Allen-McGuire v. Commissioner of Social Security

Filing 21

Memorandum Opinion and Order. For the reasons outlined herein, the Magistrate Judge finds that the decision of the Commissioner is supported by substantial evident. Accordingly, the Court AFFIRMS the decision of the Commissioner. Signed by Magistrate Judge Kenneth S. McHargh on 6/11/14. (R,N)

IN THE UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF OHIO
EASTERN DIVISION
DEANNA ALLEN-McGUIRE,
Plaintiff,
v.

COMMISSIONER OF SOCIAL
SECURITY ADMINISTRATION,
Defendant.

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CASE NO. 5:13-CV-1494

MAGISTRATE JUDGE
KENNETH S. McHARGH

MEMORANDUM OPINION &
ORDER

This case is before the Magistrate Judge pursuant to the consent of the parties. (Doc. 17).
The issue before the undersigned is whether the final decision of the Commissioner of Social
Security (“Commissioner”) denying Plaintiff Deanna Allen-McGuire’s (“Plaintiff”) application
for a Period of Disability and Disability Insurance benefits under Title II of the Social Security
Act, 42 U.S.C. §§ 416(i) and 423, is supported by substantial evidence and, therefore,
conclusive.
For the reasons set forth below, the Court AFFIRMS the Commissioner’s decision.
I. PROCEDURAL HISTORY
Plaintiff protectively filed an application for Disability Insurance benefits on May 22,
2009. (Tr. 189-97). At the time of the application, Plaintiff alleged she became disabled on June
1, 2007 due to suffering from migraine headaches, which Plaintiff later supplemented with
additional conditions. (Tr. 216).

The Social Security Administration denied Plaintiff’s

application on initial review and upon reconsideration. (Tr. 146-52).

At Plaintiff’s request, administrative law judge (“ALJ”) Robert King convened an
administrative hearing on September 15, 2011 to evaluate her application. (Tr. 93-134).
Plaintiff, represented by counsel, appeared and testified before the ALJ. (Id). A vocational
expert (“VE”), Mary Beth Kopar, also appeared and testified. (Id.).
On October 28, 2011, the ALJ issued an unfavorable decision, finding Plaintiff was not
disabled. (Tr. 71-87). After applying the five-step sequential analysis, 1 the ALJ determined
Plaintiff retained the ability to perform work existing in significant numbers in the national
economy. (Id.). Subsequently, Plaintiff requested review of the ALJ’s decision from the Appeals
Council. (Tr. 65). The Appeals Council denied the request for review, making the ALJ’s

1

The Social Security Administration regulations require an ALJ to follow a five-step sequential analysis
in making a determination as to “disability.” See 20 C.F.R. §§ 404.1520(a), 416.920(a). The Sixth Circuit
has summarized the five steps as follows:
(1)

If a claimant is doing substantial gainful activity–i.e., working for profit–she is not
disabled.

(2)

If a claimant is not doing substantial gainful activity, her impairment must be severe
before she can be found to be disabled.

(3)

If a claimant is not doing substantial gainful activity and is suffering from a severe
impairment that has lasted or is expected to last for a continuous period of at least twelve
months, and her impairment meets or equals a listed impairment, claimant is presumed
disabled without further inquiry.

(4)

If a claimant’s impairment does not prevent her from doing her past relevant work, she is
not disabled.

(5)

Even if a claimant’s impairment does prevent her from doing her past relevant work, if
other work exists in the national economy that accommodates her residual functional
capacity and vocational factors (age, education, skills, etc.), she is not disabled.

Abbott v. Sullivan, 905 F.2d 918, 923 (6th Cir. 1990); Heston v. Comm’r of Soc. Sec., 245 F.3d 528, 534
(6th Cir. 2001).

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October 28, 2011 determination the final decision of the Commissioner. (Tr. 3-9). Plaintiff now
seeks judicial review of the Commissioner’s final decision pursuant to 42 U.S.C. § 405(g).
II. EVIDENCE
A. Personal Background Information
Plaintiff was born on July 16, 1961, and was 50 years old on the date the ALJ rendered
his decision, making her “closely approaching advanced age.” 20 C.F.R. § 404.1563(d). Plaintiff
completed high school and has past relevant work as an assembler, packager, tire molder,
assembly supervisor, material handler, and phone repairer. (Tr. 124-25).
B. Medical Evidence
1. Physical Impairments
On September 16, 2006, Plaintiff visited the emergency room due to a week-long
intermittent headache that had worsened in the last two days. (Tr. 606-07). Plaintiff reported
experiencing extensive migraines in the past, but had not experienced one for approximately
three years. (Tr. 606). Plaintiff was diagnosed with acute cephalgia. (Id.). Plaintiff visited the
emergency room again for acute cephalgia on September 21, 2007. (Tr. 604). She was given
Compazine, Benadryl, and Toradol, and felt much improved thereafter. (Id.).
On October 5, 2007, Plaintiff presented to the emergency room complaining of pain in
her neck, back, and right knee. (Tr. 289-303). Plaintiff reported that she had fallen down stairs,
causing the injuries. (Tr. 291).

Images were taken of the right knee, which a radiologist

interpreted as showing mild to moderate degenerative joint disease (“DJD”). (Id.).

Upon

physical examination, Plaintiff had tenderness in the right knee, but no effusion, swelling, or
deformity. (Id.).

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In May 2008, Plaintiff underwent a physical examination. (Tr. 325-26). She reported
mild (one to two days per week) pain in her right knee, but had no issue with daily activity. (Tr.
325). On June 7, 2008, Plaintiff presented to the emergency room with complaints of headaches
and nausea. (Tr. 570-76). She was prescribed medication. (Tr. 574).
While seeking treatment at the Community Health Center (“CHC”) for drug
dependencies, which will be discussed later herein, Plaintiff spoke to Charlene Kovach,
L.I.C.D.C., Q.M.S.H., about her headaches. On March 4, 2009, Plaintiff reported to Ms. Kovach
that her headaches took everything out of her and she was planning to see doctors to have
neurological testing performed. (Tr. 529). Ms. Kovach reported that Plaintiff had rarely been in
attendance for her substance abuse therapy meetings. (Id.).
On April 28, 2009, Plaintiff reported to Ms. Kovach that her headaches decreased her
motivation and caused her to want to “lay around all day.” (Tr. 529). Ms. Kovach encouraged
her to exercise five days each week. (Id.). On May 21, 2009, Plaintiff stated she still experienced
headaches, but not on a daily basis. (Tr. 529). She expressed concern to Ms. Kovach that if she
started working, it could interfere with her husband’s disability benefits. (Id.).

Plaintiff

confessed to Ms. Kovach that she found herself unmotivated and felt it was because she had no
job or obligations, and, as a result, she “lays around a lot and has difficulty getting up in the
morning.” (Id.). Yet, in June 2009, Plaintiff indicated she experienced headaches three times per
week and hoped to obtain medical benefits so that she could receive treatment. (Tr. 497-98).
She indicated that headaches prevented her from gainful employment because they became so
painful that they forced to her lie down. (Tr. 496).

