H. BRUCE GUYTON, Magistrate Judge.
This case is before the undersigned pursuant to 28 U.S.C. § 636(b), Rule 72(b) of the Federal Rules of Civil Procedure, and the Rules of this Court for a report and recommendation regarding disposition by the District Court of Plaintiff's Motion for Summary Judgment and Memorandum in Support [Docs. 12 & 12-1] and Defendant's Motion for Summary Judgment and Memorandum in Support [Docs. 13 & 14]. Rita K. Smith ("the Plaintiff") seeks judicial review of the decision of the Administrative Law Judge ("the ALJ"), the final decision of the Defendant Carolyn W. Colvin, Acting Commissioner of Social Security ("the Commissioner").
On May 6, 2011, the Plaintiff filed an application for disability insurance benefits ("DIB") and supplemental security income ("SSI"), claiming a period of disability which began February 15, 2010. [Tr. 135]. After her application was denied initially and upon reconsideration, the Plaintiff requested a hearing. [Tr. 60-61]. On April 25, 2013, a hearing was held before an ALJ to review determination of the Plaintiff's claim. [Tr. 28-46]. On July 30, 2013, the ALJ found that the Plaintiff was not disabled. [Tr. 15-27]. The Appeals Council denied the Plaintiff's request for review [Tr. 1-5]; thus, the decision of the ALJ became the final decision of the Commissioner.
Having exhausted her administrative remedies, Plaintiff filed a Complaint with this Court on March 12, 2015, seeking judicial review of the Commissioner's final decision under Section 205(g) of the Social Security Act. [Doc. 1]. The parties have filed competing dispositive motions, and this matter is now ripe for adjudication.
The ALJ made the following findings:
[Tr. 17-23].
This case involves an application for DIB and SSI benefits. An individual qualifies for DIB if he or she: (1) is insured for DIB; (2) has not reached the age of retirement; (3) has filed an application for DIB; and (4) is disabled. 42 U.S.C. § 423(a)(1). To qualify for SSI benefits, an individual must file an application and be an "eligible individual" as defined in the Act. 42 U.S.C. § 1382(a); 20 C.F.R. § 416.202. An individual is eligible for SSI benefits on the basis of financial need and either age, blindness, or disability.
"Disability" is 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 twelve months." 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A); 20 C.F.R. §§ 404.1505(a), 416.905(a). A claimant will only be considered disabled if:
42 U.S.C. §§ 423(d)(2)(A), 1382c(a)(3)(B);
Disability is evaluated pursuant to a five-step analysis summarized as follows:
When reviewing the Commissioner's determination of whether an individual is disabled pursuant to 42 U.S.C. § 405(g), the Court is limited to determining "whether the ALJ applied the correct legal standards and whether the findings of the ALJ are supported by substantial evidence."
It is immaterial whether the record may also possess substantial evidence to support a different conclusion from that reached by the ALJ, or whether the reviewing judge may have decided the case differently.
In addition to reviewing the ALJ's findings to determine whether they were supported by substantial evidence, the Court also reviews the ALJ's decision to determine whether it was reached through application of the correct legal standards and in accordance with the procedure mandated by the regulations and rulings promulgated by the Commissioner.
On review, the plaintiff "bears the burden of proving his entitlement to benefits."
On appeal, the Plaintiff alleges two assignments of error committed by the ALJ. First, the Plaintiff contends that the ALJ erred in her application of the treating physician rule. [Tr. 12-1 at 7]. Specifically, the Plaintiff argues that the ALJ failed to assign a specific weight to the opinion of treating physician Stephen Pershing, M.D., failed to give "good reason" for declining to give the opinion great weight, and failed to appropriately weigh the factors set forth in 20 CFR §§ 404.1527(c) and 416.927(c) for determining the degree of weight the opinion was due. [
The Commissioner responds that while the ALJ was not explicit in the weight assigned to Dr. Pershing's opinion, the ALJ's residual functional capacity ("RFC") determination makes clear that no weight was assigned to the opinion. [Doc. 14 at 13]. Moreover, the Commissioner asserts that the ALJ gave good reason for declining to endorse the opinion, namely, that the opinion was inconsistent with the Plaintiff's activities, diagnostic imagining results, examination findings, and treatment records. [
The Plaintiff filed a reply, arguing that rather than addressing the ALJ's failure to apply the 20 C.F.R. §§ 404.1527(c) and 416.927(c) factors for determining what weight Dr. Pershing's opinion was due, the Commissioner's brief focused on the Plaintiff's credibility, an issue that does not absolve the ALJ's erroneous application of the treating physician rule. [Doc. 15 at 2]. Further, the Plaintiff submits that the Commissioner's explanation in regard to the lack of specific weight assigned to Dr. Pershing's opinion amounts to post-hoc rationalization, which this Court is prohibited from considering. [
The Court will address the Plaintiff's allegations of error in turn.
