JOLIE A. RUSSO, Magistrate Judge.
Plaintiff Lisa L. brings this action for judicial review of the final decision of the Commissioner of Social Security ("Commissioner") denying her applications for Title II Disability Insurance Benefits and Title XVI Social Security Income. All parties have consented to allow a Magistrate Judge enter final orders and judgment in this case in accordance with Fed. R. Civ. P. 73 and 28 U.S.C. § 636(c). For the reasons set forth below, the Commissioner's decision is reversed and this case is remanded for further proceedings.
Born in 1962, plaintiff alleges disability beginning February 7, 2010, due to anxiety, depression, fibromyalgia, migraines, and irritable bowel syndrome. Tr. 187, 199, 219. On May 16, 2014, the Administrative Law Judge ("ALJ") issued a decision finding plaintiff not disabled. Plaintiff timely appealed that decision to this Court on December 10, 2015. Tr. 881. On January 19, 2017, this Court affirmed the ALJ's decision as to all issues except for the medical opinion of Neal Musselman, D.O. Tr. 884-910. Based on this error, the Court reversed the ALJ's 2014 decision and remanded for further proceedings. Tr. 883.
On September 22, 2017, the ALJ held a second hearing, wherein plaintiff was represented by counsel and testified, as did a vocational expert. Tr. 805-36. On November 7, 2017, the ALJ issued a partially favorable decision, finding plaintiff disabled as of August 17, 2017, her 55th birthday. Tr. 776-94. After the Appeals Council denied her request for review, plaintiff filed a complaint in this Court. Tr. 911-15.
At step one of the five step sequential evaluation process, the ALJ found that plaintiff had not engaged in substantial gainful activity since the alleged onset date. Tr. 779. At step two, the ALJ determined plaintiff's fibromyalgia, migraines, aneurysm, anxiety disorder, and personality disorder were medically determinable and severe as of the alleged onset date.
Because she did not establish presumptive disability at step three, the ALJ continued to evaluate how plaintiff's impairments affected her ability to work. The ALJ resolved that, as of the alleged onset date, plaintiff had the residual functional capacity ("RFC") to perform light work as defined in 20 C.F.R. § 404.1567(b) and 20 C.F.R. § 416.967(b) except:
Tr. 782. Beginning on the date last insured, the ALJ also found that plaintiff can "frequently reach overhead bilaterally."
At step four, the ALJ determined plaintiff could not perform any past relevant work. Tr. 792. At step five, the ALJ concluded that, prior to her 55th birthday, plaintiff was capable of performing other work existing in significant numbers in the national economy despite her impairments, such as office helper, mail room sorter, and silver wrapper. Tr. 793. However, beginning on August 17, 2017, the date plaintiff's age category changed, the ALJ found her disabled. Tr. 793-94.
This case hinges on whether there is sufficient evidence in the record to establish an earlier disability onset date. Specifically, plaintiff argues the ALJ erred by: (1) discrediting her subjective symptom statements; (2) failing to address the lay testimony of her son, Robert F.; and (3) rejecting the medical opinions of physician assistant Daniela Schlechter-Keenan, social worker Leslie Ann Gellert, counselor Sharon Cabana, and Dr. Musselman.
Plaintiff asserts the ALJ erred by discrediting her subjective pain testimony regarding the extent of her impairments. Pl.'s Opening Br. 12-14 (doc. 16). When a claimant has medically documented impairments that could reasonably be expected to produce some degree of the symptoms complained of, and the record contains no affirmative evidence of malingering, "the ALJ can reject the claimant's testimony about the severity of . . . symptoms only by offering specific, clear and convincing reasons for doing so."
Thus, in formulating the RFC, the ALJ is not tasked with "examining an individual's character" or propensity for truthfulness, and instead should assess whether the claimant's subjective symptom statements are consistent with the record as a whole. SSR 16-3p,
This Court previously considered and affirmed the ALJ's rejection of plaintiff's testimony. Tr. 28-34, 906-08. On remand, the ALJ relied on many of the same legally valid reasons: both the 2014 and 2017 ALJ decisions cited to plaintiff's activities of daily living, failure to seek treatment or follow her providers' recommendations, and ability to work for many years with the same allegedly disabling impairments, as well as the lack of corroborating medical evidence.