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On July 17, 2009, Plaintiff told Ms. Kovach that she had a busy and active week. (Tr.
494). She performed banquet work, in the form of decorating and cleaning up. (Id.). Plaintiff
indicated “it has actually felt good to be busy,” and her headaches were not as frequent. (Id.).
On July 23, 2009, Plaintiff underwent a consultative physical examination with state
agency physician Vimal Patel, M.D. (Tr. 380-81). Plaintiff stated that she had experienced
migraine headaches two to three times per week her entire life. (Tr. 380). While Plaintiff had not
had a CT-scan, she reported that numerous neurologists had been unable to identify the cause of
her migraines. Plaintiff stated she was able to perform her activities of daily living, sit or stand
for two hours at a time for a total of eight hours, and lift up to ten pounds. (Id.). Upon physical
examination, Plaintiff showed decreased range of motion in her shoulders and knees, but her gait
was normal. (Tr. 381).

Dr. Patel recommended the following: “Pending results of x-rays

obtained, claimant would benefit from seeing an orthopedic surgeon vs. medical management
with physical therapy for these issues. She would also benefit from possibly seeing another
neurologist to attempt better control of her migraines.” (Id.). As to Plaintiff’s limitations, Dr.
Patel opined, “I believe these debilitating migraines cause difficulty with her being employed;
however, if she were able to get better control of this issue, she would be able to perform a desk
job.” (Id.).
On July 23, 2009, Plaintiff reported to Ms. Kovach that she experienced regular
headaches. (Tr. 493). Plaintiff claimed that she could not work any job on a regular basis
because no employer would allow her to consistently miss work due to headaches. (Id.).

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Plaintiff’s July 23, 2009 x-rays showed mild degenerative change in the right knee,
particularly prominent at the patellofemoral articulation. (Tr. 382). The left shoulder showed the
glenohumeral joint intact. (Id.).
On September 16, 2009, Cindi Hill, M.D., a state agency consultant, performed a review
of Plaintiff’s file. (Tr. 427-35). Dr. Hill opined that Plaintiff could perform medium work, with
additional limitations on climbing and overhead reaching. (Tr. 428-30).

In support of her

findings, Dr. Hill explained that Plaintiff’s allegations exceeded the support of the objective
findings in the medical evidence of record, and Plaintiff presented herself as more limited at the
consultative examination with Dr. Patel than at her visits with her treating sources. (Tr. 432).
On November 4, 2009, Plaintiff appeared to her appointment with Ms. Kovach one hour
late. (Tr. 487). She reported having “horrendous headaches,” which she attributed to stress,
having recently found out that her father had cancer. (Id.). On December 7, 2009, Ms. Kovach
talked to Plaintiff about a recent relapse of substance abuse and headaches. (Tr. 484). Ms.
Kovach opined that the headaches were likely a result of using drugs. (Id.). On January 19,
2010, Plaintiff left a message for Ms. Kovach that she was not feeling well due to headaches and
could not make her individual or group therapy sessions. (Tr. 471). Ms. Kovach indicated that
this seemed to be Plaintiff’s “method of operation.” (Id.). On February 8, 2010, Ms. Kovach
explained that she realized Plaintiff did suffer from headaches, but it appeared that she used this
“to her advantage.” (Tr. 468).
On March 8, 2010, Plaintiff began treating with Gina Horne, an internal medicine
specialist. (Tr. 664-68). A physical examination showed Plaintiff had a full range of motion in
the right knee, but some decreased strength in the left shoulder with lifting the arm. (Tr. 667).
Otherwise her physical examination was unremarkable, including her neurological findings.

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(Id.). Plaintiff reported undergoing rotator cuff repair around 1995 and having pain off and on in
her shoulder, particularly when lying down. (Tr. 669). Dr. Horne’s impressions were chronic
migraines, chronic sinusitis, right knee pain, left shoulder pain, depression, and fatigue. (Tr.
668). Dr. Horne noted that Plaintiff had not seen a physician in over one year. (Tr. 669).
Plaintiff continued to treat with Dr. Horne during the relevant period for headaches, sinusitis,
rotator cuff syndrome, low back pain, and depression, among other alleged symptoms. (Tr. 64363).
On April 10, 2010, Plaintiff presented to the emergency room due to a continuous
headache that lasted six weeks. (Tr. 567). A CT scan was performed, which returned negative,
and additional lab work also returned normal. (Id.). Plaintiff was treated with Compazine,
Toradol, and Benadryl, which significantly reduced her pain. Gary Giorgio, M.D., was unable to
identify the etiology of Plaintiff’s chronic headaches, but instructed her to follow up with Dr.
Horne and consult a neurologist or headache specialist. (Id.).
On April 22, 2010, state agency consultant Jerry McCloud, M.D., performed a second
review of the record. (Tr. 506). Dr. McCloud affirmed Dr. Hill’s physical residual functional
capacity recommendation. (Id.).
On April 23, 2010, Ms. Kovach described Plaintiff as “very worn and somewhat dazed.”
(Tr. 510). Plaintiff believed her migraine medication was not working, but making the situation
worse, so that she was groggy, unable to drive, and unable to leave her home most days. (Id.).
On April 27, 2010, Plaintiff reported to Ms. Kovach that she had blackout periods, during which
she could not remember what had occurred, but her doctor was investigating the cause. (Tr. 509).
Plaintiff returned to the emergency room on April 28, 2010, again with migraine
symptoms and explaining that she was unhappy with Dr. Horne’s treatment of her migraines.

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(Tr. 565). Although Plaintiff denied consuming alcohol, her blood alcohol level was 0.18 and
her speech was slurred. Plaintiff was treated with medication and discharged with diagnoses of
migraine headaches and alcohol abuse. (Id.).
An x-ray taken of Plaintiff’s knee in September 2010 showed mild degenerative changes.
(Tr. 640). A November 2010 MRI of Plaintiff’s left shoulder showed degenerative findings with
spurring, geode formation, and labral irregularity. (Tr. 642). There was also fluid within the
subacromial space and moderate to severe supraspinatus with milder infraspinatus and
subscapularis tendinopathy. (Id.).
On December 2, 2010, Dr. Horne adjusted Plaintiff’s migraine medications, increasing
her dosage of Topamax. (Tr. 653). Plaintiff described her headaches as occurring five to six
times per week and being of variable types, lasting for hours to days without relief. (Tr. 654).
Plaintiff stated that the headaches were of such severity that they restricted her ability to work
and complete home responsibilities. (Id.).
On December 8, 2010, Plaintiff presented to Kenneth Mooney, M.D., for an evaluation of
sinus headaches. (Tr. 625). Dr. Mooney diagnosed headaches, rhinitis, and nasal scarring on the
left side. (Tr. 632).

