Wood v. Commissioner of Social Security

Filing 25

Opinion and Order signed by Judge James S. Gwin on 5/28/15. The Court overrules the Commissioner's objections, adopts the Report and Recommendation of the Magistrate Judge and remands this case to the Administrative Law Judge for further proceedings as set forth in this order. (Related Docs. 1 , 22 ) (M,G)

UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF OHIO
------------------------------------------------------:
PENNY LEE WOOD,
:
:
Plaintiff,
:
:
v.
:
:
CAROLYN W. COLVIN,
:
ACTING COMMISSIONER OF SOCIAL :
SECURITY,
:
:
Defendant.
:
:
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CASE NO. 1:14-CV-00998

OPINION & ORDER
[Resolving Doc. 23]

JAMES S. GWIN, UNITED STATES DISTRICT JUDGE:
In this case, Plaintiff Penny Lee Wood asks the Court to reverse the decision of an
Administrative Law Judge (“ALJ”) finding that Wood is ineligible for disability insurance benefits.1/
Magistrate Judge Vecchiarelli has issued a Report and Recommendation (“R&R”) that the Court
vacate the ALJ’s decision and remand the case.2/ Defendant Commissioner of Social Security
objects to the R&R.3/ Because the ALJ failed to provide sufficient analysis regarding Plaintiff
Wood’s ulcerative colitis or frequent diarrhea, and failed to comply with the Social Security
Commission’s procedural requirements to provide reasons for not giving the treating physician’s
opinions controlling weight, the Court OVERRULES the Commissioner’s objections, ADOPTS
the recommendation of the Magistrate Judge, and REMANDS this case to the ALJ for further
proceedings consistent with this opinion.

1/

Doc. 1 at 1–2.
Doc. 3.
3/
Doc. 23. Plaintiff Wood has replied to Defendant’s objections. Doc. 24.
2/

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Case No. 1:14-cv-00998
Gwin, J.
I. Background
On April 8, 2011, Plaintiff Wood applied for a period of disability and disability insurance
benefits,4/ saying that her “depression, nerve damage neck and back, sleep disorder, ulcerated colitis,
obesity, migraines, chronic pain, menephisas, [and] Horner’s Syndrome” rendered her disabled as
of September 9, 2010.5/ Her claim was denied, both initially and on reconsideration.6/
On July 11, 2012, Plaintiff had an evidentiary hearing before an ALJ on her application.
Relevant to this decision, Plaintiff Wood submitted medical records showing that she suffers from
ulcerative colitis and frequent diarrhea.7/ Plaintiff Wood testified that this condition requires her to
take between as many as ten restroom breaks a day.8/ A vocational expert testified that an employee
who requires that many restroom breaks would need a special accommodation from an employer.9/
Also relevant to this decision, Plaintiff submitted a written opinion from her treating
physician, Dr. Petrulis, who found that Plaintiff “was unable to change positions [without]
discomfort, [was] severely impaired in her ability to hold heavy objects, . . . [and] had severe pain
all the time.”10/ All submitted medical opinions recognized (in varying degrees) that Plaintiff had
motor restrictions.11/
On September 21, 2012, the ALJ issued a decision finding Plaintiff Wood not disabled.12/

4/

See 42 U.S.C. §§ 416(I), 423.
Doc. 10 at 242.
6/
See id. at 1–4.
7/
Id. at 331, 335, 421, 440, 456, 474, 543, 558.
8/
Id. at 79.
9/
Id. at 90.
10/
Id. at 544.
11/
See id. at 101–04, 117–19, 411, 543–44.
12/
Id. at 35. On March 4, 2014, When the Social Security Commission’s Appeals Council declined to review
the ALJ’s decision, the ALJ’s decision became the Commissioner’s final decision and thus appealable to this Court. See
(continued...)
5/

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Case No. 1:14-cv-00998
Gwin, J.
Magistrate Judge Vecchiarelli’s R&R identifies two main errors with the ALJ’s decision.13/ First, in
determining Plaintiff’s residual functional capacity (“RFC”), the ALJ did not mention any of the
evidence Plaintiff submitted regarding her ulcerative colitis or frequent diarrhea.14/ Second, the ALJ
did not explain why she “reject[ed]” the opinion of Dr. Petrulis, Plaintiff’s treating physician,
regarding Plaintiff’s motor restrictions.15/
The Commissioner objected to the R&R on both issues.16/ First, the Commissioner argues
that the ALJ did in fact evaluate the claims of frequent diarrhea and ulcerative colitis and permissibly
concluded from other evidence that the conditions were non-severe impairments.17/

