LANDYA McCAFFERTY, District Judge.
Brooke Higgins moves to reverse the decision of the Commissioner of the Social Security Administration denying her application for supplemental social security income. She contends that the Administrative Law Judge ("ALJ") erred by improperly considering and weighing the medical opinions in the record. The Commissioner moves to affirm the ALJ's decision. For the reasons discussed below, the court denies the Commissioner's motion to affirm and grants Higgins's motion to reverse.
In reviewing the final decision of the Commissioner in a social security case, the court "is limited to determining whether the [Administrative Law Judge] deployed the proper legal standards and found facts upon the proper quantum of evidence."
In determining whether a claimant is disabled, the ALJ follows a five-step sequential analysis. 20 C.F.R. § 416.920(a)(4). The claimant "has the burden of production and proof at the first four steps of the process."
At the fourth step of the sequential analysis, the ALJ assesses the claimant's residual functional capacity ("RFC"), which is a determination of the most a person can do in a work setting despite her limitations caused by impairments,
A detailed factual background can be found in Higgins's statement of facts (doc. no. 9) and the Commissioner's statement of facts (doc. no. 11). The court provides a brief summary of the case here.
Higgins initially applied for supplemental security income in July 2011; however, the claim was denied in June 2013 after Higgins failed to appear for an administrative hearing.
On September 3, 2015, Higgins filed another application for supplemental security income, alleging a disability onset date of June 21, 2014, when she was 32 years old. She alleged she was disabled due to fibromyalgia, post-traumatic stress disorder ("PTSD"), anxiety, sleep apnea, gastroesophageal reflux disorder, and migraine headaches. After her claim was denied at the initial level in November 2015, she requested a hearing before an ALJ.
The ALJ held an initial hearing on July 6, 2017, and a supplemental hearing on November 21, 2017. The ALJ denied Higgins's claim for benefits in a written decision dated January 10, 2018.
At step two, the ALJ found that Higgins had the following severe impairments: anxiety, a panic disorder, agoraphobia, PTSD, depression, bipolar disorder, marijuana abuse, a back disorder, headaches, and obesity. The ALJ found that Higgins had not presented sufficient evidence to establish that her alleged fibromyalgia was a medically determinable impairment. The ALJ also found that Higgins had medically determinable, but non-severe, chronic fatigue, torticollis, polycystic ovarian syndrome, obstructive sleep apnea, and hypothyroidism.
The ALJ concluded Higgins retained the RFC to:
Admin. Rec. at 26. In assessing Higgins's RFC, the ALJ gave "great weight" to medical opinions from Dr. Landerman, a non-examining state agency psychologist who completed a paper record review, and Dr. Fuess, a non-examining psychologist who reviewed Higgins's case record. Admin. Rec. 40-41. The ALJ gave "less than great weight" to a medical opinion from Dr. Bildner, a doctor who conducted a psychological evaluation at the request of Disability Determination Services, and "little weight" to a medical opinion from Dr. Murray, Higgins's primary care physician. Admin. Rec. 40-41.
At step five, the ALJ relied on a vocational expert's testimony, and concluded that Higgins was capable of performing jobs that exist in the national economy including mail clerk and fruit distributor. Accordingly, the ALJ found that Higgins was not disabled.
The Appeals Council denied Higgins's request for review in October 2018, making the ALJ's decision the Commissioner's final decision. This action followed.
Higgins contends that the ALJ erred in considering and weighing the medical opinions about Higgins's mental function limitations. Specifically, Higgins argues that the Commissioner erred by: (1) not considering or evaluating a medical opinion in the record from Dr. Ciri, a doctor who conducted a consultative exam on Higgins in 2012; (2) giving too little weight to Dr. Bildner's opinion; (3) giving great weight to Dr. Landerman's opinion; and (4) giving little weight to Dr. Murray's opinion. The Commissioner argues that, to the extent the ALJ made any errors, reversal is not mandated.
The ALJ is required to consider and evaluate every medical opinion that she receives.
The ALJ analyzes the opinions of state agency consultants, treating sources, and examining sources under the same rubric.
