Valle v. Social Security Administration, Commissioner of

Filing 26

MEMORANDUM AND OPINION as set forth in following order. Signed by Magistrate Judge Debra C Poplin on 9/18/19. (ABF)

UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF TENNESSEE
AT KNOXVILLE
FRANCES M. VALLE,
Plaintiff,
v.
ANDREW M. SAUL,1
Acting Commissioner of Social Security,
Defendant.

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No. 3:18-CV-141-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. 21]. Now before the Court are
Plaintiff’s Motion for Summary Judgment and Memorandum in Support [Docs. 22 & 23] and
Defendant’s Motion for Summary Judgment and Memorandum in Support [Docs. 24 & 25].
Frances Mary Valle (“Plaintiff”) seeks judicial review of the decision of the Administrative Law
Judge (“the ALJ”), the final decision of Defendant Andrew M. Saul (“the Commissioner”). For
the reasons that follow, the Court will DENY Plaintiff’s motion and GRANT the Commissioner’s
motion.
I.

PROCEDURAL HISTORY
On September 27, 2012, Plaintiff filed an application for disability insurance benefits

pursuant to Title II of the Social Security Act, 42 U.S.C. § 401 et seq., alleging disability beginning
on July 1, 2011. [Tr. 163–66]. After her application was denied initially and upon reconsideration,

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.

Plaintiff requested a hearing before an ALJ. [Tr. 112–13]. A hearing was held on January 16,
2014 before ALJ John Dowling. [Tr. 59–90]. On February 10, 2014, ALJ Dowling found that
Plaintiff was not disabled. [Tr. 42–53]. The Appeals Council denied Plaintiff’s request for review
on February 2, 2015. [Tr. 1–6].
After exhausting her administrative remedies, Plaintiff filed a Complaint with this Court
on August 28, 2015, seeking judicial review of the Commissioner’s final decision under Section
405(g) of the Social Security Act. See [Doc. 1] in Valle v. Comm’r of Soc. Sec. Admin., No. 3:15cv-388-PLR-HBG; see also [Tr. 913–18]. On August 30, 2016, the Court accepted Magistrate
Judge Guyton’s report and recommendation, and remanded Plaintiff’s case with instructions to
further consider the opinion of her treating rheumatologist, Nguyet-Anh (Theresa) Tran, M.D., and
for a new evaluation of Plaintiff’s RFC. See Valle v. Colvin, No. 3:15-CV-388-PLR-HBG, 2016
WL 4534875, at *4–5 (E.D. Tenn. July 27, 2016), report and recommendation adopted by, 2016
WL 4536877 (E.D. Tenn. Aug. 30, 2016).
On November 10, 2016, the Appeals Council remanded Plaintiff’s case to ALJ Mary Ellis
Richardson for further proceedings consistent with this Court’s Order. [Tr. 909–12].2 A hearing
was held before ALJ Richardson on March 1, 2017. [Tr. 810–40]. On May 23, 2017, ALJ
Richardson issued a partially favorable decision, and found Plaintiff to be disabled beginning April
9, 2014—but not prior to that date. [Tr. 779–97]. The Appeals Council denied Plaintiff’s request
for review on March 15, 2018 [Tr. 764–66], and she subsequently filed a Complaint with this Court

2

The Appeals Council’s remand order stated that Plaintiff filed subsequent claims for Title
II and Title XVI disability benefits on August 24, 2015, and consolidated these claims for the
ALJ’s consideration. [Tr. 911]. However, because the ALJ found that Plaintiff was not disabled
from July 1, 2011 until April 9, 2014, and Plaintiff did not apply for supplemental security income
until August 24, 2015, her Title XVI claim is not under review.
2

on April 4, 2018 [Doc. 1]. The parties have filed competing dispositive motions, and this matter
is now ripe for adjudication.
II.