The

Commissioner also argues that the ALJ specifically identified clinical findings inconsistent with Dr.
Petrulis’ opinion, and thus properly rejected it.18/
II. Legal Standards
The Federal Magistrates Act requires a district court to conduct de novo review of the
objections to a report and recommendation.19/ Any issue not raised is deemed waived.20/
To establish disability under the Social Security Act, a claimant must show that she is unable
to engage in substantial activity due to the existence of a “medically determinable physical or mental
impairment that can be expected to result in death or that has lasted or can be expected to last for a

12/

(...continued)
20 C.F.R. § 404.981; 42 U.S.C. § 405(g).
13/
Doc. 22.
14/
Id. at 14, 16.
15/
Id. at 19.
16/
Doc. 23.
17/
Id. at 2.
18/
Id. at 2–3.
19/
28 U.S.C. § 636(b)(1).
20/
Funk v. Astrue, No. 1:10-cv-2867, 2012 WL 1095918, at *2 (N.D. Ohio Mar. 30, 2012).

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Case No. 1:14-cv-00998
Gwin, J.
continuous period of not less than twelve months.”21/ Agency regulations establish a five-step
sequential evaluation for use in determining whether a claimant is disabled.22/ The claimant’s
impairment must prevent her from doing her previous work, as well as any other work existing in
significant numbers in the national economy.23/ The ALJ is required to consider all medical
conditions (both severe and non-severe) at each step of the evaluation.24/
Under the “treating physician rule”25/ an ALJ must “give good reasons,” under a specific
decisional rubric, if she elects to not give a treating physician’s opinion controlling weight. 26/ “‘The
requirement of reason-giving exists, in part, to let claimants understand the disposition of their
cases,’ particularly in situations where a claimant knows that his physician has deemed him disabled
and therefore ‘might be especially bewildered when told by an administrative bureaucracy that she
is not.’”27/ The requirement also ensures meaningful review of the ALJ’s application of the rule.28/

III. Discussion
A. Lack of Analysis Regarding Ulcerative Colitis and Frequent Diarrhea

21/

See 42 U.S.C. §§ 423(d)(1)(A), 1382(c)(a)(3)(A).
20 C.F.R. § 404.1520. In Step One, the ALJ determines whether the claimant is engaged in a “substantial
gainful activity” at the time he or she seeks disability benefits. Colvin v. Barnhart, 475 F.3d 727, 730 (6th Cir. 2007).
In Step Two, the Plaintiff must show that he or she “suffers from a severe impairment in order to warrant a finding of
disability.” Id. (internal quotations omitted). In Step Three, the ALJ determines whether the claimant has a qualifying
impairment that also meets a durational requirement. See 20 C.F.R. Pt. 404, Subpt. P, App. 1. In Step Four, the ALJ
determines if the claimant’s RFC allows him to do past relevant work. Colvin, 475 F.3d at 740. Finally, in Step Five,
the ALJ determines whether the claimant is able to do any other work considering his RFC, age, education, and work
experience. Id. “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.” Id.
23/
See 42 U.S.C. §§ 423(d)(1)(A), 1382(c)(a)(3)(A).
24/
See 20 C.F.R. §§ 404.1520(a)(3), (e); 20 C.F.R. § 404.1545(a)(1).
25/
20 C.F.R. § 404.1527(d)(2).
26/
Wilson v. Comm’r of Soc. Sec., 378 F.3d 541, 544 (6th Cir. 2004).
27/
Id. (quoting Snell v. Apfel, 177 F.3d 128, 134 (2d Cir. 1999)).
28/
Id.
22/

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Case No. 1:14-cv-00998
Gwin, J.
As the R&R indicates, the ALJ’s decision does not evaluate Plaintiff Wood’s claims of
ulcerative colitis and frequent diarrhea when determining Plaintiff’s RFC.29/ Plaintiff Wood’s claims
regarding her condition of ulcerative colitis and frequent diarrhea were extensively documented. She
consistently complained of diarrhea from November of 2009 through January of 2012, and four
different doctors diagnosed her as having these conditions.30/
Not only was this medical condition well-documented, but it should have been a core issue
in the ALJ’s RFC analysis. RFC examines the claimant’s “ability to do physical and mental work
activities on a sustained basis despite limitations from her impairments.”31/ The vocational expert
testified at the hearing about the great difficulty an individual with Plaintiff’s issues would have in
finding employment. Thus, Plaintiff’s ulcerative colitis and frequent diarrhea would have had a
significant, if not dispositive impact on Plaintiff’s RFC.
It is the ALJ’s responsibility to consider all of the medical evidence regarding impairments
(severe and non-severe) at every step of the evaluation process, including when determining the
claimiant’s RFC.32/ However, Plaintiff Wood’s ulcerative colitis and frequent diarrhea were never
mentioned in the ALJ’s RFC determination, making it unclear whether the ALJ considered the
condition as she was required to.33/
The Commissioner’s objection asserts that the ALJ may have evaluated the ulcerative colitis
and disbelieved the evidence supporting it because Plaintiff had a normal swallow test and only
vague abdominal symptoms in examinations, and because the medical diagnoses were based on
29/

