Matthews v. Berryhill ( 2020 )

UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF COLUMBIA
DARNELL MATTHEWS, :
:
Plaintiff, : Civil Action No.: 18-1110 (RC)
:
v. : Re Document No.: 13, 14
:
ANDREW M. SAUL,
Commissioner of Social Security, :
:
Defendant. :
MEMORANDUM OPINION
GRANTING PLAINTIFF’S MOTION FOR JUDGMENT OF REVERSAL; DENYING DEFENDANT’S
MOTION FOR JUDGMENT OF AFFIRMANCE
Plaintiff Darnell Matthews applied for disability insurance benefits and supplemental
security income in 2014. After an Administrative Law Judge (“ALJ”) rejected his application,
Mr. Matthews sought review of that decision from this Court. On March 11, 2020, Magistrate
Judge Robinson found that the ALJ failed to properly apply the treating physician rule and
recommended that this Court remand the action to the Social Security Administration (“SSA”)
for the application of the rule and findings in accordance therewith. See Report &
Recommendation (“R&R”), ECF No. 20. This Court agrees with Magistrate Judge Robinson’s
conclusion that the ALJ failed to adequately explain why he accorded aspects of the treating
physician’s opinion little weight. This Court grants Plaintiff’s Motion for Judgment of Reversal
in part and remands this case to the SSA for further proceedings consistent with this Opinion.
I. FACTUAL BACKGROUND
A. Legal Framework
In reviewing a disability determination, the Court assesses the ALJ’s treatment of the
medical evidence in the administrative record, including the medical opinions of physicians that
have personally examined the claimant. When reviewing these medical opinions, the ALJ is
bound by two constraints at issue here. First, under the D.C. Circuit’s treating physician rule, an
ALJ must give “substantial weight” to the opinion of a claimant’s treating physician, unless it is
contradicted by substantial evidence. See Butler v. Barnhart, 353 F.3d 992, 1003 (D.C. Cir.
2004). Second, when considering any medical evidence, the ALJ is obligated to build a “logical
bridge” by sufficiently explaining the weight given to evidence in the record. See Lane-Rauth v.
Barnhart, 437 F. Supp. 2d 63, 67 (D.D.C. 2006). The Court will provide a brief framework of
each constraint before turning to the administrative proceedings in this particular case.
Beginning with the treating physician rule, when an ALJ chooses to reject the medical
opinion of a qualified treating physician, the ALJ is required to “explain his reasons for doing
so.” See Butler, 353 F.3d at 1003. The ALJ can consider six factors when judging whether the
treating physician’s opinions are well supported: “(1) [the] length of the treating relationship and
frequency of examination; (2) [the] nature and extent of the treating relationship; (3) [the]
supportability [of the physician’s conclusions]; (4) [the] consistency [of the physician’s
conclusions]; (5) [the physician’s] specialization; and (6) other factors that tend to support or
contradict the medical opinion.” Id. at 1003 n.7; see also 20 C.F.R. §§ 404.1527(c), 416.927(c).
That said, if an ALJ determines that it is appropriate to discount a treating physician’s
opinion, the ALJ does not need to reference each of these factors when explaining this decision.
See Grant v. Astrue, 857 F. Supp. 2d 146, 154–55 (D.D.C. 2012) (upholding ALJ’s decision to
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discount treating physician’s opinion even though ALJ did not explain evidence he found to be
inconsistent). Instead, the ALJ only needs to provide “good reasons” for according less than
substantial weight to the treating physician’s findings. See Turner v. Astrue, 710 F. Supp. 2d 95,
106 (D.D.C. 2010) (quoting 20 C.F.R. §§ 404.1527(d)(2), 416.927(d)(2)). As a result, citations
to contradictory evidence are sufficient explanation for an ALJ’s decision to discount the
medical opinion of a treating physician. See Grant, 857 F. Supp. 2d at 154.
Turning to the second constraint relevant to this case, the Social Security Regulations
require that the ALJ must build a “‘logical bridge’ from the evidence to his conclusion.” Banks
v. Asture, 537 F. Supp. 2d 75, 84 (D.D.C. 2008) (quoting Lane-Rauth, 437 F. Supp. 2d at 67).
Although the reviewing court must give “considerable deference” to the ALJ’s decision, it
“remains obligated to ensure that any decision rests upon substantial evidence,” Davis v. Shalala,
862 F. Supp. 1, 4 (D.D.C. 1994), and that the ALJ has “sufficiently explained the
weight . . . given to obviously probative exhibits.” Holland v. Berryhill, 273 F. Supp. 3d 55, 62
(D.D.C. 2017) (quoting Lane-Rauth, 437 F. Supp. 2d at 65). When considering conflicting
medical evidence, the ALJ is “obligated ‘to explain why [he or she] either ignored or rejected
contradictory evidence’” in medical opinions. Ward v. Berryhill, 246 F. Supp. 3d 202, 210
(D.D.C. 2017) (citing Pinkney v. Astrue, 675 F. Supp. 2d 9, 18 (D.D.C. 2009)).
In building the “logical bridge,” an ALJ errs when giving controlling weight to a medical
opinion that is “not well-supported by medically acceptable clinical and laboratory diagnostic
techniques or if it is inconsistent with the other substantial evidence in the case record.” Grant,
857 F. Supp. 2d at 154 (quoting SSR 96-2p, Giving Controlling Weight to Treating Source
Medical Opinions, 1996 WL 374118 *2 (SSA July 2, 1996)); see also 20 C.F.R. § 416.927(c)(2)
(same). Relatedly, when a plaintiff has a progressive disease and one state agency physician’s
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opinion is more recent and based on more updated information, the ALJ should give deference to
that updated opinion because it has a greater logical connection to that plaintiff’s current
condition. See Fulwood v. Heckler, 594 F. Supp. 540, 544 (D.D.C. 1984).
B. Administrative Proceedings
On September 30, 2014 and July 14, 2014, Mr. Matthews applied for disability insurance
benefits and supplemental security income respectively. ALJ’s Decision at 1. 1 To qualify for
either disability insurance benefits or supplemental security income under Titles II and XVI of
the Social Security Act, a claimant must establish that he or she is disabled. See 42 U.S.C. §§
401 et seq.; 42 U.S.C. §§ 1381 et seq. Mr. Matthews alleged that he was disabled based on
numerous conditions including: cervical and lumbar spine disorders, shoulder disorders,
paresthesia, affective disorder, anxiety, trauma/stressor-related disorder, personality/impulse
control disorder, and a substance abuse disorder. ALJ’s Decision at 4. Mr. Matthews’s claims
were denied by the Social Security Administration on December 2, 2014 and denied upon
reconsideration on April 24, 2015. Id. at 1. Mr. Matthews initially alleged that his disability
began on February 1, 2014, but later amended his onset date to January 1, 2016 after his claims
were denied. Id.