ALJ FINDINGS
In her May 23, 2017 disability decision, ALJ Richardson 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
the alleged onset date (20 CFR 404.1571 et seq. and 416.971 et seq.).
3. Since the alleged onset date of disability, July 1, 2011, the
claimant has had the following severe impairments: rheumatoid
arthritis, depression, and anxiety (20 CFR 404.1520(c) and
416.920(c)).
4. Since the alleged onset date of disability, July 1, 2011, the
claimant has not had 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 prior to April 9, 2014, the date the claimant became
disabled, the claimant had the residual functional capacity to
perform sedentary work as defined in 20 CFR 404.1567(a) and
416.967(a) except the claimant could occasionally climb ramps or
stairs. The claimant could never climb ladders, ropes, or scaffolds;
could occasionally balance, stoop, kneel, crouch, or crawl. The
claimant could occasionally reach in all directions with both upper
extremities; could frequently handle, finger, and feel with bilateral
upper extremities. The claimant should avoid all exposure to
workplace hazards, such as proximity to moving, mechanical parts
or working in high, exposed places. The claimant was able to
perform simple and detailed tasks.
6. After careful consideration of the entire record, the undersigned
finds that beginning on April 9, 2014, the claimant has the residual
functional capacity to perform sedentary work as defined in 20 CFR
404.1567(a) and 416.967(a) except the claimant could occasionally
climb ramps or stairs. The claimant could never climb ladders,
3

ropes, or scaffolds; could occasionally balance, stoop, kneel, crouch,
or crawl. The claimant could occasionally reach in all directions
with both upper extremities; could frequently handle, finger, and
feel with bilateral upper extremities. The claimant should avoid all
exposure to workplace hazards such as exposure to moving,
mechanical parts or working in high, exposed places. The claimant
is able to perform simple and detailed tasks. The claimant would
require hourly breaks throughout the workday.
7. Since July 1, 2011, the claimant has been unable to perform any
past relevant work (20 CFR 404.1565 and 416.965).
8. Prior to the established disability onset date of April 9, 2014, the
claimant was a “younger individual age 45-49”. On December 16,
2015, the claimant turned fifty years of age and entered the category
of “closely approaching advanced age” (20 CFR 404.1563 and
416.963).
9. The claimant has at least a high school education and is able to
communicate in English (20 CFR 404.1564 and 416.964).
10. Prior to April 9, 2014, transferability of job skills is not material
to the determination of disability because using the MedicalVocational Rules as a framework supports a finding that the
claimant is “not disabled,” whether or not the claimant has
transferable job skills. Beginning on April 9, 2014, the claimant has
not been able to transfer job skills to other occupations (See SSR 8241 and 20 CFR Part 404, Subpart P, Appendix 2).
11. Prior to April 9, 2014, considering the claimant’s age,
education, work experience, and residual functional capacity, there
were jobs that existed in significant numbers in the national
economy that the claimant could have performed (20 CFR 404.1569
and 404.1569a, 416.969, and 416.969a).
12. Beginning on April 9, 2014, considering the claimant’s age,
education, work experience, and residual functional capacity, there
are no jobs that existed in significant numbers in the national
economy that the claimant can perform (20 CFR 404.1569 and
404.1569a, 416.969, and 416.969a)
13. The claimant was not disabled prior to April 9, 2014, but
became disabled on that date and has continued to be disabled
through the date of this decision (20 CFR 404.1520(g) and
416.920(g)).
4

[Tr. 782–96].
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
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).
5

IV.

DISABILITY ELIGIBILITY
“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) and 1382c(a)(3)(A). A claimant will only be 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
6

“based on all the relevant medical and other evidence in your case record.” 20 C.F.R. §§
404.1520(a)(4), -(e) and 416.920(a)(4), -(e). An RFC is the most a claimant can do despite her
limitations. 20 C.F.R. §§ 404.1545(a)(1) and 416.945(a)(1).
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 found disability onset date, as Plaintiff asserts that the ALJ

failed to adequately reconsider Dr. Tran’s opinions as directed by the Court’s remand order. [Doc.
23 at 4–6]. Plaintiff contends that the ALJ erred in failing to accord controlling weight to Dr.
Tran’s June 13, 2013 opinions, as they were supported by medically acceptable clinical and
laboratory diagnostic techniques, as well as that the opinions were not inconsistent with other
substantial evidence. [Id. at 7–12].
The Commissioner maintains that substantial evidence supports the ALJ’s evaluation of
Dr. Tran’s opinions, as the ALJ identified specific inconsistencies between the opinions and the
medical records, as well as that certain of Dr. Tran’s opinions were based primarily on Plaintiff’s
subjective complaints. [Doc. 25 at 7–11]. Further, the Commissioner asserts that “[t]he ALJ’s
analysis corrects the errors identified by this Court in its remand order.” [Id. at 10].
A.

