UNITED STATES DISTRICT COURT

EASTERN DISTICT OF MICHIGAN

SOUTHERN DIVISION

AMBER KLOHA MANSFIELD,

Plaintiff, Civil Action No.: 14-11766

 Honorable Arthur J. Tarnow

v. Magistrate Judge Elizabeth A. Stafford

 

CAROLYN W. COLVIN, 

Acting Commissioner of 

Social Security,

 

Defendant. 

__________________________________/

REPORT AND RECOMMENDATION

ON CROSS-MOTIONS FOR SUMMARY JUDGMENT [R. 16, R. 19]

Plaintiff Amber Kloha Mansfield (“Mansfield”) appeals a final decision 

of Defendant Commissioner of Social Security (“Commissioner”) denying 

her applications for Disability Insurance Benefits (“DIB”) and Supplemental 

Security Income (“SSI”) under the Social Security Act (the “Act”). Both 

parties have filed summary judgment motions, which were referred to this 

Court for a Report and Recommendation pursuant to 28 U.S.C. § 

636(b)(1)(B). The Court finds that the ALJ erred by failing to adhere to the 

treating physician rule with respect to one of Mansfield’s treating 

physician’s opinions, in failing to recontact another treating physician, and 

in assessing Mansfield’s residual functional capacity without the support of 

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 1 of 36 Pg ID 1042
substantial evidence in the record. For these reasons, the Court 

RECOMMENDS that the Commissioner’s motion [R. 19] be DENIED, 

Mansfield’s motion [R. 16] be GRANTED IN PART to the extent it seeks 

remand but DENIED IN PART to the extent it seeks reversal and an award 

of benefits, and that, pursuant to sentence four of 42 U.S.C. § 405(g), the 

Commissioner’s decision be REMANDED for further proceedings 

consistent with this Report and Recommendation.

I. BACKGROUND

At the time of the hearing, Mansfield was a 25-year-old mother of 

three who had been in special education classes from the sixth grade until 

the eleventh grade, her last year of school. [R. 9-2,Tr. 64-5]. She had 

previously worked in day care, as a janitor and as a cashier. [R. 9-6, Tr. 

246]. Mansfield alleges that she stopped working because of her

“condition(s)” and “back pain.” [Id., Tr. 245; R. 9-7, Tr. 476]. She claims 

that she is disabled by back problems, sleep problems, bipolar disorder and 

other mental health problems. [R. 9-6, Tr. 245]. 

A. Procedural History

On February 23, 2011, Mansfield filed applications for DIB and SSI,

alleging disability as of March 1, 2009. [R. 9-5, Tr. 186-200]. The claims

were denied initially on June 27, 2011, and Mansfield filed a timely request 

2

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 2 of 36 Pg ID 1043
for an administrative hearing. [R. 9-4, Tr. 134-53; 156-57]. Mansfield and 

a vocational expert (VE) testified at the January 4, 2012 hearing before an 

administrative law judge (ALJ”). [R. 9-2, Tr. 58-87]. In a written decision 

dated March 1, 2012, the ALJ found Mansfield not disabled. [Id., Tr. 33-

57]. On May 25, 2012, the Appeals Council denied review, making the 

ALJ’s decision the final decision of the Commissioner for purposes of this 

review. [Id., Tr. 26-28]. Mansfield filed for judicial review of the final 

decision on May 2, 2014. [R. 1].

B. Evidence in the Record

1. Mansfield’s Testimony and Subjective Reports

Mansfield reported being 5’3” tall and weighing 176 pounds. [R. 9-6, 

Tr. 245].

1

 She complained of a bulging disc in her back, causing pain at a 

level of 6/10 and numbness that extends down her legs. [R. 9-2, Tr. 81; R.

9-6, Tr. 251]. She stated that the pain affects her ability to sit, stand, walk,

lift, carry, and climb stairs. [R. 9-2, Tr. 66-67; R., 9-6, Tr. 267; 272]. 

Mansfield’s boyfriend reported that she cannot sit, stand or lay for any 

longer than a few minutes at a time. [R. 9-6, Tr. 292]. However, she

testified she could lift about 10 to 15 pounds, and sit and stand for a halfhour each. [R. 9-2, Tr. 66; R. 9-6, Tr. 267; 272]. According to Mansfield, 

1 Mansfield does not challenge the ALJ’s evaluation of her obesity and thus 

the Court does not further address her weight. 

3

 

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 3 of 36 Pg ID 1044
she suffers from bipolar disorder and depression, which cause mood 

swings and affect her ability to get along with others, concentrate and 

complete tasks. [R. 9-2,Tr. 68-69; 72-73; 79-80; R. 9-6, Tr. 251; 272]. She 

reported not handling stress well. [R. 9-6, Tr. 273]. Finally, she testified to 

having approximately one migraine headache every two weeks, requiring 

her to lie down for an hour or two. [R. 9-2, Tr. 75-77]. 

Mansfield’s day consists of caring for her children, doing light 

housework and preparing meals. [R. 9-6, Tr. 268-69]. She has no problem 

with personal care, but has difficulty sleeping due to pain. [Id., Tr. 268]. 

She shops weekly for food, and drives her children to school and to 

appointments. [Id., Tr. 270-71]. At the time of her appeal, she reported an 

increase in back pain resulting in a prohibition on all lifting. [Id., Tr. 305]. 

She was not taking any pain or psychotropic medication at that time due to 

a pregnancy. [Id.]. 

2. Medical Evidence

a. Mental Conditions

i. Treating Sources

Mansfield’s mental health records begin in January 2009, when 

primary care physician Dr. Bodrie described her as having a history of

depression that improved with Wellbutrin. [R. 9-9, Tr. 839]. She was 

4

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 4 of 36 Pg ID 1045
instead using Celexa by November of that year, but it caused her seizurelike symptoms and she returned to using Wellbutrin. [R. 9-8, Tr. 604, 606, 

609, 612, 618; 733-34].