Significantly, plaintiff does not refer to any new evidence concerning "worsening in symptoms" or of "disabling impairment outside the home." Pl.'s Opening Br. 12-14 (doc. 16). Rather, her citations largely pertain to prior statements that were considered pursuant to the ALJ's 2014 decision and affirmed by this Court in January 2017.
Finally, contrary to plaintiff's assertion, the enactment of SSR 16-3p does not constitute a change in controlling law. Pl.'s Reply Br. 2-3 (doc. 19). Indeed, the Ninth Circuit expressly held that SSR 16-3p is a rule clarification as opposed to rule change.
Regardless, the ALJ's 2017 evaluation of plaintiff's subjective symptom statements is not erroneous. As discussed herein, the ALJ provided clear and convincing reasons, supported by substantial evidence, for discrediting plaintiff's testimony. The ALJ's decision is affirmed in this regard.
Plaintiff argues the ALJ neglected to provide a legally sufficient reason, supported by substantial evidence, to reject the lay statements of Robert F. Pl.'s Opening Br. 14-15 (doc. 16). Lay testimony concerning a claimant's symptoms or how an impairment affects the ability to work is competent evidence that an ALJ must take into account.
Robert F. completed a Third-Party Adult Function Report in December 2011. Tr. 246-53. He indicated plaintiff spends her days studying Kabbalah, doing limited chores, taking care of her cat and dog, and napping. Tr. 246-49. Robert F. further stated that plaintiff leaves the house every few days and "most of the time" has no problem doing so alone. Tr. 249. In terms of hobbies and social activities, Robert F. observed plaintiff reads, knits, takes internet classes, spends time with family, and occasionally "write[s] someone on facebook." Tr. 250. As for functional abilities, he explained that plaintiff's pain, fatigue, and depression limit her ability to lift, stand, complete tasks, and handle stress. Tr. 251-53.
The ALJ neglected to weigh or otherwise discuss Robert F.'s lay statements. Tr. 776-94. Yet the Court finds, to the extent the ALJ implicitly rejected Robert F's report, such an error was harmless.
Notably, the ALJ afforded "some weight" to the analogous third-party statements from plaintiff's partner, James J., completed in November 2012 and August 2017, and plaintiff does not now challenge that finding on appeal. Tr. 262-69, 789-90, 1014-15; Pl.'s Opening Br. 14-15 (doc. 16). As addressed in section I, the ALJ also provided clear and convincing reasons, supported by substantial evidence, to reject plaintiff's subjective symptom statements. Tr. 228-35, 782-92. The reasons and evidence cited by the ALJ in evaluating plaintiff's and James J.'s testimony is equally applicable to Robert F.'s lay statements.
Plaintiff contends the ALJ improperly discounted the opinions of Dr. Musselman, Ms. Schlechter-Keenan, Ms. Gellert, and Ms. Cabana. Pl.'s Opening Br. 5-12 (doc. 16).
At the time of the ALJ's decision, there were three types of acceptable medical opinions in Social Security cases: those from treating, examining, and non-examining doctors.
Plaintiff established care at the Carlsbad Mental Health Center in February 2009 and received intermittent counseling services until October 2010, when she ceased treatment. Tr. 431-96. On November 30, 2011, plaintiff returned to Carlsbad Mental Health Center because she was experiencing several situational stressors that were exacerbating her anxiety; she initially saw a different provider but commenced care with Dr. Musselman on December 15, 2011. Tr. 496-529.
On January 9, 2012, Dr. Musselman completed a "Provider's Statement/Medical Release" form related to plaintiff's eligibility for cash assistance from the New Mexico Department of Human Services. Tr. 227. Dr. Musselman listed plaintiff's diagnosis as post-traumatic stress disorder ("PTSD") and indicated that she became unable to work "6 months ago."
The ALJ assigned "little weight" to Dr. Musselman's opinion for four reasons. Tr. 786-87. First, the ALJ found plaintiff's "credibility had been questioned in the past when she had sought medical help or called the fire department." Tr. 786. Second, the ALJ determined Dr. Musselman's opinion was inconsistent "with the findings of Dr. Starbird, to whom [plaintiff] did not complain of PTSD symptoms or significant mood problems," and plaintiff's "robust activities of daily living." Tr. 786-87. Third, the ALJ considered "the longstanding nature of [plaintiff's mental health] complaints and the fact that [they] were not work preclusive in the past." Tr. 787. Finally, the ALJ denoted Dr. Musselman's assessment did "not square with his own treatment notes."
