HUGH W. BRENNEMAN, Jr., Magistrate Judge.
Plaintiff brings this action pursuant to 42 U.S.C. § 405(g), seeking judicial review of a final decision of the Commissioner of the Social Security Administration (Commissioner) denying his claim for disability insurance benefits (DIB).
Plaintiff was born on June 3, 1966 (AR 168).
This court's review of the Commissioner's decision is typically focused on determining whether the Commissioner's findings are supported by substantial evidence. 42 U.S.C. §405(g); McKnight v. Sullivan, 927 F.2d 241 (6th Cir. 1990). "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." Cutlip v. Secretary of Health & Human Services, 25 F.3d 284, 286 (6th Cir. 1994). A determination of substantiality of the evidence must be based upon the record taken as a whole. Young v. Secretary of Health & Human Services, 925 F.2d 146 (6th Cir. 1990).
The scope of this review is limited to an examination of the record only. This Court does not review the evidence de novo, make credibility determinations or weigh the evidence. Brainard v. Secretary of Health & Human Services, 889 F.2d 679, 681 (6th Cir. 1989). The fact that the record also contains evidence which would have supported a different conclusion does not undermine the Commissioner's decision so long as there is substantial support for that decision in the record. Willbanks v. Secretary of Health & Human Services, 847 F.2d 301, 303 (6th Cir. 1988). Even if the reviewing court would resolve the dispute differently, the Commissioner's decision must stand if it is supported by substantial evidence. Young, 925 F.2d at 147.
A claimant must prove that he suffers from a disability in order to be entitled to benefits. A disability is established by showing that the claimant cannot engage in 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. See 20 C.F.R. § 404.1505; Abbott v. Sullivan, 905 F.2d 918, 923 (6th Cir. 1990). In applying the above standard, the Commissioner has developed a five-step analysis:
Heston v. Commissioner of Social Security, 245 F.3d 528, 534 (6th Cir. 2001) (citations omitted).
The claimant bears the burden of proving the existence and severity of limitations caused by her impairments and the fact that she is precluded from performing her past relevant work through step four. Jones v. Commissioner of Social Security, 336 F.3d 469, 474 (6th Cir. 2003). However, at step five of the inquiry, "the burden shifts to the Commissioner to identify a significant number of jobs in the economy that accommodate the claimant's residual functional capacity (determined at step four) and vocational profile." Id. If it is determined that a claimant is or is not disabled at any point in the evaluation process, further review is not necessary. Mullis v. Bowen, 861 F.2d 991, 993 (6th Cir. 1988).
Plaintiff's claim failed at the fifth step of the evaluation. At the first step, the ALJ initially found that plaintiff had not engaged in substantial gainful activity since the alleged onset date of February 15, 2009, and that he met the insured status requirements of the Social Security Act through March 31, 2014 (AR 38). At the second step, the ALJ found that plaintiff had the following severe impairments: PTSD; depression; left knee pain status-post surgical repair; right shoulder pain; and obesity (AR 38). At the third step, the ALJ found that plaintiff did not have an impairment or combination of impairments that met or equaled the requirements of the Listing of Impairments in 20 C.F.R. Pt. 404, Subpt. P, App. 1 (AR 39). Specifically, plaintiff did not meet the requirements of Listings 1.02 (major dysfunction of a joint), 12.02 (organic mental disorders), 12.04 (affective disorders), 12.06 (anxiety related disorders), or 12.09 (substance addiction disorders) (AR 39-44).
The ALJ decided at the fourth step that plaintiff:
(AR 44-45). The ALJ also found that plaintiff was unable to perform any of his past relevant work (AR 56).
At the fifth step, the ALJ determined that plaintiff could perform a significant number of unskilled, light jobs in the State of Michigan) (AR 56-57). Specifically, plaintiff could perform the following: machine tender (2,500 jobs); and inspector (3,000 jobs) (AR 57). Accordingly, the ALJ determined that plaintiff has not been under a disability, as defined in the Social Security Act, from February 15, 2009 (the alleged onset date) through October 21, 2011 (the date of the decision) (AR 57-58).
Plaintiff raised one issue on appeal:
Plaintiff contends that the ALJ provided identical boilerplate statements to the treating source opinions offered by Hakima Aqel, M.D. and Darryl P. Plunkett, Ph.D., which only addressed whether the opinions should be accorded controlling weight and failed to give good reasons for the weight accorded to these opinions as required by 20 C.F.R. § 404.1527(c)(2). Treating physicians' medical opinions and diagnoses are entitled to great weight in evaluating plaintiff's alleged disability. Buxton v. Halter, 246 F.3d 762, 773 (6th Cir. 2001). "In general, the opinions of treating physicians are accorded greater weight than those of physicians who examine claimants only once." Walters v. Commissioner of Social Security, 127 F.3d 525, 529-30 (6th Cir. 1997). "The treating physician doctrine is based on the assumption that a medical professional who has dealt with a claimant and his maladies over a long period of time will have a deeper insight into the medical condition of the claimant than will a person who has examined a claimant but once, or who has only seen the claimant's medical records." Barker v. Shalala, 40 F.3d 789, 794 (6th Cir. 1994). See 20 C.F.R. § 404.1527(c)(2) ("Generally, we give more weight to opinions from your treating sources, since these sources are likely to be the medical professionals most able to provide a detailed, longitudinal picture of your medical impairment(s) and may bring a unique perspective to the medical evidence that cannot be obtained from the objective medical findings alone or from reports of individual examinations, such as consultative examinations or brief hospitalizations").
