Taylor v. Commissioner of Social Security

Filing 19

OPINION; signed by Magistrate Judge Hugh W. Brenneman, Jr (Magistrate Judge Hugh W. Brenneman, Jr., fhw)

UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF MICHIGAN
SOUTHERN DIVISION

KATHERINE L. TAYLOR,
Plaintiff,
v.

Case No. 1:14-cv-110
Hon. Hugh W. Brenneman, Jr.

COMMISSIONER OF SOCIAL
SECURITY,
Defendant.
/
OPINION
Plaintiff brings this action pursuant to 42 U.S.C. § 405(g), seeking judicial review of
a final decision of the Commissioner of the Social Security Administration (Commissioner) denying

her claim for Supplemental Security Income (SSI).
Plaintiff was born on April 25, 1959 (AR 129).1 She alleged a disability onset date
of November 1, 2010, which was amended to March 1, 2010 (AR 11, 129, 161). Plaintiff completed

the 8th grade and had previous employment as a housekeeper cleaner and laundry laborer (AR 31,
68). Plaintiff identified her disabling conditions as headaches, diarrhea, carpal tunnel syndrome,
COPD, acid reflux or GERD, diabetes, insomnia, cervical spine problems including disk space
narrowing, spurring and spondylosis, lumbar problems with degenerative changes in the lumbar
spine, left knee problems, a problem with her tibia, degenerative changes in the hip, depression,
arthritis, an old rib fracture and degenerative problems in both knees, fatigue, myalgia and
longstanding low back pain and foot sores (AR 42). An Administrative Law Judge (ALJ) reviewed
plaintiff’s claim de novo and entered a written decision denying benefits on February 27, 2013 (AR
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Citations to the administrative record will be referenced as (AR “page #”).

11-19). This decision, which was later approved by the Appeals Council, has become the final
decision of the Commissioner and is now before the Court for review.
I. LEGAL STANDARD
This court’s review of the Commissioner’s decision is typically focused on
determining whether the Commissioner’s findings are supported by substantial evidence. 42 U.S.C.
§405(g); McKnight v. Sullivan, 927 F.2d 241 (6th Cir. 1990). “Substantial evidence is more than a
scintilla of evidence but less than a preponderance; it is such relevant evidence as a reasonable mind
might accept as adequate to support a conclusion.” Cutlip v. Secretary of Health & Human Services,
25 F.3d 284, 286 (6th Cir. 1994). A determination of substantiality of the evidence must be based
upon the record taken as a whole. Young v. Secretary of Health & Human Services, 925 F.2d 146
(6th Cir. 1990).
The scope of this review is limited to an examination of the record only. This Court
does not review the evidence de novo, make credibility determinations or weigh the evidence.
Brainard v. Secretary of Health & Human Services, 889 F.2d 679, 681 (6th Cir. 1989). The fact that
the record also contains evidence which would have supported a different conclusion does not
undermine the Commissioner’s decision so long as there is substantial support for that decision in
the record. Willbanks v. Secretary of Health & Human Services, 847 F.2d 301, 303 (6th Cir. 1988).
Even if the reviewing court would resolve the dispute differently, the Commissioner’s decision must
stand if it is supported by substantial evidence. Young, 925 F.2d at 147.
A claimant must prove that he suffers from a disability in order to be entitled to
benefits. A disability is established by showing that the claimant cannot engage in substantial gainful
activity by reason of any medically determinable physical or mental impairment which can be