He recommended that Plaintiff follow up with a neurologist for her

headaches, because she was on maximum medication and still having complaints. (Id.). A
February 2011 CT of Plaintiff’s paranasal sinuses showed moderate to severe paranasal sinus
disease. (Tr. 634). Dr. Mooney prescribed medication, but Plaintiff reported she was unable to
fulfill the prescription due to monetary issues. (Tr. 644).
On December 16, 2010, Dr. Horne noted that Plaintiff had seen an orthopedist for her
shoulder and knee. (Tr. 651). Plaintiff had been referred to physical therapy, but had not yet
attended. She indicated that a cortisone injection was very helpful for her shoulder and allowed

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her to sleep through the night. (Id.). Plaintiff stated that the increase in Topamax had not
improved her headaches, which remained essentially unchanged. Dr. Horne commented that
Plaintiff had not been keeping a headache diary. (Id.).
On September 21, 2011, Plaintiff began treating with orthopedist Nilesh Shah, M.D. (Tr.
747-48). She complained of shoulder pain, worse on the left, occurring with all activities,
particularly reaching overhead. Plaintiff stated that the cortisone shot she received in December
was not helpful. Plaintiff also reported knee pain, worse on the left, which increased when
climbing stairs, walking, and lying down. Plaintiff’s physical examination showed a normal gait.
She experienced some knee pain during palpation and at the end ranges of extension. Dr. Shah
noted a patella grin. Plaintiff’s left shoulder showed normal range of motion, but there was
significantly decreased abduction and severely limited internal rotation. Her left shoulder
strength was normal, but there was pain with resisted internal and external rotation and forward
flexion. Plaintiff’s right shoulder had a normal range of motion, except for mildly limited full
abduction and internal rotation. Her right shoulder strength was normal and without pain. (Id.).
Dr. Shah examined x-rays of Plaintiff’s knees, which he opined demonstrated mild to
moderate narrowing of the medial compartment bilaterally, severe patellofemoral joint
degenerative disc disease bilaterally, and some lateralization of the patella bilaterally. (Tr. 749).
Dr. Shah aspirated Plaintiff’s knees and administrated steroid injections.

The doctor also

reviewed a November 2010 MRI of Plaintiff’s left shoulder that showed significant tendinopathy
and osteoarthritis to the glenohumeral joint and acromioclavicular (“A.C.”) joint. Dr. Shah
discussed treatment options for Plaintiff’s shoulder, and she indicated she wished to speak to a
surgeon. (Id.).

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Plaintiff returned to see Dr. Shah on October 13, 2011. (Tr. 744-46). Plaintiff explained
that injections provided relief for only a few days in her knees. Dr. Shah recommended surgical
intervention for Plaintiff’s knee due to severe patellofemoral arthritis and lack of response to
conservative treatment. (Tr. 745).

Plaintiff was to follow-up with Dr. Bell regarding the

potential for shoulder surgery. (Id.).
2. Mental Impairments & Substance Abuse
In May 2005, Plaintiff began treatment at CHC for opioid and cocaine dependence. (Tr.
317). Plaintiff reported a history of termination from past employment due to drug use. (Id.).
She was admitted for treatment on May 17, 2005. (Tr. 314). Her diagnoses upon admission
were opioid dependence, cocaine dependence, bipolar disorder, and hepatitis C. (Id.). Plaintiff
underwent methadone treatment and received counseling services. (Tr. 314, 318).
An August 2007 psychiatric progress noted described Plaintiff as tidy, coherent, not
paranoid or suicidal, and with mildly impaired judgment and cognition. (Tr. 348). Although
Plaintiff was depressed, she behaved in a friendly manner and her substance abuse was noted to
be well-controlled on methadone. On September 10, 2007, Plaintiff stated that she had begun
working full-time at Rubbermaid at the beginning of the month. (Tr. 346). In October 2007,
Plaintiff’s affect and mood were noted to be “improving.” (Tr. 340). While Plaintiff had mildly
impaired insight and judgment, she was alert, coherent, responding well to current medications.
Plaintiff’s psychiatric progress notes appear to continue reporting similar mild issues and
improvement through February of 2008. (Tr. 330-37).
On March 20, 2008, Ronald Immerman, M.D., performed a psychiatric evaluation. (Tr.
390-93). Plaintiff reported low moods and irritability on a daily basis, resulting in fractured
sleep, racing thoughts, and being easily distracted. (Tr. 390). She reported passive suicidal

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ideation and an extensive pattern of abusing drugs from early in her teenage years. (Tr. 390-91).
Plaintiff’s mental status examination was unremarkable, with Dr. Immerman observing that
Plaintiff was pleasant, cooperative, her speech was within normal limits and logical, her mood
was “ok,” and her affected normal. (Tr. 391). The doctor diagnosed bipolar disorder, anxiety
disorder, cocaine dependence, and opioid dependence (in early remission). (Tr. 392).

He

assigned a global assessment of functioning score (“GAF”) of 55, representing moderate
symptoms. (Id.). Dr. Immerman noted that Plaintiff had not been hospitalized for psychiatric
reasons. (Tr. 390).
In May 2008, Kathleen Cockfield, a nurse at Portage Path Behavior Health (“Portage
Path”), recounted Plaintiff’s report that she was clean and sober, with some decrease in
irritability. (Tr. 416). Plaintiff was excited to be starting a computer class, and her mental status
examination was unremarkable, aside from a somewhat depressed mood. (Id.).
On August 4, 2008, Nancy Keogh, Ph.D., of CHC explained that Plaintiff had lost her
full time job at Rubbermaid because of migraine headaches, illness, and drug use. (Tr. 538).
Plaintiff confessed that she had a substance relapse after losing her job. (Id.). Plaintiff’s mental
status examination was unremarkable that day. (Tr. 537-38). Dr. Keogh opined that Plaintiff was
stable from opiate use when on methadone, but could not stop using cocaine. (Tr. 538). The
doctor referred Plaintiff to RAMAR, a residential chemical dependency treatment facility. (Tr.
315-16, 538).
Plaintiff treated with Ms. Cockfield on October 30, 2008. (Tr. 410). Although Plaintiff
was irritable with decreased motivation, she was also smiling, logical, cooperative, alert, and
displaying good insight and judgment. (Id.). Plaintiff continued to attend sessions with Ms.
Cockfield through 2008, with mostly unremarkable mental status examinations. By January

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2009, Plaintiff reported that she was feeling less depressed due to an increase in Lamictal, she
was almost completely off methadone, and she was in RAMAR after care. (Tr. 405).

In

February 2009, Ms. Cockfield observed that Plaintiff was smiling, animated, with a stable mood,
and with improving insight and judgment. (Tr. 403).

