Evans v. Social Security Administration
Filing
26
MEMORANDUM OPINION. Signed by Magistrate Judge Debra C Poplin on 8/12/19. (JBR)
UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF TENNESSEE
AT KNOXVILLE
TAMMY LYNN EVANS,
Plaintiff,
v.
ANDREW M. SAUL, 1
Acting Commissioner of Social Security,
Defendant.
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No. 3:17-CV-475-DCP
MEMORANDUM OPINION
This case is before the undersigned pursuant to 28 U.S.C. § 636(b), Rule 73 of the Federal
Rules of Civil Procedure, and the consent of the parties [Doc. 14]. Now before the Court is
Plaintiff’s Motion for Summary Judgment and Memorandum in Support [Docs. 17 & 18] and
Defendant’s Motion for Summary Judgment and Memorandum in Support [Docs. 23 & 24].
Plaintiff subsequently filed a Reply [Doc. 25] to Defendant’s motion.
Tammy L. Evans (“Plaintiff”) seeks judicial review of the decision of the Administrative
Law Judge (“the ALJ”), the final decision of Defendant Nancy A. Berryhill (“the Commissioner”).
For the reasons that follow, the Court will GRANT IN PART Plaintiff’s motion and DENY the
Commissioner’s motion.
I.
PROCEDURAL HISTORY
Plaintiff filed an application for disability insurance benefits on October 25, 2014 [Tr. 175],
and subsequently protectively filed an application for supplemental security income benefits on
1
Andrew M. Saul was sworn in as the Commissioner of Social Security on June 17, 2019,
during the pendency of this case. Therefore, pursuant to Federal Rule of Civil Procedure 25(d),
Andrew M. Saul is substituted as the Defendant in this case.
January 20, 2015 [Tr. 178], pursuant to Titles II and XVI of the Social Security Act, 42 U.S.C. §§
401 et seq. and 1381 et seq., claiming a period of disability that began on August 6, 2014. After
her application was denied initially and upon reconsideration, Plaintiff requested a hearing before
an ALJ. [Tr. 124]. A hearing was held on August 17, 2016. [Tr. 36–72]. On September 16, 2016,
the ALJ found that Plaintiff was not disabled. [Tr. 10–17]. The Appeals Council denied Plaintiff’s
request for review on October 11, 2017 [Tr. 1–6], making the ALJ’s decision the final decision of
the Commissioner.
Having exhausted her administrative remedies, Plaintiff filed a Complaint with this Court
on November 6, 2017, 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 FINDINGS
The ALJ made the following findings:
1. The claimant meets the insured status requirements of the Social
Security Act through December 31, 2019.
2. The claimant has not engaged in substantial gainful activity since
August 6, 2014, the alleged onset date (20 CFR 404.1571 et seq. and
416.971 et seq.).
3. The claimant has the following severe impairments: the residual
effects of a left navicular fracture, left peroneal nerve neural lysis,
left ankle lateral ligament reconstruction; lumbago, panic disorder,
post-traumatic stress disorder, depression; bipolar disorder, and
anxiety (20 CFR 404.1520(c). and 416.921(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).
2
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) except the following limitations: occasional climbing
ladders, ropes, and scaffolding; frequent climbing ramps and stairs;
frequent balancing; occasional stooping; frequent kneeling,
crouching, and crawling; work limited to simple, routine, and
repetitive tasks; performed in a work environment free of fast-paced
work; involving only simple work-related decisions; few, if any,
workplace changes; and only occasional interaction with the public,
coworkers, and supervisors.
6. The claimant is unable to perform any past relevant work (20
CFR 404.1565 and 416.965).
7. The claimant was born on March 11, 1971 and was 43 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 at least 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 and 404.1569(a)).
11. The claimant has not been under a disability, as defined in the
Social Security Act, from August 6, 2014, through the date of this
decision (20 CFR 404.1520(g)).
[Tr. 12–17].
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
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was reached through application of the correct legal standards and in accordance with the
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.
DISABILITY ELIGIBILITY
“Disability” means an individual cannot “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 12 months.” 42 U.S.C. §§ 423(d)(1)(A) and 1382c(a)(3)(A). An individual will only be
4
considered disabled:
if 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.