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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 20 C.F.R. §416.905; Abbott v. Sullivan, 905 F.2d 918, 923 (6th Cir.
1990). In applying the above standard, the Commissioner has developed a five-step analysis:
The Social Security Act requires the Secretary to follow a “five-step
sequential process” for claims of disability. First, plaintiff must demonstrate that she
is not currently engaged in “substantial gainful activity” at the time she seeks
disability benefits. Second, plaintiff must show that she suffers from a “severe
impairment” in order to warrant a finding of disability. A “severe impairment” is one
which “significantly limits . . . physical or mental ability to do basic work activities.”
Third, if plaintiff is not performing substantial gainful activity, has a severe
impairment that is expected to last for at least twelve months, and the impairment
meets a listed impairment, plaintiff is presumed to be disabled regardless of age,
education or work experience. Fourth, if the plaintiff's impairment does not prevent
her from doing her past relevant work, plaintiff is not disabled. For the fifth and final
step, even if the plaintiff’s impairment does prevent her from doing her past relevant
work, if other work exists in the national economy that plaintiff can perform, plaintiff
is not disabled.
Heston v. Commissioner of Social Security, 245 F.3d 528, 534 (6th Cir. 2001) (citations omitted).
The claimant bears the burden of proving the existence and severity of limitations
caused by her impairments and the fact that she is precluded from performing her past relevant work
through step four. Jones v. Commissioner of Social Security, 336 F.3d 469, 474 (6th Cir. 2003).
However, at step five of the inquiry, “the burden shifts to the Commissioner to identify a significant
number of jobs in the economy that accommodate the claimant’s residual functional capacity
(determined at step four) and vocational profile.” Id. If it is determined that a claimant is or is not
disabled at any point in the evaluation process, further review is not necessary. Mullis v. Bowen, 861
F.2d 991, 993 (6th Cir. 1988).

“The federal court’s standard of review for SSI cases mirrors the standard applied
in social security disability cases.” D’Angelo v. Commissioner of Social Security, 475 F. Supp. 2d
716, 719 (W.D. Mich. 2007). “The proper inquiry in an application for SSI benefits is whether the
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plaintiff was disabled on or after her application date.” Casey v. Secretary of Health and Human
Services, 987 F.2d 1230, 1233 (6th Cir. 1993).
II. ALJ’S DECISION
Plaintiff’s claim failed at the fourth step of the evaluation. At the first step, the ALJ
found that plaintiff has not engaged in substantial gainful activity since her SSI application date of
March 23, 2011 (AR 16). At the second step, the ALJ found that plaintiff had severe impairments
of: mild degenerative changes to bilateral hips; mild degenerative changes to cervical spine; mild
degenerative change to right knee; and bilateral carpal tunnel syndrome (AR 14). At the third step,
the ALJ found that plaintiff did not have an impairment or combination of impairments that met or
equaled the requirements of the Listing of Impairments in 20 C.F.R. Pt. 404, Subpt. P, App. 1 (AR
15). Specifically, plaintiff did not meet the requirements of Listings 1.02 (major dysfunction of a
joint), 1.04 (disorders of the spine) and 11.14 (peripheral neuropathies) (AR 15).
The ALJ decided at the fourth step:
[T]hat the claimant has the residual functional capacity to lift and/or carry 20 pounds
occasionally and 10 pounds frequently; stand or walk for a total of six out of eight
hours; can sit for a total of six out of eight hours; is limited to occasional climbing of
ramps or stairs; occasional climbing of ladders, ropes, or scaffolds; occasional
balancing, stooping, kneeling, crouching, and crawling; and is able to frequently
handle and finger bilaterally.
(AR 15). The ALJ found that plaintiff was capable of performing past relevant work as a
housekeeper, work which was not precluded by her residual functional capacity (RFC) (AR 20).
Accordingly, the ALJ determined that plaintiff has not been under a disability, as defined in the
Social Security Act, at any time since March 23, 2011, the date the application for SSI was filed (AR
19).

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III. ANALYSIS
Plaintiff has raised two issues on appeal.
A.

The Commissioner erred in assigning appropriate
weight to the opinions of Jamie Hall, M.D., the
Plaintiff’s treating physician.