On June 4, 2015, Mr. Matthews filed a request for a hearing before an ALJ which was
granted; a video hearing was held on May 5, 2017. Id. Among other things, the administrative
record before the ALJ included: a Current Mental Health Status form, dated April 25, 2017,
completed by Plaintiff’s treating psychiatrist, Dr. T. Allen Gore, limiting him to “20 hours of a
1
Magistrate Judge Robinson’s Report and Recommendation adopted the ALJ’s statement of the
procedural history. See R&R at 5.
4
week” of work, Administrative Record (“AR”) 686, ECF Nos. 9-2 to 9-9; 2 Plaintiff’s own self-
evaluation, AR 328–35; numerous emergency room records, AR 507, 553, 570, 581, 593, 613; a
consultative examination from Dr. Esther Pinder, dated August 15, 2013, limiting Plaintiff to
“medium work,” AR 140; a second consultative examination from Dr. Walter Y.K. Goo, dated
October 23, 2013, also limiting Plaintiff to “medium work,” AR 153; a third consultative
examination from Dr. Alex Hemphill dated April 24, 2015, limiting Plaintiff to “light work,” AR
104–05; and cervical spine x-rays, AR 536. ALJ Theodore Annos issued his decision on June
30, 2017. ALJ’s Decision at 11.
An SSA ALJ uses a five-step process to determine whether an applicant is disabled under
the Social Security Act. See Espinosa v. Colvin, 953 F. Supp. 2d 25, 31 (D.D.C. 2013). First,
the ALJ determines whether the claimant is “engaged in substantial gainful activity.” Id.
(quoting 20 C.F.R. § 404.1520(a)(4)(i)). If the claimant is engaged in such activity, the claimant
is not disabled under the Act. If the claimant is not, the ALJ must then determine whether the
claimant has a “‘medically determinable physical or mental impairment’ that is proven ‘by
medically acceptable clinical and laboratory diagnostic techniques.’” Id. (quoting 20 C.F.R. §
404.1520(a)(4)(ii)). If the ALJ finds that the claimant has such a disability at step two, then the
ALJ proceeds to step three and determines whether the impairment is sufficiently severe. Id. An
impairment is severe if the severity of the impairment “meets or equals an impairment listed in
20 C.F.R. Part 404.” Id. (quoting 20 C.F.R. § 404.1520(a)(4)(iii)). If the claimant meets both of
these requirements, then the ALJ evaluates what the claimant’s residual functional capacity is
given the claimant’s limitations. Id. “‘Residual function capacity’ is ‘the most [the claimant]
2
Unless otherwise indicated, citations to the administrative record reference the page numbers
generated by the SSA in the bottom right of the record, not the page numbers generated by the
ECF system.
5
can still do despite [the] limitations’ caused by the impairment.” Id. (quoting 20 C.F.R. §§
404.1520(a)(4), 404.1545(a)(1)). The ALJ uses the residual functional capacity to evaluate
whether the claimant is unable to occupy a prior job at step four, and, if the claimant is unable to
occupy said job, then whether the claimant can “adapt[] to ‘other work that exists in the national
economy’” at step five. Id. (quoting 20 C.F.R. § 404.1520(a)(4)(v)). If a claim survives these
five steps, then the claimant is eligible for benefits. See id.
Here, ALJ Annos found that Mr. Matthews’s claims failed at steps three and four. See
ALJ’s Decision at 4–9. In his decision, the ALJ made alternative findings as to step five,
indicating that even if he had determined that Mr. Matthews’s impairment was severe, Mr.
Matthews could nonetheless perform other jobs in the national economy. See id. at 9–10.
C. Magistrate Judge Robinson’s Report and Recommendation
Mr. Matthews seeks this Court’s review of the ALJ’s decision in accordance with 42
U.S.C. § 405(g) and 42 U.S.C. § 1383(c)(3). See generally Complaint (“Compl.”), ECF No. 1;
Answer ¶ 2, ECF No. 2. Mr. Matthews asks this Court to reverse the agency’s judgment on the
grounds that the decision was “arbitrary, contrary to law, and unsupported by substantial
evidence.” Pl.’s Mot. for J. of Reversal (“Pl.’s Mot.”) at 1, ECF No. 13. Mr. Matthews’s
primary argument, and the only argument upon which Magistrate Judge Robinson based her
Report and Recommendation, see R&R, is that the ALJ failed to appropriately apply the treating
physician rule. See Pl.’s Mem. in Supp. of Pl.’s Mot. (“Pl.’s Mem.”) at 4–13, ECF No. 13-2.
Mr. Matthews argues that the ALJ’s error in application of the treating physician rule “is
reversible error standing alone,” id. at 11, and argues that “[r]emand is required,” id. at 13. 3 Mr.
3
The Court notes that although Plaintiff has titled his motion one for reversal, his substantive
arguments request remand, not automatic reversal.
6
Matthews makes two additional arguments: (1) that the “ALJ’s analysis of [certain] State
Agency medical consultants’ opinions regarding Plaintiff’s physical limitations [was] also
contrary to law,” see id. at 13–16; and (2) that the ALJ “erred by failing to consider Plaintiff’s
stellar work history,” id. at 17–20. Defendant moves for affirmance of the ALJ’s decision and
argues that that the ALJ appropriately applied the treating physician rule and correctly concluded
that the weight of the evidence supported denying Mr. Matthews’s claims. See Def.’s Mot. for J.
of Affirmance and Opp’n to Pl.’s Mot. (“Def.’s Mot.”) at 14–26, ECF No. 14. Defendant also
addresses Mr. Matthews’s two additional arguments, contending that (1) “substantial evidence
supports the ALJ’s evaluation of the State Agency Physicians’ Opinions, where he considered
them in the context of the entire record,” id. at 26–34; and (2) “substantial evidence supports the
ALJ’s evaluation of Plaintiff’s subjective complaints, where the ALJ was not required to make a
special allowance for Plaintiff’s work history,” id. at 34–39.
This Court referred the case to Magistrate Judge Robinson for full case management. On
March 11, 2020, Magistrate Judge Robinson issued a Report and Recommendation
recommending that the Plaintiff’s Motion for Reversal be granted, and the case be remanded for
application of the treating physician rule, and findings in accordance with the rule. See R&R at
7. Because the ALJ “neither acknowledge[ed] Dr. Gore as Plaintiff’s treating physician nor
appl[ied] the treating physician rule,” id. at 5; the ALJ failed to recognize that Plaintiff had been
receiving treatment by a specialist (a psychiatrist, not a psychologist) 4, id. at 5–6; and the ALJ
did not explain why he rejected the treating physician’s opinion, id. at 6, Magistrate Judge
4
The Court notes that in Plaintiff’s Motion for Judgment of Reversal, Mr. Matthews also
characterizes Dr. Gore as a “psychologist.” See Pl.’s Mem. at 7 (“[T]he ALJ gave no
consideration to the fact that Dr. Gore is a psychologist, a specialist in the precise area in which
he was offering his opinion.” (emphasis added)).
