GREG WHITE, Magistrate Judge.
Plaintiff John Rudish II ("Rudish") challenges the final decision of the Acting Commissioner of Social Security, Carolyn W. Colvin ("Commissioner"), denying his claim for a Period of Disability ("POD") and Disability Insurance Benefits ("DIB") under Title II and Title XVI of the Social Security Act ("Act"), 42 U.S.C. §§ 416(i), 423 et seq. This matter is before the Court pursuant to 42 U.S.C. § 405(g) and Local Rule 72.2(b).
For the reasons set forth below, it is recommended that the final decision of the Commissioner be VACATED and the case REMANDED.
On September 27, 2010, Rudish filed an application for POD and DIB alleging a disability onset date of April 17, 2008. (Tr. 10.) His application was denied both initially and upon reconsideration.
On May 17, 2012, an Administrative Law Judge ("ALJ") held a hearing during which Rudish, represented by counsel, and an impartial vocational expert ("VE") testified. On June 19, 2012, the ALJ found Rudish was able to perform a significant number of jobs in the national economy and, therefore, was not disabled. The ALJ's decision became final when the Appeals
Council denied further review.
Age forty-five (45) at the time of his administrative hearing, Rudish is a "younger person" under social security regulations. See 20 C.F.R. § 404.1563(c). (Tr. 17.) Rudish has a limited education and past relevant work as a carpenter and laborer. Id.
In order to establish entitlement to DIB under the Act, a claimant must be insured at the time of disability and must prove an inability to engage "in substantial gainful activity by reason of any medically determinable physical or mental impairment," or combination of impairments, that 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." 20 C.F.R. §§ 404.130, 404.315 and 404.1505(a).
A claimant is entitled to a POD only if: (1) he had a disability; (2) he was insured when he became disabled; and (3) he filed while he was disabled or within twelve months of the date the disability ended. 42 U.S.C. § 416(i)(2)(E); 20 C.F.R. § 404.320.
Rudish was insured on his alleged disability onset date, April 17, 2008, and remained insured through the date of the ALJ's decision, June 19, 2012. (Tr. 12.) Therefore, in order to be entitled to POD and DIB, Rudish must establish a continuous twelve month period of disability commencing between these dates. Any discontinuity in the twelve month period precludes an entitlement to benefits. See Mullis v. Bowen, 861 F.2d 991, 994 (6th Cir. 1988); Henry v. Gardner, 381 F.2d 191, 195 (6th Cir. 1967).
The ALJ found Rudish established medically determinable, severe impairments, due to degenerative disc disease and depression; however, his impairments, either singularly or in combination, did not meet or equal one listed in 20 C.F.R. Pt. 404, Subpt. P, App. 1. (Tr. 12-13.) Rudish was found incapable of performing his past relevant work, but was determined to have a Residual Functional Capacity ("RFC") for a limited range of light work. (Tr. 14, 17.) The ALJ then used the Medical Vocational Guidelines ("the grid") as a framework and VE testimony to determine that Rudish was not disabled. (Tr. 17-18.)
This Court's review is limited to determining whether there is substantial evidence in the record to support the ALJ's findings of fact and whether the correct legal standards were applied. See Elam v. Comm'r of Soc. Sec., 348 F.3d 124, 125 (6th Cir. 2003) ("decision must be affirmed if the administrative law judge's findings and inferences are reasonably drawn from the record or supported by substantial evidence, even if that evidence could support a contrary decision."); Kinsella v. Schweiker, 708 F.2d 1058, 1059 (6th Cir. 1983). Substantial evidence has been defined as "[e]vidence which a reasoning mind would accept as sufficient to support a particular conclusion. It consists of more than a mere scintilla of evidence but may be somewhat less than a preponderance." Laws v. Celebrezze, 368 F.2d 640, 642 (4th Cir. 1966); see also Richardson v. Perales, 402 U.S. 389 (1971).
