Yuchasz v. Social Security, Commissioner of

Filing 22

ORDER Granting 14 Motion to Remand and Denying 18 Motion for Summary Judgment - Signed by Magistrate Judge Mona K. Majzoub. (LBar)

UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MICHIGAN
SOUTHERN DIVISION

TODD M. YUCHASZ,
Plaintiff,
v.

CIVIL ACTION NO. 15-cv-13936
MAGISTRATE JUDGE MONA K. MAJZOUB

COMMISSIONER OF
SOCIAL SECURITY,
Defendant.
__________________________/

OPINION AND ORDER
GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT [14] AND
DENYING DEFENDANT’S MOTION FOR SUMMARY JUDGMENT [18]
Plaintiff Todd M. Yuchasz seeks judicial review of Defendant Commissioner of Social
Security’s determination that he is not entitled to social security benefits for his physical and
mental impairments under 42 U.S.C. § 405(g). (Docket no. 1.) Before the Court are Plaintiff’s
Motion for Summary Judgment (docket no. 14) and Defendant’s Motion for Summary Judgment
(docket no. 18). Plaintiff has also filed a reply brief in support of his Motion for Summary
Judgment.1 (Docket no. 19.) With consent of the parties, this case has been referred to the
undersigned for final judgment in accordance with 28 U.S.C. § 636(c) and Federal Rule of Civil
Procedure 73. (Docket no. 15.) The Court has reviewed the pleadings, dispenses with a hearing
pursuant to Eastern District of Michigan Local Rule 7.1(f)(2), and is now ready to rule.

1

Plaintiff’s reply brief does not comply with Eastern District of Michigan Local Rule 7.1(d)(3)(B), as it exceeds the
permitted length of seven pages; the Court has considered it nonetheless.

I.

PROCEDURAL HISTORY
Plaintiff protectively filed an application for a period of disability and disability insurance

benefits on April 22, 2013, alleging disability beginning February 15, 2013, due to generalized
anxiety disorder, non-alcoholic steatohepatitis, fatigue, morbid obesity, attention deficit disorder,
panic disorder with agoraphobia, personality disorder NOS, depression, heavy metal exposure,
autonomic neuropathy, and other disorders of the liver. (TR 118-19, 132, 136.) The Social
Security Administration denied Plaintiff’s claims on June 25, 2013, and Plaintiff requested a de
novo hearing. (TR 57-70, 77.) On October 28, 2014, Plaintiff appeared with a representative
and testified at the hearing before Administrative Law Judge (ALJ) Janice L. Holmes. (TR 2756.) In a February 9, 2015 decision, the ALJ found that Plaintiff was not entitled to benefits
because he was capable of performing a significant number of jobs in the national economy.
(TR 10-22.) The Appeals Council declined to review the ALJ’s decision (TR 1-3), and Plaintiff
commenced this action for judicial review. The parties then filed cross motions for summary
judgment, which are currently before the Court.
II.

HEARING TESTIMONY AND MEDICAL EVIDENCE
Plaintiff (docket no. 14 at 5-8), and the ALJ (TR 15-20) have set forth detailed, factual

summaries of Plaintiff’s medical record and the hearing testimony.

Having conducted an

independent review of Plaintiff’s medical record and the hearing transcript, the undersigned finds
that there are no material inconsistencies between these recitations of the record. Therefore, the
undersigned will incorporate the factual recitations by reference. Additionally, the undersigned
will include comments and citations to the record as necessary throughout this Opinion and
Order.

2

III.

ADMINISTRATIVE LAW JUDGE’S DETERMINATION
The ALJ found that Plaintiff had not engaged in substantial gainful activity since the

alleged onset date of February 15, 2013, and that Plaintiff suffered from the following severe
impairments:

chronic liver disease, attention deficit disorder/attention deficit hyperactivity

disorder (ADD/ADHD), affective disorders, and anxiety disorders. (TR 12.) Next, the ALJ
found that Plaintiff’s impairments did not meet or medically equal the severity of an impairment
listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. (TR 13-14.) The ALJ then found that
Plaintiff had the following residual functional capacity (RFC):
[T]he claimant has the residual functional capacity to perform medium work as
defined in 20 CFR 404.1567(c) except: he can frequently climb ramps or stairs;
never climb ladders, ropes or scaffolds; frequently balance, stoop, kneel[,] crouch
and crawl. He needs to avoid exposure to hazards, such as unprotected heights,
moving mechanical parts and operation of motor vehicles. He should have no
contact with the general public and only occasional contact with co-workers.
(TR 14-21.) Subsequently, in reliance on the vocational expert’s (VE’s) testimony, the ALJ
determined that Plaintiff was capable of performing a significant number of jobs in the national
economy. (TR 21-22.) Therefore, the ALJ found that Plaintiff was not disabled under the Social
Security Act at any time from February 15, 2013, through the date of the decision. (TR 10, 22.)
IV.