Plaintiff contends that the ALJ erred by declining to give controlling weight to the
opinions of her treating physician Dr. Hall. A treating physician’s medical opinions and diagnoses
are entitled to great weight in evaluating plaintiff's alleged disability. Buxton v. Halter, 246 F.3d
762, 773 (6th Cir. 2001). “In general, the opinions of treating physicians are accorded greater weight
than those of physicians who examine claimants only once.” Walters v. Commissioner of Social
Security, 127 F.3d 525, 529-30 (6th Cir. 1997). “The treating physician doctrine is based on the
assumption that a medical professional who has dealt with a claimant and his maladies over a long
period of time will have a deeper insight into the medical condition of the claimant than will a person
who has examined a claimant but once, or who has only seen the claimant’s medical records.”
Barker v. Shalala, 40 F.3d 789, 794 (6th Cir. 1994). See 20 C.F.R. § 416.927(c)(2) (“Generally, we
give more weight to opinions from your treating sources, since these sources are likely to be the
medical professionals most able to provide a detailed, longitudinal picture of your medical
impairment(s) and may bring a unique perspective to the medical evidence that cannot be obtained
from the objective medical findings alone or from reports of individual examinations, such as
consultative examinations or brief hospitalizations”).

Under the regulations, a treating source’s opinion on the nature and severity of a
claimant’s impairment must be given controlling weight if the Commissioner finds that: (1) the
opinion is well-supported by medically acceptable clinical and laboratory diagnostic techniques; and

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(2) the opinion is not inconsistent with the other substantial evidence in the case record. See
Gayheart v. Commissioner of Social Security, 710 F.3d 365, 375 (6th Cir. 2013). Finally, the ALJ
must articulate good reasons for not crediting the opinion of a treating source. See Wilson v.
Commissioner of Social Security, 378 F.3d 541, 545 (6th Cir. 2004); 20 C.F.R. §§ 404.1527(c)(2)
and 416.927(c)(2) (“[w]e will always give good reasons in our notice of determination or decision
for the weight we give your treating source’s opinion”).
Here, the ALJ evaluated Dr. Hall’s opinion as follows:
The claimant's primary care provider Jamie Hall M.D., offered several
opinions. First, Dr. Hall stated the claimant was disabled (Ex 9F). However, this is
a determination reserved for the Commissioner of Social Security, and Dr. Hall
provided no rational for such a definitive statement. Additionally, Dr. Hall provided
two separate statements in 2012. The first, from July, indicated the claimant could
“rarely” sit, bend, squat, crawl, kneel, reach overhead, etc., and “rarely” lift up to 10
pounds or more. Additionally, Dr. Hall stated the claimant would miss three or more
days each month because of her impairments, and would be off task 20 percent or
more of the workday because of her symptoms (Ex 10F). Finally, in November
2012, Dr. Hall opined the claimant still had the same restrictions, but was even more
limited to never being able squat, crawl, kneel, or reach over her shoulder (Ex 14F).
I have considered the opinions of Dr. Hall carefully. However, Dr. Hall’s medical
records do not support such extreme limitations, and neither to [sic] any of the
neurology or orthopedic notes. Therefore, as the opinions of Dr. Hall are
inconsistent with the preponderance of the evidence, I given Dr. Hall’s opinions little
weight.
(AR 18).
As an initial matter, the ALJ properly rejected Exhibit 9F (AR 521-22). The first
page consists of a partially illegible handwritten physical capacities assessment (AR 521) and the
second page consists of a series of diagnoses with the opinion that plaintiff is “disabled” (AR 521).
Although Dr. Hall was a treating physician, the ALJ was not bound by the doctor’s conclusion that
plaintiff was disabled. See 20 C.F.R. § 416.927(d)(1) ( “[a] statement by a medical source that you
are ‘disabled’ or ‘unable to work’ does not mean that [the Commissioner] will determine that you
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are disabled’ ). Such statements, by even a treating physician, constitute a legal conclusion that is
not binding on the Commissioner. Crisp v. Secretary of Health and Human Services, 790 F.2d. 450,
452 (6th Cir. 1986). The determination of disability is the prerogative of the Commissioner, not
the treating physician. See Houston v. Secretary of Health and Human Services, 736 F.2d 365, 367
(6th Cir. 1984).
The Court reaches a different result with respect to the ALJ’s assignment of little
weight to Dr. Hall’s physical capacities assessments from July 17, 2012 (Exhibit 10F (AR 523-24))
and November 28, 2012 (Exhibit 14F (AR 535-36)). Admittedly, these assessments state that
plaintiff has extreme limitations. However, the ALJ does not fully explain the contents or the
assessments or why the assessments are inconsistent with the medical record. The Commissioner
must provide a statement of evidence and reasons on which the decision is based. See 42 U.S.C. §
405(b)(1). While it is unnecessary for the ALJ to address every piece of medical evidence, see
Heston, 245 F.3d at 534-35, an ALJ “must articulate, at some minimum level, his analysis of the
evidence to allow the appellate court to trace the path of his reasoning.” Diaz v. Chater, 55 F.3d
300, 307 (7th Cir. 1995). “It is more than merely ‘helpful’ for the ALJ to articulate reasons . . . for
crediting or rejecting particular sources of evidence. It is absolutely essential for meaningful
appellate review.” Hurst v. Secretary of Health and Human Services, 753 F.2d 517, 519 (6th Cir.
1985). Accordingly, this matter will be reversed and remanded pursuant to sentence four of 42
U.S.C § 405(g). On remand, the Commissioner will be directed to provide a more comprehensive
articulation of the reasons for the weight assigned to Dr. Hall’s assessments of July 17, 2012 and
November 28, 2012, explaining why the assessments are inconsistent with the medical record.

