Summary
noting that "'GAF scores have been deemed unreliable' by the Social Security Administration itself" (quoting Hall v. Colvin, 18 F. Supp. 3d 144, 153 (D.R.I. 2014))
Summary of this case from Bui v. BerryhillOpinion
Civil Action No. 13-30124-KPN
07-11-2014
ORLANDO RIOS MARTINEZ, Plaintiff v. CAROLYN W. COLVIN, Acting Commissioner of Social Security Administration, Defendant
MEMORANDUM AND ORDER REGARDING PLAINTIFF'S MOTION FOR JUDGMENT ON THE PLEADINGS and DEFENDANT'S MOTION FOR JUDGMENT AFFIRMING THE COMMISSIONER'S DECISION
(Document Nos. 12 and 14)
Orlando Rios Martinez ("Plaintiff") brings this action, pursuant to 42 U.S.C. § 405(g) of the Social Security Act, for judicial review of a final decision by the Commissioner of the Social Security Administration ("Commissioner") denying his application for Social Security Disability Insurance ("SSDI") and Supplemental Security Income ("SSI") benefits. Presently before the court is Plaintiff's motion for judgment on the pleadings and the Commissioner's motion to affirm the decision.
The parties have consented to this court's jurisdiction. See 28 U.S.C. § 636(c); FED. R. CIV. P. 73. For the following reasons, the court will allow Plaintiff's motion, to the extent it seeks a remand, and will deny the Commissioner's motion to affirm.
I. DISCUSSION
The parties are well aware of the factual and procedural history of this case, the standard of review, and the applicable five-step sequential analysis. Plaintiff argues that substantial evidence does not support the Administrative Law Judge ("ALJ")'s assessed residual functional capacity for two reasons. First, with regard to his physical impairments, Plaintiff argues that the ALJ erred in finding he was capable of performing heavy exertional work. Second, Plaintiff asserts that the ALJ failed to accord controlling weight to the opinions of his treating sources when assessing his mental impairments. While the court does not find Plaintiff's first argument persuasive, the second issue warrants remand.
A. Physical Impairments
Plaintiff argues that the ALJ's residual functional capacity assessment, which allowed for his doing heavy exertional work, was inconsistent with record evidence concerning his type 2 diabetes, back pain, and knee pain. In response, the Commissioner argues that the assessment was supported by substantial evidence. The Commissioner, in the court's view, has the better argument.
"The findings of the Commissioner of Social Security as to any fact, if supported by substantial evidence, shall be conclusive." 42 U.S.C. § 405(g). A reviewing court will uphold the Commissioner's findings "if a reasonable mind, reviewing the evidence in the record as a whole, could accept it as adequate to support [her] conclusion." Irlanda Ortiz v. Sec'y of Health & Human Servs., 955 F.2d 765, 769 (1st Cir. 1991) (quotation omitted). The Commissioner is responsible for determining issues of credibility, drawing inferences from the record, and resolving conflicts in the evidence. Id.
Here, the ALJ concluded that Plaintiff had the residual functional capacity to perform heavy exertional work with certain limitations, including "instructions consistent with performing work at the SVP1 and SVP2 level, no interaction with the general public . . . maintain[ing] concentration, persistence, and pace for two hour blocks of time over a normal eight hour workday and forty hour workweek, and . . . adjust[ing] to routine minor type changes at work." (Administrative Record ("A.R.") at 20.) In reaching this conclusion, the ALJ noted that Plaintiff claimed disability due to vision problems, high blood sugar, high blood pressure, back pain and knee pain, but explained that, although Plaintiff's "medically determinable impairments could reasonably be expected to cause the alleged symptoms," his "statements concerning the intensity, persistence, and limiting effects of these symptoms [were] not fully credible" as they were inconsistent with the objective record evidence. (A.R. at 20-21.)
As for Plaintiff's diabetes, the ALJ explained that treatment records indicated that this impairment did not cause end organ damage, functional limitation, edema, or significant complications. "In fact", the ALJ continued, Plaintiff's "most significant problem with regard to diabetes is that [he] has some trouble sticking with a diabetic diet and requires diabetes education." (A.R. at 21.) Still, the ALJ noted, Plaintiff had lost weight with counseling and continued to improve his condition, exercised on a stair machine for one hour at a time, and walked twenty minutes to one hour daily. Such activities, the ALJ opined, supported "the conclusion that [Plaintiff] is able to stand/walk for extended periods of time and that his diabetes has not progressed to the point that it limits him as he has alleged." (Id.)
As for Plaintiff's alleged vision problems, the ALJ relied on Dr. Kevin Hulseberg, who, after examining Plaintiff, determined that, although he needs reading glasses, he did not have retinopathy. Moreover, with respect to Plaintiff having pterygium, a "benign growth of the conjunctiva that is affected by sunlight," that "does not affect his vision." (A.R. at 21.)
