United States District Court, E.D. Michigan, Southern Division
OPINION & ORDER
SEAN F. COX, District Judge.
Plaintiff Thomas Dewey ("Plaintiff") brings this action pursuant to 42 U.S.C. § 405(g) challenging the final decision of Defendant Commissioner of Social Security ("the Commissioner") denying his applications for Social Security Disability benefits and Supplemental Security Income benefits. Both parties filed motions for summary judgment, which are presently before this Court. As explained below, this Court concludes that the Administrative Law Judge failed to properly evaluate the medical opinion evidence from Plaintiff's treating psychiatrist and failed to properly evaluate and explain her credibility assessment of Plaintiff. This Court shall therefore enter judgment in favor of Plaintiff, REVERSING the Commissioner's decision and REMANDING this case to the Social Security Administration for further administrative proceedings, pursuant to the fourth sentence of 42 U.S.C. § 405(g). As such, the Court shall GRANT IN PART Plaintiff's Motion for Summary Judgment and shall DENY the Commissioner's Motion for Summary Judgment.
A. Procedural History
Plaintiff filed concurrent applications for Social Security Disability benefits ("SSD") and Supplemental Security Income benefits ("SSI") on January 28, 2010, alleging disability since March 23, 2009. Plaintiff's claims were denied at the initial administrative stages. Plaintiff appealed and requested a de novo hearing before an administrative law judge ("ALJ").
That hearing was held before ALJ JoErin O'Leary on December 21, 2011. Plaintiff, who was represented by counsel, appeared and testified at that hearing. In a written decision issued on January 25, 2012, ALJ O'Leary concluded that Plaintiff "has not been under a disability within the meaning of the Social Security Act from March 23, 2009, through the date of" the decision.
Plaintiff requested review of the ALJ's decision by the Appeals Council. The Appeals Council denied review, rendering the ALJ's adverse decision the Commissioner's final decision.
B. The Administrative Record
The administrative record is quite extensive. The Court includes here some of the evidence in the record that is relevant to the issues in this Opinion and Order.
Plaintiff testified that he began experiencing severe constant chest pain in 2009. At that time, he treated with Richard Hall, D.O., for that chest pain. Dr. Hall prescribed a variety of medications, but Plaintiff's symptoms continued.
On April 19, 2009, Plaintiff went to the emergency department at Caro Community Hospital, due to chest pain. (Tr. at 255). At that time, Plaintiff reported having sharp chest pains of moderate severity, that worsened with breathing or movement. A physical exam revealed muscle tenderness in the chest wall. (Tr. at 258). Plaintiff was diagnosed with atypical chest pain, costochondritis in the chest wall (an inflammation of the cartilage that connects the ribs to the breastbone) and marijuana abuse. (Tr. at 256). Plaintiff was treated with medications and was discharged.
But Plaintiff presented to the emergency department at Caro Community Hospital again on April 24, 2009, via ambulance, and was unconscious and unresponsive upon arrival. Plaintiff's friend reported that Plaintiff grabbed his chest and then passed out. (Tr. at 262).
During the next few months, Plaintiff underwent several tests. X-rays of his chest and a CT scan of Plaintiff's head were unremarkable. (Tr. at 491). Plaintiff had a cardiovascular workup which was normal. (Tr. at 521). Plaintiff had a cardiac catheterization that revealed that Plaintiff "has widely patent coronary arteries and normal left ventricular function" and has "normal renal arteries." (Tr. at 374). After reporting experiencing recurrent episodes of syncope, Plaintiff underwent a tilt-table test, which was negative. After those tests, Plaintiff's treaters diagnosed him with chest pain probably secondary to costochondritis. Plaintiff was given various medications for pain.
On December 14, 2009, Plaintiff went to the emergency room at Hills and Dales General Hospital, again complaining of chest pain. (Tr. at 362). With respect to the history of the present illness, the report stated, in pertinent part:
Ths is a 31-year old gentleman who always was reasonably healthy. He said he has been having pain in his chest, going on for several months, started actually last spring. He has had quite extensive work up, including stress tests, cardiac cath, echocardiogram, Holter monitor, and endoscopy and apparently none have found any abnormalities. He was told that his doctors were thinking it was "costochondritis." He said it is constant pain, right in the center of his chest and just never seems to go away, day or night. He occasionally gets nauseous, vomits once in a while.
(Tr. at 362). The report indicates that the physician sat down with Plaintiff and discussed the testing that had been performed thus far, which was quite extensive. The physician noted that the only thing he could see that had not been done was a CT scan looking for a mass or dissection and he therefore ordered a CT scan. ( Id. ). The report states:
CT scan was done and, unfortunately, the radiologist did in fact find some significant findings. There was an 8 mm right midlobe nodule and then a right hilar 2.8 cm mass. The radiologist said that the possibility of neoplastic process must be excluded.
So, I went over all this with the patient. He was at least happy that somebody finally found something, he said, because it was just getting frustrating for him, but he is motivated to follow up. He asked if I had anything else for pain, other than this Percocet which he is on, which he said didn't really help. We will put him on a Duragesic patch. That will get him through his appointment at least.
(Tr. at 363).
As to the masses in his chest, Plaintiff testified that a thoracic surgeon at the University of Michigan said it was too risky to biopsy or remove the masses. Plaintiff has scans done every six months to see if the masses are growing. (12/21/11 Hr. Tr. at 41; see also Tr. at 443, noting "there is no evidence of increased metabolic activity" with respect to the masses but recommending new scans of the chest in six months). Plaintiff testified that his family doctor, Dr. Hall, believes the masses in his chest are what is causing his chest pain but, to date, the doctors are not sure. ( Id. at 41-42).
After the masses were found, Plaintiff has continued to complaint of chest pain. He has also continued to report dizziness and passing out on various occasions. ( See, e.g., Tr. at 434 & 438). Plaintiff's treating physicians have continued to prescribe pain medications and medications for depression.
Plaintiff testified at the December 21, 2011 administrative hearing that he suffers from significant chest pain, fainting of an unknown cause, two masses in his chest that appear to be benign, hypertension, arthritis in the knees, lower back pain, and depression and anxiety. (12/21/11 Hrg. Tr. at 41-42).
Plaintiff testified that his symptoms include: passing out at various times, constant chest pain that feels like a tightness around his heart, dizziness, shortness of breath upon exertion, panic attacks at least twice per day, difficulty sleeping, problems with concentration and memory, fluctuating weight, knee pain and numbness, and nausea. ( Id. at 41-42, 47-48, 57-58, 63-64).
During the hearing, Plaintiff testified as to what a "typical day" is like for him:
Q. Okay. Can you give me an idea of your typical day?
A. Well, I usually get up roughly 7:00-7:30 when the boys, my boys wake up.
Q. Okay. How old are your kids?
A. My oldest one is four and my youngest one is almost 17 months.
A. I usually get up in the morning with the kids and with my wife. We usually have breakfast together with the kids. My oldest son, he is in preschool, so we usually do his homework or, you know, ...