LAW AND ANALYSIS
A.

Standard of Review

Pursuant to 42 U.S.C. § 405(g), this Court has jurisdiction to review the Commissioner’s
final decisions. Judicial review of the Commissioner’s decisions is limited to determining
whether his findings are supported by substantial evidence and whether he employed the proper
legal standards. See Richardson v. Perales, 402 U.S. 389, 401 (1971); Walters v. Comm’r, 127
F.3d 525, 528 (6th Cir. 1997). Substantial evidence is more than a scintilla but less than a
preponderance; it is “‘such relevant evidence as a reasonable mind might accept as adequate to
3

support a conclusion.’” Richardson, 402 U.S. at 401 (quoting Consolidated Edison Co. v. NLRB,
305 U.S. 197, 229 (1938)); Walters, 127 F.3d at 528. It is not the function of this Court to try
cases de novo, resolve conflicts in the evidence, or decide questions of credibility. See Brainard
v. Sec’y of Health and Human Servs., 889 F.2d 679, 681 (6th Cir. 1989); Garner v. Heckler, 745
F.2d 383, 387 (6th Cir. 1984).
In determining the existence of substantial evidence, the court must examine the
administrative record as a whole. See Kirk v. Sec’y of Health and Human Servs., 667 F.2d 524,
536 (6th Cir. 1981), cert. denied, 461 U.S. 957 (1983). If the Commissioner’s decision is
supported by substantial evidence, it must be affirmed, even if the reviewing court would decide
the matter differently, Kinsella v. Schweiker, 708 F.2d 1058, 1059 (6th Cir. 1983), and even if
substantial evidence also supports the opposite conclusion. See Her v. Comm’r, 203 F.3d 388,
389-90 (6th Cir. 1999); Mullen v. Bowen, 800 F.2d 535, 545 (6th Cir. 1986) (en banc) (noting
that the substantial evidence standard “presupposes that there is a zone of choice within which
the decisionmakers can go either way, without interference by the courts”).
B.

Framework for Social Security Determinations

Plaintiff’s Social Security disability determination was made in accordance with a fivestep sequential analysis. In the first four steps, Plaintiff was required to show that:
(1)

Plaintiff was not presently engaged in substantial gainful employment; and

(2)

Plaintiff suffered from a severe impairment; and

(3)

the impairment met or was medically equal to a “listed impairment;” or

(4)

Plaintiff did not have the residual functional capacity (RFC) to perform relevant
past work.

See 20 C.F.R. § 404.1520(a)-(f). If Plaintiff’s impairments prevented Plaintiff from doing past
work, the Commissioner, at step five, would consider Plaintiff’s RFC, age, education, and past
4

work experience to determine if Plaintiff could perform other work. If not, Plaintiff would be
deemed disabled. See id. at § 404.1520(g). The Commissioner has the burden of proof only on
“the fifth step, proving that there is work available in the economy that the claimant can
perform.” Her, 203 F.3d at 391. To meet this burden, the Commissioner must make a finding
“supported by substantial evidence that [the claimant] has the vocational qualifications to
perform specific jobs.” Varley v. Sec’y of Health and Human Servs., 820 F.2d 777, 779 (6th Cir.
1987).

This “substantial evidence” may be in the form of vocational expert testimony in

response to a hypothetical question, “but only ‘if the question accurately portrays [the
claimant’s] individual physical and mental impairments.’” Id. (citations omitted).
C.

