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Mason v. Commissioner of Social Security

United States District Court, W.D. Michigan, Southern Division

September 21, 2017

JODY A. MASON, Plaintiff,


          RAY KENT United States Magistrate Judge

         Plaintiff brings this action pursuant to 42 U.S.C. § 405(g), seeking judicial review of a final decision of the Commissioner of the Social Security Administration (Commissioner) denying her claim for disability insurance benefits (DIB).

         Plaintiff alleged a disability onset date of January 20, 2013. PageID.200. Plaintiff identified her disabling conditions as: bipolar with psychosis; degenerative disc disease; schizoaffective disorder bipolar type; complex regional pain syndrome; osteoarthritis; and panic attacks. PageID.203. Prior to filing her application for DIB, plaintiff completed two years of college and canine grooming school, and had past employment as a veterinary assistant, dog groomer and receptionist. PageID.78-81, 204. The administrative law judge (ALJ) reviewed plaintiff's claim de novo and entered a written decision denying benefits on April 17, 2015. PageID.52-66. This decision, which was later approved by the Appeals Council, has become the final decision of the Commissioner and is now before the Court for review.


         This Court's review of the Commissioner's decision is typically focused on determining whether the Commissioner's findings are supported by substantial evidence. 42 U.S.C. §405(g); McKnight v. Sullivan, 927 F.2d 241 (6th Cir. 1990). “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. Secretary of Health & Human Services, 25 F.3d 284, 286 (6th Cir. 1994). A determination of substantiality of the evidence must be based upon the record taken as a whole. Young v. Secretary of Health & Human Services, 925 F.2d 146 (6th Cir. 1990).

         The scope of this review is limited to an examination of the record only. This Court does not review the evidence de novo, make credibility determinations or weigh the evidence. Brainard v. Secretary of Health & Human Services, 889 F.2d 679, 681 (6th Cir. 1989). The fact that the record also contains evidence which would have supported a different conclusion does not undermine the Commissioner's decision so long as there is substantial support for that decision in the record. Willbanks v. Secretary of Health & Human Services, 847 F.2d 301, 303 (6th Cir. 1988). Even if the reviewing court would resolve the dispute differently, the Commissioner's decision must stand if it is supported by substantial evidence. Young, 925 F.2d at 147.

         A claimant must prove that he suffers from a disability in order to be entitled to benefits. A disability is established by showing that the claimant cannot engage in 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. See 20 C.F.R. § 404.1505; Abbott v. Sullivan, 905 F.2d 918, 923 (6th Cir. 1990). In applying the above standard, the Commissioner has developed a five-step analysis:

The Social Security Act requires the Secretary to follow a “five-step sequential process” for claims of disability. First, plaintiff must demonstrate that she is not currently engaged in “substantial gainful activity” at the time she seeks disability benefits. Second, plaintiff must show that she suffers from a “severe impairment” in order to warrant a finding of disability. A “severe impairment” is one which “significantly limits . . . physical or mental ability to do basic work activities.” Third, if plaintiff is not performing substantial gainful activity, has a severe impairment that is expected to last for at least twelve months, and the impairment meets a listed impairment, plaintiff is presumed to be disabled regardless of age, education or work experience. Fourth, if the plaintiff's impairment does not prevent her from doing her past relevant work, plaintiff is not disabled. For the fifth and final step, even if the plaintiff's impairment does prevent her from doing her past relevant work, if other work exists in the national economy that plaintiff can perform, plaintiff is not disabled.

Heston v. Commissioner of Social Security, 245 F.3d 528, 534 (6th Cir. 2001) (citations omitted).

         The claimant bears the burden of proving the existence and severity of limitations caused by her impairments and the fact that she is precluded from performing her past relevant work through step four. Jones v. Commissioner of Social Security, 336 F.3d 469, 474 (6th Cir. 2003). However, at step five of the inquiry, “the burden shifts to the Commissioner to identify a significant number of jobs in the economy that accommodate the claimant's residual functional capacity (determined at step four) and vocational profile.” Id. If it is determined that a claimant is or is not disabled at any point in the evaluation process, further review is not necessary. Mullis v. Bowen, 861 F.2d 991, 993 (6th Cir. 1988).


         Plaintiff's claim failed at the fifth step of the evaluation. At the first step, the ALJ found that plaintiff did not engage in substantial gainful activity during the relevant time period, which is from January 20, 2013 (her alleged onset date) through June 30, 2014 (her date last insured). PageID.54. At the second step, the ALJ found that through the date last insured, plaintiff had severe impairments of: obesity; complex regional pain syndrome of the right lower extremity; status post lumbar laminectomy; sciatica; lumbar radicular syndrome of the right lower extremity; degenerative disc disease of the lumbar spine; schizoaffective disorder; anxiety disorder, not otherwise specified; posttraumatic stress disorder (PTSD); and cannabis abuse in early remission. PageID.54. At the third step, the ALJ found that, through the date last insured, plaintiff did not have an impairment or combination of impairments that met or equaled the requirements of the Listing of Impairments in 20 C.F.R. Pt. 404, Subpt. P, App. 1. PageID.55.

