United States District Court, W.D. Michigan, Southern Division
JODY A. MASON, Plaintiff,
COMMISSIONER OF SOCIAL SECURITY, Defendant.
KENT United States Magistrate Judge
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
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.
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).
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.
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
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
Heston v. Commissioner of Social Security, 245 F.3d
528, 534 (6th Cir. 2001) (citations omitted).
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).
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.
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.
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.
has raised two issues on appeal related to her mental
A. The ALJ failed to properly evaluate the
medical opinion evidence and to properly
determine plaintiff's mental RFC.
1. Dr. Thebert's opinions
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”).
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
[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 ...