Cordeiro v. Berryhill et al
Filing
55
Chief Judge Patti B. Saris: MEMORANDUM AND ORDER entered.Plaintiff's motion to vacate (Docket No. 45 ) is ALLOWED and the Commissioner's motion to affirm (Docket No. 26 ) is DENIED. The Court remands to the Social Security Administration for further proceedings consistent with this memorandum and order. SO ORDERED.(Lara, Miguel)
UNITED STATES DISTRICT COURT
DISTRICT OF MASSACHUSETTS
______________________________
)
CHERYL ANN CORDEIRO,
)
)
Plaintiff,
)
)
v.
)
Civil Action
)
No. 18-10203-PBS
ANDREW M. SAUL, Commissioner of
)
the Social Security Administration,)
)
Defendant.
)
______________________________
)
MEMORANDUM AND ORDER
August 2, 2019
Saris, C.J.
INTRODUCTION
Plaintiff Cheryl Ann Cordeiro brings this action under 42
U.S.C. § 405(g) for judicial review of a final decision denying
her application for Social Security Disability Insurance
(“SSDI”). She suffers from major depressive and anxiety
disorders and seeks SSDI benefits for September 1, 2000 to
December 31, 2005. She claims that the Administrative Law Judge
(“ALJ”) ignored and misconstrued key evidence, failed to develop
the record, and misapplied the vocational expert’s testimony.
For the following reasons, the Court ALLOWS Plaintiff’s
motion to vacate (Docket No. 45) and remands. The Court DENIES
the Commissioner’s motion to affirm (Docket No. 26).
1
FACTUAL BACKGROUND
The following facts are taken from the administrative
record. Plaintiff is a 59-year-old woman who lives with her
husband of 38 years in Somerset, Massachusetts.
I.
Educational and Work History
Plaintiff has an eleventh-grade education and has not
earned a GED. She volunteered at a women’s center from 1994 to
1996. Between 1995 and 2000, she worked as a babysitter at a
counseling office. She resigned from that position due to severe
depression and panic attacks. She worked as a caregiver parttime from 2008 to 2014. She was insured for the purposes of SSDI
through December 31, 2005.
II.
Medical History
At age 13, Plaintiff was admitted to a psychiatric facility
after overdosing on her mother’s medications in an attempted
suicide. She has a family history of mental illness but not
suicide attempts or substance abuse. She has consistently
reported being a victim of sexual, physical, and domestic abuse.
On August 8, 2000, at age 40, Plaintiff sought mental
health treatment at Child and Family Services of Fall River
(“CFS”) following a severe depressive incident that she called a
“nervous breakdown.” Soon after, Dr. Marshall Wold, a
psychiatrist who saw her four times, diagnosed her with “Major
Depressive Disorder, Recurrent, Severe With Psychotic Features.”
2
See Am. Psychiatric Ass’n, Diagnostic and Statistical Manual of
Mental Disorders (4th ed., text rev. 2000) code 296.34 (DSM-IVTR). Dr. Wold prescribed her Zoloft, which improved but did not
eliminate her symptoms. Plaintiff also saw John McMullen, a
licensed independent clinical social worker at CFS. He noted
slight improvements in her symptoms, some of which were followed
by recurrences. Mr. McMullen also continuously noted that she
felt unable to return to work. Plaintiff was forced to stop
treatment at CFS at the end of 2000 due to a lack of insurance.
On February 4, 2002, CFS formally terminated its relationship
with Plaintiff. In that document, CFS noted that her GAF had
improved as a result of treatment.
Around the time of her nervous breakdown in 2000, Plaintiff
applied for disability benefits (though it is unclear from the
record which state or federal disability program she applied
to). A hearing on her application was scheduled for November 7,
2000, but she was erroneously sent a denial letter and did not
attend. She did not appeal the erroneous denial because she was
debilitated following her breakdown.
After her 2000 treatment at CFS, there is a gap in the
medical records regarding Plaintiff’s psychiatric condition.