An ALJ may disregard "the opinion of any physician, including a treating physician, if that opinion is brief, conclusory, and inadequately supported by clinical findings."
Here, substantial evidence supports the ALJ's conclusion. Dr. Musselman treated plaintiff twice before rendering his disability opinion. Tr. 520-30. During Dr. Musselman's initial evaluation, he reiterated the previous provider's recounting of symptoms and diagnoses of depression, PTSD, anxiety, and cannabis abuse, but noted that plaintiff was "vague in terms of complaints" and "did not present with acute disturbances of mood, thought or behavior consistent with an exacerbation of the above disorders." Tr. 521. He also noted plaintiff "appeared to be stoned"; when confronted with this observation, plaintiff "laughed and stated `that's funny.'"
During their follow-up session on January 6, 2012, three days before Dr. Musselman authored his disability opinion, plaintiff "present[ed] with a relatively stable mental status and without acute disturbances of mood, thought or behavior." Tr. 530. While plaintiff reported "stuggl[ing] to maintain adequate self-worth," her "[s]leep and appetite [were stable and] her general functioning appears adequate."
After generating his disability opinion, Dr. Musselman continued to treat plaintiff for approximately seven months and chart her persistent symptoms. Tr. 531-37. He nonetheless generally described plaintiff's mental status as "relatively stable" and "without acute disturbances of mood, thought or behavior."
Further, Dr. Musselman did not recommend medication until April 2012 — more than three months after he provided his disability opinion — when plaintiff reported an "increased level of generalized anxiety." Tr. 534. The following session, in June 2012, plaintiff "appear[ed] better focused and less distracted." Tr. 535. In addition to starting medication, plaintiff had relocated from Carlsbad to Santa Fe, New Mexico, to relieve stress associated with living in close proximity to her parents and sister.
Two months later, in August 2012, plaintiff presented for her for final appointment. Tr. 537. She informed Dr. Musselman that she was again relocating — this time to Portland, Oregon — to pursue "a romantic relationship with an old friend."
Therefore, as the ALJ resolved, Dr. Musselman's chart notes contravene his disability opinion. This is especially true given the timing of Dr. Musselman's medical source statement; plaintiff had only recently resumed mental health treatment at Carlsbad Mental Health Center as of January 2012 and there were concerns surrounding her sobriety and compliance with treatment. Moreover, while plaintiff was experiencing certain stressors and mental health symptoms, there was nothing in the record as of January 2012 to support the attested level of severity. Indeed, as discussed in section I, plaintiff engaged in a relatively wide-slate of daily activities during the adjudication period, some of which are outlined in Dr. Musselman's chart notes.
In sum, the ALJ proffered legally sufficient reasons, supported by substantial evidence, for affording less weight to Dr. Musselman's opinion. Any purported error in relation to the additional rationales furnished by the ALJ is harmless.
While only "acceptable medical sources" can diagnose and establish that a medical impairment exists, evidence from "other sources" can be used to determine the severity of that impairment and how it affects the claimant's ability to work. 20 C.F.R. § 404.1527(f). At the time of the ALJ's decision, nonacceptable medical sources included physician's assistants, counselors, and nurse practitioners. 20 C.F.R. §§ 404.1502(a), 416.902(a); SSR 06-03p,
Plaintiff commenced a primary care relationship with Ms. Schlechter-Keenan, P.A., in October 2013. Tr. 710, 1681. In December 2013, plaintiff initiated care with Ms. Gellert (social worker) for treatment of her psychological symptoms. Tr. 702-05. Ms. Gellert provided counseling to plaintiff through February 2013, when Ms. Gellert went on maternity leave. Tr. 687, 689, 696-97, 700-02, 736. In April 2016, Ms. Cabana began providing mental health counseling to plaintiff. Tr. 1124-27. Ms. Cabana provided treatment on a weekly basis through the ALJ's second hearing. Tr. 813, 1125-1226, 1542-75, 1703.
In July 2017, Ms. Schlechter-Keenan filled out a form regarding plaintiff's physical and mental limitations. Tr. 1681-83-05. In terms of physical abilities, Ms. Schlechter-Keenan opined plaintiff could: occasionally lift/carry two to five pounds, frequently lift/carry zero pounds, stand/walk or sit for 30 minutes at one time and for a total of three hours in an eight-hour workday, never climb or balance, and occasionally stoop/bend, kneel, crouch, crawl, reach, handle, and finger. Tr. 1681-82. In terms of mental abilities, Ms. Schlechter-Keenan checked boxes indicting plaintiff was markedly limited in the categories of: concentration, persistence, or pace; ability to interact with others; ability to understand, remember, or apply information; and ability to adapt or manage oneself. Tr. 1682-83. Furthermore, Ms. Schlechter-Keenan indicated plaintiff was likely to miss two full work days or more per month and would struggle with attention and concentration twenty percent of the time. Tr. 1683.