ALJ’s Treatment of Dr. Tran’s Opinions

Plaintiff submits that the ALJ “did not make a proper ‘controlling weight’ analysis[,] nor
did the ALJ properly weight the treating physician’s opinions after presumably finding the treating
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physicians’ opinions were not controlling.” [Doc. 23 at 14].
Plaintiff first established care with Dr. Tran on August 8, 2012 for treatment of her
diagnosed rheumatoid arthritis, and reported tenderness in her right wrist, left elbow, right knee,
and right ankle. [Tr. 531]. Plaintiff was prescribed prednisone and continued treatment with Dr.
Tran on August 27, 2012 [Tr. 528], October 12, 2012 [Tr. 526], and November 21, 2012 [Tr. 566].
During a March 15, 2013 follow-up examination with Dr. Tran, Plaintiff reported tenderness in
her elbows, right ankle, and hip, but did not display any swelling, warmth, or erythema in any of
her joints. [Tr. 671–73]. Additionally, Plaintiff displayed limited range of motion in her bilateral
upper extremities. [Tr. 671]. Plaintiff returned to see Dr. Tran on July 31, 2013 [Tr. 695],
September 24, 2013 [Tr. 692], and December 2, 2013 [Tr. 686]. Although Plaintiff reported
stiffness during her appointment on December 2, 2013, she had no tenderness, swelling, or
erythema in any of her joints, as well as full range of motion in all of her joints except for reduced
range of motion in her bilateral elbows. [Tr. 686–88]. The ALJ characterized Plaintiff’s treatment
with Dr. Tran during this time period as Plaintiff seeking “treatment for her rheumatoid arthritis
with intermittent flares,” but objective medical findings “were consistent with the ability to
perform a range of sedentary work.” [Tr. 786].
Dr. Tran completed a Medical Questionnaire and Medical Source Statement on June 13,
2013. [Tr. 677–83]. In the Medical Questionnaire, Dr. Tran stated that Plaintiff’s primary
diagnosis was rheumatoid arthritis, and that her prognosis was fair while she continued to receive
immune suppressant drugs. [Tr. 677]; see [Tr. 1101]. However, Dr. Tran opined that Plaintiff was
not capable of sustaining employment on a regular basis until her disease was under better control,
due to her prolonged morning stiffness, pain, and swelling of joints. [Id.]. Further, Dr. Tran stated
that Plaintiff’s arthritis resulted in the need for frequent breaks, of ten to fifteen minutes every
8

hour, in order to stretch to prevent stiffness. [Tr. 1101]. On July 25, 2013, Dr. Tran added that
Plaintiff’s hourly breaks needed to be “away from [her] workstation,” and noted that Plaintiff has
long-standing rheumatoid arthritis and deformities in her elbows that would make it difficult for
her to perform usual upper extremity duties. [Tr. 677].
In the accompanying Medical Source Statement, Dr. Tran opined that Plaintiff could
occasionally lift and carry up to twenty pounds; and that she could sit, stand, and walk for one hour
at a time without interruption and for three to four hours total [Tr. 1094–95], including a separate
break time away from her work station to stretch every one hour [Tr. 679].3 Dr. Tran stated that
these limitations were supported by Plaintiff’s March 13, 2013 laboratory results, which were a
marker for active disease. [Tr. 679, 1095]. Next, Dr. Tran opined that Plaintiff could occasionally
reach, handle, finger, feel, and push/pull with both hands, and that she could occasionally operate
foot controls with both feet. [Tr. 680, 1096]. With respect to Plaintiff’s postural activities, Dr.
Tran found that Plaintiff could occasionally climb stairs and ramps, balance, stoop, kneel, crouch,
and crawl, but that she could never climb ladders or scaffolds. [Tr. 681, 1097]. Dr. Tran stated
that her opinion regarding Plaintiff’s use of her hands and feet, as well as postural limitations, was
due to clinical findings, Plaintiff’s report of her activity, and overall clinical impression. [Tr. 680–
81, 1096–97]. Dr. Tran found that Plaintiff could never be exposed to unprotected heights or
moving mechanical parts; but that she could occasionally be exposed to operating a motor vehicle,
humidity and wetness, dust, odors, fumes and pulmonary irritants, extreme cold and heat, and
vibrations. [Tr. 682, 1098]. Lastly, Dr. Tran indicated that the Medical Source Statement