Except for one visit to a doctor for lower back pain after a
motor vehicle accident in 2002, the next medical care reflected
in the records is Plaintiff’s August 2007 visit to Dr. Gloria
3
Mercado, a physician at Healthfirst Family Care Center.
Plaintiff saw Dr. Mercado more than thirty times over the next
ten years for treatment of a variety of physical issues.
Throughout those ten years, Dr. Mercado consistently referenced
Plaintiff’s severe depression and anxiety in her progress notes
and prescribed Plaintiff Celexa and Xanax to treat these
symptoms. In 2008, Dr. Mercado wrote a note excusing Plaintiff
from jury duty based on the attention deficits caused by her
anxiety and depression. In March 2017, Dr. Mercado wrote that
Plaintiff “has [had] anxiety and depression since 2000.”
In January 2016, Plaintiff suffered a severe depressive
incident and went to the emergency department of Corrigan Mental
Health Center in Fall River, Massachusetts. Alison Hathaway, a
licensed independent clinical social worker, described Plaintiff
as in “crisis” and referred her to urgent care. Plaintiff was
regularly evaluated at Corrigan for several months, during which
she made slow and inconsistent progress. In June 2016, Dr. Roger
Boshes, a psychiatrist whom Plaintiff had seen multiple times at
Corrigan, filed out two assessments for her. He diagnosed her
with chronic PTSD related to late onset psychosis, depression,
debilitating anxiety, and agoraphobia. He found Plaintiff to be
disabled and unable to hold a job.
In August 2016, Plaintiff first saw Mary Cruz, a licensed
independent clinical social worker at East Side Counseling.
4
Ms. Cruz made a primary diagnosis of chronic PTSD and a
secondary diagnosis of generalized anxiety disorder. Ms. Cruz
saw Plaintiff at least twenty times between August 2016 and May
2017. During that time, she did not note any consistent
amelioration of Plaintiff’s symptoms.
III. Medical Opinions
In the fall of 2000, Dr. Wold, Plaintiff’s treating
psychiatrist at CFS, assigned Plaintiff a Global Assessment of
Functioning (“GAF”) score of 41. A GAF score rates a person’s
overall level of functioning. See DSM-IV-TR at 34. A GAF score
of 41-50 indicates serious symptoms or any serious impairment in
social or occupational functioning, such as an inability to have
personal relationships or keep a job. Id.
On October 13, 2000, Disability Evaluation Services (“DES”)
at the University of Massachusetts Medical School conducted a
review of Plaintiff’s medical records in connection with her
application for disability benefits. Dr. Paul Kaufman, a boardcertified psychiatrist, and Pat Gaucher, a registered nurse,
determined that Plaintiff suffered from sleep disturbance,
decreased energy, feelings of guilt and worthlessness,
difficulty concentrating, and paranoid thinking. They also found
that she suffered from panic attacks and fatigue. They noted her
marked difficulties in maintaining social functioning and
deficiencies in concentration, persistence, and pace.
5
Accordingly, they concluded that she was disabled for the
purposes of Supplemental Security Income (“SSI”) benefits
because she met the criteria for the listed impairment for
depressive disorders (12.04).
In 2016, state agency consultants reviewed Plaintiff’s
medical records and determined that her impairments were not
severe. In the April 2016 reconsideration opinion, the state
agency consultant noted that Plaintiff was treated from August
2000 to May 2001 for depression that the medical evidence
indicated improved with medication. It is not clear that these
consultants had Dr. Wold’s opinion or the DES findings.
Apparently, Dr. Wold was deceased by then.
