Hazelwood v. Social Security Administration
Filing
27
MEMORANDUM OPINION OF THE COURT. Signed by Magistrate Judge Barbara D. Holmes on 4/17/17. (DOCKET TEXT SUMMARY ONLY-ATTORNEYS MUST OPEN THE PDF AND READ THE ORDER.)(dt)
IN THE UNITED STATES DISTRICT COURT
MIDDLE DISTRICT OF TENNESSEE
NASHVILLE DIVISION
TERESA GAYLE HAZELWOOD
v.
NANCY A. BERRYHILL
Acting Commissioner of
Social Security 1
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No. 3:13-0563
MEMORANDUM
Plaintiff filed this action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3) to obtain
judicial review of the final decision of the Social Security Administration (“Commissioner”),
denying Plaintiff’s claim for Disability Insurance Benefits (“DIB”) and Supplemental Security
Income (“SSI”), as provided under Titles II and XVI of the Social Security Act (“the Act”). The
case is currently pending on Plaintiff’s motion for judgment on the administrative record (Docket
Entry No. 14), to which Defendant has responded (Docket Entry No. 20). Plaintiff has also filed
a subsequent reply to Defendant’s response (Docket Entry No. 22). This action is before the
undersigned for all further proceedings pursuant to the consent of the parties and the District
Judge in accordance with 28 U.S.C. § 636(c) (Docket Entry No. 23).
Upon review of the administrative record as a whole and consideration of the parties’
filings, Plaintiff’s motion is DENIED and the decision of the Commissioner is AFFIRMED.
1
Nancy A. Berryhill became the Acting Commissioner of Social Security on January 23, 2017.
Under Rule 25(d) of the Federal Rules of Civil Procedure, Nancy A. Berryhill is substituted for former
Acting Commissioner Carolyn W. Colvin as the defendant in this suit.
1
I. INTRODUCTION
Plaintiff filed applications for DIB and SSI on October 8, 2009. See Transcript of the
Administrative Record (Docket Entry No. 10) at 81-82. 2 She alleged a disability onset date of
June 15, 2009. AR 81-82. Plaintiff alleged that she was unable to work because of arthritis, back
problems, a history of surgery on her neck and lower back, depression, and a suicide attempt.
AR 99-100. 3
Plaintiff’s applications were denied initially and upon reconsideration. AR 81-84. Upon
her request for a hearing before an administrative law judge (“ALJ”), Plaintiff appeared with
counsel and testified at a hearing before ALJ Scott C. Shimer on November 21, 2011. AR 37. On
January 20, 2012, the ALJ denied the claim. AR 14-16. On April 8, 2013, the Appeals Council
denied Plaintiff’s request for review of the ALJ’s decision (AR 1-3), thereby making the ALJ’s
decision the final decision of the Commissioner. This civil action was thereafter timely filed, and
the Court has jurisdiction. 42 U.S.C. § 405(g).
II. THE ALJ FINDINGS
The ALJ issued an unfavorable decision on January 20, 2012. AR 14-16. Based upon the
record, the ALJ made the following enumerated findings:
1. The claimant meets the insured status requirements of the Social Security Act
through December 31, 2014.
2
The Transcript of the Administrative Record is hereinafter referenced by the abbreviation “AR”
followed by the corresponding page number(s) as numbered in large black print on the bottom right
corner of each page. All other filings are hereinafter referenced by the abbreviation “DE” followed by the
corresponding docket entry number and page number(s) where appropriate.
3
The Commissioner also found evidence of chronic obstructive pulmonary disease (“COPD”)
and osteopenia. AR 99-100.
2
2. The claimant has not engaged in substantial gainful activity since June 15,
2009, the alleged onset date (20 CFR 404.1571 et seq., and 416.971 et seq.).
3. The claimant has the following severe impairments: cervical degenerative disc
disease with fusion and major depressive disorder (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 Administrative Law Judge
finds that the claimant has the residual functional capacity to perform a
limited range of light work as defined in 20 CFR 404.1567(b) and 416.967(b);
except that she can occasionally reach overhead with the bilateral upper
extremities; occasionally able to balance, bend, stoop, crouch, crawl and climb
ramps and stairs; but never able to climb ladders, ropes or scaffolds.
Additionally, the claimant is able to have occasional contact with the public.
***
6. The claimant is unable to perform any past relevant work (20 CFR 404.1565
and 416.965).
***
7. The claimant was 49 years old on the alleged onset date, defined as a younger
individual. The claimant is currently 52 years old, defined as closely
approaching advanced age. (20 CFR 404.1563 and 416.963).
8. The claimant has a high school education with one year of college, 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 82-41 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)).
***
3
11. The claimant has not been under a disability, as defined in the Social Security
Act, from June 15, 2009, through the date of this decision (20 CFR
404.1520(g) and 416.920(g)).
AR 19-31.
III. REVIEW OF THE RECORD
The parties and the ALJ have thoroughly summarized and discussed the medical and
testimonial evidence of the administrative record. Accordingly, the Court will discuss those
matters only to the extent necessary to analyze the parties’ arguments.