However, in June 2009, Plaintiff

complained of low motivation, depression, and migraines. (Tr. 401). Ms. Cockfield wrote that
Plaintiff appeared tired and depressed, but was cooperative, with intact judgment and a logical
thought process. (Id.).
On August 26, 2009, Ms. Kovach wrote that Plaintiff was tearful and described verbal
abuse from her husband. (Tr. 490). Plaintiff indicated that Social Security benefits may be the
only way for her to get out of her marriage. (Id.). A September 3, 2009 treatment note indicated
Plaintiff was depressed and taking Lamictal and Lexapro for mood stabilization. (Tr. 396).
On September 4, 2009, Ms. Cockfield completed a Mental Status Questionnaire,
explaining that she had treated Plaintiff from May 2008 through September 2009. (Tr. 422-24).
Ms. Cockfield described Plaintiff as having a depressed mood and low motivation, but normal
speech. Additionally, Plaintiff’s ability to remember, understand, and follow directions were
intact, and she had no deficiencies in social functioning. Ms. Cockfield indicated that Plaintiff’s
depressed mood and migraines made functioning difficult. (Id.).
On September 22, 2009, David Dietz, Ph.D., a state agency reviewing consultant,
performed a review of Plaintiff’s file. (Tr. 427-35). Dr. Dietz concluded that Plaintiff could
perform three to four-step tasks in an environment where she did not have to maintain high
production demands or schedules. (Tr. 452).
On December 14, 2009, Theresa Wilson, a licensed social worker at CHC, explained that
Plaintiff struggled with depression due to her father’s recent diagnosis with cancer. (Tr. 480). A

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December 18, 2009 treatment note indicates that Plaintiff stopped taking her anti-depressant
medications and recently re-started because she believed they may help with depression. (Tr.
478). On December 28, 2009, Plaintiff told Ms. Kovach that she felt as though she had been in a
“tailspin” since she stopped taking Lamictal. (Tr. 476).
On August 4, 2010, Plaintiff underwent a clinical evaluation at Portage Path. (Tr. 670).
The report indicates Plaintiff had been absent from treatment at Portage Path since September
2009. (Tr. 682). Plaintiff stated that when she began having problems with headaches, she
stopped taking medication and dropped out of treatment. (Id.). Her mental status examination
showed a depressed and anxious mood, but appropriate affect, logical thought process, clear
speech, and poor to fair judgment. (Tr. 686).
On May 17, 2010, state agency consultant Bruce Goldsmith, reviewed Plaintiff’s updated
medical records. (Tr. 577). He affirmed Dr. Dietz’s September 2009 opinion. (Id.).
On August 23, 2010, Sameera Khan, M.D., of Portage Path conducted a psychiatric
evaluation of Plaintiff. (Tr. 689). Plaintiff told Dr. Khan that she had a long history of headaches
that were not treated by medication, and she could not tolerate the medication. Plaintiff also
described sadness, depression, crying episodes, not wanting to leave bed, low motivation and
energy, hopelessness, and anxiousness. (Id.).

The mental status examination showed that

Plaintiff was alert, with decreased psychomotor activity, coherent speech, fair mood, and no
anxiety. (Tr. 690). Dr. Khan recommended psychopharmacology and psychotherapy treatments
and added Wellbutrin to Plaintiff’s medication. (Tr. 691). A treatment note from September 22,
2010 indicates that Plaintiff was only taking half of her Wellbutrin prescription. (Tr. 733).
Plaintiff began missing numerous treatment sessions at Portage Path toward the end of
2010 and into 2011. (Tr. 706-13, 719-22, 724, 732). On June 29, 2011, Plaintiff treated with Dr.

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Khan, who indicated he had not seen her since September 2010. (Tr. 699). Plaintiff reported that
she had long-run out run out of medication. She was tearful and explained that she could not get
up to do anything, her insurance had run out, and she was experiencing greater depression. (Id.).
Dr. Khan observed that Plaintiff had normal speech, was adequately groomed, had negative
thoughts but was non-delusional, heard voices, was depressed and anxious, had impaired
judgment, and was cooperative with appropriate eye contact. (Id.). Dr. Khan started Plaintiff on
psychotropic medication again. (Tr. 700). On June 30, 2011 Portage Path treatment notes
indicated that Plaintiff recently resumed anti-depressant medication. (Tr. 698).

Plaintiff’s

medical treatment had stopped when she lost Access to Care eligibility, which was terminated
because she had not paid a token fee and re-registered. (Id.).
On September 14, 2011, Dr. Khan completed a Medical Source Statement speaking to
Plaintiff’s mental limitations. (Tr. 741-43). Dr. Khan opined that Plaintiff suffered from marked
to extreme limitations in the following areas: maintaining concentration and attention for two
hour periods; performing activities within a schedule; maintaining regular attendance; sustaining
ordinary routine without special supervision; completing a normal workweek without
interruption from symptoms and performing at a consistent pace; accepting instructions and
responding appropriately to criticism from supervisors; and getting along with coworkers or
peers. Dr. Khan also found that Plaintiff suffered from a number of moderate limitations.
Additionally, Dr. Khan indicated that Plaintiff had suffered from three or more episodes
of decompensation within the past 12 months, each of which were at least two weeks in duration.
In support of his assessment, Dr. Khan wrote that Plaintiff exhibited a “markedly poor ability to
focus and effectively problem solve,” her moods and chronic pain were disruptive, and she had

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been seen for multiple psychiatric treatment sessions. The doctor also indicated that previous
treatment records were reviewed. (Id.).
III. SUMMARY OF THE ALJ’S DECISION
The ALJ made the following findings of fact and conclusions of law:
1. The claimant last met the insured status requirements of the Social Security Act on
December 31, 2012.
2. The claimant did not engage in substantial gainful activity since June 1, 2007, the alleged
onset date.
3. The claimant has the following severe impairments: (1) osteoarthritis of the thoracic
spine; (2) degenerative joint disease of both knees; (3) history of right rotator cuff surgery
in 1995; (4) osteoarthritis of the left shoulder with rotator cuff syndrome and
tendinopathy; (5) history of carpal tunnel syndrome; (5) headaches; (6) paranasal sinus
disease and allergic rhinitis; (7) generalized anxiety disorder, poorly documented; (8)
depressive disorder, not otherwise specified; and (9) polysubstance abuse and
dependence.
4. The claimant does not have an impairment or combination of impairments that meets or
medically equals the severity of one of the listed impairments in 20 C.F.R. Part 404,
Subpart P, Appendix 1.
5. After careful consideration of the entire record, I find that, through the date last insured,
the claimant had the residual functional capacity to perform light work as defined in 20
C.F.R. 404.1567(b). She can lift and/or carry twenty pounds occasionally and ten pounds
frequently. She can stand and/or walk (with normal breaks) for at least six hours in an
eight hour workday. She can sit (with normal breaks) for at least six hours in an eight
hour workday. She has no restriction in her ability to push and/or pull, (including the
operation of and or foot controls), other than as restricted by her limitations on
lifting/carrying. She can occasionally climb ramps and stairs. She can occasionally climb
ladders, ropes or scaffolds. She can frequently stoop and can occasionally knee, crouch,
and crawl. She can reach in all directions without restrictions, except that she can only
occasionally reach overhead bilaterally. She can frequently handle and finger bilaterally.
She cannot work in extreme cold and she needs to avoid concentrated exposure to
substantial noise and vibration. She needs to avoid concentrated exposure to respiratory
irritants such as fumes, odors, dusts, gases, poor ventilation, etc. Mentally, she is limited
to simple, routine, repetitive tasks, involving only simple, work-related decisions and in
general, relatively few workplace changes. She cannot interact with others in situations
involving substantial negotiation, persuasion, or conflict resolution. She cannot work in
an environment with extremely high quotas, very strict time limits or deadlines, or
extremely fast-paced production demands (such as those encountered in piece work or on
a fast moving assembly line).