Analysis

The Social Security Act authorizes “two types of remand: (1) a post judgment remand in
conjunction with a decision affirming, modifying, or reversing a decision of the [Commissioner]
(a sentence-four remand); and (2) a pre-judgment remand for consideration of new and material
evidence that for good cause was not previously presented to the [Commissioner] (a sentence-six
remand).” Faucher v. Sec’y of Health and Human Servs., 17 F.3d 171, 174 (6th Cir. 1994)
(citing 42 U.S.C. § 405(g)). Under a sentence-four remand, the Court has the authority to “enter
upon the pleadings and transcript of the record, a judgment affirming, denying, or reversing the
decision of the [Commissioner], with or without remanding the cause for a hearing. 42 U.S.C. §
405(g). Where there is insufficient support for the ALJ’s findings, “the appropriate remedy is
reversal and a sentence-four remand for further consideration.” Morgan v. Astrue, 10-207, 2011
WL 2292305, at *8 (E.D. Ky. June 8, 2011) (citing Faucher, 17 F.3d at 174).
Plaintiff asserts that this matter should be remanded under sentence four because (1) the
ALJ failed to properly consider the opinions of his treating physician and treating psychiatrist;

5

and (2) the ALJ impermissibly rejected the statement of Plaintiff’s sister, Tina Rondeau.
(Docket no. 14 at 10-19.)
It is well settled that the opinions of treating physicians are generally accorded substantial
deference. In fact, the ALJ must give a treating physician’s opinion complete deference if it is
supported by clinical and laboratory diagnostic evidence and it is not inconsistent with the other
substantial evidence in the record. 20 C.F.R. §§ 404.1527(c)(2), 416.927(c)(2). When an ALJ
determines that a treating source’s medical opinion is not controlling, he must determine how
much weight to assign that opinion in light of several factors: (1) length of the treatment
relationship and the frequency of examination; (2) nature and extent of the treatment
relationship; (3) supportability of the opinion; (4) consistency of the opinion with the record as a
whole; (5) specialization of the treating source; and (6) other factors.

20 C.F.R. §§

404.1527(c)(2)-(6), 416.927(c)(2)-(6).
There is no per se rule that requires an articulation of each of the six regulatory factors
listed in 20 C.F.R. §§ 404.1527(c)(2)-(6), 416.927(c)(2)-(6). Norris v. Comm’r of Soc. Sec., No.
11-CV-11974, 2012 WL 3584664, at *5 (E.D. Mich. Aug. 20, 2012) (citing Tilley v. Comm’r of
Soc. Sec., 394 F. App’x 216, 222 (6th Cir. 2010)). An ALJ’s failure to discuss the requisite
factors may constitute harmless error (1) if “a treating source's opinion is so patently deficient
that the Commissioner could not possibly credit it;” (2) “if the Commissioner adopts the opinion
of the treating source or makes findings consistent with the opinion;” or (3) “where the
Commissioner has met the goal of [§ 1527(c)]—the provision of the procedural safeguard of
reasons—even though she has not complied with the terms of the regulation.” Nelson v. Comm’r
of Soc. Sec., 195 F. App’x 462, 470 (6th Cir. 2006) (quoting Wilson v. Comm’r of Soc. Sec., 378
F.3d 541, 547 (6th Cir. 2004)).

6

The Commissioner requires its ALJs to “always give good reasons in [their] notice of
determination or decision for the weight [they] give [a] treating source’s opinion.” 20 C.F.R.
§§ 404.1527(c)(2), 416.927(c)(2). Those good reasons must be “supported by the evidence in
the case record, and 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.” Wilson, 378 F.3d at 544 (quoting SSR 96-2p, 1996 WL 374188, at *5 (1996)). The
district court should not hesitate to remand when the Commissioner has failed to identify the
weight assigned to a treating physician’s opinion and provide good reasons for that weight. See
Cole v. Astrue, 661 F.3d 931, 939 (6th Cir. 2011) (“This Court has made clear that ‘[w]e do not
hesitate to remand when the Commissioner has not provided ‘good reasons’ for the weight given
to a treating physician's opinion and we will continue remanding when we encounter opinions
from ALJ's that do not comprehensively set forth the reasons for the weight assigned to a treating
physician's opinion.”) (citing Hensley v. Astrue, 573 F.3d 263, 267 (6th Cir. 2009)).
Plaintiff treated with primary care physician Christa B. Williams, M.D. for his physical
and mental impairments from February 2012 to July 2013. (TR 266-97, 331-42.) On August 19,
2013, Dr. Williams completed a medical statement form regarding Plaintiff’s mental
impairments and his claim for disability, on which she indicated that Plaintiff suffered from,
among other things, generalized persistent anxiety; a persistent, irrational fear of a specific
object, activity, or situation resulting in a compelling desire to avoid the dreaded object, activity,
or situation; and recurrent severe panic attacks manifested by a sudden unpredictable onset of
intense apprehension, fear, terror, and sense of impending doom occurring on the average of at
least one a week. (TR 298-300.) Dr. Williams opined that Plaintiff had a marked restriction in
activities of daily living; marked difficulties in maintaining social functioning; deficiencies in

