Jefferson v. Commissioner of Social Security Administration
Filing
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OPINION AND ORDER RULING ON REPORT AND RECOMMENDATION adopting 26 Report and Recommendation, reversing the decision of the Commissioner pursuant to sentence four of 42 U.S.C. § 405(g) and remanding the matter for further administrative proceedings. Signed by Honorable Bruce Howe Hendricks on 05/05/2016. (bshr, )
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF SOUTH CAROLINA
Carolyn Jefferson,
) Civil Action No.: 1:15-cv-786-BHH
)
Plaintiff, )
)
)
OPINION AND ORDER
v.
)
)
Carolyn W. Colvin, Commissioner of
)
Social Security,
)
Defendant. )
)
______________________________
Plaintiff Carolyn Jefferson (“Plaintiff”) brought this action pursuant to 42 U.S.C.
§ 1383(c)(3) to obtain judicial review of a final decision of Defendant, Commissioner of
Social Security (“Commissioner”), denying her claim for Disability Insurance Benefits
(“DIB”). In accordance with 28 U.S.C. § 636(b)(1)(B) and Local Rules 73.02(B)(2)(a)
and 83.VII.02, D.S.C., this matter was referred to United States Magistrate Judge Shiva
V. Hodges, for pretrial handling. On February 4, 2016, the Magistrate Judge issued a
Report and Recommendation (“Report”) in which she found that the Court cannot
determine that the Commissioner’s decision is supported by substantial evidence.
Accordingly, the Magistrate Judge recommended reversing the Commissioner’s
decision and remanding the case for further administrative proceedings. (ECF No. 26.)
The Commissioner filed Objections on February 22, 2016. (ECF No. 28.) For the
reasons stated below, the Court adopts the Report in part, reverses the Commissioner’s
decision and remands the case for further administrative proceedings.
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FACTUAL AND PROCEDURAL BACKGROUND
The Report sets forth in detail the relevant facts and standards of law on this
matter, and the Court incorporates them and summarizes below in relevant part.1
Plaintiff was 51 years old at the time of the most recent hearing. She completed two
years of college and obtained an associate’s degree in business. She has past relevant
work experience as a retail sales clerk and a collections agent. On February 2, 2010,
Plaintiff filed an application for DIB alleging a disability since May 20, 2009, due to
diabetes, depression, carpel tunnel syndrome, arthritis, hypertension, anxiety, and
obesity, which was denied initially and on reconsideration. (R. at 13–14.) A hearing was
held before an Administrative Law Judge (“ALJ”) who issued an unfavorable decision on
September 21, 2011, finding Plaintiff was not disabled under the Act. The Appeals
Council subsequently issued an order vacating the ALJ’s decision and remanding the
case to the ALJ. A second hearing was held before an ALJ, who issued an unfavorable
decision on January 16, 2014, finding Plaintiff was not disabled under the Act. The
Appeals Council denied Plaintiff’s request for review, making the ALJ’s decision the final
decision of the Commissioner. Plaintiff subsequently filed an action in this Court on
February 24, 2015. (ECF No. 1.)
REPORT AND RECOMMENDATION
In the sixty-three page Report, the Magistrate Judge recommends affirming the
ALJ’s decision. (ECF No. 26 at 61.) The Magistrate Judge makes only a
recommendation to this Court. The recommendation has no presumptive weight, and
the responsibility to make a final determination remains with the Court. Mathews v.
Weber, 423 U.S. 261 (1976). The Court is charged with making a de novo determination
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Unless otherwise noted, the following background is drawn from the Report.
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of those portions of the Report to which specific objection is made, and the Court may
accept, reject, or modify, in whole or in part, the recommendation of the Magistrate
Judge, or recommit the matter with instructions. 28 U.S.C. § 636(b)(1). “However, the
Court is not required to review, under a de novo or any other standard, the factual or
legal conclusions of the Magistrate Judge as to those portions of the report and
recommendation to which no objections are addressed. While the level of scrutiny
entailed by the Court’s review of the Report thus depends on whether or not objections
have been filed, in either case the Court is free, after review, to accept, reject, or modify
any of the Magistrate Judge’s findings or recommendations.” Wallace v. Housing Auth.
of the City of Columbia, 791 F. Supp. 137, 138 (D.S.C. 1992) (internal citations omitted).
STANDARD OF REVIEW
The role of the federal judiciary in the administrative scheme established by the
Social Security Act is a limited one. Under 42 U.S.C. § 405(g), the Court may only
review whether the Commissioner’s decision is supported by substantial evidence and
whether the correct law was applied. See 42 U.S.C. § 405(g) (“The findings of the
Commissioner of Social Security as to any fact, if supported by substantial evidence,
shall be conclusive . . . .”); Myers v. Califano, 611 F.2d 980, 982 (4th Cir. 1980).
