Angela Edwards v. Comm of Social Security
Filing
OPINION filed: AFFIRMED, decision not for publication. Ralph B. Guy , Jr., (authoring) Circuit Judge; Jeffrey S. Sutton, Circuit Judge and David W. McKeague, Circuit Judge.
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NOT RECOMMENDED FOR FULL-TEXT PUBLICATION
File Name: 16a0032n.06
No. 15-3546
UNITED STATES COURT OF APPEALS
FOR THE SIXTH CIRCUIT
FILED
ANGELA EDWARDS,
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Plaintiff-Appellant,
v.
COMMISSIONER OF SOCIAL SECURITY,
Defendant-Appellee.
_________________________________/
Jan 19, 2016
DEBORAH S. HUNT, Clerk
On Appeal from the United States
District Court for the Southern
District of Ohio
Before: GUY, SUTTON, and McKEAGUE, Circuit Judges
RALPH B. GUY, JR., Circuit Judge. Angela Edwards brought this action for review
of the Commissioner’s final decision denying her applications for Social Security Disability
Insurance Benefits (DIB) and Supplemental Security Income (SSI). See 42 U.S.C. §§ 405(g) and
1383(c)(3). Edwards argues that the decision failed to properly weigh certain treating source
medical opinions and, therefore, was not supported by substantial evidence. The district court
rejected plaintiff’s contentions, and we affirm.
I.
Edwards applied for DIB and SSI in October 2007, alleging disability beginning April 1,
2006, at age 41, due to physical and mental impairments. Edwards, who did not complete 12th
grade or obtain a GED, had past relevant work experience as a customer service representative,
telemarketer, housekeeper, and factory packer. After her applications were denied initially and
upon reconsideration, a hearing was held before an administrative law judge (ALJ) on January
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26, 2010. The ALJ issued a partially favorable decision finding that Edwards was not disabled
prior to January 14, 2010, but that her worsened mental condition rendered her disabled as of
January 14, 2010. Granting Edwards’ request for review, the Appeals Council vacated that
decision and remanded for further consideration and reassessment of her residual functional
capacity. In doing so, the Appeals Council stated that it was “not clear in light of the medical
evidence of record that the residual functional capacity assessment in the hearing decision
represent[ed] the most the claimant can do despite her impairments.”
A second hearing was held before a different ALJ on April 4, 2012. Further medical
evidence was provided, Edwards testified again, and testimony was received from another
medical expert and a different vocational expert. Employing the familiar five-step sequential
evaluation process required by 20 C.F.R. §§ 404.1520 and 416.920, the ALJ concluded that
Edwards had not been under a disability within the meaning of the Social Security Act since the
date of her applications for DIB and SSI.
In that decision, the ALJ found Edwards had severe impairments consisting of
degenerative joint disease in the knees (status post-bilateral arthroscopic surgeries), obesity
(post-gastric bypass surgery), lumbar spondylosis, affective disorder, anxiety disorder, and
estimated borderline intelligence. Edwards has not challenged the ALJ’s determination that her
impairments, considered singly and in combination, did not meet or equal the severity of any
listed impairment. See 20 C.F.R., pt. 404, subpt. P, app. 1, 1.04A (spine), 1.02A (knees),
1.00(B)(2)(b) (inability to ambulate effectively), 12.04 (affective disorders), and 12.06 (anxiety
disorders); 20 C.F.R. §§ 404.1525-1526, 416.925-926.1
1
In reaching that conclusion, the ALJ evaluated the B criteria under Listings 12.04 and 12.06 and found that
Edwards’ mental impairments resulted in mild restriction in the activities of daily living; moderate difficulty
maintaining social functioning; moderate difficulty maintaining concentration, persistence, or pace; and no episodes
of decompensation of extended duration.