7
Robinson concluded that “the ALJ failed to consider Dr. Gore’s opinion in accordance with th[e]
exacting standard” of the treating physician rule. Id. at 6–7.
In its opposition to the Report and Recommendation, Defendant maintains that this Court
should affirm the ALJ’s decision because it was supported by substantial evidence. See
generally Def.’s Objections to the R&R (“Def.’s Obj.”), ECF No. 21. Plaintiff responds by
urging this Court to adopt the Report and Recommendation in full and offers an alternative
ground for granting his motion. See Pl.’s Opp’n to Def.’s Objections (“Pl.’s Opp’n”) at 1, ECF
No. 22. Although the Report and Recommendation was limited to discussion of the treating
physician rule, see generally R&R, Mr. Matthews argues that the ALJ’s evaluation of
physicians’ opinions with respect to Mr. Matthews’s physical limitations was also contrary to
law. Id. at 3.
II. LEGAL STANDARDS
Two different legal standards apply to this case. The first standard, which applies to the
report and recommendation of a magistrate judge, is de novo. The second, which applies to the
factual decisions of the ALJ, is the “substantial evidence” standard. The Court analyzes each
standard of review in turn.
Under Local Civil Rule 72.3(b), a party may object to a magistrate judge’s proposed
findings and recommendations. Local Civil Rule 72.3(b) further provides that “[t]he objections
shall specifically identify the portions of the proposed findings and recommendations to which
objection is made and the basis for the objection.” LCvR 72.3(b). If a party objects, a district
court reviews the portions of a magistrate judge’s report that have been objected to de novo. See
LCvR 72.3(c); Means v. District of Columbia, 999 F. Supp. 2d 128, 132 (D.D.C. 2013). In their
objections to the recommendations, the parties may not present new issues or arguments to the
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district judge; “only those issues that the parties have raised in their objections to the Magistrate
Judge’s report will be reviewed by this court . . . Furthermore, objecting to only certain portions
of the Magistrate Judge’s report ‘does not preserve all the objections one may have.’” Aikens v.
Shalala, 956 F. Supp. 14, 19–20 (D.D.C. 1997) (citations omitted). “The district judge ‘may
accept, reject, or modify, in whole or in part, the findings and recommendations of the magistrate
judge, or may recommit the matter to the magistrate judge with instructions.’” Platt v. District of
Columbia, 168 F. Supp. 3d 253, 259–60 (D.D.C. 2016) (quoting LCvR 72.3(c)).
As for the second standard of review, when a district court reviews an ALJ’s disability
findings, it must determine whether the ALJ applied the correct legal standards. See Butler, 353
F.3d at 999 (citing 42 U.S.C. §§ 405(g), 1383(c)(3)). A district court is not to reweigh the
evidence and “determine . . . whether [the plaintiff] is disabled.” Id. Rather, the court
“assess[es] only whether the ALJ’s finding . . . is based on substantial evidence.” Id.
“Substantial evidence is ‘such relevant evidence as a reasonable mind might accept as adequate
to support a conclusion.’” Id. (quoting Richardson v. Perales, 402 U.S. 389, 401 (1971)). Said
differently, the substantial evidence standard “requires more than a scintilla, but can be satisfied
by something less than a preponderance of the evidence.” Id. (quoting Fla. Mun. Power Agency
v. FERC, 315 F.3d 362, 365–66 (D.C. Cir. 2003)).
In this Circuit, “substantial-evidence review is highly deferential to the agency fact-
finder.” Rossello ex rel. Rossello v. Astrue, 529 F.3d 1181, 1185 (D.C. Cir. 2008); see 42 U.S.C.
§ 405(g) (“The findings of the Commissioner of Social Security as to any fact, if supported by
substantial evidence, shall be conclusive[.]”); Butler, 353 F.3d at 999 (“The Commissioner’s
ultimate determination will not be disturbed if it is based on substantial evidence in the record
and correctly applies the relevant legal standards.” (citations omitted)). Additionally, “[t]he
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plaintiff bears the burden of demonstrating that the Commissioner’s decision [was] not based on
substantial evidence or that incorrect legal standards were applied.” Settles v. Colvin, 121 F.
Supp. 3d 163, 169 (D.D.C. 2015) (quoting Muldrow v. Astrue, No. 11-cv-1385, 2012 WL
2877697, at *6 (D.D.C. July 11, 2012)).
III. ANALYSIS
Defendant objects to Magistrate Judge Robinson’s conclusion that the ALJ failed to apply
the treating physician rule on three grounds and asserts that substantial evidence supported the
ALJ’s decision. See Def.’s Obj. at 2. First, Defendant argues that the ALJ’s treatment of Dr.
Gore as Plaintiff’s treating physician does not warrant remand because: (1) “the regulations do
not require a specific factor-by-factor analysis in evaluating medical opinions” and (2) “the ALJ
considered Dr. Gore’s opinion using the factors applicable to treating physician opinions.” 5 See
id. at 3–7. Second, Defendant argues that this Court should uphold the ALJ’s decision because,
although “the ALJ did not explicitly address [a] one-hour [mental health treatment] session,” id.
at 8, he cited to records of the session in his decision, see id. at 7–8. Third, the Defendant asserts
that remand is not warranted based on the ALJ’s characterization of Dr. Gore’s qualifications as
a psychologist instead of a psychiatrist as the record reflects because this argument “elevates
form over substance.” See id. at 8–9.
5
Defendant also argues that Dr. Gore was not a treating physician as defined by the regulations
because the record does not reflect that Dr. Gore treated Mr. Matthews on an ongoing basis, the
frequency expected for treatment of the condition. Def.’s Obj. at 3. However, as Plaintiff points
out, Defendant has waived this argument by failing to raise it before the magistrate judge. See
Pl.’s Opp’n at 1–2; Students Against Genocide v. Dep’t of State, 257 F.3d 828, 834–35 & n.10
(D.C. Cir. 2001); see also Intercollegiate Broad. Sys., Inc. v. Copyright Royalty Bd., 574 F.3d
748, 755 (D.C. Cir. 2009) (“[Appellant] has forfeited its argument by failing to raise it in its
opening brief.” (citing Sw. Airlines Co. v. Transp. Sec. Admin., 554 F.3d 1065, 1072 (D.C. Cir.
2009))). In light of this Court’s remand of the case to the ALJ for further proceedings,
Defendant may re-assert this argument to the ALJ in the first instance within the context of the
ALJ’s determination of what weight to give Dr. Gore’s non-controlling opinion.
10
In response, Plaintiff argues that the Magistrate Judge correctly found that the ALJ failed
to appropriately apply the treating physician rule and urges this Court to adopt the Report and
Recommendation in full. See Pl.’s Opp’n at 1. Plaintiff also raised two additional arguments
before the Magistrate Judge which the R&R did not address. 6 First, Plaintiff argues that the
ALJ’s analysis of medical evidence relating to Plaintiff’s physical limitations is contrary to law
and unreasonable. See id. at 3; Pl.’s Mem. at 13–16. Second, Plaintiff argues that the ALJ
erroneously weighed Plaintiff’s work history in a manner contrary to agency policy. See Pl.’s
Mem. at 17–20. Because the Court disagrees with the ALJ’s assessment of Mr. Matthews’s
physical limitations, it will address this argument as well. The Court will discuss each
contention in turn.
