Graybeal v. Social Security Administration, Commissioner of (RLJ2)
Filing
16
MEMORANDUM AND OPINION as set forth in following order. Signed by Magistrate Judge C Clifford Shirley, Jr on 1/3/18. (ABF)
UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF TENNESSEE
AT KNOXVILLE
LISA GAIL GRAYBEAL,
Plaintiff,
v.
NANCY A. BERRYHILL,1
Acting Commissioner of Social Security,
Defendant.
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No. 3:16-CV-560-CCS
MEMORANDUM OPINION
This case is before the undersigned pursuant to 28 U.S.C. § 636(b), Rule 72(b) of the
Federal Rules of Civil Procedure, and the consent of the parties [Doc. 12]. Now before the Court
is the Plaintiff’s Motion for Summary Judgment and Memorandum in Support [Docs. 10 & 11]
and the Defendant’s Motion for Summary Judgment and Memorandum in Support [Docs. 13 &
14]. Lisa Gail Graybeal (“the Plaintiff”) seeks judicial review of the decision of the Administrative
Law Judge (“the ALJ”), the final decision of Defendant Nancy A. Berryhill, Acting Commissioner
of Social Security (“the Commissioner”). For the reasons that follow, the Court will GRANT IN
PART the Plaintiff’s motion, and DENY the Commissioner’s motion.
I.
PROCEDURAL HISTORY
On February 8, 2013, the Plaintiff filed an application for disability insurance benefits and
supplemental security income benefits pursuant to Title II and XVI of the Social Security Act, 42
U.S.C. §§ 401-403, 1381-1385, claiming a period of disability that began on May 1, 2011. [Tr.
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During the pendency of this case, Nancy A. Berryhill replaced Acting Commissioner
Carolyn W. Colvin. Pursuant to Federal Rule of Civil Procedure 25(d), Nancy A. Berryhill is
substituted as the Defendant in this case.
194-202]. After her application was denied initially and upon reconsideration, the Plaintiff
requested a hearing before an ALJ. [Tr. 149]. A hearing was held on June 19, 2015. [Tr. 39-67].
On September 4, 2015, the ALJ found that the Plaintiff was not disabled. [Tr. 20-38]. The Appeals
Council denied the Plaintiff’s request for review [Tr. 1-6], making the ALJ’s decision the final
decision of the Commissioner.
Having exhausted her administrative remedies, the Plaintiff filed a Complaint with this
Court on September 15, 2016, seeking judicial review of the Commissioner’s final decision under
Section 405(g) of the Social Security Act. [Doc. 1]. The parties have filed competing dispositive
motions, and this matter is now ripe for adjudication.
II.
ALJ FINDGINS
The ALJ made the following findings:
1. The claimant meets the insured status requirements of the Social
Security Act through December 31, 2016.
2. The claimant has not engaged in substantial gainful activity since
May 1, 2011, the alleged onset date (20 CFR 404.1571 et seq., and
416.971 et seq.).
3. The claimant has the following severe impairments: fibromyalgia
(although not diagnosed by a specialist); hypertension[;]
degenerative disc disease of the lumbar spine; obesity; and
depression (20 CFR 404.1520(c) and 416.920(c)).
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 CFR Part 404, Subpart P, Appendix 1
(20 CFR 404.1520(d), 404.1525, 404.1526, 416.920(d), 416.925
and 416.926).
5. After careful consideration of the entire record, the undersigned
finds that the claimant has the residual functional capacity to
perform light work as defined in 20 CFR 404.1567(b) and
416.967(b). She can lift/carry 10 pounds frequently, 20 pounds
occasionally; sit/stand/walk 6 hours out of an 8-hour day; and would
2
need a sit/stand option for 30-45 minutes. She could occasionally
climb ramps, stairs, balance, and stoop, kneel, and crouch; and never
climb ladders, ropes, or scaffolds, or crawl. She would need to avoid
concentrated exposure to hazards. She would need to have only
simple, routine, tasks, in that she could apply common sense
understanding to carry out oral, written and diagrammatic
instructions. She would need low stress jobs, with few changes in
the work setting and no executive level function.