3

The Commissioner suggests, and the Court agrees, that this notation was presumably
added at the same time as Dr. Tran’s addition to Plaintiff’s Medical Questionnaire on July 25,
2013.
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contained her opinion about only Plaintiff’s current limitations. [Tr. 683, 1099].
Dr. Tran also wrote a letter on January 2, 2014 detailing that Plaintiff “would benefit from
disability benefits given chronic rheumatoid arthritis and osteoarthrosis,” as well as that “[t]hese
conditions limit her ability to work right now.” [Tr. 1333]. Then, on April 9, 2014, Dr. Tran wrote
another letter stating that Plaintiff “has severe rheumatoid arthritis that is currently not well
controlled,” and that “[s]he has pain in the hands, wrists, shoulders, hips, and knees. [Tr. 1351].
Dr. Tran noted that Plaintiff’s pain “is aggravated by bearing weight unilaterally on one side when
using a cane,” and that Plaintiff has difficulty walking even when using the cane. [Id.]. Lastly,
Dr. Tran stated that Plaintiff’s use of a wheelchair would hopefully be for a short-term period of
two to three months, but it “may be needed intermittently for an indefinite period of time.” [Id.].
In the disability decision, the ALJ reviewed the respective medical opinions provided by
Dr. Tran, and first afforded little weight to the June 13, 2013 Medical Source Statement. [Tr. 788].
First, the ALJ found that “the ability to perform a reduced range of light work implied by the
lifting, carrying, walking and standing limitations is too optimistic,” and the overall record
reflected that Plaintiff should be limited to no more than sedentary exertion stretching back to the
alleged onset date. [Id.]. However, the ALJ also found that Dr. Tran’s opined occasional
manipulative restrictions were overly restrictive “in light of several factors,” including Plaintiff’s
reported daily activities. [Id.]. The ALJ noted that Plaintiff “engaged in a wide range of activities
of daily living,” such as reading the Bible, reporting that she sings and sends text messages, using
a computer and accessing Facebook, driving, and working two days a week in early 2017. [Id.].
Therefore, the ALJ found that Plaintiff could frequently handle, finger, and feel with both upper
extremities. [Id.].

10

The ALJ also afforded little weight to Dr. Tran’s accompanying Medical Questionnaire on
June 13, 2013. [Tr. 788]. The ALJ afforded little weight to the opinion “before the established
onset date insofar as it suggests [Plaintiff] was incapable of working at that time because [Dr. Tran]
does not mention any objective medical findings in support of this opinion.” [Id.]. Additionally,
the ALJ noted that the issue of disability is reserved to the Commissioner, and the opinion was not
consistent with Plaintiff’s reported activities of daily living. [Id.]. Similarly, the ALJ assigned
little weight to Dr. Tran’s January 2, 2014 letter because the issue of disability is reserved for the
Commissioner, the opinion relied too heavily on Plaintiff’s subjective complaints and was
inconsistent with her activities of daily living, and was vague and did not specify the degree of
opined limitations. [Tr. 789].
The ALJ, however, assigned great weight to Dr. Tran’s “brief letter” on April 9, 2014, first
noting that when compared to Dr. Tran’s past opinions, “this letter described a worsening of
[Plaintiff’s] physical condition . . . further supporting the conclusion that [Plaintiff’s] overall
physical condition had worsened in the spring of 2014.” [Tr. 790]. The ALJ found that this
opinion was “consistent with the medical signs and findings” that demonstrated a worsening of
Plaintiff’s overall condition, which the ALJ previously discussed while comparing August 12,
2013, January 2, 2014, and July 29, 2014 opinions from Plaintiff’s treating physician, Susan
Dowdy, M.D. [Tr. 790]; see [Tr. 789]. When discussing Dr. Tran’s April 9, 2014 opinion, the
ALJ noted that Plaintiff’s sedimentation rate on March 10, 2014 was 32, and treatment notes from
Dr. Tran on April 7, 2019 stated that Plaintiff has had “significant worsening” of her rheumatoid
arthritis with several swollen joints that required increased medication. [Tr. 790]; see [Tr. 1345].
Additionally, the ALJ noted Dr. Tran’s specialty in rheumatology as especially relevant due to
Plaintiff’s primary medical impairment. [Tr. 790].
11