         The ALJ decided at the fourth step that, “through the date last insured, the claimant had the residual functional capacity to perform sedentary work as defined in 20 CFR 404.1567(a) except she is limited to simple work and may not perform any fast paced work.” PageID.56. The ALJ also found that plaintiff was unable to perform any past relevant work. PageID.64.

         At the fifth step, the ALJ determined that through the date last insured, plaintiff could perform a significant number of unskilled, sedentary exertional jobs in the national economy. PageID.64-65. Specifically, the ALJ found that plaintiff could perform the following unskilled work in the region (defined as the State of Michigan): bench assembler (4, 900 jobs); inserter (3, 600 jobs); and sorter (5, 000 jobs). PageID.65. Accordingly, the ALJ determined that plaintiff has not been under a disability, as defined in the Social Security Act, from January 10, 2013 (the alleged onset date) through June 30, 2014 (the date last insured). PageID.65-66.


         Plaintiff has raised two issues on appeal related to her mental limitations[1]:

A. The ALJ failed to properly evaluate the medical opinion evidence and to properly determine plaintiff's mental RFC.
1. Dr. Thebert's opinions

         Plaintiff contends that the ALJ erred by giving only limited weight to the opinions of her treating psychiatrist, Michael Thebert, M.D. A treating physician's medical opinions and diagnoses are entitled to great weight in evaluating plaintiff's alleged disability. Buxton v. Halter, 246 F.3d 762, 773 (6th Cir. 2001). “In general, the opinions of treating physicians are accorded greater weight than those of physicians who examine claimants only once.” Walters v. Commissioner of Social Security, 127 F.3d 525, 529-30 (6th Cir. 1997). “The treating physician doctrine is based on the assumption that a medical professional who has dealt with a claimant and his maladies over a long period of time will have a deeper insight into the medical condition of the claimant than will a person who has examined a claimant but once, or who has only seen the claimant's medical records.” Barker v. Shalala, 40 F.3d 789, 794 (6th Cir. 1994). Under the regulations, a treating source's opinion on the nature and severity of a claimant's impairment must be given controlling weight if the Commissioner finds that: (1) the opinion is well-supported by medically acceptable clinical and laboratory diagnostic techniques; and (2) the opinion is not inconsistent with the other substantial evidence in the case record. See Gayheart v. Commissioner of Social Security, 710 F.3d 365, 375 (6th Cir. 2013); 20 C.F.R. § 404.1527(c)(2). Finally, the ALJ must articulate good reasons for not crediting the opinion of a treating source. See Wilson v. Commissioner of Social Security, 378 F.3d 541, 545 (6th Cir. 2004); 20 C.F.R. § 404.1527(c)(2) (“[w]e will always give good reasons in our notice of determination or decision for the weight we give your treating source's opinion”).

         Here, the ALJ evaluated three opinions given by Dr. Thebert. The ALJ gave limited weight to the doctor's opinions expressed in an April 29, 2014 questionnaire (PageID.763-770):

[T]he undersigned has considered the April 2014 psychiatric assessment from Dr. Thebert who assessed the claimant with numerous marked limitations in the areas of her ability to sustain concentration and persistence, in her ability to interact socially and adaptation incapable of even low stress work, psychosis restricts any work and [sic] would miss more than three times a month (Exhibit 8F). However, he found her only moderately limited in her ability to understand, remember and carry out one or two step instructions; interact appropriately with the general public, ask simple questions or request assistance; feels reasonable [sic] well when not in a stressful environment (Exhibit 8/F). In deciding whether or not to adopt the treating source's opinion in this situation, the following factors are to be considered along with any other appropriate factors: the examining relationship, the treatment relationship in terms of its frequency and duration, supportability, consistency, and specialization. Particular attention is to be given to the consistency of the opinion with other evidence, the qualifications of the source, and the degree to which the source offers supporting explanations for the opinion (20 CFR 404.1527(d) & (f) and Social Security Ruling 96-2p).
The assessment of Dr. Thebert with numerous marked limitations is afforded limited weight as it is inconsistent with the claimant's treatment and outpatient therapy notes, which showed the claimant had improvement in her symptoms with her prescribed medication regimen and outpatient counseling. Her mental status exams were relatively normal with only occasional mood fluctuations and her intermittent increase in symptoms were noted to be possibly associated with her pain symptomatology (Exhibit 3F/66, 73). Moreover, the undersigned notes that the GAF rating is only a subjective estimate by a clinician, however Dr. Thebert assigned a GAF rating of 55 consistently throughout his records, Exhibit 3F/10, 16, 23, 30, 36, 42, 55, 62, 69, 76, 82, 88, 94; 6F/28, 55; 7F/109, 120, 130, 131; 55; 10F/11, 22, 33, 44; 13F/10, 21, 32; 15F/54), which is inconsistent with his statement of disability and is more consistent with the signs and findings upon examination in the record. Furthermore, the record ...

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