IV. DISCUSSION AND CONCLUSIONS OF LAW
A. Standard of Review
The determination of disability under the Act is an administrative decision. The only
questions before this Court upon judicial review are: (i) whether the decision of the
Commissioner is supported by substantial evidence, and (ii) whether the Commissioner made
legal errors in the process of reaching the decision. 42 U.S.C. § 405(g). See Richardson v.
Perales, 402 U.S. 389, 401, 91 S. Ct. 1420, 28 L. Ed. 2d 842 (1971) (adopting and defining
substantial evidence standard in context of Social Security cases); Kyle v. Comm’r of Soc. Sec.,
609 F.3d 847, 854 (6th Cir. 2010). The Commissioner’s decision must be affirmed if it is
supported by substantial evidence, “even if there is substantial evidence in the record that would
have supported an opposite conclusion.” Blakley v. Comm’r of Soc. Sec., 581 F.3d 399, 406 (6th
Cir. 2009) (quoting Key v. Callahan, 109 F.3d 270, 273 (6th Cir. 1997)); Jones v. Comm’r of
Soc. Sec., 336 F.3d 469, 477 (6th Cir. 2003); Her v. Comm’r of Soc. Sec., 203 F.3d 388, 389-90
(6th Cir. 1999).
4
Substantial evidence is defined as “more than a mere scintilla” and “such relevant
evidence as a reasonable mind might accept as adequate to support a conclusion.” Richardson,
402 U.S. at 401 (quoting Consol. Edison Co. v. NLRB, 305 U.S. 197, 229, 59 S. Ct. 206, 83 L.
Ed. 126 (1938)); Rogers v. Comm’r of Soc. Sec., 486 F.3d 234, 241 (6th Cir. 2007); LeMaster v.
Weinberger, 533 F.2d 337, 339 (6th Cir. 1976) (quoting Sixth Circuit opinions adopting
language substantially similar to that in Richardson).
The Court’s review of the Commissioner’s decision is limited to the record made in the
administrative hearing process. Jones v. Secretary, 945 F.2d 1365, 1369 (6th Cir. 1991). A
reviewing court may not try the case de novo, resolve conflicts in evidence, or decide questions
of credibility. See, e.g., Garner v. Heckler, 745 F.2d 383, 387 (6th Cir. 1984) (citing Myers v.
Richardson, 471 F.2d 1265, 1268 (6th Cir. 1972)). The Court must accept the ALJ’s explicit
findings and determination unless the record as a whole is without substantial evidence to
support the ALJ’s determination. 42 U.S.C. § 405(g). See, e.g., Houston v. Sec’y of Health &
Human Servs., 736 F.2d 365, 366 (6th Cir. 1984).
B. Determining Disability at the Administrative Level
The claimant has the ultimate burden of establishing an entitlement to benefits by proving
her “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 12 months.”
42 U.S.C. § 432(d)(1)(A). The asserted impairment(s) must be demonstrated by medically
acceptable clinical and laboratory diagnostic techniques. See 42 U.S.C. §§ 432(d)(3) and
1382c(a)(3)(D); 20 C.F.R. §§ 404.1512(a), (c), and 404.1513(d). “Substantial gainful activity”
not only includes previous work performed by the claimant, but also, considering the claimant’s
5
age, education, and work experience, any other relevant work that exists in the national economy
in significant numbers regardless of whether such work exists in the immediate area in which the
claimant lives, or whether a specific job vacancy exists, or whether the claimant would be hired
if she applied. 42 U.S.C. § 423(d)(2)(A).
In the proceedings before the Social Security Administration, the Commissioner must
employ a five-step, sequential evaluation process in considering the issue of the claimant’s
alleged disability. See Heston v. Comm’r of Soc. Sec., 245 F.3d 528, 534 (6th Cir. 2001); Abbot
v. Sullivan, 905 F.2d 918, 923 (6th Cir. 1990). First, the claimant must show that she is not
engaged in “substantial gainful activity” at the time disability benefits are sought. Cruse v.
Comm’r of Soc. Sec., 502 F.3d 532, 539 (6th Cir. 2007); 20 C.F.R. §§ 404.1520(b), 416.920(b).
Second, the claimant must show that she suffers from a severe impairment that meets the
12-month durational requirement. 20 C.F.R. §§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii). See also
Edwards v. Comm’r of Soc. Sec., 113 F. App’x 83, 85 (6th Cir. 2004). Third, if the claimant has
satisfied the first two steps, the claimant is presumed disabled without further inquiry, regardless
of age, education or work experience, if the impairment at issue either appears on the regulatory
list of impairments that are sufficiently severe as to prevent any gainful employment or equals a
listed impairment. Combs v. Comm’r of Soc. Sec., 459 F.3d 640, 643 (6th Cir. 2006); 20 C.F.R.
§§ 404.1520(d), 416.920(d). A claimant is not required to show the existence of a listed
impairment in order to be found disabled, but such showing results in an automatic finding of
disability that ends the inquiry. See Combs, supra; Blankenship v. Bowen, 874 F.2d 1116, 1122
(6th Cir. 1989).
