DAN AARON POLSTER, District Judge.
Plaintiff Juliette Patterson challenges the final decision of Defendant, Acting Commissioner of Social Security, denying her application for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 416(I), 423, and 1381 et seq. The Court referred the case to Magistrate Judge Kathleen B. Burke for preparation of a Report and Recommendation ("R&R") pursuant to 42 U.S.C. § 405(g) and Local Rule 72.2(b). After reviewing the record, Magistrate Judge Burke recommends that the Commissioner's decision be affirmed. R&R 1, Doc #: 17. However, Plaintiff objects to the R&R on three separate grounds. Obj. 2-6, Doc #: 18.
The Court has reviewed the record, the briefings, the R&R, and the Plaintiff's Objections. For the reasons set forth herein, the Court adopts in part the R&R, vacates the decision of the Administrative Law Judge ("ALJ"), and remands the case to the Social Security Administration ("SSA") for further proceedings consistent with this opinion.
On January 18, 2012, Plaintiff filed an application for DIB and SSI, alleging a disability based on Crohn's disease, osteoporosis, stroke, and high blood pressure. Tr. of Proceedings 78, Doc #: 11. According to Plaintiff's claim, the onset of disability was August 5, 2010. Tr. 78. The Ohio Division of Disability Determination ("DDD") denied Plaintiff's claims initially on June 1, 2012, and upon reconsideration on October 12, 2012. Tr. 8. Thereafter, Plaintiff requested an administrative hearing before the Office of Disability Adjudication and Review. Tr. 143-44.
On November 6, 2013, a hearing was held before ALJ Penny Loucas.
Pursuant to 42 U.S.C. § 405(g), this Court's review of the ALJ's decision "is limited to determining whether it is supported by substantial evidence and was made pursuant to proper legal standards." Rogers v. Comm'r of Soc. Sec., 486 F.3d 234, 241 (6th Cir. 2007). Substantial evidence is defined as "more than a scintilla of evidence but less than a preponderance, or "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Id. (quoting Cutlip v. Sec'y of Health & Human Servs., 25 F.3d 284, 286 (6th Cir. 1994)). On judicial review, it is not necessary that this Court agree with the ALJ's finding. Id. (citing Her v. Comm'r of Soc. Sec., 203 F.3d 388, 389-90 (6th Cir. 1999)). Rather, the ALJ's finding must only be substantially supported by the record. Id.
After a thorough review of the record, Magistrate Judge Kathleen B. Burke has issued an R&R, recommending that the ALJ's decision be affirmed. Under the relevant statute, Plaintiff is entitled to object to this R&R within 14 days after being served with a copy. 28 U.S.C. § 636(b)(1). The failure to timely file written objections to a Magistrate Judge's R&R constitutes a waiver of the right to obtain a de novo review of the R&R in the district court. United States v. Walters, 638 F.2d 947, 949-50 (6th Cir. 1981). The failure to file written objections also results in a waiver of the right to appeal. Thomas v. Arn, 728 F.2d 813 (6th Cir. 1984). When objections are filed, the district court must make a "de novo determination of those portions of the report or specified proposed findings or recommendations to which objection is made." 28 U.S.C. § 636(b)(1)(C).
The relevant inquiry for this Court is whether the ALJ's decision is substantially supported by the record. Her, 203 F.3d at 389-90.
Based on Plaintiff's objections, the Court must review the record, including medical records, opinions, and testimony, de novo. 28 U.S.C. § 636(b)(1)(C).
The record reveals the following facts in relation to Plaintiff's claim that her mental impairment is severe for the purposes of 20 C.F.R. §§ 404.1520(c) and 416.920(c):
In addition, the Ohio DDD referred Plaintiff to Dr. Herschel Pickholtz, a licensed psychologist, for a consultative examination. Tr. 533. On April 14, 2012, Plaintiff saw Dr. Pickholtz, who compiled a report regarding the evaluation.
