Kovacs Mathews v. Commissioner of Social Security Administration

Filing 26

Memorandum Opinion and Order that the ALJ's no disability finding lacks substantial evidence. This matter is reversed and remanded for further administrative proceedings consistent with this opinion. Signed by Magistrate Judge William H. Baughman, Jr., on 4/29/19. (D,Ky)

IN THE UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF OHIO
EASTERN DIVISION

SUSAN KOVACS MATHEWS,
Plaintiff,
v.
COMMISSIONER
OF
SOCIAL
SECURITY ADMINISTRATION,
Defendant.

)
)
)
)
)
)
)
)
)
)

CASE NO. 1:18 CV 0667

MAGISTRATE JUDGE
WILLIAM H. BAUGHMAN, JR.

MEMORANDUM OPINION &
ORDER

Introduction
Before me1 is an action by Susan Kovacs Matthews under 42 U.S.C. § 405(g) for
judicial review of the final decision of the Commissioner of Social Security denying her
applications for disability insurance benefits (“DIB”) and supplemental security income
(“SSI”).2 Because the Commissioner’s no disability finding lacks substantial evidence,
this matter is reversed and remanded for further administrative proceedings consistent with
this opinion

Issue Presented
The ALJ must give a treating physician’s opinions of controlling weight or,
alternatively, give good reasons for lesser weight assigned. The ALJ gave the opinions of
the treating neurologist no weight. He gave the opinions of the state agency reviewing

1
2

ECF No. 23. The parties have consented to my exercise of jurisdiction.
ECF No. 1.

physicians great weight. But he incorporated greater physical limitation in the residual
functional capacity (“RFC”) than the reviewing physicians opined.

The reviewing

physicians’ opinions predate the treating source’s opinions. Does substantial evidence
support the weight assigned to the treating source opinion?

Analysis
This is a straight-forward case in which Matthews challenges the weight assigned
to the opinion of her treating neurologist, Dr. Vakili of the Cleveland Clinic.
The Sixth Circuit in Gayheart v. Commissioner of Social Security3 emphasized that
the regulations require two distinct analyses in evaluating the opinions of treating sources.4
The Gayheart decision directed that the ALJ must first determine if the opinion must
receive controlling weight as well-supported by clinical and laboratory techniques and as
not inconsistent with other evidence in the administrative record.5 If the ALJ decides not
to give the opinion controlling weight, then a rebuttable presumption exists that the treating
physician’s opinion should receive great deference.6 This presumption may be rebutted by
application of the factors set forth in 20 C.F.R. §§ 404.1527(c)(2)(i)-(ii), (3)-(6).7 The
Court cautioned against collapsing these two distinct analyses into one.8

3

Gayheart v. Comm’r of Soc. Sec., 710 F.3d 365 (6th Cir. 2013).
Id. at 375-76.
5
Id. at 376.
6
Rogers v. Comm’r of Soc. Sec., 486 F.3d 234, 242 (6th Cir. 2007).
7
Gayheart, 710 F.3d at 376.
8
Id.
2
4

Despite the seemingly clear mandate of Gayheart, the Sixth Circuit in later decisions
has adopted an approach that permits these two separate analyses to be merged into one so
long as the ALJ states “good reasons” for the weight assigned, applying the regulatory
factors governing each analytical step.9 Also, despite the reality that a unified statement of
these “good reasons” greatly enhances meaningful judicial review,10 some authority exists
for looking outside the unified statement for analysis of the weight assigned to a treating
source’s opinion.11 Going beyond the reasons stated in the unified statement takes the
Court in the hazy gray area where the sirens of de novo review and post hoc rationalization
reside. A reviewing district court must avoid both. An ALJ cannot avoid reversal by
merely citing exhibits in the record that might support her findings without discussing the
content of those exhibits and explaining how that content provides support.12 Nor can
counsel for the Commissioner save a decision from reversal by citing to evidence in the
record not cited and adequately discussed by the ALJ.13 It is for the ALJ, not the court or
Commissioner’s counsel, to “build a logical bridge from the evidence to the conclusion.”14

9

E.g., Biestek v. Comm. of Soc. Sec., 880 F.3d 778, 785 (6th Cir. 2017).
Smith v. Comm. of Soc. Sec., No. 5:13cv870, 2104WL1944247, at **7-8 (N.D. Ohio
May 14, 2014).
11
See, e.g., Heston v. Comm’r of Soc. Sec., 245 F.3d 528 (6th Cir. 2001).
12
Smith, 2104WL1944247, at *7.
13
Sharp v. Comm’r of Soc. Sec., No. 1:14-cv-523, 2015 WL 3545251 (S.D. Ohio June 4,
2015) (citing Keeton v. Comm’r of Soc. Sec., 583 F. App’x 515, 524 (6th Cir. 2014)),
report and recommendation adopted by 2015 WL 3952331 (S.D. Ohio June 29, 2015).
14
Hale v. Colvin, No. 3:13cv182, 2014 WL 868124, at *8 (S.D. Ohio March 5, 2014).
3
10