In January 2010, Mansfield underwent a psychiatric evaluation by Dr. 

Ann Tadeo of the M.P.A. Group NFP, LTD. [Id., Tr. 733-34]. Mansfield 

described her history of depression and anxiety, which improved with

Wellbutrin; a family history of bipolar disorder and suicide; a history of 

suffering from physical, emotional and verbal abuse throughout her life 

from multiple abusers; and a host of other life stressors. [Id., Tr. 733]. She 

told Dr. Tadeo that she had been placed on medical leave from work due to 

kidney stones. [Id.]. Dr. Tadeo diagnosed Mansfield with bipolar disorder, 

issued her a Global Assessment of Functioning (“GAF”) score of 45-50,2

suggested that Mansfield receive a doubled prescription for Wellbutrin and 

Desyrel for insomnia. [Id., Tr. 734]. During subsequent visits, nurse 

practitioner Phil Sweet of the M.P.A. Group found that Mansfield continued 

2 “The GAF scale is a method of considering psychological, social, and 

occupational function on a hypothetical continuum of mental health. The 

GAF scale ranges from 0 to 100, with serious impairment in functioning at a 

score of 50 or below. Scores between 51 and 60 represent moderate 

symptoms or a moderate difficulty in social, occupational, or school 

functioning.” Norris v. Comm'r of Soc. Sec., No. 11-5424, 461 Fed. Appx. 

433, 436 n.1 (6th Cir. 2012) (citations omitted). Scores in the range of 61-

70 indicate some mild symptoms. Karger v. Comm’r of Soc. Sec., 414 Fed. 

Appx. 739, 745 (6th Cir. 2011).

5

 

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 5 of 36 Pg ID 1046
to have a GAF of 50. [R. 9-8, Tr. 741; 745]. 

While Mansfield initially felt worse on her new dosage, her symptoms 

improved when the M.P.A. Group added a mood stabilizer to the regimen. 

[R. 9-8, Tr. 735, 739, 741]. Over the course of the next year, Mansfield 

reported to Sweet that she was doing well on her medications, although 

she was noncompliant sometimes. [Id.,Tr. 741-44]. In January 2011, she 

began therapy with a social worker at the M.P.A. Group, and reported that 

she had been doing well. [R. 9-9, Tr. 799]. 

Also in January 2011, Dr. Tadeo completed a mental residual 

functional capacity (“RFC”) assessment, finding Mansfield moderately 

limited in her abilities to remember locations and work procedures, and to 

understand and carry out one or two-step instructions, and markedly limited 

in her abilities to understand and carry out detailed instructions, and to 

maintain attention and concentration for extended periods. [R. 9-7, Tr. 

570]. Mansfield was moderately limited in her ability to maintain a 

schedule, work without supervision or distraction, make simple work-related 

decisions and complete a normal workday without interruption from her 

symptoms. [Id.,Tr. 571]. She was further moderately limited in her ability 

to interact with co-workers and the general public; accept instructions and 

respond appropriately to criticism from supervisors; maintain socially 

6

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 6 of 36 Pg ID 1047
appropriate behavior and basic standards of cleanliness; respond to 

changes or set realistic goals; take appropriate precautions from normal 

hazards; and travel in unfamiliar places or use public transportation. [Id.]. 

In a psychological examination report dated February 2011, Dr. 

Tadeo detailed her observations and findings, including that Mansfield 

reported being persistently depressed, and vacillated between being happy 

and elated one minute, and irritable and angry the next. [Id., Tr. 572]. 

While Mansfield was being provided biweekly treatment, she “misses 

numerous appointments, mostly because she forgets them.” [Id., Tr. 573]. 

Dr. Tadeo noted that, during a mental status examination, Mansfield was 

pleasant and cooperative, but her mood was irritable with congruent affect. 

[Id.]. Mansfield’s concentration, focus and memory were fair, as were her 

insight and judgment. [Id.] Dr. Tadeo reiterated that Mansfield suffered 

from bipolar disorder and maintained a GAF score of 50. [Id.]. It appears 

Dr. Tadeo also completed a medical needs-JET form for Mansfield, 

diagnosing her with bipolar disorder, but the remainder of the form is not 

completed, and there appears to be a second page that is missing. [Id., Tr. 

575]. 

During a May 2011 medication review, Dr. Tadeo indicated that 

Mansfield remained on her medications into May 2011, and that she was 

7

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 7 of 36 Pg ID 1048
“ornery” when she missed doses. [R. 9-8, Tr. 746]. By July 2011, 

Mansfield was not taking any mediation due to her pregnancy. [R. 9-9, Tr. 

825]. After reporting that she was experiencing significant difficulties in 

August 2011, her obstetrician again started her on a mood stabilizer and 

she felt improvement by her next visit the following month. [R. 9-9, Tr. 766-

67]. During the course of Mansfield’s therapy in 2011, she described

numerous life problems and often being stressed, and expressed that 

treatment was helping overall. [Id., Tr, 800-35]. Nonetheless, she regularly 

missed appointments, including the final two that were scheduled in 

November and December. [Id.]. 

ii. Consultative and Non-Examining Sources

Mansfield underwent a consultative psychological examination with 

Dr. Michael Brady on June 2, 2011, where she reported that she suffered 

from bipolar disorder with depressive symptom that were present for the 

past five years. [R. 9-7, Tr. 470]. According to Dr. Brady’s report, 

Mansfield described her years of physical abuse, and represented that she 

left work as a cashier in 2008 because she relocated. [Id., Tr. 471]. He 

observed Mansfield to have a depressed mood, and to be accurately 

reporting her symptomology. [Id., Tr. 471-72]. A mental status exam 

resulted in a diagnosis of recurrent, moderate major depressive disorder, 

8

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 8 of 36 Pg ID 1049
learning disorder and borderline personality disorder, and Dr. Brady issued

Mansfield a GAF score of 60. [Id., Tr. 473]. He opined that Mansfield’s 

ability to relate with others and maintain concentration were fair, but that 

she might struggle to perform complex tasks and deal with normal 

workplace stressors. [Id.]. 