6. The claimant is unable to perform any past relevant work. (20
CFR 404.1565 and 416.965).
7. The claimant was born on July 30, 1971 and was 39 years old,
which is defined as a younger individual age 18-49, on the alleged
disability onset date (20 CFR 404.1563 and 416.963).
8. The claimant has a high school education and is able to
communicate in English (20 CFR 404.1564 and 416.964).
9. Transferability of job skills is not material to the determination
of disability because using the Medical-Vocational Rules as a
framework supports a finding that the claimant is “not disabled,”
whether or not the claimant has transferable job skills (See SSR 8241 and 20 CFR Part 404, Subpart P, Appendix 2).
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 (20 CFR 404.1569, 404.1569(a), 416.969, and 416.969(a)).
11. Thus, the undersigned finds that the claimant has not been under
a disability, as defined in the Social Security Act, from May 1, 2011,
through the date of this decision (20 CFR 404.1520(g) and
416.920(g)).
[Tr. 25-33].
III.
STANDARD OF REVIEW
When reviewing the Commissioner’s determination of whether an individual is disabled
pursuant to 42 U.S.C. § 405(g), the Court is limited to determining whether the ALJ’s decision
was reached through application of the correct legal standards and in accordance with the
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procedure mandated by the regulations and rulings promulgated by the Commissioner, and
whether the ALJ’s findings are supported by substantial evidence. Blakley v. Comm’r of Soc. Sec.,
581 F.3d 399, 405 (6th Cir. 2009) (citation omitted); Wilson v. Comm’r of Soc. Sec., 378 F.3d 541,
544 (6th Cir. 2004).
Substantial evidence is “more than a scintilla of evidence but less than a preponderance; it
is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.”
Cutlip v. Sec’y of Health & Human Servs., 25 F.3d 284, 286 (6th Cir. 1994) (citations omitted). It
is immaterial whether the record may also possess substantial evidence to support a different
conclusion from that reached by the ALJ, or whether the reviewing judge may have decided the
case differently. Crisp v. Sec’y of Health & Human Servs., 790 F.2d 450, 453 n.4 (6th Cir. 1986).
The substantial evidence standard is intended to create a “‘zone of choice’ within which the
Commissioner can act, without the fear of court interference.” Buxton v. Halter, 246 F.3d 762,
773 (6th Cir. 2001) (quoting Mullen v. Bowen, 800 F.2d 535, 545 (6th Cir. 1986)). Therefore, the
Court will not “try the case de novo, nor resolve conflicts in the evidence, nor decide questions of
credibility.” Garner v. Heckler, 745 F.2d 383, 387 (6th Cir. 1984) (citation omitted).
On review, the plaintiff “bears the burden of proving his entitlement to benefits.” Boyes v.
Sec’y. of Health & Human Servs., 46 F.3d 510, 512 (6th Cir. 1994) (citation omitted).
IV.
ANALYSIS
“Disability” is the “inability to engage in any substantial gainful activity by reason of any
medically determinable physical or mental impairment which can be expected to result in death or
which has lasted or can be expected to last for a continuous period of not less than twelve months.”
42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A); 20 C.F.R. §§ 404.1505(a), 416.905(a). A claimant
will only be considered disabled if:
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his physical or mental impairment or impairments are of such
severity that he is not only unable to do his previous work but
cannot, considering his age, education, and work experience, engage
in any other kind of substantial gainful work which exists in the
national economy, regardless of whether such work exists in the
immediate area in which he lives, or whether a specific job vacancy
exists for him, or whether he would be hired if he applied for work.