Dr. Boshes found in June 2016 that Plaintiff had “extreme”
impairments in a number of areas, including remembering
locations and work-like procedures; understanding and
remembering instructions; maintaining attention and
concentration; interacting with others; accepting instructions
and criticism at work; interacting with coworkers and peers
without exhibiting behavioral extremes; and tolerating normal
levels of stress. He also found “marked” deficits in areas such
as carrying out instructions; working within schedules;
functioning without special supervision; asking simple
questions; and making plans. He further found a “moderate”
impairment in her ability to behave appropriately and adhere to
6
basic standards of cleanliness. Dr. Boshes determined that
Plaintiff’s impairments would interfere with her ability to work
at least 20 percent of the time and require her to miss work
about five times per month for treatment. He concluded that
Plaintiff could not work on a regular and sustained basis.
In September 2016, Ms. Cruz wrote a letter to the Social
Security Administration on Plaintiff’s behalf. She described
Plaintiff’s medical and employment history and noted that
Plaintiff had repeatedly stopped treatment due to a lack of
insurance. She concluded that Plaintiff’s “prolonged periods of
depression and anxiety . . . impaired her ability to function in
a working environment.”
IV.
Vocational Expert’s Testimony
Diane Durr, a vocational expert, testified before the ALJ
about the work ability of hypothetical people of the same age,
education, and vocational background as Plaintiff. First, Ms.
Durr testified that an individual who could perform simple tasks
at all exertion levels, tolerate occasional interpersonal
interactions at work, and adapt to routine changes in the work
environment could perform the work of a hand packager,
dishwasher, or cleaner but could not do Plaintiff’s past work.
Second, she stated that the same individual who was either offtask for 20 percent of the workday due to symptoms of
7
depression, fatigue, and other mental impairments or had to be
absent from work two days per month would be unemployable.
V.
Plaintiff’s and Husband’s Testimony
As part of her SSDI application, Plaintiff completed a
self-diagnostic “Function Report” in October 2015. She claimed
to be consistently anxious, depressed, impaired in both her
memory and attention, socially isolated, unable to do housework,
and bedridden for much of the day. She checked boxes indicating
she could drive and cook but described having severe difficulty
with both tasks in written responses.
Plaintiff testified before the ALJ that she suffers from
severe depression, PTSD, anxiety, and agoraphobia. She has no
relationship with her family other than her husband and son and
has no friends. She almost never leaves her home. Due to extreme
fatigue and lightheadedness, she sleeps for at least six hours
each day during waking hours and cannot be active for more than
a few hours at a time. She is only able to engage in very
minimal housework and cannot consistently cook for herself, do
laundry, clean, or shop for groceries. Her deficits in memory
and attention prevent her from reading a newspaper or watching
television. She testified that her nervous breakdown in August
2000 was caused by emotional abuse from her father.
Plaintiff’s husband testified before the ALJ that Plaintiff
was severely depressed between 2000 and 2005. He confirmed she
8
suffered a nervous breakdown in August 2000 but was not
hospitalized because they lacked medical insurance. He does most
of the housework. He said Plaintiff has nonexistent
relationships with friends and family. He confirmed Plaintiff
sleeps for most of the day and often cannot get out of bed. He
testified that Plaintiff is completely incapable of maintaining
full-time employment.
LEGAL STANDARD
Under the Social Security Act, a claimant seeking SSI must
prove that she is disabled, i.e., “unable to engage in any
substantial gainful activity by reason of any medically
determinable physical or mental impairment . . . for a
continuous period of not less than twelve months.” 42 U.S.C.
§ 1382c(a)(3)(A). The Commissioner uses a five-step sequential
evaluation process to assess a claim for disability benefits.
See 20 C.F.R. § 404.1520(a)(4); Purdy v. Berryhill, 887 F.3d 7,
9-10 (1st Cir. 2018). The evaluation ends at any step if the
Commissioner finds that the claimant is or is not disabled. 20
C.F.R. § 404.1520(a)(4). The steps are as follows:
1) if the applicant is engaged in substantial gainful
work activity, the application is denied; 2) if the
claimant does not have, or has not had within the
relevant time period, a severe impairment or
combination of impairments, the application is denied;
3) if the impairment meets the conditions for one of
the “listed” impairments in the Social Security
regulations, then the application is granted; 4) if the
applicant’s “residual functional capacity” [RFC] is
9
such that he or she can still perform past relevant
work, the application is denied; and 5) if the
applicant, given his or her [RFC], education, work
experience, and age, is unable to do any other work,
the application is granted.