Plaintiff challenges the ALJ’s assignment of little weight to the June 13, 2013 Medical
Source Statement and accompanying Medical Questionnaire. Plaintiff claims that the ALJ erred
in not assigning these opinions controlling weight because the ALJ did not find that Dr. Tran’s
opinions were not supported by acceptable clinical and laboratory diagnostic techniques, or that
the opinions were inconsistent with other substantial evidence. Plaintiff asserts that there was not
a contradictory rheumatologist opinion and the ALJ failed to properly explain what evidence was
inconsistent with the opinions. Further, Plaintiff claims that the ALJ failed to then properly
analyze the factors set forth in 20 C.F.R. § 404.1527(c)(2).
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); 416.927(c)(2).4 When an opinion does not garner controlling weight, the appropriate
weight to be given to the opinion will be determined based upon the length of treatment, frequency
of examinations, 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. Id.
The ALJ is not required to explain how he considered each of these factors, but must

4

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.
12

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 v. Comm’r of
Soc. Sec., 378 F.3d 541, 544 (6th Cir. 2004); 20 C.F.R. §§ 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).
Here, the ALJ did not engage in the “two-step” evaluation process required for evaluating
the opinions of Plaintiff’s treating rheumatologist, Dr. Tran. See Cadle v. Comm’r of Soc. Sec., No.
5:12-CV-3071, 2013 WL 5173127, at *5 (N.D. Ohio Sept. 12, 2013). The ALJ failed to first
determine whether Dr. Tran’s June 13, 2013 opinions were entitled to controlling weight by
considering whether her opinions were “well-supported by medically acceptable clinical and
laboratory diagnostic techniques” and “not inconsistent with the other substantial evidence in [the]
case record.” Gayheart v. Comm’r of Soc. Sec., 710 F.3d 365, 376 (6th Cir. 2013) (citing 20 C.F.R.
§ 404.1527(c)(2)). In Gayheart, the Sixth Circuit explained that although “the ALJ provided a
modicum of reasoning” for assigning little weight to a treating source’s opinion, these reasons
were relevant to how the “opinions should be weighed after determining they were not
controlling.” Id. at 377. As this District has explained:

13

Thus, in light of Sixth Circuit jurisprudence, the Court finds that the
regulations require an ALJ to first articulate whether, and why, a treating
source’s 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, i.e., the controlling-weight test, and,
second, to the extent the treating source’s opinion is not entitled to
controlling weight, the ALJ must then weigh the regulations’ balancing
factors—the length of the treatment relationship and the frequency of the
examination, the nature and extent of the treatment relationship, the
supportability of the opinion, the consistency of the opinion with the record
as a whole, the specialization of the source, and any other factors which tend
to support or contradict the opinion—to determine the amount of weight the
opinion deserves.
Klusmeier v. Berryhill, No. 3:16-cv-039, 2017 WL 1066641, at *6 (E.D. Tenn. Mar. 21, 2017).
In the disability decision, the ALJ “shortcut the process,” as the ALJ “did not explain
whether [Dr. Tran’s] opinion[s] [were] entitled to controlling weight or give any indication that
[they were] first assessed for controlling weight before moving into the regulatory balancing
factors.” Id. The ALJ did not detail whether the Medical Source Statement and Medical
Questionnaire were supported by medically acceptable techniques or inconsistent with other
substantial evidence. Rather, the ALJ stated that she assigned little weight to the Medical Source
Statement because the opined lifting, carrying, walking, and standing limitations were too
optimistic, but that Plaintiff’s reported daily activities did not support the opined manipulative
restrictions. [Tr. 788]. Similar to Gayheart, although the ALJ stated internal inconsistencies
existed between Dr. Tran’s opinions and Plaintiff’s reported daily activities, this factor is properly
applied only after the ALJ determined that Dr. Tran’s opinions were not entitled to controlling
weight. See 710 F.3d at 376.
Ultimately, the failure to properly examine whether a treating physician’s opinion is
entitled to controlling weight, and not providing “good reasons” for the weight assigned to the
opinion, hinders a meaningful review of whether the ALJ properly applied the treating physician
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rule. See id. at 377. While the Sixth Circuit has instructed that courts should not hesitate to remand
a case when an ALJ fails to adhere to the treating physician rule, see Wilson v. Comm’r of Soc.
Sec., 378 F.3d 541, 545 (6th Cir. 2004), remand is not necessary if the violation of the “good
reason” rule is harmless. Cole v. Astrue, 661 F.3d 931, 940 (6th Cir. 2011). Error is harmless
when:
(1) a treating source’s opinion is so patently deficient that the Commissioner could
not possibly credit it; (2) if the Commissioner adopts the opinion of the treating
source or makes findings consistent with the opinion; or (3) where the
Commissioner has met the goal of [20 C.F.R. § 416.967(c)(2)]. . . even though she
has not complied with the terms of the regulation.
Friend v. Comm’r of Soc. Sec., 375 F. App’x 543, 551 (6th Cir. 2010) (citation omitted). “In the
last of these circumstances, the procedural protections at the heart of the rule may be met when the
‘supportability’ of a doctor’s opinion, or its consistency with other evidence in the record, is
indirectly attacked via an ALJ’s analysis of a physician’s other opinions or his analysis of the
claimant’s ailments.” Id. (citing Nelson v. Comm’r of Soc. Sec., 195 F. App’x 462, 470–72 (6th
Cir. 2006)).
Accordingly, the Court finds that the last of these exceptions is applicable, as although the
ALJ did not properly engage in the controlling weight analysis, she provided good reasons for
assigning little weight to Dr. Tran’s Medical Source Statement and Medical Questionnaire. See,
e.g., Klusmeier v. Berryhill, No. 3:16-CV-039, 2017 WL 1066641, at *7 (E.D. Tenn. Mar. 21,
2017) (“Although the ALJ did not discuss whether Dr. McElligott’s opinion was entitled to
controlling weight before balancing the regulatory factors, the ALJ sufficiently explained what
weight the opinion deserved and the reasons for that weight, which the Court finds is supported by
substantial evidence and makes clear to subsequent reviewers the reason for the assignment of
limited weight.”).
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First, the ALJ properly stated how the opined manipulative restrictions—that Plaintiff
could occasionally reach overhead, reach in all other directions, handle, finger, feel, push, and pull
with bilateral upper extremities—were inconsistent with Plaintiff’s reported daily activities. See,
e.g., Dyer v. Soc. Sec. Admin., 568 F. App’x 422, 427 (6th Cir. 2014) (noting that plaintiff’s daily
activities of “personal hygiene and grooming, cooking, cleaning, laundry, driving, shopping,
visiting with friends and family, caring for her ill mother, and taking care of her pet bird”
constituted substantial evidence in support of a finding that the plaintiff was not disabled and
assigning little weight to treating physician’s opinion). The ALJ detailed that Plaintiff reported
being able to read the Bible, send text messages, use a computer, drive, and work two days a week.
Although Plaintiff challenges the ALJ’s characterization regarding her ability to read the
Bible, as she contends that she testified that she only studies the Bible when Jehovah’s Witnesses
visit her home once a month [Doc. 23 at 6], substantial evidence supports the ALJ’s finding that
the remaining reported daily activities, such as being able to use a computer and drive, lead to a
conclusion that Plaintiff could frequently handle, finger, and feel with both upper extremities. Cf.
Gayheart v. Comm’r of Soc. Sec., 710 F.3d 365, 377 (6th Cir. 2013) (finding that although the ALJ
cited to reported daily activities as evidence that the plaintiff’s mental impairments were not as
severe as alleged, the record did not support a finding that the plaintiff could perform the cited
activities on a sustained basis).
Further, Plaintiff claims that the ALJ conflictingly chose evidence that was allegedly
inconsistent with Dr. Tran’s opined disabling limitations. However, the Court notes that the ALJ
assigned little weight to Dr. Tran’s June 13, 2013 Medical Source Statement, in part, because the
opined RFC, as well as lifting, carrying, walking, and standing limitations, were too optimistic.
The Court finds that the ALJ’s review of the medical record provided substantial evidence to
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support her finding that Plaintiff’s condition worsened in the spring of 2014, as well as the
disability onset date. Although Plaintiff would interpret the medical evidence differently, the
Court finds that the ALJ’s determination was within her “zone of choice.” Blakley v. Comm’r of
Soc. Sec., 581 F.3d 399, 407 (6th Cir. 2009); see also Huizar v. Astrue, No. 3:07CV411-J, 2008
WL 4499995, at *3 (W.D. Ky. Sept. 29, 2008) (“While plaintiff understandably argues for a
different interpretation of the evidence from that chosen by the ALJ, the issue is not whether
substantial evidence could support a contrary finding, but simply whether substantial evidence
supports the ALJ’s findings.”).
Next, with respect to the Medical Questionnaire, the ALJ properly stated that Dr. Tran did
not mention any objective medical findings in support of the opinion. See Helm v. Comm’r of Soc.
Sec. Admin., 405 F. App’x 997, 1000 (6th Cir. 2011) (noting the ALJ’s notation of the lack of
objective findings as a good reason for discounting a treating physician’s opinion). Additionally,
the ALJ properly found that Dr. Tran’s opinion on Plaintiff’s disability is an opinion on an issue
reserved to the Commissioner, as a treating physician’s opinion that their patient is disabled is not
“giv[en] any special significance.” 20 C.F.R. § 404.1527(e); see, e.g., Johnson v. Comm’r of Soc.
Sec., 535 F. App’x 498, 505 (6th Cir. 2013) (“[A] treating physician’s opinion is only entitled to
such . . . deference when it is a medical opinion. If the treating physician instead submits an
opinion on an issue reserved to the Commissioner—such as whether the claimant is disabled,
unable to work, the claimant’s RFC, or the application of vocational factors—his decision need
only explain the consideration given to the treating source’s opinion. The opinion, however, is not
entitled to any particular weight.”) (internal citations and quotation marks omitted). Lastly, the
ALJ again found that this opinion was inconsistent with Plaintiff’s reported daily activities.

