PAUL BARBADORO, District Judge.
Jennifer Louise Lavoie is a forty-one year old woman from Warner, New Hampshire who previously worked as an automobile mechanic, heavy equipment operator, office helper, and store clerk. Lavoie applied for disability insurance benefits ("DIB") and supplemental security income ("SSI") in March 2006, alleging disability due to degenerative disc disease of the lumbar spine, obesity, and depression. In June 2013, an Administrative Law Judge issued a written decision finding that Lavoie was not disabled. Here, Lavoie challenges the Social Security Administration's denial of her claims. The Social Security Commissioner, in turns, seeks to have the ruling affirmed.
Pursuant to Local Rule 9.1, the parties have submitted a joint statement of stipulated facts (Doc. No. 11).
In accordance with 42 U.S.C. § 405(g), I have the authority to review the administrative record and the pleadings submitted by the parties, and to enter a judgment affirming, modifying, or reversing the final decision of the Commissioner. That review is limited, however, "to determining whether the [Administrative Law Judge] used the proper legal standards and found facts [based] upon the proper quantum of evidence."
If the substantial evidence standard is met, the ALJ's factual findings are conclusive, even where the record "arguably could support a different conclusion."
Lavoie filed claims for DIB and SSI in March 2012, alleging disability as of August 2009. Doc. No. 11 at 1. She later amended her alleged onset date to October 29, 2011.
In his decision, the ALJ evaluated Lavoie's claims under the five step process described in 20 C.F.R. §§ 404.1520(a)(4) and 416.920(a)(4). The ALJ found at step one that Lavoie had not engaged in substantial gainful activity since October 29, 2011, her amended alleged onset date. Tr. at 14. At step two, the ALJ determined that Lavoie had severe impairments of degenerative disc disease of the lumbar spine, obesity, and depression. Tr. at 14. At step three, the ALJ found that Lavoie's impairments did not meet or equal any of the listed impairments. Tr. at 14-16. The ALJ then concluded at step five that Lavoie had the residual functional capacity to perform jobs that existed in significant numbers in the national economy. Tr. at 22-23. The ALJ accordingly found that Lavoie was not disabled.
In August 2014, the Appeals Council denied Lavoie's request to review the ALJ's decision. Tr. at 2-7. As such, the ALJ's decision constitutes the Commissioner's final decision, and this matter is now ripe for judicial review.
Lavoie argues that a remand is required because (1) the ALJ erred in evaluating Lavoie's credibility and subjective complaints, (2) the ALJ improperly afforded little weight to the opinion of Lavoie's treating physician, (3) Lavoie's assessed residual functional capacity is not supported by substantial evidence, and (4) the Commissioner failed to meet his burden at step five. Doc. No. 9 at 1. For the reasons explained below, I conclude that the ALJ erred in assigning little weight to Lavoie's treating physician's opinion, and that a remand is therefore warranted here.
A treating source's opinion is entitled to controlling weight so long as that opinion is "well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence ..." 20 C.F.R. §§ 404.1527(c)(2), 416.927(c)(2). Even if a treating source's opinion deserves less than controlling weight, it is "entitled to deference." SSR 96-2p, 1996 WL 374188 (July 2, 1996), at *4.
To determine how much weight a treating source's opinion should receive, the ALJ must consider the nature and extent of the treatment relationship, the opinion's supportability and consistency with the record as a whole, the treating source's area of specialization, if any, and any other relevant factors.
Here, Lavoie's treating provider was Dr. Francis Milligan, a primary care physician who treated Lavoie for more than a decade. Tr. at 366. In June 2012, at Dr. Milligan's suggestion, Lavoie underwent a functional assessment with physical therapist Christopher Herd. Tr. at 330-32, 360-62. At that assessment, Lavoie complained of difficulty walking, difficulty with daily activities, headache, numbness and back pain. Tr. at 331. PT Herd noted that Lavoie showed consistent effort with grip strength testing, but "less than maximal effort with all lifts limited by back pain." Tr. at 360. PT Herd opined that Lavoie could lift and carry up to ten pounds, could occasionally sit, stand, walk, bend, kneel, squat, reach, and drive, but was unable to climb. Tr. at 361. He also wrote that Lavoie could frequently perform fine motor tasks, could lift a maximum of ten pounds from floor to overhead, and was restricted to sedentary work. PT Herd then concluded that Lavoie's "[o]verall ... return to work prognosis is fair-poor at this time secondary to her continued symptoms of pain with mobility and strength deficits." Tr. at 330, 360.
On August 10, 2012, Dr. Milligan drafted a short letter addressed "To Whom it May Concern." Tr. at 359. In that letter, Dr. Milligan noted that Lavoie had undergone functional capacity testing "to see if she was able to work," and stated that Lavoie's "return to work prognosis is fair-poor at this time." Tr. at 359. Dr. Milligan included with his letter PT Herd's June 2012 assessment. Tr. at 359-62.
Dr. Milligan then completed a Physical Residual Functional Capacity Questionnaire on October 5, 2012. Tr. at 366-69. In that questionnaire, Dr. Milligan described Lavoie's symptoms as "pain, numbness, pain that interferes with mobility, anxiety sensation of something crawling on her skin, fatigue," and noted that Lavoie described her pain as "10/10 on 0-10 pain scale." Tr. at 366. He then opined that Lavoie's impairments were "reasonably consistent with [her] symptoms and functional limitations and [Lavoie's] experience of pain and that her back impairment and depression caused symptoms that frequently interfered with her attention and concentration needed to perform even simple work tasks and rendered her incapable of performing even low-stress jobs." Doc. No. 11 at 17 (citing Tr. at 366-67). To support his opinions, Dr. Milligan cited "imaging reports, flat affect, tearful, reduced mobility, paresthesias, depression, insomnia, tenderness lumbar spine [and] paravertebral muscles and intercostal muscles." Tr. at 366. Finally, with respect to Lavoie's functional limitations, Dr. Milligan again deferred to PT Herd's assessment. Tr. at 367-68;
The ALJ assigned Dr. Milligan's opinion, and PT Herd's functional assessment upon which Dr. Milligan relied, "little weight." Tr. at 21. The ALJ discounted these opinions because they were "partially, but not entirely, consistent with or supported by the evidence of record."
The ALJ's one-paragraph analysis of Dr. Milligan's opinion was inadequate to explain why that opinion, in its entirety, was entitled to little weight.
In discounting Dr. Milligan's opinion, the ALJ did not specifically address these various conclusions, cite contradictory medical opinions or evidence, or otherwise explain why these findings were unsupported by the record.
In an attempt to save the ALJ's decision, the Commissioner points to record evidence that conflicts with Dr. Milligan's opinions, and therefore supports the conclusion that Dr. Milligan's opinions were not entitled to controlling weight. She cites, for example, a number of treatment records that allegedly undermine Dr. Milligan's conclusion that Lavoie's pain and depression frequently interfered with her attention and concentration. Doc. No. 12-1 at 8-9. This argument is unpersuasive, however, because a reviewing court "cannot uphold the ALJ's decision based on rationales unarticulated in the record."
Simply put, the ALJ did not provide a sufficiently clear basis to discount Dr. Milligan's opinions. And, as such, a remand is required.
For the foregoing reasons, I deny the Commissioner's motion to affirm (Doc. No. 12), grant Lavoie's motion to reverse (Doc. No. 9), and remand the case for further proceedings pursuant to the fourth sentence of 42 U.S.C. § 405(g). The clerk is directed to enter judgment accordingly and close the case.
SO ORDERED.