The findings of the Commissioner are not subject to reversal merely because there exists in the record substantial evidence to support a different conclusion. Buxton v. Halter, 246 F.3d 762, 772-3 (6th Cir. 2001) (citing Mullen v. Bowen, 800 F.2d 535, 545 (6th Cir. 1986)); see also Her v. Comm'r of Soc. Sec., 203 F.3d 388, 389-90 (6th Cir. 1999)("Even if the evidence could also support another conclusion, the decision of the Administrative Law Judge must stand if the evidence could reasonably support the conclusion reached. See Key v. Callahan, 109 F.3d 270, 273 (6
In addition to considering whether the Commissioner's decision was supported by substantial evidence, the Court must determine whether proper legal standards were applied. Failure of the Commissioner to apply the correct legal standards as promulgated by the regulations is grounds for reversal. See, e.g.,White v. Comm'r of Soc. Sec., 572 F.3d 272, 281 (6
Finally, a district court cannot uphold an ALJ's decision, even if there "is enough evidence in the record to support the decision, [where] the reasons given by the trier of fact do not build an accurate and logical bridge between the evidence and the result." Fleischer v. Astrue, 774 F.Supp.2d 875, 877 (N.D. Ohio 2011) (quoting Sarchet v. Chater, 78 F.3d 305, 307 (7
Rudish argues that the ALJ discounted the opinion of his treating physician, Patricia Matto, D.O., without giving good reasons for doing so. (ECF No. 14 at 9-12.) Furthermore, Rudish also asserts that the ALJ improperly rejected the results of a functional capacity evaluation. Id. at 12-13. The Commissioner argues Dr. Matto's opinion was not well-supported by objective clinical findings and the limitations she ascribed to Rudish were inconsistent with other substantial evidence of record. (ECF No. 16 at 8-10.) The Commissioner also maintains that the ALJ was not required to give any special deference to the functional capacity evaluation performed by a non-medical source. Id. at 10-11.
Under Social Security regulations, the opinion of a treating physician is entitled to controlling weight if such opinion (1) "is well-supported by medically acceptable clinical and laboratory diagnostic techniques" and (2) "is not inconsistent with the other substantial evidence in [the] case record." Meece v. Barnhart, 2006 WL 2271336 at * 4 (6th Cir. Aug. 8, 2006); 20 C.F.R. § 404.1527(c)(2). "[A] finding that a treating source medical opinion . . . is inconsistent with the other substantial evidence in the case record means only that the opinion is not entitled to `controlling weight,' not that the opinion should be rejected." Blakley v. Comm'r of Soc. Sec., 581 F.3d 399 (6th Cir. 2009) (quoting Soc. Sec. Rul. 96-2p, 1996 SSR LEXIS 9 at *9); Meece, 2006 WL 2271336 at * 4 (Even if not entitled to controlling weight, the opinion of a treating physician is generally entitled to more weight than other medical opinions.) Indeed, "[t]reating source medical opinions are still entitled to deference and must be weighed using all of the factors provided in 20 C.F.R. § 404.1527 and 416.927." Blakley, 581 F.3d at 408.
If the ALJ determines a treating source opinion is not entitled to controlling weight, "the ALJ must provide `good reasons' for discounting [the opinion], reasons that are `sufficiently specific to make clear to any subsequent reviewers the weight the adjudicator gave to the treating source's medical opinion and the reasons for that weight.'" Rogers, 486 F.3d at 242 (quoting Soc. Sec. Ruling 96-2p, 1996 SSR LEXIS 9 at * 5). The purpose of this requirement is two-fold. First, a sufficiently clear explanation "`let[s] claimants understand the disposition of their cases,' particularly where a claimant knows that his physician has deemed him disabled and therefore `might be bewildered when told by an administrative bureaucracy that she is not, unless some reason for the agency's decision is supplied.'" Id. (quoting Wilson v. Comm'r of Soc. Sec., 378 F.3d 541, 544 (6th Cir. 2004)). Second, the explanation "ensures that the ALJ applies the treating physician rule and permits meaningful appellate review of the ALJ's application of the rule." Wilson, 378 F.3d at 544. Because of the significance of this requirement, the Sixth Circuit has held that the failure to articulate "good reasons" for discounting a treating physician's opinion "denotes a lack of substantial evidence, even where the conclusion of the ALJ may be justified based upon the record." Rogers, 486 F.3d at 243.
