RAY KENT, Magistrate Judge.
Plaintiff brings this action pursuant to 42 U.S.C. § 405(g), seeking judicial review of a final decision of the Commissioner of Social Security Administration (Commissioner) which denied her claim for disability insurance benefits (DIB).
Plaintiff alleged a disability onset date of November 15, 2013. PageID.246. Plaintiff identified her disabling conditions as no thyroid, bipolar, and depression. PageID.250. Prior to applying for DIB, plaintiff completed the 12th grade, had additional job training in office administration, and had past employment as a hotel housekeeper and a debt collector. PageID.251. An Administrative law judge (ALJ) reviewed plaintiff's claim de novo and entered a written decision denying benefits on April 14, 2016. PageID.46-56. This decision, which was later approved by the Appeals Council, has become the final decision of the Commissioner and is now before the Court for review.
This Court's review of the Commissioner's decision is typically focused on determining whether the Commissioner's findings are supported by substantial evidence. 42 U.S.C. § 405(g); McKnight v. Sullivan, 927 F.2d 241 (6th Cir. 1990). "Substantial evidence is 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." Cutlip v. Secretary of Health & Human Services, 25 F.3d 284, 286 (6th Cir. 1994). A determination of substantiality of the evidence must be based upon the record taken as a whole. Young v. Secretary of Health & Human Services, 925 F.2d 146 (6th Cir. 1990).
The scope of this review is limited to an examination of the record only. This Court does not review the evidence de novo, make credibility determinations or weigh the evidence. Brainard v. Secretary of Health & Human Services, 889 F.2d 679, 681 (6th Cir. 1989). The fact that the record also contains evidence which would have supported a different conclusion does not undermine the Commissioner's decision so long as there is substantial support for that decision in the record. Willbanks v. Secretary of Health & Human Services, 847 F.2d 301, 303 (6th Cir. 1988). Even if the reviewing court would resolve the dispute differently, the Commissioner's decision must stand if it is supported by substantial evidence. Young, 925 F.2d at 147.
A claimant must prove that he suffers from a disability in order to be entitled to benefits. A disability is established by showing that the claimant cannot engage in substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than twelve months. See 20 C.F.R. §404.1505; Abbott v. Sullivan, 905 F.2d 918, 923 (6th Cir. 1990). In applying the above standard, the Commissioner has developed a five-step analysis:
Heston v. Commissioner of Social Security, 245 F.3d 528, 534 (6th Cir. 2001) (citations omitted). The claimant bears the burden of proving the existence and severity of limitations caused by her impairments and the fact that she is precluded from performing her past relevant work through step four. Jones v. Commissioner of Social Security, 336 F.3d 469, 474 (6th Cir. 2003). However, at step five of the inquiry, "the burden shifts to the Commissioner to identify a significant number of jobs in the economy that accommodate the claimant's residual functional capacity (determined at step four) and vocational profile." Id. If it is determined that a claimant is or is not disabled at any point in the evaluation process, further review is not necessary. Mullis v. Bowen, 861 F.2d 991, 993 (6th Cir. 1988).
Plaintiff's claim failed at the fourth step of the evaluation. At the first step, the ALJ found that plaintiff had not engaged in substantial gainful activity since the alleged onset date of November 15, 2013, and met the insured status requirements of the Social Security Act through September 30, 2018. PageID.48.
At the second step, the ALJ found that plaintiff had severe impairments of: status post-surgery to remove thyroid gland; status post abdominal surgery for lysis adhesions; fatigue syndrome; attention deficit hyperactivity disorder (ADHD); and anxiety ("rule out" a personality disorder). PageID.48. At the third step, the ALJ found that plaintiff did not have an impairment or combination of impairments that met or equaled the requirements of the Listing of Impairments in 20 C.F.R. Pt. 404, Subpt. P, App. 1. PageID.49.
The ALJ decided at the fourth step that, "[a]fter careful consideration of the entire record, the undersigned finds that the claimant has the residual functional capacity to perform light work as defined in 20 CFR 404.1567(b) limited to simple work with one to two steps with occasional public contact and may not perform fast paced work." PageID.50.
The ALJ also found that plaintiff is capable of performing her past relevant work as a housekeeper, work which does not require the performance of work-related activities precluded by plaintiff's residual functional capacity (RFC). PageID.54.
However, the ALJ continued to the fifth step, stating that in the alternative, plaintiff could perform a significant number of unskilled jobs at the light exertional level in the national economy. PageID.54-55. Specifically, the ALJ found that plaintiff could perform unskilled, light work in the national economy such as mail sorter (while the ALJ identified ",000" jobs, the vocational expert testified that 18,000 such jobs existed), office helper (35,000 jobs), and information clerk (28,000 jobs). PageID.42, 55-56. Accordingly, the ALJ determined that plaintiff has not been under a disability, as defined in the Social Security Act, from November 15, 2013 (the alleged onset date) through April 14, 2016 (the date of the decision). PageID.55-56.