According to Dr. Pickholtz's report, Plaintiff indicated that she was unable to work due to "pain, back problems, knee and ankle problems, and Crohn's disease and Shingles." Tr. 534. She described her relationship with her boyfriend of 10 years as "okay" and reported good or close relationships with her children, parents, and siblings. Tr. 534. Plaintiff described a past relationship in which she was physically and mentally abused. Tr. 534. She also admitted to psychiatric history running in the family, stating that her son is paranoid schizophrenic. Tr. 534.
Plaintiff reported that her primary care physician diagnosed her with psychiatric conditions but explained that she did not want treatment. Tr. 535. She described one "bout of depression" and stated that she was depressed because of "financial and physical issues." Tr. 535. Dr. Pickholtz's report explains that Plaintiff showed "some psychiatric symptoms of some depression." Tr. 535. Without psychiatric treatment, Plaintiff was experiencing "mild performance issues at work" and "mild interactional issues with others." Tr. 536. However, Plaintiff was able to resume some daily duties and responsibilities. Tr. 536. She also described her ability to deal with work pressure and maintain relationships with coworkers as "average" and reported no problems at work. Tr. 536. Upon examination, Dr. Pickholtz indicated that Plaintiff's behavior was "unremarkable," stating that she "presented in a normal fashion." Tr. 537. He also noted that Plaintiff did not exhibit any symptoms of anxiety, determining that the impact of residual depression relative to her daily activities appeared to be within the moderate range. Tr. 537-38.
Moreover, Plaintiff reported to Dr. Pickholtz taking care of her hygiene, changing clothes daily, and maintaining household duties. Tr. 539. She indicated that she sweeps the floor four times per month, vacuums and mops one time per month, shops one time per month, and cooks dinner four times per week. Tr. 539. She also uses her cell phone, watches television, and plays cards on a daily basis. Tr. 539. Although she described reading magazines, Dr. Pickholtz indicated that her ability to understand and remember television and written material was mildly impaired. Tr. 539. Plaintiff also reported that she sees her boyfriend three times per week, socializes with relatives one time per week, and visits her mother two times per week. Tr. 539. She also attends religious services three times per year. Tr. 539.
Based on his observations—as well as a review of Form SSA 3367, Form SSA-5002, Progress Notes by Dr. Lane dated November 12, 2011, and Progress Notes by Dr. Fleming dated April 13, 2010—Dr. Pickholtz diagnosed Plaintiff with adjustment disorder as well as depressed mood and depressive disorder, both mild to moderate. Tr. 540. He opined that her capacity to understand, remember, and carry out instructions for unskilled labor was not seriously impaired. Tr. 540. However, Dr. Pickholtz indicated that Plaintiff was slightly impaired in her ability to perform one to three step tasks and somewhat impaired in her capacity to relate to coworkers and supervisors and handle work pressures. Tr. 541. At the conclusion of his report, Dr. Pickholtz assigned Plaintiff a Global Assessment of Functioning ("GAF") score of 58.
On May 6, 2012, state agency reviewing psychologist Dr. Robyn Hoffman reviewed Plaintiff's file. Tr. 73-75. Dr. Hoffman's review indicates that Plaintiff had moderate problems with social interactions and concentration, persistence, or pace. Tr. 73-75. Dr. Hoffman opined that Plaintiff could perform a wide range of tasks that involve no fast pace or production quotas. Tr. 73-75. Dr. Hoffman also opined that Plaintiff could superficially and infrequently interact with others. Tr. 74-75. Finally, on October 4, 2012, state agency psychologist Dr. Deryck Richardson reviewed Plaintiff's file and affirmed Dr. Hoffman's opinion. Tr. 104-05.
In addition to these medical opinions, the Court also considers the testimony at the November 2013 administrative hearing in this case. At the November 2013 hearing before ALJ Loucas, Plaintiff's testified briefly about her mental impairment and its effect on her daily life. Plaintiff testified that she has not gone to church regularly in years because she is embarrassed about using the restroom during church and worries about the smell. Tr. 43. She also stated that her depression affects her ability to work. Tr. 51. Upon questioning from her attorney, Plaintiff indicated that she has spoken to a therapist on two occasions and plans to see a psychiatrist in the future. Tr. 51.
