GREG WHITE, Magistrate Judge.
Plaintiff Anthony G. Moss ("Moss") challenges the final decision of the Acting Commissioner of Social Security, Carolyn W. Colvin ("Commissioner"), denying his claim for Supplemental Security Income ("SSI") under Title XVI of the Social Security Act ("Act"), 42 U.S.C. § 1381 et seq. This matter is before the Court pursuant to 42 U.S.C. § 405(g) and the consent of the parties entered under the authority of 28 U.S.C. § 636(c)(2).
For the reasons set forth below, the final decision of the Commissioner is VACATED and the case REMANDED for further consideration consistent with this Opinion.
On September 17, 2010, Moss filed an application for SSI alleging a disability onset date of June 16, 1995 and claiming he was disabled due to chronic back pain, a pinched nerve, breathing problems, and "mechanical aorta valve."
On August 22, 2012, an Administrative Law Judge ("ALJ") held a hearing during which Moss, represented by counsel, and an impartial vocational expert ("VE") testified. (Tr. 516-547.) During the hearing, Moss amended his disability onset date to September 17, 2010. (Tr. 17.) On September 28, 2012, the ALJ found Moss was able to perform a significant number of jobs in the national economy and, therefore, was not disabled. (Tr. 17-27.) The ALJ's decision became final when the Appeals Council denied further review. (Tr. 6-8.)
Age fifty-three (53) at the time of his administrative hearing, Moss is a "person closely approaching advanced age" under social security regulations. See 20 C.F.R. § 416.963 (d). Moss has a 9
During the August 22, 2012 hearing, Moss testified to the following:
The ALJ determined Moss had no past relevant work. (Tr. 542.) She then posed the following hypothetical to the VE:
(Tr. 543.)
The VE testified such an individual could perform the jobs of packager, shipping weigher, and production inspector. (Tr. 544.) The VE clarified that "[d]espite the fact that the DOT does not recognize that positions may allow for an ability to sit or stand, these positions . . . are, indeed, performed on that basis. And that's based on my experience with job placement and labor market conditions." (Tr. 543-544.)
The ALJ asked whether the jobs identified would be available if the individual needed to use a cane for walking beyond the work station. (Tr. 544.) The VE stated that use of a cane would not affect those jobs "for any ambulation activities" but "would effect it if the assistive device was needed for the standing component of the sit/stand aspect since bilateral upper extremity involvement is needed for completion of job tasks." Id.
The ALJ also asked whether the identified jobs had any "allowance to lie down during the course of a work day." (Tr. 545.) The VE responded that they did not. Id. Finally, the ALJ asked whether the identified jobs required any reading. Id. The VE stated "[t]here would not be any reading component for completion of the functions of the position." Id.
Moss' attorney then asked the VE the following:
(Tr. 545-546.)
A disabled claimant may be entitled to receive SSI benefits. 20 C.F.R. § 416.905; Kirk v. Sec'y of Health & Human Servs., 667 F.2d 524 (6
The ALJ found Moss established medically determinable, severe impairments, due to history of valve replacement with Coumadin therapy; degenerative disc disease at L3-S1; degenerative joint disease L3-4; thoracic spine degenerative joint disease; depression and adjustment disorder with mixed anxiety/depression; however, his impairments, either singularly or in combination, did not meet or equal one listed in 20 C.F.R. Pt. 404, Subpt. P, App. 1. (Tr. 19-21.) Moss was determined to have a Residual Functional Capacity ("RFC") for a limited range of light work. (Tr. 21.) The ALJ then used the Medical Vocational Guidelines ("the grid") as a framework and VE testimony to determine that Moss was not disabled. (Tr. 25-27.)