On June 6, 2011, another consulting doctor, Joe DeLoach, Ph.D,

reviewed Mansfield’s records and opined that her disorder caused mild 

restriction in activities of daily living, moderate difficulties in social 

functioning and moderate limitations in the ability to maintain concentration, 

persistence and pace. [R. 9-3, Tr. 95]. Dr. DeLoach found Mansfield to be

moderately limited in her abilities to understand, remember and carry out 

detailed instructions, maintain attention and concentration for extended 

periods, and work with others and accept criticism and supervision, but that 

she could complete simple tasks on a sustained basis. [Id., Tr. 98-99]. 

b. Physical Conditions

i. Treating Sources

The first record of Mansfield complaining of lower back pain is from 

2007, when she was pregnant. [R. 9-9, Tr. 878]. Dr. James Bodrie opined 

that the pain would likely resolve after delivery. [Id.]. When she 

complained about lower back pain again in January 2009, Dr. Bodie was 

9

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 9 of 36 Pg ID 1050
not sure whether the pain was secondary to kidney stones. [Id., Tr. 839]. 

A lumbar x-ray taken a year later was negative. [R. 9-7, Tr. 457]. In March 

2010, Mansfield sought treatment for back pain at an urgent care clinic 

because she was out of pain medication. [Id., Tr. 554-60). An exam 

revealed tenderness and a decreased range of motion (“ROM”) due to pain 

with a negative straight leg raising test, and she was prescribed Vicodin for 

lower back pain and sacroiliac joint dysfunction. [Id., Tr. 554-55]. 

When Dr. Bodrie examined Mansfield in April 2010 and she winced 

with even a light touch to her low back, he questioned her credibility. [R. 9-

9, Tr. 849]. However, an MRI taken after that appointment revealed a 

diffuse disc bulge at L5-S1 with impression upon the ventral thecal sac, but

no canal stenosis and no nerve root impingement. [R. 9-7, Tr. 456]. Given 

the abnormal MRI and continued symptoms, Dr. Bodrie referred her to a 

pain clinic in April 2010 . [R. 9-9, Tr. 851]. Mansfield requested that Dr. 

Bodie prescribe work restrictions, but there is no indication he did. [Id.]. 

Dr. Bodie had issued no-work prescriptions for Mansfield from December 

2009 to February 2010, but Mansfield told Dr. Tadeo that that medical 

leave was due to kidney stones. [R. 9-7, Tr. 584-87; R. 9-8,Tr. 733]. 

Pain clinic physician Dr. Sam Morkon began treating Mansfield in 

May 2010. He diagnosed her with facet joint arthropathy and degenerative 

10

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 10 of 36 Pg ID 1051
disc disease and scheduled her for epidural steroids. [R. 9-8,Tr. 621-22]. 

Over the next two months, she received a series of epidural steroid 

injections, but her response was poor, so she was prescribed Mobic (an 

anti-inflammatory pain medication) and physical therapy. [Id., Tr. 624-30]. 

Nonetheless, there is no indication in the record that she received physical 

therapy. 

In July 2010, Mansfield went to the emergency room complaining of 

back pain. [R. 9-8,Tr. 672]. The examining physician assistant (PA) found

that Mansfield’s back was not tender to palpation and had a full range of 

motion, and a straight leg raising test was negative. [Id.] The PA’s clinical 

impression was acute exacerbation of chronic lower back pain, for which 

she gave Mansfield an injection of Toradol and Norflex, as well as other 

medications for home treatment of the pain and inflammation. [Id., Tr. 672-

73]. That same month, when she established a treating relationship with 

Dr. Albert Yong, he noted tenderness in her lumbar spine. [R. 9-7, Tr. 429]. 

In August 2010, Mansfield returned to the emergency room 

complaining of back pain following a fall. [R. 9-8, Tr. 689-94]. An exam 

revealed muscle spasms and decreased range of motion secondary to 

pain, but a lumbar x-ray was normal. [Id., Tr. 690 & 696]. She was given 

Toradol, Norflex and Tylenol #3. [Id., Tr. 691]. Mansfield saw Dr. Yong 

11

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 11 of 36 Pg ID 1052
three more times in August for her back pain. His records indicate that she 

was feeling better by the end of the month, but was still mildly tender. [R.

9-7, Tr. 424-26]. 

In December 2010, Mansfield went to the emergency room after a car 

accident and was diagnosed with an acute lumbar strain. [R. 9-8, Tr. 706-

12]. When she complained of continuing back pain from the accident at 

urgent care the following week, an exam revealed a tender lumbar spine, a 

normal gait and no neurological deficits, and she was prescribed Toradol, 

Ultram and Flexeril. [R. 9-7, Tr. 499-503]. On December 22, 2010, Dr. 

Yong treated Mansfield for back pain radiating to her right leg. [Id., Tr. 414-

17]. Although he found no sensory deficits, he noted that her spine was 

tender, that a straight leg raising test was positive at 45 degrees on the left, 

and that she reported difficulty walking sometimes. [Id., Tr. 416]. Dr. Yong 

concluded that Mansfield’s acute low back pain had deteriorated, and 

prescribed Vicodin. [Id.]. Mansfield returned to the emergency room in 

January 2011 complaining of back pain and leg numbness, and she was 

given Toradol and released with a steady gait. [R. 9-8, Tr. 713-18]. 

