JOE L. WEBSTER, Magistrate Judge.
Plaintiff, Terry Wayne Thompson, seeks review of a final decision of the Commissioner of Social Security denying his claims for disability insurance benefits ("DIB") and supplemental security income ("SSI"). The Court has before it the certified administrative record
Plaintiff filed applications for DIB and SSI on August 22, 2013, alleging a disability onset date of August 31, 2012. (Tr. 100-01, 200-12.) The applications were denied initially and again upon reconsideration. (Id. at 132-36, 142-49.) A hearing was then held before an Administrative Law Judge ("ALJ") at which Plaintiff, his attorney, and a vocational expert ("VE") were present. (Id. at 37-69.) On April 13, 2016 the ALJ determined that Plaintiff was not disabled under the Act. (Id. at 18-29.) On March 30, 2017, the Appeals Council denied Plaintiff's request for review, making the ALJ's determination the Commissioner's final decision for purposes of review. (Id. at 1-6.)
The scope of judicial review of the Commissioner's final decision is specific and narrow. Smith v. Schweiker, 795 F.2d 343, 345 (4th Cir. 1986). Review is limited to determining if there is substantial evidence in the record to support the Commissioner's decision. 42 U.S.C. § 405(g); Hunter v. Sullivan, 993 F.2d 31, 34 (4th Cir. 1992); Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990). "[I]n reviewing for substantial evidence, [the Court] do[es] not re-weigh conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the [Commissioner]." Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996). The issue before the Court, therefore, is not whether Plaintiff is disabled but whether the Commissioner's finding that he is not disabled is supported by substantial evidence and was reached based upon a correct application of the relevant law. Id.
The ALJ followed the well-established sequential analysis to ascertain whether the claimant is disabled, which is set forth in 20 C.F.R. §§ 404.1520 and 416.920. See Albright v. Comm'r of Soc. Sec. Admin., 174 F.3d 473, 475 n.2 (4th Cir. 1999).
Prior to step four, the ALJ determined Plaintiff's residual functional capacity ("RFC"). (Id. at 23-27.) Based on the evidence as a whole, the ALJ determined that Plaintiff retained the RFC to perform light work
(Id. at 23.) At the fourth step, the ALJ determined that Plaintiff was not capable of performing past relevant work. (Id. at 27.) Finally, at step five, the ALJ found there were other jobs that existed in significant numbers in the national economy that Plaintiff could perform such as counter clerk, page, or usher. (Id. at 28-29.) Consequently, the ALJ determined that Plaintiff was not disabled from the alleged onset date through the decision date. (Id. at 29.)
Plaintiff first argues that the ALJ erred by failing to "analyze the opinion of [certified physician assistant Theresa Williamson] at all. . . ." (Docket Entry 12 at 4-9.)
In the present matter, the ALJ found, in pertinent part, that Plaintiff has mild difficulties in social functioning and mild restrictions in activities of daily living. (Tr. 22.) The ALJ further found that Plaintiff could perform a range of light work but that Plaintiff was limited to "doing simple routine tasks/instructions, but not at a production rate (such as assembly line work), to making simple work-related decisions, and to sustaining concentration/pace for two hour segments throughout the duration of a standard eight-hour workday." (Id. at 23.) This assessment was based largely on the medical opinion of consultative examiner Alexander Lopez, M.S., which the ALJ gave substantial weight. (Id. at 22, 26-27, 447-52.)
Aside from the consultative exam, the evidence of Plaintiff's severe depression came from records of his 2014 and 2015 visits to mental health services providers through Monarch. (Id. at 26, 571-83, 618-58, 695-98.) At his first visit on April 1, 2014, licensed clinical social worker Peter J. Basone assigned Plaintiff a GAF score of 45 (id. at 571-80),
The ALJ reviewed Plaintiff's treatment notes from Monarch. He noted that "mental status examinations of the claimant mostly demonstrated a normal appearance, normal motor activity, good insight, normal speech, clear goal-directed thought processes, good judgment, intact cognition, intact orientation, good concentration/attention, a normal flow of thought, and appropriate thought content." (Id. at 26, 578, 582, 621, 627, 630, 637, 641, 646-47, 653, 656, 658.) The ALJ also considered the GAF score documented at Plaintiff's first visit, but found it too restrictive. (Id. at 26, 580.) The ALJ did not address PAC Williamson's MSS.