This Court's review is limited to determining whether there is substantial evidence in the record to support the ALJ's findings of fact and whether the correct legal standards were applied. See Elam v. Comm'r of Soc. Sec., 348 F.3d 124, 125 (6
The findings of the Commissioner are not subject to reversal merely because there exists in the record substantial evidence to support a different conclusion. Buxton v. Halter, 246 F.3d 762, 772-3 (6
In addition to considering whether the Commissioner's decision was supported by substantial evidence, the Court must determine whether proper legal standards were applied. Failure of the Commissioner to apply the correct legal standards as promulgated by the regulations is grounds for reversal. See, e.g.,White v. Comm'r of Soc. Sec., 572 F.3d 272, 281 (6
Finally, a district court cannot uphold an ALJ's decision, even if there "is enough evidence in the record to support the decision, [where] the reasons given by the trier of fact do not build an accurate and logical bridge between the evidence and the result." Fleischer v. Astrue, 774 F.Supp.2d 875, 877 (N.D. Ohio 2011) (quoting Sarchet v. Chater, 78 F.3d 305, 307 (7
Moss argues the ALJ erred because the decision entirely ignores the opinion of his treating cardiologist, Fadhil Hussein, M.D., F.A.C.C. Moss asserts "[t]here is no mention of this opinion" in the decision and the ALJ "failed to provide any reason, let alone good reason, for the weight given to Dr. Hussein's opinion." (Doc. No. 15 at 11.) He maintains Dr. Hussein's opinion is important because "it is inconsistent with an ability to perform the range of light work identified by the [ALJ] and consistent with sedentary work exertionally." Id. He notes that "[a]t age 51 (amended onset date), Mr. Moss is disabled under the Medical-Vocational Guidelines `Grids,' even if he could perform sedentary work." Id. Moss also asserts that Dr. Hussein's opinion is supported by "the objective medical record documenting longstanding cardiac issues." Id.
The Commissioner argues the ALJ's failure to address Dr. Hussein's opinion constitutes harmless error.
Under Social Security regulations, the opinion of a treating physician is entitled to controlling weight if such opinion (1) "is well-supported by medically acceptable clinical and laboratory diagnostic techniques" and (2) "is not inconsistent with the other substantial evidence in [the] case record." Meece v. Barnhart, 2006 WL 2271336 at * 4 (6
If the ALJ determines a treating source opinion is not entitled to controlling weight, "the ALJ must provide `good reasons' for discounting [the opinion], reasons that are `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.'" Rogers, 486 F.3d at 242 (quoting Soc. Sec. Ruling 96-2p, 1996 SSR LEXIS 9 at * 5). The purpose of this requirement is two-fold. First, a sufficiently clear explanation "`let[s] claimants understand the disposition of their cases,' particularly where a claimant knows that his physician has deemed him disabled and therefore `might be bewildered when told by an administrative bureaucracy that she is not, unless some reason for the agency's decision is supplied.'" Id. (quoting Wilson v. Comm'r of Soc. Sec., 378 F.3d 541, 544 (6
In some circumstances, however, a violation of the "good reasons" rule may be considered "harmless error." The Sixth Circuit has found these circumstances present where (1) "a treating source's opinion is so patently deficient that the Commissioner could not possibly credit it," (2) "the Commissioner adopts the opinion of the treating source or makes findings consistent with the opinion," or (3) "the Commissioner has met the goal of § 1527(d) — the provision of the procedural safeguard of reasons — even though she has not complied with the terms of the regulation." Wilson, 378 F.3d at 547. See also Cole v. Astrue, 661 F.3d 931, 940 (6
Nevertheless, the opinion of a treating physician must be based on sufficient medical data, and upon detailed clinical and diagnostic test evidence. See Harris v. Heckler, 756 F.2d 431, 435 (6
Here, the record reflects Moss has a longstanding history of cardiac problems.
On March 28, 2008, Moss presented to Dr. Hussein for a follow-up visit.
On that same date, Dr. Hussein completed a Basic Medical Form for the Lucas County Department of Job and Family Services. (Tr. 233-234.) Therein, he described Moss' medical conditions as chronic atrial fibrillation with coumadin therapy; history of multiple valve surgeries; and, vasospasm (coronary). (Tr. 233.) He noted that Moss' first visit was in November 2005 with office visits every 3 to 6 months as needed. Id. With regard to Moss' physical functional capacity, Dr. Hussein stated Moss could lift/carry no more than 6 to 10 lbs. (Tr. 234.) He also noted that Moss' standing and walking capabilities were affected, but did not offer an opinion as to how many hours Moss could stand/walk during a normal eight hour work day. Id. Dr. Hussein noted no significant limitations in Moss' abilities to push/pull, bend, reach, handle, or engage in repetitive foot movements. Id. Finally, Dr. Hussein determined that Moss' physical limitations were permanent in nature. Id.