§§ 423(d)(2)(A) and 1382c(a)(3)(B).
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) and -(e), 416.920(a)(4), -(e). An RFC is the most a claimant can do despite his
limitations. §§ 404.1545(a)(1) and 416.945(a)(1).
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The claimant bears the burden of proof at the first four steps. Walters, 127 F.3d at 529.
The burden shifts to the Commissioner at step five. Id. At the fifth step, the Commissioner must
prove that there is work 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)).
V.
ANALYSIS
Plaintiff challenges the ALJ’s finding that she was not disabled, as she asserts that the ALJ
did not properly analyze the opinion of her treating physician, Dr. Paul D’Cruz, as required by the
treating physician rule. [Doc. 18 at 17–20]. Additionally, Plaintiff claims that the ALJ’s decision
is not supported by substantial evidence because he failed to adequately consider all of the medical
evidence of record. [Id. at 20–24]. Further, Plaintiff asserts that the ALJ selectively relied on
portions of the record to discredit her subjective complaints, and failed to appropriately consider
the objective evidence supporting her symptoms. [Id. at 23–24]. Lastly, Plaintiff maintains that
the ALJ improperly gave “significant weight” to the opinions of the nonexamining state agency
consultants who did not review the entire record. [Id. at 24]. The Court will address Plaintiff’s
specific allegations of error in turn.
A.
Plaintiff’s Mental Impairments
Plaintiff claims that the ALJ failed to provide good reasons for assigning little weight to
Dr. D’Cruz’s opinion; as despite her extensive treating relationship with Dr. D’Cruz, “the ALJ
discounted the evidence with only a short and conclusory statement.” [Doc. 18 at 18]. Plaintiff
maintains that although the ALJ found that Dr. D’Cruz’s opinion described severe symptoms
“from a brief period of exacerbation and are inconsistent [with] the other reports,” the ALJ failed
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to describe how he arrived at this conclusion. [Id.]; see [Tr. 16]. Plaintiff also asserts that the ALJ
failed to consider the entire record with respect to her mental health treatment. [Doc. 18 at 21].
The Commissioner claims that the ALJ properly found that other than a brief period of
exacerbation, Dr. D’Cruz’s treatment notes and the medical record did not reflect the severity of
the symptoms detailed in his opinion. [Doc. 24 at 25]. Further, the Commissioner asserts that the
ALJ’s discussion of the medical evidence demonstrates that the ALJ considered the entire record,
and thus, he was not required to extensively cite Plaintiff’s entire treatment record with Dr. D’Cruz
and Cherokee Health Systems. [Id. at 26]. In response, Plaintiff claims that the Commissioner
attempts to provide post hoc rationalizations for the ALJ’s failure to appropriately consider Dr.
D’Cruz’s opinion. [Doc. 25 at 3].
Plaintiff first began treatment with Dr. D’Cruz at Cherokee Health Systems on August 30,
2010, where she reported previously being diagnosed with bipolar disorder and that she suffered
from depression. [Tr. 558]. Dr. D’Cruz saw her until September 2011, when Plaintiff’s primary
care physician took over prescribing her psychotropic medications. [Tr. 554-55]. Dr. D’Cruz
began treating Plaintiff again in September 2014 following a referral to Cherokee Health Systems
from her treating physician, Hollis Cotton, M.D. [Tr. 519, 555]. Plaintiff stopped working on
August 6, 2014 [Tr. 204], and saw Dr. Cotton on August 13, 2014, complaining of stress and
depression, in addition to her physical impairments [Tr. 509]. Dr. Cotton noted that Plaintiff was
prescribed daily medication to treat her depression [Tr. 513]. On September 4, 2014, Plaintiff was
seen by Jean Patterson, LCSW at Cherokee Health Systems at the request of Dr. Cotton [Tr. 519].
Plaintiff then began mental health treatment with Dr. D’Cruz and Ms. Patterson, and was
diagnosed with mood disorder, unspecified, rule out bipolar disorder, not otherwise specified, and
a mild form of spina bifida. [Id.].