Finally, vocational expert Mark Anderson was also present at the November 2013 hearing. The ALJ asked Mr. Anderson whether a hypothetical individual could perform Plaintiff's past work with her physical limitations but the following mental characteristics: can maintain concentration, persistence, and pace for two-hour blocks of time over a normal work week, and can adjust to routine and expected changes in the workplace. Tr. 56. Mr. Anderson stated that such an individual could perform Plaintiff's past work as a sealing machine operator, crafter, inspector, finisher, and grinder as Plaintiff performed it. Tr. 56.
The record reveals the following facts in relation to Plaintiff's physical impairments, which include Crohn's disease, osteoporosis, stroke, and high blood pressure:
In addition to the medical records, there are also several medical opinions included in the Transcript. On October 24, 2013, Dr. Lane, Plaintiff's treating physician, completed a physical medical source statement on behalf of Plaintiff. Tr. 571-79. Dr. Lane noted that, due to back pain and disc space narrowing shown in Plaintiff's lumbar x-ray, Plaintiff could occasionally lift and carry up to 10 pounds. Tr. 571. In addition, Plaintiff could do the following: occasionally push and pull, sit for eight hours in two-hour stints, stand for two hours in one-hour stints, walk for one hour, occasionally stoop, and frequently balance. Tr. 572-74. However, Dr. Lane opined that Plaintiff could never climb stairs, ramps, ladders, and scaffolds or kneel, crouch, or crawl. Tr. 572-74. Dr. Lane found that, based on intermittent tingling in Plaintiff's left foot, Plaintiff could only frequently use her left foot controls. Tr. 573. Finally, Dr. Lane opined that Plaintiff had environmental restrictions and could not operate heavy machinery or motor vehicles due to her medications' side effects. Tr. 575.
On June 1, 2012, state agency physician Dr. Michael Lehv reviewed Plaintiff's file. Tr. 71-73. Regarding Plaintiff's physical residual functional capacity ("RFC"), Dr. Lehv found that Plaintiff could: lift up to 20 pounds occasionally; lift up to 10 pounds frequently; sit, stand, and/or walk with normal breaks for about six hours of an eight-hour work day; climb ramps and stairs without limits; and push and pull without limits. Tr. 71-72. State agency physician Dr. Diane Manos reviewed Plaintiff's file on September 30, 2012, and affirmed Dr. Lehv's findings. Tr. 101-03.
Finally, there is abundant testimony from the November 2013 administrative hearing regarding Plaintiff's physical impairments. Plaintiff testified to the following:
In addition to Plaintiff's own testimony at the November 2013 administrative hearing, vocational expert Mr. Anderson testified to the following:
The ALJ considered this testimony, in addition to the medical evidence, in determining whether Plaintiff was entitled to disability benefits under the Act. Tr. 11-20.
In this case, Plaintiff timely filed written objections to the R&R. Plaintiff objects to the Magistrate Judge's affirmation of the ALJ's decision denying her DIB and SSI benefits on three separate grounds. First, Plaintiff alleges that the ALJ's decision that Plaintiff's mental health impairment was not severe is unsupported by substantial evidence and resulted in reversible error. Obj. 2. Second, Plaintiff alleges that the ALJ produced reversible error by violating the "treating physician rule" with respect to the testimony of Plaintiff's primary care physician, Dr. Mary K. Lane. Obj. 3. Finally, Plaintiff claims that the ALJ improperly determined Plaintiff's residual functional capacity by failing to account for Plaintiff's severe Crohn's disease. Obj. 5. In turn, the Commissioner argues that the ALJ reasonably assessed Plaintiff's mental functioning, the medical opinions of physical functioning, and the limitations related to Crohn's disease. Def.'s Br. on the Merits 6-17, Doc #: 15. Thus, the Commissioner argues, the ALJ's decision should be affirmed. Def.'s Br. 6-17.
Under the Social Security Act ("Act"), eligibility for benefit payments depends on the existence of a disability. 42 U.S.C. § 423(a). Disability is defined as the "inability to engage in any 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 12 months." 42 U.S.C. § 423(d)(1)(A). The Act provides that an individual shall be determined to be under a disability only if her "physical or mental impairment or impairments are of such severity that [she] is not only unable to do [her] previous work but cannot, considering [her] age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy." 42 U.S.C. § 423(d)(2)(A).
