's findings of fact are conclusive and must be upheld by this Court "so long as substantial evidence supports them and no error of law occurred." Dixon v. Massanari, 270 F.3d 1171, 1176 (7th Cir. 2001). "Substantial evidence means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Id The Court may not reweigh the evidence or substitute its judgment for that of the ALJ but may only determine whether substantial evidence supports the ALJ's conclusion. Overman v. Astrue, 546 F.2d 456, 462 (7th Cir. 2008) (citing Schmidt v. Apfel, 201 F.3d 970, 972 (7th Cir. 2000); Skinner v. Astrue, 478 F.3d 836, 841 (7th Cir. 2007)). The ALJ "need not contain a complete written evaluation of every piece of evidence." McKinzey v. Astrue, 641 F.3d 884, 891 (7th Cir. 2011) (quoting Schmidt v. Barnhart, 395 F.3d 737, 744 (7th Cir. 2005)). However, the "ALJ's decision must be based upon consideration of all the relevant evidence." Herron v. Shalala 19 F.3d 329, 333 (7th Cir. 1997). To be affirmed, the ALJ must articulate his analysis of the evidence in his decision. The ALJ must "provide some glimpse into his reasoning" and "build an accurate logical bridge from the evidence to his conclusion." Dixon, 270 F.3d at 1176. The scope of review is confined to the rationale offered by the ALJ. See SEC v. Chenery Corp., 318 U.S. 80, 93-95 (1943); Parker v. Astrue, 597 F.3d 920, 922 (7th Cir. 2010).
The ALJ first noted that Booker had a previous DIB application with a final decision dated March 27, 2013. [
At step two, the ALJ found Booker's severe impairments to include "chronic obstructive pulmonary disease, coronary artery disease, hypertension, hyperlipidemia, diabetes, hypothyroidism, obesity and history of carpel tunnel surgery." [Id. (citations omitted).] The ALJ further considered Booker's transient ischemic attacks, depression, and anxiety and determined that these conditions were not severe impairments. [
Before step four, "[a]fter careful consideration of the entire record," the ALJ determined that Booker had the RFC to perform light work with the following specific restrictions:
[
Booker argues that the ALJ incorrectly evaluated the medical evidence and that the Appeals Council erroneously determined that newly-submitted evidence was not new and material. The Court addresses each issue in turn.
Booker argues that the ALJ incorrectly evaluated the medical evidence and thus reached an inappropriate RFC. Booker principally argues that the ALJ ran afoul of the treating physician rule
Dr. Moreland, Booker's treating physician since 2001, completed several assessments opining as to Booker's physical and mental limitations.
The ALJ, however, did not give Dr. Moreland's opinions controlling weight, observing that the "ultimate issue of disability is reserved to the Commissioner." [
The so-called treating physician rule requires the ALJ to give a physician's opinion controlling weight if it is "(1) supported by medical findings[] and (2) consistent with substantial evidence in the record." Elder v. Astrue, 529 F.3d 408, 415 (7th Cir. 2008) (citing 20 C.F.R. § 404.1527(d)(2); Skarbek v. Barnhart, 390 F.3d 500, 503 (7th Cir. 2004)). But "[e]ven when an ALJ decides not to give controlling weight to a treating physician's opinion, the ALJ is not permitted simply to discard it." Scrogham v. Colvin, 765 F.3d 685, 697 (7th Cir. 2014). Rather, the regulations require the ALJ to assign a weight to the opinion based upon several factors:
Scrogham, 765 F.3d at 697 (quoting 20 C.F.R. § 404.1527(c)(2)-(5)) (alterations in original). The ALJ must "minimally articulate his reasons" for assigning a particular weight to the physician's opinion. Clifford v. Apfel, 227 F.3d 863, 870 (7th Cir. 2000) (quoting Scivally v. Sullivan, 966 F.2d 1070, 1076 (7th Cir. 1992)).
The Court agrees that the ALJ's assessment of Dr. Moreland's opinion requires remand. First, the ALJ failed to explain what weight he assigned to Dr. Moreland's opinion, instead concluding that the opinion did not warrant "persuasive weight." As the "ALJ [was] not permitted simply to discard" the opinion once he determined it did not warrant controlling weight, Scrogham, 765 F.3d at 697, he was required to explain what weight the opinion warranted so that the Court could assess whether he properly accommodated any limitations in the RFC. See Larson v. Astrue, 615 F.3d 744, 751 (7th Cir. 2010) ("Even if the ALJ had articulated good reasons for rejecting Dr. Rhoades's opinion, it still would have been necessary to determine
The Court cannot assume that the ALJ considered all evidence and decided to give Dr. Moreland's opinion no weight, particularly in light of the evidence that the ALJ failed to address that lends support to Dr. Moreland's conclusions. For example, Dr. Koselke opined that Booker "exhibits moderate depressive symptoms with low energy and low motivation. Her ability to work would be primarily be affected by her physical/medical difficulties, and secondarily by her moderate depressive symptoms." [
Additionally, while the ALJ properly restricted the relevant disability period to March 28, 2013 due to the res judicata effect of the prior disability determination, the factors for evaluating a treating physician's opinion expressly require the ALJ to consider the length of the treating relationship. See 20 CF.R. § 404.1527(c)(2)(i) ("Generally, the longer a treating source has treated you and the more times you have been seen by a treating source, the more weight we will give to the source's medical opinion."); id. (c)(2)(ii) ("Generally, the more knowledge a treating source has about your impairment(s) the more weight we will give to the source's medical opinion. . . ."). While the ALJ mentioned that Dr. Moreland has treated Booker since 2001, the ALJ makes no mention of Dr. Moreland's treatment records prior to March 2013. These records reveal that Dr. Moreland consistently diagnosed Booker with depression since at least 2011. [E.g.,
Finally, the ALJ found "the opinions of the reviewing physicians with Disability Determination Services persuasive, as they benefited from reviewing the entire medical evidence of record." [
The ALJ, after confronting the contrary evidence, may well again conclude that Dr. Moreland's opinions do not warrant controlling weight. But the ALJ must "build an accurate and logical bridge from the evidence to the conclusion." Clifford, 227 F.3d at 872. The ALJ failed to do so in this case, leaving unaddressed evidence that did not support his opinion. Accordingly, remand is required so that the ALJ may evaluate the opinions in light of this evidence and then actually assign a weight to Dr. Moreland's opinions.
