DAVID R. GRAND, Magistrate Judge.
Plaintiff Shawn Marie Huntington ("Huntington") brings this action pursuant to 42 U.S.C. § 405(g), challenging the final decision of Defendant Commissioner of Social Security ("Commissioner") denying her application for Disability Insurance Benefits ("DIB") under the Social Security Act (the "Act"). Both parties have filed summary judgment motions (Docs. #11, #13), which have been referred to this Court for a Report and Recommendation pursuant to 28 U.S.C. § 636(b)(1)(B).
For the reasons set forth below, the Court finds that the Administrative Law Judge's ("ALJ") conclusion that Huntington is not disabled under the Act is not supported by substantial evidence. Accordingly, the Court recommends that the Commissioner's Motion for Summary Judgment (
Huntington was 45 years old at the time of her alleged onset date of June 9, 2015, and at 5'4" tall weighed approximately 125 pounds during the relevant time period. (Tr. 159, 176). She completed high school but had no college education. (Tr. 177). She worked consistently, first as a personal trainer and then as a shift manager at a grocery store, before she suffered a back injury at work in June of 2015. (Tr. 28-29, 38, 177, 191). She now alleges disability primarily as a result of ongoing back pain, as well as depression and bipolar disorder. (Tr. 38, 176).
After Huntington's application for DIB was denied at the initial level on May 16, 2017 (Tr. 70-77), she timely requested an administrative hearing, which was held before ALJ Crystal White-Simmons on December 11, 2017 (Tr. 24-52). Huntington, who was represented by attorney Charles Palmer, testified at the hearing, as did vocational expert ("VE") Zachary Matthews. (Id.). On January 29, 2018, the ALJ issued a written decision finding that Huntington is not disabled under the Act. (Tr. 10-20). On April 17, 2018, the Appeals Council denied review. (Tr. 1-5). Huntington timely filed for judicial review of the final decision on June 12, 2018. (Doc. #1).
The Court has thoroughly reviewed the transcript in this matter, including Huntington's medical record, Function and Disability Reports, and testimony as to her conditions and resulting limitations. Instead of summarizing that information here, the Court will make references and provide citations to the transcript as necessary in its discussion of the parties' arguments.
Under the Act, DIB are available only for those who have a "disability." See Colvin v. Barnhart, 475 F.3d 727, 730 (6th Cir. 2007). The Act defines "disability" as 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 12 months." 42 U.S.C. § 423(d)(1)(A). The Commissioner's regulations provide that a disability is to be determined through the application of a five-step sequential analysis:
Scheuneman v. Comm'r of Soc. Sec., No. 11-10593, 2011 WL 6937331, at *7 (E.D. Mich. Dec. 6, 2011) (citing 20 C.F.R. § 404.1520); see also Heston v. Comm'r of Soc. Sec., 245 F.3d 528, 534 (6th Cir. 2001). "The burden of proof is on the claimant throughout the first four steps. . . . If the analysis reaches the fifth step without a finding that claimant is not disabled, the burden transfers to the [defendant]." Preslar v. Sec'y of Health & Human Servs., 14 F.3d 1107, 1110 (6th Cir. 1994).
Following this sequential analysis, the ALJ found that Huntington is not disabled under the Act. At Step One, the ALJ found that Huntington has not engaged in substantial gainful activity since June 9, 2015 (the alleged onset date). (Tr. 12). At Step Two, the ALJ found that she has the severe impairments of sacroiliitis, post traumatic chronic pain syndrome, bipolar disorder, and anxiety. (Id.). At Step Three, the ALJ found that Huntington's impairments, whether considered alone or in combination, do not meet or medically equal a listed impairment. (Tr. 13).
The ALJ then assessed Huntington's residual functional capacity ("RFC"), concluding that she is capable of performing light work, with the following additional limitations: no climbing of ladders, ropes, or scaffolds; occasional climbing of ramps and stairs; occasional balancing, stooping, kneeling, crouching, and crawling; limited to simple and routine tasks; only occasional decision-making and occasional changes in the work setting; no interaction with the public; and must have the ability to alternate between sitting and standing after 30 minutes. (Tr. 14).
