United States District Court, D. Oregon, Portland Division
OPINION AND ORDER
JOHN V. ACOSTA, Magistrate Judge.
Pollyanna Williams challenges the Commissioner's decision denying her application for disability insurance benefits ("DIB") and Supplemental Security Income ("SSI") under Title II and Title XVI of the Social Security Act ("Act"). This court has jurisdiction under 42 U.S.C. § 405(g). For the reasons set forth below, the Commissioner's decision is reversed and remanded for additional proceedings.
Williams filed her applications for DIB and SIS on June 22 and 14, 2010, alleging disability since September 25, 2007, due to severe physical and mental impairments, including fibromyalgia; status post lumbar fusion, fractures, spondylosis, and spondylolisthesis; status post left wrist open reduction internal fixation and hardware removal; status post carpal tunnel syndrome release, right trigger thumb, and Dupuytren's contracture release; mild osteopenia bilaterally in her hands; and bilateral metatarsophalangeal osteoarthritis and bunions; chronic insomnia; depression, obsessive-compulsive disorder, Bipolar II, and post-traumatic stress disorder. Williams alleged a disability onset date of April 1, 2006. Williams's applications were denied initially and upon reconsideration. On June 6, 2012, after a timely request for a hearing, Williams appeared by video and testified before an administrative law judge ("ALJ"). Williams was represented by counsel, Marlene Yesquen. Steve Cardinal, an impartial vocational expert ("VE"), also appeared and testified. Following the hearing, the record was left open until June 13, 2012, for Williams's representative to file a medical source statement. No additional medical source statements were filed.
On June 29, 2012, the ALJ issued a decision finding Williams not disabled, as defined by the Act. Williams filed a request for review of the ALJ's decision. On July 23, 2013, the Appeals Council denied Williams's request for review of the ALJ's decision, making it the final decision of the Commissioner. 20 C.F.R. §§ 404.981, 422.210.
The court reviews the Commissioner's decision to ensure the proper legal standards were applied and the findings were supported by substantial evidence in the record. 42 U.S.C. § 405(g). Batson v. Comm'r, of the Soc. Sec. Admin., 359 F.3d 1190, 1193 (9th Cir. 2004). The ALJ applied the five-step sequential disability determination process set forth in 20 C.F.R. § 404.1520. Bowen v. Yuckert, 482 U.S. 137, 140 (1987). The ALJ resolved Williams's claim at Step Four of that process, determining the severity of Williams's impairments, individually and in combination, did not meet or medically equal the criteria of Listings § 1.02 or § 1.04. As such, Williams retained the residual functional capacity ("RFC") to perform her past work. Additionally, the ALJ also noted Williams could perform other work in the national economy.
A claimant's RFC is an assessment of the sustained work-related activities she can still do on a regular and continuing basis, despite the limitations imposed by his impairments. 20 C.F.R. §§ 404.1520(e), 404.1545; Social Security Ruling ("SSR") 96-8p. The ALJ assessed Williams's RFC as follows:
[T]he claimant has the residual functional capacity to perform light work as defined in 20 CFR 404.1567(b) and 416.967(b) except she can lift/carry 20 pounds occasionally and 10 pounds frequently. In an 8-hour workday, she can stand/walk for 2 hours and sit for 6 hours. She can occasionally balance, stoop, kneel, crouch, or crawl. She can occasionally climb ramps, stairs, ladders, or scaffolds. Finally, she can frequently handle bilaterally.
Williams asserts several challenges to the ALJ's decision to deny her benefits application. Specifically, she contends the ALJ failed to properly reject the opinion of her treating physician, Kristine A. Groskopp, D.O.; and the ALJ committed error by substituting his own opinion for that of Dr. Groskopp's. Next, Williams charges the ALJ failed to properly consider the combined effect of her many impairments, severe and non-severe, to determine whether in combination those impairments would satisfy a specified Listing. Thirdly, Williams contends the ALJ erred in assessing her credibility and failed to make specific findings. Finally, Williams maintains the ALJ relied upon an incomplete hypothetical to the VE and disregarded the VE's testimony that included all of her impairments.
As explained below, the court finds the ALJ failed to set forth specific and legitimate reasons for discounting Dr. Groskopp's medical testimony. In addition, the ALJ failed to provide clear and convincing reasons for rejecting Williams's subjective testimony regarding her pain and symptoms. The ALJ's failure to consider properly the testimony of Dr. Groskopp and Williams resulted in an incomplete hypothetical to the VE. Further, the ALJ's RFC determination is not supported by substantial evidence in the record. All of these issues must be resolved by the ALJ before a determination of disability can be made. Upon remand, the ALJ is required to complete the five-step disability determination. Accordingly, the decision of the ALJ is reversed and the case is remanded for additional proceedings.