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After weighing the evidence, the ALJ determined that Edwards retained the physical
capacity to perform work activities that required her to lift/carry or push/pull no more than 20
pounds occasionally and 10 pounds frequently; stand/sit/walk for six hours in an eight-hour day
with normal breaks; never crawl, climb ladders or scaffolds, or work at unprotected heights or
around hazardous machinery; and only occasionally stoop, kneel, crouch, or climb ramps or
stairs. In addition, the ALJ found that Edwards could only perform work that involved simple,
routine, or repetitive tasks that did not require a rapid pace, more than ordinary changes in setting
or duties, or more than minimal interaction with coworkers, supervisors or the public. Finally,
given her age, limited education, and residual functional capacity, the ALJ concluded that
Edwards could perform both her past relevant work as a factory packer and other unskilled light
work that exists in the national economy (i.e., inspector, folder/stacker, and machine tender).
That became the final decision of the Commissioner when the Appeals Council denied review,
and this action followed.
The magistrate judge reviewed Edwards’ claims of error and recommended reversal on
the grounds that the ALJ had failed to comply with the “treating source rule.” Concluding
otherwise, however, the district court sustained the Commissioner’s objections, declined to adopt
the magistrate judge’s report and recommendation, and affirmed the Commissioner’s denial of
Edwards’ applications for DIB and SSI. Edwards appealed.
II.
The Commissioner determines whether a claimant is disabled within the meaning of the
Social Security Act, and judicial review is limited to “whether the Commissioner’s decision ‘is
supported by substantial evidence and was made pursuant to proper legal standards.’” Ealy v.
Comm’r of Soc. Sec., 594 F.3d 504, 512 (6th Cir. 2010) (quoting Rogers v. Comm’r of Soc. Sec.,
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486 F.3d 234, 241 (6th Cir. 2007)). Failure to follow the agency’s own rules and regulations
denotes a lack of substantial evidence, although violation of a procedural requirement may be
deemed harmless error. Cole v. Astrue, 661 F.3d 931, 940 (6th Cir. 2011). On appeal, the
district court’s conclusions on these issues are reviewed de novo. Id. at 937.
The agency’s regulations require that a treating source’s medical opinion concerning the
nature and severity of a claimant’s impairments be given “controlling weight” as long as it “[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[.]”
20 C.F.R.
§§ 404.1527(c)(2), 416.927(c)(2). If a treating source’s opinion is not found controlling, the ALJ
must determine the weight that it should be given based on a number of factors, including the
length, frequency, nature, and extent of the treatment relationship, as well as the “area of
specialty and the degree to which the opinion is consistent with the record as a whole and is
supported by relevant evidence.” Gayheart v. Comm’r of Soc. Sec., 710 F.3d 365, 376 (6th Cir.
2013); see 20 C.F.R. §§ 404.1527(c)(2)-(6), 416.927(c)(2)-(6).
As a procedural requirement, the ALJ must also provide “good reasons” for discounting
the weight to be given to a treating source’s opinion. Gayheart, 710 F.3d at 376. The reasons
must be supported by the evidence in the record and sufficiently specific to ensure that the rule is
applied and to permit meaningful review. Id. Edwards contends that the ALJ’s reasons for
discounting certain treating source opinions were insufficient because, as we explained in
Gayheart, an ALJ may not apply more rigorous scrutiny to a treating source’s opinion than to an
examining or reviewing source’s opinion “as a means to justify giving such an opinion little
weight.” Id. at 380.
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Initially, as Edwards acknowledges on appeal, the ALJ did not err by declining to give
controlling weight to the conclusory opinions reported by a number of treating sources on a
succession of Department of Job and Family Services’ “Request for Limited Medical Data”
forms. Each of those forms simply listed Edwards’ relevant diagnoses and indicated without
explanation that she was unable to work for a period of twelve months from the date the form
was completed.
See White v. Comm’r of Soc. Sec., 572 F.3d 272, 286 (6th Cir. 2009)
(recognizing that conclusory statements from medical sources may properly be discounted by an
ALJ). Indeed, the regulations make clear that no special significance is to be given to the source
of an opinion on issues that are reserved to the Commissioner—including statements that a
claimant is “disabled” or “unable to work.” See20 C.F.R. §§ 404.1527(d)(3), 416.927(d)(3).