At Step Four, the ALJ found that Huntington is not capable of performing any of her past relevant work. (Tr. 17). At Step Five, the ALJ determined, based in part on the VE's testimony in response to hypothetical questions, that Huntington is capable of performing the jobs of office clerk (158,000 jobs nationally), record clerk (42,000 jobs), and office helper (116,000 jobs). (Tr. 18-19). As a result, the ALJ concluded that Huntington is not disabled under the Act. (Tr. 19).
The District Court has jurisdiction to review the Commissioner's final administrative decision pursuant to 42 U.S.C. § 405(g). Judicial review under this statute is limited in that the court "must affirm the Commissioner's conclusions absent a determination that the Commissioner has failed to apply the correct legal standard or has made findings of fact unsupported by substantial evidence in the record." Longworth v. Comm'r of Soc. Sec., 402 F.3d 591, 595 (6th Cir. 2005) (internal citations omitted). Substantial evidence is "more than a scintilla of evidence but less than a preponderance; it is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Rogers v. Comm'r of Soc. Sec., 486 F.3d 234, 241 (6th Cir. 2007) (internal quotations omitted). In deciding whether substantial evidence supports the ALJ's decision, the court does "not try the case de novo, resolve conflicts in evidence or decide questions of credibility." Bass v. McMahon, 499 F.3d 506, 509 (6th Cir. 2007).
When reviewing the Commissioner's factual findings, the court is limited to an examination of the record and must consider the record as a whole. See Bass, 499 F.3d at 512-13; Wyatt v. Sec'y of Health & Human Servs., 974 F.2d 680, 683 (6th Cir. 1992). The court "may look to any evidence in the record, regardless of whether it has been cited by the Appeals Council," or in this case, the ALJ. Heston, 245 F.3d at 535; Walker v. Sec'y of Health & Human Servs., 884 F.2d 241, 245 (6th Cir. 1989). There is no requirement, however, that either the ALJ or this court discuss every piece of evidence in the administrative record. See Kornecky v. Comm'r of Soc. Sec., 167 F. App'x 496, 508 (6th Cir. 2006) ("[A]n ALJ can consider all evidence without directly addressing in his written decision every piece of evidence submitted by a party.") (internal quotations omitted). If the ALJ's decision is supported by substantial evidence, "it must be affirmed even if the reviewing court would decide the matter differently and even if substantial evidence also supports the opposite conclusion." Cutlip v. Sec'y of Health & Human Servs., 25 F.3d 284, 286 (6th Cir. 1994) (internal citations omitted).
In her motion, Huntington argues that the ALJ erred in discounting the October 19, 2017 opinion of her treating physician, Craig Peppler, D.O, regarding her back impairment.
(Tr. 423). The ALJ considered this opinion, saying only:
(Tr. 17).