I. Dr. Groskopp - Treating Physician
Williams argues the ALJ completely rejected the opinion of her treating physician, Dr. Groskopp, without providing clear and convincing reasons. In addition, Williams challenges the ALJ's decision to credit the findings of the examining physician, Dr. Jeffery Solomon's, over those of Dr. Groskopp's on the issue of disability.
To establish a physical or mental impairment, a claimant must provide evidence from medical sources. The Code of Federal Regulations ("Code") defines "acceptable medical sources" as: licensed physicians, optometrists and, podiatrists; licensed or certified psychologists; and qualified speech language pathologists. 20 C.F.R. § 404.1513(a). Further, a distinction is made among the opinions of three types of physicians: (1) those who treat the claimant ("treating physician"); (2) those who examine but do not treat the claimant ("examining physician"); and (3) those who neither examine nor treat claimant, but review claimant's medical records ("non-examining physician"). 20 C.F.R. § 404.1527(d); Holohan v. Massanari, 246 F.3d 1195, 1201-02 (9th Cir. 2001). Regardless of the classification of a particular medical provider, the ALJ is never relieved of his obligation to consider evidence submitted by each source and provide some reason for rejecting that evidence. See 20 C.F.R. § 404.1527(d) ("Regardless of its source, we will evaluate every medical opinion we receive.").
Generally more weight is ascribed to the opinion of a treating source than to the opinions of physicians who do not treat the claimant. Holohan, 246 F.3d at 1201-02; Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 1996). The ALJ may not reject the uncontroverted opinion or ultimate conclusions of a treating physician (or examining physician) without providing "clear and convincing" reasons supported by substantial evidence in the record. Lester, 81 F.3d at 830-31. "The Ail can meet this burden by setting out a detailed and thorough summary of the facts and conflicting clinical evidence, stating his interpretation thereof, and making findings." Magallanes v. Bowen, 881 F.2d 747, 750 (9th Cir. 1989) (quotations and citation omitted).
If, however, a treating physician's opinion is contradicted by another acceptable medical source, an ALJ may reject the treating doctor's opinion by providing specific and legitimate reasons that are supported by substantial evidence. Ryan v. Comm'r of Soc. Sec., 528 F.3d 1194, 1198 (9th Cir. 2004). This is so because, even when contradicted, a treating physician's opinion is still owed deference and will often be "entitled to the greatest weight... even if it does not meet the test for controlling weight." Orn v. Astrue, 495 F.3d 625, 633 (9th Cir. 2007). An ALJ can satisfy the "substantial evidence" requirement by "setting out a detailed and thorough summary of the facts and conflicting clinical evidence, stating his interpretation thereof, and making findings." Reddick v. Chater, 157 F.3d 715, 725 (9th Cir. 1998). "The Ail must do more than state conclusions. He must set forth his own interpretations and explain why they, rather than the doctors', are correct." Id.
In fact, Social Security Regulations provide that, when a treating source's opinions arc not given controlling weight, ALJs must apply the factors set forth in 20 C.F.R. § 404.1527(c)(2)(i-ii) and (c)(3-6) in determining how much weight to give each opinion. These factors are length of the treatment relationship and the frequency of examination, § 404.1527(e)(2)(i), nature and extent of the treatment relationship, § 404.1527(c)(2)(ii), "supportability, " § 404.1527(c)(3), consistency, § 404.1527(c)(4), specialization, § 404.1527(c)(5), and other factors that tend to support or contradict the opinion, § 404.1527(c)(6).
Turning to the medical evidence in this Case, on September 23, 2010, Dr. Groskopp completed a "Physical Residual Functional Capacity Questionnaire" based upon three prior examinations of Williams, dating back to April 1, 2010. Dr. Groskopp diagnosed Williams with bilateral carpal tunnel syndrome/Dupuytren's contractures of hands, S/P lumbar spinal fractures x 4, spondylolisthesis and degenerative disc, and fibromyalgia. (Tr. 594.) Dr. Groskopp noted Williams's symptoms included: "pain, swelling [and] numbness in the hands; pain in feet, back, neck, shoulders all over'; fatigue!!; insomnia; mental fogginess; depression." (Tr. 594.) Dr. Groskopp added that the nature, location, frequency, severity and precipitating factors of Williams's pain included: "multiple areas of muscle, 17 out of 17 trigger' points - daily! !" (Tr. 594.) Clinical findings and objective signs were "17 Out of 17 paired trigger points" and degenerative disc disease of the lumbar spine. (Tr. 594.) Previous treatments included "multiple surgeries; Savella; muscle relaters, antidepressants, etc." (Tr. 594.) Dr. Groskopp opined Williams's impairments lasted or could be expected to last at least twelve months. ...