TIMOTHY S. BLACK, District Judge.
This is a Social Security disability benefits appeal. At issue is whether the administrative law judge ("ALJ") erred in finding the Plaintiff "not disabled" and therefore not entitled to supplemental security income ("SSI") and disability insurance benefits ("DIB"). (See Administrative Transcript ("Tr.") (Tr. 10-19) (ALJ's decision)).
Plaintiff filed his applications for DIB and SSI on February 3, 2011. (Tr. 193, 199). He alleged disability since November 13, 2007, due to lumbar spine degenerative disc disease and numbness and weakness in his left leg. (Tr. 12-13, 193, 199). The state agency denied Plaintiff's applications at the initial stage of review (Tr. 129, 132) and upon reconsideration (Tr. 138, 145).
At Plaintiff's request, the ALJ convened an administrative hearing on August 16, 2012. (Tr. 27-82). Plaintiff appeared with his counsel and testified. (Tr. 32-76). An independent vocational expert also testified. (Tr. 76-81).
On September 5, 2012, the ALJ issued a decision finding that Plaintiff had the severe impairments of degenerative disc disease of the lumbar and obesity, but determined that neither of these impairments, alone or in combination, met or medically equaled a Listing. The ALJ concluded that Plaintiff was not disabled at any time through the date of his decision. (Tr. 18-19). The Appeals Council denied Plaintiff's request for review and this appeal followed. (Tr. 1-3).
Plaintiff is 44 years old. (Tr. 33). He completed eleventh grade. (Tr. 37). Plaintiff's past relevant work experience includes saw operator, delivery driver, shipping clerk, and welder.
The ALJ's "Findings," which represent the rationale of her decision, were as follows:
(Tr. 12-19).
In sum, the ALJ concluded that Plaintiff was not under a disability as defined by the Social Security Regulations, and was therefore not entitled to SSI or DIB. (Tr. 19).
On appeal, Plaintiff argues that: (1) the ALJ failed to accord proper weight to Plaintiff's treating physician; (2) the ALJ impermissibly substituted her own opinion for that of the examining physicians; and (3) the ALJ erred in selectively picking portions of the record to support her non-disability finding. The Court will address each error in turn.
The Court's inquiry on appeal is to determine whether the ALJ's non-disability finding is supported by substantial evidence. 42 U.S.C. § 405(g). Substantial evidence is "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 401 (1971). In performing this review, the Court considers the record as a whole. Hephner v. Mathews, 574 F.2d 359, 362 (6th Cir. 1978). If substantial evidence supports the ALJ's denial of benefits, that finding must be affirmed, even if substantial evidence also exists in the record upon which the ALJ could have found plaintiff disabled. As the Sixth Circuit has explained:
Felisky v. Bowen, 35 F.3d 1027, 1035 (6th Cir. 1994).
The claimant bears the ultimate burden to prove by sufficient evidence that he is entitled to disability benefits. 20 C.F.R. § 404.1512(a). That is, he must present sufficient evidence to show that, during the relevant time period, he suffered an impairment, or combination of impairments, expected to last at least twelve months, that left him unable to perform any job in the national economy. 42 U.S.C. § 423(d)(1)(A).
The record reflects that:
Plaintiff suffered a work-related low back injury on February 16, 2007, while working in a factory. Plaintiff tried to keep working despite his injury and did work for several months, but ultimately stopped working beginning November 13, 2007, which is his alleged onset date. Imaging studies of the lumbar spine demonstrated an anular tear at the L4-5 level and advanced degenerative disc disease at the L5-S1 level. (Tr. 13).
Plaintiff had Workman's Compensation consulting physicians. In May 2008, Judith Wachendorf, M.D., recommended that Plaintiff be limited to a range of sedentary work activity for a limited period of two months. In March 2009, orthopedic specialist Alan Kohlhaas concluded that Plaintiff was limited to sedentary type work "at the present time" but recommended reexamination in 60 days, after Plaintiff completed a course of steroid injunctions. (Tr. 16). In October 2010, Nancy McDonough, M.D., suggested that Plaintiff should avoid lifting more than 10 to 15 pounds occasionally and recommended that he alternate between sitting, standing, and walking every 20 minutes.
Plaintiff initially treated with two chiropractic physicians, Drs. Robert Pruitt and Dr. Robert Spees. These physicians arranged for Plaintiff to have a surgical consultation. This consultation was conducted by Dr. John Roberts on November 8, 2007 shortly before Plaintiff stopped working. (Tr. 336-349). Dr. Roberts, having reviewed the MRI of record (Tr. 432), advised Dr. Spees that he believed Plaintiff's pain was "arising from the highly collapsed disc at the L5-S1 level in addition to the annular tear evidence at the L4-L5 level" (Tr. 338). Dr. Roberts opined that this would continue to be very bothersome (i.e., painful) for Plaintiff and that he may "require a spine fusion of the involved levels." Dr. Roberts recommended strengthening exercises, restriction to light duty work, and analgesics. (Tr. 13).