Those conclusory opinions were permissibly weighed based on factors such as the length,
frequency, nature and extent of the treatment relationship.
Next, we find that the ALJ provided adequate reasons for discounting the extremely
limited physical capacity assessment provided by treating physician Rafael Bloise, M.D., on
January 8, 2010. Specifically, Dr. Bloise’s assessment indicated that Edwards could only stand
or walk for thirty minutes of an eight-hour workday; could only sit for thirty minutes of an eighthour workday; could only lift up to ten pounds frequently and five pounds occasionally; and was
moderately limited in her abilities to push, pull, bend, reach, handle, see, hear, speak and perform
repetitive foot movements. However, although Dr. Bloise examined Edwards six times between
July 2009 and October 2010, there were “no clinical findings in his treatment notes that would
support such extreme limitations.” Even on January 8, 2010, Dr. Bloise’s physical examination
did not include musculoskeletal or neurological assessments.
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Nor do the treatment records from orthopedists James Abbott, M.D., and Jon Sulentic,
D.O., from July 2008 through November 2009 lend greater weight to Dr. Bloise’s functional
capacity assessment.
Edwards has osteoarthritis in both knees and underwent arthroscopic
surgery for a torn medial meniscus first in the left knee in September 2008 and then in the right
knee in March 2009.
Edwards emphasizes, as she did at both hearings, that the surgical
treatment notes confirmed bilateral degenerative joint disease with specific areas of moderate to
severe chondromalacia (cartilage damage). A month after the first surgery, Dr. Abbott noted that
Edwards was walking comfortably and reported no knee pain. Surgery on the right knee was
less successful, and Edwards was seen for pain by Dr. Sulentic. Edwards declined referral to a
pain clinic and received a total of three Supartz injections in October and November 2009.
At the first hearing, medical expert Donald Junglas, M.D., an internist, testified that Edwards’
degenerative changes and obesity would cause discomfort but did not necessarily mean that she
had more than mild arthritis.
Edwards, who weighed more than 300 pounds at the time of the first hearing, underwent
gastric bypass surgery in November 2010, and had lost nearly 100 pounds at the time of the
second hearing in April 2012.
An x-ray of her right knee in August 2011 showed mild
degenerative changes, and Edwards sought treatment from orthopedist Todd Kelley, M.D., in
February 2012. Dr. Kelley ordered x-rays of Edwards’ right knee that showed subtle arthrosis,
small joint effusion, and joint space narrowing that was not previously well defined. Edwards
reported that the weight loss had benefited her knee pain, and Dr. Kelley observed that she
ambulated independently without an assistive device and had a mild to moderate antalgic gait.
Her left knee had full range of motion and no effusion, while her right knee had mild effusion
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and crepitus with range of motion from 5 to 115 degrees. The following month, Dr. Kelley
administered a cortisone injection in her right knee and offered to do so periodically as needed.
Finally, the ALJ provided adequate reasons for discounting the mental functional
capacity assessments of: (1) treating psychologist Steve Warkany, M.Ed., M.S.E., dated October
3, 2007; and (2) treating psychiatrist Anthony Whitaker, M.D., dated January 14, 2010. Edwards
argues that the ALJ improperly discounted these two treating source opinions because they were
based on self-reports during clinical interviews. This court has explained that when “mental
illness is the basis of a disability claim, clinical and laboratory data may consist of the diagnosis
and observations of professionals trained in the field of psychopathology.” Blankenship v.
Bowen, 874 F.2d 1116, 1121 (6th Cir. 1989) (quoting Poulin v. Bowen, 817 F.2d 865, 873-74
(D.C. Cir. 1987)). Also, “[t]he report of a psychiatrist should not be rejected simply because of
the relative imprecision of the psychiatric methodology or the absence of substantial
documentation, unless there are other reasons to question the diagnostic techniques.” Id.
