KIMBERLY A. JOLSON, Magistrate Judge.
Plaintiff, Robert L. Foreman, brings this action under 42 U.S.C. § 405(g) seeking review of a final decision of the Commissioner of Social Security ("Commissioner") denying his application for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI"). For the reasons set forth below, it is
Plaintiff filed his application for DIB and SSI on February 6, 2015, alleging that he was disabled beginning October 12, 2002. (Tr. 322-34). After his application was denied initially and on reconsideration, the Administrative Law Judge (the "ALJ") held a hearing on October 27, 2017. (Tr. 36-55). At the hearing, Plaintiff amended his alleged onset date to February 3, 2015, and dismissed his claim for DIB. (Tr. 38-39). As such, the ALJ only considered Plaintiff's claim for SSI. (Tr. 16). On April 26, 2018, the ALJ issued a decision denying Plaintiff's application for benefits. (Tr. 16-29). The Appeals Council denied Plaintiff's request for review, making the ALJ's decision the final decision of the Commissioner. (Tr. 1-4).
In his decision, the ALJ found that Plaintiff had not engaged in substantial gainful activity since October 12, 2002, his alleged onset date. (Tr. 19). He found that Plaintiff suffers from the following severe impairments: disorders of the spine, degenerative joint disease, obesity, anxiety disorder, and mood disorder. (Id.). The ALJ, however, found that none of Plaintiff's impairments, either singly or in combination, met or medically equaled a listed impairment. (Tr. 19).
As for Plaintiff's residual functional capacity ("RFC"), the ALJ opined:
(Tr. 22).
On February 11, 2019, Plaintiff filed the instant case seeking a review of the Commissioner's decision. (Doc. 1). This matter is now fully briefed and ripe for resolution. (See Docs. 9, 10, 11).
The ALJ summarized the testimony from Plaintiff's hearing:
(Tr. 23).
The ALJ also usefully summarized Plaintiff's medical records and symptoms:
(Tr. 24-25).
After thoroughly reviewing the hearing testimony and medical record, the ALJ concluded that Plaintiff's statements about the intensity, persistence, and limiting effects of his symptoms were "somewhat inconsistent with the record." (Tr. 25). The ALJ elaborated on this conclusion:
(Id.).
The ALJ then turned to the opinion evidence. First, he considered the opinions of state agency consultants, Dr. Venkatachala Sreenivas and Dr. Leon Hughes, who opined in 2015 that Plaintiff could perform light exertional work but with certain postural limitations. (Tr. 26). The ALJ afforded these opinions "significant weight," explaining that "they are generally consistent with the record[.]" (Id.). He noted that, although the consultants did not treat or examine Plaintiff, "they provided specific reasons for their opinions about [his] residual functional capacity showing that they were grounded in evidence in the case record, including careful consideration of the treating and examining doctor's opinion as well as the claimant's allegations about his symptoms and limitations." (Id.).
Next, the ALJ considered the opinions of state consultants, Dr. Cindy Matyi and Dr. Jame Lai, who opined as to Plaintiff's mental health limitations in the workplace. (Id.). The ALJ assigned their opinions "some weight," explaining that they cited "the old version of the B criteria," were "vague," and were "not in specific vocational terms." (Id.).
The ALJ then turned to the opinions of Plaintiff's treating physician Dr. Michael Sayegh. In February 2015, Dr. Sayegh opined in a medical source statement that Plaintiff had limited ability to sit, stand, and walk due to pain and should avoid bending, stooping, lifting, and carrying. (Tr. 574). He also opined that Plaintiff's concentration and ability to think clearly could be impacted by his pain and medications. (Id.). In August 2017, Dr. Sayegh partially completed another medical source statement. (Tr. 651-54). He noted that, as of July 27, 2017, Plaintiff was no longer his patient. (Tr. 651). He listed Plaintiff's diagnoses and opined that they were expected to last at least twelve months. (Id.). However, he did not complete the remaining three pages of the form and did not opine on Plaintiff's functional limitations. (See Tr. 652-54).
The ALJ afforded Dr. Sayegh's opinions "little weight." He explained:
(Tr. 26-27).
Finally, the ALJ considered the opinion of consultative examiner, Dr. Sarah Barwick, who opined in May 2015 that Plaintiff lacked the capacity to respond appropriately to work pressure in a work setting. (Tr. 27). The ALJ assigned this opinion "some" weight "to the extent that it is consistent with the record," but explained that it "is not well explained and lacks specificity." (Id.).