An ALJ must follow a five-step sequential analysis set out in agency regulations in order to determine whether an individual is disabled under the Act. The five steps can be summarized as follows:
R&R 12; 20 C.F.R. §§ 404.1520, 416.920; Bowen v. Yuckert, 482 U.S. 137, 140-42 (1987). The claimant has the burden of proof at Steps One through Four of this analysis, and the burden shifts to the Commissioner at Step Five. Walters v. Comm'r of Soc. Sec., 127 F.3d 525, 529 (6th Cir. 1997).
Plaintiff argues that the ALJ's decision that her mental health impairment is not "severe" was unsupported by substantial evidence and resulted in reversible error. Obj. 2. Namely, Plaintiff claims that the ALJ erred at Step Two of the disability analysis. 20 C.F.R. §§ 404.1520, 416.920; Bowen, 482 U.S. at 140-42. The Magistrate Judge recommends that the ALJ's decision be affirmed, finding no error at Step Two of the analysis. R&R 11-18. After reviewing the evidence, the Court finds that the ALJ's decision is substantially supported by the record and did not result in reversible error.
At Step Two of the disability analysis, a claimant must show that she suffers from a "severe" medically determinable physical or mental impairment. 20 C.F.R. § 404.1520(a)(4)(ii). An impairment is severe when it significantly limits a claimant's physical or mental ability to do basic work activities. 20 C.F.R. §§ 404.1520(c), 416.920(c). Basic work activities include "(1) physical functions; (2) the capacity to see, hear, and speak; (3) understanding, carrying out, and remembering simple instructions; (4) use of judgment; (5) responding appropriately to supervision, co-workers, and usual work situations; and (6) dealing with change in a routine work setting." Simpson v. Comm'r Soc. Sec., 344 Fed. App'x 181, 190 (6th Cir. 2009) (quoting 20 C.F.R. §§ 404.1521(a), (b), 416.921(a), (b)) (internal quotation marks omitted). To rate the severity of an impairment, an ALJ also considers four broad, functional areas described in Section 12.00C of the Listing of Impairments, including (1) activities of daily living; (2) social functioning; (3) concentration, persistence, or pace; and (4) episodes of decompensation. Tr. 12.
The Sixth Circuit has adopted a "lenient interpretation of the severity requirement," which is in part a response to the Secretary's questionable practice of denying meritorious claims in the 1980s. Higgs v. Bowen, 880 F.2d 860, 862 (6th Cir. 1988). Therefore, an impairment can be considered not severe "only if it is a slight abnormality that minimally affects work ability regardless of age, education, and experience." Id. (citing Farris v. Sec'y of Health & Human Servs., 773 F.2d 85, 90 (6th Cir. 1985)). Nevertheless, the Court may still employ the severity requirement to "screen out claims that are `totally groundless' solely from a medical standpoint." Id. at 863. Additionally, in evaluating the severity requirement, the Sixth Circuit has noted that the mere diagnosis of a physical or mental condition says nothing about its severity. Id.
Based on the evidence and testimony, the ALJ found "no persuasive evidence" that Plaintiff experienced more than mild limitations in her activities of daily living, social functioning, and concentration, persistence, or pace. Tr. 12. The ALJ also determined that Plaintiff had no episodes of decompensation as a result of her mental impairment. Tr. 12. In finding that Plaintiff's mental impairment was not severe, the ALJ recognized that Plaintiff lives independently, frequently socializes with her boyfriend and others, watches television, reads magazines, and plays cards. Tr. 12-13. The ALJ gave "some" weight to Dr. Pickholtz's opinion. Tr. 17. She explained that she credited his opinion that Plaintiff was not significantly impaired in her ability to understand, remember, and carry out simple tasks, as this was consistent with the record as a whole. Tr. 17. However, the ALJ noted that Dr. Pickholtz's opinion was inconsistent with itself and other evidence in the record—namely, evidence that Plaintiff has no difficulty managing her daily affairs and maintaining positive relationships with others. Tr. 17. For the same reasons, the ALJ gave "little" weight to the state agency psychologists' opinions, which relied upon Dr. Pickholtz's findings. Tr. 17-18. Plaintiff claims that the ALJ erred in crediting Plaintiff's own remarks over Dr. Pickholtz's medical opinion. Pl.'s Br. 10. The Court disagrees.