On November 5, 2009, Moss presented to the Flower Hospital Emergency Center with complaints of sudden onset chest pain and shortness of breath. (Tr. 470-481.) He was placed on a cardiac monitor, which showed normal sinus rhythm. (Tr. 471.) An EKG was performed, which was normal. (Tr. 473.) The emergency room physicians consulted with Dr. Hussein, who determined based on the normal EKG findings that Moss did not need further treatment or admission. (Tr. 476.) He indicated Moss should take his cardiac medication as prescribed and follow-up with Dr. Hussein on an outpatient basis. Id.
The next treatment note in the medical record from Dr. Hussein is dated March 18, 2010. (Tr. 328.) On examination, Dr. Hussein found regular heart rate and rhythm, but noted "loud secondary heart sound, loud mechanical valve sound, and aortic flow murmur." Id. Dr. Hussein concluded Moss was "hemodynamically stable with no evidence of fluid overload," but observed that "[u]nfortunately, he has mild to moderate [aortic stenosis] and mild MR as documented on the most recent echocardiogram." Id. He continued Moss on his current medications (Cardizem, Coumadin, Flexeril, and Percocet) and ordered a follow-up visit in one year. Id.
On October 13, 2010, Moss underwent an echocardiogram which showed (1) normal left ventricular size and wall thickness with low normal left ventricular function; (2) moderately dilated left atrium and moderately dilated right atrium; (3) mildly dilated right ventricle with mild right ventricular dysfunction; (4) aortic valve replacement with trace aortic insufficiency and moderate to severe aortic valve stenosis; (5) thickened mitral valve with mild MR: and, (6) mild to moderate tricuspid regurgitation. (Tr. 259.)
Moss followed-up with Dr. Hussein on October 21, 2010, reporting chest heaviness and palpitations. (Tr. 323.) On examination, Dr. Hussein noted regular rate and rhythm, a "crisp valve sound," and systolic ejection murmur. Id. A holter monitor electrocardiogram was performed that day, which revealed premature atrial complexes; supraventricular tachycardia, non-sustained; sinus rhythm/BBB; sinus bradycardia/BBB; and, sinus tachycardia/BBB. (Tr. 258.) Dr. Hussein concluded Moss' chest heaviness and palpitations were "probably secondary to ventricular ectopy" and ordered that a 24 hour holter monitor be performed. (Tr. 323.)
On June 8, 2011, state agency physician Leon Hughes. M.D., completed a physical residual functional capacity assessment. (Tr. 341-348.) Dr. Hughes concluded Moss could lift and carry 10 pounds frequently and 20 pounds occasionally; stand and/or walk for a total of 6 hours in an 8 hour workday; and, sit for a total of 6 hours in an 8 hour workday. (Tr. 342.) He further offered that Moss had unlimited push/pull capacity and could frequently climb ramps/stairs, stoop, kneel, and crouch. (Tr. 342-343.) However, Moss could only occasionally crawl and could never climb ladders, ropes or scaffolds due to his chronic back pain. Id. Dr. Hughes further opined that Moss must avoid all exposure to unprotected heights and machinery; and avoid concentrated exposure to extreme cold, extreme heat, humidity, and fumes, odors, gases, dusts, and poor ventilation. (Tr. 345.) Finally, Dr. Hughes noted that "[t]here is a functional capacity evaluation in file done by Job and Family Services in 2008 but this is being given no weight as this is remote." (Tr. 347.)
On April 18, 2012, Moss established care with cardiologist Syed Sohail Ali, M.D. (Tr. 493-494.) Moss' chief complaint was fatigue. (Tr. 493.) Dr. Ali noted a past medical history of aortic valve pathology; chronic back pain; osteoarthritis; and, chronic smoking. Id. He remarked that Moss had not seen a cardiologist for over a year and had failed to have his coumadin level checked "for a long time." Id. On examination, Dr. Ali noted that Moss' "[h]eart rate was regular in rate and rhythm with loud aortic valve prosthesis sound with a 3/6 systolic murmur." Id. An EKG performed that day showed ectopic atrial bradycardia with left ventricular hypertrophy and QRS widening. Id. Dr. Ali ordered blood work and a 2D transthoracic echocardiogram for evaluation of valve function. Id. He also encouraged Moss to quit smoking. (Tr. 494.)