Under the regulations, a treating source's opinion on the nature and severity of a claimant's impairment must be given controlling weight if the Commissioner finds that: (1) the opinion is well-supported by medically acceptable clinical and laboratory diagnostic techniques; and (2) the opinion is not inconsistent with the other substantial evidence in the case record. See Gayheart v. Commissioner of Social Security, 710 F.3d 365, 375 (6th Cir. 2013); 20 C.F.R. § 404.1527(c)(2). Finally, the ALJ must articulate good reasons for not crediting the opinion of a treating source. See Wilson v. Commissioner of Social Security, 378 F.3d 541, 545 (6th Cir. 2004); 20 C.F.R. § 404.1527(c)(2) ("[w]e will always give good reasons in our notice of determination or decision for the weight we give your treating source's opinion").
The ALJ addressed Dr. Plunketts' mental RFC assessment as follows:
(AR 53).
As an initial matter, it is unclear from the ALJ's decision as to whether the he viewed Dr. Plunkett as a treating psychologist or an examining psychologist. While the ALJ noted the absence of any records from Dr. Plunkett, the doctor stated that he first treated plaintiff on May 1, 2009 and most recently treated him on June 25, 2010, the date he prepared the assessment (AR 746). The Commissioner must provide a statement of evidence and reasons on which the decision is based. See 42 U.S.C. § 405(b)(1). While it is unnecessary for the ALJ to address every piece of medical evidence, see Heston, 245 F.3d at 534-35, an ALJ "must articulate, at some minimum level, his analysis of the evidence to allow the appellate court to trace the path of his reasoning." Diaz v. Chater, 55 F.3d 300, 307 (7th Cir. 1995). "It is more than merely `helpful' for the ALJ to articulate reasons . . . for crediting or rejecting particular sources of evidence. It is absolutely essential for meaningful appellate review." Hurst v. Secretary of Health and Human Services, 753 F.2d 517, 519 (6th Cir. 1985). In this instance, the Court cannot follow the ALJ's reasoning with respect to Dr. Plunkett to perform an appellate review. Accordingly, this matter will be reversed and remanded pursuant to sentence four of 42 U.S.C. § 405(g). On remand, the Commissioner should determine whether Dr. Plunkett's opinion is that of a treater or an examiner, and then evaluate the opinion accordingly.
Dr. Aqel prepared both a mental and physical RFC assessment of plaintiff. The ALJ addressed Dr. Aqel's mental RFC assessment as follows:
(AR 53).
In addition, the ALJ addressed Dr. Aqel's physical RFC as follows:
(AR 54).
There is no question that Dr. Aqel treated plaintiff. The issue presented is whether the ALJ gave good reasons for the weight assigned to Dr. Aqel's opinion. While the ALJ's decision set forth plaintiff's medical history at length (AR 45-52), he did not provide a sufficient explanation for why Dr. Aqel's opinions were not consistent with, or supported by, the weight of the evidence. Nor does the ALJ explain how Dr. Aqel's assessment was based on plaintiff's inaccurate history.
In addition, the ALJ does not explain why Dr. Aqel could not rely on plaintiff's subjective complaints in evaluating his mental condition. The Sixth Circuit has recognized the subjective nature of mental impairments, stating that "[m]ental disorders are not uncommonly diagnosed after one interview." Blankenship, 874 F.2d at 1121 (emphasis added). As the Sixth Circuit explained:
Blankenship, 874 F.2d at 1121, quoting Poulin v. Bowen, 817 F.2d 865, 873-74 (D.C. Cir. 1987) (brackets in original).
Based on this record, the ALJ failed to give good reasons for the weight assigned to Dr. Aqel's opinion. See Wilson, 378 F.3d at 545. However, "an agency's violation of its procedural rules will not result in reversible error absent a showing that the claimant has been prejudiced on the merits or deprived of substantial rights because of the agency's procedural lapses." Id. at 546-47. As the party attacking the agency's determination, plaintiff has the burden of establishing that the error was harmful. See Shinseki v. Sanders, 556 U.S. 396, 409-10 (2009). Here, plaintiff has met that burden by pointing out: the lack of evidence to support the ALJ's determination that Dr. Aqel relied on an inaccurate history and subjective complaints; that Dr. Aqel was a physician at the VA where plaintiff sought treatment since 2009; and that Dr. Aqel's physical RFC assessment was based in part on plaintiff's longitudinal course of care and an x-ray from November 16,2009, revealing moderate osteoarthritis and prior ACL repair (AR 778).
Accordingly, this matter should be reversed and remanded pursuant to sentence four of 42 U.S.C. § 405(g). On remand, the ALJ should re-evaluate the mental and physical RFC assessments completed by Dr. Aqel.
For the reasons discussed, the Commissioner's decision will be