Huntington now argues that the ALJ erred in failing to give good reasons, supported by substantial evidence, for discounting Dr. Peppler's opinion. Indeed, the treating physician rule "mandate[s] that the ALJ `will' give a treating source's opinion controlling weight if it `is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in [the] case record.'" Cole v. Astrue, 661 F.3d 931, 937 (6th Cir. 2011) (quoting 20 C.F.R. § 404.1527(c)(2)
As set forth above, the ALJ discounted Dr. Peppler's opinion because it was "not consistent with the medical evidence of record" — and, arguably more specifically, because Huntington had "seen improvements with physical therapy." (Tr. 17). There are several problems with this analysis, however. To begin with, courts have recognized that unsupported, conclusory statements that medical opinions are inconsistent with the evidence of record fall short of satisfying the treating physician rule's "good reasons" requirement. See, e.g., Guyaux v. Comm'r of Soc. Sec., No. 13-12076, 2014 WL 4197353, at *16 (E.D. Mich. Aug. 22, 2014) (ALJ's rejection of treating physician opinion "based on the bare statement that it is conclusory and not supported by the medical evidence" was insufficient, warranting remand); Castro v. Comm'r of Soc. Sec., No. 12-12822, 2013 WL 4012824, at *10 (E.D. Mich. Aug. 6, 2013) (ALJ's "one-sentence reason for rejecting the [treating physician's] assessment, i.e., that `it is not consistent with the treatment records or the record as a whole,' is insufficient"). Indeed, this Court remanded a case to the ALJ fairly recently on nearly identical facts, recognizing that the ALJ failed to articulate good reasons, supported by substantial evidence, for rejecting the treating physician's opinion. See Rines v. Comm'r of Soc. Sec., No. 16-13887, 2017 WL 4786144, at *3-5 (E.D. Mich. Oct. 24, 2017). In Rines, the Court explained:
Id. at *3 (emphasis in original) (internal citations omitted). Here too, then, the ALJ's statement that Dr. Peppler's opinion is "not consistent with the medical evidence of record" (Tr. 17) is "unhelpful boilerplate that sheds no light on precisely which portions of the record undermine [his] opinions." Rines, 2017 WL 4786144, at *3.
Moreover, to the extent the ALJ discounted Dr. Peppler's opinion because Huntington saw "improvements with physical therapy" and because it was "not consistent with the medical evidence of record" (Tr. 17), such reasons are not supported by substantial evidence. As set forth above, Huntington injured her back at work on June 9, 2015, while attempting to pull a large rack of 80 gallon-cartons of milk into a refrigerated unit. A June 29, 2015 MRI showed a broad disc protrusion and facet arthropathy at L4-L5, with abutment of the L5 nerve roots within the lateral recesses and effacement of the right L4 root within the root foramen; disc desiccation at L5-S1; and foraminal stenosis with L5 root abutment. (Tr. 211-12). Huntington then underwent physical therapy — attending nineteen visits between July 10, 2015, and August 25, 2015. (Tr. 213-66). By the end of this course of physical therapy, Huntington's back pain had improved somewhat and, although she continued to report soreness in her low back and tightness in her hips, she was "looking forward to returning to work." (Tr. 217). Thus, the ALJ's observation that Huntington saw "improvements with physical therapy" might be correct as to this brief two-month period.
However, Huntington's condition appears to have deteriorated significantly over the next two years. Huntington returned to work part-time, but with no lifting restrictions, in September of 2015. (Tr. 400). At a November 18, 2015 independent medical evaluation ("IME") with Steve Geiringer, M.D., in connection with her worker's compensation claim, it was noted that after she returned to work on even a part-time basis, "her symptoms returned and eventually she was back to square one." (Id.). On physical examination, she had limited range of motion in the lumbar spine; there was tenderness in several areas; and provocative maneuvers for the SI joint were painful. (Id.). Nevertheless, Dr. Geiringer opined that Huntington suffered from only a lumbar strain with abnormal mechanics, and he recommended she remain off work while she completed an additional course of physical therapy. (Tr. 400-01).
Huntington then dutifully attended twenty-four more physical therapy sessions between November 2015 and February 2016. (Tr. 287). By the time she was discharged from her second course of physical therapy, Huntington still reported "great difficulty" lifting twenty pounds; she had pain with flexion, extension, and rotation; her straight-leg raise testing was painful bilaterally; and her then-treating physician, Anne Abrahamson, M.D., opined that she should remain off work. (Tr. 363-67). At a follow-up visit to Dr. Abrahamson's office on April 20, 2016, Huntington expressed a desire to resume her full work duties, but indicated that even doing housework and lifting twenty pounds resulted in increased pain. (Tr. 368).