Plaintiff now argues that the ALJ's failure to address PAC Williamson's MSS constitutes reversible error. (Docket Entry 12 at 39.) For the reasons that follow, on the specific facts of this case, the Court agrees that remand is appropriate.
Social Security Ruling 06-03p provides that "acceptable medical sources" include licensed physicians (medical or osteopathic doctors) and licensed or certified psychologists — but not certified physician assistants or licensed clinical social workers. 2006 WL 2329939 at *2 (2006).
Id. (internal citations omitted) (citing 20 CFR §§ 404.1513(a), 416.913(a), 404.1527(a)(2), (d), 416.927(a)(2), (d)). However, the Ruling also recognizes that
Id. at *3. "[W]hen such opinions may have an effect on the outcome of the case," the ALJ "should explain the weight given to [the] opinion[] . . . or otherwise ensure that the discussion of the evidence in the determination or decision allows a claimant or subsequent reviewer to follow the adjudicator's reasoning." Id. at *6.
Here, the ALJ neither explained the weight given to the MSS nor discussed the MSS in his decision. As explained below, this inadequacy in the ALJ's analysis frustrates meaningful review. Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015). The Commissioner counters that PAC Williamson's opinion would not affect the outcome of this case and therefore the ALJ was not obligated to weigh it. (Docket Entry 16 at 7-11.) Specifically, the Commissioner notes that (1) the MSS was a checkbox form, which is of limited probative value; (2) the ALJ thoroughly reviewed the Monarch records in detail, and noted that Plaintiff's mental status exams yielded benign results; (3) the MSS contains no functional limitations; and (4) substantial evidence supports the ALJ's conclusions that Plaintiff suffered from only mild limitations in social functioning and mild restrictions in activities of daily living. (Id.) If noted by the ALJ, these facts would all constitute good reasons for giving PAC Williamson's MSS little or no weight. Indeed, these considerations may be precisely why the ALJ did not incorporate further social or other limitations into the RFC. But the decision itself leaves the court to guess. Mascio, 780 F.3d at 637. PAC Williamson's opinion that Plaintiff has moderate limitations in social functioning, if adopted, would likely indicate that some social limitations in the work setting were necessary. See Panna v. Colvin, No. 1:14CV229, 2015 WL 5714403, at *4 (W.D.N.C. Aug. 31, 2015) (unpublished), report and recommendation adopted, 2015 WL 5725246 (W.D.N.C. Sept. 29, 2015) (unpublished); Russell v. Colvin, No. 1:14-cv-00203, 2015 WL 3766228, at *4-5 (W.D.N.C. June 16, 2015). Thus, the Court cannot say that it could not have affected the outcome of the case where, as here, the RFC includes no social limitations at all. In any event, it is the role of the fact finder, and not that of the Court, to determine how the opinion should be weighed.
More critically, it is entirely unclear whether the ALJ considered PAC Williamson's MSS at all (as required by the Regulations) because the ALJ neither acknowledged nor discussed the MSS in his decision. The Court notes that it is ordinarily entitled to rely on an ALJ's representation that he considered the entire record, absent evidence to the contrary. See Reid v. Comm'r of Soc. Sec., 769 F.3d 861, 865 (4th Cir. 2014) (citing Hackett v. Barnhart, 395 F.3d 1168, 1173 (10th Cir.2005)). Here, however, although the ALJ stated that he considered the entire record (Tr. 18, 20, 23), there is some evidence that the ALJ did not review PAC Williamson's MSS. First, the ALJ twice cites to "Exhibit 20F," which represents the MSS in the administrative record, but appears to have confused Exhibit 19F with Exhibit 20F and cited to Exhibit 20F in error.
In sum, it is not clear whether the ALJ considered PAC Williamson's opinion, and if he did, why he dismissed it or otherwise declined to incorporate restrictions consistent with it. None of this necessarily means that Plaintiff is disabled under the Act and the undersigned expresses no opinion on that matter. Nevertheless, the undersigned concludes that the proper course here is to remand this matter for further administrative proceedings. The Court declines consideration of the additional issues raised by Plaintiff at this time. Hancock v. Barnhart, 206 F.Supp.2d 757, 763-764 (W.D. Va. 2002) (on remand, the prior decision of no preclusive effect, as it is vacated and the new hearing is conducted).
After a careful consideration of the evidence of record, the Court finds that the ALJ's decision is not susceptible to judicial review. Accordingly, this Court