ELIZABETH A. PRESTON DEAVERS, Chief Magistrate Judge.
Plaintiff, Brandi L. Moore ("Plaintiff"), brings this action under 42 U.S.C. § 405(g) for review of a final decision of the Commissioner of Social Security ("Commissioner") denying her application for Social Security Disability Insurance benefits ("SSDI") and Supplemental Security Income benefits ("SSI"). This matter is before the United States Magistrate Judge for a Report and Recommendation on Plaintiff's Statement of Errors (ECF No. 14), the Commissioner's Memorandum in Opposition (ECF No. 18), Plaintiff's Reply (ECF No. 19), and the administrative record (ECF No. 9). For the following reasons, it is
Plaintiff applied for disability benefits and supplemental security income on May 19, 2014.
Plaintiff testified that she was involved in a car accident on June 12, 2008 which affected her ability to work. (R. at 40-43.) Plaintiff also testified that she was married and had two daughters, ages ten and five. (R. at 45.) Plaintiff stated that the cane she was using at the administrative hearing was prescribed to her "about six months after the [car] accident." (Id.) Before using the cane, she testified she was using a walker and wheelchair during those six months. (Id.)
Plaintiff testified that she worked in 2010 for a college doing "phone work and telemarketing." (R. at 47.) She further testified that the job "let her go" after a couple of months. (Id.) When asked why she is unable to work, Plaintiff testified that in 2010 and 2011 when she was pregnant she "gained over 200 pounds in eight months." (R. at 50.) She also testified that she experienced convulsions at that time and emergency services were called. (R. at 50-51.) She further testified that she continues to have problems with standing and walking. (R. at 51-52.) Plaintiff also testified that getting dressed takes her "about three-and-a-half hours." (R. at 52.)
Plaintiff testified that she has difficulty with her memory sometimes such as not being able to think of certain words. (R. at 56.) Regarding her ability to maintain attention and concentration, she testified she loses her concentration a lot. (R. at 56-57.) She testified that she gets two-and-a-half hours to four hours of sleep a night and naps four days a week. (R. at 58-59.) She further testified that she cannot walk the length of a city block without taking a break. (R. at 60.)
Connie O'Brien testified as the vocational expert ("VE") at the November 2016 hearing. (R. at 62-71.) The VE testified that Plaintiff's past work included office manager and customer representative. (R. at 64.) The ALJ asked the VE to assume a hypothetical individual with the Plaintiff's age, education, and past jobs who can lift and/or carry twenty pounds occasionally; can lift and/or carry ten pounds frequently; can stand and/or walk four hours out of an eight hour work day and sit six hours out of an eight hour work day; with pushing and pulling limited as per exertional weight limits; who can never climb ladders, ropes, or scaffolds; can occasionally climb ramps or stairs; can occasionally balance, stoop, kneel, crouch, or crawl; can do goal-based production work measured by end result, not pace work; with work limited to simple, routine, and repetitive tasks; who is off task five percent of the work day; who must work in a low stress job defined as only having occasional decisionmaking required and only occasional changes in the work setting; with only occasional interaction with the public, coworkers, and supervisors. (R. at 65.) Assuming those limitations, the VE testified that the hypothetical individual could not perform any of Plaintiff's past work, but could work as an office helper, photocopy machine operator, and route clerk. (R. at 65-66.)
The ALJ asked the VE to take the first hypothetical but to assume the sedentary level and that a cane would be required for ambulation. (R. at 68.) Assuming those limitations, the VE testified that the hypothetical individual could not perform any of Plaintiff's past work, but could work as an addresser, inspector, and document specialist. (Id.) The ALJ asked the VE to take the second hypothetical but add the limitation that frequent supervision would be required for both mental and physical reasons and that the individual would have memory problems or would need additional help perhaps in constant reminders to stay on task and to be on time. (R. at 69.) Assuming those limitations, the VE testified that the hypothetical individual would be precluded from competitive work. (Id.) The VE further testified that if the additional limitation of the hypothetical individual being consistently late to work three times a month were added to any of the previous hypotheticals this would preclude the hypothetical individual from work. (Id.) The VE also testified that if the additional limitation of the hypothetical individual being off task ten percent of the day were added to any of the previous hypotheticals this would preclude the hypothetical individual from work. (Id.)