Having found that the ALJ's evaluation of Dr. Moreland's opinion requires remand, the Court summarily addresses Booker's remaining arguments regarding the ALJ's treatment of the medical evidence.
First, Booker contends that the ALJ failed to weigh the opinion of Dr. Djodjeva, a consultative examining physician. As Booker acknowledges, however, the ALJ discussed Dr. Djodjeva's findings at length. Moreover, while Dr. Djodjeva conducted an exam and made numerous medical findings that ultimately informed the ALJ's RFC assessment, Dr. Djodjeva did not render any RFC or similar opinion. Most critically, Booker fails to explain what else the ALJ should have done to accommodate Dr. Djodjeva's findings. See, e.g., Schmidt v. Astrue, 496 F.3d 833, 844-45 (7th Cir. 2007) (requiring the claimant to explain how further consideration could impact ALJ's decision). Accordingly, the ALJ's treatment of Dr. Djodjeva's opinion does not warrant reversal.
Next, Booker briefly argues that the ALJ erred by assessing Booker with greater RFC restrictions than the state agency consulting physicians on the basis of evidence that was unavailable to those physicians. But Booker does not argue that this evidence required more restrictions than those imposed by the ALJ. See, e.g., id. This argument also fails.
Finally, Booker argues that Dr. Koselke's assessment that Booker has "moderate depressive symptoms" runs afoul of the O'Connor-Spinner rule that the ALJ must accommodate all supported limitations in concentration, persistence, or pace in the claimant's RFC. See O'Connor-Spinner v. Astrue, 627 F.3d 614, 620 (7th Cir. 2010)). Booker conflates an assessment of a medical condition with a functional limitation. Dr. Koselke assessed Booker with moderate symptoms of depression, but made no findings that Booker was limited in concentration, persistence, or pace. Thus, while the ALJ was required to consider how Dr. Koselke's opinion may support Dr. Moreland's opinion as explained above, Dr. Koselke's findings did not require an accommodation for limitations in concentration, persistence, or pace.
Finally, Booker argues that the Appeals Council erred in determining that additional submitted medical evidence was not "new and material" and then by failing to include the records in the administrative record. The Commissioner responds that the Appeals Council's determination was discretionary and unreviewable; that even if it were reviewable, Booker has failed to demonstrate that the records were new and material; and that the Appeals Council was not required to include the records in the administrative record.
The Appeals Council in this case issued its standard, boilerplate denial of review: "We have found no reason under our rules to review the Administrative Law Judge's decision.
Therefore, we have denied your request for review." [
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The Seventh Circuit has explained the limited circumstances in which this Court may review the Appeals Council's decision:
Stepp v. Colvin, 795 F.3d 711, 722 (7th Cir. 2015) (citations omitted). Thus, where the Appeals Council determines that the additional evidence is new and material, but otherwise determines that it would not impact the ALJ's decision, that determination is unreviewable. Id. However, the Court may review a determination that additional evidence was not new and material. Id. at 725.
Moreover, even where the Appeals Council determines that the additional evidence is not new and material, it must "[a]ssociate a copy of the evidence the appropriate section of the file, placing all medical evidence in the F section" to be "included in the certified administrative record if the case is appealed to Federal court." HALLEX I-3-5-20. And it is the Commissioner that "certifie[s]" that the record filed in this Court is complete. [
The Appeals Council appears to have determined that the additional records are not new and material, thus making the Council's decision subject to limited review. See Stepp, 795 F.3d at 722; Farell v. Astrue, 692 F.3d 767, 771 (7th Cir. 2012). But the problem is that the Court cannot assess whether the records are in fact new and material because the additional evidence was not submitted to this Court.
For the foregoing reasons, the Court concludes that the Appeals Council has committed legal error and that the ALJ has failed to build a logical bridge from the evidence to the conclusion. The Magistrate Judge therefore recommends that the District Judge
Any objections to the Magistrate Judge's Report and Recommendation shall be filed with the Clerk in accordance with 28 U.S.C. § 636(b)(1) and Fed. R. Civ. P. 72(b), and failure to timely file objections within fourteen days after service shall constitute a waiver of subsequent review absent a showing of good cause for such failure.