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Ultimately, a violation of the treating physician rule may be harmless where “the ALJ’s
analysis meet[s] the goal of the rule even if not meeting its letter.” Nelson v. Comm’r of Soc. Sec.,
195 F. App’x 462, 470–72 (6th Cir. 2006). Here, like in Nelson, the reasoning provided by the
ALJ demonstrates that Dr. Tran’s opinions were found to be inconsistent with other substantial
evidence, i.e., the ALJ’s significant discussion of the medical record and additional opinions to
find that Plaintiff’s rheumatoid arthritis significantly worsened in the spring of 2014. The ALJ
noted that during an April 17, 2014 visit with Dr. Tran, Plaintiff required increasing doses of
prednisone and additional medication to treat her symptoms, and received a referral to an ENT on
April 7, 2014 for treatment of chronic dizziness and ear pain. [Tr. 790]. When assigning great
weight to Dr. Tran’s April 9, 2014 letter, the ALJ reviewed the worsening of Plaintiff’s rheumatoid
arthritis and symptoms reflected in Dr. Tran’s treatment notes, as well as increased medication.
[Id.]. In contrast, the ALJ previously described Plaintiff’s treatment with Dr. Tran from August
2012 through December 2013 as “the record shows [Plaintiff] sought treatment for her rheumatoid
arthritis with intermittent flares.” [Tr. 785].
The ALJ also compared opinions from Plaintiff’s treating physician, Dr. Susan Dowdy, on
January 2, 2014 and July 28, 2014. [Tr. 789]. In particular, the ALJ noted “several factors” that
suggested Plaintiff’s condition had worsened, including that she had begun picking at herself as of
May 22, 2014, Plaintiff had increased her Lyrica intake due to worsening symptoms of her
peripheral neuropathy, and Plaintiff stated on May 22, 2014 that her arthritis had become so severe
that she began using a walker for ambulation. [Tr. 789–90]. Lastly, in the disability decision, the
ALJ acknowledged Dr. Tran’s treatment relationship with Plaintiff, as well as her specialty as a
rheumatologist. [Tr. 790].

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Accordingly, the Court finds that although the ALJ failed to first assess Dr. Tran’s June
13, 2013 opinions for controlling weight, the ALJ proceeded to provide “good reasons” for the
weight assigned to the opinions, and the discussion of the opinions demonstrates to the Court the
reasons why Dr. Tran’s opinions were assigned little weight. See, e.g., Klusmeier v. Berryhill, No.
3:16-CV-039, 2017 WL 1066641, at *10 (E.D. Tenn. Mar. 21, 2017). “Even when considering
claims alleging violation of the treating-source rule, we continue to believe that [w]hen remand
would be an idle and useless formality, courts are not required to convert judicial review of agency
action into a ping-pong game.” Hall v. Comm’r of Soc. Sec., 148 F. App’x 456, 463 (6th Cir.
2005) (internal quotations omitted). Therefore, the goal of the treating physician rule was met,
and the ALJ’s error with respect to her controlling weight analysis was harmless.
B.