As for Plaintiff's knee pain, the ALJ explained that (a) imaging of his right and left knees in March of 2011 was normal, (b) Plaintiff does not receive treatment for knee pain and, further, (c) treatment records documented significant physical activity on his part. And although the ALJ acknowledged that treatment records reflected some low back pain, (a) Plaintiff did not receive treatment for that pain, (b) imaging showed "minimal findings," and (c) he was able to exercise regularly.
In the court's view, the ALJ's decision was supported by substantial evidence. Accordingly, a remand on this issue is unnecessary. See Irlanda Ortiz, 955 F.2d at 770 (remand unnecessary when substantial evidence supports a decision even if "the record arguably could support a different conclusion").
B. Treating Source Opinions
Plaintiff next argues that the ALJ erred in according little weight to the opinions of his treating sources, Monika Faber, M.S., and Mary Colegeo, A.P.R.N., when assessing his residual functional capacity. In response, the Commissioner asserts that the ALJ appropriately discounted the opinions of Ms. Faber and Ms. Colageo, both non-"acceptable medical sources," because their opinions were not supported by their own treatment notes and were inconsistent with other record evidence. Plaintiff, in the court's opinion, has the better argument.
An administrative law judge must give controlling weight to the opinion of a "treating source" when that opinion is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is consistent with substantial evidence in the record. See 20 C.F.R. § 416.927(c)(2); 20 C.F.R. § 404.1527(c)(2). When an administrative law judge does not accord a treating source's opinion controlling weight, he or she must consider the length, nature and extent of the treatment relationship, the opinion's supportability and consistency with the record as a whole, the treating source's area of specialization, and any other relevant factors to determine the weight the opinion deserves. See 20 C.F.R. § 416.927(c)(2)-(6); 20 C.F.R. § 404.1527(c)(2)-(6). The administrative law judge must also provide "good reasons" for the weight ultimately assigned to the treating source opinion. See 20 C.F.R. § 416.927(c)(2); 20 C.F.R. § 404.1527(c)(2).
Plaintiff recognizes that Ms. Faber and Ms. Colegeo, respectively a therapist and a nurse practitioner, are not "acceptable medical sources" under the Commissioner's regulations and, therefore, their opinions are not accorded controlling weight. Social Security Ruling ("SSR") 06-03P, 2006 WL 2329939, at *2 (Aug. 9, 2006) ("[O]nly 'acceptable medical sources' can be considered treating sources, as defined in 20 CFR 404.1502 and 416.902, whose medical opinions may be entitled to controlling weight."). Still, Ms. Faber and Ms. Colegeo are both "other medical sources," whose opinions must be appropriately weighed. As this court has explained, an administrative law judge may not "ignore 'other medical sources' or fail to adequately explain the weight given to such evidence." Taylor v. Astrue, 899 F. Supp. 2d 83, 88 (D. Mass. 2012). "Thus, although 'other medical sources' are not entitled to controlling weight and an administrative law judge is not required to provide 'good reasons' for the weight assigned to such opinions nor consult the factors" in 20 C.F.R. § 416.927(c)(2)-(6); 20 C.F.R. § 404.1527(c)(2)-(6), "he or she still must adequately explain his treatment of the opinion so that a reviewer can determine if the decision is supported by substantial evidence." Taylor, 899 F. Supp. 2d at 88-89.
Here, the ALJ did not adequately explain why she assigned "little weight" to the opinions of Ms. Faber and Ms. Colegeo. To be sure, the ALJ stated generally that their conclusions were not supported by their own treatment records; for example, the ALJ discounted side effects of medication listed in their report because treatment records had noted no side effects. That is incorrect in at least one instance. (See A.R. at 343 ("Pills are making him sleepy.").)
The ALJ also stated that conclusions reached by Ms. Faber and Ms. Colegeo were "internally inconsistent" (A.R. at 17), but she provided only one supposed inconsistency, namely, their representation that Plaintiff had a Global Assessment of Functioning ("GAF") score of 55, "which is indicative of only moderate limitations." (A.R. at 18 (emphasis added).) However, "GAF scores have been deemed unreliable" by the Social Security Administration itself and, accordingly, it would be an error for an administrative law judge to focus on a doctor's assessed GAF scores, rather than the doctor's findings and opinions, to credit or discredit medical evidence. Hall v. Colvin, --- F. Supp. 2d ---, 2014 WL 1832184, at *8 (D. R.I. May 8, 2014). Simply put, an administrative law judge cannot draw a reliable inference from a single GAF score, standing alone. Id.
The GAF scale gauges an individual's psychological, social, and occupational functioning on a scale of 0 to 100. American Psychiatric Ass'n., Diagnostic and Statistical Manual of Mental Disorders 34 (4th ed. TR 2000). Scores of 51 to 60 indicate moderate symptoms or difficulty in functioning. Id.
