DONETTA W. AMBROSE, Senior District Judge.
Plaintiff filed an application for disability benefits pursuant to Title II, alleging disability beginning on March 18, 2010, as the result of mental and physical impairments. Her claim was denied initially and upon hearing. The Appeals Council denied her request for review. Plaintiff now appeals the Commissioner's decision. For the following reason, Plaintiff's Motion will be granted, and Defendant's denied. This matter will be remanded for further proceedings consistent with this Opinion.
Judicial review of the Commissioner's final decisions on disability claims is provided by statute. 42 U.S.C. §§ 405(g) 6 and 1383(c)(3) 7. Section 405(g) permits a district court to review the transcripts and records upon which a determination of the Commissioner is based, and the court will review the record as a whole. See 5 U.S.C. §706. When reviewing a decision, the district court's role is limited to determining whether the record contains substantial evidence to support an ALJ's findings of fact.
A district court cannot conduct a
Plaintiff asserts that the ALJ erred on the following grounds: 1) in weighing the medical opinion evidence, including the opinion of Plaintiff's treating psychologist; and 2) in failing to include all of her limitations in the RFC.
First, Plaintiff asserts that the ALJ erred in giving little weight to the opinion of her treating psychologist, Nancy Baker, and affording great weight to the opinion of a state agency physician, Dr. Heil.
"It is axiomatic that the Commissioner cannot reject the opinion of a treating physician without specifically referring to contradictory medical evidence."
In this case, the ALJ found that Plaintiff had "severe" impairments,
In turn, Dr. Heil's August 18, 2011 analysis included medical record evidence from Blair Medical Associates, relating to Plaintiff's physical condition; it also included an assessment of Plaintiff's activities of daily living. There is no suggestion in the record that he examined or met with Plaintiff.
The ALJ afforded Dr. Baker's "assessment little weight, since . . . her opinion is inconsistent with her findings, the clinical findings of record, and with other substantial evidence." Instead, the ALJ gave "significant probative weight" to Dr. Heil's report, which he found "consistent with and supported by the medical evidence of record."
It may be true that Dr. Baker's opinion was inconsistent, either internally or with clinical findings and other substantial evidence. Unfortunately, the ALJ's opinion does not allow assessment of those supposed inconsistencies. The only medical evidence of record that the ALJ discusses regarding Plaintiff's mental condition is reports of Dr. Heil and Dr. Baker. Thus, it is wholly unclear which medical evidence he deemed consistent with Dr. Heil's opinion, and which clinical evidence he deemed inconsistent with the opinions offered by Dr. Baker. Moreover, Dr. Heil's opinion was not based on any medical provider's assessment of Plaintiff's mental condition; his opinion predated her treatment with Dr. Baker.
Defendant points out several instances in the record in which non-mental health providers commented on Plaintiff's mental state at the time of her appointments.
Moreover, the ALJ rendered his analysis of Plaintiff's mental condition in connection with his assessment of whether Plaintiff's anxiety and panic attacks, which he deemed "severe impairments," met or equaled Listing 12.06. He concluded that Plaintiff's impairment did not meet the criteria of that Listing, which requires that Plaintiff be completely unable to function independently outside the area of her home. In his subsequent discussion of the RFC, the ALJ referred to Plaintiff's mental impairment as follows: "The claimant's severe mental impairments consisting of anxiety and panic attacks are analyzed above in Finding 4 [at step three of the sequential process]." He rendered no further analysis of Plaintiff's mental impairments beyond his analysis in step three. The failure to meet or equal a Listing, however, is not dispositive of disability. As the ALJ acknowledged, after arriving at a negative conclusion at step three of the sequential analysis, the analysis must continue to step four. Here, it is unclear that the ALJ fully considered Plaintiff's mental impairments in connection with the RFC. Review is further complicated by the fact that the ALJ, unlike Dr. Heil, found Plaintiff's anxiety and panic attacks "severe," but the discrepancy is unexplained.
Second, Plaintiff complains that the RFC failed to include all of her functional limitations. "`Residual functional capacity is defined as that which an individual is still able to do despite the limitations caused by his or her impairment(s).'"
As regards Plaintiff's mental impairments, the ALJ found that Plaintiff suffered from moderate limitations in social functioning, concentration, persistence, and pace. The RFC states,
This RFC adequately accounts for the limitations found by the ALJ.
In sum, this matter will be remanded for further proceedings in order for the ALJ to clarify or re-evaluate his treatment of the medical opinion evidence regarding Plaintiff's mental impairments. An appropriate Order follows.
AND NOW, this 4th day of September, 2014, it is hereby ORDERED, ADJUDGED, and DECREED that Plaintiff's Motion is GRANTED, and Defendant's DENIED, and this matter is remanded for further proceedings consistent with the foregoing Opinion.