“Put simply, . . . there must be some effort . . . to explain why it is the treating physician’s
conclusion that gets the short end of the stick.”15
With these principles in mind, I turn to the treatment of Dr. Vakili’s opinions.
Dr. Vakili gave two opinions, one on December 18, 2015, and a second one on
March 6, 2017.16 Both are consistent. These opinions support a disability finding based
on limitations with fingering and handling and sustainability (the need for frequent breaks,
time off task, and absences). Dr. Vakili’s treating relationship with Matthews began in
January 2015 and extended through March 2017 for purposes of this record. From time to
time, Matthews saw two other providers at the Cleveland Clinic, Drs. Khan (her primary
care physician) and Mazon (a rheumatologist).
The state agency reviewing sources, whose opinions the ALJ gave great weight, did
not review either of Dr. Vakili’s opinions. The state agency sources had the benefit of
some of the treatment notes of the Cleveland Clinic physicians through approximately May
2015.17 Despite giving these opinions great weight, the ALJ found Matthews capable of a
more restrictive RFC – sedentary18 – than the state reviewing sources opined (light).19

15

Friend v. Comm’r of Soc. Sec., 375 F. App’x 543, 552 (6th Cir. 2010).
ECF No. 13, Transcript (“Tr.”) at 349-51, 440-42.
17
Id. at 60-62, 73- 75, 88-90, 99-101.
18
Id. at 17.
19
Id. at 70, 83, 96, 107.
4
16

The ALJ discussed Dr. Vakili20 and Matthews’s course of treatment generally.21
Matthews amended her onset date at the hearing to April 2014, which coincides with the
onset of her treating relationship with Dr. Khan.22
The ALJ found Matthews’s depression not severe and included no mental
limitations in the RFC.23 Although Matthews’s treating sources diagnosed depression, and
Dr. Vakili included that in his opinions, the impairments causing the limitations, according
to Dr. Vakili’s opinions, are rheumatoid arthritis, lumbar degenerative disc disease,
tendonitis of the ankles, hallux valgus of the feet, and migraines, all of which the ALJ
found severe.24
The vocational expert (“VE”) testified that the limitations on the use of the hands
and absences, off-task behavior, and breaks opined by Dr. Vakili would preclude a
significant number of jobs in the national economy.25
The bottom line is whether substantial evidence supports the ALJ’s assignment of
“no weight” to Dr. Vakili’s opinions. To reach this conclusion in favor of the ALJ, the
medical records would have to paint a vastly different picture from the one put forward in
the decision – and that is not the case here. Admittedly, the treatment notes show some
good days and bad days. Matthews’s attorney argues that any improvement was short-

20

Id. at 21.
Id. at 18-20.
22
Id. at 14, 17.
23
Id. at 15, 17.
24
Id. at 14.
25
Id. at 56-57.
21

5

lived and longitudinally the medical evidence supports the limitations assigned by Dr.
Vakili.

Since January 2015, only two visits support that Matthews experienced

improvement in her systems. The overwhelming medical evidence in the record from
January 2015 through January 2017 reflects that Matthews continued to experience severe
headaches, migraines, and rheumatoid arthritis pain.
The only reason the ALJ gave in support of assigning “no weight” to Dr. Vakili’s
opinions is that the opinions were “unsupported and inconsistent with the record as a
whole.”26 There are no source opinions contemporary to those of Dr. Vakili. The state
agency reviewing sources did not have the benefit of Dr. Vakili’s opinions or the bulk of
Dr. Vakili’s treatment notes. Yet the ALJ assigned the state agency reviewing sources
opinions great weight, while undercutting that weight by rejecting their opinions favoring
light work and adopting a sedentary RFC. Dr. Vakili’s opinions matter because had the
ALJ given them controlling or substantial weight, there would be no jobs Matthews could
perform according to the VE.
The ALJ improperly discounted Dr. Vakili’s opinions by cherry-picking the record,
focusing only on the medical evidence supportive of the RFC while ignoring the multiple
office visits reflecting continued complaints of pain, rheumatoid arthritis symptoms,
headaches, and migraines – medical records which support that Matthews’s migraines and
rheumatoid arthritis were not under control. The weight the ALJ assigned to Dr. Vakili’s
opinions lacks substantial evidence. Remand is required.

26

Id. at 21.
6

Conclusion
The ALJ’s no disability finding lacks substantial evidence. This matter is reversed
and remanded for further administrative proceedings consistent with this opinion. On
remand, the ALJ must properly weigh Dr. Vakili’s opinions and articulate good reasons
for the weight assigned.
IT IS SO ORDERED.
Dated: April 29, 2019

s/ William H. Baughman, Jr.
United States Magistrate Judge

7