A. The Weight of Dr. Gore’s Opinion
The Magistrate Judge held that the ALJ failed to consider Dr. Gore’s opinion in
accordance with 20 C.F.R. § 404.1527(c) and the treating physician rule because the ALJ
incorrectly concluded that the Plaintiff “has not undergone any mental health treatment during
the period under review, except for a mandated psychological evaluation in June 2016.” ALJ’s
Decision at 7. Defendant argues, contrary to the Magistrate Judge’s finding, that the ALJ
correctly applied the treating physician rule when assigning Dr. Gore’s opinion little weight
because the physician’s opinion lacked explanation, failed to provide specific functional
limitations, and lacked support. Def.’s Obj. at 2, 9; Def.’s Mot. at 18. Defendant also argues
that the R&R’s recommendation to remand is not warranted based on the ALJ’s characterization
of Plaintiff’s mental health treatment and that doing so would elevate form over substance. See
6
Plaintiff incorporated his motion for judgment of reversal in his opposition to
Defendant’s objection to the R&R. See Pl.’s Opp’n at 3–4 (“Plaintiff respectfully submits that
the Court should . . . grant Plaintiff’s Motion for Judgment of Reversal.”).
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Def.’s Obj. at 7–8. First, the Court addresses the treating physician rule. Then, because the
Court concludes that the ALJ appropriately followed the treating physician rule in declining to
extend controlling weight to Dr. Gore’s opinion, it turns to the remaining weight given to Dr.
Gore’s opinion. Ultimately, because the ALJ failed to adequately explain the weight given to Dr.
Gore’s opinion in light of his specialization and treating relationship with Plaintiff, this Court
affirms the R&R’s recommendation of remand for further proceedings. 7
1. The Treating Physician Rule
Under the D.C. Circuit’s treating physician rule, when “a claimant’s treating physicians
have great familiarity with [his] condition, their reports must be accorded substantial weight.”
See Butler, 353 F.3d at 1003 (quoting Williams v. Shalala, 997 F.2d 1494, 1498 (D.C. Cir.
1993)). Such an opinion by a treating physician is “binding on the fact-finder unless
contradicted by substantial evidence.” Id.; see 20 C.F.R. 404.1527(c)(2); Poulin v. Bowen, 817
F.2d 865, 873 (D.D.C. 1987); Turner, 710 F. Supp. 2d at 105–06 (holding that conflicts between
physician’s treatment notes and his assessment of claimant can mitigate deference ALJ must give
physician). Thus, the district court’s role is not to determine whether the treating physician’s
opinion should have been accorded controlling weight; instead, it is to determine whether the
ALJ’s decision was supported by substantial evidence. See Butler, 353 F.3d at 1003.
When an ALJ chooses to reject the opinion of a qualified treating physician, the ALJ is
required to “explain his reasons for doing so.” Id. The ALJ can consider six factors when
judging whether the treating physician’s opinions are well supported, Butler, 353 F.3d at 1003
7
Although this Court respectfully disagrees with the Magistrate Judge’s ruling on the
treating physician rule, it agrees with her ultimate resolution of remanding the case for further
proceedings in light of the ALJ’s insufficient explanation for awarding Dr. Gore’s opinion “little
weight” overall.
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n.7; see 20 C.F.R. §§ 404.1527(c), 416.927(c); however, if an ALJ determines that it is
appropriate to discount a treating physician’s opinion, the ALJ does not need to reference each of
these factors when explaining this decision, see Grant, 857 F. Supp. 2d at 154–55 (upholding
ALJ’s decision to discount treating physician’s opinion even though ALJ did not explain
evidence he found to be inconsistent). Instead, the ALJ need only provide “good reasons” for
according less than substantial weight to the treating physician’s findings. See Turner, 710 F.
Supp. 2d at 106 (quoting 20 C.F.R. §§ 404.1527(d)(2), 416.927(d)(2)). Citations to
contradictory evidence can be sufficiently explanatory. Compare Grant, 857 F. Supp. 2d at 154
(concluding that “ALJ’s decision noted the contrary evidence in the record, [which] satisfies the
requirement to explain the rejection of the treating physician’s opinion”), with Ward, 246 F.
Supp. 3d at 209 (remanding because ALJ failed to reference or discuss treating physician’s
medical opinion in his ruling).
Here, the ALJ sufficiently explained his reasons for refusing to award the opinion of Dr.
Gore, Plaintiff’s treating physician, controlling weight. See Butler, 353 F.3d at 1003. Dr. T.
Allen Gore of Contemporary Family Services had been treating Plaintiff for alcohol abuse and
anxiety disorders since March 2016, three months after the alleged onset date. See AR 686; Pl.’s
Mem. at 6. Dr. Gore stated that Plaintiff “is able to work up to 20 hours a week under supportive
employment due to his mental status and being under [a] doctor’s care.” AR 686. Regarding Dr.
Gore’s opinion, the ALJ stated that
Allen Gore, M.D., opined in April 2017 that the claimant would be limited to
working 20 hours per week under supportive employment due to his mental status
and being under doctor’s care (14F/l). I assign this opinion little weight, as it is not
supported with a detailed explanation or relevant, does not indicate the claimant's
specific functional limitations, and is inconsistent with the medical evidence of
record as a whole, including the findings and reported activities described in the
preceding paragraph (see 6E; 3F/3; 5F/21; 6F/3; 8F/27, 44, 57, 67, 88; l0F/1, 5- 7,
11-12).
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ALJ’s Decision at 8.
The ALJ did sufficiently explain his reasons for according less weight to Dr. Gore’s
opinion. The ALJ found that Dr. Gore’s opinions were not well-substantiated based on the lack
of support for Dr. Gore’s conclusions and the inconsistency of his opinions with the medical
evidence of record as a whole. See id.; Butler, 353 F.3d at 1003 n.7 (citing 20 CFR
§§ 404.1527(d)(2)–(6), 416.927(d)(2)–(6)). Therefore, the ALJ provided “good reasons” for
rejecting Dr. Gore’s unsupported conclusion that Plaintiff could only work 20 hours/week by
referencing two of the six factors in the SSA regulations. See Grant, 857 F. Supp. 2d at 154–55;
Turner, 710 F. Supp. 2d at 106.