If the claimant’s impairment does not render her presumptively disabled, the fourth step
evaluates the claimant’s residual functional capacity in relationship to her past relevant work.
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Combs, supra. “Residual functional capacity” (“RFC”) is defined as “the most [the claimant] can
still do despite [her] limitations.” 20 C.F.R. §§ 404.1545(a)(1). In determining a claimant’s RFC,
for purposes of the analysis required at steps four and five, the ALJ is required to consider the
combined effect of all the claimant’s impairments, mental and physical, exertional and
nonexertional, severe and nonsevere. See 42 U.S.C. §§ 423(d)(2)(B), (5)(B); Foster v. Bowen,
853 F.2d 483, 490 (6th Cir. 1988). At the fourth step, the claimant has the burden of proving an
inability to perform past relevant work or proving that a particular past job should not be
considered relevant. Cruse, 502 F.3d at 539; Jones, 336 F.3d at 474. If the claimant cannot
satisfy the burden at the fourth step, disability benefits must be denied because the claimant is
not disabled. Combs, supra.
If a claimant is not presumed disabled but shows that past relevant work cannot be
performed, the burden of production shifts at step five to the Commissioner to show that the
claimant, in light of the claimant’s RFC, age, education, and work experience, can perform other
substantial gainful employment and that such employment exists in significant numbers in the
national economy. Longworth v. Comm’r of Soc. Sec., 402 F.3d 591, 595 (6th Cir. 2005)
(quoting Walters v. Comm’r of Soc. Sec., 402 F.3d 525, 529 (6th Cir. 1997)). See also Felisky v.
Bowen, 35 F.3d 1027, 1035 (6th Cir. 1994). To rebut a prima facie case, the Commissioner must
come forward with proof of the existence of other jobs a claimant can perform. Longworth, 402
F.3d at 595. See also Kirk v. Sec’y of Health & Human Servs., 667 F.2d 524, 528 (6th Cir. 1981),
cert. denied, 461 U.S. 957, 103 S. Ct. 2428, 77 L. Ed. 2d 1315 (1983) (upholding the validity of
the medical-vocational guidelines grid as a means for the Commissioner of carrying his burden
under appropriate circumstances). Even if the claimant’s impairments prevent the claimant from
doing past relevant work, if other work exists in significant numbers in the national economy that
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the claimant can perform, the claimant is not disabled. Rabbers v. Comm’r of Soc. Sec., 582 F.3d
647, 652 (6th Cir. 2009). See also Tyra v. Sec’y of Health & Human Servs., 896 F.2d 1024,
1028-29 (6th Cir. 1990); Farris v. Sec’y of Health & Human Servs., 773 F.2d 85, 88-89 (6th Cir.
1985); Mowery v. Heckler, 771 F.2d 966, 969-70 (6th Cir. 1985).
If the question of disability can be resolved at any point in the sequential evaluation
process, the claim is not reviewed further. 20 C.F.R. § 404.1520(a)(4). See also Higgs v. Bowen,
880 F.2d 860, 863 (6th Cir. 1988) (holding that resolution of a claim at step two of the evaluative
process is appropriate in some circumstances).
C. The ALJ’s Five-Step Evaluation of Plaintiff
In the instant case, the ALJ resolved Plaintiff’s claim at step five of the five-step process.
The ALJ found that Plaintiff met the first two steps, but determined at step three that Plaintiff
was not presumptively disabled because she did not have an impairment or combination of
impairments that met or medically equaled the severity of one of the listed impairments in
20 C.F.R. Part 404, Subpart P, Appendix 1. At step four, the ALJ found that Plaintiff was unable
to perform any past relevant work. At step five, the ALJ found that Plaintiff’s RFC allowed her
to perform a range of light work with other express limitations to account for her severe
impairments, and that considering her age, education, work experience, and RFC, there are jobs
that exist in significant numbers in the national economy that Plaintiff can perform. AR 19-31.
D. Plaintiff’s Assertions of Error
Plaintiff argues that the ALJ erred by (1) failing to properly evaluate the treating
physician’s opinion; (2) mischaracterizing the evidence of record and not properly weighing the
opinions of Plaintiff’s mental health providers; and (3) failing to properly evaluate Plaintiff’s
credibility. DE 14-1 at 1-2. Plaintiff therefore requests that this case be reversed and benefits
8
awarded, or, alternatively, remanded pursuant to sentence four of 42 U.S.C. § 405(g) for further
consideration. Id. at 25.
Sentence four of 42 U.S.C. § 405(g) states the following:
The court shall have power to enter, upon the pleadings and transcript of the
record, a judgment affirming, modifying, or reversing the decision of the
Commissioner of Social Security, with or without remanding the cause for a
rehearing.
42 U.S.C. § 405(g), 1383(c)(3). “In cases where there is an adequate record, the
[Commissioner’s] decision denying benefits can be reversed and benefits awarded if the decision
is clearly erroneous, proof of disability is overwhelming, or proof of disability is strong and
evidence to the contrary is lacking.” Mowery v. Heckler, 771 F.2d 966, 973 (6th Cir. 1985).