Mansfield was evaluated by neurosurgeon Dr. S. T. Chakravarthi that 

same month. [R. 9-9, Tr. 779]. The exam revealed a normal gait except 

some left leg limp, no neurological deficits and a negative straight leg 

12

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 12 of 36 Pg ID 1053
raising test. [Id.]. The doctor recommended a repeat MRI and opined that 

surgery was not likely to improve Mansfield’s outcome. [Id.]. The January

28, 2011, MRI that followed and that was compared with the April 2010 

study showed, at L5-S1, stable mild degenerative disc disease, a mild 

annular tear, stable mild disc bulging and stable mild bilateral arthropathy. 

[Id., Tr. 781]. A bone scan conducted the same day was normal. [Id., Tr. 

783]. Dr. Chakravarthi wrote Dr. Yong a letter on February 8, 2011, noting 

that the MRI scan showed no change and that surgery was not a viable 

option due to its high failure rate. [Id., Tr. 785]. He recommended 

conservative treatment including pain injections, although those did not 

help Mansfield previously. [Id.]. Dr. Chakravarthi concluded, “At present, I 

think she is disabled because of the pain.” [Id.]. 

Dr. Yong saw Mansfield two days later, and observed tenderness in 

her lumbar spine, a straight leg restriction at 45 degrees on the left, but no 

sensory deficit. [R. 9-7, Tr. 412-13]. His impression was that her acute low 

back pain was unchanged, and prescribed Vicodin to be taken twice daily. 

[Id., Tr. 413]. Dr. Yong filled out a medical needs form for Mansfield the 

same day, opining that she is disabled from all work “for now” and was

being referred to a specialist. [Id., Tr. 578-79]. Dr. Yong believed that 

Mansfield’s condition was stable; it was not improving or deteriorating. 

13

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 13 of 36 Pg ID 1054
[Id.]. 

In an accompanying medical needs-JET form, Dr. Yong opined that 

Mansfield was disabled from work for six months and that her restrictions 

included only occasional lifting of ten pounds or less, and sitting less than 

six hours a day. [Id., Tr. 582]. Confusingly, Dr. Yong checked three

different boxes with regard to her ability to sit and stand, stating she was 

simultaneously capable of standing/walking less than two hours, at least 

two hours, and at least six hours a day. [Id.]. It appears that he may have 

attempted to cross out the latter time period. [Id.] Adding more confusion, 

the second page of this form is missing from the record, but the 

accompanying cover letter indicates that Dr. Yong certified that Mansfield 

needed medical assistance with meal preparation, shopping, laundry, and 

housework, and that she could not participate in Work First because she 

would be required to sit too long. [Id., Tr. 577]. 

Mansfield next saw Dr. Yong relative to her back pain in June 2011,

when she requested that he fill out a form for her disability application. [R.

9-9, Tr. 789-90]. At that time, she reported no pain and her spine was only 

mildly tender with no neurological deficit. [Id.]. During this same period of 

time, Mansfield was being followed for her pregnancy by her obstetrician 

Dr. Douglas Saylor. In May, 2011, Dr. Saylor permitted Mansfield to start 

14

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 14 of 36 Pg ID 1055
walking for exercise, gradually working up to a distance of two miles, as 

tolerated. [Id., Tr. 761]. However, the following month, she reported back 

pain and was diagnosed with sacroiliac dysfunction, so Dr. Saylor

prescribed a back brace. [Id., Tr. 762]. 

In November 2011, a physician assistant at Dr. Yong’s office treated 

Mansfield for back pain after the birth of her baby. [Id., Tr. 787; 791-93]. 

An exam revealed a grossly intact range of motion and mild tenderness 

with a negative straight leg raising test. [Id., Tr. 792]. The PA informed 

Mansfield that her back issues did not warrant narcotic treatment, and 

instead prescribed an anti-inflammatory, a medication to treat numbness 

and tingling symptoms, and physical therapy. [Id., Tr. 791; 793]. 

Mansfield was also treated for headaches six times in 2009 and once 

in 2010. [R. 9-7, Tr. 392-98, 514-24; R. 9-8, 593-600, 604-605, 609, 611-

14; R. 9-9, Tr. 840-44]. Migraine was the diagnosis at three of these 

appointments, while the others resulted in diagnoses including tension 

headaches, sinusitis and medication side effects. [Id.]. She reported 

improvement in symptoms with Mobic and Ultram. [R. 9-9, Tr. 841]. CT 

scans and brain MRIs taken during this period all yielded normal results. 

[R. 9-7, Tr. 451, 464, 466-67; R. 9-8, Tr. 601). An EEG conducted to rule 

out epilepsy revealed rare left temporal slow waves, but no doctor 

15

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 15 of 36 Pg ID 1056
connected this to Mansfield’s headaches. [R. 9-7, Tr. 461-63]. 

ii. Consultative and Non-Examining Sources

R. Scott Lazzara M.D. conducted a physical consultative exam of 

Mansfield on June 15, 2011. [Id., Tr. 476-80]. According to his report, 

Mansfield said that she stopped working in 2008 due to back pain, that she 

was able to sit for ten minutes, stand and walk for fifteen and that she was 

restricted from lifting more than ten pounds. [Id., Tr. 476]. Dr. Lazzara 

found that Mansfield had a slightly reduced range of motion in the 

dorsolumbar spine and walked with a mild limp, but otherwise had normal 

musculoskeletal functioning. [Id., Tr. 477-80]. He opined that Mansfield’s 

“degree of impairment appears mild, and that the only treatments 

warranted in light of her pregnancy were therapy and anti-inflammatories.” 

[Id., Tr. 480]. 