First, the Court acknowledges that there is evidence in the record that might support a finding that Plaintiff's mental impairment is in fact severe. For instance, the Court recognizes that Plaintiff's primary care physician diagnosed her with depression and prescribed Prozac. Tr. 729-30. In addition, several of Plaintiff's physicians observed tearful or depressed behavior during her office visits. Tr. 328-543. During an independent evaluation, Dr. Pickholtz found sufficient evidence to support a diagnosis for adjustment disorder with depressed mood, both mild to moderate. Tr. 540. Plaintiff has also complained of being stressed and indicated on multiple occasions that she feels like her life is "falling apart." Tr. 328; Tr. 371; Tr. 279. Finally, Plaintiff's testimony at the November 2013 hearing indicates that her depression affects her ability to work. Tr. 51. Based on this evidence, the ALJ might have found that Plaintiff's mental impairment was "severe" for the purposes of 20 C.F.R. §§ 404.1520(c) and 416.920(c).
However, there is also substantial evidence indicating that Plaintiff's mental impairment is not severe. Plaintiff reported on several occasions that she was not experiencing depression, stress, or anxiety. Tr. 81 (noting that Plaintiff denied psych reasons for not being able to complete tasks and denied social problems due to her stress and worry); Tr. 543 (noting "no depression/anxiety" or prior treatment for mental illness). Although Plaintiff testified that she had spoken with a therapist twice, the ALJ correctly observes that "there are no therapy notes in the record to corroborate her testimony." Tr. 12.
Furthermore, the ALJ correctly observes that portions of Dr. Pickholtz's opinion are inconsistent with itself and the record and accordingly afforded it little weight. Tr. 17. During his evaluation, Dr. Pickholtz opined that Plaintiff's "affect appeared to be normal," her "mood appeared to be appropriate," and she was not experiencing "any levels of anxiety." Tr. 537-38. Plaintiff also reported no problems at work that related to her mental impairment. Tr. 536. In fact, Plaintiff suggested that she maintained good relationships with her co-workers. Tr. 536. Likewise, the record suggests that the Plaintiff completes routine daily tasks with only mild limitations, most of which are physical in nature. Tr. 536-39. Nevertheless, Dr. Pickholtz determined that Plaintiff was somewhat impaired in her ability to relate to friends and relatives and handling the pressures of work. Tr. 17. It was not unreasonable for the ALJ to find that this was inconsistent with other evidence. Thus, the ALJ's decision to discredit this portion of Dr. Pickholtz's opinion was justified and substantially supported by other evidence in the record. Cf. McGrew v. Comm'r of Soc. Sec., 343 Fed. App'x 26, 30 (6th Cir. 2009) (holding that inconsistency with other evidence in the record was a "good reason" for discounting a medical opinion).
As previously discussed, this Court is limited to determining whether the ALJ's decision is supported by substantial evidence and was made pursuant to proper legal standards. Rogers, 486 F.3d at 241. The ALJ's decision to discredit certain evidence was well-reasoned and substantially supported by the record—namely, the abundant evidence that Plaintiff was not significantly limited in her ability to do basic work activities. See 20 C.F.R. § 404.1521(a). Therefore, the ALJ's finding that Plaintiff's mental impairment was not severe did not result in reversible error. The Court upholds this finding.
As discussed above, the ALJ's finding that Plaintiff's mental impairment was not severe was substantially supported by the record. However, the Court finds that the ALJ did not properly consider Plaintiff's mental impairments in assessing her RFC. This error warrants remand for further proceedings.