7

concentration, persistence, or pace; repeated episodes of decompensation in work or work-like
settings; and a complete inability to function independently outside his home. (TR 298-99.)
Additionally, Dr. Williams opined that Plaintiff’s impairments presented several functional
limitations. (TR 299-300.) For example, Dr. Williams opined that Plaintiff was moderately
impaired in his ability to understand, remember, and carry out detailed instructions; make simple
work-related decisions; and accept instructions and respond appropriately to criticism from
supervisors. Dr. Williams also opined that Plaintiff was markedly impaired in his ability to
maintain attention and concentration for extended periods, to interact appropriately with the
general public, and to maintain socially appropriate behavior. Dr. Williams further opined that
Plaintiff’s abilities to perform activities within a schedule, maintain regular attendance, complete
a normal workday and workweek without interruptions from psychologically based symptoms,
and respond appropriately to changes in the work setting were extremely impaired. Lastly, Dr.
Williams made the following comment: “At this time there is no question in my mind that Mr.
Yuchasz is disabled by his severe generalized anxiety disorder.”

(TR 300 (emphasis in

original).)
Plaintiff also treated with psychiatrist Paul T. Rajasekhar, M.D. from July 2013 to April
2014, for his mental impairments. (TR 323-25, 347-50, 363-66, 376-81, 421-23.) On March 31,
2014, Dr. Rajasekhar completed a medical statement form substantially similar to the one
completed by Dr. Williams, on which he indicated that Plaintiff suffered from, among other
things, generalized persistent anxiety, autonomic hyperactivity, apprehensive expectation,
recurrent obsessions or compulsions, and recurrent and intrusive recollections of a traumatic
experience. (TR 384-86.) Dr. Rajasekhar opined that Plaintiff exhibited a marked restriction in
activities of daily living; an extreme difficulty in maintaining social functioning; deficiencies of

8

concentration, persistence, or pace; and repeated episodes of decompensation.

(TR 384.)

Additionally, Dr. Rajasekhar opined that Plaintiff’s impairments presented several functional
limitations. (TR 385-86.) For example, Dr. Rajasekhar found that Plaintiff was moderately
impaired in his ability to remember locations and work-like procedures, and to understand,
remember, and carry out very short and simple instructions. He opined that Plaintiff’s abilities to
understand, remember, and carry out detailed instructions; maintain attention and concentration
for extended periods; sustain an ordinary routine without special supervision; make simple workrelated decisions; and ask simple questions or request assistance were markedly impaired. Dr.
Rajasekhar further opined that Plaintiff’s abilities to perform activities within a schedule,
maintain regular attendance, work in coordination and proximity with others, complete a normal
workday and workweek without interruptions from psychologically-based symptoms, interact
appropriately with the general public, get along with coworkers or peers without distracting them
or exhibiting behavioral extremes, and respond appropriately to changes in the work setting were
extremely impaired. Lastly, Dr. Rajasekhar checked “yes” next to the following pre-printed
statement: “In my opinion, after a review of my file, Todd Yuchasz has been disabled and
unable to work since February, 2013.” (TR 386.)
The ALJ discussed Dr. Williams and Dr. Rajasekhar’s treatment notes and opinions and
rendered the following assessment:
Limited weight is accorded to the opinions provided by the claimant’s primary
care physician and psychiatrist as discussed below. Both of these opinions
consisted primarily of circling answers and making check marks on pre-printed
forms provided by the claimant’s representative.
. . . [With regard to Dr. Williams’s opinion, t]he ultimate issue of disability is a
medical-vocational determination reserved for the Commissioner (SSR 96-5p).
Limited weight is accorded to this opinion, which [] appears to be primarily based
on the claimant’s subjective self-reports. I also note that Dr. Williams is not a
specialist in the mental health field.
9