While the ALJ failed to consider Dr. Gore’s examining relationship, treatment
relationship, specialization, or the fact that Dr. Gore’s opinion is the only medical opinion of
record relating to the adjudicated period based on actual examination of Plaintiff, an ALJ’s
citations to contradictory evidence alone are enough to decline to extend controlling weight to
the medical opinion of a treating physician. See Grant, 857 F. Supp. 2d at 154. ALJ Annos
found that Dr. Gore’s opinion was “not supported with a detailed explanation . . . and [wa]s
inconsistent with the medical evidence of record as a whole, including the [Plaintiff’s] reported
activities” and consistently normal psychiatric evaluations. See ALJ Decision at 8. Therefore, as
was the case for the ALJ in Grant who “determined that the opinion of [Plaintiff’s] treating
physician was ‘inconsistent with the record as whole’ and was not supported by objective
medical evidence,” the regulations required ALJ Annos to conclude that Dr. Gore’s opinion was
not controlling. See Grant, 857 F. Supp. 2d at 154 (citing SSR 96-2p, Giving Controlling Weight
14
to Treating Source Medical Opinions, 1996 WL 374188 at *2 (July 2, 1996)); see also 20 C.F.R.
§ 416.927(c)(2) (same). 8
The most notable contradictory evidence in the record is Dr. Gore’s opinion that Plaintiff
is “able to work up to 20 hours a week under supportive employment due to his mental health
status and being under [a] doctor’s care.” AR 686. These findings conflict with Dr. Gore’s notes
from the same day, which indicate that, although Plaintiff’s mood was “depressed,” he had good
or appropriate memory, judgment, appearance, behavior, and speech. Id. Further, the ALJ cited
considerable contradictory evidence detailing Plaintiff’s prior psychiatric evaluations in the
record, which noted depression and anxiety, but otherwise described normal findings. 9
8
Although the Court agrees with the R&R’s recommendation for remand, the Court finds
that the Magistrate Judge misstated the treating physician rule. 20 C.F.R. § 404.1527(c)(2); see
six factors listed infra Section I.A. The R&R found that “the ALJ failed to consider Dr. Gore’s
opinion in accordance with [the six factors in the SSA Regulations].” R&R at 6. However, the
ALJ did explicitly consider two of the six factors—supportability and consistency—in declining
to extend controlling weight to the treating source’s opinion. See ALJ’s Decision at 8 (emphasis
added) (“I assign [Dr. Gore’s] opinion little weight, as it is not supported with a detailed
explanation . . . and is inconsistent with the medical evidence of record as a whole, including the
findings and [the Plaintiff’s] reported activities.”). The ALJ then went on to cite evidence in the
record that contradicted Dr. Gore’s opinion. In this Circuit, the ALJ does not err when declining
to “expressly state his reason for not applying the treating physician rule” because “ not[ing] the
contradictory evidence in the record . . . supplies the reason.” Williams, 997 F.2d at 1499.
Therefore, the ALJ’s citations to contradictory evidence in the record are enough to decline to
extend controlling weight to Dr. Gore’s treating source opinion.
9
The ALJ’s conflicting evidence was: (1) Plaintiff’s own self-evaluation, stating that he
can do many activities of daily living, AR 328–35; (2) a regular check-up at Howard Faculty
Practice Plan noting normal psychiatric evaluations, AR 469; (3) emergency room records from
Howard University Hospital again noting normal psychiatric findings, AR 507; (4) treatment
notes for back pain at Howard University Faculty Practice Plan Orthopedics and Rehabilitative
Services again noting normal psychiatric findings, AR 515; (5) emergency room records for
chest pain at United Medical Center again noting normal psychiatric findings, AR 553; (6) same,
AR 570; (7) same, AR 583; (8) emergency room records for paresthesia at United Medical
Center again noting normal psychiatric findings, AR 593; (9) treatment notes for pneumonia
from United Medical Center Emergency Room again noting normal psychiatric findings, AR
614; (10) Dr. Gore’s psychiatric evaluation of Plaintiff dated June 6, 2016 stating “[patient]
depressed on and off for past year,” but otherwise normal mental health status, AR 632, 636–38;
(11) Deborah Callaway, also from Contemporary Family Services observed Plaintiff’s moderate
15
Therefore, unlike in Butler, it is very possible to “discern from the record the ALJ’s basis for
rejecting [the treating physician’s] opinions.” 353 F.3d at 1002.
Conclusory and short explanations are generally insufficient to explain “why [the ALJ]
has rejected the treating physician’s opinion and how the doctor’s assessment is contradicted by
substantial evidence.” Settles, 121 F. Supp. 3d at 170 (quoting Espinosa, 953 F. Supp. 2d at 32
(D.D.C. 2013)). However, ALJ Annos’s explanation, though brief, sufficiently explains his
reasons for rejecting the treating physician’s opinion—“it [was] not supported with a detailed
explanation or relevant, does not indicate the claimant’s specific functional limitations, and is
inconsistent with the medical evidence of record as a whole.” ALJ’s Decision at 8. Further,
unlike the ALJ in Perkins v. Berryhill, who provided a conclusory explanation that the treating
physician’s opinion was “not fully consistent with [the] treatment notes,” No. 17-cv-1013, 2019
WL 2010696, at *5 (D.D.C. March 13, 2019), here, the ALJ cited to eleven instances of
conflicting evidence in the record. ALJ’s Decision at 8. Thus, the ALJ’s decision to decline to
extend controlling weight to Dr. Gore’s opinion was supported by substantial evidence. See
Butler, 353 F.3d at 1003.
2. The ALJ’s Treatment of Dr. Gore’s Opinion
Although the ALJ satisfied the treating physician rule, he insufficiently explained the
weight he gave to Dr. Gore’s opinion. The Court finds that the ALJ failed to consider Dr. Gore’s
phobia, severe racing thoughts, moderate depression, and moderate flat affect, AR 642–43.
Because Plaintiff cites to opposing medical evidence, see Pl.’s Mot at 8–9, the diverse array of
psychological and psychiatric evidence in this opinion “create[s] a situation ‘where conflicting
evidence allows reasonable minds to differ as to whether the claimant is disabled.’” Turner, 710
F. Supp. 2d at 107 (citing Walker v. Bowen, 834 F.2d 635, 640 (7th Cir. 1987)). Therefore, “[i]n
such situations, ‘the responsibility for that decision falls on the Commissioner (or his designate,
the ALJ).’” Id. (quoting Walker, 834 F.2d at 640). Therefore, it was reasonable for the ALJ to
conclude that the treating physician’s opinion was “inconsistent with the medical evidence of
record as a whole.” See ALJ’s Decision at 8.
16
opinion in accordance with the regulations. The ALJ did not adequately explain Dr. Gore’s
opinion in the context of: (1) Dr. Gore’s specialization in psychiatry and (2) Dr. Gore’s treating
relationship with Plaintiff. See 20 C.F.R. § 416.927(c). Therefore, the Court agrees with the
Magistrate Judge’s recommendation that the ALJ failed to adequately explain his decision to
discount Dr. Gore’s opinion. See R&R at 6–7.
Under the regulations, if an ALJ declines to extend controlling weight to a treating
physician’s opinion, he must still consider the opinion in the context of the physician’s
specialization and treating relationship. See 20 C.F.R. § 416.927(c).
