ROBERT L. MILLER, JR., District Judge.
Isaiah Moore seeks judicial review of a final decision denying his application for disability insurance benefits and supplemental security income under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 423 and 1383 et seq. The court has jurisdiction over this action pursuant to 42 U.S.C. § 405(g). For the following reasons, the court vacates the Commissioner's decision and remands this case for further proceedings consistent with this opinion.
Mr. Moore's application for disability insurance benefits and supplemental security income was denied initially, on reconsideration, and after an administrative hearing at which he, Bernard Stevens, M.D., and a vocational expert testified. Based on the record before him, the ALJ found that Mr. Moore had severe impairments—morbid obesity, gout, and low back pain with radiculopathy—but concluded that none of his impairments met or medically equaled any of the impairments listed in 20 C.F.R. Pt. 404, Subpt. P, App. 1.
The ALJ decided that Mr. Moore had the residual functional capacity to perform sedentary work, as defined in 20 C.F.R. §§ 404.1567(a), 416.967(a), with limitations,
When the Appeals Council denied Mr. Moore's request for review, the ALJ's decision became the Commissioner's final decision.
The issue before the court isn't whether Mr. Moore is disabled, but whether substantial evidence supports the ALJ's decision that he wasn't disabled.
Mr. Moore presents four issues for review: (1) whether substantial evidence supported the ALJ's determination that he didn't have a medically determinable mental impairment; (2) whether the ALJ's credibility determination complied with relevant legal standards; (3) whether the ALJ properly weighed the opinion evidence; and (4) whether the ALJ's residual functional capacity finding accounted for all of Mr. Moore's impairments. Mr. Moore asks the court to either reverse the Commissioner's decision and award benefits or remand the case for further proceedings.
Mr. Moore first argues that the ALJ erred at step two of the sequential evaluation of disability when he determined that Mr. Moore didn't have a medically determinable mental impairment even though the mental health specialists that either examined Mr. Moore or reviewed his records found mental impairments. At step two, Mr. Moore had to show that he had "a medically determinable physical or mental impairment." 20 C.F.R. §§ 404.1521, 416.921. The threshold showing of a severe or non-severe impairment can't be established only by a claimant's "statement of symptoms, a diagnosis, or a medical opinion to establish the existence of an impairment," but must be shown "by medically acceptable clinical and laboratory diagnostic techniques."
Consultative psychologist Dr. Roger Parks conducted a mental status examination at which Mr. Moore exhibited concentration problems, difficulty with serial sevens, and was assessed a GAF score of 50, which suggests serious symptoms or a "serious impairment in social, occupational, or school functioning." AM. PSYCHIATRIC ASS'N, DIAGNOSTIC & STATISTICAL MANUAL OF MENTAL DISORDERS 34 (4th ed. 2000). Based on these findings, Dr. Parks diagnosed Mr. Moore with major depressive disorder.
Dr. Parks's report supports a finding of a mental impairment; he is a specialist, diagnosed Mr. Moore with major depressive disorder based on a mental status examination, and the ALJ didn't find that Dr. Parks's mental status examination lacked medically acceptable clinical and laboratory diagnostic techniques. Nonetheless, the ALJ found that "the records don't support a finding of a mental impairment." [Doc. No. 15-2 at 24]. This conclusory finding doesn't provide this court with a logical bridge between his conclusion and the evidence in the record that would allow the court to properly review his finding. See
The ALJ also pointed to brief mental health assessments made by physicians during treatment appointments, for example, a remark that Mr. Moore had appropriate mood and affect and was cooperative during a follow-up appointment for gout treatment to support his finding of no mental impairment.
Mr. Moore also contends that the ALJ's credibility determination didn't comply with relevant legal standards because he didn't consider Mr. Moore's daily activities, his symptoms and level of pain, aggravating factors, mediation, treatment, and limitations.
