BRIAN K. EPPS, Magistrate Judge.
Betty Ann Wright appeals the decision of the Acting Commissioner of Social Security denying her applications for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") under the Social Security Act. Upon consideration of the briefs, the record evidence, and the relevant statutory and case law, the Court
Plaintiff protectively applied for DIB and SSI on January 22, 2009, alleging a disability onset date December 11, 2008. Tr. ("R."), pp. 201, 581-91, 686. Plaintiff was forty-seven years old at her alleged disability onset date and was fifty-three years old when the Administrative Law Judge ("ALJ") issued the decision currently under consideration. R. 210, 581. Plaintiff applied for disability benefits based on a combination of alleged impairments, including Hepatitis C, cirrhosis of the liver, gastroesophageal issues, and depression. R. 203-04, 253-56, 661. Prior to her alleged disability, Plaintiff accrued a relevant work history that included working as a store manager at a convenience store. R. 209, 250, 264-65.
The Social Security Administration denied Plaintiff's applications initially and on reconsideration. R. 311-14. Plaintiff then requested a hearing before an ALJ, R. 372-74, and the ALJ held a hearing on October 29, 2010. R. 277-310. The ALJ issued an unfavorable decision on January 18, 2011, R. 315-29. The Appeals Council ("AC") vacated the January 18th decision and remanded the case. R. 352-56. The AC directed that a new ALJ hear the case on remand, finding an abuse of discretion by the first ALJ evidenced by "the repetitive use of pejorative and emotionally charged words and phrases" in the first administrative opinion. R. 354.
A new ALJ held two hearings, one on September 11, 2013, and one on January 28, 2014. R. 220-76. At the hearings, the ALJ heard testimony from Plaintiff, who was represented by counsel, and from Kim Bennett, a Vocational Expert ("VE").
Applying the sequential process required by 20 C.F.R. §§ 404.1520 and 416.920, the ALJ found:
R. 203-09.
Because the ALJ determined Plaintiff could perform her past relevant work, the sequential evaluation process stopped, and the ALJ concluded Plaintiff was not under a disability, as defined in the Social Security Act, from December 11, 2008, through the date of the decision, April 4, 2014. R. 210. When the AC denied Plaintiff's request for review, R. 1-7, the Commissioner's decision became "final" for the purpose of judicial review. 42 U.S.C. § 405(g). Plaintiff then filed this civil action requesting reversal or remand of the adverse decision. Plaintiff argues the Commissioner's decision is not supported by substantial evidence because (1) the postural restrictions found by the ALJ preclude Plaintiff from performing her past relevant work as she testified she actually performed it; (2) the ALJ improperly analyzed Plaintiff's mental functioning, including failing to adequately explain the weight accorded to the opinion of a state agency psychologist and to acknowledge probative global assessment of functioning ("GAF") scores in the record; and (3) the ALJ improperly evaluated Plaintiff's credibility.
Judicial review of social security cases is narrow and limited to the following questions: (1) whether the Commissioner's findings are supported by substantial evidence, and (2) whether the Commissioner applied the correct legal standards.
The Commissioner's factual findings should be affirmed if there is substantial evidence to support them.
The deference accorded the Commissioner's findings of fact does not extend to her conclusions of law, which enjoy no presumption of validity.
The case should be remanded because the ALJ failed to properly analyze Plaintiff's mental functioning, including failing to adequately explain the weight accorded to the opinion of a state agency psychologist. The administrative record regarding Plaintiff's mental functioning is, at best, confusing. The ALJ's discussion of Plaintiff's mental functioning is internally inconsistent, thereby making it impossible for the Court to determine whether the administrative decision is supported by substantial evidence.
When considering how much weight to give a medical opinion, the ALJ must consider a number of factors:
Social Security Ruling ("SSR") 96-6p provides that findings of fact made by state agency medical and psychological consultants regarding the nature and severity of an individual's impairments must be treated as expert opinion evidence of a nonexamining source at the ALJ and AC levels of administrative review. SSR 96-6p, 1996 WL 374180, at *1 (July 2, 1996). Although ALJs are not bound by the findings of state agency doctors, "they may not ignore these opinions and must explain the weight given to the opinions in their decisions." SSR 96-6p. Numerous courts have recognized this duty to address the opinions of state agency doctors.
The ALJ's opinion clearly shows that he was aware, and considered some, of the opinion from state agency psychologist, Jessica Anderton. Indeed, the ALJ referenced Dr. Anderton by name in conducting his step two severity analysis to determine Plaintiff's depression was a non-severe impairment, R. 204, and stated he gave Dr. Anderton's opinion "some weight" in formulating Plaintiff's RFC. R. 209 (citing Ex. 22F, Mental Residual Functional Capacity Assessment, R. 1162-65). The sum total of the ALJ's explanation for affording "some weight" to Dr. Anderton's opinion states, "This opinion is consistent with the other substantial evidence of record that claimant's depression is controlled by medication." R. 209. The Commissioner does not point to, and the Court does not find, any other citation in the administrative opinion specifying what this other substantial evidence of record is or how any particular portions of Dr. Anderton's various findings comport, or conflict, with such evidence.