. . . Dr. Rajasekhar did not offer any personal commentary regarding the
claimant’s impairments, abilities or limitations. (Exhibit 13F). Limited weight is
accorded to this opinion. While difficulties impacting the claimant’s work related
abilities have been established, even this report does not appear to preclude the
claimant’s ability to follow short, simple instructions, as permitted under the
residual functional capacity assessment. Once again, the ultimate issue of
disability is a medical-vocational determination reserved for the Commissioner
(SSR 96-5p).
(TR 19-20.)
The reasons cited by the ALJ for discounting Dr. Williams and Dr. Rajasekhar’s opinions
are certainly common, legitimate reasons used by ALJs in discounting medical opinions, and
they touch on some of the regulatory factors, such as the supportability of the opinion and the
specialization of the treating source.

In this case, however, the ALJ’s assertion that Dr.

Williams’s opinion appears to be based on Plaintiff’s subjective self-reports is wholly
conclusory, and it lacks any substantive basis or supporting explanation of the evidence upon
which the Court can conduct a meaningful review. Additionally, the ALJ’s finding that Dr.
Rajasekhar’s report does not appear to preclude Plaintiff’s ability to follow short, simple
instructions is directly contradicted by Dr. Rajasekhar’s reported opinion that Plaintiff’s ability
to understand, remember, and carry out very short and simple instructions is moderately
impaired. (See TR 385.) Consequently, these two reasons provided by the ALJ for discounting
Dr. Williams and Dr. Rajasekhar’s opinions do not constitute good reasons under the regulations.
The ALJ did properly discount Dr. Williams and Dr. Rajasekhar’s opinions that Plaintiff
is totally disabled, as the ultimate issue of disability is reserved to the Commissioner, not the
treating or examining physician. Kidd v. Comm’r, 283 F. App’x 336, 341 (6th Cir. 2008). Thus,
when a medical or non-medical source offers an opinion on “an issue reserved to the
Commissioner, such as whether the claimant is disabled, the ALJ need not accord that opinion

10

controlling weight.”

Id. (citing Bass v. McMahon, 499 F.3d 506, 511 (6th Cir. 2007)).

Nevertheless, the ALJ is required to give Dr. Williams and Dr. Rajasekhar’s opinions regarding
Plaintiff’s functional limitations controlling weight if they are supported by clinical and
laboratory diagnostic evidence and are not inconsistent with the other substantial evidence in the
record. See 20 C.F.R. § 404.1527(c)(2). The ALJ did not assign controlling weight here, and her
decision is completely devoid of any discussion or analysis of how Dr. Williams and Dr.
Rajasekhar’s opinions relate to the record evidence in terms of supportability and consistency, or
otherwise. The ALJ has therefore failed to sufficiently explain or provide good reasons for her
determination that Dr. Williams and Dr. Rajasekhar’s opinions regarding Plaintiff’s functional
limitations are not entitled to complete deference.

This is a reversible error, and the

circumstances necessary under Nelson for the ALJ’s error to be rendered harmless do not exist
here.

See Blakley v. Comm’r of Soc. Sec., 581 F.3d 399, 407-08, 409 (6th Cir. 2009).

Accordingly, remand of this matter for a proper assessment of Dr. Williams and Dr. Rajasekhar’s
opinions is warranted.
Because the assessment of the medical and non-medical opinion evidence will potentially
change upon remand, and in the interests of judicial economy, Plaintiff’s remaining claims of
error will not be considered.
Accordingly, IT IS ORDERED that Plaintiff's Motion for Summary Judgment [14] is
GRANTED, and Defendant’s Motion for Summary Judgment [18] is DENIED. This matter is
remanded pursuant to sentence four of 42 U.S.C. § 405(g) for a proper assessment of Dr.
Williams and Dr. Rajasekhar’s opinions in accordance with the treating physician rule.

Dated: March 9, 2017

s/ Mona K. Majzoub__
MONA K. MAJZOUB
UNITED STATES MAGISTRATE JUDGE
11

PROOF OF SERVICE
I hereby certify that a copy of this Opinion and Order was served upon counsel of record
on this date.
Dated: March 9, 2017

s/ Lisa C. Bartlett
Case Manager

12