Mr. Warkany’s functional capacity assessment dated October 3, 2007, was provided after
Edwards was referred to Core Behavioral Health for mental health treatment following a visit to
the psychiatric emergency services in August 2007 for depression, insomnia, auditory
hallucinations, suicidal thoughts, and superficial cuts to her forearms.
Mr. Warkany’s
assessment opined that Edwards was markedly limited in “her ability to maintain attention and
concentration, perform at a consistent pace, get along with coworkers and respond to changes in
the work setting.”
The basis for his assessment was identified only as “interviews with
clinicians” without specifying to whom that referred, but the ALJ considered the possibility that
Mr. Warkany was referring to himself since he had been the clinician who signed the initial
intake assessment of Edwards dated September 26, 2007. Assuming that was the case, however,
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the record of that initial intake assessment did not reflect self-reports or clinical observations
regarding her functional limitations beyond stating the diagnoses of bipolar disorder (most recent
episode depressed), personality disorder NOS, and a current Global Assessment Functioning
(GAF) score of 50 with a high in the past year of 55.
The ALJ explained that he gave more weight to the consultative psychological evaluation
by Richard Sexton, Ph.D., dated December 11, 2007, because it contained the most thorough
mental status examination in the file. That evaluation was based on his examination, as well as
Edwards’ self-reports regarding her ability to live independently, care for herself, perform
regular household chores, and maintain a few friendships. Dr. Sexton concluded that Edwards
was capable of performing simple repetitive tasks, was able to carry out simple instructions, and
was mildly impaired in her ability to interact with others and tolerate daily work stress. The ALJ
also gave significant weight to the opinion of Alice Chambly, Psy.D., who reviewed the record
for the state agency in January 2008.
Dr. Chambly opined that Edwards was capable of
performing simple routine tasks that have low production standards and require no more than
superficial interactions with coworkers, supervisors, or the public.
Dr. Whitaker provided a mental residual functional capacity assessment just before the
first hearing in January 2010, which indicated that Edwards was markedly limited in many workrelated functions and moderately limited in the rest. Dr. Whitaker also signed an incomplete
mental impairment questionnaire for counsel dated January 19, 2010, which concluded that
Edwards would miss more than four days of work per month. Dr. Whitaker’s opinions were
based on Edwards’ initial visit on January 14, 2010, when he diagnosed bipolar disorder with
antipsychotic features, antisocial personality disorder, panic disorder, PTSD, and ADHD.
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However, Dr. Whitaker provided an incomplete questionnaire that did not identify signs or
symptoms or rate any of the Paragraph B criteria.2
Further, psychiatrist Alfred Jonas, M.D., the medical expert who testified at the hearing
in April 2012, disagreed with Dr. Whitaker’s suggestion that Edwards experienced “thought
broadcasting,” and found no support in the record for the diagnoses of antisocial personality
disorder or ADHD. Dr. Jonas testified that Edwards should be limited to work involving simple
routine tasks that did not require a lot of social interaction. Despite Edwards’ assertion on
appeal, it is a misreading of Rogers, 486 F.3d at 245, to suggest that a reviewing opinion may be
given greater weight than a treating source’s opinion only if it relies on a report from a specialist
that was not available to the treating source. See SSR 96-6p, 1996 WL 374180, at *3 (July 2,
1996) (“In appropriate circumstances, opinions from State agency medical and psychological
consultants and other program physicians and psychologists may be entitled to greater weight
than the opinions of treating or examining sources.”); 20 C.F.R. § 404.1527(e)(2)(i)-(ii)
(evaluation of non-examining medical expert opinion).
Review of the record as a whole reveals that the ALJ addressed the relevant evidence and
provided adequate reasons for discounting the treating source opinions relied upon by Edwards
in assessing her residual functional capacity for work-related activities.
AFFIRMED.
2
Edwards has abandoned reliance on an assessment that was signed by Dr. Whitaker “for Dr. Rahman” and dated
March 9, 2012, which noted that Dr. Whitaker had just seen Edwards on March 7, 2012, but had otherwise not seen
her since the initial visit on January 14, 2010.
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