The Commissioner argues, "Plaintiff's physical impairments were her primary concern and her doctor had only recently proscribed psychotropic medication." Comm'r's Br., p. 8 (citing R. 1164). Moreover, contends the Commissioner, because Plaintiff does not contest her depression is controlled by medication, Plaintiff has not established an impairment to her mental functioning that would have made any difference to the outcome of this case.
Dr. Anderton completed a Psychiatric Review Technique Form ("PRT"), (Ex. 21F, R. 1148-61), and a more detailed Mental Residual Functional Capacity Assessment ("MRFC"), (Ex. 22F, R. 1162-65). In the PRT, Dr. Anderton found Plaintiff had "moderate" restrictions of activities of daily living and "moderate" difficulties in maintaining concentration, persistence, or pace. R. 1158. Dr. Anderton noted Plaintiff appeared credible, had a recent onset of "significant depressive symptoms, related to ongoing physical problems," and had "a severe mental impairment." R. 1160.
In the more detailed MFRC covering twenty detailed categories of functioning, Dr. Anderton found Plaintiff to be "moderately limited" in six categories, including (1) understanding and remembering detailed instructions, (2) maintaining attention and concentration for extended periods, and (3) completing a normal workday and workweek without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods. R. 1162-63. Dr. Anderton opined Plaintiff was able to interact appropriately and cooperatively, but had an impaired stress tolerance that indicated Plaintiff would function best in a low stress, stable work environment. R. 1164. She further opined Plaintiff's "serious mental symptoms" were intertwined with physical issues.
These various levels of mental limitations are particularly relevant to determining whether Plaintiff can perform her past relevant work as department manager at a convenience store, a skilled job requiring social interaction. The VE classified as a department manager Plaintiff's past relevant work as a convenience store manager. R. 265. The varied duties of this skilled work may include listening to customer complaints, resolving problems to restore and promote good public relations, and performing customer service activities as required.
Yet, in the administrative opinion, the ALJ only cited to the MFRC, and even then did not explain why he accepted some, but rejected other, portions of Dr. Anderton's opinion. For example, the ALJ appeared to agree with Dr. Anderton that Plaintiff has mild limitations in social functioning, R. 204, 1158, but then included no social deficits in Plaintiff's RFC, R. 205.
The Court agrees with the Commissioner's argument that "the ALJ is not required to adopt a physician's carte blanche medical opinion." Comm'r's Br., p. 7. But that is not what Plaintiff argued. Rather, Plaintiff argued the ALJ had to explain his reasoning for accepting or rejecting various aspects of the opinion offered by Dr. Anderton: "The ALJ either accepted the opinion of SSA's state agency psychologist and failed to account for limitations identified in that opinion, or he rejected that opinion without explanation. Remand is required in either instance." Pl.'s Reply, p. 6.
The lack of explanation is even more problematic in light of the GAF scores in the record ranging from forty-five to fifty-five.
Because the ALJ provided no specific information about why he gave "some weight" to only certain portions of Dr. Anderton's opinion, the Court has nothing to evaluate to determine whether the ALJ properly considered the entirety of Dr. Anderton's findings, or if he did, why he rejected the portions that conflicted with his ultimate RFC determination. Compounding the problem of the ALJ failing to explain why he rejected some portions of Dr. Anderton's opinion is the internal inconsistency of seeming to accept some portions of the opinion, and then without warning or explanation, pivoting 180 degrees and rejecting any limitations in the RFC based on findings that were seemingly, initially accepted.
Although it is clear that the ALJ considered at least portions of Dr. Anderton's findings, the ALJ failed to offer any explanation for cherry picking only portions that supported his conclusions about Plaintiff's mental functioning. "It is not enough to discover a piece of evidence which supports [the administrative] decision, but to disregard other contrary evidence. The review must take into account and evaluate the record as a whole."
The Commissioner's post-hoc explanation of why the ALJ's analysis on Plaintiff's mental functioning does not change the disability determination cannot excuse the error because the Court cannot now engage in an administrative review that was not done in the first instance at the administrative level, but rather must examine the administrative decision as delivered.
The Commissioner suggests as a solution an "alternative finding" that even if Plaintiff could not return to her past relevant work, there were other jobs existing in the national economy Plaintiff could perform. Comm'r's Br., p. 3. As set forth above, the ALJ stopped the sequential process at the fourth step when he determined Plaintiff could perform her past relevant work. R. 209. Although the VE initially identified some sedentary jobs for Plaintiff in response to a hypothetical from the ALJ, R. 266-67, counsel mounted a vigorous cross-examination, and those jobs never made it into the final administrative decision.
The ALJ must base his decision on the entire record, not just the portions that support his ultimate conclusion. Because he did not do that in this case, the ALJ's decision is not based upon substantial evidence.
For the reasons set forth above, the Court
SO REPORTED and RECOMMENDED.
20 C.F.R. §§ 404.1567(b) & 416.967(b).