Remand Order

Plaintiff contends that the “ALJ failed to adequately reconsider Dr. Tran’s opinion as
directed by the [Court].” [Doc. 23 at 4]. Plaintiff reviews her treatment with Dr. Tran, as well as
repeats her claims that the ALJ improperly assigned little weight to Dr. Tran’s June 13, 2013
opinions. The Commissioner asserts that “[t]he ALJ’s analysis corrects the errors identified by
this Court in its remand order.” [Doc. 25 at 10].
In adopting Magistrate Judge Guyton’s report and recommendation, the Court previously
remanded Plaintiff’s case “to the ALJ for further consideration of Dr. Tran’s opinion and for a new
evaluation of plaintiff’s residual functional capacity.” Valle v. Colvin, No. 3:15-CV-388-PLRHBG, 2016 WL 4536877, at *1 (E.D. Tenn. Aug. 30, 2016). However, in Magistrate Judge
Guyton’s report and recommendation, the Court noted that the previous ALJ failed to assign a
specific weight to Dr. Tran’s Medical Questionnaire and Medical Source Statement, as well as
“the ALJ ‘somewhat’ modified the opinion because Dr. Tran had based part of his opinion upon
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the Plaintiff’s reported activity level, and the ALJ found the Plaintiff was not ‘entirely credible.’”
Valle v. Colvin, No. 3:15-CV-388-PLR-HBG, 2016 WL 4534875, at *4 (E.D. Tenn. July 27,
2016), report and recommendation adopted by, 2016 WL 4536877 (E.D. Tenn. Aug. 30, 2016).
The Court found that the ALJ improperly failed to explain the specific weight granted to the
opinions, what portion of the opinions were modified, or explain why these portions of the opinions
were modified. Id. at *4–5. Therefore, the Court recommended “that the case be remanded to the
ALJ for clarification of the weight accorded to the opinion of Dr. Tran and the reasons for
according such weight pursuant to 20 C.F.R. § 404.1527(c)(2).” Id. at *5. The Appeals Council
subsequently remanded Plaintiff’s case “for further proceedings consistent with the order of the
[C]ourt.” [Tr. 911].
There

is

“disagreement

amongst

federal

courts

as

to

whether

an

ALJ’s failure to follow the Appeals Council instructions may serve as an independent ground for
reversal.” Kearney v. Colvin, 14 F. Supp. 3d 943, 950 (S.D. Ohio 2014) (collecting cases); see
also Kaddo v. Comm’r of Soc. Sec., 238 F. Supp. 3d 939, 943 (E.D. Mich., 2017) (noting “[t]here
is no consensus among federal courts regarding whether an ALJ’s failure to follow Appeals
Council directives in a remand order may serve as independent grounds for reversal, in the absence
of some other error”). The Sixth Circuit does not appear to have had the opportunity to address
this question, and District Courts within the Sixth Circuit have disagreed on the issue. Id.; see
Shope v. Comm’r of Soc. Sec., 2015 WL 3823165 at * 8 (S.D. Ohio June 19, 2015) (“The
overwhelming majority of courts in this circuit, however, have determined that federal courts lack
jurisdiction to consider whether an administrative law judge complied with the Appeals Council’s
instructions on remand.”), report and recommendation adopted by, 2015 WL 6155919 (S.D. Ohio
Oct. 20, 2015). However, this District has previously held that an ALJ’s failure to follow the
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dictates of the Appeals Council’s instructions constitutes an error requiring remand. See Salvati
v. Astrue, No. 3:08-cv-494, 2010 WL 546490, at *4–5 (E.D. Tenn. Feb. 10, 2010).
In the present case, however, Plaintiff has not established that ALJ Richardson failed to
follow the Appeals Council’s instructions in accordance with this Court’s remand order. The ALJ
assigned a specific weight to Dr. Tran’s opinions, and detailed what portions of the opinions were
not adopted. Plaintiff repeats her arguments regarding the ALJ’s treatment of the Medical Source
Statement and Questionnaire, but the Court has found that any error with respect to the ALJ’s
controlling weight analysis was harmless error. By specifically detailing the weight afforded to
Dr. Tran’s opinions, as well as providing good reasons for the weight assigned to these opinions,
the ALJ “met the directives” of the Appeals Council’s order. Kearney, 14 F. Supp. 3d at 950.
Therefore, the ALJ followed the instructions of the Appeals Council and this Court, and Plaintiff’s
argument raises no basis for remand in this case.
V.

CONCLUSION
Based on the foregoing, Plaintiff’s Motion for Summary Judgment [Doc. 22] will be

DENIED, and the Commissioner’s Motion for Summary Judgment [Doc. 24] will be GRANTED.
The decision of the Commissioner will be AFFIRMED. The Clerk of Court will be DIRECTED
to close this case.
ORDER ACCORDINGLY.

Debra C. Poplin
United States Magistrate Judge

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