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6. The claimant is unable to perform any past relevant work.
7. The claimant was born on July 1, 1961 and was 45 years old, which is defined as a
younger individual age 18-49, on the alleged disability onset date.
8. The claimant has at least a high school education and is able to communicate in English.
...
10. Considering the claimant’s age, education, work experience, and residual functional
capacity, there are jobs that exist in significant numbers in the national economy that the
claimant can perform.
11. The claimant has not been under a disability, as defined in the Social Security Act, from
June 1, 2007, through the date of this decision.
(Tr. 73-87) (internal citations omitted).
IV. DISABILITY STANDARD
A claimant is entitled to receive Disability Insurance and/or Supplemental Security
Income benefits only when she establishes disability within the meaning of the Social Security
Act. See 42 U.S.C. §§ 423, 1381. A claimant is considered disabled when she cannot perform
“substantial gainful employment by reason of any 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 continuous period of not less than twelve (12) months.” See 20 C.F.R. §§ 404.1505, 416.905.
V. STANDARD OF REVIEW
Judicial review of the Commissioner’s benefits decision is limited to a determination of
whether, based on the record as a whole, the Commissioner’s decision is supported by substantial
evidence, and whether, in making that decision, the Commissioner employed the proper legal
standards. See Cunningham v. Apfel, 12 F. App’x 361, 362 (6th Cir. 2001); Garner v. Heckler,
745 F.2d 383, 387 (6th Cir. 1984); Richardson v. Perales, 402 U.S. 389, 401 (1971).
“Substantial evidence” has been defined as more than a scintilla of evidence but less than a
preponderance of the evidence. See Kirk v. Sec’y of Health & Human Servs., 667 F.2d 524, 535
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(6th Cir. 1981). Thus, if the record evidence is of such a nature that a reasonable mind might
accept it as adequate support for the Commissioner’s final benefits determination, then that
determination must be affirmed. Id.
The Commissioner’s determination must stand if supported by substantial evidence,
regardless of whether this Court would resolve the issues of fact in dispute differently or
substantial evidence also supports the opposite conclusion. See Mullen v. Bowen, 800 F.2d 535,
545 (6th Cir. 1986); Kinsella v. Schweiker, 708 F.2d 1058, 1059 (6th Cir. 1983). This Court may
not try the case de novo, resolve conflicts in the evidence, or decide questions of credibility. See
Garner v. Heckler, 745 F.2d 383, 387 (6th Cir. 1984). However, it may examine all the evidence
in the record in making its decision, regardless of whether such evidence was cited in the
Commissioner’s final decision. See Walker v. Sec’y of Health & Human Servs., 884 F.2d 241,
245 (6th Cir. 1989).
VI. ANALYSIS
Plaintiff argues that the ALJ’s residual functional capacity (“RFC”) assessment is not
supported by substantial evidence, because the ALJ failed to appropriately assess a number of
opinions issued by medical sources. For the reasons that follow, Plaintiff’s arguments do not
warrant reversal or remand.
A. Plaintiff’s Treating Physician
Plaintiff contends that the ALJ erred in failing to grant controlling weight to the opinion
of her treating psychiatrist, Dr. Khan. Dr. Khan first treated Plaintiff on August 23, 2010. In
September 2011, the doctor completed a medical source statement describing his opinions as to
the extent of Plaintiff’s mental limitations. (Tr. 741-43). He opined that Plaintiff suffered from
a number of moderate, marked, and extreme limitations. (Id.).

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When assessing the medical evidence contained within a claimant’s file, it is wellestablished that an ALJ must give special attention to the findings of the claimant’s treating
source. See Wilson v. Comm’r of Soc. Sec., 378 F.3d 541, 544 (6th Cir. 2004). The treating
source doctrine recognizes that physicians who have a long-standing treating relationship with an
individual are better equipped to provide a complete picture of the individual’s health and
treatment history. Id.; 20 C.F.R. § 404.1527(c)(2). Under the Social Security Regulations,
opinions from such physicians are entitled to controlling weight if the opinion (1) “is wellsupported by medically acceptable clinical and laboratory diagnostic techniques,” and (2) “is not
inconsistent with the other substantial evidence in [the] case record.” 20 C.F.R. § 404.1527(c)(2).
The treating source’s opinions are not entitled to such deference, however, if they are
unsupported by the medical data in the record, or are inconsistent with the other substantial
evidence in the record. See Miller v. Sec’y of Health & Human Servs., No. 91-1325, 1991 WL
229979, at *2 (6th Cir. Nov. 7, 1991) (Table). When the treating physician’s opinions are not
entitled to controlling weight, the ALJ should apply specific factors to determine how much
weight to give the opinion. Wilson, 378 F.3d at 544, see 20 C.F.R. § 404.1527(c)(2)-(6). The
regulations also advise the ALJ to provide “good reasons” for the weight accorded to the treating
source’s opinion. 20 C.F.R. § 404.1527(c). Regardless of how much weight is assigned to the
treating physician’s opinions, the ALJ retains the power to make the ultimate decision of whether
the claimant is disabled. Walker v. Sec’y of Health & Human Servs., 980 F.2d 1066, 1070 (6th
Cir. 1992) (citing King v. Heckler, 742 F.2d 968, 973 (6th Cir. 1984)).
In the present case, the ALJ assessed Dr. Khan’s medical source statement and attributed
“little weight” to the opinions contained therein. (Tr. 83-84). The ALJ explained that the
opinions were inconsistent with the record as a whole and not support by objective evidence

