Administrative – ALJ improperly rejected physician’s opinion

Where an administrative law judge is required to analyze six factors before rejecting a treating physician’s opinion, and the ALJ here did not analyze or apply the factors before discounting a medical opinion concerning a woman’s medical impairments and ability to perform certain functions, a remand was required.

Background

On Feb. 10, 2011, the Social Security Administration determined that Lakenisha Dowling had been disabled since April 15, 2009. However, on Nov. 3, 2016, an administrative law judge, or ALJ, found that appellant’s disability had ceased as of March 31, 2013. It found that, as of that date, appellant possessed a residual functional capacity, or RFC, “to perform sedentary work.” The district court affirmed the ALJ’s decision.

Medical opinion

When determining appellant’s Social Security disability status, the ALJ was required to consider the medical opinions of appellant’s treating physicians. Section 404.1527(c)(2) sets out two rules an ALJ must follow when evaluating a medical opinion from a treating physician.

First, it establishes the “treating physician rule,” under which the medical opinion of a treating physician is entitled to “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.” Second, if a medical opinion is not entitled to controlling weight, an ALJ must consider each of six factors to determine the weight the opinion should be afforded.

Dr. Gross, appellant’s treating physician from 2011 through 2016, submitted a treating source statement concerning appellant’s medical impairments and ability to perform certain physical functions. Substantial evidence supports the ALJ’s decision to not give controlling weight to the medical opinion contained in Dr. Gross’s statement. This is because a reasonable mind could conclude that the opinion conflicts with other evidence in the record.

It does not follow, however, that the ALJ had free reign to attach whatever weight to that opinion that he deemed fit. The ALJ was required to consider each of the six § 404.1527(c) factors before casting Dr. Gross’s opinion aside. The ALJ plainly failed to do so.

While an ALJ is not required to set forth a detailed factor-by-factor analysis in order to discount a medical opinion from a treating physician, it must nonetheless be apparent from the ALJ’s decision that he meaningfully considered each of the factors before deciding how much weight to give the opinion. In this case, it is far from apparent that the ALJ considered, or was even aware of, each of the § 404.1527(c) factors. In addition to ignoring a majority of the specific factors, the ALJ’s decision was bereft of any reference to the factors as a whole.

The ALJ simply declared that he possessed “the discretion to give less [than controlling] weight” to the opinion of the treating physician. The ALJ never so much as hinted that his discretion was checked by the factors enumerated in § 404.1527(c), which it is. In failing to acknowledge and apply each of these six factors, the ALJ erred. This error necessitates a remand in this case.

RFC assessment

The ALJ also relied on an incorrect regulatory framework when he assessed appellant’s RFC. He did not cite to 20 C.F.R. § 416.945, titled “Your residual functional capacity,” which explains how ALJs should assess a claimant’s RFC. Nor did he cite to the 1996 Social Security ruling that provides guidance on how to properly evaluate an RFC. Finally, the ALJ did not indicate that his RFC assessment was rooted in a function-by-function analysis of how appellant’s impairments impacted her ability to work.

Next, the ALJ expressed appellant’s RFC “in terms of [] exertional levels of work” without first engaging in “a function-by-function analysis.” This was wrong. And the ALJ did not properly assess the extent to which appellant’s sitting problems impacted her ability to work. Third, the ALJ failed to analyze whether appellant’s RFC was impacted by her need to work near a restroom and take frequent bathroom breaks.

Reversed and remanded.

Dowling v. Commissioner of Social Security Administration (Lawyers Weekly No. 001-017-21, 20 pp.) (Stephanie Thacker, J.) Appeal No. 19-2141. Jan. 21, 2021. From D.S.C. (Mary G. Lewis, J.) William Daniel Mayes for Appellant. Brittany Johanna Gigliotti for Appellee.