Furthermore, a court can reverse the decision and immediately award benefits if all essential
factual issues have been resolved and the record adequately establishes a claimant’s entitlement
to benefits. Faucher v. Secretary, 17 F.3d 171, 176 (6th Cir. 1994). See also Newkirk v. Shalala,
25 F.3d 316, 318 (1994). The Court will address each of Plaintiff’s assertions of error below.
1. The treating physician’s opinion.
Plaintiff first argues that the ALJ improperly rejected the opinion of Dr. Richard Meyer,
her treating physician. DE 14-1 at 12. Plaintiff asserts that the ALJ failed to consider his “fairly
extensive treating relationship” with her. Id. at 14. Plaintiff also points to multiple “objective
findings” in Dr. Meyer’s office notes that she claims provide substantial support for Dr. Meyer’s
opinion that Plaintiff “should be considered disabled due to her condition.” Id. at 13-14.
It is firmly established that a treating physician’s opinion will be given controlling weight
if it is “well-supported by medically acceptable clinical and laboratory diagnostic techniques and
is not inconsistent with the other substantial evidence in [the] case record.” 20 C.F.R.
§ 404.1527(c)(2). If the ALJ determines that the treating physician’s opinion is not entitled to
9
controlling weight, the ALJ must provide “good reasons” for the weight that is assigned to the
opinion. Id.
The opinion of Dr. Meyer is contained in a letter from November 14, 2011, which states
in part:
[Plaintiff] suffers from severe chronic pain related to degenerative disease of her
cervical and thoracic spine. In addition, she is showing neurological signs related
to her cervical spine disease including hand weakness and numbness. It is my
opinion that [Plaintiff] should be considered disabled related to this condition and
that she should receive social security disability benefits as such.
AR 434. Despite this opinion, the Court emphasizes that the “ultimate determination of disability
is a matter reserved to the Commissioner.” Gaskin v. Comm’r of Soc. Sec., 280 F. App’x 472,
475 (6th Cir. 2008). It is therefore the Commissioner’s role to make a determination as to
whether a claimant is able to work despite any functional limitations stemming from an alleged
medical condition. See Coldiron v. Comm’r of Soc. Sec., 391 F. App’x 435, 439 (6th Cir. 2010)
(“The Social Security Act instructs that the ALJ-not a physician-ultimately determines a
claimant’s RFC.”) (citing 42 U.S.C. § 432(d)(5)(B)). Dr. Meyer’s opinion that Plaintiff is
disabled thus has little bearing on the ALJ’s analysis. See Christman v. Sec’y of Health & Human
Servs., 9 F.3d 106 (6th Cir. 1993) (“The regulations indicate that ‘a statement by your physician
that you are disabled or unable to work does not mean that we will determine that you are
disabled. [The Commissioner has] to review the medical findings and other evidence that support
a physician’s statement that you are disabled.’”) (internal citation omitted) (emphasis in
original).
Here, the ALJ reviewed the record and determined that Dr. Meyer’s opinion was not
consistent with the medical evidence contained therein. The ALJ specifically noted that
Dr. Meyer’s opinion regarding disability appeared to be inconsistent with his own office notes,
10
including his assertion that Plaintiff was demonstrating weakness and numbness in her hands
even though he had not actually examined her hands at any point. AR 29. The ALJ also noted
that Plaintiff was “consistently found [to be] neurologically intact” (AR 29), which contradicts
Dr. Meyer’s claim that Plaintiff was “showing neurological signs.” AR 434.
Dr. Meyer correctly notes that Plaintiff has been diagnosed with degenerative disc
disease, a finding that is supported by imaging studies from February of 2009. AR 378-79.
However, Dr. Meyer provides no opinion as to any functional limitations allegedly caused by
Plaintiff’s condition, instead offering a conclusory opinion that Plaintiff “should be considered
disabled” (AR 434), a statement that offers no insight regarding the severity of the condition. See
Carney v. Colvin, No. 3:12-cv-0744, 2015 WL 5089783, at *8 (M.D. Tenn. Aug. 17, 2015)
(affirming ALJ’s decision to discount the opinion of a physician who provided only “a
conclusory assertion that [the claimant] was unable to work” but “fail[ed] to give specifics as to
what actual limitations were imposed on [the claimant’s] functional ability”). In fact,
Dr. Meyer’s letter does not appear to represent a “medical opinion” under the relevant
regulation:
Medical opinions are statements from physicians and psychologists or other
acceptable medical sources that reflect judgments about the nature and severity of
your impairment(s), including your symptoms, diagnosis and prognosis, what you
can still do despite impairment(s), and your physical or mental restrictions.
20 C.F.R. § 404.1527(a)(2) (emphasis added).
It is undisputed that the MRI findings from February of 2009 reveal moderate central
canal stenosis and moderate to severe foraminal stenosis at the T1-2 level, as well as “mild
central canal and foraminal stenosis otherwise.” AR 379. However, “disability is determined by
the functional limitations imposed by a condition, not the mere diagnosis of it.” Hill v. Comm’r
of Soc. Sec., 560 F. App’x 547, 551 (6th Cir. 2014) (internal citation omitted). Dr. Meyer’s letter
11
offers no opinion as to the functional limitations caused by Plaintiff’s condition, thereby
diminishing any value the letter may have lent to the ALJ’s analysis. See Coldiron, 391 F. App’x
at 441 (“[T]he ALJ is not bound by conclusory statements of doctors[.]”).