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Plaintiff returned to see Dr. D’Cruz on November 26, 2014 for management of her
medication, and Dr. D’Cruz diagnosed mood disorder, not otherwise specified, ruled out bipolar
disorder, type II, and mild obsessive-compulsive disorder [Tr. 553]. Plaintiff then began regular
treatment with Ms. Patterson, as the Government documented treatment notes for 43 visits from
September 4, 2014 through June 14, 2016. See [Doc. 24 at 14]. These treatment notes reflect
depression, low energy, lack of motivation, and an overwhelmed feeling, as well as that Plaintiff’s
father was near death and that she took care of him every weekend. [Tr. 1100]. However, the
Government also details that the initial treatment note states that Plaintiff had “just quit her job as
[a] pharm tech” because of a “conflict with [her] boss.” [Id.]. Plaintiff continued to see Dr. D’Cruz
to manage her medication. [Tr. 556].2
On April 8, 2016, Dr. D’Cruz and Ms. Patterson co-wrote a letter detailing Plaintiff’s
therapy and psychiatric services through Cherokee Health Systems. [Tr. 577]. The opinion stated
that Plaintiff was compliant with appointments, medications, and treatment; as well as that she had
been diagnosed with bipolar disorder, mood disorder, obsessive compulsive disorder, and
agoraphobia with panic. [Id.]. Additionally, Dr. D’Cruz noted that Plaintiff was being considered
for a possible diagnosis of post-traumatic stress disorder. [Id.]. The opinion detailed the mental
health symptoms that Plaintiff experienced as a result of these diagnoses. [Tr. 577–78]. However,
the descriptions of the symptoms for panic disorder, agoraphobia, bipolar disorder, obsessive
compulsive disorder, mood disorder, and post-traumatic stress disorder were general descriptions,
and did not specifically discuss Plaintiff. [Id.].
2
Both parties have extensively documented the medical record with respect to Plaintiff’s
mental and physical impairments. The Court has reviewed the briefs and medical record, and will
only discuss the most pertinent portions of the record.
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The opinion then stated that Plaintiff “also has some severe back, hip, leg and foot
problems” which “negatively impact her mental stability.” [Tr. 578]. Dr. D’Cruz and Ms.
Lawrence noted that Plaintiff found it “difficult to sit, lie down[,] or stand without severe pain and
this has led to behavioral deactivation.” [Id.]. Lastly, the opinion stated that Plaintiff’s “mental
health diagnoses are severe and will be ongoing, requiring continual medications and therapy to
help stabilize her.” [Tr. 580].
On January 2, 2015, state agency psychological consultant Brad Williams, M.D., reviewed
the evidence of record at the initial level of the agency’s review. [Tr. 73–81]. With respect to
Plaintiff’s mental limitations, Dr. Williams stated that Plaintiff alleged bipolar disorder,
depression, and mood swings, but found that Plaintiff had no severe mental impairments. [Tr. 78].
Dr. Williams opined that Plaintiff had mild limitations in the restriction of activities of daily living,
maintaining social functioning, as well as maintaining concentration, persistence, or pace. [Id.].
At the reconsideration level of the agency’s review, on February 11, 2015, state agency
psychological consultant Douglas Robbins, Ph.D. reached the same conclusions. [Tr. 91–93].
In the disability decision, the ALJ first found that Plaintiff’s panic disorder, post-traumatic
stress disorder, depression, bipolar disorder, and anxiety all qualified as severe impairments. [Tr.
12]. When determining Plaintiff’s RFC, however, the ALJ stated that the severity of Plaintiff’s
complaints “exceeds what is reasonably expected in light of the objective findings.” [Tr. 15]. The
ALJ noted that treatment records show “mild to moderate psychological symptoms, with the
exception of some brief exacerbations.” [Id.].
Next, the ALJ found that Plaintiff had the following mental limitations: work limited to
simple, routine and repetitive tasks; performed in a work environment free of fast-paced work;
involving only simple work-related decisions; few, if any, workplace changes; and only occasional
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interaction with the public, coworkers, and supervisors. [Id.]. The ALJ stated that these limitations
were consistent with and supported by Dr. Cruz’s reports, as well as other treatment notes from
Cherokee Health Systems.
