MARY GORDON BAKER, Magistrate Judge.
This case is before the court for a Report and Recommendation pursuant to Local Rule 73.02(B)(2)(a), D.S.C., concerning the disposition of Social Security cases in this District, and Title 28, United States Code, Section 636(b)(1)(B). The Plaintiff, Robin Alfreda Cole, brought this action pursuant to Section 205(g) of the Social Security Act, as amended, (42 U.S.C. Section 405(g)), to obtain judicial review of a final decision of the Commissioner of Social Security Administration regarding her claim for disability insurance benefits ("DIB") under Title II of the Social Security Act. For the reasons stated herein, the undersigned recommends that the Commissioner's findings be reversed and remanded.
The Plaintiff applied for DIB on May 16, 2012, and was 43 years old on her alleged disability onset date of August 1, 2010. (R. 155.) The Plaintiff claimed disability due to depression, stenosis, spondylosis, degenerative disc disease ("DDD"), severe headaches, numbness in legs, protruding disc in lower back/sacral, fusing in thoracic spine, and fusion in cervical neck area. (R. 178.) The Plaintiff's application for DIB was denied initially and on reconsideration. (R. 89-92, 96-97.) The Plaintiff requested a hearing, which was held on May 22, 2014, before an Administrative Law Judge ("ALJ"). The ALJ issued his decision on August June 17, 2014, and it is now the Commissioner's final decision for purposes of judicial review. (R. 16-24.) The Plaintiff filed an appeal to the Appeals Council which was denied review. (R. 5-10.) In making the determination that the Plaintiff was not entitled to benefits, the Commissioner adopted the following findings of the ALJ:
(R. 16-24.)
The Act provides that disability benefits shall be available to those persons insured for benefits, who are not of retirement age, who properly apply, and who are under a "disability." 42 U.S.C. § 423(a). "Disability" is defined in the Act as the inability to "engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which 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" twelve months. See 42 U.S.C. § 423(d)(1)(A).
To facilitate a uniform and efficient processing of disability claims, the Act has by regulation reduced the statutory definition of "disability" to a series of five sequential questions. An examiner must consider whether the claimant (1) is engaged in substantial gainful activity, (2) has a severe impairment, (3) has an impairment which equals an illness contained in the Administration's official Listing of Impairments found at 20 C.F.R. Part 4, Subpart P, Appendix 1, (4) has an impairment which prevents past relevant work, and (5) has an impairment which prevents him from doing substantial gainful employment. See 20 C.F.R. § 404.1520. If an individual is found not disabled at any step, further inquiry is unnecessary. See 20 C.F.R. § 404.1520(a)(4); see also Hall v. Harris, 658 F.2d 260 (4th Cir. 1981).
A plaintiff is not disabled within the meaning of the Act if she can return to past relevant work as it is customarily performed in the economy or as the claimant actually performed the work. See SSR 82-62, 1982 WL 31386, at *3. The plaintiff bears the burden of establishing her inability to work within the meaning of the Act. 42 U.S.C. § 423(d)(5). She must make a prima facie showing of disability by showing that she is unable to return to her past relevant work. Grant v. Schweiker, 699 F.2d 189, 191 (4th Cir. 1983); see also Pass v. Chater, 65 F.3d 1200, 1203 (4th Cir. 1995).
Once an individual has established an inability to return to her past relevant work, the burden is on the Commissioner to come forward with evidence that the plaintiff can perform alternative work and that such work exists in the regional economy. See Grant, 699 F.2d at 191. The Commissioner may carry the burden of demonstrating the existence of jobs available in the national economy which the plaintiff can perform despite the existence of impairments which prevent the return to past relevant work by obtaining testimony from a vocational expert. See id. at 191-92.
The scope of judicial review by the federal courts in disability cases is narrowly tailored to determine whether the findings of the Commissioner "are supported by substantial evidence and whether the correct law was applied." Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990); see also Richardson v. Perales, 402 U.S. 389 (1971); 42 U.S.C. § 405(g). Consequently, the Act precludes a de novo review of the evidence and requires the court to uphold the Commissioner's decision as long as it is supported by substantial evidence. Pyles v. Bowen, 849 F.2d 846, 848 (4th Cir. 1988) (citing 42 U.S.C. § 405(g); Smith v. Schweiker, 795 F.2d 343, 345 (4th Cir. 1986)). The phrase "substantial evidence" is defined as:
Smith v. Chater, 99 F.3d 635, 637-38 (4th Cir. 1996) (internal quotation marks and citations omitted). Thus, it is the duty of this Court to give careful scrutiny to the whole record to assure that there is a sound foundation for the Commissioner's findings, and that her conclusion is rational. Thomas v. Celebrezze, 331 F.2d 541, 543 (4th Cir. 1964). If there is substantial evidence to support the decision of the Commissioner, that decision must be affirmed. Blalock v. Richardson, 483 F.2d 773, 775 (4th Cir. 1972).
The Plaintiff asserts the ALJ erred in the following three ways:
(Dkt. No. 12.)
The Plaintiff argues that the ALJ did not properly weigh the opinions of Dr. William E. Prenatt, the Plaintiff's treating family practitioner, and the opinions of the state agency physicians in his residual functional capacity ("RFC") analysis (Dkt. No. 12 at 20-28.) Under the regulations of the Social Security Administration, the Commissioner is obligated to consider all medical evidence and the opinions of medical sources, including treating physicians. 20 C.F.R. § 404.1545; see also 20 C.F.R. § 404.1527. The regulation, known as the "Treating Physician Rule," imposes a duty on the Commissioner to "evaluate every medical opinion we receive." 20 C.F.R. § 404.1527(c). Special consideration is to be given to the opinions of treating physicians of the claimant, based on the view that "these sources are likely to be the medical professionals most able to provide a detailed, longitudinal picture of [the claimant's] medical impairment(s) and may bring a unique perspective to the medical evidence that cannot be obtained from objective medical findings alone or from reports of individual examinations, such as consultative examinations or brief hospitalizations." 20 C.F.R. § 404.1527(c)(2).