An echocardiogram performed on April 20, 2012 showed overall preserved left ventricular systolic function; reduced left ventricular diastolic compliance; mild mitral and tricuspid regurgitation; and normally functioning St. Jude aortic valve with trace to mild insufficiency. (Tr. 496.) It also showed a left ventricular estimated ejection fraction of 55%. Id.
In the decision, the ALJ acknowledged that Moss' severe impairments included "history of valve replacement with Coumadin therapy." (Tr. 19.) After recounting the medical evidence regarding Moss' degenerative disc and joint disease, the ALJ discussed Moss' cardiac impairment as follows:
(Tr. 23.) With regard to the opinion evidence, the ALJ found that "the State Agency physician's physical assessment is generally consistent with the evidence of record" and accorded it "some weight." (Tr. 25.) There is no discussion of Dr. Hussein's March 2008 opinion or, indeed, any express mention of Dr. Hussein in the decision.
The ALJ then assessed the following RFC:
(Tr. 21.)
As noted above, the ALJ does not address Dr. Hussein's March 2008 opinion that Moss was limited to lifting/carrying no more than 6 to 10 pounds and that this limitation was permanent in nature. The Commissioner does not challenge that Dr. Hussein was Moss' treating physician at the time. Nor does the Commissioner argue that the ALJ was not required to address Dr. Hussein's opinion because it was rendered several years prior to Moss' September 2010 onset date.
Rather, the Commissioner argues the ALJ's failure to discuss Dr. Hussein's opinion constitutes harmless error under Wilson v. Comm'r of Soc. Sec., 378 F.3d 541, 547 (6
At the time he rendered his opinion, Dr. Hussein had treated Moss for his heart condition for over two years. He specifically identified Moss' medical problems (chronic atrial fibrillation, history of multiple valve surgeries and coronary vasospasm) and opined both that Moss' standing/walking capabilities were affected and that he was unable to lift/carry more than 6 to 10 pounds. (Tr. 233-234.) Dr. Hussein also expressly concluded that Moss' physical limitations were permanent in nature. Id. In a brief submitted to the ALJ prior to the hearing, Moss identified Dr. Hussein's March 2008 opinion and relied upon it in arguing that he was disabled. (Tr. 209-210.) Moreover, during the hearing (and in response to a question from Moss' attorney), the VE testified that the limitations identified by Dr. Hussein would constitute sedentary work. (Tr. 545-546.) The Commissioner does not contest that, because Moss was over fifty years old as of his amended onset date, he would be considered disabled under the Medical-Vocational Guidelines ("Grids"), even if he could perform sedentary work.
In light of the above, the Court finds the ALJ was required to address Dr. Hussein's opinion and provide "good reasons" for discounting it; i.e., "reasons that are `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.'" Rogers, 486 F.3d at 242 (quoting Soc. Sec. Ruling 96-2p, 1996 SSR LEXIS 9 at * 5). Clearly, the ALJ failed to do so. There is no mention of Dr. Hussein's March 2008 opinion anywhere in the decision and no explanation is provided regarding the ALJ's implicit rejection of Dr. Hussein's lifting/carrying restrictions. The ALJ fails to even identify Dr. Hussein as one of Moss' treating physicians, despite the fact that he appears to have regularly treated Moss from November 2005 to at least October 2010. The only indication that the ALJ was aware of Dr. Hussein's treatment of Moss for his longstanding cardiac issues is the ALJ's passing reference to the fact that "[d]uring October 2010, there were some abnormal heart findings." (Tr. 23.)
Based on the above, the Court finds the ALJ failed to provide "good reasons" for implicitly rejecting Dr. Hussein's March 2008 opinion. The only question remaining is whether the ALJ's failure to do so constitutes "harmless error." The Court finds it does not. As noted above, the Sixth Circuit has found that a violation of the "good reasons" rule may be considered "harmless error" where (1) "a treating source's opinion is so patently deficient that the Commissioner could not possibly credit it," (2) "the Commissioner adopts the opinion of the treating source or makes findings consistent with the opinion," or (3) "the Commissioner has met the goal of § 1527(d) — the provision of the procedural safeguard of reasons — even though she has not complied with the terms of the regulation." Wilson, 378 F.3d at 547.