Nevertheless, the opinion of a treating physician must be based on sufficient medical data, and upon detailed clinical and diagnostic test evidence. See Harris v. Heckler, 756 F.2d 431, 435 (6
Rudish asserts that the ALJ failed to give appropriate weight to the opinion of his treating physician, Dr. Matto. Specifically, Rudish points to a Medical Source Statement completed by Dr. Matto on September 16, 2010. (Tr. 289-296.) Therein, Dr. Matto indicated that she saw Rudish at least once every three months since a work related injury sustained in May of 2008. (Tr. 289.) Dr. Matto noted that Rudish suffered from lumbar disc protrusion causing "[c]onstant low back pain with intermittent spasm." Id. She explained that Rudish's pain was "daily" and precipitating factors included prolonged sitting, standing, and walking. Id. The pain "waxes + wanes in intensity daily." Id. Dr. Matto identified positive signs such as reduced range of motion in the lumbar spine and in both hips, abnormal posture, trigger points, tenderness, muscle spasm, abnormal gait, and positive straight leg raising test. (Tr. 289-290.) She further noted that range of motion testing was limited by pain. (Tr. 290.) Dr. Matto, however, did not believe that emotional factors contributed to Rudish's functional limitations. Id. She found that Rudish's pain was severe enough to constantly interfere with attention and concentration. Id. Dr. Matto observed that the side effects of Rudish's medications included dizziness and drowsiness. (Tr. 290-291.) Dr. Matto did not indicate how long she believed Rudish could sit continuously, but did note that he would need to alternate postures by walking for 15 minutes. (Tr. 291.) She did, however, state that Rudish could sit for a total of four hours in an eight-hour work day. (Tr. 292.) In what seems somewhat contradictory, Dr. Matto indicated that Rudish could stand or walk for 15 minutes before alternating postures by sitting or lying down, but then indicated alternating postures was not medically indicated. (Tr. 292.) She stated that Rudish could stand or walk for a total of two hours in an eight-hour work day. Id. Dr. Matto also averred that Rudish would require a one-hour long rest break in a reclining or supine position in addition to regularly allowed rest breaks in order to relieve pain. (Tr. 293.) She opined that Rudish could lift up to 20 pounds occasionally and up to 10 pounds frequently. (Tr. 294.) Finally, Dr. Matto believed that Rudish would be absent from work more than three times per month due to his impairments, which had persisted at their present level for the past two years. (Tr. 296.)
The ALJ addressed Dr. Matto's opinion as follows:
(Tr. 16.)
The Commissioner does not challenge Rudish's assertion that Dr. Matto qualifies as a treating physician. (ECF No. 16 at 8-10.) The ALJ, therefore, was required to provide good reasons for rejecting the limitations she assessed. Without any meaningful analysis or discussion, the ALJ offered four reasons for effectively rejecting Dr. Matto's opinion: (1) it was "incomplete;" (2) it did not reference specific clinical findings; (3) it was inconsistent with the medical evidence; and, (4) it was inconsistent with Rudish's daily activities. (Tr. 16.)
The first reason offered by the ALJ for rejecting Dr. Matto's opinion — that the assessment was incomplete — is without merit. Rudish argues that rejecting the opinion of treating source merely because there is one, minor omission on the form is "not a factor considered under the regulations, and is otherwise an insufficient reason here." (ECF No. 14 at 11.) As accurately pointed out by Rudish, "the only section of the eight page opinion that is incomplete is question 11A which asks the physician for her opinion regarding Plaintiff's ability to continuously sit during a workday."