As previously discussed, the ALJ discounted Dr. Meyer’s opinion based on its
inconsistency with office notes that failed to document any neurological symptoms relating to
Plaintiff’s hands, as well as the lack of consistent clinical findings other than tenderness of
Plaintiff’s thoracic spine. AR 28-29. Indeed, Plaintiff demonstrated a full range of motion,
normal stability, and normal strength in her upper extremities approximately one year after the
MRI. AR 362-63. Plaintiff similarly exhibited no symptoms in her upper and lower extremities
on February 22, 2010. AR 358-59. A physical examination in July of 2011 revealed a normal
gait and station, and no neurological findings. AR 409-10.
Moreover, as discussed by Defendant, the MRI on which Plaintiff relies as support for
Dr. Meyer’s opinion took place more than four months prior to the alleged onset of disability
date. This fact does not by itself render the MRI findings immaterial, 4 and there is no indication
that the ALJ dismissed the MRI on such grounds. 5 However, it is significant that the record
contains additional evidence indicating that Plaintiff continued to demonstrate no functional or
neurologic deficiencies well after the February 2009 MRI. Her muscle strength and tone were
normal on July 21, 2009, with no evidence of numbness. AR 289. On September 28, 2009,
Plaintiff denied back pain and showed normal strength, with no indication of upper extremity
4
See DeBoard v. Comm’r of Soc. Sec., 211 F. App’x 411, 414 (6th Cir. 2006) (“We do not
endorse the position that all evidence or medical records predating the alleged date of the onset of
disability, or evidence submitted in support of an earlier proceeding, are necessarily irrelevant[.]”).
5
The ALJ specifically discussed both the MRI findings and Dr. Meyer’s reliance on these
findings. AR 22-23.
12
weakness or significant decrease in her range of motion. AR 281-82. On December 23, 2009,
Plaintiff reported that she “rarely or never [has] pain” (AR 273), and demonstrated normal
muscle strength with no neurologic findings. AR 271. On February 2, 2010, exactly one year
after the MRI, Plaintiff demonstrated a full range of motion in her elbows and wrist, normal
handgrip, normal fine finger movement, normal finger extension, and normal motor strength in
both the upper and lower extremities. AR 303.
Finally, the Court notes that in November of 2009, Plaintiff reported that her application
for unemployment benefits had been denied. AR 247. The filing of an application for
unemployment benefits further undermines Plaintiff’s claim that her condition was disabling as
of June 15, 2009, because,
[a]pplications for unemployment and disability benefits are inherently
inconsistent ... There is no reasonable explanation for how a person can claim
disability benefits under the guise of being unable to work, and yet file an
application for unemployment benefits claiming that [she] is ready and willing to
work.
Workman v. Comm’r of Soc. Sec., 105 F. App’x 794, 801-02 (6th Cir. 2004) (internal citation
and quotations omitted); see also Villarreal v. Comm’r of Soc. Sec., No. 2:13-cv-15197, 2014
WL 6750327, at *7 (E.D. Mich. Nov. 30, 2014) (“[The claimant] applied for both jobs and
unemployment benefits after his alleged onset date—representing that he was ready, willing, and
able to work—which is obviously not consistent with his allegations of disabling pain.”).
Although the precise date of Plaintiff’s application for unemployment benefits is unknown, the
record indicates that Plaintiff continued to present herself as “ready and willing to work” through
November of 2009, but was “unable to find a job due to losing her nursing license.” AR 246. A
note from September of 2009 indicates that Plaintiff “[h]ad a blast” working in the kitchen at the
VA, and “[w]ould like a dif[ferent] job,” but was concerned with finding a job that would “match
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her pay grade.” AR 395. Such evidence detracts from Plaintiff’s credibility, as discussed in detail
below, and suggests that Plaintiff’s condition was not disabling as late as November of 2009,
approximately nine months after the MRI findings were produced, and nearly five months after
the alleged onset date.
Based on the foregoing, the Court finds that there is substantial evidence to support the
ALJ’s decision to discount Dr. Meyer’s November 14, 2011 letter. The ALJ discussed the
specific inconsistencies in Dr. Meyer’s own clinical findings that undermined his opinion
regarding Plaintiff’s allegedly disabling condition (AR 24, 28-29), thereby providing “good
reasons” for discounting the opinion in accordance with 20 C.F.R. § 404.1527(c)(2). Dr. Meyer’s
letter fails to discuss any functional limitations allegedly caused by Plaintiff’s condition, and
numerous records indicate that Plaintiff did not suffer any functional or neurological deficits
despite the degenerative disc disease and accompanying stenosis revealed in the MRI from
February of 2009. The Court therefore rejects this assertion of error.