Here, the Commissioner appears to rely on the third of these exceptions; i.e., that the ALJ met the goal of the "good reasons" requirement by "indirectly addressing" Dr. Hussein's opinion through its discussion of other evidence in the record. The Court rejects this argument. The fact that the ALJ accorded "some weight" to a state agency physician opinion that itself rejected Dr. Hussein's opinion as "remote" is wholly insufficient to excuse compliance with the "good reasons" requirement. First, the ALJ's discussion of Dr. Hughes' opinion is cursory, at best. The decision states only that Dr. Hughes' opinion is accorded "some weight" because it is "generally consistent" with the record, but fails to explain the basis for this statement. The ALJ also fails to make any express mention of the fact that Dr. Hughes rejected Dr. Hussein's 2008 opinion
Second, the Court rejects the Commissioner's apparent argument that an ALJ's failure to provide "good reasons" for rejecting a treating physician opinion may be excused where the ALJ agrees with a state agency physician who rejected that opinion. This Court has previously ruled that an ALJ cannot base his or her rejection of a treating physician's opinion upon an inconsistency with a state agency physician opinion. See, e.g., Rudish v. Colvin, 2014 WL 6879314 (N.D. Ohio Dec. 4, 2014); Brewer v. Astrue, 2011 WL 2461341 at *7 (N.D. Ohio Jun. 17, 2011) ("To do so would turn the treating physician rule on its head [as] [i]t is well established that the opinions of non-examining physicians carry little weight when they are contrary to the opinion of a treating physician."), citing Shelman v. Heckler, 821 F.2d 316, 321 (6
Gayheart v. Comm'r of Soc. Sec., 710 F.3d 365, 377 (6
Third, the Court rejects the Commissioner's argument that the ALJ's passing reference to Dr. Hussein's October 2010 treatment notes is sufficient to meet the goal of the "good reasons" requirement. The ALJ's entire discussion of Moss' longstanding, permanent cardiac issues is one short paragraph. (Tr. 23.) Although courts have, on occasion, found an ALJ's failure to provide "good reasons" to be harmless error where the ALJ thoroughly evaluates the medical evidence regarding an impairment, that is simply not the case here. The decision herein provides very little discussion of Moss' cardiac problems, despite the fact that it acknowledges his history of valve replacement with coumadin therapy as a severe impairment. (Tr. 19.)
Finally, the Court rejects the Commissioner's argument that "[p]ursuant to Drummond,
The Commissioner's brief contains virtually no discussion of the relevant medical evidence. The Commissioner also fails to discuss the previous ALJ decision or support her argument that Moss' cardiac condition had not changed since then. See McPherson v. Kelsey, 125 F.3d 989, 995-96 (6th Cir.1997) ("[I]ssues adverted to in a perfunctory manner, unaccompanied by some effort at developed argumentation, are deemed waived. It is not sufficient for a party to mention a possible argument in the most skeletal way, leaving the court to put flesh on its bones."); Meridia Prods. Liab. Litig. v. Abbott Labs., 2006 WL 1275512 (6th Cir. May 11, 2006). Moreover, the Court notes that Dr. Hussein rendered his opinion in March 2008, one month after the previous ALJ's February 26, 2008 decision.
Accordingly, the Court finds the ALJ erred in failing to address Dr. Hussein's March 2008 opinion and, further, that its failure to do so was not "harmless error." Although there may be many good reasons to reject Dr. Hussein's opinion, the ALJ is required to articulate those reasons in order to allow for meaningful appellate review. Because the ALJ failed to do so here, the Court is constrained to remand for further consideration of Dr. Hussein's opinion.
For the foregoing reasons, the Court finds the decision of the Commissioner not supported by substantial evidence. Accordingly, the decision is VACATED and the case is REMANDED, pursuant to 42 U.S.C. § 405(g) sentence four for further proceedings consistent with this opinion.
IT IS SO ORDERED.