Dr. Johnson wrote a letter regarding Plaintiff on May 5, 2014. (R. at 604.) Dr. Johnson indicated that Plaintiff had been seen in his office since September 2008 for management of her chronic medical conditions and pain control. (Id.) Dr. Johnson also wrote:
(Id.) On March 23, 2015, Dr. Johnson wrote an almost identical letter adding that Plaintiff has attempted to return to work but was unable secondary to her physical limitations and that she has plans to investigate surgical weight loss. (R. at 614.)
On November 14, 2016, Dr. Johnson wrote a substantially similar letter to his first two, writing:
(R. at 766.)
Throughout Plaintiff's visits with Dr. Johnson, the doctor indicated the following regarding Plaintiff: mild left hip degenerative change with spurring at the femoral head-neck junction, no acute osseous abnormality (R. at 431); complaints of left hip, knee, and back pain (R. at 435, 443-44, 487, 490, 494); numbness of the feet (R. at 435); complaints of anxiety (R. at 436, 444, 487, 505); use of a cane for ambulation (R. at 436, 444, 506, 509), as well as attending appointments and ambulating without the cane (R. at 439, 769, 776, 783); reports of ambulation tolerance improved with water aerobics (R. at 439, 443, 486); ability to do housework with the use of pain medications (R. at 439); reports of improvement in mood and pain due to increased physical activity (R. at 475); weight issues (R. at 486); medication changes (R. at 486); complaints of fatigue (R. at 490); substance dependence issues (R. at 540, 550, 582-83); discontinuing water aerobics (R. at 809, 862); normal reflexes (R. at 783, 810); normal mood and affect (R. at 810, 816, 848); pelvic pain (R. at 815); and decreased range of motion of bilateral hips (R. at 848).
Dr. Karen Bretz is a State agency psychological consultant who completed an assessment of Plaintiff on July 21, 2014. (R. at 605-12.) Throughout Dr. Bretz's assessment the car accident is noted as occurring in 2006.
Plaintiff reported that on a typical day she gets up at 8:00 AM, "tends to her morning hygiene, takes her medication, changes her daughter's diaper, then helps her older daughter get breakfast, and tries to manage her pain by sitting and standing and changing positions." (Id.) She also reported that she "spends most of her day watching television and playing with her children[,]" that she does no household chores, that her husband is responsible for paying the bills, and that she goes to bed at various times. (Id.)
Dr. Bretz made the following observations about Plaintiff:
(R. at 608-09.) Dr. Bretz diagnosed Plaintiff with Major Depressive Disorder, moderate, with anxious distress. (R. at 609.)
On March 22, 2017, the ALJ issued his decision. (R. at 12-29.) At step one of the sequential evaluation process,
At step four of the sequential process, the ALJ set forth Plaintiff's residual functional capacity ("RFC") as follows:
Relying on testimony from the VE, the ALJ concluded that Plaintiff is unable to perform any of her past relevant work. (R. at 27.) The ALJ found that considering Plaintiff's age, education, work experience, and RFC, there are jobs that exist in significant numbers in the national economy that Plaintiff can perform. (Id.) He therefore concluded that Plaintiff was not disabled under the Social Security Act from June 12, 2008, through the date of the administrative decision. (R. at 28.)
When reviewing a case under the Social Security Act, the Court "must affirm the Commissioner's decision if it `is supported by substantial evidence and was made pursuant to proper legal standards.'" Rabbers v. Comm'r of Soc. Sec., 582 F.3d 647, 651 (6th Cir. 2009) (quoting Rogers v. Comm'r of Soc. Sec., 486 F.3d 234, 241 (6th Cir. 2007)); see also 42 U.S.C. § 405(g) ("[t]he findings of the Commissioner of Social Security as to any fact, if supported by substantial evidence, shall be conclusive . . . ."). Under this standard, "substantial 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, 486 F.3d at 241 (quoting Cutlip v. Sec'y of Health & Hum. Servs., 25 F.3d 284, 286 (6th Cir. 1994)).