Plaintiff set forth four issues (with sub-issues):
Plaintiff contends that the ALJ erred by failing to find that her bipolar disorder, depression, obsessive compulsive behavior, and headaches were severe impairments. A "severe impairment" is defined as an impairment or combination of impairments "which significantly limits your physical or mental ability to do basic work activities." 20 C.F.R. § 404.1520(c). Upon determining that a claimant has one severe impairment the ALJ must continue with the remaining steps in the disability evaluation. See Maziarz v. Secretary of Health & Human Services, 837 F.2d 240, 244 (6th Cir. 1987). Once the ALJ determines that a claimant suffers from a severe impairment, the fact that the ALJ failed to classify a separate condition as a severe impairment does not constitute reversible error. Maziarz, 837 F.2d at 244. However, an ALJ should consider such non-severe conditions in determining the claimant's residual functional capacity. Id. See Hedges v. Commissioner of Social Security, 725 Fed. Appx. 394, 395 (6th Cir. 2018) ("[O]nce an ALJ finds that a claimant has at least one severe impairment at step two of the disability analysis, the ALJ must then `consider the limiting effects of all [the claimant's] impairment(s), even those that are not severe' in evaluating the claimant's ability to work in step four. 20 C.F.R. § 404.1545(e)[.]"). "The fact that some of [the claimant's] impairments were not deemed to be severe at step two is therefore legally irrelevant." Anthony v. Astrue, 266 Fed. Appx. 451, 457 (6th Cir. 2008).
As discussed, the ALJ found that plaintiff had severe impairments of status postsurgery to remove thyroid gland, status post abdominal surgery for lysis adhesions, fatigue syndrome, ADHD, and anxiety. PageID.48. In rejecting plaintiff's claims regarding her other conditions, the ALJ stated as follows:
PageID.48-49.
Based on this record, it appears that the ALJ considered plaintiff's non-severe impairments of headaches and obsessive compulsive disorder (OCD). As discussed, infra, the ALJ considered plaintiff's OCD when he explicitly reviewed the listing for that condition. The ALJ, however, did not address plaintiff's diagnosis of bipolar disorder, despite the fact that plaintiff identified bipolar disorder on her disability report and was diagnosed with this condition as early as May 9, 2012. See PageID.250, 295. In this regard, Exhibit 3F is identified in part as "Progress Notes Bipolar Type II (stable) . . .", see PageID.294, and Dr. Mohammad specifically addressed this diagnosis in his opinion stating "[t]he diagnoses we have [for plaintiff] are Bi-Polar Disorder II, Attention Deficit Disorder and Obsessive Compulsive Disorder," see PageID.470.
It is unclear from the record why the ALJ failed to address the bipolar disorder. As discussed, when an ALJ finds one or more conditions to be severe impairments at step two, the failure to identify another condition as a severe impairment is legally irrelevant, because the ALJ is required to consider the limiting effects of all impairments, "even those that are not severe", in crafting the RFC. Thus, the ALJ's failure to identify the bipolar disorder as a severe impairment is not, in and of itself, an error requiring reversal. However, in this case, the Court concludes that the ALJ erred by failing to consider the effects of this non-severe impairment in crafting the RFC. When the ALJ proceeded to step three, he evaluated plaintiff's condition under Listings 12.06 ("Anxiety and obsessive-compulsive disorders") and 12.08 ("Personality and impulse-control disorders"). PageID.49-50. However, even though plaintiff was diagnosed and treated for bipolar disorder, the ALJ does not explain why he did not address this condition under Listing 12.04 ("Depressive, bipolar and related disorders").
Because the ALJ failed to address the bipolar disorder, it is not clear from the record whether he considered the effects of this non-severe impairment in crafting the RFC. See, e.g., Pruitt v. Commissioner of Social Security, No. 14-CV-11230, 2015 WL 5730023 at *5 (E.D. Mich. Aug. 24, 2015), R&R adopted, 2015 WL 5697633 (E.D. Mich. Sept. 29, 2015) (where the ALJ found that the plaintiff had non-severe impairments including HIV, but made no reference to the listings relevant to HIV or the other non-severe impairments in the step-three analysis, the court remanded the case, noting that "[w]ithout an adequate discussion from the ALJ, it is not clear whether she considered Plaintiff's HIV at step three of the sequential evaluation process."). Similarly, it is not clear to the Court in this case as to whether the ALJ considered the bipolar disorder.
The Commissioner must provide a statement of evidence and reasons on which the decision is based. See 42 U.S.C. § 405(b)(1). While it is unnecessary for the ALJ to address every piece of medical evidence, see Heston, 245 F.3d at 534-35, an ALJ "must articulate, at some minimum level, his analysis of the evidence to allow the appellate court to trace the path of his reasoning." Diaz v. Chater, 55 F.3d 300, 307 (7th Cir. 1995). "It is more than merely helpful for the ALJ to articulate reasons . . . for crediting or rejecting particular sources of evidence. It is absolutely essential for meaningful appellate review." Hurst v. Secretary of Health and Human Services, 753 F.2d 517, 519 (6th Cir. 1985) (internal quotation marks omitted). Accordingly, this matter should be reversed and remanded pursuant to sentence four of 42 U.S.C. § 405(g). On remand, the Commissioner should address the limiting effects, if any, of plaintiff's bipolar disorder and adjust her RFC accordingly.