On September 6, 2016, Huntington underwent a second IME with Dr. Geiringer. (Tr. 395-97). At that time, she reported continued pain in her low back, radiating down both thighs to the knees, worse with physical activity. (Tr. 396). On examination, Dr. Geiringer again noted "objective signs of abnormal mechanics from the lumbar spine, which again themselves arise from asymmetric lumbar muscle tightness." (Id.). He further indicated that his prior recommendation still applied — i.e., that Huntington undergo "manual physical therapy" — and he continued to characterize her condition as a "simple, uncomplicated back strain." (Tr. 396-97). Dr. Geiringer opined that, while she underwent additional physical therapy, Huntington could work with a 10-pound lifting restriction, so long as bending, stooping, and twisting from the waist was limited. (Tr. 397).
Huntington then began treating with Dr. Peppler at Spine, Sports & Occupational Medicine on October 27, 2016. (Tr. 448-51). She reported "rather intense pain" in the mid-buttocks region, worse on the right, which occasionally radiated down the posterior aspect of her leg, often giving her a feeling of pelvic pressure. (Tr. 449). Dr. Peppler disagreed with Dr. Geiringer's opinion that Huntington had merely suffered a lumbar strain, saying: "A lumbar strain injury, typically, would have healed weeks to months prior to his independent medical examination . . .; therefore, I do not feel that a lumbar strain injury should have been entertained at all." (Id.). After reviewing Huntington's June 2015 MRI and conducting a physical examination, Dr. Peppler's impression was chronic pain syndrome and low back and buttocks pain, and he wanted to rule out SI joint syndrome. (Tr. 450). He prescribed oral steroids and discussed the possibility of a fluoroscopically guided SI joint injection, which could help identify the generator of Huntington's pain. (Id.). Dr. Peppler further indicated that Huntington could return to work with the following restrictions: no lifting, pushing, or pulling greater than 15 pounds; must be allowed to change position as necessary for her pain; and no prolonged bending or twisting at the waist. (Tr. 451).
At a follow-up visit to Dr. Peppler on December 1, 2016, Huntington reported that she had been able to return to work with these restrictions on a very limited basis; she was working only three-hour shifts and could not fully recover within 24 hours. (Tr. 437). Dr. Peppler recommended an SI joint injection to determine whether she suffered from SI joint mediated pain; he reiterated his request that the insurance company authorize such injections on January 12, 2017. (Tr. 438, 461-62). That same day, Dr. Peppler issued a disability certificate indicating that Huntington could work three-hour shifts but should avoid back-to-back days of work. (Tr. 445). These restrictions were renewed after examinations on April 1 and May 18, 2017. (Tr. 442-43).
On April 27, 2017, Huntington underwent a consultative physical examination with Bina Shaw, M.D. (Tr. 414-21). Dr. Shaw noted that Huntington had received the SI joint injection from Dr. Peppler just the day before and therefore had no significant severe current pain. (Tr. 415). Dr. Shaw's impression was a history of a work-related injury with lumbar strain and symptomatic SI joint pain, improved with SI joint injections. (Tr. 417). She suggested that Huntington avoid frequent bending, twisting, and lifting of more than 20 pounds, and further stated that Huntington could slowly increase her hours — from nine per week to twenty per week — over a period of three to six months. (Id.).
On June 1, 2017, Dr. Peppler wrote a letter in response to Dr. Geiringer's opinion that Huntington's problems were all strain-related and that she should continue with physical therapy. (Tr. 455-57). In relevant part, Dr. Peppler stated:
(Tr. 456-57 (emphasis added)).
Huntington returned to see Dr. Peppler on July 13, 2017, at which time he indicated that the results of the SI injection confirmed the diagnosis of post-traumatic sacroiliitis, which he described as "a very difficult, frustrating condition for both the patient and the physician." (Tr. 427). At that point, Dr. Peppler opined that Huntington had reached maximum medical improvement and would be unlikely to significantly improve. (Id.). He further indicated that Huntington was working with restrictions of no more than three shifts per week; no more than three hours in duration; and no back-to-back shifts. (Id.). According to Dr. Peppler, Huntington "will require these restrictions on a permanent basis." (Id.). On October 19, 2017, Huntington returned to see Dr. Peppler with a nurse case manager who wanted "to clarify her status with regards to maximum medical improvement and permanent work restrictions." (Tr. 423). At that time, Dr. Peppler reiterated his position, saying:
(Id.) (emphasis in original).
