REPORT AND RECOMMENDATION
PAIGE J. GOSSETT, Magistrate Judge.
This social security matter is before the court for a Report and Recommendation pursuant to Local Civil Rule 83.VII.02 (D.S.C.). The plaintiff, Thomas Bryan O'Rourke, brought this action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3) to obtain judicial review of a final decision of the defendant, Acting Commissioner of Social Security ("Commissioner"), denying his claims for Disability Insurance Benefits ("DIB"). Having carefully considered the parties' submissions and the applicable law, the court concludes that the Commissioner's decision should be remanded for further consideration as explained below.
SOCIAL SECURITY DISABILITY GENERALLY
Under 42 U.S.C. § 423(d)(1)(A) and (d)(5), as well as pursuant to the regulations formulated by the Commissioner, the plaintiff has the burden of proving disability, which is defined as an "inability to do 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." 20 C.F.R. § 404.1505(a); see also Blalock v. Richardson, 483 F.2d 773 (4th Cir. 1973). The regulations require the Administrative Law Judge ("ALJ") to consider, in sequence:
(1) whether the claimant is engaged in substantial gainful activity;
(2) whether the claimant has a "severe" impairment;
(3) whether the claimant has an impairment that meets or equals the requirements of an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1 ("the Listings"), and is thus presumptively disabled;
(4) whether the claimant can perform his past relevant work; and
(5) whether the claimant's impairments prevent him from doing any other kind of work. 20 C.F.R. § 404.1520(a)(4).2 If the ALJ can make a determination that a claimant is or is not disabled at any point in this process, review does not proceed to the next step. Id.
Under this analysis, a claimant has the initial burden of showing that he is unable to return to his past relevant work because of his impairments. Once the claimant establishes a prima facie case of disability, the burden shifts to the Commissioner. To satisfy this burden, the Commissioner must establish that the claimant has the residual functional capacity, considering the claimant's age, education, work experience, and impairments, to perform alternative jobs that exist in the national economy. 42 U.S.C. § 423(d)(2)(A); see also McLain v. Schweiker, 715 F.2d 866, 868-69 (4th Cir. 1983); Hall v. Harris, 658 F.2d 260, 264-65 (4th Cir. 1981); Wilson v. Califano, 617 F.2d 1050, 1053 (4th Cir. 1980). The Commissioner may carry this burden by obtaining testimony from a vocational expert. Grant v. Schweiker, 699 F.2d 189, 192 (4th Cir. 1983).
ADMINISTRATIVE PROCEEDINGS
In September 2012, O'Rourke applied for DIB, alleging disability beginning March 1, 2012. O'Rourke's application was denied initially and upon reconsideration, and he requested a hearing before an ALJ. A hearing was held on January 29, 2015, at which O'Rourke appeared and testified and was represented by Melissa L. Franklin Hill, Esquire. After hearing testimony from a vocational expert, the ALJ issued a decision on March 20, 2015 finding that O'Rourke was not disabled from his alleged onset date of March 1, 2012 through the date of the decision. (Tr. 10-22.)
O'Rourke was born in 1951 and was sixty years old on his disability onset date. He has a high school education and special training as a computer programmer and has past relevant work experience as a computer programmer. (Tr. 182-83.) O'Rourke alleged disability due to vertigo. (Tr. 182.)
In applying the five-step sequential process, the ALJ found that O'Rourke had not engaged in substantial gainful activity since his alleged onset date. The ALJ also determined that O'Rourke's vertigo and obesity were severe impairments. However, the ALJ found that O'Rourke did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1 (the "Listings"). The ALJ further found that O'Rourke retained the residual functional capacity
to perform light work as that work is defined in the regulations with additional limits. In particular, he can occasionally climb ramps and stairs, balance, stoop, kneel, crouch, and crawl. He can never climb ladders, ropes, or scaffolds. He must avoid all exposure to hazardous machinery and unprotected heights. He must avoid driving or operating a motor vehicle in the dark, at night, or in low visibility as part of his job duties. He is further restricted to work that does not contain consolidated employee work areas, which the undersigned defines as more than five people in a 15-foot circumference around an individual employee's work space.