42 U.S.C. §§ 423(d)(2)(A), 1382c(a)(3)(B); 20 C.F.R. §§ 404.1505(a), 416.905(a).
Disability is evaluated pursuant to a five-step analysis summarized as follows:
1. If claimant is doing substantial gainful activity, he is not disabled.
2. If claimant is not doing substantial gainful activity, his
impairment must be severe before he can be found to be disabled.
3. If 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 his
impairment meets or equals a listed impairment, claimant is
presumed disabled without further inquiry.
4. If claimant’s impairment does not prevent him from doing his
past relevant work, he is not disabled.
5. Even if claimant’s impairment does prevent him from doing his
past relevant work, if other work exists in the national economy that
accommodates his residual functional capacity (“RFC”) and
vocational factors (age, education, skills, etc.), he is not disabled.
Walters v. Comm’r of Soc. Sec., 127 F.3d 525, 529 (6th Cir. 1997) (citing 20 C.F.R. § 404.1520).
A claimant’s residual functional capacity (“RFC”) is assessed between steps three and four and is
“based on all the relevant medical and other evidence in your case record.” 20 C.F.R. §§
404.1520(a)(4), -(e), 416.920(a)(4), -(e). An RFC is the most a claimant can do despite his
limitations. §§ 404.1545(a)(1), 416.945(a)(1).
The claimant bears the burden of proof at the first four steps. Id. The burden shifts to the
Commissioner at step five. Id. At the fifth step, the Commissioner must prove that there is work
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available in the national economy that the claimant could perform. Her v. Comm’r of Soc. Sec.,
203 F.3d 388, 391 (6th Cir. 1999) (citing Bowen v. Yuckert, 482 U.S. 137, 146 (1987)).
In the present case, the Plaintiff contends that the ALJ did not properly weigh the medical
opinion of treating physician Janet McNeil, M.D., and further erred in his consideration of the
opinions offered by non-treating, non-examining state agency physicians at the initial and
reconsideration levels. [Doc. 11 at 18-22]. The Plaintiff additionally argues that new medical
records exists that warrant remand pursuant to sentence six of 42 U.S.C. § 405(g). [Id. at 22-23].
The Court will address the Plaintiff’s allegations of error in turn.
A.
Medical Opinions
Dr. McNeil has been the Plaintiff’s treating physician since March 26, 2007. The Plaintiff
receives treatment primarily for back pain, fibromyalgia, and fatigue. During the Plaintiff’s initial
exam, she completed a fibromyalgia questionnaire, wherein she indicated that her pain was 8/10,
fatigue 10/10, stiffness 7/10, headaches 3/10, sleep disturbance 10/10, bowel disturbance, 5/10,
and depression 6/10. [Tr. 447]. On examination, the Plaintiff demonstrated 18/18 positive tender
points, joint tenderness in the elbows, waist, and hands, and reduced range of motion with pain in
the lower back. [Tr. 445]. The Plaintiff was diagnosed with fibromyalgia, fatigue, insomnia, low
back pain, anxiety, and arthritis, not otherwise specified. [Tr. 442].
Dr. McNeil continued to treat the Plaintiff on a monthly basis through 2015, consistently
noting 18/18 positive tender points, fatigue, “brain fog,” anxiety, and shoulder and back pain with
reduced range of motion. [Tr. 349-451, 475-513, 599-627]. Based on treatment received by
orthopedic physician, J. McDonald Burkhart, M.D., Dr. McNeil agreed that the Plaintiff’s pain
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and numbness in her thigh was consistent with meralgia paresthetica.2 [Tr. 621, 655]. Sitting
increased pain and numbness. [Tr. 621, 612].
Imaging studies include an August 2013 x-ray of the lumbar spine revealing mild
spondylosis [Tr. 622], a September 2013 MRI of the lumbar spine indicating degenerative disc
disease at T11-12 and facet joint arthropathy at L4-5 and L5-S-1 [Tr. 655], and a May 2015 MRI
of the thoracic spine and pelvis demonstrating mildly prominent thoracic kyphosis and mild
degenerative changes and facet joint arthritis at L5-S1 [Tr. 661, 713].