Purdy, 887 F.3d at 10 (quoting Seavey v. Barnhart, 276 F.3d 1, 5
(1st Cir. 2001)). A claimant’s RFC is “the most [the claimant]
can still do despite [her] limitations.” 20 C.F.R.
§ 404.1545(a)(1). Past relevant work encompasses “work that [the
claimant has] done within the past 15 years, that was
substantial gainful activity, and that lasted long enough for
[her] to learn to do it.” Id. § 404.1560(b)(1). If a claimant
cannot still perform her past relevant work, the ALJ will assess
whether there is any other work the claimant “can adjust to”
that “exist[s] in significant numbers in the national economy.”
Id. § 416.1560(c)(1).
The claimant bears the burden of proof for steps one
through four. Purdy, 887 F.3d at 9. If the analysis proceeds to
step five, the Government bears the burden of proof to present
evidence of specific jobs the claimant can perform. Id. at 10.
AGENCY DECISION
On October 9, 2015, Plaintiff applied for SSDI benefits for
the period from September 1, 2000 through December 31, 2005. 1 The
claim was denied initially on February 12, 2016 and upon
1
The period at issue is between Plaintiff’s alleged onset
date and her date last insured.
10
reconsideration on May 5, 2016. An ALJ held a hearing on April
12, 2017 and denied Plaintiff’s claim on July 6, 2017.
At step one of the five-step evaluation process, the ALJ
found that Plaintiff did not engage in substantial gainful
activity between September 1, 2000 and December 31, 2005. At
step two, she concluded that Plaintiff’s major depressive
disorder was a severe impairment. At step three, the ALJ found
that Plaintiff’s impairment did not meet or medically equal any
impairments listed under 20 C.F.R. Part 404, Subpart P, Appendix
1, specifically listing 12.04 for depressive disorders. She
noted that Plaintiff did not experience any “marked” or
“extreme” limitations as required to satisfy the “paragraph B”
criteria because she only had “mild” limitations understanding,
remembering, applying information, and managing herself and
“moderate” limitations interacting with others and
concentrating. She also found that Plaintiff had “more than
minimal” capacity to handle change and therefore did not satisfy
the “paragraph C” criteria.
The ALJ then determined Plaintiff’s RFC. She held that,
while Plaintiff’s impairment could reasonably be expected to
cause her symptoms, Plaintiff’s statements about the severity of
her depression and anxiety were not supported by the medical
evidence. Relying on treatment notes taken by Mr. McMullen and
Dr. Wold in 2000, the ALJ described Plaintiff’s symptoms as
11
moderate and improving with treatment. She explained that the
absence of inpatient psychiatric admissions and other mental
health treatment during the relevant timeframe undercut the
alleged severity of Plaintiff’s symptoms and suggested that
medication was effective. She arrived at the following RFC:
[Plaintiff could] perform a full range of work at all
exertional levels but with the following nonexertional
limitations – [Plaintiff] was limited to the
performance of simple tasks; could tolerate occasional
interaction with supervisors, coworkers, and the
general public; and could adapt to routine changes in
a work environment.
The ALJ gave little weight to Dr. Boshes’s assessment because it
came more than ten years after Plaintiff’s last insured date.
She also gave little weight to the October 2000 DES evaluation
because it was based on “a handful of counseling and medication
management records.”
At step four, the ALJ noted that Plaintiff could not
perform her past relevant work as a babysitter. Finally, at step
five, the ALJ concluded that, as the vocational expert
testified, Plaintiff could perform the work of a hand packager,
dishwasher, or cleaner and was therefore not disabled.