Although the substantial evidence standard is deferential, it is not trivial. The Court must "`take into account whatever in the record fairly detracts from [the] weight'" of the Commissioner's decision. TNS, Inc. v. NLRB, 296 F.3d 384, 395 (6th Cir. 2002) (quoting Universal Camera Corp. v. NLRB, 340 U.S. 474, 487 (1951)). Nevertheless, "if substantial evidence supports the ALJ's decision, this Court defers to that finding `even if there is substantial evidence in the record that would have supported an opposite conclusion.'" Blakley v. Comm'r of Soc. Sec., 581 F.3d 399, 406 (quoting Key v. Callahan, 109 F.3d 270, 273 (6
Finally, even if the ALJ's decision meets the substantial evidence standard, "`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.'" Rabbers, 582 F.3d at 651 (quoting Bowen v. Comm'r of Soc. Sec., 478 F.3d 742, 746 (6th Cir. 2007)).
Plaintiff puts forth two assignments of error. First, Plaintiff asserts that the ALJ failed to provide good reasons for rejecting the findings of Dr. Johnson. (ECF No. 14, at pg. 6-10.) Second, Plaintiff asserts that the mental RFC is not supported by substantial evidence. (Id. at 11-13.) The Undersigned addresses each in turn.
The ALJ generally gives deference to the opinions of a treating source "since these sources are likely to be the medical professionals most able to provide a detailed, longitudinal picture of [a patient's] medical impairment(s) and may bring a unique perspective to the medical evidence that cannot be obtained from the objective medical filings alone . . . ." 20 C.F.R. § 416.927(c)(2); Blakley, 581 F.3d at 408. If the treating physician's opinion is "well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in the [claimant's] case record, [the ALJ] will give it controlling weight." 20 C.F.R. § 404.1527(c)(2).
If the ALJ does not afford controlling weight to a treating physician's opinion, the ALJ must meet certain procedural requirements. Wilson v. Comm'r of Soc. Sec., 378 F.3d 541, 544 (6th Cir. 2004). Specifically, if an ALJ does not give a treating source's opinion controlling weight:
Id. Furthermore, an ALJ must "always give good reasons in [the ALJ's] notice of determination or decision for the weight [the ALJ] give[s] your treating source's opinion." 20 C.F.R. § 416.927(c)(2). Accordingly, the ALJ's reasoning "must be sufficiently specific to make clear to any subsequent reviewers the weight the adjudicator gave to the treating source's medical opinion and the reasons for that weight." Friend v. Comm'r of Soc. Sec., 375 F. App'x 543, 550 (6th Cir. 2010) (internal quotation omitted). The Sixth Circuit has stressed the importance of the good-reason requirement:
Wilson, 378 F.3d at 544-45. Thus, the reason-giving requirement is "particularly important when the treating physician has diagnosed the claimant as disabled." Germany-Johnson v. Comm'r of Soc. Sec., 313 F. App'x 771, 777 (6th Cir. 2008) (citing Rogers, 486 F.3d at 242). There is no requirement, however, that the ALJ "expressly" consider each of the Wilson factors within the written decision. See Tilley v. Comm'r of Soc. Sec., 394 F. App'x 216, 222 (6th Cir. 2010).
Finally, the Commissioner reserves the power to decide certain issues, such as a claimant's residual functional capacity. 20 C.F.R. § 404.1527(d). Although the ALJ will consider opinions of treating physicians "on the nature and severity of your impairment(s)," opinions on issues reserved to the Commissioner are generally not entitled to special significance. 20 C.F.R. § 404.1527(d); Bass v. McMahon, 499 F.3d 506, 511 (6th Cir. 2007).
Here, the parties do not dispute that Dr. Johnson was Plaintiff's treating physician. Plaintiff, however, insists that the ALJ failed to provide good reasons for assigning his opinion only little weight. The Undersigned disagrees.