The ALJ's second reason for rejecting Dr. Matto's opinion was that it allegedly failed to provide specific clinical findings used in developing the opinion. (Tr. 16.) This statement is simply inaccurate. Dr. Matto's opinion unequivocally indicates that the limitations assessed therein are based on the diagnosis of lumbar disc protrusion, as well as the following clinical observations: reduced range of motion in the lumbar spine and in both hips; abnormal posture; trigger points; tenderness; muscle spasm; abnormal gait; and, positive straight leg raising test. (Tr. 289-291.) To the extent the ALJ intended to suggest that Dr. Matto failed to reference MRIs or x-rays confirming the diagnosis of lumbar disc protrusion, the ALJ has failed to explain how such an omission undermines Dr. Matto's opinion, especially where the ALJ found Rudish's severe impairments included degenerative disc disease. Furthermore, an MRI from May 2008 indicates that Rudish had moderate disc space narrowing at L4-L5, as well as L5-S1, with small disk protrusion at both levels. (Tr. 265.) While the opinion of a treating physician must be based on sufficient medical data and upon detailed clinical and diagnostic test evidence, the failure of a treating source to allude to such evidence does not necessarily undermine his opinion where it is not seriously disputed that such evidence is contained in the record.
The ALJ's third reason for rejecting Dr. Matto's opinion, that "medical evidence ... establishes that [Rudish] can sustain full-time employment," is conclusory and devoid of explanation, thus depriving this Court of the ability to conduct a meaningful review. The ALJ failed to reference specific medical evidence of record that was inconsistent with Dr. Matto's opinion. The ALJ mentions the opinions of three mental health consultants that are wholly irrelevant to the physical limitations assessed by Dr. Matto. The ALJ also rejected as not coming from an acceptable medical source the examination findings of an occupational therapist which were arguably even more restrictive than those of Dr. Matto. (Tr. 17.) The only other medical evidence concerning Rudish's physical functional limitations cited by the ALJ are the opinions of two State Agency medical consultants, whose findings are admittedly less restrictive than Dr. Matto's findings. Id. The ALJ appears to have ascribed some weight to these opinions, though he incorporated a more restrictive lifting restriction while expressly rejecting their opinion that Rudish required a sit/stand option.
Gayheart v. Comm'r of Soc. Sec., 710 F.3d 365, 377 (6
Accordingly, inconsistencies with the opinions of non-treating State Agency physicians do not constitute "good reasons" for rejecting the opinion of Dr. Matto, a treating source. Therefore, this Court cannot accept the ALJ's blanket assertion that Dr. Matto's opinion was inconsistent with the medical evidence.
The fourth and final reason given by the ALJ for rejecting Dr. Matto's opinion was that Rudish's daily activities are consistent with full-time employment. Nevertheless, the ALJ does not explain how Rudish's daily activities undermine Dr. Matto's opinion. Elsewhere in the opinion, the ALJ references Rudish driving from Buffalo, New York on one occasion in 2008 and the fact that Rudish continues to drive.
The mere fact that Rudish is able to perform the activities discussed in the paragraph above in spite of his alleged pain is not necessarily indicative of an ability to perform substantial gainful activity for eight hours a day. See, e.g. Walston v. Gardner, 381 F.2d 580, 586 (6
Finally, the Commissioner raises several arguments in her brief regarding purported inconsistencies between Dr. Matto's opinion as to Rudish's functional limitations and her treatment notes, which allegedly reveal a lack of physical examinations. (ECF No. 16 at 9-10.) However, the ALJ did not offer this explanation in his decision. Accordingly, these arguments constitute post hoc rationale that this Court cannot rely on to supplement the reasoning set forth in the ALJ's decision. See, e.g., Bable v. Astrue, 2007 U.S. Dist. LEXIS 83635, 27-28 (N.D. Ohio Oct. 31, 2007) (citing NLRB v. Ky. River Cmty. Care, Inc., 532 U.S. 706, 715, n. 1, 121 S.Ct. 1861, 149 L.Ed.2d 939 (2001)); Sarchet v. Chater, 78 F.3d 305 (7
The Court finds that the ALJ erred by failing to give good reasons for rejecting the limitations assessed by Dr. Matto. As such, in the interests of judicial economy, the Court declines to address Rudish's remaining assignments of error.
For the foregoing reasons, the Court finds the decision of the Commissioner not supported by substantial evidence. Accordingly, the decision should be VACATED and the case REMANDED, pursuant to 42 U.S.C. § 405(g) sentence four, for further proceedings consistent with this Report and Recommendation.