The Appeals Council denied Plaintiff’s request for review
on January 11, 2018, making the ALJ’s decision the final
decision of the Commissioner. The case is now ripe for review
under 42 U.S.C. §§ 405(g) and 1383(c)(3).
12
STANDARD OF REVIEW
A district court reviews an ALJ’s decision “to determine
‘whether the final decision is supported by substantial evidence
and whether the correct legal standard was used.’” Coskery v.
Berryhill, 892 F.3d 1, 3 (1st Cir. 2018) (quoting Seavey, 276
F.3d at 9). The substantial evidence standard is “not high” and
requires only “such relevant evidence as a reasonable mind might
accept as adequate to support a conclusion.” Biestek v.
Berryhill, 139 S. Ct. 1148, 1154 (2019) (quoting Consol. Edison
Co. v. NLRB, 305 U.S. 197, 229 (1938)). In applying this
standard, a court “must bear in mind that it is the province of
the ALJ . . . to find facts, decide issues of credibility, draw
inferences from the record, and resolve conflicts in the
evidence.” Johnson v. Colvin, 204 F. Supp. 3d 396, 407 (D. Mass.
2016) (citing Ortiz v. Sec’y of Health & Human Servs., 955 F.2d
765, 769 (1st Cir. 1991)).
In reviewing for legal error, “[f]ailure of the [ALJ] to
apply the correct legal standards as promulgated by the
regulations or failure to provide the reviewing court with the
sufficient basis to determine that the [ALJ] applied the correct
legal standards are grounds for reversal.” Weiler v. Shalala,
922 F. Supp. 689, 694 (D. Mass. 1996). Where application of the
correct legal standard could lead to a different conclusion, a
court must remand to the agency. See Da Rosa v. Sec’y of Health
13
& Human Serv., 803 F.2d 24, 26 (1st Cir. 1986). However, remand
is not necessary if it “will amount to no more than an empty
exercise.” Ward v. Comm’r of Soc. Sec., 211 F.3d 652, 656 (1st
Cir. 2000).
DISCUSSION
I.
Listed Impairment
Plaintiff first challenges the ALJ’s conclusion at step
three that she did not meet the criteria for listed impairment
12.04 governing depressive, bipolar, and related disorders. To
meet listing 12.04, a claimant must satisfy the criteria of
paragraph A and the criteria of either paragraph B or paragraph
C. 20 C.F.R. pt. 404, subpt. P, app. 1. Paragraph A is satisfied
if the claimant provides medical documentation of at least five
symptoms of depressive disorder. Id. Under paragraph B, the
claimant must show at least one “extreme” or two “marked”
limitations in the following areas: understanding, remembering,
or applying information; interacting with others; concentrating,
persisting, or maintaining pace; and adapting or managing
herself. Id. The paragraph C criteria require the claimant to
show a “serious and persistent” mental disorder, meaning medical
documentation over at least two years and evidence of ongoing
treatment that improves the symptoms and minimal capacity to
adapt to change. Id. The ALJ found that Plaintiff failed to
14
satisfy either the paragraph B or paragraph C criteria, but
neither conclusion was supported by substantial evidence.
As an initial matter, the ALJ did not discuss the medical
opinions in the record, or any medical evidence whatsoever. The
record contains evidence from Plaintiff’s treatment at CFS in
2000 and from her medical and psychiatric care starting in 2007.
The record also contains medical opinions from two treating
sources (Dr. Wold and Dr. Boshes) and DES consultants, all of
whom stated that Plaintiff was disabled. In 2000, Dr. Wold
reported that Plaintiff suffered from major depressive disorder
and had a GAF of 41. In 2016, Dr. Boshes opined that Plaintiff
had extreme and marked impairments that precluded her from
working. The DES consultants, one of whom was a board-certified
psychiatrist, even specifically found that Plaintiff satisfied
the criteria for listing 12.04. Yet the ALJ ignored all of the
medical evidence in concluding that Plaintiff did not satisfy
paragraph B or paragraph C for listing 12.04. See Nguyen v.