Dr. Ciri conducted a consultative examination on Higgins during the pendency of Higgins's initial application for supplemental security income in January 2012. At that time, Dr. Ciri noted that Higgins was visibly affected by depression and anxiety. Dr. Ciri administered a Wechsler Adult Intelligence test, and Higgins scored in the low average range. Dr. Ciri assigned Higgins a 50 on the "GAF" (Global Assessment of Functioning) scale. Dr. Ciri's opinion states that "[Higgins's] testing performance was impacted by anxiety, and she had significant difficulty, at times, producing answers on demand." Admin. Rec. at 443. Dr. Ciri observed that Higgins expressed difficulties with memory, rendering it "likely that she could have difficulties remembering and carrying out instructions."
The ALJ did not address Dr. Ciri's medical opinion in the written decision. As mentioned, an ALJ is required to evaluate all medical opinions. Ordinarily, "an ALJ's failure to consider a medical opinion in the record at all is legal error that requires remand."
The Commissioner acknowledges that the ALJ did not address Dr. Ciri's opinion but argues that this error does not mandate reversal because: (1) Dr. Ciri's opinion pre-dates the start of the relevant period; (2) the ALJ had, and considered, five other opinions regarding Higgins's mental limitations; (3) Dr. Ciri's opinion did not include a detailed mental RFC assessment and did not conclude that Higgins was precluded from performing all work; and, (4) it is not clear that the RFC would have been more restrictive if the ALJ had considered Dr. Ciri's report. Thus, the Commissioner contends that any error was harmless. The court is not persuaded by the Commissioner's arguments.
First, an ALJ is not free to disregard a medical opinion because the opinion predates the alleged onset of disability. Although such opinions may be of limited relevance in isolation, evidence that predates the onset of disability may help establish disability when considered and evaluated in combination with later evidence.
Second, the presence of multiple medical opinions on an issue does not obviate the requirement that an ALJ "always consider the medical opinions" in the claimant's case record. 20 C.F.R. § 416.927(b). Although an ALJ does not need to address every individual piece of evidence that is cumulative or unhelpful to the claimant, "an ALJ is not free to simply ignore medical opinions supporting a claimant's position."
In addition, the ALJ's failure to consider and evaluate Dr. Ciri's opinion may have caused the ALJ to erroneously give lesser weight to other favorable medical opinions. For example, the ALJ gave "less than great weight" to Dr. Bildner's opinion that Higgins was "unable to sustain prolonged attention and concentration," "unable to manage stress common to a work setting," and "unable to maintain a consistent schedule," because Dr. Bildner's opinion purportedly did not "state what objective evidence [Dr. Bildner] relied upon in making her assessment." Admin. Rec. 41. However, Dr. Bildner's opinion explicitly states that she reviewed Dr. Ciri's opinion in rendering her own opinion. Admin. Rec. 654. The ALJ also gave "little weight" to Dr. Murray's opinion, Higgins's treating physician, because the "objective evidence does not support extreme or marked limitations." Admin. Rec. 41. However, Dr. Ciri's opinion contains objective evidence that supports Dr. Murray's opinion. Therefore, if the ALJ had considered Dr. Ciri's opinion and the objective evidence contained therein, the ALJ may have afforded greater weight to the other favorable opinions and assessed Higgins as having a more restrictive RFC.
Although the Commissioner argues that reversal is not required, the Commissioner has not provided the court with legal authority that supports this outcome. On the contrary, numerous courts have remanded in similar circumstances.
Therefore, because it is the task of the ALJ, not this court, to resolve conflicts in the evidence and determine whether a claimant is disabled, this court remands the case to the ALJ.
Because the court concludes that the ALJ's failure to address Dr. Ciri's medical opinion requires reversal, the court need not address Higgins's additional challenges regarding the weight the ALJ afforded the other medical opinions in the record. Indeed, the ALJ may decide to assign different weights to those opinions after considering and evaluating Dr. Ciri's opinion.
For the foregoing reasons, Higgins's motion to reverse (doc. no. 8) is granted, and the Commissioner's motion to affirm (doc. no. 10) is denied. The clerk of court shall enter judgment in accordance with this order and close the case.
SO ORDERED.