On June 29, 2015, Dr. McNeil completed a “Medical Source Statement of Ability to Do
Work-Related Activities (Physical).” [Tr. 719-24]. Therein, Dr. McNeil opined that the Plaintiff
could lift and carry up to 20 pounds occasionally but carrying more than 10 pounds would cause
pain. [Tr. 719]. Dr. McNeil explained that the Plaintiff’s ability to lift and carry was affected by
pain and weakness in her shoulders and upper arms, noting reduced range of motion of the
shoulders bilaterally and significant weakness on examination. [Id.]. Moreover, Dr. McNeil
explained that the Plaintiff has pain in her upper back, exhibited by tenderness on examination.
[Id.]. As to the Plaintiff’s ability to stand, walk, and sit, Dr. McNeil opined that the Plaintiff could
sit for four to five hours but only 20-30 minutes uninterrupted, and she could stand and walk for
one to two hours but only 15 minutes uninterrupted. [Tr. 720]. Dr. McNeil related that the Plaintiff
becomes very stiff and has increased pain with prolong sitting. [Id.]. Similarly, the Plaintiff
experiences increased pain, numbness, and weakness of her left leg if she stands or walks for long
2
“Meralgia paresthetica is a condition characterized by tingling, numbness and burning
pain in you outer thigh. The cause of meralgia paresthetica is compression of the nerve that
supplies sensation to the skin surface of your thigh.”
Mayo Clinic,
https://www.mayoclinic.org/diseases-conditions/meralgia-paresthetica/symptoms-causes/syc20355635 (last updated Feb. 23, 2017).
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periods of time due to meralgia paresthetica. [Id.]. The Plaintiff must also lay down four times a
day for 15-30 minutes to manage her pain, weakness, and fatigue. [Tr. 720].
As to the use of her hands and feet, Dr. McNeil opined that the Plaintiff could reach
overhead on an occasional basis (but was limited with height), and could occasionally reach,
handle, finger, and push or pull. [Tr. 721]. Dr. McNeil noted pain, weakness, and reduced range
of motion of the shoulders as limiting the Plaintiff’s use of her hands. [Id.]. The Plaintiff could
also occasionally operate foot controls with her right foot but never with her left foot due to
numbness. [Id.]. Dr. McNeil explained that using the right foot contributed to increased back
pain. [Id.]. With regard to postural activities, the Plaintiff could never climb stairs, ramps, ladders,
or scaffolds, balance, stoop, kneel, crouch, or crawl. [Tr. 722]. Dr. McNeil attributed the postural
limitations to the Plaintiff sometimes falling as a result of pain, numbness, and weakness in her
lower left extremities, as well as fatigue and back pain. [Id.]. Dr. McNeil also assessed
environmental restrictions, opining that the Plaintiff could never be exposed to unprotected
heights, moving mechanical parts, pulmonary irritants, extreme cold or heat, or vibrations, but
could occasionally be exposed to humidity and wetness and frequently operate a motor vehicle.
[Tr. 723].
Elaborating on the specific medical and clinical findings supporting her opinion, Dr.
McNeil observed that the Plaintiff suffers from pain caused by fibromyalgia, specifically noting
the presence of 18 positive tender points, severe fatigue, poor memory, and worsening brain fog,
as well as chronic neck pain. [Id.]. Dr. McNeil attributed the foregoing limitations as having been
present since 2010. [Tr. 724].
The ALJ assigned “little weight” to Dr. McNeil’s opinion, finding “[h]er restrictions were
too severe and she has not referred the claimant to a rheumatologist for management of the
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fibromyalgia . . .” [Tr. 30]. The ALJ continued, “instead [Dr. McNeil] has chose to treat the
claimant with narcotic medications, even in light of fairly benign diagnostic studies.” [Id.]. The
ALJ emphasized that the Plaintiff has not been diagnosed or treated by a rheumatologist or other
specialist and concluded that nothing in the record supported “such severe restrictions” as those
opined by Dr. McNeil. [Tr. 31].