In Simpson, the Sixth Circuit held that an ALJ failed to incorporate the claimant's significant—but not severe—mental impairments into the calculation of her RFC. 344 Fed. App'x at 194. The facts in Simpson are strikingly similar to the case at hand, as the case involved a non-severe mental impairment and a severe physical impairment. Id. at 190. In Simpson, the ALJ found that because the claimant's mental impairment was not severe, it would not be considered in assessing her RFC. Id. The Sixth Circuit held that this was error. Id. The Circuit has previously held that it is "`legally irrelevant' that some of a claimant's impairments were considered non-severe, when others were found to be severe, because a finding of severity as to even one impairment clears the claimant of step two of the analysis and should cause the ALJ to consider both the severe and non-severe impairments in the remaining steps." Id. (quoting Anthony v. Astrue, 266 Fed. App'x 451, 457 (6th Cir. 2008)). In fact, once one severe impairment is found, "the combined effect of all impairments must be considered in assessing the RFC, even if other impairments would not be severe." White v. Comm'r of Soc. Sec., 312 Fed. App'x 779, 787 (6th Cir. 2009); accord Fisk v. Astrue, 253 Fed. App'x 580, 584 (6th Cir. 2007) (holding that ALJ properly considered all of claimant's impairments, including non-severe impairments, when determining RFC).
It is clear from the record that the ALJ considered Plaintiff's physical impairments in assessing the RFC. Tr. 15-18. It is also clear, however, that the ALJ did not consider Plaintiff's mental impairment, which she had previously found to be non-severe, in assessing the RFC. The ALJ merely discusses the weight she has afforded to Plaintiff's psychologists and her reasons for that weight—not the mental impairment and the evidence regarding it. Tr. 17-18. This stands in stark contrast to the extensive list of physical impairments that details several Exhibits and considers Plaintiff's own testimony. Tr. 16. Pursuant to Sixth Circuit case law, the ALJ must consider "the combined effect of all impairments," including those that were designated not severe. White, 312 Fed. App'x at 787. Because the ALJ failed to do so, the Court remands the case for proper consideration of Plaintiff's RFC.
Plaintiff asserts that the ALJ erred by "assigning only little weight to Dr. Lane's opinion," as Dr. Lane was entitled to controlling weight under the treating physician rule. Pl.'s Br. 13. In the alternative, Plaintiff argues that the ALJ still committed reversible error by failing to provide good reasons for discounting a treating source opinion. Pl.'s Br. 18. In response, the Commissioner argues that the ALJ explicitly considered all evidence and gave "good reasons" for her decision. Def.'s Br. 10-11. In fact, the Commissioner also argues that the ALJ was correct in finding that there is no objective evidence to corroborate Dr. Lane's opinion. Def.'s Br. 12. Thus, the Commissioner argues, the ALJ's findings should be affirmed. Def.'s Br. 17.
Pursuant to the treating physician rule, an ALJ "must give the opinion of a treating source controlling weight if [she] finds the opinion `well supported by medically acceptable clinical and laboratory diagnostic techniques' and `not inconsistent with other substantial evidence in the case record.'" Wilson v. Comm'r of Soc. Sec., 378 F.3d 541, 544 (6th Cir. 2004) (quoting 20 C.F.R. § 404.1527(c)(2)) ("Generally, we give more weight to opinions from your treating sources"). The treating physician rule is based on the rationale that treating sources are "the medical professionals most able to provide a detailed, longitudinal picture of [a claimant's] medical impairment(s) and may bring a unique perspective to the medical evidence that cannot be obtained from the objective medical findings alone." 20 C.F.R. § 404.1527(c)(2). As a result, "there remains a presumption, albeit a rebuttable one, that the opinion of a treating physician is entitled to great deference, its non-controlling status notwithstanding." Rogers, 486 F.3d at 242.
If an ALJ gives a treating source's opinion less than controlling weight, she must give "good reasons" for doing so. Wilson, 378 F.3d at 544. The ALJ's reasons for discrediting a treating source's opinion must be "sufficiently specific" to make clear to any subsequent reviewers the weight given to the opinion and the reasons for that weight. Id. The Sixth Circuit has held that it is not enough to dismiss a treating physician's opinion as inconsistent with other evidence of record. Friend v. Comm'r of Soc. Sec., 375 Fed. App'x 543, 552 (6th Cir. 2010). Rather, there must be some effort to identify the specific discrepancies and to explain "why it is the treating physician's conclusion that gets the short end of the stick." Id. In articulating the "good reasons" for discrediting a treating physician's opinion, an ALJ must consider various factors, including (1) the length, nature, and extent of the relationship; (2) specialization of the physician; (2) supportability of the opinion; and (4) the consistency of the opinion with the record as a whole. Bowen, 478 F.3d at 747; 20 C.F.R. § 416.927(c).