Doc. 22 at 13.
See id. at 4–5 (summarizing medical history).
31/
Doc. 10 at 39; see 20 C.F.R. § 404.1545.
32/
See 20 C.F.R. §§ 404.1520(a)(3), (e); 20 C.F.R. § 404.1545(a)(1).
33/
Doc. 22 at 13; see also Doc. 10 at 35–44.
30/

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Case No. 1:14-cv-00998
Gwin, J.
Plaintiff’s own reports.34/
According to the Commissioner, based on this evidence it was permissible for the ALJ to find
the ulcerative colitis was not a severe impairment. While it is possible that the ALJ might have used
such reasoning, the decision is silent on the topic of ulcerative colitis and therefore it is impossible
to know. This lack of explicit evaluation on a core issue precludes “meaningful review” of the ALJ’s
decision, and therefore requires reversal.
B. Rejection of Dr. Petrulis’s Opinion
The R&R also finds the ALJ failed to satisfy the requirements of the treating physician rule
when the ALJ rejected, without explanation, Dr. Petrulis’s opinion that Plaintiff Wood has numerous
motor impairments.35/ The ALJ instead relied on the opinion of another physician, Dr. Bradford,
when the ALJ found Plaintiff had normal gait, muscle strength, reflexes, range of motion for elbows,
wrist, and fingers and abilities for fine and gross manipulations.36/ Whether the ALJ rejected all of
Dr. Petrulis’s opinion, or merely the portions directly contradicted by Dr. Bradford, remains unclear
given the language of the decision.37/ Although the ALJ’s decision discusses Plaintiff’s motor skills,
it does not discuss other parts of Dr. Petrulis’s opinion.38/ However, the Court need not decide just
how much of Dr. Petrulis’s opinion the ALJ rejected, because the ALJ’s explanation fails to satisfy
the treating physician rule.
Although an ALJ’s explanation for discounting the treating source’s opinion may be brief,
it must still be “sufficiently specific to make clear to any subsequent reviewers the weight given to
34/

Doc. 23 at 2.
Doc. 22 at 17–19; see 20 C.F.R. § 404.1527(d)(2).
36/
Doc. 10 at 42.
37/
See id. at 42.
38/
See id. at 543–45.
35/

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Case No. 1:14-cv-00998
Gwin, J.
the treating physician’s opinion and the reasons for that weight.”39/ By accepting a competing
opinion from another doctor, the ALJ implicitly rejected Dr. Petrulis’s opinion.40/ The ALJ’s
decision, however, fails to give “good reasons” for giving Dr. Petrulis’s opinion so little weight.41/
The ALJ did not explain why she found Dr. Bradford’s opinion more persuasive than Dr.
Petrulis’s,42/ or why she considered Dr. Petrulis’s opinion to be inconsistent with the record as a
whole.43/ The ALJ’s failure to explain her reasoning thoroughly is unhelpful to both the Plaintiff and
reviewing courts, and requires reversal of her decision.
IV. Conclusion
For the foregoing reasons, the Court OVERRULES the Commissioner’s objections,
ADOPTS the Magistrate Judge’s Report and Recommendation, and REMANDS this case to the
Administrative Law Judge for further proceedings consistent with this opinion.
IT IS SO ORDERED.

s/
James S. Gwin
JAMES S. GWIN
UNITED STATES DISTRICT JUDGE

Dated: May 28, 2015

39/

Wilson, 378 F.3d at 544 (quoting S.S.R. 96-2P, 1996 WL 374188, at *5 (S.S.A.)) (internal quotation marks

omitted).
40/

Cf. Karger v. Comm’r of Soc. Sec., 414 F. App’x 739, 752–53 (6th Cir. 2011) (holding that an ALJ may
indirectly attack the treating physician’s opinion through adequate citation to conflicting evidence).
41/
See Bogle v. Sullivan, 998 F.2d 342, 347–48 (6th Cir. 1993).
42/
Friend v. Comm’r of Soc. Sec., 375 F. App’x 543, 552 (6th Cir. 2010).
43/
See Bogle, 998 F.2d at 347–48.

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