Under the Social Security Act and its implementing regulations, if a treating physician’s
opinion as to the nature and severity of an impairment is (1) well-supported by medically
acceptable clinical and laboratory diagnostic techniques and (2) is not inconsistent with the other
substantial evidence in the case record, it must be given “controlling weight.” 20 C.F.R. §§
404.1527(c)(2), 416.927(c)(2).
When an opinion does not garner controlling weight, the
appropriate weight to be given to an opinion will be determined based upon the length of treatment,
frequency of examination, nature and extent of the treatment relationship, amount of relevant
evidence that supports the opinion, the opinion’s consistency with the record as a whole, the
specialization of the source, and other factors which tend to support or contradict the opinion. §§
404.1527(c)(1)-(6), 416.927(c)(1)-(6).
When an ALJ does not give a treating physician’s opinion controlling weight, the ALJ must
always give “good reasons” for the weight given to a treating source’s opinion in the decision. §§
404.1527(c)(2), 416.927(c)(2). A decision denying benefits “must contain specific reasons for the
weight given to the treating source’s medical opinion, supported by evidence in the case record,
and must be sufficiently specific to make clear to any subsequent reviewers the weight the
adjudicator gave to the treating source’s medical opinion and the reasons for the weight.” Soc.
Sec. Rul. 96-2p, 1996 WL 374188, at *5 (July 2, 1996).
The Plaintiff argues the ALJ did not provide good reason for rejecting Dr. McNeil’s
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opinion and failed to balance all of the regulator factors, including the length, frequency, nature,
and extent of the treating relationship. [Doc. 11 at 19]. The Plaintiff protests that nothing within
the regulations or rulings promulgated by the Commissioner require a treating physician, such as
Dr. McNeil, to refer a patient to a rheumatologist for fibromyalgia management. [Id. at 19-21].
Although Dr. McNeil is not a rheumatologist, the Plaintiff contends that her opinion was entitled
to greater deference due to the nature of the treating relationship. [Id.]. The Court agrees.
Social Security Ruling 12-2p, 2012 WL 3104869, at *1 (July 25, 2012) sets forth the
requisite criteria for diagnosing fibromyalgia and evaluating the impairment in disability claims.
Importantly, “[a] licensed physician (a medical or osteopathic doctor) is the only acceptable
medical source who can provide” evidence establishing fibromyalgia as a medical determinable
impairment. Id. at *2. Nowhere does the ruling require that a claimant be diagnosed or treated by
a rheumatologist or other specialist. In the present matter, there is no dispute whether the
Plaintiff’s has a medical determinable impairment of fibromyalgia as the ALJ concluded at step
two that the Plaintiff’s fibromyalgia was a severe impairment. [Tr. 25]. However, the ALJ appears
to discount Dr. McNeil’s opinion primarily on the premise that she was not a rheumatologist and
the Plaintiff was not referred to one for treatment. To be sure, the ALJ observed at step two that
the Plaintiff’s fibromyalgia was a severe impairment “although not diagnosed by a specialist.”
[Id.]. In weighing Dr. McNeil’s opinion in the RFC portion of the decision, the ALJ repeatedly
observed that the Plaintiff was “not referred . . . to a rheumatologist for management of the
fibromyalgia” and the Plaintiff “has not seen a rheumatologist to date.” [Tr. 30-31].