Generally, [the ALJ] give[s] more weight to medical opinions from [a plaintiff’s]
treating sources, since these sources are likely to be the medical professionals most
able to provide a detailed, longitudinal picture of [a plaintiff’s] medical
impairment(s) and may bring a unique perspective to the medical evidence that
cannot be obtained from the objective medical findings alone or from reports of
individual examinations, such as consultative examinations or brief
hospitalizations.
Id. § 416.927(c)(2). First, “the more knowledge a treating source has about [a plaintiff’s]
impairment(s) the more weight [an ALJ] will give to the source’s medical opinion.” Id. at
§ 416.927(c)(2)(ii). Therefore, an ALJ will “generally give more weight to the medical opinion
of a specialist about medical issues related to his or her area of specialty than to the medical
opinion of a source who is not a specialist.” Id. at § 416.927(c)(5). Second, “the longer a
treating source has treated [a plaintiff] and the more times [a plaintiff] has been seen by a
treating source, the more weight [an ALJ] will give to the source’s medical opinion.” Id. at
§ 416.927(c)(2)(i).
Here, the ALJ failed to consider Dr. Gore’s opinion in the context of Dr. Gore’s
specialization and treating relationship. First, as Plaintiff’s psychiatrist, Dr. Gore is most able to
give a longitudinal picture of Plaintiff’s impairments and provides a unique perspective that the
17
ALJ cannot obtain from consultative examinations or brief hospitalizations. Id. § 416.927(c)(2).
Instead of considering Dr. Gore’s opinion in light of his unique knowledge and specialty, the
ALJ used reports from consultative examinations and brief hospitalizations to discount Dr.
Gore’s opinion and award it “little weight” altogether. ALJ’s Decision at 8. The regulations
suggest that this is improper. They provide the example that if a plaintiff’s eye doctor notices
that the plaintiff has complained about “neck pain during [] eye examinations, [the ALJ] will
consider the eye doctor’s medical opinion with respect to [plaintiff’s] neck pain, but [] will give
it less weight than that of another physician who has treated [] the neck pain.” 20 C.F.R.
§ 416.927(c)(2)(ii). Here, the ALJ did the reverse. The ALJ failed to sufficiently explain his
choice to award “little weight” to Dr. Gore’s specialist assessment of Plaintiff’s psychiatric
conditions, while, at the same time, crediting emergency room and orthopedic physicians’ one-
time assessments of Plaintiff’s “normal” psychiatric findings while they treated Plaintiff for
unrelated physical ailments. See n.9 infra. The ALJ’s failure to explain his reasoning is
especially puzzling because Dr. Gore specializes in psychiatry. Therefore, the ALJ should have
given Dr. Gore’s opinion greater weight than the opinions of emergency room and orthopedic
physicians, because Dr. Gore actually treated Plaintiff for his depression, anxiety, and
personality disorder. See 20 C.F.R. §416.927(c)(2)(ii). 10
10
The R&R recommends that the ALJ’s decision be overturned, in part, because the ALJ
incorrectly characterized Dr. Gore’s examination of Plaintiff as a “psychological examination.”
ALJ’s Decision at 7 (emphasis added). In fact, Dr. Gore is a psychiatrist and performed
psychiatric evaluations of Plaintiff during the relevant period. AR 686. A psychiatrist is a
medical doctor, whereas a psychologist holds a non-medical doctorate degree, usually a PhD or
PsyD. See Ralph Ryback, M.D., Psychiatrist vs. Psychologist, Psychology Today (Jan. 4, 2016),
https://www.psychologytoday.com/us/blog/the-truisms-wellness/201601/psychiatrist-vs-
psychologist. While the ALJ used incorrect terminology to describe Dr. Gore’s report, the ALJ
recognized the key difference, as evidenced by his reference to Dr. Gore as “Allen Gore, M.D.”
ALJ’s Decision at 8 (emphasis added).
18
Second, the ALJ insufficiently accounted for the frequency of Dr. Gore’s examinations of
Plaintiff in the context of his treating relationship. The ALJ incorrectly stated that Plaintiff “has
not undergone any mental health treatment during the period under review other than a mandated
psychological evaluation in June 2016.” ALJ’s Decision at 7. While the record with regard to
Plaintiff’s mental health treatment is sparse, Dr. Gore’s April 2017 evaluation of Plaintiff stated
that he “started outpatient services in 2016 and currently receives services, medication
management, case management and therapy.” AR 686. Additionally, Plaintiff testified at the
hearing that he typically sees his psychiatrist every two weeks. See AR 38. However, the only
mental health treatment notes in the record are from March 2016, June 2016, and October
2016. 11 Therefore, further factual development on remand concerning Plaintiff’s mental health
treatment is needed to determine the appropriate weight to give Dr. Gore’s opinion based on the
length of treatment and how many times Dr. Gore has seen Plaintiff. See 20 C.F.R.
§ 416.927(c)(2)(i); Poulin, 817 F.2d at 874 (instructing that “[t]he presence of a mental disorder
should be documented primarily on the basis of reports from . . . psychiatrists”). Thus, remand is
appropriate, because “the [C]ourt cannot determine the ALJ’s rationale” for completely
discounting Dr. Gore’s opinion “without further findings or clearer explanation for the decision.”
Ademakinwa v. Astrue, 696 F. Supp. 2d 107, 111 (D.D.C. 2010).
B. Mr. Matthews’s Physical Limitations 12
Next, Plaintiff argues that the ALJ erred when analyzing the medical evidence regarding
his physical condition. See Pl.’s Mem. at 13–16. The only medical opinions in the record
11
The record also contains mental health evaluations from before the relevant period.
See AR 457 (Family Matters of Greater Washington on March 21, 2013).
12
Plaintiff first raised the physical limitations issue in his Motion, see Pl.’s Mem. at 13–
14, and raised it again in his Opposition, see Pl.’s Opp’n at 3. Although the R&R addressed only
Plaintiff’s concerns regarding the treating physician rule, see generally R&R, this Court will also
19
regarding Plaintiff’s physical condition were those of state agency medical consultants. See id.
at 13. The state agency medical opinions at issue here are those of Dr. Esther Pinder, dated
August 15, 2013; Dr. Walter Goo, dated October 23, 2013; and Dr. Alex Hemphill, dated April
24, 2015. 13 Plaintiff argues that the ALJ incorrectly determined his residual functional capacity
to perform “medium work” by according greatest weight to 2013 medical opinions when the
only issues related to January 2016 and after. See Pl.’s Mem. at 13–14. 14 Defendant, in contrast,
argues that substantial evidence supports the ALJ’s decision to assign relatively less weight to
consider Plaintiff’s argument regarding the ALJ’s evaluation of his physical limitations. “The
district judge must determine de novo any part of the magistrate judge’s disposition that has been
properly objected to.” Fed. R. Civ. P. 72(b)(3). Even though the R&R did not address Plaintiff’s
physical limitations argument, Pl.’s Mem. at 13–16, and, while Plaintiff did not specifically
“object[] to” “the magistrate judge’s disposition,” Plaintiff did raise this issue in pleadings
responsive to the R&R. See Aikens v. Shalala, 956 F. Supp. 14, 19 (D.D.C. 1997) (district courts
can consider issues that parties raised in their responses to the R&R). Therefore, the Court will
review the issue.