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B.

The Commissioner erred at Step 2 of the
Sequential Evaluation Process, when the
Administrative Law Judge failed to classify
plaintiff’s obesity; headaches; chronic diarrhea;
COPD; GERD; diabetes; insomnia; cervical disc
space narrowing, spurring, spondylosis; lumbar
spondylosis; degenerative hypertrophy; left knee
meniscus tear; left knee degenerative changes with
joint effusion; degenerative changes to right tibia
with arrow edema; depression; arthritis; fatigue;
chronic low back pain; decreased lumbar spinal
range of motion; decreased strength; and myalgia
as “severe” conditions and failed to consider the
limitations caused by the conditions when
determining plaintiff’s RFC.

Plaintiff contends that the ALJ erred by failing to include a number of medical
conditions as severe impairments at step two of the sequential process. A “severe impairment” is
defined as an impairment or combination of impairments “which significantly limits your physical
or mental ability to do basic work activities.” 20 C.F.R. § 416.920(c). Upon determining that a
claimant has one severe impairment the ALJ must continue with the remaining steps in the disability
evaluation. See Maziarz v. Secretary of Health & Human Services, 837 F.2d 240, 244 (6th Cir.
1987). Once the ALJ determines that a claimant suffers from a severe impairment, the fact that the
ALJ failed to classify a separate condition as a severe impairment does not constitute reversible
error. Maziarz, 837 F.2d at 244. An ALJ can consider such non-severe conditions in determining
the claimant’s residual functional capacity. Id. “The fact that some of [the claimant’s] impairments
were not deemed to be severe at step two is therefore legally irrelevant.” Anthony v. Astrue, 266
Fed. Appx. 451, 457 (6th Cir. 2008). Here, the ALJ found that plaintiff suffered from the severe
impairments of: mild degenerative changes to bilateral hips; mild degenerative changes to cervical
spine; mild degenerative change to right knee; and bilateral carpal tunnel syndrome (AR 14). The

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ALJ’s failure to include plaintiff’s other claimed conditions as severe impairments at step two is
legally irrelevant. Accordingly, plaintiff’s error will be denied.

IV. CONCLUSION
For the reasons discussed, the Commissioner’s decision will be REVERSED and
REMANDED pursuant to sentence four of 42 U.S.C. § 405(g). On remand, the Commissioner is
directed to provide a more comprehensive articulation of the reasons for the weight assigned to Dr.
Hall’s assessments of July 17, 2012 and November 28, 2012, explaining why the assessments are
inconsistent with the medical record. An order consistent with this opinion will be issued forthwith.

Dated: March 25, 2015

/s/ Hugh W. Brenneman, Jr.
HUGH W. BRENNEMAN, JR.
United States Magistrate Judge

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