The ALJ thoroughly discussed Dr. Johnson's opinions and concluded that they were generally inconsistent with objective findings, his treatment notes, imaging reports, and other providers findings. (R. at 21-25.) Substantial evidence supports this conclusion. For instance, Plaintiff demonstrated "normal findings" at a number of visits. (See, e.g., R. at 21 ("She had normal findings with the exception of her weight at 203 pounds and decreased range of motion of her right hip status post June of 2008 accident and surgical repair."); 21 ("Her lumbar spine x-ray on December 30, 2008 was essentially normal."); 21 ("Findings on exam including decreased range of motion of her right hip due to pain and use of a cane, but otherwise normal findings including strength."); 22 ("On exam, she had no focal deficits, intact cranial nerves with normal sensation, normal reflexes, normal coordination and normal muscle strength and tone."); 22 ("She had decreased range of motion in her left hip, with otherwise normal findings."); 22 ("Her left and right knee x-rays indicated normal appearing knees and her lumbar spine x-ray was unremarkable.").)
The ALJ also noted the indications of Plaintiff's substance abuse issues. (See, e.g., R. at 21 ("Throughout these notes are [Dr. Johnson's] concerns about the possibility of opiate dependency, with the claimant on Vicodin even prior to her car accident, and being unable to reduce her usage."); 21 ("Dr. Johnson [included] a diagnosis of continued Sedative hypnotic/anxiolytic dependence.").) Additionally, the ALJ indicated that Plaintiff had reported improvements in her condition with water aerobics. (See, e.g., R. at 22 ("She reported overall doing well and performing water aerobics and seated aerobics at the YMCA."); 22 ("On May 14, 2013, the claimant reported doing water aerobics at the YMCA three days a week and feeling her mood and pain were better due to increased physical activity.") (emphasis in original); 22 ("She presented without her cane on January 28, 2014, reporting increased ambulation tolerance with water aerobics classes with workouts increasing in intensity.") (emphasis in original).) The ALJ properly considered these inconsistencies, including activities of daily living, as good reasons to discount Dr. Johnson's opinion. See Hummel v. Comm'r of Soc. Sec., No. 2:16-cv-937, 2018 WL 1373869, at *3 (S.D. Ohio March 19, 2018) (finding inconsistency, including activities of daily living, constitutes good reason to discredit treating physician's opinion).
The ALJ assigned "little weight" to the opinions in the letters from Dr. Johnson. (R. at 23-24.) First, the ALJ properly afforded no weight to Dr. Johnson's opinion that Plaintiff could not work because the determination of disability is reserved to the Commissioner. 20 C.F.R. § 404.1527(d). Furthermore, the ALJ noted that Dr. Johnson's treatment notes "reflect generally normal findings as to most systems with the exception of the range of motion and cane use and occasionally anxiety, some of it in conjunction with reduction of her pain medications and concerns over her polysubstance (medication) dependence issues, which was also noted by other treating doctors." (Id.) The ALJ additionally indicated that Dr. Johnson had noted Plaintiff's improvement with the YMCA water aerobics program. (Id.) The ALJ did note that he "considered [Dr. Johnson's] opinion in so far as it supports [Plaintiff's] sedentary exertional level [RFC], with particular consideration of the objective findings in [Dr. Johnson's] treatment notes and suggestion that [Plaintiff's] obesity was a complicating factor. Further limitation is not supported by the objective findings in [Dr. Johnson's] notes, the imaging results, or findings by other providers." (Id.)