13
The record also contains an additional opinion regarding Plaintiff’s physical condition:
the report of Dr. Veronica Bedeau, dated December 2, 2014. See AR 80–81. However, Dr.
Bedeau’s opinion is not at issue in these proceedings because she “opined that the claimant’s
physical impairments were non-severe. [The ALJ] assign[ed] this opinion little weight, as it is
not consistent with the medical evidence of record as a whole showing that the claimant does
have severe physical impairments resulting in functional limitations.” See ALJ Decision at 7.
Neither party disputes the ALJ’s finding with respect to Dr. Bedeau’s opinion.
14
At steps four and five of the disability determination, the ALJ must engage in a
residual functional capacity (“RFC”) analysis. The RFC analysis involves an inquiry into the
medical evidence (1) to determine the claimant’s ability to return to past work and (2) to assess
whether future employment of any variety is possible. See 20 C.F.R. §§ 404.1520, 404.1545,
416.920, 416.945; SSR 96–8p: Policy Interpretation Ruling—Titles II and XVI: Assessing
Residual Functional Capacity in Initial Claims, 1996 WL 374184 (July 2, 1996). When
performing the RFC assessment, SSR 96–8p requires that the ALJ assess the claimant’s ability to
perform sustained “work-related physical and mental activities,” SSR 96–8p, 1996 WL 374184,
at *2, by examining his exertional and non-exertional capacities, such as sitting, walking,
hearing, and tolerance for temperature extremes. Id. at *5–6. The ALJ is required to “discuss
the individual’s ability to perform sustained work activities in an ordinary work setting on a
regular and continuing basis (i.e., 8 hours a day for 5 days a week, or an equivalent work
schedule), and to describe the maximum amount of each work-related activity the individual can
perform based on the evidence available in the case record.” Id. at *7; see also Lane-Rauth, 437
F. Supp. 2d at 67.
20
Dr. Hemphill’s April 2015 opinion, namely that 2013 medical opinions by Doctors Pinder and
Goo were more consistent with the rest of the medical evidence. See Def.’s Mot. at 31–32. The
Court agrees with Mr. Matthews that the ALJ failed to sufficiently explain his decision to weigh
the opinions of Doctors Pinder and Goo more heavily than Dr. Hemphill’s updated opinion when
reviewing Plaintiff’s degenerative condition.
When determining whether a claimant is disabled, the Social Security rulings instruct the
ALJ to provide a “narrative discussion” that
contain[s] a thorough . . . analysis of the objective medical and other evidence,
including the individual’s complaints of pain and other symptoms and the
adjudicator’s personal observations, if appropriate; . . . a resolution of any
inconsistencies in the evidence as a whole; and . . . a logical explanation of the
effects of the symptoms, including pain, on the individual’s ability to work.
SSR 96–8p, 1996 WL 374184, at *7. “Stated another way, SSR 96–8p requires that the ALJ
must build a ‘logical bridge’ from the evidence to his conclusion.” Banks, 537 F. Supp. 2d at 84
(quoting Lane-Rauth, 437 F. Supp. 2d at 67).
Although reviewing courts must give “considerable deference” to the ALJ’s decision,
courts “remain[] obligated to ensure that any decision rests upon substantial evidence,” Davis,
862 F. Supp. at 4, and that the ALJ has “sufficiently explained the weight . . . given to obviously
probative exhibits,” see Holland, 273 F. Supp. 3d at 62 (quoting Lane-Rauth, 437 F. Supp. 2d at
65). When considering conflicting medical evidence, the ALJ is “obligated ‘to explain why [he
or she] either ignored or rejected contradictory evidence’” in medical opinions. Ward, 246 F.
Supp. 3d at 210 (citing Pinkney, 675 F. Supp. 2d at 18). It is insufficient explanation when an
ALJ awards “great weight” to a medical opinion because it was “‘consistent’ with record
evidence” if that opinion conflicts with other medical sources and the plaintiff’s testimony. See
Higgins v. Saul, No. 16-cv-27, 2019 WL 4418681, at *15 (holding that “ALJ inadequately
explained her reliance on the state agency consultants’ opinions” because she “improperly
21
rejected the plaintiff’s and [other doctor’s] statements and did not explicitly address other
evidence in the record that is inconsistent with state agency consultants’ opinions.”).
Further, when a plaintiff has a progressive disease and one state agency physician’s
opinion is more recent and based on more updated information, the ALJ should give deference to
that updated opinion. See Fulwood, 594 F. Supp. at 544 (holding that ALJ improperly gave older
opinion on plaintiff’s progressive asbestosis more weight because updated opinion that was
given three years later had “far greater relevance to [p]laintiff’s actual and total condition”);
McLaurin v. Colvin, 121 F. Supp. 3d 134, 141–42 (D.D.C. 2015) (upholding ALJ’s decision to
give greater weight to more recent medical opinion because it was consistent with other evidence
in the record). Additionally, when considering the evidence, the ALJ errs when he or she gives
controlling weight to a medical opinion that is “‘not well-supported by medically acceptable
clinical and laboratory diagnostic techniques or if it is inconsistent with the other substantial
evidence in the case record.’” Grant, 857 F. Supp. 2d at 154 (quoting SSR 96-2p, Giving
Controlling Weight to Treating Source Medical Opinions, 1996 WL 374118 *2 (SSA July 2,
1996) (rejecting medical opinion in part because “there had been no laboratory tests performed in
the previous four years that supported [the] opinion”)).
Here, the ALJ failed to provide a “narrative discussion” when resolving “inconsistencies
in the evidence as a whole,” SSR 96–8p, 1996 WL 374184, at *7, regarding the opinions of
Doctors Pinder and Goo that Plaintiff could perform “medium work” with Dr. Hemphill’s more
recent opinion that Plaintiff could only perform “light work,” ALJ Decision at 7. Because Dr.
Hemphill’s opinion that Plaintiff could only perform “light work,” AR 103, contradicted the
opinions of Doctors Pinder and Goo that Plaintiff could perform “medium work,” AR 140, 153,
22
the ALJ was “obligated to explain why [he] rejected contradictory evidence,” Ward, 246 F.
Supp. 3d at 210 (internal quotations omitted).