[Id.].
Additionally, the ALJ summarized these reports as
demonstrating that Plaintiff had been treated for a variety of psychological symptoms beginning
several years before the alleged onset date, and that she was able to work full-time despite these
symptoms for several years. [Id.]. The ALJ found that there was “no clear evidence of significant,
sustained, worsening of her mental impairments.” [Id.]. Lastly, the ALJ assigned little weight to
Dr. Cruz’s April 8, 2016 letter, finding that although it describes more severe symptoms, “they
appear to be from a brief period of exacerbation and are inconsistent [with] the other reports.”
[Id.].
In considering a claim of disability, the ALJ generally must give the opinion of the
claimant’s treating physician “controlling weight.” 20 C.F.R. §§ 404.1527(c); 416.927(c)(2).3
However, the ALJ must do so only 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] case record.” Id. If the opinion is not given controlling weight, as here, the ALJ
must consider the following factors to determine what weight to give it: “the length of the treatment
relationship and the frequency of examination, the nature and extent of the treatment relationship,
supportability of the opinion, consistency of the opinion with the record as a whole, and the
3
The treating physician rule has been abrogated as to claims filed on or after March 27,
2017. See 20 C.F.R. §§ 404.1520c; 416.920c (“We will not defer or give any specific evidentiary
weight, including controlling weight, to any medical opinion(s) . . . including those from your
medical sources.”); see also Revisions to Rules Regarding the Evaluation of Medical Evidence, 82
Fed. Reg. 5844-01, 2017 WL 168819, at *5852–57 (Jan. 18, 2017). The new regulations eliminate
the term “treating source,” as well as what is customarily known as the treating physician rule. As
Plaintiff’s application was filed before March 27, 2017, the treating physician rule applies. See
id. §§ 404.1527; 416.927.
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specialization of the treating source,” as well as “other factors.” Wilson v. Comm’r of Soc. Sec.,
378 F.3d 541, 544 (6th Cir. 2004) (citing 20 C.F.R. § 404.1527).
The ALJ is not required to explain how he considered each of these factors but must
nonetheless give “good reasons” for giving a treating physician’s opinion less than controlling
weight. Francis v. Comm’r of Soc. Sec., 414 F. App’x 802, 804 (6th Cir. 2011); see also Morr v.
Comm’r of Soc. Sec., 616 F. App’x 210, 211 (6th Cir. 2015) (holding “good reasons” must be
provided “that are sufficiently specific to make clear to any subsequent reviewers the weight given
to the treating physician’s opinion and the reasons for that weight”) (citing Wilson, 378 F.3d at
544; 20 C.F.R. §§ 404.1527(c)(2) & 416.927(c)(2)).
The Court notes that an ALJ “has final responsibility for deciding an individual’s RFC . . .
and to require the ALJ to base her RFC finding on a physician’s opinion, ‘would, in effect, confer
upon the treating source the authority to make the determination or decision about whether an
individual is under a disability.’” Rudd v. Comm’r of Soc. Sec., 531 F. App’x 719, 728 (6th Cir.
2013) (quoting SSR 96-5p, 1996 WL 1374183, at *2 (July 2, 1996)). In the present case, Dr.
D’Cruz’s letter does not opine in depth on Plaintiff’s functional limitations due to her mental
impairments; rather, it states that Plaintiff’s physical impairments impact her mental stability, lists
and describes Plaintiff’s diagnosed mental impairments, and states that her mental health diagnoses
are severe.4 The ALJ assigned little weight to Dr. D’Cruz’s opinion, and failed to address the
4
The April 8, 2016 letter constitutes an opinion from Plaintiff’s treating psychologist, Dr.
D’Cruz, as medical opinions are “statements from acceptable medical sources that reflect
judgments about the nature and severity of [a claimant’s] impairment(s), including [their]
symptoms, diagnosis and prognosis . . . .” 20 C.F.R. § 404.1527(a)(1); see also Fairchild v. Colvin,
14 F. Supp. 3d 908, 917 n.5 (S.D. Ohio 2014) (finding that because a treating psychiatrist “signed
off” on statements given by a licensed social worker, those statements were considered the opinion
of the treating psychiatrist).