"Where the opinion of a treating physician is not supported by objective evidence or is inconsistent with the other medical evidence in the record, this Court generally will uphold an ALJ's decision to discount that opinion." Price v. Comm'r of Soc. Sec., 342 F. App'x 172, 175-76 (6th Cir. 2009) (citations omitted). Here, Dr. Johnson's opinions within his three almost identical letters contradicted his own treatment notes, medical evidence from other providers, and Plaintiff's own self-reports. The ALJ properly afforded only little weight to his opinions. See Leeman v. Comm'r of Soc. Sec., 449 F. App'x 496, 497 (6th Cir. 2011) ("ALJs may discount treating-physician opinions that are inconsistent with substantial evidence in the record[.]"); Coldiron v. Comm'r of Soc. Sec., 391 F. App'x 435, 440 (6th Cir. 2010) (finding the "lack of internal consistency" in a treating source's opinion constituted "good reason"). It is therefore
A plaintiff's RFC "is defined as the most a [plaintiff] can still do despite the physical and mental limitations resulting from her impairments." Poe v. Comm'r of Soc. Sec., 342 F. App'x 149, 155 (6th Cir. 2009); see also 20 C.F.R. §§ 404.1545(a), 416.945(a). The determination of RFC is an issue reserved to the Commissioner. 20 C.F.R. §§ 404.1527(e), 416.927(e). Nevertheless, substantial evidence must support the Commissioner's RFC finding. Berry v. Astrue, No. 1:09-cv-000411, 2010 WL 3730983, at *8 (S.D. Ohio June 18, 2010). When considering the medical evidence and calculating the RFC, "`ALJs must not succumb to the temptation to play doctor and make their own independent medical findings.'" Simpson v. Comm'r of Soc. Sec., 344 F. App'x 181, 194 (6th Cir. 2009) (quoting Rohan v. Chater, 98 F.3d 966, 970 (7th Cir. 1996)); see also Isaacs v. Astrue, No. 1:08-cv-00828, 2009 WL 3672060, at *10 (S.D. Ohio Nov. 4, 2009) (holding that an "ALJ may not interpret raw medical data in functional terms") (internal quotations omitted).
An ALJ is required to explain how the evidence supports the limitations that he set forth in the claimant's RFC:
S.S.R. 96-8p, 1996 WL 374184, at *6-7 (internal footnote omitted).
Plaintiff asserts that the ALJ's RFC determination is not supported by substantial evidence. In his efforts to challenge the ALJ's mental RFC determination, Plaintiff asserts that the mental RFC "is materially inconsistent with Dr. Bretz's functional limitations." (ECF No. 14, at pg. 11.) Dr. Bretz is a State agency psychological consultant. (R. at 605-12.) "[T]he opinions of non-examining state agency medical consultants have some value and can, under some circumstances, be given significant weight." Douglas v. Comm'r of Soc. Sec., 832 F.Supp.2d 813, 824. (S.D. Ohio Sept. 19, 2011). Indeed, the Commissioner views such medical sources "as highly qualified physicians and psychologists who are experts in the evaluation of the medical issues in disability under the [Social Security] Act." Id.; § 416.927(d), (f). "Consequently, opinions of one-time examining physicians and record-reviewing physicians are weighed under the same factors as treating physicians including supportability, consistency, and specialization." Douglas, 832 F. Supp. 2d at 824. Even though an ALJ "must consider [the] findings of State agency medical and psychological consultants, [he or she] is not bound by any findings made by State agency or psychological consultants." Renfro v. Barnhart, 30 F. App'x 431, 436 (6th Cir. 2002) (internal quotations and citation omitted).
Dr. Bretz opined that Plaintiff spent an excessive amount of time completing the paperwork, had trouble limiting her answers to the questions being asked, that her ability to understand, remember, and carry out instruction appeared to be somewhat impaired, that she had difficulty distinguishing between relevant and irrelevant information, that her ability to sustain concentration and persistence was somewhat impaired, that her ability to interact with others may be somewhat impaired by her anxiety, and that her ability to adapt to changes in the work environment is somewhat impaired by her depression. (R. at 608-09.) Dr. Bretz also noted that Plaintiff's appearance was consistent with her age, she drove herself to the appointment, her speech was tangential with normal volume and pace, her thought processes were clear and without loose associations or obvious delusions, she seemed easily engaged in appropriate spontaneous conversation, and she was very polite and pleasant. (Id.) Dr. Bretz diagnosed Plaintiff with Major Depressive Disorder, moderate, with anxious stress. (R. at 609.)
The ALJ discussed Dr. Bretz's opinions as follows:
(R. at 25-26.)