The ALJ explained his rejection of Dr. Hemphill’s opinion by stating that it was “not
consistent with the objective findings and the claimant’s work activities described in the
preceding paragraph.” ALJ Decision at 7. Similarly, the ALJ awarded “great weight” to the
medical opinions of Doctors Pinder and Goo because “it is consistent with the record as a whole,
including the objective findings and the claimant’s work activities described above.” ALJ’s
Decision at 7. 15 However, like the ALJ in Higgins who “inadequately explained her reliance on
the state agency consultants’ opinions” by ignoring the plaintiff’s and other doctor’s statements,
as well as objective evidence in the record, 2019 WL 4418681, at *15, here, the ALJ
inadequately explained his reliance on the 2013 state agency opinions by failing to account for
(1) Plaintiff’s testimony that his work involved lifting only 15–20 lbs. (i.e., not up to 50 lbs., as is
required for medium work), AR 40, (2) Dr. Hemphill’s 2015 examination of Plaintiff, limiting
him to “light work,” AR 103, and (3) updated medical records, including “the recent 1/15/16
exam when muscle spasm, impaired gait and positive [straight leg raises] were noted,” id., and x-
rays showing “multilevel degenerative disc disease with moderate narrowing of discs,” AR 536.
15
The “work activities described above” references Plaintiff’s past part-time warehouse
work from approximately August 2014 to January 2016 (the alleged onset date). AR 40–42.
The Vocational Expert classified this position as “medium work.” AR 60. However, the
regulations classify medium work as lifting up to 50 lbs. at a time with frequent lifting of objects
weighing up to 25 lbs., 20 C.F.R. § 404.1567(c), and Plaintiff testified that he lifted only 15-20
lbs., AR 42. Plaintiff also worked at Giant Grocery Store for three weeks in 2016 but stopped
because of his health problems. AR 42–43. Three weeks of attempted work following the
alleged onset date does not imply that Plaintiff is capable of substantial gainful employment.
SSR 96-8p (defining substantial gainful employment as “8 hours a day, 5 days a week, or an
equivalent work schedule”); Roth v. Sullivan, No. 90-cv-00581, 1990 WL 183584, at *2 (D.D.C.
Nov. 8, 1990) (quoting Cornett v. Califano, 590 F.2d 91, 94 (4th Cir. 1978) (“The ability . . . to
work only on an intermittent basis is not the ability to engage in ‘substantial gainful activity.’”)).
23
Further, like the claimant in Fulwood, Plaintiff’s “degenerative disc disease,” AR 536, is
a progressive disease, meaning the disease gets worse over time, 594 F. Supp. at 544. Therefore,
Dr. Hemphill’s more recent opinion, from almost two years later, limiting Plaintiff to “light
work,” AR 103, has “far greater relevance to Plaintiff’s actual and total condition” like the
medical opinion in Fulwood from three years later, 594 F. Supp at 544. Thus, the ALJ
insufficiently explained his decision to award “great weight” to the 2013 opinions of Doctors
Pinder and Goo despite their not having observed the Plaintiff’s “antalgic stance” and gait,
“limited range of motion,” “increased lordosis” of the spine, “right-sided muscle spasms,”
“restricted” flexion and rotation, and “positive straight leg” tests on March 19, 2015. Not only
did Dr. Hemphill have the benefit of updated observations when drafting his opinion, his
conclusions are “well supported by medically acceptable clinical and laboratory diagnostic
techniques,” Grant, 857 F. Supp. 2d at 154, in the form of cervical spine x-rays taken just two
months after Dr. Hemphill’s opinion, on June 24, 2015, showing “multilevel degenerative disc
disease with moderate narrowing of the disc[s].” AR 536. Conflicting evidence can create
situations where reasonable minds differ and in such cases the ALJ’s decision should stand.
Turner, 710 F. Supp. 2d at 107. Under these circumstances, however, it was unreasonable for
the ALJ to afford “little weight” to Dr. Hemphill’s updated and corroborated opinion, at least
without further explanation. See ALJ Decision at 7.
Although outdated medical records are not “stale,” an ALJ errs when failing to explain
his or her reasoning for crediting an older medical opinion, while dismissing an updated one.
See Ward, 246 F. Supp. 3d at 210 (remanding where ALJ insufficiently explained decision to
afford “great weight” to outdated state agency physician’s opinion over more recent opinion);
Higgins, 2019 WL 4418681, at *15. Like the ALJ in Higgins, the ALJ here did not adequately
24
explain his reliance on the older opinions, given the existence of updated evidence in the record
contradicting those opinions. 2019 WL 4418681, at *15. “The fact that additional medical
evidence was added to the record after [doctors’] opinions renders them no less valid as of the
dates they were written” because the regulations only require that the ALJ’s decisions are
supported by substantial evidence. See Goodman v. Colvin, 233 F. Supp. 3d 88, 106 (D.D.C.
2017) (quoting Etheridge v. Comm’r of Soc. Sec., No. JKB-15-697, 2015 WL 6769116, at *2 (D.
Md. Oct. 30, 2015)). However, “it is reversible error for an ALJ to fail in his written decision to
explain sufficiently the weight he has given certain probative items of evidence.” Turner, 710 F.
Supp. 2d at 105; Cobb v. Astrue, 770 F. Supp. 2d 165, 171 (D.D.C. 2011) (reversing ALJ’s
“extremely generic and abstract” declaration that plaintiff could perform “light work”). The
ALJ’s decision to accord “great weight” to the opinion furthest removed from Plaintiff’s current
condition was reversible error because he insufficiently explained the weight given to updated
medical evidence that supported Dr. Hemphill’s more recent opinion concerning a degenerative
condition, thereby failing to build a “logical bridge.” 16 Therefore, on remand, further
explanation is needed regarding the ALJ’s decision to award the 2013 opinions of Doctors Pinder
and Goo “great weight” while awarding Dr. Hemphill’s 2015 opinion “little weight.” ALJ’s
Decision at 7. 17
16
The ALJ’s failure to explain the weight given to the state agency medical opinions may
be outcome-determinative. Based on the Plaintiff’s “advanced age” and “history of unskilled
work,” if the ALJ found Plaintiff to be limited to “light work”—as opposed to “medium work”—
the Social Security Administration’s Grid Rules may perhaps require a finding of “Disabled.” 20
C.F.R. § 404, Subpt. P, App. 2, 202.04, Table 2.
17
An additional matter may also be considered on remand. In his Motion for Judgment
of Reversal, Plaintiff raises the issue that the ALJ failed to consider Plaintiff’s “stellar work
history” in his credibility determination. Pl.’s Mem. at 17–20. Because neither party raised the
issue of the ALJ’s credibility determination in their responses to the R&R, this Court will not
reevaluate the ALJ’s treatment of Plaintiff’s work history as it relates to the credibility
determination. The parties may address this topic on remand.
25
V. CONCLUSION
For the foregoing reasons, Plaintiff’s Motion for Judgment of Reversal (ECF No. 13) is
GRANTED and Defendant’s Motion for Judgment of Affirmance (ECF No. 14) is DENIED.
An order consistent with this Memorandum Opinion is separately and contemporaneously issued.
Dated: September 10, 2020 RUDOLPH CONTRERAS
United States District Judge
26