C. The ALJ’s Application of the Disability Framework

DIB and SSI are available for those who have a “disability.” See 

Colvin v. Barnhart, 475 F.3d 727, 730 (6th Cir. 2007). A “disability” is the 

“inability to engage in any 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 12 months.” 42 U.S.C. §§ 

16

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 16 of 36 Pg ID 1057
423(d)(1)(A), 1382c(a)(3)(A).

The Commissioner determines whether an applicant is disabled by 

analyzing five sequential steps. First, if the applicant is “doing substantial 

gainful activity,” he or she will be found not disabled. 20 C.F.R. § 

1520(a)(4); 20 C.F.R. § 416.920(a)(4).

3

 Second, if the claimant has not 

had a severe impairment or a combination of such impairments4 for a 

continuous period of at least 12 months, no disability will be found. Id. 

Third, if the claimant’s severe impairments meet or equal the criteria of an 

impairment set forth in the Commissioner’s Listing of Impairments, the 

claimant will be found disabled. Id. If the fourth step is reached, the 

Commissioner considers its assessment of the claimant’s residual 

functional capacity (“RFC”), and will find the claimant not disabled if he or 

she can still do past relevant work. Id. At the final step, the Commissioner 

reviews the claimant’s RFC, age, education and work experiences, and 

determines whether the claimant could adjust to other work. Id. The 

claimant bears the burden of proof throughout the first four steps, but the 

burden shifts to the Commissioner if the fifth step is reached. Preslar v. 

3 Sections 1520(a)(4) and 920(a)(4), which pertain to DIB and SSI 

respectively, list the same five-step analysis.

4 A severe impairment is one that “significantly limits [the claimant’s] 

physical or mental ability to do basic work activities.” §§ 1520(c); 920(c).

17

 

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 17 of 36 Pg ID 1058
Sec’y of Health & Human Servs., 14 F.3d 1107, 1110 (6th Cir. 1994). 

Following the five-step sequential analysis, the ALJ concluded that 

Mansfield was not disabled. At Step One, she determined that Mansfield 

had not engaged in substantial gainful activity since her alleged onset date. 

[R. 9-2, Tr. 38]. At Step Two, the ALJ found the following severe 

impairments: “bipolar disorder, learning disorder not otherwise specified, 

obesity, migraine headaches, mild degenerative disc disease of L5-S1, and 

stable mild disc bulging at L5-S1 slightly eccentric to the left with mild facet 

arthropathy.” [Id.]. At Step Three, she concluded that none of Mansfield’s 

impairments, either alone or in combination, met or medically equaled a 

listed impairment, specifically comparing them to Listings 1.04 (Disorders of 

the spine), 11.00 (Neurological), 12.02 (Organic mental disorders), and 

12.04 (Affective disorders). [Id., Tr. 39-41].

The ALJ determined that Mansfield had mild restrictions in activities 

of daily living, moderate restrictions in social function and moderate 

limitations in maintaining concentration, persistence and pace with no 

episodes of decompensation. [Id.] The ALJ then assessed Mansfield’s 

residual functional capacity (RFC), finding her capable of light work 

except that she can only occasionally balance, bend, stoop, 

kneel , crouch, or crawl . . . only occasionally climb stairs and 

ramps but never climb ladders, ropes or scaffolds [and] would 

be limited to simple, routine and repetitive tasks involving no 

18

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 18 of 36 Pg ID 1059
more than simple work related decisions [and] only occasional 

interaction with the public, coworkers, and supervisors.

[Id., Tr. 42]. Based on this RFC, the ALJ determined at Step Four that 

Mansfield could not engage in any of her past relevant work. [Id., Tr. 50]. 

However, at Step Five, the ALJ determined, with the assistance of VE 

testimony, that there were a significant number of jobs in the national 

economy that a hypothetical claimant like Mansfield could perform given 

her age, education, vocational experience and RFC. [Id., Tr. 51-52]. The 

VE testified that such a hypothetical claimant could perform the jobs of 

machine tender (7,800 jobs in the state), light assembly (14,000 jobs) or 

line attendant (4,800 jobs). [Id., Tr. 51]. 

II. STANDARD OF REVIEW

Pursuant to § 405(g), this Court’s review is limited to determining 

whether the Commissioner’s decision is supported by substantial evidence 

and was made in conformity with proper legal standards. Gentry v. Comm’r 

of Soc. Sec., 741 F.3d 708, 722 (6th Cir. 2014). 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.” Rogers v. Comm’r of Soc. Sec., 486 F.3d 234, 241 

(6th Cir. 2007) (internal quotation marks and citation omitted). Only the 

evidence in the record below may be considered when determining 

19

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 19 of 36 Pg ID 1060
whether the ALJ’s decision is supported by substantial evidence. Bass v. 

McMahon, 499 F.3d 506, 513 (6th Cir. 2007). “If the [Commissioner’s]

decision is supported by substantial evidence, it must be affirmed even if 

the reviewing court would decide the matter differently, and even if 

substantial evidence also supports the opposite conclusion.” Cutlip v. 

Sec’y of Health & Human Servs., 25 F.3d 284, 286 (6th Cir. 1994) (internal 

citations omitted). 

The significant deference accorded the Commissioner’s decision is 

conditioned on the ALJ’s adherence to governing standards. “Chief among 

these is the rule that the ALJ must consider all evidence in the record when 

making a determination, including all objective medical evidence, medical 

signs, and laboratory findings.” Gentry, 741 F.3d at 723. See also 

Rogers, 486 F.3d at 249. In other words, substantial evidence cannot be 

based upon fragments of the evidence, and “must take into account 

whatever in the record fairly detracts from its weight.” Garner v. Heckler, 

745 F.2d 383, 388 (6th Cir. 1984) (internal quotation marks and citation 

omitted). 