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weight assigned to the opinions of the nonexamining state agency psychological consultants.
However, “the ALJ’s decision still must say enough ‘to allow the appellate court to trace
the path of his reasoning.’” Stacey v. Comm’r of Soc. Sec., 451 F. App’x 517, 519 (6th Cir. 2011)
(quoting Diaz v. Chater, 55 F.3d 300, 307 (7th Cir. 1995)). In this regard, the ALJ does not detail
his reasoning or support for the mental limitations set forth in Plaintiff’s RFC. The ALJ stated that
his conclusions were consistent with and supported by Dr. D’Cruz’s and Ms. Patterson’s reports,
although he does not discuss the extensive mental health treatment records in any detail. See, e.g.,
Hogston v. Comm’r of Soc. Sec., No. CIV.A. 12-12626, 2013 WL 5423781, at *12 (E.D. Mich.
Sept. 26, 2013) (noting “the ALJ’s discussion of Dr. Pinson’s treatment—beyond doing little more
than effectively listing each of Dr. Pinson’s findings—included no discussion of Dr. Pinson’s
opinion, particularly as it related to Plaintiff’s mental impairments”). While the ALJ found that
Plaintiff’s panic disorder, post-traumatic stress disorder, depression, bipolar disorder, and anxiety
were severe impairments, the ALJ did not review the medical record with respect to these
impairments, or explain his findings on the functional limitations of these mental impairments.
See, e.g., Evans v. Comm’r of Soc. Sec., No. 1:10–cv–779, 2011 WL 6960619, at *14, 16 (S.D.
Ohio Dec. 5, 2011) (remanding where the Court was “unable to discern from the ALJ’s opinion
how he arrived at the RFC decision and what evidence he relied on in making that decision,”
explaining that “[s]imply listing some of the medical and other evidence contained in the record
and setting forth an RFC conclusion without linking such evidence to the functional limitations
ultimately imposed in the RFC is insufficient to meet the ‘narrative discussion’ requirement of
SSR 96–8.”), report and recommendation adopted by, 2012 WL 27476 (S.D. Ohio Jan. 5, 2012).
This lack of detailed reasoning is compounded by the fact that the ALJ’s RFC
determination with respect to Plaintiff’s mental impairments was not based upon any medical
12
opinion. Although an ALJ is not required to base his opinion on any medical opinion, Rudd v.
Comm’r of Soc. Sec., 531 F. App’x 719, 728 (6th Cir. 2013), the ALJ assigned little weight to Dr.
D’Cruz’s opinion and did not discuss the weight assigned to the opinions of Dr. Williams and Dr.
Robbins—the nonexamining state agency psychologists.
Further, the ALJ failed to explain how Dr. D’Cruz’s opinion, which the ALJ found
described more severe symptoms, was not supported by the remainder of Plaintiff’s mental health
treatment records. The ALJ stated that “[t]here is no clear evidence of significant, sustained,
worsening of her mental impairments,” while also discounting the severe symptoms detailed in
Dr. D’Cruz’s opinion because “they appear to be from a brief period of exacerbation and are
inconsistent [with] the other reports.” [Tr. 15]. Although the ALJ found that several of Plaintiff’s
mental health impairments were severe impairments, he based the assessed mental limitations, in
part, on Plaintiff’s ability to work for several years despite her mental health treatment. First, the
Court notes that an ALJ is not required to discuss every piece of evidence in the medical record.
See Kornecky v. Comm’r of Soc. Sec., 167 F. App’x 496, 507–08 (6th Cir. 2006) (“[A]n ALJ can
consider every piece of evidence without addressing [all the evidence] in his opinion.”). The ALJ,
however, subsequently failed to discuss or review Plaintiff’s treatment records in any detail,
especially her mental health treatment after leaving her job and the death of her father—a period
which Plaintiff claims resulted in her “worsening mental health.” [Doc. 18 at 19].