In August 2017, Ms. Gellert and Ms. Cabana completed forms at the request of plaintiff's attorney.
Concerning Ms. Cabana, plaintiff's attorney asked whether plaintiff was likely "to miss 16 hours or more a month from even a simple sedentary job because of her symptoms." Tr. 1703. Ms. Cabana responded in the affirmative and further indicated that plaintiff would experience daily attention and concentration problems.
Although the ALJ analyzed the opinions of Ms. Schlechter-Keenan, Ms. Gellert, Ms. Cabana separately, he largely relied on the same reasons and evidence in affording them "little weight." Tr. 787-88. Namely, the ALJ determined these opinions "did not accord with the overall medical evidence record, including an absence of psychiatric hospitalizations or inpatient treatment, generally unremarkable mental status examinations, with no notations of memory issues and [plaintiff's] testimony of symptom amelioration from continued therapy."
To the extent Ms. Gellert opined as to plaintiff's physical impairments, the ALJ rejected that portion of her report as "clearly outside of her area of expertise." Tr. 787. Finally, the ALJ found Ms. Schlechter-Keenan's "assessment of [plaintiff's] issues with headaches does not comport with the absence of emergency room visits for headache exacerbations and [plaintiff's] testimony that Imitrex works to manage her headaches although it may take a period of time to `kick in.'"
An ALJ may reject a lay opinion that is inconsistent with the medical record.
The ALJ's rejection of Ms. Gellert's and Cabana's opinions, as well as Ms. Schlechter-Keenan's mental limitations, is supported by substantial evidence. These providers' underlying chart notes are not compatible with the assessed degree of impairment. Tr. 655-711, 1124-1226, 1542-75. Ms. Gellert's and Ms. Schlechter-Keenan's notes, in particular, demonstrate intact mood, behavior, mood, affect, orientation, judgment, insight, memory, attention, concentration, and thought content. Tr. 655-711. Moreover, as addressed in other portions of this opinion, plaintiff's daily activities reflect mental capabilities beyond those evaluated by Ms. Cabana, Ms. Gellert, and Ms. Schlechter-Keenan. Critically, in contrast to these providers' delineated severe psychological limitations, plaintiff graduated from a group sailing class; conducted online research regarding boats, property, and breeding cats (because she was considering taking this on as an incomebearing hobby); and traveled independently out-of-state to attend family events.
Although the ALJ provided legally sufficient reasons, supported by substantial evidence, for discrediting the mental limitations in Ms. Schlechter-Keenan's report, he wholly failed to weigh the assessed physical limitations. In fact, the only physical impairment mentioned in relation to Ms. Schlechter-Keenan's opinion is plaintiff's headaches. Tr. 788. However, as both the ALJ and Ms. Schlechter-Keenan acknowledged, plaintiff has been diagnosed with fibromyalgia, which is known for causing "chronic pain throughout the body . . . and fatigue."
Given that the RFC is drastically different from Ms. Schlechter-Keenan's physical report, the ALJ's omission was not harmless.
The decision whether to remand for further proceedings or for the immediate payment of benefits lies within the discretion of the court.
As addressed herein, the ALJ committed harmful legal error by discrediting the physical restrictions assessed by Ms. Schlechter-Keenan. The record is nonetheless ambiguous regarding the extent of plaintiff's limitations. On the one hand, Ms. Schlechter-Keenan opined that plaintiff was seriously physically impaired, limiting her to a less than sedentary RFC. Tr. 1681-82. On the other hand, there is little in the record prior to the date last insured to support the degree of limitation attested to by Ms. Schlechter-Keenan. Plaintiff's self-reports, as well as her daily activities, reflect a wider range of physical abilities.
In light of these ambiguities in the record, the Court declines to credit Ms. Schlechter-Keenan's opinion as to plaintiff's physical functional capabilities and instead remands this case for further proceedings.
For the foregoing reasons, the Commissioner's decision is REVERSED and this case is REMANDED for further proceedings.
IT IS SO ORDERED.