2. The opinion of Plaintiff’s mental health providers.
Plaintiff next accuses the ALJ of misrepresenting the evidence of record to reject the
opinions of mental health providers at the Mental Health Cooperative (“MHC”) and Centerstone.
DE 14-1 at 16, 20. Plaintiff specifically claims that the ALJ “failed to note the definitions of
[the] ‘moderate’ and ‘marked’ limitations” that she was assigned in a clinically related group
form (“CRG”) completed by Kelly Zachary on November 9, 2009. Id. at 19; AR 243-45.
Plaintiff also cites SSR 06-03p 6 to support her assertion that the ALJ provided insufficient
reasons for rejecting the assessment contained in this CRG. DE 14-1 at 18.
6
SSR 06-03p has been rescinded effective March 27, 2017. Because Plaintiff’s complaint was
filed in June of 2013, however, the Court applies SSR 06-03p to the instant analysis.
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Plaintiff’s assertions are unavailing for numerous reasons. The most glaring error in
Plaintiff’s argument is her contention that the ALJ “simply did not provide the required ‘good
reasons’ for discounting the treating source opinion, and a review of the decision shows that his
analysis failed to comport with the requirements of SSR 06-[0]3p.” DE 14-1 at 20. Plaintiff
references her “treating providers at Centerstone” (id.), but she fails to identify any actual
treating provider at Centerstone. 7 Her entire argument instead focuses on an initial assessment in
the form of a clinically related group evaluation (“CRG”), which was completed by Kelly
Zachary, an admissions coordinator at Mental Health Cooperative (“MHC”), on November 9,
2009. AR 243-45. However, Ms. Zachary does not represent an “acceptable medical source,” a
fact conceded by Plaintiff elsewhere in her brief, and Ms. Zachary’s opinion is therefore not
subject to the “treating physician rule” contained in 20 C.F.R. § 404.1527(c)(2), which requires
that the ALJ provide “good reasons” for declining to give controlling weight to a treating
provider’s opinion. Even if Ms. Zachary did represent an “acceptable medical source” for
purposes of 20 C.F.R. § 404.1527(c)(2), her sole interaction with Plaintiff consisted of an “intake
assessment” on November 9, 2009 following Plaintiff’s admission to MHC after reporting that
she had experienced a suicidal ideation. AR 262. This falls well short of establishing a treating
relationship that would be subject to the treating physician rule. Cf. Kornecky v. Comm’r of Soc.
Sec., 167 F. App’x 496, 506 (6th Cir. 2006) (“[A] single visit does not constitute an ongoing
treatment relationship.”). Plaintiff’s reliance on the treating physician rule is therefore meritless.
7
The ALJ also refers to “Centerstone records” in the opinion (AR 29), although the records he
references are identified as “medical records from The Estuary, Inc.” AR 393-404. It is unclear to the
undersigned whether “Centerstone” and “The Estuary” are in fact the same mental health organization.
Regardless, Plaintiff fails to identify any treating provider from either “Centerstone” or “The Estuary.”
15
Plaintiff’s reliance on SSR 06-03p is similarly misguided. Plaintiff alleges that the ALJ
violated SSR 06-03p by failing to “provide sufficient rationale for rejecting” the CRG. DE 14-1
at 18. To the contrary, the ALJ specifically discussed how the CRG was “situational” and based
on a brief admission to MHC and not a treating relationship, which is precisely one of the factors
that must be considered. See SSR 06-03p, 2006 WL 2329939, *2 (Aug. 9, 2006) (requiring the
Commissioner to consider the “treatment relationship between the individual and a treating
source, including its length, nature, and extent as well as frequency of examination”). The ALJ
also noted that Ms. Zachary was not an acceptable medical source, an additional factor for
consideration under SSR 06-03p. See id. (requiring the ALJ to consider the “examining
relationship between the individual and the ‘acceptable medical source’”).
The ALJ further noted that the Global Assessment of Functioning score (“GAF”) of 45
contained in the CRG did not represent an assessment of Plaintiff’s mental status, but was
instead used to “track the clinical progress of an individual in global terms.” AR 26 (citing DSMIV). This is especially significant in the instant case as it appears that Plaintiff was discharged
from MHC the day after she was admitted (AR 260), and did not show up for a scheduled
follow-up appointment four days later. AR 266. Furthermore, as noted by Defendant, Plaintiff
was assigned a GAF score of 61 by an acceptable medical source approximately two months
later. AR 296, 300. 8 It was therefore not improper for the ALJ to accord “little weight” to the
GAF score based on the brevity of the treatment at MHC, as well as the fact that the score was
not assigned by an acceptable medical source. The Court also notes that even if the score had
been assigned by an acceptable source, the Commissioner “has declined to endorse the [GAF]
8
A GAF score of 61 “indicates only ‘some mild symptoms.’” Martin v. Comm’r, Soc. Sec.
Admin., 61 F. App’x 191, 196 (6th Cir. 2003) (citing the American Psychiatric Association’s Diagnostic
and Statistical Manual of Mental Disorders).
16
score for use in the Social Security and SSI disability programs[.]” Kennedy v. Astrue, 247 F.