The Court's review "is limited to determining whether the Commissioner's decision is supported by substantial evidence and was made pursuant to proper legal standards." Winn v. Comm'r of Soc. Sec., 615 F. App'x 315, 320 (6th Cir. 2015); see also 42 U.S.C. § 405(g). "[S]ubstantial evidence is defined as `more than a scintilla of evidence but less than a preponderance; it is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.'" Rogers v. Comm'r of Soc. Sec., 486 F.3d 234, 241 (6th Cir. 2007) (quoting Cutlip v. Sec'y of HHS, 25 F.3d 284, 286 (6th Cir. 1994)).
"After the Appeals Council reviews the ALJ's decision, the determination of the council becomes the final decision of the Secretary and is subject to review by this Court." Olive v. Comm'r of Soc. Sec., No. 3:06 CV 1597, 2007 WL 5403416, at *2 (N.D. Ohio Sept. 19, 2007) (citing Abbott v. Sullivan, 905 F.2d 918, 922 (6th Cir. 1990); Mullen v. Bowen, 800 F.2d 535, 538 (6th Cir. 1986) (en banc)). If the Commissioner's decision is supported by substantial evidence, it must be affirmed, "even if a reviewing court would decide the matter differently." Id. (citing 42 U.S.C. § 405(g); Kinsella v. Schweiker, 708 F.2d 1058, 1059-60 (6th Cir. 1983)).
In his sole assignment of error, Plaintiff asserts that the ALJ failed to provide good reasons for not assigning controlling weight to the opinions of his treating physician, Dr. Sayegh. (See generally Doc. 9).
Two related rules govern how an ALJ is required to analyze a treating physician's opinion. Dixon v. Comm'r of Soc. Sec., No. 3:14-cv-478, 2016 WL 860695, at *4 (S.D. Ohio Mar. 7, 2016). The first is the "treating physician rule." Id. The rule requires an ALJ to "give controlling weight to a treating source's opinion on the issue(s) of the nature and severity of the claimant's impairment(s) if the opinion is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in the case record." LaRiccia v. Comm'r of Soc. Sec., 549 F. App'x 377, 384 (6th Cir. 2013) (quoting 20 C.F.R. § 404.1527(c)(2)) (internal quotation marks omitted).
Closely associated is "the good reasons rule," which requires an ALJ always to give "good reasons . . . for the weight given to the claimant's treating source opinion." Dixon, 2016 WL 860695, at *4 (quoting Blakely, 581 F.3d at 406 (alterations in original)); 20 C.F.R. § 404.1527(c)(2). In order to meet the "good reasons" standard, the ALJ's determination "must be 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." Cole, 661 F.3d at 937.
Wilson v. Comm'r of Soc. Sec., 378 F.3d 541, 544 (6th Cir. 2004) (internal citation and quotation marks omitted). The treating physician rule and the good reasons rule together create what has been referred to as the "two-step analysis created by the Sixth Circuit." Allums v. Comm'r of Soc. Sec., 975 F.Supp.2d 823, 832 (N.D. Ohio 2013).
Here the ALJ satisfied both steps. First, he recognized that, under the treating physician rule, treating physicians' opinions are generally afforded deference. He explained:
(Tr. 26-27).
With that framework in mind, the ALJ articulated good reasons, under the second step of the analysis, for assigning Dr. Sayegh's opinions "little weight." First, he found that Dr. Sayegh's opinions were too vague. (Tr. 27). He explained:
(Id.).
Plaintiff resists this explanation, maintaining that "[w]hile Dr. Sayegh may not have provided a traditional function-by-function analysis," he "identifies specific functional limitations," including that Plaintiff cannot bend, stoop, lift, or crawl. (Doc. 9 at 7). But in reviewing Dr. Sayegh's opinions, the Court finds that the ALJ reasonably concluded that they were unclear and overly vague.