In the instant case, the ALJ afforded "little weight" to the Plaintiff's treating physician, Dr. Lane. Tr. 17. Dr. Lane opined that Plaintiff had the following characteristics: can lift and carry up to ten pounds occasionally; can sit for up to eight hours total in an eight-hour work day for up to two hours at a time; can walk for up to one hour total in an eight-hour work day for up to one hour at a time; can only frequently operate left foot controls or balance; can only occasionally push, pull, or stoop; can never climb ladders, ropes, scaffolds, ramps, or stairs; can never kneel, crouch, or crawl; should not work around heights, moving mechanical parts, or vibrations; should not operate a motor vehicle; cannot shop, travel without a companion, or walk at a reasonable pace on rough or uneven surfaces. Tr. 17. The ALJ identified the limitations of Dr. Lane's medical opinion, noting,
Tr. 17.
First, contrary to Plaintiff's assertions, the ALJ reasonably found that Dr. Lane's opinion is not "well supported by medically acceptable clinical and laboratory diagnostic techniques." Wilson, 378 F.3d at 544. Dr. Lane's report lists "low back pain worsened with pushing and pulling," "intermittent tingling in left foot," and "low back pain worsened by standing and walking" as the evidence supporting her opinion. Tr. 571-73. As the R&R correctly observes, "`back pain' is not objective clinical or diagnostic evidence.'" R&R 20 n.3. Nor is intermittent tingling in the left foot. The Court notes in passing that Form HA-1151-BK (06-2006) contemplates the possibility of "symptoms including pain etc." as medical or clinical findings to support an assessment. Tr. 571-73. However, beyond one x-ray finding, these symptoms are corroborated by no medical or clinical evidence. As the ALJ notes, Plaintiff never saw an orthopedic specialist, spine surgeon, or chronic pain management specialist. Tr. 17. Because there is no objective evidence corroborating Dr. Lane's findings, reports of subjective symptoms of pain are not sufficient to satisfy this prong.
Pursuant to Sixth Circuit case law, failure of this first prong alone allows the ALJ to give the treating physician's opinion less than controlling weight. Wilson, 378 F.3d at 544. Thus, the Court need not examine the second prong: whether Dr. Lane's opinion is consistent with the record as a whole. However, the Court notes that Dr. Lane's opinion does not appear inconsistent with the record. The ALJ determined that Dr. Lane's opinion was inconsistent with Plaintiff's reported activities, "which include attending regular church services outside her home, performing routine household chores, and shopping for necessities." Tr. 17. First, there is only evidence that Plaintiff is not a regular churchgoer as a result of her medical condition. Tr. 42-43; Tr. 539; Tr. 676. Second, these activities as reported appear consistent with Dr. Lane's findings: standing for up to two hours total for up to one hour at a time, walking for up to one hour total for up to one hour at a time, and lifting and carrying up to ten pounds occasionally. Tr. 17. For instance, Plaintiff has described her grocery shopping as brief and difficult, stating that she leans on a shopping cart, gets what she wants, and leaves. Tr. 46. She can no longer bring her grandchildren with her because she is unable to go up and down aisles with them. Tr. 46. Because the Court remands for other reasons, described above, and because finding that Dr. Lane's report is not based on medically acceptable clinical and laboratory diagnostic techniques sufficiently supports not giving Dr. Lane's opinion controlling weight, the Court need not rule on this inconsistency. However, on remand, the ALJ may wish to reconsider these findings as part of her broader reevaluation of the case.