The ALJ’s decision suggests, and is indeed the position of the Commissioner [Doc. 14 at
12], that the failure to be treated by a rheumatologist supports a finding that the Plaintiff’s
fibromyalgia is not as limiting as alleged. Although the specialization of a treating source is an
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appropriate factor to consider under the regulations, the significance of this factor must be weighed
against the length of treatment, frequency of examination, nature and extent of the treatment
relationship, amount of relevant evidence that supports the opinion, and the opinion’s consistency
with the record as a whole. Moreover, “[w]hen a person alleges [fibromyalgia], longitudinal
records reflecting ongoing medical evaluation and treatment from acceptable medical sources are
especially helpful in establishing both the existence and severity of the impairment.” Social
Security Ruling 12-2p, 2012 WL 3104869 at *3.
The Commissioner cites to Sarchet v. Chater, 78 F.3d 305, 307 (7th Cir. 1996) in which
case the Seventh Circuit observed that “[f]ibromyalgia is a rheumatic disease and the relevant
specialist is a rheumatologist.” This Court agrees with the Seventh Circuit’s observation but
disagrees with the Commissioner’s reliance on the case for the proposition that failure to seek
treatment by a rheumatologist “suggests that Plaintiff’s condition was not as severe as opined by
Dr. McNeil and undermines her opinion.” [Doc. 14 at 12]. Dr. McNeil is an “acceptable medical
source” whose eight year treating relationship affords “longitudinal records” concnering the
Plaintiff’s diagnosis, treatment, examination findings, and symptoms of fibromyalgia. See Soc.
Sec. Rul. 12-2p, 2012 WL 3104869 at *2. Dr. McNeil’s treatment records consistently document
positive tender point testing, fatigue, memory problems, and anxiety, symptoms commonly
associated with fibromyalgia. See Kalmbach v. Comm’r of Soc. Sec., 409 F. App’x 852, 862 (6th
Cir. 2011) (observing that disability claims based on fibromyalgia “are related to the symptoms
associated with the condition—including complaints of pain, stiffness, fatigue, and inability to
concentrate—rather than the underlying condition itself); see also Soc. Sec. Rul. 12-2p, 2012 WL
3104869 at *3 (noting common symptoms of fibromyalgia include fatigue, cognitive or memory
problems (“fibro fog”), waking unrefreshed, depression, anxiety disorder, or irritable bowel
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syndrome). Therefore, while a rheumatologist may be the preferred treatment provider for
fibromyalgia patients, nothing within the ALJ’s decision suggests that Dr. McNeil’s treatment and
examination findings were contrary to medically acceptable practices in diagnosing and treating
fibromyalgia or that the limitations assessed were unsupported by Dr. McNeil’s treatment notes.
Nor is there any basis for discounting Dr. McNeil’s opinions merely because the Plaintiff was not
referred to a rheumatologist.
In addition to noting that the Plaintiff was not treated by a rheumatologist, the only other
reason cited by the ALJ for rejecting Dr. McNeil’s opinion is that Dr. McNeil “instead choose to
treat the claimant with narcotic medications, even in light of fairly benign diagnostic studies.” [Tr.
30]. Although the ALJ’s rational may undermine the severity of some of the other impairments
for which Dr. McNeil rendered treatment, “in light of the unique evidentiary difficulties associated
with the diagnosis and treatment of fibromyalgia, opinions that focus solely upon objective
evidence are not particularly relevant.” Rogers v. Comm’r of Soc. Sec., 486 F.3d 234, 245 (6th
Cir. 2007); see Preston v. Sec’y of Health & Human Servs., 854 F.2d 815, 820 (6th Cir. 1988)
(noting that fibromyalgia “patients manifest normal muscle strength and neurological reactions
and have a full range of motion”).