A treating physician's medical opinions and diagnoses are entitled to great weight in evaluating plaintiff's alleged disability. Buxton v. Halter, 246 F.3d 762, 773 (6th Cir. 2001). "In general, the opinions of treating physicians are accorded greater weight than those of physicians who examine claimants only once." Walters v. Commissioner of Social Security, 127 F.3d 525, 529-30 (6th Cir. 1997). "The treating physician doctrine is based on the assumption that a medical professional who has dealt with a claimant and his maladies over a long period of time will have a deeper insight into the medical condition of the claimant than will a person who has examined a claimant but once, or who has only seen the claimant's medical records." Barker v. Shalala, 40 F.3d 789, 794 (6th Cir. 1994). See 20 C.F.R. §404.1527(c)(2) ("Generally, we give more weight to opinions from your treating sources, since these sources are likely to be the medical professionals most able to provide a detailed, longitudinal picture of your 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, such as consultative examinations or brief hospitalizations").
Under the regulations, a treating source's opinion on the nature and severity of a claimant's impairment must be given controlling weight if the Commissioner finds that: (1) the opinion is well-supported by medically acceptable clinical and laboratory diagnostic techniques; and (2) the opinion is not inconsistent with the other substantial evidence in the case record. See Gayheart v. Commissioner of Social Security, 710 F.3d 365, 375 (6th Cir. 2013); 20 C.F.R. § 404.1527(c)(2). Finally, the ALJ must articulate good reasons for not crediting the opinion of a treating source. See Wilson v. Commissioner of Social Security, 378 F.3d 541, 545 (6th Cir. 2004); 20 C.F.R. §404.1527(c)(2) ("[w]e will always give good reasons in our notice of determination or decision for the weight we give your treating source's opinion").
The ALJ addressed Dr. Mohammad's treatment and opinions as follows:
PageID.51-53.
Although Dr. Mohammad specifically diagnosed plaintiff with bipolar disorder, the ALJ did not address the effects of this condition in evaluating the doctor's opinions. While it is unnecessary for the ALJ to address every piece of medical evidence (which in some cases span hundreds of pages), he needs to summarize the plaintiff's medical history in sufficient detail for the Court to understand the ALJ's reasoning. See Hurst, 753 F.2d at 519; Diaz, 55 F.3d at 307. Here, the administrative record includes over 70 pages of treatment notes from Dr. Mohammad (Exhibits 1F, 3F and 5F), as well as seven pages of opinions in two medical source statements (Exhibits 7F and 8F). The ALJ's cryptic summaries of the treatment notes and opinions are not sufficiently detailed to allow the Court to trace his reasoning. Accordingly, the matter will be reversed and remanded on this basis as well. On remand, the Commissioner should re-evaluate Dr. Mohammad's treatment notes and determine whether plaintiff met the requirements of Listing 12.04.
RFC is a medical assessment of what an individual can do in a work setting in spite of functional limitations and environmental restrictions imposed by all of his medically determinable impairments. 20 C.F.R. § 404.1545. It is defined as "the maximum degree to which the individual retains the capacity for sustained performance of the physical-mental requirements of jobs." 20 C.F.R. Part 404, Subpt. P, App. 2, § 200.00(c). The thrust of this alleged error is that the RFC is flawed because the ALJ's determination that Dr. Mohammad's opinions were not consistent with his treatment records was "practically void of any basis." Plaintiff's Brief (ECF No. 10, PageID.528). As discussed in § B, supra, this matter is being reversed and remanded because the Court could not follow the ALJ's reasoning, due in part to the ALJ's cryptic summaries of the doctor's treatment notes and opinions. Plaintiff's claim of error will be addressed on remand, when the Commissioner re-evaluates Dr. Mohammad's opinions, addresses the limitations of her bipolar disorder, and adjusts her RFC accordingly.
The ALJ acknowledged that plaintiff had some limitations in concentration, persistence and pace, by restricting her RFC "to simple work with one to two steps with occasional public contact and may not perform fast paced work." PageID.50. Plaintiff contends that the ALJ's determination was flawed because he failed to consider the effects of her non-severe impairments including bipolar disorder. Plaintiff's claims of error will be addressed on remand, when the Commissioner re-evaluates Dr. Mohammad's opinions, addresses the limitations of her bipolar disorder, and adjusts her RFC accordingly.
Plaintiff's brief did not address this argument. Accordingly, this claim of error will be denied.
For these reasons, the Commissioner's decision will be