As set forth above, given all of this medical evidence, the reasons articulated by the ALJ for discounting this treating physician opinion are simply not borne out in the record. Specifically, the ALJ discounted Dr. Peppler's opinion because Huntington had "seen improvements with physical therapy" and because it was "not consistent with the medical evidence of record." (Tr. 17). In reality, however, although Huntington's back pain improved somewhat after her first round of physical therapy — which ended in August of 2015 — the record indicates that her pain worsened significantly when she attempted to return to work after that time, a fact that the ALJ ignored. Huntington then treated with Dr. Peppler, a specialist, for more than one year. Both of these facts lend credence to his October 2017 opinion. See 20 C.F.R. § 404.1527(c)(1) and (5) (length of the treatment relationship and specialization of the treating source are relevant factors to consider in weighing treating physician's opinion). And, the ALJ failed to mention Dr. Peppler's finding that, in the end, the many physical therapy appointments Huntington attended resulted in "no improvement whatsoever." (Tr. 456). Moreover, Dr. Peppler's opinion that Huntington cannot perform full-time work would seem to square with the opinion of the consultative examiner, Dr. Shaw, who opined in April 2017 that — with continued improvement — she might still only be capable of working twenty hours per week by October 2017. (Tr. 417).
While the ALJ did, earlier in her decision, mention some medical records that reflected normal findings (Tr. 16), she failed to meaningfully weigh that evidence against the significant evidence discussed above, and instead, simply rejected Dr. Peppler's opinion because it "is not consistent with the medical evidence of record" and because she found that Huntington improved with physical therapy. (Tr. 17). Again, based on the foregoing, the Court simply cannot find that substantial evidence supports either of these aspects of the ALJ's decision to discount Dr. Peppler's opinion, and remand is required. See Minor v. Comm'r of Soc. Sec., 2013 WL 264348, at *17 (6th Cir. Jan. 24, 2013) (ALJ does not fairly discharge his duties when he fails to discuss significant contradictory portions of the medical records); Roberts v. Colvin, 2015 WL 181658, at *10 (E.D. Mich. Jan. 14, 2015) (noting that while ALJ need not discuss all record evidence, "the quality and volume of evidence not discussed by the ALJ may `raise[] serious doubts about the supportability of the ALJ's RFC finding' and overall conclusions") (quoting Wilcox v. Comm'r of Soc. Sec., 2014 WL 4109921, at *7 (E.D. Mich. Aug.19, 2014)).
For the foregoing reasons, the Court
The parties to this action may object to and seek review of this Report and Recommendation, but are required to act within fourteen (14) days of service of a copy hereof as provided for in 28 U.S.C. §636(b)(1) and Fed. R. Civ. P. 72(b)(2). Failure to file specific objections constitutes a waiver of any further right of appeal. See Thomas v. Arn, 474 U.S. 140 (1985); Howard v. Sec'y of HHS, 932 F.2d 505, 508 (6th Cir. 1991); United States v. Walters, 638 F.2d 947, 949-50 (6th Cir. 1981). The filing of objections which raise some issues, but fail to raise others with specificity, will not preserve all the objections a party might have to this Report and Recommendation. See Willis v. Sec'y of HHS, 931 F.2d 390, 401 (6th Cir. 1991); Smith v. Detroit Fed'n of Teachers Local 231, 829 F.2d 1370, 1373 (6th Cir. 1987). Pursuant to E.D. Mich. L.R. 72.1(d)(2), a copy of any objections is to be served upon this magistrate judge.