When the Commissioner has failed to adhere to its procedures, the 

harmless error standard applies and reversal is not warranted unless the 

claimant has been prejudiced or deprived of substantial rights. Rabbers v. 

20

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 20 of 36 Pg ID 1061
Comm’r of Soc. Sec., 582 F.3d 647, 654 (6th Cir. 2009). An ALJ’s failure to 

use an “adjudicatory tool” that does not change the outcome of the decision 

is harmless. Id. at 655-56. On the other hand, substantial errors like 

ignoring evidence in the record or failing to follow the treating physician rule 

are not harmless. Id.; Cole v. Astrue, 661 F.3d 931, 940 (6th Cir. 2011); 

Gentry, 741 F.3d at 729. An “ALJ’s failure to follow agency rules and 

regulations denotes a lack of substantial evidence, even where the 

conclusion of the ALJ may be justified based upon the record.” Cole, 661 

F.3d at 939-40 (internal quotation marks and citation omitted).

With these standards in mind, this Court finds that the ALJ’s 

determination that Mansfield is not disabled is supported by substantial 

evidence.

III. ANALYSIS

In her motion for summary judgment, Mansfield argues that the ALJ 

failed to give sufficient weight to the opinions of her treating psychiatrist, 

primary care physician and neurosurgeon, and to the lay opinion of her 

boyfriend. She further argues that the ALJ’s RFC is not supported by 

substantial evidence. The Court finds that Mansfield’s claim of errors

regarding the weighing of Dr. Tadeo’s opinion and the ALJ’s RFC have 

merit requiring remand.

21

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 21 of 36 Pg ID 1062
A. Treating Physician Rule

Mansfield argues that the ALJ’s assessment of her treating 

physician’s opinions contravenes the requirements of the treating physician 

rule. The “treating physician rule” requires an ALJ to give controlling weight 

to a treating physician’s opinions regarding the nature and severity of a 

claimant’s condition when those opinions are well-supported by medically 

acceptable clinical and diagnostic evidence, and not inconsistent with other 

substantial evidence. 20 C.F.R. § 404.1527(c)(2); Gentry, 741 F.3d at 723, 

727-29; Rogers, 486 F.3d at 242-43. “Even when not controlling, however, 

the ALJ must consider certain factors, including the length, frequency, 

nature, and extent of the treatment relationship; the supportability of the 

physician’s conclusions; the specialization of the physician; and any other 

relevant factors,” and give appropriate weight to the opinion. Gentry, 741 

F.3d at 723. In all cases, a treating physician’s opinion is entitled to great 

deference. Id.

When declining to give a treating physician’s opinion controlling 

weight, an ALJ must provide good reasons. “Those good reasons must be 

‘supported by the evidence in the case record, and must be sufficiently 

specific to make clear to any subsequent reviewers the weight the 

adjudicator gave to the treating source's medical opinion and the reasons 

22

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 22 of 36 Pg ID 1063
for that weight.’” Blakley v. Comm'r Of Soc. Sec., 581 F.3d 399, 406-07 

(6th Cir. 2009) (quoting Soc. Sec. Rul. 96–2p, 1996 WL 374188, at *5).

Mansfield argues that the ALJ gave inadequate consideration to Dr. 

Tadeo’s mental RFC. [R. 9-7, Tr. 570-71]. The Court agrees. The ALJ 

described Dr. Tadeo’s medical RFC as stating that “the claimant was 

markedly limited in her ability to understand and remember detailed 

instructions, in her ability to carry out detailed instructions, and in her ability 

to maintain attention and concentration for extended periods.” [R. 9-2, Tr. 

48]. She did not describe Dr. Tadeo’s many other restrictions, including the 

moderate limitations that she placed on Mansfield’s ability to maintain a 

regular schedule, work without supervision or distraction, make simple 

work-related decisions, complete a normal workday without interruption 

from her symptoms, interact with co-workers and the general public, accept 

instructions and respond appropriately to criticism from supervisors. [R. 9-

7, Tr. 570-71]. Additionally, the ALJ never assigned any weight to Dr. 

Tadeo’s opinion, or gave good reasons for refusing to assign it controlling 

weight. Instead, the ALJ gave “great weight” to the mental health opinion 

of Dr. Brady, the consulting examiner, that Mansfield “could relate and 

interact with others, including coworkers and supervisors,” and that her 

“ability to maintain concentration was fair.” [Id.]. 

23

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 23 of 36 Pg ID 1064
Violation of the treating physician rule may sometimes result in only 

harmless error, such as when the opinion is patently deficient, where the 

violation was de minimus, or where the goals of the procedural protection 

are otherwise met despite the lack of compliance. Wilson v. Comm’r of 

Soc. Sec., 378 F.3d 541, 547 (6th Cir. 2004). None of those exceptions 

exist here. 

The error here is not de minimus because, if Dr. Tadeo’s opinion

were given controlling weight, Mansfield would necessarily be found to 

require additional restrictions that might result in finding that there are not a 

sufficient number of jobs in the workplace she could perform. Specifically, 

Dr. Tadeo’s findings call into question Mansfield’s ability to perform simple,

routine tasks, to make simple work related decisions and to work with 

limited supervision, as required by the ALJ’s RFC. Additionally, although 

the Commissioner argues that Dr. Tadeo’s opinion is patently deficient, it 

contradicts itself by conceding that the ALJ incorporated some of Dr. 

Tadeo’s restrictions in her RFC. 

The Commissioner’s argument that the ALJ implicitly weighed Dr. 

Tadeo’s opinion, thereby meeting the goal behind the procedural

safeguard, lacks merit. First, the treating physician rule “is not simply a 

formality,” but is a safeguard put in place to inform otherwise bewildered 

24

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 24 of 36 Pg ID 1065
claimants why their physicians’ opinions were rejected and to permit

meaningful review on appeal. Cole v. Astrue, 661 F.3d 931, 937 (6th Cir. 