In his first opinion, from February 25, 2015, Dr Sayegh opined that Plaintiff had the following limitations: "limited ability to sit/stand, walk [due to] pain; No bending, stooping, lifting, crawling; concentration and ability to think clearly may be affected by pain + meds (opioid therapy)." (Tr. 574). The rest of Dr. Sayegh's medical source statement is similarly threadbare. He listed his diagnoses and noted that he suffered from back pain for years due to an auto accident. (Tr. 573). Under the section asking for a description of "all pertinent findings on clinical examination (with dates) related to the patient's condition," Dr. Sayegh provided only, "lumbar paraspinal muscle tenderness/trigger pts., neuro sensation mod, tendon reflexes left leg, left leg raising test mildly positive." (Id.). Similarly, under the section asking for "available consultative/diagnostic testing . . . on file regarding the patient's condition," Dr. Sayegh wrote simply "MRI—L 3/22/12." As for "treatments/future treatments," he provided, "possible LESI, facet inj., rhizotomy, PT, CT, tens unit, back brace." (Id.). He also listed his medications and corresponding dosages. (Tr. 574). Finally, when asked for a written description of "the prescribed therapy and the patient's response to therapy," Dr. Sayegh wrote only "see above, helping pain and sciatica." (Id.).
Dr. Sayegh's second opinion is even less substantial. On August 28, 2017, Dr. Sayegh completed just part of a functional capacity checklist. (Tr. 651-54). Importantly, he noted that he no longer treated Plaintiff and that his last appointment with him was on July 27, 2017. (Tr. 651). He listed his diagnoses and noted that his prognosis was "fair." (Id.). However, Dr. Sayegh left the rest of the checklist blank and consequently, did not provide any opinions regarding his functional limitations. (See Tr. 652-54).
Given the conclusory and vague nature of Dr. Sayegh's opinions, substantial evidence supports the ALJ's decision discounting them. Indeed, another district court recently upheld an ALJ's decision for similar reasons. See Phillips v. Berryhill, No. 3:16-CV-193-CHL, 2017 WL 6045451, at *4 (W.D. Ky. Dec. 6, 2017). In Phillips, the court upheld the ALJ's decision rejecting the treating physician's opinion on the basis that it was vague, unexplained, and exaggerated. See id. Upon review of the treating physician's opinion, the court noted that, on a section of the form asking for an explanation of the basis for any functional limitations, the treating physician wrote only "`MRI" and "back surgery.'" Id. (citation omitted). The court found this explanation "both unclear and unhelpful in judging the rationale behind the limitations [the treating physician] placed on Plaintiff." Id. Moreover, the treating physician "did not attach any MRI results to her opinion or explain how specifically the `MRI' and `back surgery' supported her suggested limitations." Id. And, like the treating physician in this case, the treating physician in Phillips left an important explanatory section of the form blank. Id.
Ultimately, the court concluded that, "[b]ecause of the conclusory and explanation-free nature of [the treating physician's] limitations and the lack of supporting, objective findings, substantial evidence support[ted] the ALJ's decision to deny her opinion controlling weight." Id. (citing F.R. § 404.1527(c)(3) (stating that the more a medical source presents relevant evidence and explains the basis behind her medical opinion, the more weight the ALJ will afford to it)).
The same is true here. The ALJ applied the proper standard to Dr. Sayegh's opinions; however, he was not required to afford them controlling weight because they were unclear and unhelpful in ascertaining Plaintiff's functional limitations. See id. As the court noted in Phillips, "[t]he lack of objective medical evidence to support the [treating source] opinion qualifies as a `good reason' as used in 20 C.F.R. § 404.1527(c)." Consequently, Plaintiff has failed to show reversible error. See also Acosta v. Comm'r of Soc. Sec., No. 17-12414, 2018 WL 7254256, at *9-10 (E.D. Mich. Sept. 6, 2018), report and recommendation adopted, No. 17-12414, 2019 WL 275931 (E.D. Mich. Jan. 22, 2019) (holding that treating physician's opinions were vague and could not be "translate[d] into functional limitations that [could] be properly incorporated into an RFC," because, for example, the opinion does "not explain how plaintiff was limited or whether she could only do certain activities for a certain amount of time in each day"); Hanna v. Colvin, No. 5:13CV1360, 2014 WL 3749420, at *15 (N.D. Ohio July 30, 2014) (upholding ALJ's decision rejecting treating physician's opinion on the grounds that it was incomplete and internally inconsistent, and noting that "courts have upheld an ALJ's rejection of a physician opinion on the grounds that it is inconsistent, unclear, or vague"); Bennett v. Comm'r of Soc. Sec., No. 1:07-CV-1005, 2011 WL 1230526, at *4 (W.D. Mich. Mar. 31, 2011) (upholding ALJ's decision discounting physician's vague opinion) (citing Tempesta v. Astrue, No. CV-08-00003 (FB), 2009 WL 211362, at *7 (E.D.N.Y. Jan. 28, 2009) (characterizing treating physician's opinion as "vague," and therefore of little value to the ALJ)).