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regarding the claimant’s mental status. The ALJ also explained that Dr. Khan based his opinion
largely on Plaintiff’s subjective complaints, which was inappropriate here, because many factors
detracted substantially from Plaintiff’s overall credibility. (Id.).
Plaintiff contends that it was error for the ALJ to reject the medical source statement
because it was based on her subjective complaints. She argues that there is no support for this
conclusion. According to Plaintiff, Dr. Khan based his treating source statement on evidence
obtained through the objective process of mental status evaluations and observations by the
doctor and other healthcare provides at Portage Path.
It is somewhat unclear whether Dr. Khan based the limitations set forth in the medical
source statement primarily on Plaintiff’s complaints, because there is no express indication from
the doctor that he did so. Even so, Dr. Khan’s treatment notes and others from Portage Path
draw into question the extent of the doctor’s reliance on Plaintiff’s self-reports. The vast
majority of mental healthcare treatment notes show predominantly mild to moderate findings.
The most serious symptoms appear to come from Plaintiff’s self-reports in June and August 2011
sessions. As a result, it seems that the ALJ concluded Dr. Khan based his opinions on Plaintiff’s
subjective complaints. The ALJ found that Plaintiff was not credible, and provided substantial
reasons to support his credibility determination, which Plaintiff does not challenge.
Nonetheless, assuming that the ALJ’s analysis is insufficient to comply with the treating
source rule, any error in this regard does not necessitate remand. A violation of the doctrine may
be deemed harmless where the ALJ satisfies the goal of the “good reasons” requirement despite
failing to adhere to the letter of the regulation. Friend v. Comm’r of Soc. Sec., 375 F. App’x 543,
551 (6th Cir. 2010) (quoting Wilson, 378 F.3d at 547). “If the ALJ’s opinion permits the
claimant and a reviewing court a clear understanding of the reasons for the weight given a

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treating physician’s opinion, strict compliance with the rule may sometimes be excused.” Id. In
Nelson v. Comm’r of Soc. Sec., 195 F. App’x 462, 470-71 (6th Cir. 2006), the ALJ failed to
strictly comply with the mandates of the treating source doctrine. However, the Sixth Circuit
concluded that “the ALJ’s evaluation of [the plaintiff’s] mental impairments indirectly attacks
both the supportability of [the treating physicians’] opinions and the consistency of those
opinions with the rest of the record evidence.” Id. at 470. Because the ALJ’s discussion of the
other evidence “implicitly provided sufficient reasons for not giving . . . controlling weight” to
the treating physicians, the Sixth Circuit concluded that the ALJ’s decision satisfied the purposes
of the treating physician rule. Id. at 472.
In this case, the ALJ’s opinion, taken as a whole, thoroughly evaluates and analyzes the
evidence and indicates the weight given. The ALJ’s opinion indirectly attacks the supportability
and consistency of Dr. Khan’s medical source statement.

As such, the Court has a sufficient

basis to understand the ALJ’s rationale for assigning little weight to Dr. Khan.
An examination of the ALJ’s opinion shows that Dr. Khan’s medical source statement
findings were inconsistent with and not supported by the record. For example, Dr. Khan found
that Plaintiff had a medically documented history of three episodes of decompensation, each
lasting at least two weeks, within a 12 month period. (Tr. 84). However, the ALJ’s thorough
discussion of Plaintiff’s mental health treatment notes reveals no such episodes (Tr. 80-82), and
the Court is unaware of any in the record. Plaintiff points to no evidence to support such a
significant finding by Dr. Khan. It appears that Plaintiff never suffered from any episodes of
decompensation lasting for an extended duration. Furthermore, as the ALJ noted, Dr. Khan
opined Plaintiff had a marked loss in her ability to accept criticism from supervisors and get
along with co-workers without distracting those workers. (Tr. 84).

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However, the ALJ’s

discussion of the evidence shows no support for such a limitation. As the ALJ observed, Ms.
Cockfield found Plaintiff had no deficiencies in social interaction. (Tr. 83). Again, Plaintiff
points to no evidence that would show she had such a serious limitation in getting along with
others, would distract co-workers, or struggled to accept criticism from authority figures.
Overall, the ALJ recounted the marked and extreme limitations that Dr. Khan assigned,
but mental status evaluations of Plaintiff throughout the relevant period generally reveal mild to
moderate findings. For instance, an August 2007 examination found Plaintiff to display “a tidy
appearance, coherent speech, and mild impairments in cognition, insight, and judgment.” (Tr.
80). In February 2009, Plaintiff was well groomed, smiling, and logical, with stable mood and
affect. (Tr. 81).

While the ALJ acknowledged that Plaintiff suffered from symptoms and

limitations arising out of her impairments, the medical evidence does not support Dr. Khan’s
serious limitations. The undersigned also notes that a review of the evidence and the ALJ’s
opinion does not indicate that the ALJ mischaracterized Dr. Khan’s opinion or the Portage Path
treatment records as Plaintiff alleges.
Plaintiff further contends that by rejecting her treating source’s opinion, the ALJ
inappropriately substituted his lay opinion for that of a medical professional. This argument is
not well-taken. The ALJ is not bound by the opinion of a treating physician when that opinion is
not well-supported or contradicted by other evidence. See Miller v. Sec’y of Health & Human
Servs., No. 91-1325, 1991 WL 229979, at *2 (6th Cir. Nov. 7, 1991) (Table); c.f. Meece v.
Barnhart, 192 F. App’x 456, 465 (6th Cir. 2006) (“the ALJ may not substitute his own medical
judgment for that of the treating physician where the opinion of the treating physician is
supported by the medical evidence . . . While the ALJ may have prescribed different pain
medication than that prescribed by Plaintiff’s doctors, this decision is beyond the expertise of the

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ALJ and is not a legitimate basis for an adverse credibility determination.”). In the present case,
the ALJ’s opinion provided reasonable grounds to devalue the opinion of Dr. Khan and his
finding is supported by substantial evidence. Thus, in accordance with the regulations, the ALJ
gave less than controlling weight to the doctor’s opinion while formulating the RFC. The ALJ’s
actions do not demonstrate that he acted beyond his duties to make medical judgments.
Accordingly, Plaintiff’s argument lacks merit.
Plaintiff asserts that when the ALJ discounted the various medical opinions in the record,
including, but not limited to, her treating psychiatrist, the ALJ failed to devalue the opinions
based on the factors set forth in 20 C.F.R. § 404.1527. Plaintiff implies that the ALJ is required
to address each of the factors denoted in the listing when discounting medical opinion evidence.
But, Plaintiff has not identified, and the Court is unaware of, any binding case law demanding an
ALJ to specify how he analyzed these factors individually.