In support of her argument, Plaintiff points to several examples in the medical record. After
Plaintiff was referred by Dr. Cotton to Ms. Patterson for an evaluation, her clinical assessment on
September 4, 2014, was “Mood Disorder, Unspec” and “Rule Out [] Bipolar Disorder, NOS.” [Tr.
519]. These diagnoses, as well as mild obsessive-compulsive disorder, were confirmed by Dr.
D’Cruz on November 26, 2014.
[Tr. 553].
Dr. D’Cruz noted that Plaintiff endorsed an
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improvement in her depression, but that she was having anxiety. [Id.]. When reporting to Dr.
D’Cruz for management of her medication on May 25, 2015, Plaintiff reported that she was doing
poorly, Dr. D’Cruz noted that her mood was anxious, irritable, and depressed, and changed her
medication. [Tr. 729]. On June 23, 2015, Dr. D’Cruz noted that Plaintiff’s symptoms were
worsening [Tr. 727], although he also stated that Plaintiff had decided to stop taking one of her
prescribed medications, Effexor, in March of 2015. [Tr. 754–56]. Dr. D’Cruz noted on November
2, 2015 that Plaintiff reported that her mood and anxiety were better after a change in medication.
[Tr. 721].
Then, on January 28, 2016, Plaintiff continued to report an increase in anxiety, obsessive
compulsive disorder, and depression, in part due to the death of her father. [Tr. 719]. On February
19, 2016, Plaintiff claimed that her depression was much worse, to the point where it was
“paralyzing,” and that she was unable to get out of bed. [Tr. 736]. During her next visit with Dr.
D’Cruz, on April 27, 2016, Plaintiff reported that she was feeling more depressed and anxious and
that she constantly worries, although Dr. D’Cruz noted that Plaintiff had chosen to cut back on her
prescribed Prozac. [Tr. 718]. Lastly, on June 14, 2016, Ms. Patterson noted that Plaintiff was still
grieving the death of her father, was depressed and anxious, as well as worrying constantly, and
that her obsessive-compulsive disorder was fairly severe. [Tr. 1309].
Ultimately, due to the ALJ’s conclusory discussion of Plaintiff’s mental impairments and
the medical record, the Court is unable to follow the ALJ’s reasoning that Plaintiff’s mental
impairments did not result in a significant, sustained worsening of her symptoms, while also
discrediting Dr. D’Cruz’s opinion detailing more severe symptoms because it described a brief
period of exacerbation. See Johnson v. Comm'r of Soc. Sec., No. 1:14-CV-672, 2015 WL 5714522,
at *4 (W.D. Mich. Sept. 29, 2015) (“By failing to address plaintiff's treatment history from April
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2011 through November 2012, the ALJ has failed to articulate an analysis of the evidence which
allows this Court to trace the path of her reasoning.”); Johnson v. Comm’r of Soc. Sec., No. 1:12CV-66, 2013 WL 1249225, at *17 (E.D. Tenn. Feb. 28, 2013) (holding that “[i]t may be that the
ALJ’s ultimate conclusion was correct; however, upon close review of the ALJ’s decision and the
inadequacy of explanations given for some of his determinations, [the Court] cannot conclude the
ALJ’s decision was supported by substantial evidence”), report and recommendation adopted by,
2013 WL 1247681 (E.D. Tenn. Mar. 26, 2013).
The Commissioner claims that the ALJ properly analyzed Dr. D’Cruz’s medical opinion
by finding that other than a brief period of exacerbation, Dr. D’Cruz’s records, along with
Plaintiff’s entire treatment at Cherokee Health Systems, did not support the severe symptoms in
the opinion. [Doc. 24 at 25]. Further, the Commissioner asserts that the ALJ was not required to
extensively discuss the entire record where it is clear that the ALJ considered the entire record.
[Id. at 26]; see Rudd v. Comm’r, 531 F. App’x 719, 730 (6th Cir. 2013).