“Substantial evidence has been defined innumerable times as more than a scintilla, but
less than preponderance.” Thomas v. Celebrezze, 331 F.2d 541, 543 (4th Cir. 1964);
see, e.g., Daniel v. Gardner, 404 F.2d 889 (4th Cir. 1968); Laws v. Celebrezze, 368
F.2d 640 (4th Cir. 1966); Tyler v. Weinberger, 409 F. Supp. 776 (E.D. Va. 1976). In
order for a reviewing court to determine whether the Commissioner based a decision on
substantial evidence, “the decision must include the reasons for the determination . . . .”
Green v. Chater, 64 F.3d 657, 1995 WL 478032, *2 (4th Cir. 1995) (citing Cook v.
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Heckler, 783 F.2d 1168, 1172 (4th Cir. 1986)). The statutorily mandated standard
precludes a de novo review of the factual circumstances that substitutes the Court’s
findings for those of the Commissioner. See, e.g., Vitek v. Finch, 438 F.2d 1157 (4th
Cir. 1971); Hicks v. Gardner, 393 F.2d 299 (4th Cir. 1968). Accordingly, “the court
[must] uphold the [Commissioner’s] decision even should the court disagree with such
decision as long as it is supported by ‘substantial evidence.’” Blalock v. Richardson, 483
F.2d 773, 775 (4th Cir. 1972). As noted by Judge Sobeloff in Flack v. Cohen, 413 F.2d
278 (4th Cir. 1969), “[f]rom this it does not follow, however, that the findings of the
administrative agency are to be mechanically accepted. The statutorily granted right of
review contemplates more than an uncritical rubber stamping of the administrative
action.” Id. at 279. “[T]he courts must not abdicate their responsibility to give careful
scrutiny to the whole record to assure that there is a sound foundation for the
[Commissioner’s] findings, and that his conclusion is rational.” Vitek, 438 F.2d at 115758.
DISCUSSION
The Commissioner filed objections to the Report on February 22, 2016. (ECF No.
28.) She objects to the Magistrate Judge’s finding that the ALJ’s decision to accord little
weight to the opinions of Plaintiff’s treating physicians, Dr. Eduardo Cifuentes (“Dr.
Cifuentes”) and Dr. Betty Anita-Obong (“Dr. Anita-Obong”), is unsupported by
substantial evidence. (Id. at 1.)
As an initial matter, this aspect of the ALJ’s decision was only one of the many
reasons the Magistrate Judge offered for recommending the Court reverse the
Commissioner’s decision and remand the matter for further administrative proceedings.
Specifically, the Magistrate Judge also found that she could not determine whether
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substantial evidence supported the ALJ’s findings that: (1) Dr. Wendy Molinaroli’s
opinions should be accorded little weight; (2) Plaintiff’s carpel tunnel syndrome is not a
severe impairment and therefore no restrictions related to carpel tunnel syndrome
should be imposed in the RFC assessment; (3) Plaintiff’s depressive disorder is not a
severe impairment and therefore no restrictions related to depressive disorder should
be imposed as in the RFC assessment; (4) Plaintiff’s combination of impairments did
not meet or medically equal the severity of one of the listed impairments in 20 C.F.R.
Part 404, Subpart P, App’x 1; and (5) Plaintiff’s individual symptoms did not satisfy the
“paragraph B” criteria under Listing 12.06. (ECF No. 26 at 48–62.) Thus, even if the
Court were to grant the Commissioner’s objections here, remand would still be proper
based on the numerous other grounds relied on by the Magistrate Judge, to which the
Commissioner does not object. Nevertheless, the Court employs de novo review to
consider the Commissioner’s specific arguments.2
The Commissioner asserts that in making the findings regarding the ALJ’s
treatment of Dr. Cifuentes’s and Dr. Anita-Obong’s opinions, the Magistrate Judge
“imposed a standard that is not required by the governing regulations, re-weighed the
evidence, and substituted her judgment for the ALJ’s.” (ECF No. 28 at 1.)
Regulations require that a treating physician’s opinion be given controlling weight
if that opinion “is well-supported by medically acceptable clinical and laboratory
diagnostic techniques and is not inconsistent with the other substantial evidence” in the
record. 20 C.F.R. § 404.1527(c)(2); see, e.g., Mastro v. Apfel, 270 F.3d 171, 178 (4th
Cir. 2001). “By negative implication, if a physician’s opinion is not supported by clinical
2
As always, the Court says only what is necessary to address such arguments against the already
meaningful backdrop of a thorough Report of the Magistrate Judge; exhaustive recitation of law and fact
exists there.