Chater, 172 F.3d 31, 35 (1st Cir. 1999) (“The ALJ was not at
liberty to ignore medical evidence . . . .”).
Instead, the ALJ found that Plaintiff did not meet the
paragraph B criteria primarily based on her 2015 self-diagnostic
“Function Report.” Plaintiff points out that the ALJ’s reading
of this report was selective. For example, to support her
finding that Plaintiff had “mild” limitations in understanding,
15
remembering and applying information, the ALJ noted that the
report indicated that Plaintiff could cook, manage money, and
drive. However, Plaintiff also indicated in the report that her
memory loss made cooking “difficult” and that she struggled
“retaining info.” To support her finding that Plaintiff had
“moderate” social impairments, the ALJ relied on the check-box
response that Plaintiff could shop and go out alone. Later in
the 2015 report, though, Plaintiff wrote that she rarely shops,
does not like driving alone, and isolates herself from people as
much as possible. The ALJ’s finding that Plaintiff had
“moderate” deficits in concentration relied on check-box
responses indicating she could drive, travel alone, shop, and do
housework. But Plaintiff also described difficulty in all those
areas. Most importantly, Plaintiff filled out the self-report in
2015, a decade after the end of the insured period. While the
ALJ gave little weight to Dr. Boshes’s opinion in determining
Plaintiff’s RFC because it was outside the insured period, she
relied exclusively on Plaintiff’s self-report from the exact
same time period at step three.
In determining that Plaintiff failed to satisfy the
criteria of paragraphs B and C, the ALJ also focused on the lack
of inpatient admissions during the relevant time period. While
in some circumstances a failure to pursue or comply with
treatment may support a finding that a claimant is not disabled,
16
an ALJ must consider whether the claimant had good reasons for
her failure to do so. See Alcantara v. Astrue, 257 F. App’x 333,
333-36 (1st Cir. 2007) (per curiam). The record here indicates
that Plaintiff lacked medical insurance during the relevant
timeframe and halted medical care for this reason. Plaintiff’s
treatment history and lack of inpatient admissions therefore do
not provide substantive evidence of improvement. See
Sincavage v. Barnhart, 171 F. App’x 924, 927 (3d Cir. 2006)
(faulting the ALJ for drawing a negative inference from the
claimant’s failure to seek counseling because he ignored the
claimant’s testimony that she lacked adequate insurance
coverage); Perry v. Colvin, 91 F. Supp. 3d 139, 149-51 (D. Mass.
2015) (finding that the ALJ drew an impermissible negative
inference based on the claimant’s inconsistent treatment history
where good causes, including the inability to pay for
medications, explained gaps in treatment).
In sum, the ALJ did not provide substantial evidence to
conclude that Plaintiff’s condition did not meet listing 12.04
because she ignored the medical evidence, selectively relied on
a self-report from a decade later, and drew unsupported
conclusions from Plaintiff’s lack of treatment history.
II.
Residual Functional Capacity
Plaintiff also contends that the ALJ improperly weighed the
medical opinions in determining her RFC. Under the applicable
17
regulations, a “medical source” is “an individual who is
licensed as a healthcare worker by a State and working within
the scope of practice permitted under State or Federal law.” 20
C.F.R. § 404.1502(d). An “acceptable medical source” includes a
“licensed physician.” Id. § 404.1502(a)(1). A “treating source”
is an “acceptable medical source who provides [the claimant]
with medical treatment or evaluation and who has, or has had, an
ongoing treatment relationship with [the claimant].” Id.
§ 404.1527(a)(2). Both Dr. Wold and Dr. Boshes qualify as
treating sources because they each saw Plaintiff multiple times
as part of an ongoing treatment relationship.
The ALJ must give “[c]ontrolling weight . . . to a treating
physician’s opinion on the nature and severity of a claimant’s
impairments 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
record.” 2 Johnson, 204 F. Supp. 3d at 409 (quoting 20 C.F.R.