Under some circumstances, the opinions of the treating physicians are to be accorded controlling weight. Even where the opinions of the treating physicians of the claimant are not accorded controlling weight, the Commissioner is obligated to weigh those opinions in light of a broad range of factors, including the examining relationship, the nature and extent of the treatment relationship, supportability of the opinions in the medical record, consistency, and whether the treating physician was a specialist. 20 C.F.R. § 404.1527(c)(1)-(5). "A treating physician is entitled to great weight because it reflects a judgment based on continuing observation over a number of years." Campbell v. Bowen, 800 F.2d 1247, 1250 (4th Cir. 1986). An ALJ must provide specific and legitimate reasons supported by the record for the weight given to a treating physician's opinion. See Bishop v. Commissioner of Social Sec., 583 Fed. App'x. 65, 67 (4th Cir.2014) ("given the specific and legitimate reasons provided, the ALJ was permitted to reject the treating physician's opinion in its entirety"); Mastro v. Apfel, 270 F.3d 171, 178 (4th Cir.2001) (finding no error in ALJ's decision not to give a treating physician's opinion controlling weight where specific and legitimate grounds were given); Doyal v. Barnhart, 331 F.3d 758, 764 (10th Cir. 2003) (holding the ALJ was required to provide specific, legitimate reasons for rejecting treating physician's opinion).
Considering the factors under 20 C.F.R. § 404.1527(c)(1)-(5), Dr. Prenatt's opinions must be examined closely. Dr. Prenatt has been the primary treating physician for the Plaintiff for several years. In determining the Plaintiff's RFC, the ALJ stated that he gave "little weight" to the opinions from treating family practitioner Dr. Prenatt. (R. 23.) In finding the Plaintiff could perform sedentary work
(R. 23.) The ALJ did not elaborate on how Dr. Prenatt's limitations were inconsistent with the record and his clinical findings.
On June 10, 2013,
"[T]he ALJ must state `specific reasons for the weight given to the treating source's medical opinion,' to enable reviewing bodies to identify clearly the reasons for the ALJ's decision." Sharp v. Colvin, 660 F. App'x 251 (4th Cir. 2016) (quoting Social Security Ruling (SSR) 96-2p, 61 Fed. Reg. 34,490, 34,492 (July 2, 1996)). The ALJ may not generally cite to the record to discredit a medical source opinion, but must identify "a particular category of evidence." Id. (finding ALJ's analysis was sufficient where "the ALJ did not cite specific pages in the record [but] his explanation relied on and identified a particular category of evidence."). In Sharpe, the Fourth Circuit held that the ALJ's citation to an opinion's inconsistency with the treating physician's office notes was sufficient to satisfy SSR 96-2p. Id. The Sharpe court analyzed the treating physician's practice notes and concluded that substantial evidence supported the ALJ's Decision.
In the case at bar, the ALJ's finding that Dr. Prenatt's limitations were inconsistent with "evidence of record" is not a "specific reason" as required by SSR 96-2p. The ALJ's finding that Dr. Prenatt's limitations were inconsistent with "his clinical findings on examination" does identify a particular category of evidence as required by Sharpe. However, this court is unable to determine if the weight given to Dr. Prenatt's opinion is supported by substantial evidence. The court has reviewed Dr. Prenatt's records, which are substantial. (R. 308-316, 349-358, 366-386.) This court does not readily see an inconsistency between Dr. Prenatt's records and his opinion.
This court is most troubled, however, with the ALJ's synopsis of the Plaintiff's testimony regarding Dr. Prenatt's opinion. The ALJ stated that the Plaintiff testified that Dr. Prenatt asked the Plaintiff what she could do and then filled out the form containing his opinion accordingly. (R. 23.) The ALJ then concluded that Dr. Prenatt's opinion was merely "the claimant's subjective complaints as opposed to a valid medical opinion." (Id.) The ALJ's finding is not an accurate synopsis of the Plaintiff's testimony, and his subsequent conclusion is flawed.
The Plaintiff testified as follows:
(R. 56-57.) The Plaintiff repeatedly testified that Dr. Prenatt "had me do things," "asked me to do certain things," "helped me get up on the table, asked me if I could lay down flat, had me grab his hands." The testimony was clear that Dr. Prenatt actually made the Plaitniff perform tasks to evaluate her abilities. To state that Dr. Prenatt only asked the Plaintiff questions and then wrote her answers on the form is a mischaracterization of the testimony and not supported by any evidence in the record.
This court finds that substantial evidence does not support the ALJ's finding the Dr. Prenatt's opinion was entitled to little weight. The only specific reason discussed in any detail by the ALJ was a mischaracterization of the Plaintiff's testimony. The other specific reason simply cited to Dr. Prenatt's "clinical findings on examination," which, upon review, this court does not find constitutes substantial evidence in light of the mischaracterized testimony. Therefore, this court recommends that the ALJ's Decision be reversed and remanded for a new hearing and does not reach the Plaintiff's other assignments of error.
It is therefore
IT IS SO RECOMMENDED.