2011). Further, since the ALJ’s analysis reached the fifth step, she had the 

burden to accurately assess Mansfield’s impairments. Howard v. Comm'r 

of Soc. Sec., 276 F.3d 235, 238 (6th Cir. 2002). The Commissioner cannot 

carry its burden by implication. Moreover, there is no evidence in the ALJ’s 

opinion of an implicit attack on Dr. Tadeo’s opinion; the ALJ never once 

challenged Dr. Tadeo’s findings in light of the other evidence in the record.

This error, therefore, requires remand. 

B. RFC for Light Work

When testifying that Mansfield could perform other jobs, the VE relied 

upon a hypothetical that incorporated the ALJ’s finding that Mansfield had 

an RFC that allowed for light work, with no restrictions on the substantial 

periods of walking, standing or sitting presumed under that classification. 

20 C.F.R. §§ 404.1567(b), 416.967(b). The RFC for light work also 

assumes that Mansfield is capable of lifting up to 20 pounds and to 

frequently lift 10 pounds. Id. Thus, the Commissioner has the burden to 

demonstrate by substantial evidence in the record that Mansfield has the 

capacity for substantial periods of walking, standing or sitting without 

limitation, for lifting up to 20 pounds, and for lifting 10 pounds frequently. 

25

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 25 of 36 Pg ID 1066
Howard, 276 F.3d at 238. 

Mansfield argues that the ALJ improperly gave insufficient weight to 

the opinions of Dr. Chakravarthi and Dr. Yong that she was disabled, and 

to Dr. Yong’s restrictions as outlined in his February 2011 JET form. [R. 9-

9, Tr. 785; R. 9-7, Tr. 578-79, 582]. Mansfield further faults the ALJ for not 

considering the missing second page of Dr. Yong’s medical needs-JET 

forms, for inferring from an unchecked box that Dr. Yong meant that 

Mansfield was no longer disabled from performing any work activity, and for 

failing to clear up the ambiguity in the form caused by Dr. Yong checking 

off boxes indicating both that Mansfield could stand for no more than two 

hours and that she could stand up to six hours. As a result, Mansfield 

argues, the ALJ erred by failing to incorporate Dr. Yong’s limitations in her 

RFC. The Court agrees that there are obvious gaps in the record that the 

ALJ should have addressed, that the ALJ did not give good reasons for not 

following Dr. Yong’s weight and sitting restrictions, and that the ALJ’s RFC 

is not supported by substantial evidence in the record.

Ordinarily, “[t]he burden of providing a complete record, defined as 

evidence complete and detailed enough to enable the Secretary to make a 

disability determination, rests with the claimant.” Landsaw v. Secretary of 

Health and Human Services, 803 F.2d 211, 214 (6th Cir. 1986). However, 

26

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 26 of 36 Pg ID 1067
“[w]here there are obvious gaps in the record, the ALJ has the duty to 

develop the administrative record with respect to the missing evidence.” 

Kendall v. Astrue, No. CIV.A. 2:10-263-DCR, 2011 WL 4388794, at *5 

(E.D. Ky. Sept. 20, 2011). This duty arises from the fact that Social 

Security proceedings are not adversarial, so the ALJ must “investigate facts 

and develop the arguments both for and against granting benefits.” Sims v. 

Apfel, 530 U.S. 103, 110–11 (2000). Courts evaluate whether an ALJ has 

failed to fully develop the record on a case-by-case basis. Umara v. 

Comm'r of Soc. Sec., No. 2:12-CV-1119, 2013 WL 6001003, at *4 (S.D. 

Ohio Nov. 12, 2013), adopted by 2014 WL 116370 (S.D. Ohio Jan. 10, 

2014). “As long as there is sufficient evidence in the record for him to 

make a decision regarding the claimant’s disability, it is within the discretion 

of an ALJ to close the record.” Penn v. Comm'r of Soc. Sec., No. 

1:10CV1885, 2012 WL 646057, at *8 (N.D.Ohio Feb.28, 2012).

Of further import, while it is true that the determination of disability is 

reserved for the Commissioner and the ALJ was not required to give 

controlling weight to Mansfield’s treating physicians’ opinions that she is 

disabled, the ALJ was still required to carefully consider those opinions and

to seek clarification when needed. 

[O]ur rules provide that adjudicators must always carefully 

consider medical source opinions about any issue, including 

27

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 27 of 36 Pg ID 1068
opinions about issues that are reserved to the Commissioner. 

For treating sources, the rules also require that we make every 

reasonable effort to recontact such sources for clarification 

when they provide opinions on issues reserved to the 

Commissioner and the bases for such opinions are not clear to 

us.

SSR 96–5p, 1996 WL 374183, at *2. See also Ferguson v. Comm'r, 628 

F.3d 269, 273 (6th Cir.2010) (recontact required when ALJ finds that 

treating physician’s opinion is not supported by evidence in the record, but 

the ALJ is uncertain about the bases for the opinion).

In this case, the ALJ gave little weight to the opinions of Dr. Yong and 

Dr. Chakravarthi that Mansfield was disabled, finding simply that their 

opinions were “inconsistent with credible medical evidence of record,” and 

that Dr. Yong’s opinion was ambiguous with respect to Mansfield’s walking 

and standing restrictions. [R. 9-2, Tr. 46]. The ALJ appears to have opined 

that Manfield’s diagnoses of mild degenerative disc disease, stable mild 

bulging disc and stable mild bilateral facet arthropathy rendered her 

symptoms mild and her functional abilities mildly limited. [R. 9-2, Tr. 50]. 