Here, too, the ALJ relied exclusively on Plaintiff's GAF score to demonstrate the supposed inconsistencies in Ms. Faber and Ms. Colegeo's report, essentially ignoring their concerns regarding his hallucinations as well as his paranoid, suicidal and homicidal ideation. (A.R. at 476-79.) Given the limited insight a GAF score provides regarding a claimant's ability to function, this was error. See Hall, 2014 WL 1832184, at *8 ("[A] GAF score of 75 does not mean that a person is functioning 10 units better than a person with a score of 65, nor does a GAF of 40 indicate a person is functioning half as well as a person with a score of 80.") (quoting Social Security Administration Administrative Memorandum, AM-13066 (July 22, 2013)).
Moreover, the court cannot discern from the record whether Ms. Faber and Ms. Colegeo's reported GAF score of 55 is a clerical error. Their report listed Plaintiff's "Current" GAF as of July 19, 2012, to be 55 and his "Highest GAF Past Year" as 48. (A.R. at 476.) A review of Plaintiff's treatment records, however, reveals a single instance, in 2011 and 2012 of a GAF score of 55. (A.R. at 356 (February 9, 2011), 448 (February 13, 2012).) Thus, whether the "Past Year" refers to 2012 or 2011, the highest GAF score in either year was 55, not 48. In contrast, the treatment records themselves consistently reflect a GAF score of 48 over the course of both 2011 and 2012. (See A.R. at 343, 345, 347, 349, 351, 437, 440, 443, 453, 457, 461, 465, 468, 472.) If 48 is the more correct GAF score then, contrary to the ALJ's assertion, there was no inconsistency. GAF scores of 41 to 50 indicate serious symptoms or impairment in social, occupational, or school functioning. See American Psychiatric Ass'n., Diagnostic and Statistical Manual of Mental Disorders 34 (4th ed. TR 2000). --------
The ALJ also rejected as unsupported by the treatment records Ms. Faber and Ms. Colegeo's finding that Plaintiff would be absent from work more than four days per month due to her impairments. As an example, the ALJ noted that Ms. Faber and Ms. Colegeo found that Plaintiff's "paranoid ideation often causes him to lose his impulse control and that he experiences hallucinations." The ALJ found, however, that the "records generally document[ed] improvement in his condition with treatment" except when he failed to take medication. (A.R. at 23.) The ALJ further explained
While some treatment records note that the claimant was slightly disheveled, mood was very depressed and angry, affect was restricted, and his thoughts were circumferential, the claimant's cognition remained intact, his energy levels were good and activity variable. He was also described as pleasant, friends, neatly groomed, and cooperative. His affect was full and appropriate and speech within normal limits. His thoughts were well organized and goal directed and sensorium was clear. The claimant described his sleep and appetite as satisfactory and the claimant denied medication side effects.(Id. (citations to record omitted).) The court, however, has some difficulty following the ALJ's reasoning.
First, as to Plaintiff's paranoid ideation and hallucinations, the record provides ample support for Ms. Faber and Ms. Colegeo's conclusions. (See. A.R. at 347 ("Continues to hear people calling his name in daytime."), 351 ( Plaintiff "hears a voice commanding him" to kill a former coworker, hallucinates a man or woman standing by his bed, feels someone in his bed at times, attempted suicide in front of a police officer, stabbed himself in the leg and back and, on one occasion, when seeking treatment for suicidal ideation, told hospital personnel that he "might as well kill himself" after a patient in a waiting room upset him), 454 ("Still hearing voices, sometimes worse, sometimes better."), 462 ("Occ [sic] sound of a door slamming which he investigates and no one is there. . . . Door slamming is not frightening because he knows no one can get in but family members.") And with regard to the ALJ's discussion of Plaintiff's appearance and general mood, it is unclear to the court what bearing, if any, these observations have on Ms. Faber and Ms. Colegeo's conclusions regarding his paranoid, suicidal and homicidal ideation, seemingly the most relevant facts in his claim. (See. A.R. at 479.)
Given the discrepancies between the ALJ's reasons for discounting their opinions and the record, it is clear that she inadequately and inaccurately evaluated the opinions of Ms. Faber and Ms. Colegeo. Compare Simumba v. Colvin, 2014 WL 1032609, at *9 (D. Mass. Mar. 14, 2014) (administrative law judge supported decision to assign "limited weight" to other source where many of her reasons mirrored factors recommended by the Social Security Administration). Accordingly, the court is unable to conclude that the ALJ's decision is supported by substantial evidence. See Taylor, 899 F. Supp. 2d at 90 (remanding where it was unclear whether the administrative law judge properly evaluated a nurse practitioner's opinion and the court could not follow his reasoning). In short, the ALJ's decision lacks a coherent explanation regarding the weight assigned to the opinions of Ms. Faber and Ms. Colegeo and a remand is necessary.
II. CONCLUSION
For the reasons stated, Plaintiff's motion for judgment on the pleadings, to the extent it seeks a remand, is ALLOWED and the Commissioner's motion to affirm is DENIED. SO ORDERED. July 11, 2014
/s/ Kenneth P. Neiman
KENNETH P. NEIMAN
U.S. Magistrate Judge