Briefly, the ALJ also found that Dr. Sayegh's opinions were "extreme and not consistent with the record, as detailed above, which shows the claimant was fairly normal on examination." (Tr. 27). Plaintiff asserts that the ALJ "failed to cite any specific treatment note or other part of the medical record to support" this conclusion. (Doc. 9 at 8). However, upon review of his decision, it is clear that the ALJ simply referred back to his earlier discussion of the records. (Tr. 27). Indeed, his opinion details various inconsistencies as well as benign or mild exam findings. (See, e.g., Tr. 24 (discussing 2009 exam records showing full strength, intact reflexes and sensory but antalgic gait); id. (discussing 2011 EMG records showing no evidence of overt lumbosacral radiculopathy, but showing findings indicative of early/mild sensory demyelinating peripheral neuropathy); id. (discussing March 2011 MRI results showing minimal impingement that had not significantly changed, but showing that his posterior central disc protrusion at L4-L5 had progressed); id. (discussing treatment with Dr. Sayegh, including exam records showing decreased sensation in the left lower leg and mild positive straight leg raise on the left leg); id. (discussing Dr. Sayegh's treatment records, including exam records revealing lower back trigger points and tenderness bilaterally, as well as anxiety and panic attacks); Tr. 24-25 (discussing exam records showing moderate decreased sensation and decreased tendon reflexes, as well as mildly positive straight leg raise tests on the left side); Tr. 25 (discussing October 2017 lumbar x-rays revealing osteopenia without acute osseous abnormalities, mild multi-level degenerative disc disease and facet disease in the lumbar)).
After considering these records, the ALJ concluded that the intensity of Plaintiff's symptoms as alleged were not supported by the record. He explained that Plaintiff's examinations, "as detailed above," were "fairly normal," and that any "abnormalities were fairly mild." (Id.). Accordingly, Plaintiff's argument that the ALJ failed to cite any treatment notes in support of his conclusion is unpersuasive.
At base, although Plaintiff may disagree with the ALJ's conclusion, the ALJ's decision to reject Dr. Sayegh's opinion was appropriate because he found it vague, lacking specificity, extreme, and inconsistent with the record. Further, the ALJ's explanation provided sufficient detail to satisfy the good-reasons requirement. See, e.g., Acosta, 2018 WL 7254256, at *9-10 (finding that the treating physicians' opinions were "too vague to provide any insight to plaintiff's specific functional abilities"); Phillips, 2017 WL 6045451, at *4 (upholding ALJ's decision discounting treating physician's opinion on the basis that it was "unclear and unhelpful in judging the rationale behind the limitations she placed on plaintiff"); Hanna (upholding ALJ's decision discounting treating physician's opinion where opinion was inconsistent with the medical evidence and incomplete and internally inconsistent). The ALJ therefore did not err in declining to assign Dr. Sayegh's opinions controlling weight.
Based on the foregoing, it is
If any party objects to this Report and Recommendation, that party may, within fourteen (14) days of the date of this Report, file and serve on all parties written objections to those specific proposed finding or recommendations to which objection is made, together with supporting authority for the objection(s). A District Judge of this Court shall make a de novo determination of those portions of the Report or specific proposed findings or recommendations to which objection is made. Upon proper objection, a District Judge of this Court may accept, reject, or modify, in whole or in part, the findings or recommendations made herein, may receive further evidence or may recommit this matter to the Magistrate Judge with instructions. 28 U.S.C. § 636(b)(1).
The parties are specifically advised that failure to object to the Report and Recommendation will result in a waiver of the right to have the district judge review the Report and Recommendation de novo, and also operates as a waiver of the right to appeal the decision of the District Court adopting the Report and Recommendation. See Thomas v. Arn, 474 U.S. 140 (1985); United States v. Walters, 638 F.2d 947 (6th Cir. 1981).
IT IS SO ORDERED.