An ALJ's credibility determination is "entitled to special deference because the ALJ is in a better position than the reviewing court to observe a witness," but those determinations "are not immune from review."
The ALJ's adverse credibility determination rested on his finding that Mr. Moore's "testimony of his significantly limiting condition is . . . not credible in view of the minimal objective findings. While the claimant has some limitations, his allegations that he can do almost nothing is inconsistent and out of proportion with the overall record." [Doc. No. 15-2 at 28]. The court can't uphold this credibility determination because it's based on a lack of objective evidence to support Mr. Moore's allegations of pain and limitations and doesn't demonstrate that the ALJ considered the other required factors, including the Mr. Moore's daily activities, aggravating factors, medication, treatment, and limitations. See
Mr. Moore next argues that the ALJ improperly discounted the opinion of his treating neurologist, Julian Ungar-Sargon, M.D., Ph.D. Dr. Ungar-Sargon examined Mr. Moore seven times and reviewed EMG/NCV studies and CT scans. Dr. Ungar-Sargon diagnosed him with, among other things, lumbar disc displacement, compression of the spinal nerve root, pelvic pain, sacroiliitis, and thoracic spondylosis. The record includes a note from Dr. Ungar-Sargon that Mr. Moore was under his care for spinal degenerative arthritis and was "totally disabled from gainful employment." [Doc. No. 15-8 at 73]. Dr. Ungar-Sargon's opinion that Mr. Moore was totally disabled is the only opinion of Dr. Ungar-Sargon's to which the ALJ assigned weight, giving it "no weight" because it was based on Mr. Moore's subjective complaints and was inconsistent with the studies and progress notes in the record. [Doc. No. 15-2 at 28].
Whether Mr. Moore is disabled is a determination reserved to the Commissioner and medical evidence on that issue isn't controlling. 20 C.F.R. §§ 404.1527(d)(1), 416.927(d)(1). But that wasn't the basis the ALJ articulated for affording Dr. Ungar-Sargon's opinion "no weight" and, despite his opinion addressing an issue reserved to the Commissioner, the ALJ still was required to properly consider and weigh Dr. Ungar-Sargon's opinions.
While the ALJ asserted that Dr. Ungar-Sargon's opinion was inconsistent with the objective evidence, his review of the evidence includes testing that could support those opinions. The ALJ noted that Dr. Ungar-Sargon's lumbar spine examination revealed hypertonicity, spasms, and tenderness; straight leg testing was positive on the left; and sensory examinations showed a loss of all modality in lower extremities and a loss of lower reflexes. The ALJ noted that while the lumbar spine CT scan was normal, the EMG/NCV studies indicated chronic left L4-L5 radiculopathy and the thoracic spine CT scan showed a few anterior osteophytes. The ALJ didn't adequate explain why this testing didn't support Dr. Ungar-Sargon's opinions or why, despite these results, he found that Dr. Ungar-Sargon's opinion was based solely on Mr. Moore's subjective complaints. See
The ALJ's finding that Dr. Ungar-Sargon's opinion warranted no weight was also erroneous because he didn't fully consider the regulatory factors before assigning weight to his opinions. The Commissioner concedes that the ALJ didn't consider all of the regulatory factors, but argues that he sufficiently complied with the regulations because he discussed most of the regulatory factors. The court can't agree. The ALJ must address all of the regulatory factors before assigning weight to medical and psychological opinions,
Mr. Moore also contends that the ALJ's residual functional capacity determination isn't supported by substantial evidence because the determination didn't account for all of Mr. Moore's impairments. Because the ALJ's residual functional capacity determination is based on his determination that Mr. Moore had no mental impairment and his improper evaluation of the medical evidence in the record, the ALJ should reconsider his residual functional capacity finding after reassessing his step two determination and properly weighing the opinion evidence on remand. See
The court VACATES the Commissioner's decision and REMANDS this case for further proceeding consistent with this opinion.
SO ORDERED.