Dr. Pershing treated the Plaintiff regularly from June 7, 2011 through March 20, 2013. [Tr. 204-07, 255-58, 281, 308-96]. The Plaintiff was treated for degenerative disk disease of the lumbar spine and degenerative joint disease of the knees. [Tr. 207]. The Plaintiff complained of chronic back and bilateral knee pain that had become severe over the past several years. [
On February 26, 2013, Dr. Pershing rendered two opinions: (1) a "Medical Statement Regarding Knee Problem for Social Security Disability Claim" [Tr. 384-85], and (2) a "Medical Statement Regarding Shoulder Problem for Social Security Disability Claim" [Tr. 389-90]. In regard to the Plaintiff's knees, Dr. Pershing opined that the Plaintiff had left and right knee problems, chronic pain, stiffness, swelling and tenderness, limitation of motion, instability, and an inability to ambulate effectively, including an inability to walk a block at a reasonable pace on a rough or uneven surface, walk enough to shop or bank, or climb a few steps at a reasonable pace with the use of a single handrail. [Tr. 384]. Dr. Pershing concluded that the Plaintiff suffered from severe pain that limited her to only being able to work one hour per day, sit or stand for 15 minutes at one time, bend or balance very seldom, could never stoop or climb, and could never lift any amount of weight on either an occasional or frequent basis. [Tr. 385].
In regard to the Plaintiff's shoulders, Dr. Pershing opined that while the Plaintiff could only sit for 15 minutes at one time, she could sit for a total of 60 minutes in a workday, and could occasionally lift 5 pounds, use her left and right arm below shoulder level, and raise her right arm above shoulder level but never her left arm. [Tr. 389].
In the disability determination, the ALJ discussed a July 25, 2011 treatment note, in which Dr. Pershing "notice marked improvement in her overall sense of well being." [Tr. 21, 258]. The Plaintiff was noted as sleeping better, but that her left shoulder pain continued to disrupt her sleep. [
Finally, the ALJ addressed Dr. Pershing's findings regarding the Plaintiff's knees as opined in his medical statement. [Tr. 21]. The ALJ concluded that he "does not accord this opinion great weight. The claimant herself has reported that she can ambulate effectively, and independently shop and bank." [
Under the Social Security Act and its implementing regulations, if a treating physician's opinion as to the nature and severity of an impairment is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in the case record, it must be given controlling weight. 20 C.F.R.§§ 404.1527(c)(2) and 416.927(c)(2). But where an opinion does not garner controlling weight, the appropriate weight to be given to an opinion will be determined based upon the following factors: length of treatment, frequency of examination, nature and extent of the treatment relationship, amount of relevant evidence that supports the opinion, the opinion's consistency with the record as a whole, the specialization of the source, and other factors which tend to support or contradict the opinion. 20 C.F.R.§§ 404.1527(c)(2) and 416.927(c)(2).
When an ALJ does not give a treating physician's opinion controlling weight, the ALJ must always give "good reasons" for the weight given to a treating source's opinion in the decision. 20 C.F.R. §§ 404.1527(c)(2) and 416.927(c)(2). A decision denying benefits "must contain specific reasons for the weight given to the treating source's medical opinion, supported by 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 the weight." Soc. Sec. Rul. 96-2p, 1996 WL 374188 at *5 (1996). Nonetheless, the ultimate decision of disability rests with the ALJ.
The first assignment of error the Plaintiff alleges in regard to the ALJ's application of the treating physician rule is that the ALJ failed to assign a specific weight to Dr. Pershing's opinion. Although it is clear from the ALJ's decision that Dr. Pershing's opinion was not accorded controlling weight, the Court finds that the ALJ failed to identify the level of deference the opinion was accorded. Declining to give a treating physician's controlling weight does not mean that the opinion was rejected.
In the present case, the Court agrees with the Commissioner that the ALJ's RFC determination makes clear that no weight was assigned to Dr. Pershing's opinion. This conclusion does not require any speculation on the Court's part, as suggested by the Plaintiff, because the ALJ's finding that the Plaintiff is capable of medium work is directly at odds with all of the limitations assessed by Dr. Pershing. However, the Court finds that the ALJ failed to provide good reason for rejecting Dr. Pershing's opinion, which brings the Court to the Plaintiff's second allegation of error.