(Tr. 14.) The ALJ found that O'Rourke was capable of performing past relevant work as a computer programmer, and that this work did not require the performance of work-related activities precluded by O'Rourke's residual functional capacity. Therefore, the ALJ found that O'Rourke was not disabled from the alleged onset date of March 1, 2012 through the date of the decision.
The Appeals Council denied O'Rourke's request for review on September 7, 2016, making the decision of the ALJ the final action of the Commissioner. (Tr. 1-3.) This action followed.
STANDARD OF REVIEW
Pursuant to 42 U.S.C. § 405(g), the court may review the Commissioner's denial of benefits. However, this review is limited to considering whether the Commissioner's findings "are supported by substantial evidence and were reached through application of the correct legal standard." Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996); see also 42 U.S.C. § 405(g); Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987). Thus, the court may review only whether the Commissioner's decision is supported by substantial evidence and whether the correct law was applied. See Myers v. Califano, 611 F.2d 980, 982 (4th Cir. 1980). "Substantial evidence" means "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion; it consists of more than a mere scintilla of evidence but may be somewhat less than a preponderance." Craig, 76 F.3d at 589. In reviewing the evidence, the court may not "undertake to re-weigh conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the [Commissioner]." Id. Accordingly, even if the court disagrees with the Commissioner's decision, the court must uphold it if it is supported by substantial evidence. Blalock, 483 F.2d at 775.
ISSUES
O'Rourke raises the following issues for this judicial review:
I. The ALJ failed to properly assess medical opinion evidence.
II. The ALJ did not explain his finding regarding the Plaintiff's residual functional capacity, as required by Social Security Ruling 96-8p.
III. The ALJ failed to properly evaluate the credibility of the Plaintiff.
(Pl.'s Br., ECF No. 12.)
DISCUSSION3
O'Rourke first argues that the ALJ erred in failing to consider and weigh an opinion from Dr. Michelle M. Lyon. The law applicable to O'Rourke's application provides that regardless of the source, the Commissioner will evaluate every medical opinion received. 20 C.F.R. § 404.1527(c). Typically, the Social Security Administration accords greater weight to the opinion of treating medical sources because treating physicians are best able to provide "a detailed, longitudinal picture" of a claimant's alleged disability. See 20 C.F.R. § 404.1527(c)(2). However, "the rule does not require that the testimony be given controlling weight." Hunter v. Sullivan, 993 F.2d 31, 35 (4th Cir. 1992) (per curiam). Rather, a treating physician's opinion is evaluated and weighed "pursuant to the following non-exclusive list: (1) whether the physician has examined the applicant, (2) the treatment relationship between the physician and the applicant, (3) the supportability of the physician's opinion, (4) the consistency of the opinion with the record, and (5) whether the physician is a specialist." Johnson v. Barnhart, 434 F.3d 650, 654 (4th Cir. 2005) (citing 20 C.F.R. § 404.1527). Any other factors that may support or contradict the opinion should also be considered. 20 C.F.R. § 404.1527(c)(6). In the face of "persuasive contrary evidence," the ALJ has the discretion to accord less than controlling weight to such an opinion. Mastro v. Apfel, 270 F.3d 171, 178 (4th Cir. 2001). Further, "if a physician's opinion is not supported by clinical evidence or if it is inconsistent with other substantial evidence, it should be accorded significantly less weight." Id. (quoting Craig, 76 F.3d at 590).
Additionally, SSR 96-2p provides that a finding that
a treating source medical opinion is not well-supported by medically acceptable clinical and laboratory diagnostic techniques or is inconsistent with the other substantial evidence in the case record means only that the opinion is not entitled to "controlling weight," not that the opinion should be rejected. Treating source medical opinions are still entitled to deference and must be weighed using all of the factors provided in 20 CFR 404.1527 and 416.927. In many cases, a treating source's medical opinion will be entitled to the greatest weight and should be adopted, even if it does not meet the test for controlling weight.
SSR 96-2p, 1996 WL 374188, at *5. This Ruling also requires that an ALJ's decision "contain specific reasons for the weight given to the treating source's medical opinion, supported by the evidence in the case record, and 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." Id.