In the present case, it is not clear to the Court that the ALJ’s “factual findings as a whole
show that [he] implicitly considered the record as a whole.” Id. The Commissioner maintains that
the ALJ “acknowledged that Plaintiff’s impairments had worsened,” as he found more significant
limitations than the nonexamining state agency psychological consultants, as well as finding
several of Plaintiff’s mental impairments to be severe. [Doc. 24 at 27]. The ALJ, however, failed
to discuss the medical record regarding the worsening of Plaintiff’s mental impairments, what
period qualified as a brief exacerbation, or how the medical record did not support the more severe
symptoms in Dr. D’Cruz’s opinion. Additionally, the ALJ did not identify any specific
inconsistencies between Dr. D’Cruz’s opinion and the medical record. See Gayheart v. Comm’r
of Soc. Sec., 710 F.3d 365, 377 (6th Cir. 2013) (holding there must be some effort to “identify the
15
substantial evidence that is purportedly inconsistent” with the opinion of a treating physician if the
opinion is not assigned controlling weight); Zanders v. Comm’r of Soc. Sec., No. 1:13-CV-137,
2014 WL 272165, at *6 (S.D. Ohio Jan. 23, 2014) (“When a treating physician cites to specific
objective findings in support of his opinion, it is incumbent upon the ALJ to explain, with citations
to the record, why he believes those objective findings are ‘conclusory’ or do not support the
treating physician’s opinion to enable this Court to engage in meaningful review of the decision.”),
report and recommendation adopted by, 2014 WL 695841 (S.D. Ohio Feb. 24, 2014). Therefore,
the Court cannot rely upon the Commissioner’s post hoc rationalizations to support the ALJ’s RFC
determination. See, e.g., Schroeder v. Comm'r of Soc. Sec., No. 11-14778, 2013 WL 1316748, at
*13 (E.D. Mich. Mar. 1, 2013) (“Thus, the Commissioner's post hoc rationalization is not an
acceptable substitute for the ALJ's lack of rationale concerning his omission in considering the
opinion of plaintiff's treating physician.”), report and recommendation adopted by, 2013 WL
1294127 (E.D. Mich. Mar. 29, 2013).
Ultimately, the ALJ failed to appropriately review the medical record to support his
reasoning that this “brief period of exacerbation” did not constitute “significant, sustained,
worsening of her mental impairments,” as well as for the Court to determine the basis for the
mental limitations in the RFC determination. [Tr. 15]; see, e.g., Campbell v. Berryhill, No. 3:15CV-551-TAV-CCS, 2017 WL 1024338, at *10 (E.D. Tenn. Mar. 15, 2017) (“Here, the Court is
unable to determine why certain limitations assessed by Dr. Blaine are an overestimate of
plaintiff’s abilities, particularly where it is not entirely clear to begin with which limitations were
accepted and which were rejected. As evidenced by the parties’ arguments, for example, the record
contains conflicting evidence regarding plaintiff’s manipulative abilities. Therefore, without
further explanation from the ALJ, the Court is unable to trace the ALJ’s path of reasoning.”).
16
Further, although the ALJ found that the RFC was consistent with the reports of Dr. D’Cruz and
Plaintiff’s mental health treatment at Cherokee Health Systems, he did not detail what the assessed
limitations were based on, or how they were supported by the record. Accordingly, the Court
cannot conduct a meaningful review of the disability decision, and thus the ALJ’s decision is not
supported by substantial evidence. See Stacey v. Comm’r of Soc. Sec., 451 F. App’x 517, 519 (6th
Cir. 2011).
B.
Plaintiff’s Remaining Claims
As the Court has already found that it cannot conduct a meaningful review of the ALJ’s
decision with respect to the mental limitations in Plaintiff’s RFC, on remand, the ALJ should
consider the remainder of Plaintiff’s arguments. The ALJ should ensure to review the entire
medical record with respect to Plaintiff’s physical and mental impairments and appropriately
weigh the opinions of Plaintiff’s treating physician and the nonexamining state agency consultants.
VI.
CONCLUSION
Based on the foregoing, Plaintiff’s Motion for Summary Judgment [Doc. 17] will be
GRANTED IN PART, and the Commissioner’s Motion for Summary Judgment [Doc. 23] will
be DENIED. This case will be REMANDED to the SSA for the ALJ to reconsider the medical
evidence of record in the RFC determination consistent with this opinion.
ORDER ACCORDINGLY.
Debra C. Poplin
United States Magistrate Judge
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