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evidence or if it is inconsistent with other substantial evidence, it should be accorded
significantly less weight.” Craig v. Chater, 76 F.3d 585, 590 (4th Cir. 1996). In such a
circumstance, “the ALJ holds the discretion to give less weight to the testimony of a
treating physician in the face of persuasive contrary evidence.” Mastro, 270 F.3d at 178.
If a treating physician’s opinion does not merit controlling weight, the ALJ is to
evaluate it using the following factors: (1) whether the physician has examined the
applicant; (2) the nature and extent of the treatment relationship; (3) the extent to which
the opinion is supported by relevant medical evidence; (4) the extent to which the
opinion is consistent with the record as a whole; (5) the relevance of the physician’s
medical specialization to the opinion; and (6) any other factor that tends to support or
contradict the opinion. 20 C.F.R. § 404.1527(c); see SSR 96–2p; Hines v. Barnhart, 453
F.3d 559, 563 (4th Cir. 2006). However, the Fourth Circuit has not mandated an
express discussion of each factor and another court in this district has held that “an
express discussion of each factor is not required as long as the ALJ demonstrates that
he applied the . . . factors and provides good reasons for his decision.” Hendrix v.
Astrue, No. 1:09-cv-1283, 2010 WL 3448624, at *3 (D.S.C. Sept. 1, 2010); see §
404.1527(c)(2) (requiring ALJ to give “good reasons” for weight given to treating
source’s opinion). A district court will not disturb an ALJ’s determination as to the weight
to be assigned to a medical opinion, including the opinion of a treating physician,
“absent some indication that the ALJ has dredged up ‘specious inconsistencies’ . . . or
has not given good reason for the weight afforded a particular opinion.” Craft v. Apfel,
164 F.3d 624, 1998 WL 702296, at *2 (4th Cir. 1998) (per curiam) (unpublished table
decision) (internal citation omitted).
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Here, Dr. Cifuentes opined in a mental RFC assessment that Plaintiff was
markedly limited in her ability to carry out detailed instructions and respond
appropriately to changes in the work setting, as well as in her ability to complete a
normal workday and work week without interruptions from psychologically based
symptoms and to perform at a consistent pace without an unreasonable number and
length of rest periods. (R. at 633–35.) The ALJ accorded little weight to Dr. Cifuentes’s
opinion, finding it “inconsistent with his treatment notes.” (R. at 23.) Specifically, the ALJ
found that the marked limitations opined by Dr. Cifuentes were inconsistent with
Plaintiff’s GAF scores that indicated mild to moderate symptoms. (R. at 23.) The ALJ
provided no further explanation for his decision to accord Dr. Cifuentes’s opinion little
weight.
Other courts in this district have found that where an ALJ’s decision to discount a
treating physician’s opinion is based solely on inconsistent GAF scores, the Court
cannot adequately determine whether that decision is supported by substantial
evidence. See Parker v. Colvin, No. 0:13-CV-00153-DCN, 2014 WL 4793711, at *3
(D.S.C. Sept. 25, 2014) (noting that “an inconsistent GAF score alone, without further
context and additional evidence, is insufficient to discount a treating physician’s
opinions” and remanding where the ALJ’s primary reason for discounting the treating
physician’s opinion was inconsistency with GAF scores); Green v. Astrue, No. 1:10-cv1840, 2011 WL 1770262, *18 (D.S.C. May 9, 2011) (finding “the ALJ erred in relying
heavily on [a GAF score] in discounting the opinion of Plaintiff’s treating psychiatrist”);
cf. Radley v. Colvin, No. 6:13-cv-569, 2014 WL 3571446, *26 (D.S.C. July 17, 2014)
(“To the extent the ALJ’s citation to the GAF scores in assessing [the treating
physician’s] opinions of the plaintiff’s limitations due to pain was in error, the
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undersigned finds that such error was at most harmless as the ALJ gave several valid
reasons for discounting [the treating physician’s] opinion.”).
The Magistrate Judge relied on Parker in part to recommend that the ALJ’s
decision to discount Dr. Cifuentes’s opinion was not supported by substantial evidence.