App’x 761, 766 (6th Cir. 2007) (internal citations omitted); see also Kornecky, 167 F. App’x at
511 (“[W]e are not aware of any statutory, regulatory, or other authority requiring the ALJ to put
stock in a GAF score in the first place.”).
Plaintiff’s additional argument regarding the ALJ’s alleged failure to “note the definitions
of [] ‘moderate’ and ‘marked’ limitations’” in the CRG is also unpersuasive. Plaintiff appears to
argue that the ALJ committed reversible error by failing to explain in the opinion that the
definitions of “moderate” and “marked” in the CRG are different from those “customarily used
in Social Security disability evaluations.” DE 14-1 at 20. It is not the ALJ’s responsibility,
however, to explain this distinction; the ALJ’s duty instead involves weighing the evidence,
making independent findings of fact, and determining whether a claimant is entitled to benefits
under the Act. Blair v. Comm’r of Soc. Sec., No. 98-3581, 1999 WL 196497, *2 (6th Cir.
March 26, 1999) (citing Richardson v. Perales, 402 U.S. 389, 399-400 (1971)). The ALJ
fulfilled this duty by providing a detailed discussion of Plaintiff’s admission to MHC and
analysis of the GAF score contained in the CRG. AR 25-27. He specifically discussed the
numeric rankings included in the CRG, and explained how the evidence of record did not support
the GAF score assigned by Ms. Zachary. 9 There is no indication that the ALJ misinterpreted the
“functional assessment” section of the CRG, as Plaintiff suggests.
9
As discussed supra, the ALJ also correctly noted that Ms. Kelly did not represent an “acceptable
medical source” (AR 26), thus rendering her opinion incapable of establishing the existence of an
impairment under the very ruling Plaintiff cites in support of her argument. See SSR 06-03p, 2006 WL
2329939, *2 (Aug. 9, 2006) (“Information from these ‘other sources’ cannot establish the existence of a
medically determinable impairment. Instead, there must be evidence from an ‘acceptable medical source’
for this purpose.”)
17
Plaintiff finally contends that the ALJ’s decision “cannot stand” because the ALJ “failed
to even acknowledge that [Plaintiff] was diagnosed with Major Depressive Disorder[.]” DE 14-1
at 20. It escapes Plaintiff’s attention that the ALJ in fact determined that her major depressive
disorder represented a severe impairment. AR 19. This claim, too, is therefore erroneous. This
assertion of error is accordingly rejected.
3. Plaintiff’s credibility.
Plaintiff argues that the ALJ’s reliance on MRI findings documenting Plaintiff’s back
condition to discredit her testimony is misrepresentation of the record. DE 14-1 at 21-22.
Plaintiff additionally claims that the ALJ improperly discounted her credibility based on a
mischaracterization of emergency room records that showed significant neck pain in September
of 2009. Id. at 22. Plaintiff finally contends that the ALJ improperly “attempted to show, or at
least imply, that Plaintiff pursued disability based on her financial needs more than her
functional status.” Id. at 23.
Plaintiff cites SSR 96-7p, which states in part that an ALJ’s credibility determination
must include “specific reasons” that are “sufficiently specific to make clear to the individual and
to any subsequent reviewers the weight the adjudicator gave to the individual's statements and
the reasons for that weight.” 1996 WL 374186, *4 (July 2, 1996). 10 “[B]lanket assertions that the
claimant is not believable will not pass muster, nor will explanations as to credibility which are
not consistent with the entire record and the weight of the relevant evidence.” Rogers v. Comm’r
of Soc. Sec., 486 F.3d at 248. However, the ALJ’s credibility determination is “entitled to
10
SSR 96-7p has been superseded by SSR 16-3p, which became effective on March 28, 2016.
However, because Plaintiff’s complaint was filed in June of 2013, SSR 96-7p applies to the Court’s
analysis of this claim.
18
deference, because of the ALJ’s unique opportunity to observe the claimant and judge her
subjective complaints.” Buxton v. Halter, 246 F.3d 762, 773 (6th Cir. 2001).
Plaintiff’s contention that the ALJ improperly “minimize[d] the severity of Plaintiff’s
spinal impairments” by failing to include all of the findings from the February 2009 MRI
(DE 14-1 at 22) is a red herring. The ALJ clearly identified and discussed all of the findings from
the MRI in his opinion, including “moderate central and moderate to severe bilateral foraminal
stenosis” at the T1-2 level. See AR 22, 379. The fact that the ALJ quoted some, but not all, of the
findings from the MRI later in the opinion does not prove that the ALJ used insidious
machinations to discredit Plaintiff’s testimony.
Additionally, Plaintiff’s argument ignores the crux of the ALJ’s discussion, which
emphasizes that Plaintiff received conservative care from her providers and presented with mild
clinical symptoms throughout the course of her treatment with Dr. Meyer despite the MRI
findings:
Even though Dr. [Paul] McCombs reviewed these results and indicated they were
positive for stenosis at T1-2, treatment only included some Celebrex and
telephonic follow-up care. Additionally, the claimant did not respond to telephone
messages. There is also no evidence that suggested the claimant required
additional surgery, as she continually alluded to throughout the evidence. Even
examinations by treating physician, Dr. Meyer were impressive only for their lack
of clinical findings.