Plaintiff asserts that the "ALJ gave no indication that Dr. Bretz's opinions were inconsistent with the record or not well-supported." (ECF No. 14, at pg. 12.) This assertion is not entirely correct, as the ALJ pointed out that while Plaintiff had reported doing no household chores, her treatment records indicated that she was able to perform some household chores with treatment. (R. at 26.) Nevertheless, Plaintiff asserts that the ALJ's mental RFC determination "appears to be materially inconsistent with Dr. Bretz's opinions." (ECF No. 14, at pg. 12.) The fact that the ALJ did not incorporate all of Dr. Bretz's restrictions, despite attributing significant weight to her opinion, is not legal error in and of itself. See White v. Comm'r of Soc. Sec., 970 F.Supp.2d 733, 753 (N.D. Ohio Sept. 10, 2013) (noting that the ALJ's decision not to incorporate all of the State agency examining physician's restrictions, despite attributing significant weight to his opinion, was "not legal error in and of itself"). "While an ALJ must consider and weigh medical opinions, the RFC determination is expressly reserved to the Commissioner." Id. (citing Ford v. Comm'r of Soc. Sec., 114 F. App'x 194, 198 (6th Cir. 2004)). Indeed, "there is no legal requirement for an ALJ to explain each limitation or restriction he [or she] adopts or, conversely, does not adopt from a non-examining physician's opinion, even when it is given significant weight." Smith v. Comm'r of Soc. Sec., No. 5:11-cv-2104, 2013 WL 1150133, at *11 (N.D. Ohio March 19, 2013) (citing Ford, 114 F. App'x at 198.)
Here, the ALJ's mental RFC determination accounted for mental and social limitations, finding that Plaintiff could only engage in simple, routine, and repetitive tasks, would need to be off task five percent of the workday, would need a low stress job with only occasional changes in the work setting, and could have only occasional interaction with supervisors, co-workers, or the general public. (R. at 19-20.) Medical evidence substantially supports the ALJ's RFC without the additional limitations that Plaintiff asserts were part of Dr. Bretz's opinion. For example, upon numerous mental examinations Plaintiff was noted to be alert and cooperative, have a normal mood and affect, have normal attention span and concentration, have an intact memory for recent and remote events, and denied memory loss or mental disturbance. (See, e.g., R. at 437, 441, 444, 476, 481, 487, 495, 508, 540, 543, 547, 579, 583, 592, 769.) Here, the Undersigned finds that substantial evidence demonstrates that the ALJ's RFC adequately accounted for all of the limitations that he found credible. Coldiron, 391 F. App'x at 439 ("The ALJ is charged with the responsibility of evaluating the medical evidence and the claimant's testimony to form an assessment of [the claimant's] residual functional capacity.") (quoting Webb v. Comm'r of Soc. Sec., 368 F.3d 629, 633 (6th Cir. 2004) (citation omitted). It is therefore
In sum, from a review of the record as a whole, the Undersigned concludes that substantial evidence supports the ALJ's decision denying benefits. Accordingly, it is
If any party seeks review by the District Judge of this Report and Recommendation, that party may, within fourteen (14) days, file and serve on all parties objections to the Report and Recommendation, specifically designating this Report and Recommendation, and the part in question, as well as the basis for objection. 28 U.S.C. § 636(b)(1); Fed. R. Civ. P. 72(b). Response to objections must be filed within fourteen (14) days after being served with a copy. Fed. R. Civ. P. 72(b).
The parties are specifically advised that the failure to object to the Report and Recommendation will result in a waiver of the right to de novo review by the District Judge and waiver of the right to appeal the judgment of the District Court. See, e.g., Pfahler v. Nat'l Latex Prod. Co., 517 F.3d 816, 829 (6th Cir. 2007) (holding that "failure to object to the magistrate judge's recommendations constituted a waiver of [the defendant's] ability to appeal the district court's ruling"); United States v. Sullivan, 431 F.3d 976, 984 (6th Cir. 2005) (holding that defendant waived appeal of district court's denial of pretrial motion by failing to timely object to magistrate judge's report and recommendation). Even when timely objections are filed, appellate review of issues not raised in those objections is waived. Robert v. Tesson, 507 F.3d 981, 994 (6th Cir. 2007) ("[A] general objection to a magistrate judge's report, which fails to specify the issues of contention, does not suffice to preserve an issue for appeal . . . .") (citation omitted)).
See 20 C.F.R. §416.920(a)(4); see also Henley v. Astrue, 573 F.3d 263, 264 (6th Cir. 2009); Foster v. Halter, 279 F.3d 348, 354 (6th Cir. 2001).