§ 404.1527(c)(2)). Even if not given controlling weight, a
treating source’s medical opinion generally receives more weight
2
20 C.F.R. § 416.920c contains new rules regarding the
weight given to treating sources that apply to claims filed on
March 27, 2017 or later. See Purdy, 887 F.3d at 13 n.8. Because
Plaintiff filed her claim on October 9, 2015, the old rules
govern this appeal.
18
than opinions from other medical sources. 20 C.F.R.
§ 416.1527(c)(2); Purdy, 887 F.3d at 13.
However, a number of factors determine the appropriate
weight to give to the opinions of treating and other medical
sources. 20 C.F.R. § 416.1527(c). For all sources, the ALJ must
consider whether the source examined the claimant, the support
the source provides for her opinion, the consistency of the
opinion with the record as a whole, and the specialty of the
source. Id. For a treating source, the length, nature, and
extent of the treatment relationship and frequency of
examination are also relevant considerations. Id. An ALJ need
not expressly address each factor identified by the regulations
but must provide “good reasons” for the weight assigned to the
opinion of a treating source. Bourinot v. Colvin, 95 F. Supp. 3d
161, 177 (D. Mass. 2015) (quoting 20 C.F.R. § 404.1527(c)(2)).
In evaluating Plaintiff’s RFC, the ALJ gave little weight
to Dr. Wold’s opinion because she found that Plaintiff’s
symptoms had improved with medication. The 2000 treatment notes
from CFS (which, to be fair, are frequently illegible) do
describe some improvements in Plaintiff’s symptoms (like
sleeping better) while she was taking Zoloft. Moreover, CFS’s
termination statement says that Plaintiff’s condition improved.
However, Dr. Wold assigned Plaintiff a GAF score of 41 in
September 2000, indicating she was severely impaired and unable
19
to hold a job. The notes do not describe a significant enough
improvement in Plaintiff’s symptoms to allow her to return to
work. See Hagan v. Colvin, 52 F. Supp. 3d 167, 174-76 (D. Mass.
2014) (finding that treatment notes describing the improvement
of symptoms with medication could not support a finding of “not
disabled” where the notes also indicated the recurrence of
symptoms during treatment). Most significantly, the ALJ did not
account for the low GAF score of 41.
The ALJ also gave little weight to the opinion of Dr.
Boshes because he treated Plaintiff in 2016, long after the
relevant period ended in 2005. The ALJ may properly consider
that an opinion came more than a decade after the insured period
in determining the weight the opinion should receive. However,
the opinion of Dr. Boshes, a treating physician, which he
provided after she suffered a nervous breakdown, does shed some
light on Plaintiff’s mental illness and corroborates the medical
evidence from 2000 showing severe symptoms, including the 2000
DES disability determination, Dr. Wold’s treatment notes, and
his GAF score of 41. At the very least, the ALJ erred in not
considering Dr. Boshes’s opinion in determining what weight, if
any, to give Plaintiff’s 2015 self-report, which she viewed
through such a rosy lens at step three.
20
The ALJ therefore erred in her assessment of the proper
weight to give to the treating source medical opinions in
determining Plaintiff’s RFC. 3
ORDER
Accordingly, Plaintiff’s motion to vacate (Docket No. 45)
is ALLOWED and the Commissioner’s motion to affirm (Docket No.
26) is DENIED. The Court remands to the Social Security
Administration for further proceedings consistent with this
memorandum and order.
SO ORDERED.
/s/ PATTI B. SARIS________
Hon. Patti B. Saris
Chief U.S. District Judge
3
Given the ALJ’s errors at step three and in determining
Plaintiff’s RFC, the Court need not address Plaintiff’s
additional arguments that the ALJ failed to adequately develop
the record in light of the gaps in medical evidence and
misapplied the vocational expert’s testimony at step five.
21
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