While including a thorough

assessment of each factor might be helpful in assisting a claimant to better understand the ALJ’s
decision, the text of the regulation only requires that the ALJ “consider” all of the factors. Id. It
is well-established that an ALJ may consider evidence without expressly discussing it within his
opinion. Kornecky v. Comm’r of Soc. Sec., 167 F. App’x 496, 507-08 (6th Cir. 2006).
Specifically in regard to the treating source, the regulations only require the ALJ to provide
“ ‘good reasons . . . for the weight . . . given to the treating source’s opinion’ –not an exhaustive
factor-by-factor analysis.” Francis v. Comm’r of Soc. Sec., 414 F. App’x 802, 804 (6th Cir.
2011) (alterations in original). Thus, Plaintiff’s argument is not well-take.
B. State Agency Reviewing Psychologists
Plaintiff asserts that the ALJ erred in relying on the opinion of the state agency reviewing
psychologist Dr. Dietz. In September 2009, Dr. Dietz opined that Plaintiff could perform three-

22

and four-step tasks in an environment without high production demands or schedules. (Tr. 83,
452). The ALJ assigned “great weight” to the opinion. (Tr. 83).
Plaintiff contends that the ALJ should not have assigned such weight, because Dr. Dietz
did not have the completed medical record when conducting his review. As an initial matter, the
Court points out that Dr. Dietz’s opinion was not the most recent state agency opinion of record.
After reviewing the updated record in May 2010, Dr. Goldsmith affirmed Dr. Dietz’s opinion.
(Tr. 577). The ALJ also attributed “great weight’ to the opinion of Dr. Goldsmith. (Tr. 83).
Plaintiff cites Blakley v. Commissioner, 581 F.3d 399, 409 (6th Cir. 2009) in support of
her argument regarding Dr. Dietz. In Blakley the Sixth Circuit held that the ALJ’s choice to
attribute greater weight to the state agency physicians over the plaintiff’s treating sources was
reversible error because the consultants’ opinions were based on an incomplete case record. The
Sixth Circuit remanded the case, in part, because the court “require[d] some indication that the
ALJ at least considered” the effect of subsequent medical records on the reliability of the state
agency assessments. Id. (quoting Fisk v. Astrue, 253, F. App’x 580, 585 (6th Cir. 2007)); see
Brooks v. Soc. Sec. Admin., 430 F. App’x 468, 482 (6th Cir. 2011).
Following Blakley, the Sixth Circuit indicated that “[t]here is no categorical requirement
that the non-treating source’s opinion be based on a ‘complete’ or ‘more detailed and
comprehensive’ case record. The opinions need only be ‘supported by evidence in the case
record.’ ” Helm v. Comm’r of Soc. Sec. Admin., 405 F. App’x 997, 1002 (6th Cir. 2011) (internal
citations omitted). In McGrew v. Comm’r, 343 F. App’x 26, 30-32 (6th Cir. 2009) the Sixth
Circuit found an ALJ’s reliance on state agency medical opinions based on an incomplete record
was proper, because the ALJ considered medical examinations after the state assessments and
accounted for changes in the plaintiff’s condition in the RFC. In this case, the ALJ expressly

23

addressed much of the additional evidence post-dating the state agency opinions and
acknowledged that the state agency opinions were generally supported by the record. (Tr. 81-82).
The ALJ included within the RFC stricter limitations than those assigned by the state agency
physicians, further demonstrating that he accounted for the post-dated evidence.
Additionally, this case is distinguishable from Blakely in light of its facts. In Blakely, the
ALJ failed to comply with the treating source rule in relation to three treating physicians,
including ignoring one treating source’s opinion altogether. Blakley, 581 F.3d at 407-08. Here,
the ALJ’s opinion adequately explained why he gave less than controlling weight to Dr. Khan’s
opinion when determining the RFC. An ALJ’s unsupported rejection of a treating source and
reliance on non-examining sources without full access to the record appeared to be the
“overriding danger” that existed in Blakely, is not similarly present here. See Curry v. Colvin,
4:13-CV-00312, 2013 WL 5774028, at *17 (N.D. Ohio Oct. 24, 2013).
Plaintiff also asserts that the ALJ was required to provide “good reasons” for assigning
great weight to Dr. Dietz’s opinion. However, Plaintiff points to no authority requiring the ALJ
to justify his decision for attributing such weight to a state agency reviewing physician.
According to Plaintiff, the ALJ also erred by failing to apply the same level of scrutiny to
the opinions of the state agency physicians as he did to the opinions issued by Drs. Khan and
Patel.

She cites to Gayheart v. Commmissioner of Social Security, 710 F.3d 365, 375-76 (6th

Cir. 2013) for the proposition that the ALJ may not apply greater scrutiny to a treating-source
opinion than that applied to opinions issued by state agency reviewing physicians. In Gayheart,
the ALJ relied on the state agency reviewers’ opinions over that of the treating source, but had
failed to acknowledge stark inconsistencies between the state agency opinions and the record. Id.
at 379-80. For instance, the ALJ failed to mention that one state agency doctor changed his

24

testimony from opining that the claimant met Listing 12.06, to later stating there was insufficient
evidence to show a mental listing was met or equaled. Id. at 379. Here, Plaintiff shows no such
stark inconsistencies between the state agency opinions and the record. Such inconsistencies do
exist, however, in regard to treating physician Dr. Khan’s opinion. Accordingly, the present case
is distinguishable from the facts in Gayheart. Additionally, Dr. Patel is a one-time examining
physician, not a treating source, and as such, Gayheart is inapplicable.
Finally, Plaintiff cites Shelman v. Heckler, 821 F.2d 316, 321 (6th Cir. 1987) for the
proposition that the opinion of a non-examining physician is entitled to only little weight if it is
contrary to the opinion of a treating physician. Plaintiff’s characterization of Shelman requires
some further clarification. In Shelman the Sixth Circuit began by explaining that an ALJ is not
bound by the finding of a claimant’s treating source when the opinion lacks sufficient support
from medical data. Id. at 320-21. However, the court went on observe that the ALJ failed to
make a finding that the plaintiff’s treating sources were unsupported by objective medical
evidence. Id. at 321. Because the ALJ did not explain why the treating physician was rejected,
the Sixth Circuit found it unreasonable for the ALJ to credit a non-examining physician’s
opinion over that of a treating source. Id.; see Gholston v. Comm’r Soc. Sec., No. 5:11-CV-1482,
2012 WL 4092811, at *7 (N.D. Ohio Sept. 17, 2012) (citing Brumett v. Comm’r of Soc. Sec., No.
1:07-CV-955, 2009 WL 690250, at *8 (S.D. Ohio Mar. 11, 2009)). Here, unlike in Shelman, the
ALJ found Dr. Shah’s opinion was not entitled to controlling weight and his opinion adequately
met the goal of the treating source doctrine. Thus, the ALJ reasonably accorded great weight to
the opinions of the state agency reviewers.

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C. One-Time Physical Consultative Examiner
As to consultative examiner Dr. Patel, Plaintiff argues that the ALJ failed to give “good
reasons” for assigning “little weight” to the doctor’s opinion. Dr. Patel examined Plaintiff on
one occasion in July 2009. (Tr. 380-81). It is well-settled that the opinions of a one-time
examining physician are not entitled to any special level of deference. Barker v. Shalala, 40 F.3d
789, 794 (6th Cir. 1994). The rationale of the treating physician rule simply does not apply to
the opinions of one-time examiners. Id. Hence, the ALJ did not have to provide “good reasons”
for the weight assigned to Dr. Patel’s opinions. Nonetheless, the ALJ indicated why he did not
accept the doctor’s opinion in total.
The ALJ did not fully credit Dr. Patel because the doctor based much of his opinion on
Plaintiff’s subjective complaints. (Tr. 83). A review of the doctor’s report shows Dr. Patel
significantly grounded his recommendation on Plaintiff’s self-reports.