Prior to seeing Dr. Roberts, Plaintiff had undergone an EMG performed on August 24, 2007 by Dr. Robinson. (Tr. 333-335). Dr. Robinson's testing demonstrated predominately left sided radiculopathy. (Id.) Dr. Robinson's findings prompted Dr. Spees to refer Plaintiff to the surgical consultation with Dr. Roberts.
Plaintiff was reluctant to undergo a significant surgical procedure and elected more conservative care, including extensive chiropractic care. (Tr. 421-620, 621-637). Plaintiff also sought treatment with Dr. Mitchell Simons, a pain management physician. Plaintiff saw Dr. Simons extensively. (Tr. 638-643, 657-667, 668-670, 671-674).
Dr. Simons provided a treating source opinion and RFC assessment dated August 7, 2012.
In terms of his RFC assessment, Dr. Simons stated that Plaintiff was capable of sitting for about four hours in a normal eight-hour working day (with normal breaks) and standing and walking about two hours in the same span of time. Dr. Simons further indicated that Plaintiff would need to take unscheduled breaks during an eight hour workday about every 30 minutes. He further opined that Plaintiff's impairments would likely produce good days and bad days, estimating that Plaintiff would likely be absent from work as a result of his back problems more than four days a month.
Plaintiff did undergo a one-time consultative examination with Dr. Phillip Swedburg, a physician appointed to examine him at the request of the state agency. (Tr. 675-685). Dr. Swedberg, like Dr. Simons, limited Plaintiff to no more than four hours sitting in an eight hour day (although otherwise suggesting greater functional abilities). Dr. Swedberg found that Plaintiff demonstrated no paravertebral muscle spasm, no muscle weakness or atrophy, no tenderness, negative straight leg raise test, normal sensation, brisk deep tendon reflexes, and no evidence of radiculopathy. (Tr. 13).
An examination performed in May 2008 for Plaintiff's Workman's Compensation claim demonstrated tenderness at the lumbosacral junction and decreased sensation over the left lower leg, no muscle spasm, 5/5 strength, normal reflexes, and good range of motion. The examining physician noted that Plaintiff walked with an antalgic gait and appeared to be uncomfortable sitting. Another consultative exam in March 2009 demonstrated no neurologic abnormalities but a somewhat painful range of motion. Orthopedist Alan Kohlhass, M.D., noted that Plaintiff was able to ambulate well without his cane during that visit. An exam in October 2010 demonstrated slightly reduced leg strength on the left side and decreased sensation over the left foot, but no other significant abnormalities. Dr. Kohlhass noted that Plaintiff ambulated without an assistive device, but had a stiff-legged gain; was independent with a home exercise program; his care and medications were "stable;" and, an MRI showed a broad left paracentral non-compressive disc involving L5-S1 with mild to moderate discogenic spondylosis, a small disc deformity at L4-5, and mild facet arthropathy.
The ALJ found that Plaintiff had the RFC to perform light work as defined in 20 CFR 404.1567(b) and 416.967(b), with these additional limitations: claimant is able to stand or walk continuously for 30 minutes per hour, for a total of 4 hours in an 8 hour workday; he is able to sit for 6 hours in an 8 hour workday; the claimant is able to occasionally balance, stoop, kneel, crouch, crawl, and climb ramps or stairs; he can never climb ladders, ropes, or scaffolds; the claimant will occasionally use a cane for ambulating outside of his home; he should avoid concentrated exposure to extreme cold and vibration; and, the claimant should avoid all exposure to hazards, including heights and machinery.
First, Plaintiff maintains that the ALJ failed to accord proper weight to his treating physician, Dr. Simons.
Generally, the medical opinions of treating physicians are afforded greater deference than those of non-treating physicians. Rogers v. Comm'r of Soc. Sec., 486 F.3d 234, 242 (6th Cir. 2007). "Because treating physicians are `the medical professionals most able to provide a detailed, longitudinal picture of [a claimant's] medical impairment(s) and may bring a unique perspective to the medical evidence that cannot be obtained from the objective medical findings alone,' their opinions are generally accorded more weight than those of non-treating physicians." Id. at 242 (quoting 20 C.F.R. § 416.927(d)(2)). A treating physician's opinion is given "controlling weight" if it is supported by "medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with other substantial evidence in the case record." Id.