In this case, the ALJ considered a one-page form entitled "Primary Care Provider's Statement" completed by Dr. Lyon and dated March 25, 2013. This statement simply indicated that Dr. Lyon last examined O'Rourke on January 7, 2013, that O'Rourke had been under her care since October 9, 2012, and that O'Rourke was not able to work full-time as a computer programer and had not been able to since March 2012. The ALJ gave limited weight to this opinion, observing that Dr. Lyons's "analysis was in specific reference to a `check box' format and did not include specific reference to clinical findings or test results that support the opinion. Additionally, her opinion is an overly broad conclusion of disability that does not contain an analysis for the assigned limits." (Tr. 18.)
However, the record also contains a lengthy form entitled "Physical Residual Functional Capacity Questionnaire" completed by Dr. Lyons and dated February 18, 2013. (Tr. 326-30.) This opinion was not considered or otherwise mentioned by the ALJ. Although it is a form, it also contains opined limitations and lists clinical findings and objective signs. O'Rourke argues that the failure of the ALJ to evaluate this opinion requires remand, and the court is constrained to agree.
The Commissioner argues that there is no reasonable possibility that this opinion would have changed the ALJ's decision and suggests reasons for discounting this opinion. However, without any analysis or even suggestion in the ALJ's decision that this opinion was considered, the court is simply unable to determine whether the ALJ's evaluation of this evidence is supported by substantial evidence. See Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015) (noting that "remand is necessary" because the court is "left to guess [at] how the ALJ arrived at his conclusions"). In light of Dr. Lyons's opined limitations in the February 2013 opinion, the ALJ's failure to evaluate or even mention this opinion is insufficient for meaningful judicial review. This is particularly so because the February 2013 opinion does not appear to contain the issues that the ALJ identified in discounting Dr. Lyons's one-page opinion. Because it is unclear whether the ALJ considered the February 2013 opinion, the court is unable to determine whether the decision is supported by substantial evidence and is constrained to recommend that this matter be remanded for further consideration of Dr. Lyons's opinions.4
Further consideration of this evidence may impact O'Rourke's remaining issues. Therefore, in light of the court's recommendation that this matter be remanded for further consideration, the court need not address the plaintiff's remaining issues, as they may be rendered moot on remand. See Boone v. Barnhart, 353 F.3d 203, 211 n.19 (3d Cir. 2003) (remanding on other grounds and declining to address claimant's additional arguments).
RECOMMENDATION
Based on the foregoing, the court recommends that the Commissioner's decision be reversed pursuant to sentence four of 42 U.S.C. § 405(g) and that the case be remanded to the Commissioner for further consideration as discussed above.
The parties' attention is directed to the important notice on the next page.
Notice of Right to File Objections to Report and Recommendation
The parties are advised that they may file specific written objections to this Report and Recommendation with the District Judge. Objections must specifically identify the portions of the Report and Recommendation to which objections are made and the basis for such objections. "[I]n the absence of a timely filed objection, a district court need not conduct a de novo review, but instead must `only satisfy itself that there is no clear error on the face of the record in order to accept the recommendation.'" Diamond v. Colonial Life & Acc. Ins. Co., 416 F.3d 310 (4th Cir. 2005) (quoting Fed. R. Civ. P. 72 advisory committee's note).
Specific written objections must be filed within fourteen (14) days of the date of service of this Report and Recommendation. 28 U.S.C. § 636(b)(1); Fed. R. Civ. P. 72(b); see Fed. R. Civ. P. 6(a), (d). Filing by mail pursuant to Federal Rule of Civil Procedure 5 may be accomplished by mailing objections to:
Robin L. Blume, Clerk
United States District Court
901 Richland Street
Columbia, South Carolina 29201
Failure to timely file specific written objections to this Report and Recommendation will result in waiver of the right to appeal from a judgment of the District Court based upon such Recommendation. 28 U.S.C. § 636(b)(1); Thomas v. Arn, 474 U.S. 140 (1985); Wright v. Collins, 766 F.2d 841 (4th Cir. 1985); United States v. Schronce, 727 F.2d 91 (4th Cir. 1984).