Dr. Patel opined: “I

believe these debilitating migraines cause difficulty with [Plaintiff] being employed; however, if
she were able to get better control of this issue, she would be able to perform a desk job.” (Tr.
381). In formulating this opinion, Dr. Patel relied on Plaintiff’s report that she experienced
migraines “her whole life, 2-3 per week.” (Tr. 380).

The ALJ concluded that Plaintiff’s

statements were highly unreliable, drawing into question Dr. Patel’s opinion.
Plaintiff also asserts that she should have been limited to sedentary work, because Dr.
Patel recommended a “desk job.” Plaintiff asserts that this physical limitation was supported by
the findings of Dr. Patel’s physical examination. The examination showed decreased range of
motion in Plaintiff’s knees and shoulders, decreased strength in both shoulders, and decreased
strength in the right knee. (Tr. 381).

Assuming that Dr. Patel intended to recommended

sedentary work by his reference to a “desk job,” the ALJ’s discussion of other medical evidence

26

undermines Dr. Patel’s findings. Both state agency reviewing physicians Drs. Hill and McCloud
opined that Plaintiff could perform more than sedentary work. (Tr. 83). Further, the ALJ
recounted Plaintiff’s conservative treatment during the relevant period of steroid injections and
her failure to attend physical therapy, though he acknowledged that in 2011, Plaintiff was
referred to an orthopedic surgeon. (Tr. 77).
Furthermore, even if the ALJ erred in failing to credit Dr. Patel’s recommendation of a
desk job, remand for further proceedings on this ground would be futile.

During the

administrative hearing, the VE identified jobs that Plaintiff could perform at the sedentary level
of physical exertion with the same mental limitations included in the controlling RFC. (Tr. 127).
For example, the VE identified the following sedentary positions: surveillance systems monitor,
inspector, polisher, and lens inserter. (Tr. 128). It follows that remand based on this allegation of
error would result in no different outcome, as jobs exist in significant numbers in the national
economy that Plaintiff could perform with a limitation to sedentary work. See Kobetic v. Comm’r
of Soc. Sec., 114 F. App’x 171, 173 (6th Cir. 2004) (When “remand would be an idle and useless
formality,” courts are not required to “convert judicial review of agency action into a ping-pong
game.”) (quoting NLRB v. Wyman-Gordon Co., 394 U.S. 759, 766, n. 6, 89 S.Ct. 1426, 22
L.Ed.2d 709 (1969)).
D. Examining Physician Dr. Shah
Regarding Dr. Shah, Plaintiff maintains that the ALJ “grossly mischaracterized” the
doctor’s treatment records.

More specifically, Plaintiff asserts that the ALJ improperly

supported the RFC by citing to x-rays of Plaintiff’s knees that showed mild to moderate
narrowing of the medial compartment (Tr. 77), but omitted a discussion of Plaintiff’s severe
patellofemoral degenerative joint disease found by Dr. Shah in four view x-rays. She argues that

27

the ALJ was required to give good reasons for why her bilateral severe patellofemoral arthritis
did not prevent her from performing light work.
Plaintiff’s arguments lacks merit. The ALJ was correct in observing that on September
21, 2011, Dr. Shah opined that x-rays of Plaintiff’s knees showed mild to moderate narrowing of
the medial compartment. (Tr. 747-49). The ALJ did not go on to also acknowledge that x-rays
showed severe patellofemoral joint degenerative disc disease. (Tr. 749). Even so, the ALJ’s
failure does not warrant remand. It is well-settled that the ALJ is not required to discuss every
piece of evidence in the record; an ALJ “can consider all the evidence without directly
addressing in his written decision every piece of evidence submitted by a party.” Kornecky v.
Comm’r of Soc. Sec., 167 F. App’x 496, 507-08 (6th Cir. 2006); Dennis v. Comm’r of Soc. Sec.,
779 F. Supp. 2d 727, 731 (E.D. Mich. 2011). The ALJ acknowledged that Plaintiff suffered
from degenerative joint disease. The ALJ expressly noted Dr. Shah’s treatment in October 13,
2011 where the doctor referred Plaintiff to an orthopedic surgeon for her patellofemoral
condition, because of its severity and her lack of response to conservative treatment. (Tr. 77).
Thus, the ALJ’s opinion shows that he did not ignore evidence of Plaintiff’s severe degenerative
joint disease.
Furthermore, Plaintiff cites to no authority indicating that the ALJ has an obligation to
give good reasons as to why a particular diagnosis does not result in disability. The mere
diagnosis of a condition does not speak to its severity or indicate the functional limitations
caused by the ailment. See Young v. Sec’y of Health & Human Servs., 925 F.2d 146, 151 (6th
Cir. 1990). As a result, the fact that Dr. Shah diagnosed Plaintiff with severe patellofemoral
degenerative joint disease is not enough to show that the condition was disabling. Accordingly,
Plaintiff’s allegation of error does not warrant remand.

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E. The ALJ’s Formulation of the RFC
Finally, Plaintiff claims that the ALJ cannot create the RFC independent of the medical
evidence contained in the record. Plaintiff further asserts that the ALJ acted inappropriately in
formulating the RFC because none of the state physicians who reviewed the claim provided a
medical opinion anywhere near the RFC stated by the ALJ.
Plaintiff’s arguments are not well founded. The ALJ assessed all of the medical opinion
evidence, along with other evidence relevant to Plaintiff’s claim. The ALJ did not formulate the
RFC while ignoring opinions from medical sources. What is more, the ALJ’s RFC varied from
those of the state agency physicians in that it was more restrictive.
Simply because the ALJ’s RFC deviates from medical opinions in the record, does not
lead to the conclusion that he has acted inappropriately. As Plaintiff notes the ALJ is to assess
the “residual functional capacity based on all of the relevant medical and other evidence.” See 20
C.F.R. § 404.1545(a) (emphasis added). It is the ALJ’s prerogative to weight the medical
evidence, testimony, daily activities, and other evidence in the record, and based on that
evaluation, to formulate the RFC. The ALJ does not act as medical expert by doing so. Given
that the ALJ’s RFC is supported by substantial evidence, remand is inappropriate.
VII. DECISION
For the foregoing reasons, the Magistrate Judge finds that the decision of the
Commissioner is supported by substantial evidence. Accordingly, the Court AFFIRMS the
decision of the Commissioner.
IT IS SO ORDERED.
s/ Kenneth S. McHargh
Kenneth S. McHargh
United States Magistrate Judge
Date: June 11, 2014.
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