When a treating source opinion is not entitled to controlling weight, the regulations provide that the ALJ must consider several factors when determining what weight to give the opinion. 20 C.F.R. § 404.1527(d)(2), 416.927(d)(2). The factors include: the examining relationship, the treating relationship (its length, frequency of examination, and its nature and extent), the supportability by clinical and laboratory signs, consistency, specialization, and other enumerated criteria. 20 C.F.R. § 404.1527(d), 416.927(d).
A violation of the "good reasons rule" is considered harmless error if: (1) the treating source's opinion is so patently deficient that the commissioner could not possibly credit it; (2) if the Commissioner adopts the opinion of the treating source or makes findings consistent with the opinion; or (3) where the Commissioner has met the goals of Section 1527(d)(2)...even though he or she has not complied with the terms of the regulation. Cole v. Astrue, 661 F.3d 931, 940 (6th Cir. 2011). In the last of these circumstances, the procedural protections at the heart of the rule may be met when the "supportability" of the doctor's opinion, or its consistency with other evidence in the record, is indirectly attacked via an ALJ's analysis of a physician's other opinions or his analysis of the claimant's ailments. Nelson v. Comm'r of Soc. Sec., 195 F. App'x 462, 470-71 (6th Cir. 2006). In other words, "[i]f the ALJ's opinion permits the claimant and a reviewing court a clear understanding of the reasons for the weight given a treating physician's opinion, strict compliance with the rule may sometimes be excused." Friend v. Comm'r of Soc. Sec., 375 F. App'x 543, 551 (6th Cir. 2010).
The ALJ offered two "reasons" for rejecting Dr. Simons' opinion: (1) Dr. Simons clearly wishes to help Plaintiff in his Social Security and Workers' Compensation claims; and (2) Plaintiff often reported good pain control with ongoing use of medications, therapies, and injections. First, the ALJ's "reason" is nothing more than speculation. The ALJ fails to cite any support for his allegation that Dr. Simons overstated Plaintiff's limitations to help him obtain benefits. Second, the ALJ explained that Dr. Simons's opinion was not supported by his own treatment notes, which indicated that Plaintiff had been stable in pain management. (Tr. 17).
Moreover, all of the factors in 20 C.F.R. 404.1527 support giving Dr. Simons' opinion great weight. First, Dr. Simons is a "specialist," with special training and expertise in the area of pain management. Second, the "frequency of examination" reflects that Dr. Simons saw Plaintiff at least
Accordingly, rejecting Dr. Simons's opinion is not supported by substantial evidence.
Next, Plaintiff argues that the ALJ impermissibly substituted her own RFC opinion for that of the examining physicians.
The RFC is an administrative finding of fact of the most that a claimant can perform despite his medical impairments. 20 C.F.R. § 404.1545(a), 416.945(a). It is solely the province of the ALJ to formulate the RFC. Edwards v. Comm'r of Soc. Sec., 97 F. App'x 567, 569 (6th Cir. 2004). The assessment must be based upon all of the relevant evidence, not just medical source opinions. 20 C.F.R. §§ 404.1546(c), 416.946(c). Here, the ALJ did not rely on the record in determining Plaintiff's RFC.
The ALJ gave consultative physician, Dr. Swedberg, great weight. (Tr. 16).
When, as here, the non-disability determination is not supported by substantial evidence, the Court must decide whether to reverse and remand the matter for rehearing or to reverse and order benefits granted. The Court has authority to affirm, modify or reverse the Commissioner's decision "with or without remanding the cause for rehearing." 42 U.S.C. § 405(g); Melkonyan v. Sullivan, 501 U.S. 89, 100 (1991).
Generally, benefits may be awarded immediately "only if all essential factual issues have been resolved and the record adequately establishes a plaintiff's entitlement to benefits." Faucher v. Sec'y of Health & Human Servs., 17 F.3d 171, 176 (6th Cir. 1994); see also Abbott v. Sullivan, 905 F.2d 918, 927 (6th Cir. 1990); Varley v. Sec'y of Health & Human Servs., 820 F.2d 777, 782 (6th Cir. 1987).
The Court may award benefits where the proof of disability is strong and opposing evidence is lacking in substance, so that remand would merely involve the presentation of cumulative evidence, or where the proof of disability is overwhelming. Faucher, 17 F.3d at 176; see also Felisky, 35 F.3d at 1041; Mowery v. Heckler, 772 F.2d 966, 973 (6th Cir. 1985). Such is the case here.
Here proof of disability
The decision of the Commissioner, that David Sweet was not entitled to supplemental security income, is hereby found to be
The Clerk shall enter judgment accordingly, and this case shall be