AR 29. Plaintiff fails to address any of these reasons in her brief, which leads the Court to the
conclusion that Plaintiff has conceded the merits of the ALJ’s analysis.
Plaintiff also claims that the ALJ “misrepresented” her emergency room visit in
September of 2009 by stating that Plaintiff presented with “complaints of chronic neck pain,
which [was] noted to be mild.” AR 22. The Court emphasizes, however, the following excerpt
from the note documenting this visit:
19
No complaints of significant back pain. Denies symptoms of radicular numbness
in lower extremities. No history to suggest radiating pain to legs. Nothing to
suggest significant weakness of lower extremities. Nothing in history to suggest
cervical spasm/torticollis. No history of upper extremity weakness or paralysis.
The patient presents with a history of mild neck pain.
AR 281 (emphasis added). Plaintiff’s discharge instructions included an assessment that her neck
pain was “most likely caused by a strain of the muscles,” which was described as “a very
common injury.” AR 284. It is unclear how the ALJ’s description of mild neck pain represents a
mischaracterization of the record. In fact, the ALJ’s statements about the extent of Plaintiff’s
next pain during the September 2009 emergency room visit are entirely consistent with the
record.
Plaintiff finally claims that the ALJ discounted her credibility by insinuating that she had
pursued disability benefits due to financial needs and not “functional status.” DE 14-1 at 23. It is
true that the ALJ referenced notes in the record suggesting that Plaintiff’s pain was not as severe
as she alleged during her hearing, and that Plaintiff suffered from a “lack of employment due to
reasons other than disability.” AR 29-30. Indeed, Plaintiff indicated to a mental health provider
in November of 2009, several months after her alleged onset date, that her back pain was
“intermittent.” AR 394. The provider also noted that physical therapy was “recommended
repeatedly” to Plaintiff, but added that “there was nothing to suggest that [Plaintiff] had pursued
this with her doctors.” AR 394. The provider even opined that “[i]n general I do not believe
[Plaintiff] was proactive about her health[.]” AR 394. The ALJ also noted that Plaintiff advised
the provider in September of 2009, more than three months after her alleged onset, that she
would prefer to find a new job that “match[ed] her pay grade.” AR 395.
Plaintiff cites no statute, ruling, or opinion demonstrating that the ALJ’s consideration of
these records was inappropriate. Quite the opposite, it was the ALJ’s duty to consider such
20
evidence. See 20 C.F.R. § 404.1529(c)(3) (stating that when evaluating the intensity and
persistence of a claimant’s symptoms, the Commissioner “will consider all of the evidence
presented, including information about [the claimant’s] prior work record[.]”).
Plaintiff’s argument fails to address the abundance of additional evidence cited by the
ALJ in support of his credibility determination, including equivocal testimony regarding the
termination of her job for stealing prescription medication, drug-seeking behavior, 11 filing an
application for unemployment benefits, 12 and a lack of clinical findings suggesting any
functional limitations. AR 29-30. The Sixth Circuit has stated that “[w]hen a credibility
determination regarding a claimant’s subjective complaint is at issue, we affirm if the ALJ’s
determination is ‘reasonable and supported by substantial evidence.’” Hernandez v. Comm’r of
Soc. Sec., 644 F. App’x 468, 476 (6th Cir. 2016) (quoting Rogers, 486 F.3d at 249). The ALJ
provided such substantial evidence in the instant case. The Court therefore finds no error in the
credibility determination.
11
On April 20, 2011, Dr. Meyer noted that Plaintiff “has filled the opioids at more than one
pharmacy” and “has been filling the opioids prescriptions earlier than every 30 days ... She must use one
pharmacy ... If she uses more than one pharmacy or tries to refill the opioids early I will stop prescribing
them for her.” AR 412. The ALJ properly relied on such evidence to discount Plaintiff’s credibility. See
Jackson v. Comm’r of Soc. Sec., No. 1:14-cv-628, 2015 WL 4611472, at *7 (W.D. Mich. July 31, 2015)
(“With respect to plaintiff’s drug seeking behavior, courts have held that such behavior can form a basis
for rejecting a claimant's testimony regarding pain and limitations.”) (internal citations omitted).
12
See Siler v. Astrue, No. 11-391, 2012 WL 2603656, at *13 (E.D. Ky. July 5, 2012) (“When a
claimant files for unemployment, [she] is stating that [she] is ready, willing and able to work ... Yet, when
a claimant files for disability benefits, [she] is stating that he is unable to work ... Thus, it was reasonable
for the ALJ to consider Plaintiff’s inconsistent representations to the government in assessing [her]
credibility.”) (internal citations omitted).
21
V. CONCLUSION
For all of these reasons, Plaintiff’s motion for judgment on the administrative record
(DE 14) is DENIED. An appropriate Order will accompany this memorandum.
__________________________
BARBARA D. HOLMES
United States Magistrate Judge
22
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