First, the ALJ only addressed Dr. Pershing's medical statement relating to the Plaintiff's knees. Dr. Pershing, however, completed two medical statements, one pertaining to the Plaintiff's knees and one pertaining to the Plaintiff's shoulders. Even accepting the Commissioner's position that no weight was given to either opinion, the ALJ's decision provides zero reason, much less good reason, for rejecting the medical statement regarding the Plaintiff's shoulders. The ALJ's failure to provide an explanation for the weight assigned to this opinion is significant. The purpose of the good reason rule is to allow claimants to "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 [he] is not."
Second, the ALJ did not provide good reason for rejecting Dr. Pershing's opinion regarding the Plaintiff's knees. The ALJ states that he does not accord the opinion great weight, because the Plaintiff "has reported she can ambulate effectively, and independently shop and bank." [Tr. 21]. The ALJ, however, does not cite where in the record the Plaintiff reported having no problems walking or doing certain activities such as shopping or banking. The Commissioner cites to the Plaintiff's Function Report, statements made during a consultative examination, and her testimony during the administrative hearing, none of which provide substantial evidence for the ALJ's conclusion. The Plaintiff indicated in her Function Report and during a July 6, 2011 consultative examination that she could handle her own finances and did her own grocery shopping about once a week. [Tr. 152, 170, 210-11]. The Plaintiff elaborated during her testimony before the ALJ that when she walks or does activities, such as grocery shop, her pain increases. [Tr. 34]. She explained that she could probably walk for 10-15 minutes before having a problem. [
Not only did the ALJ fail to provide good reason for declining to assign great weight to Dr. Pershing's opinions, he also neglected the factors set forth in 20 C.F.R. §§ 404.1527(c) and 416.927(c). The ALJ's opinion is absent of consideration of the length of treatment, frequency of examination, the nature and extent of the treatment relationship, or the specialization of the source.
The Commissioner spends much of her brief arguing that substantial evidence supports the ALJ's credibility finding, focusing on the Plaintiff's reported activities, her failure to seek treatment until 15 months after her alleged onset date,
Of course, "[t]hat is not to say that a violation of the procedural requirement of § 1527[(c)](2) could never constitute harmless error."
The Court does not find that any of those exceptions apply here. Upon review of the record, the Court does not find Dr. Pershing's opinions to be patently deficient, nor does the Court find that the ALJ adopted the opinions. Finally, because the ALJ's decision does not sufficiently explain the reasons for his conclusion, the Commissioner cannot show that the ALJ has otherwise met the regulation's goal.
Accordingly, the Court finds the Plaintiff's allegation of error is well-taken. The Court will recommend that the case be remanded to the ALJ for reconsideration of Dr. Pershing's opinions.
Next, the Plaintiff contends that the ALJ erred in affording controlling weight to nonexamining state agent K. Steinhardt. [Doc. 12-1 at 14]. The Plaintiff submits that Steinhardt, who completed a form entitled "Physical Residual Functional Capacity Assessment" on November 18, 2011 [Tr. 261-268], failed to indicate her credentials as a medical professional on the assessment form, and that the Tennessee Licensure Verification list does not indicate whether Steinhardt holds a doctorate degree. [Doc. 12-1 at 14]. Plaintiff's counsel brought this fact to the ALJ's attention during the administrative hearing, objecting to the exhibit on the grounds that the qualifications of Steinhart are not notated on the assessment form. [Tr. 30-31]. The Plaintiff does not seek to have the exhibit stricken from the record, however. [Doc. 15 at 5]. Instead, the Plaintiff contends Steinhardt's lack of unidentifiable credentials makes her an "other source" rather than an "acceptable medical source" pursuant to 20 C.F.R. §§ 404.1513 and 416.1513.
[Doc. 12-1 at 14].
The Commissioner argues that Steinhardt is an "acceptable medical source" because her signature appears elsewhere in the record, notably a form entitled "Disability Determination and Transmittal" pertaining to reconsideration of the Plaintiff's application for benefits, which is signed by "Kasiel Steinhardt M.D." [Doc. 14 at 15 (citing Tr. 45-46)]. The Commissioner also points out that Steinhardt's signature on the Physical Residual Functional Capacity Assessment form indicates that she is a medical consultant. [
The Court observes that while the signature block on the Physical Residual Functional Capacity Assessment form does not indicate whether Steinhardt is a physician, the form does indicate that she is a medical consultant. [Tr. 268]. However, qualifications for medical consultants include "acceptable medical sources" as well as non-physicians who are limited to evaluating impairments for which they are qualified.
However, because the Court recommends remanding this case to the ALJ for reconsideration of Dr. Pershing's opinions, the weight assigned to Steinhardt will necessarily have to be reconsidered in light of the degree of deference the ALJ chooses to afford to Dr. Pershing.
Based upon the foregoing, it is hereby