(ECF No. 26 at 42.) She also relied on her finding that “the ALJ’s evaluation fails to
reflect any consideration of the other relevant factors in 20 C.F.R. § 404.1527(c).” (Id. at
43.) The Court finds no error in the Magistrate Judge’s analysis and agrees with her
findings. Indeed, while an ALJ need not explicitly discuss every factor under
404.1527(c) in deciding what weight to give a medical opinion, some explanation is
required. See Munson v. Astrue, No. 5:08-CV-110-D(3), 2008 WL 5190490, at *3
(E.D.N.C. Dec. 8, 2008) (“[T]he ALJ need ‘not explicitly discuss all the § 404.1527(d)3
factors for each of the medical opinions,’ as long as good reasons are provided for the
assigned weight.”) (internal quotation marks and citation omitted). Without further
explanation by the ALJ in the instant matter, the Court cannot determine whether the
ALJ’s decision to accord Dr. Cifuentes’s opinion little weight is supported by substantial
evidence. This objection is therefore overruled.
As for Dr. Anita-Obong, she reported that Plaintiff suffered from pain as a result
of radiculopathy and a cervical strain she received in a car accident. (R. at 744.) Dr.
Anita-Obong opined that Plaintiff’s disabling pain would prevent her from working full
time at even a sedentary position. (R. at 744.) In his decision, the ALJ found that the
medical evidence of record did not support this opinion. (R. at 21.) He noted that: (1)
Plaintiff is prescribed Ibuprofen for pain; (2) she has not been referred to a pain
3
In 2012, the Commissioner revised 20 C.F.R. § 404.1527 and deleted the former paragraph (c)
pertaining to the duty to recontact a physician. The remaining subsections were re-numbered, and
404.1527(d) now appears as 404.1527(c).
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management specialist, but instead, declined injections for her symptoms of shoulder
pain and has deferred surgery for her carpel tunnel syndrome; and (3) she did not
attend physical therapy when initially prescribed by another physician. (R. at 21.)
The Magistrate Judge found that the “ALJ’s explanation of his decision to accord
little weight to Dr. Anita-Obong’s opinion does not reflect adequate consideration of the
relevant factors under 20 C.F.R. § 404.1527(c).” (ECF No. 26 at 44.) In support, the
Magistrate Judge noted that the ALJ did not consider Dr. Anita-Obong’s status as a
treating physician and her relationship with Plaintiff and failed to consider other medical
evidence in the record including: (1) Dr. Anita-Obong’s observation that Plaintiff had
swelling in her middle finger and tenderness over her right hip joint following the car
accident in January 2011 (R. at 649–50); (2) Dr. Anita-Obong referred Plaintiff for
physical therapy and x-rays immediately following her car accident and subsequently for
electrodiagnostic studies and consultations with other physicians (R. at 650, 746–47);
(3) electrodiagnostic studies showed Plaintiff to have moderately severe median
neuropathy in her right hand and middle trigger finger and Dr. Gerald Shealy
recommended surgery (R. at 746–47); and (4) Dr. Shane Woolf diagnosed moderate
right shoulder AC joint arthritis and bilateral carpel tunnel syndromes (R. at 748). (ECF
No. 26 at 44–45.)
The Commissioner argues that in making these findings, the Magistrate Judge
re-weighed the evidence and substituted her judgment for the ALJ’s. The Court agrees.
The ALJ provided specific reasons for discounting Dr. Anita-Obong’s opinion such that
the Court has the ability to determine whether the ALJ’s decision is supported by
substantial weight, and finds that it is. See Munson, 2008 WL 5190490, at *3. While
there may be conflicting evidence in the record, the Court’s role is not to reweigh the
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evidence and come to its own conclusion as to the value of Dr. Anita-Obong’s opinion.
See Johnson v. Barnhart, 434 F.3d 650, 653 (4th Cir. 2005) (holding that a reviewing
court should not undertake to reweigh conflicting evidence, make credibility
determinations, or substitute its judgment for that of the ALJ). Accordingly, this objection
is granted.
CONCLUSION
The Court has carefully reviewed the record, including the findings of the ALJ
and the Commissioner’s objections to the Report. Upon de novo review, the Court
concurs in the recommendation of the Magistrate Judge that it cannot determine
whether substantial evidence in the record supports the ALJ’s treatment of Dr.
Cifuentes’s opinion. However, the Court finds that the ALJ’s treatment of Dr. AnitaObong’s opinion is supported by substantial evidence. Accordingly, the Court ADOPTS
the Report in part, REVERSES the decision of the Commissioner’s decision, and
REMANDS under sentence four of 42 U.S.C. § 405(g) for further administrative
proceedings. On remand, the ALJ should consider the grounds for remand articulated in
this Order as well as those stated in the Magistrate Judge’s Report to which the
Commissioner did not object.
IT IS SO ORDERED.
/s/Bruce Howe Hendricks
United States District Judge
May 5, 2016
Greenville, South Carolina
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