Finally, the Court finds that the ALJ gave "good reasons" for affording Dr. Lane's opinion little weight. Pursuant to the factors enumerated in 20 C.F.R. § 416.927(c), the ALJ considered the specialization of the physician, supportability of the opinion, and consistency with the record as a whole. The ALJ noted that Dr. Lane was Plaintiff's primary care physician and did not specialize in orthopedics. Tr. 17. Nor did Plaintiff see an orthopedic specialist, spine surgeon, or chronic pain management specialist to corroborate Dr. Lane's findings. Tr. 17. In addition, the ALJ noted that the record contained evidence of negative straight leg raise testing, normal reflexes, normal strength, and a full range of motion in all extremities. Tr. 16. The ALJ observed that Plaintiff's treatment has been largely conservative and that she has responded well to treatment. Tr. 16. In fact, a sigmoidoscopy revealed significant improvement of her sigmoid stricture related to her Crohn's disease. Tr. 604. Additionally, diagnostic studies of Plaintiff's arm showed no radiculopathy or other neuropathy. Tr. 16.
While Plaintiff identifies other evidence in the record that may support Dr. Lane's opinion, there is, more importantly, substantial evidence that supports the ALJ's decision. See Buxton v. Halter, 246 F.3d 762, 772 (6th Cir. 2001) ("The findings of the Commissioner are not subject to reversal merely because there exists in the record substantial evidence to support a different conclusion"). The Court therefore affirms the ALJ's decision to afford "little weight" to Dr. Lane's opinion.
Although the ALJ determined that Plaintiff's Crohn's disease was a "severe" impairment, Plaintiff claims that it was not properly accounted for during the RFC assessment. Pl.'s Br. 20. However, because the Court remands for a holistic reconsideration of the RFC, the Court will not address this issue on review: it would be meaningless to address this issue until a revised Step Four analysis has been completed.
Nevertheless, the Court must address the parties' briefings regarding the opinion of gastroenterologist Dr. Maxwell, as there is a great deal of debate as to whether the ALJ properly construed his comment. In Dr. Maxwell's report dated November 5, 2013, he states, "I am not sure of the reasons for disability recommendations." Tr. 678. This comment follows an extensive discussion of Plaintiff's medical history, current condition, and attempt to obtain disability benefits. Tr. 675-78. In her December 2013 decision, the ALJ described Dr. Maxwell's comment as follows:
Tr. 18 (internal citations omitted). This is the only point at which the ALJ discussed Dr. Maxwell's report in her findings. There are two problems with this paraphrasing of Dr. Maxwell's report. First, although the ALJ indicates that she affords Dr. Maxwell's comment "no weight," it appears that the comment was in fact given some weight. Tr. 18. Dr. Maxwell's comment appears to be the sole source of gastroenterological opinion in this case, and, as Plaintiff correctly observes, the ALJ "seems to have ignored all of Dr. Maxwell's comments and recommendations beside the single sentence" referenced in her opinion. Pl.'s Br. 23. At no point in her Findings of Fact and Conclusions of Law does the ALJ consider the substantive content of Dr. Maxwell's medical opinion. Plaintiff notes that this "casts doubt on the influence the statement really had on [her] RFC and the consideration given to her Crohn's disease." Pl.'s Br. 24.
Second—and more importantly—the ALJ made a misstatement of the record as to Dr. Maxwell's comment. The ALJ puts words in Dr. Maxwell's mouth, interpreting this comment to mean that he was uncertain "as to why the claimant had received recommendations from others to apply for disability benefits." Tr. 18. As Plaintiff correctly observes, Dr. Maxwell's comment ("I am not sure of the reasons for disability recommendations") is ambiguous. Pl.'s Br. 23. There are several reasonable interpretations of this sentence, and the Court notes that the meaning the ALJ chose may not even be the most reasonable interpretation of the statement in context.
While the Court defers to the ALJ on findings of fact and medical evidence, the Court does not defer to her questionable interpretation of a grammatically ambiguous statement. While the issues associated with Dr. Maxwell's comment do not constitute reversible error, the Court notes that the interpretation of the available gastroenterological evidence must be reevaluated on remand. The Court leaves to the discretion of the ALJ whether additional evidence is necessary. See Simpson, 344 Fed. App'x at 189.
For the reasons set forth above, the Court