Further problematic, as argued by the Plaintiff [Doc. 11 at 18-19], is the ALJ’s
consideration of the state agency physicians’ opinions in this case. The ALJ gave “little weight”
to the opinion of the state agency physician at the initial level, Sannagai Brown, M.D., who opined
limitations consistent with sedentary work. [Tr. 30, 75-76, 88-89]. Dr. Brown found fibromyalgia
was the only severe impairment which, according to the ALJ, “should not limit [the Plaintiff]
walking as much.” [Tr. 30]. The ALJ gave no explanation for disagreeing with Dr. Brown’s
opinion. It is insufficient to discount a medical opinion without some reasoned explanation,
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supported by substantial evidence, for departing from a conclusion reached by a trained medical
provider. See Isaacs v. Astrue, 2009 WL 3672060, at *10 (S.D. Ohio Nov. 4, 2009) (“The residual
functional capacity opinions of treating physicians, consultative physicians, and medical experts
who testify at hearings are crucial to determining a claimant’s RFC because ‘[i]n making the
residual functional capacity finding, the ALJ may not interpret raw medical data in functional
terms.’”) (quoting Deskin v. Comm’r Soc. Sec., 605 F.Supp.2d 908, 912 (N.D. Ohio 2008)).
The ALJ then gave “significant weight” to the opinion of the state agency physician at the
reconsideration level, Charles Settle, M.D., who opined limitations consistent with the Plaintiff’s
RFC for light work except that the ALJ added a sit/stand limitation and additional environmental
restrictions. [Tr. 30, 103-06, 118-21]. The ALJ likewise provided no discussion or explanation
why the opinion offered by Dr. Settle was entitled to more deference than the opinion of Dr. Brown
and, more importantly, the opinion of Dr. McNeil. “Unless a treating source’s opinion is given
controlling weight, the administrative law judge must explain in the decision the weight given to
the opinions of a State agency medical or psychological consultant or other program physician,
psychologist, or other medical specialist.” 20 C.F.R. §§ 404.1527(e)(3)(ii) and 416.927(e)(3)(ii)
(emphasis added); see Soc. Sec. Rul. 96-6p, 1996 WL 374180, at *2 (July 2, 1996) (stating the
same). The ALJ’s conclusory assignment of significant weight to Dr. Settle’s opinion fails to
satisfy the standard promulgated by the Commissioner and constitutes error. See Wilson, 378 F.3d
at 545 (“It is an elemental principle of administrative law that agencies are bound to follow their
own regulations.”).
Accordingly, the Court finds that the ALJ did not satisfy the good reason requirement for
rejecting Dr. McNeil’s opinion, an error that was further compounded by the ALJ’s failure to
explain the assignment of weight to the opinions of the state agency physicians, Dr. Brown and
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Dr. Settles, and explain the basis for the weight given to each individually and in relationship to
each other. Therefore, the Court will order that the case be remanded to the ALJ to reweigh the
opinions of Dr. McNeil, Dr. Brown, and Dr. Settles.
B.
New Evidence
The Plaintiff has submitted medical records from a rheumatologist that post-dates the
ALJ’s September 4, 2015 decision. [Doc. 11-1 at 1-8]. The Plaintiff moves for a sentence six
remand, arguing that these later generated medical records are “new” and “material” evidence and
that “good cause” exist for not presenting this evidence during the administrative proceedings.
[Docs. 11 at 22-23, 15 at 3-4]. The Commissioner argues that the Plaintiff has not met her burden
in establishing that the medical evidence warrants a sentence six remand. [Doc. 14 at 15-20]. The
Court finds that it need not reach the merits of this issue as it has already determined that a remand
is appropriate in this case. Upon remand, the ALJ may consider all relevant evidence, including
the rheumatology records submitted by the Plaintiff.
V.
CONCLUSION
Based on the foregoing, the Plaintiff’s Motion for Summary Judgment [Doc. 10] will be
GRANTED IN PART, and the Commissioner’s Motion for Summary Judgment [Doc. 13] will
be DENIED. This case will be REMANDED to the Social Security Administration with
instructions that the ALJ reweigh the opinions of Dr. McNeil, Dr. Brown, and Dr. Settles, and
determine and explain what weight, if any, the rheumatology records submitted should be given.
ORDER ACCORDINGLY.
s/ C. Clifford Shirley, Jr.
United States Magistrate Judge
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