However, Dr. Yong found that Mansfield’s conditions caused “acute” low 

back pain, and by “stable” he meant neither deteriorating nor improving. 

[R. 9-7, Tr. 412-13, 578-79]. Dr. Chakravarthi likewise determined that that 

Mansfield’s “mild” bulging disc caused disabling pain. [R. 9-9, Tr. 779]. In 

violation of SSR 96–5p, the ALJ failed to carefully consider that Drs. Yong 

28

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 28 of 36 Pg ID 1069
and Chakravarthi believed that Mansfield’s objectively determined medical 

conditions could cause her acute pain before finding that she could walk, 

stand or sit without restrictions. 

The ALJ also failed to recontact Dr. Yong for clarification regarding 

the bases for his opinions that she found ambiguous, contrary to the 

directive of SSR 96-5p. She further ignored the gap in the record created 

by the missing second page to Dr. Yong’s JET form. That gap should have 

been obvious to the ALJ because the cover letter accompanying the form

stated that Dr. Yong certified that Mansfield had a medical need for 

assistance with meal preparation, shopping, laundry, and housework, and 

that she could not participate in Work First because she would be required 

to sit too long. [R. 9-7, Tr. 577]. 20 C.F.R. § 404.1527(c)(2); Gentry, 741 

F.3d at 723, 727-29; Rogers, 486 F.3d at 242-43. 

Instead of seeking to clarify Dr. Yong’s JET’s form, the ALJ used the 

ambiguity as a reason to assign little weight to his opinion despite the fact 

that he was a treating physician. [R. 9-2, Tr. 46]. The ALJ’s failure to 

clarify Dr. Yong’s ambiguous restrictions in violation of SSR 96-5p cannot 

be considered a “good reason” for not giving Dr. Yong’s opinion controlling 

weight.

Moreover, the ALJ was required give sufficiently specific reasons for 

29

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 29 of 36 Pg ID 1070
not giving controlling weight to Dr. Yong’s opinion that Mansfield could lift 

only ten pounds occasionally and could sit for no more than six hours a 

day. Blakley, 581 F.3d at 406-07. In conclusory manner, the ALJ stated 

that Dr. Yong’s opinion was contradicted by credible medical evidence of 

record, but she cited no such medical evidence that would support her 

finding that Mansfield can lift up to twenty pounds and up to ten pounds 

frequently, or could sit for more than six hours. 

Nor did the ALJ cite medical evidence to establish that Mansfield 

could walk or stand without restriction. This omission was contrary to the 

requirement that the ALJ provide a narrative discussion to support each 

conclusion.

The RFC assessment must include a narrative discussion describing 

how the evidence supports each conclusion, citing specific medical 

facts (e.g., laboratory findings) and nonmedical evidence (e.g., daily 

activities, observations). In assessing RFC, the adjudicator must 

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 

describe the maximum amount of each work-related activity the 

individual can perform based on the evidence available in the case 

record. The adjudicator must also explain how any material 

inconsistencies or ambiguities in the evidence in the case record 

were considered and resolved.

S.S.R. 96–8p, 1996 WL 374184, at *6–7 (internal footnote omitted). Here, 

the ALJ did not discuss at all the bases for her opinions that Mansfield was 

able to perform the standing, walking, sitting or lifting required by light work 

30

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 30 of 36 Pg ID 1071
in an ordinary work setting on a regular and continuing basis.

Moreover, instead of relying on medical expertise, the ALJ took it 

upon herself to frame an RFC by evaluating the “relatively normal findings” 

from Mansfield’s clinical examinations. [R. 9-2, Tr. 50]. In this regard, the 

ALJ erred by “playing doctor.” Allen v. Comm'r of Soc. Sec., No. 12–

15097, 2013 U.S. Dist. LEXIS 150236, *44–45, 2013 WL 5676254 

(E.D.Mich. Sept. 13, 2013) adopted by 2013 U.S. Dist. LEXIS 149851, 

2013 WL 5676251 (E.D.Mich. Oct. 18, 2013). “[C]ourts have stressed the 

importance of medical opinions to support a claimant’s RFC, and cautioned 

ALJs against relying on their own expertise in drawing RFC conclusions 

from raw medical data.” Id. (collecting cases). When, as here, the claimant 

suffers from well-documented impairments, “an expert medical advisor is 

necessary to properly evaluate plaintiff's impairments, symptoms and 

functional limitations.” Id. at *16.

Notably, Dr. Lazzara, the consultant whose opinion the ALJ appeared 

to give great weight despite never saying so [see R. 9-2, 45 & 50], 

rendered no opinion regarding Mansfield’s abilities to walk, stand, sit or lift 

weight. [R. 9-7, 476-80]. Given the requirements of S.S.R. 96–8p for 

evidence supporting each conclusion, Dr. Lazzara’s conclusion that 

Mansfield’s “impairment appears mild” is too vague to support the ALJ’s 

31

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 31 of 36 Pg ID 1072
RFC. The ALJ’s greater reliance on Dr. Lazzara instead of Mansfield’s 

treating physicians was clear error, since he examined her only once and 

did not review the results of her MRI studies. [Id.] See 20 C.F.R. § 

404.1527(d)(2) (treating sources provide a longitudinal picture of medical 

impairments than cannot be obtained from consultants).

The ALJ ostensibly relied in part on Mansfield’s description of her 

activities of daily living to conclude that she is “not as limited as one would 

expect,” stating: 

The claimant is apparently able to care for multiple young 

children at home, which can be quite demanding both 

physically and emotionally, without great assistance. The 

claimant reported in her function reports that she is able to 

clean up the house, perform personal care activities, cook, 

shop, drive, walk for a long time, and watch television.

[R. 9-2, Tr. 50]. However, contrary to the ALJ’s portrayal of Mansfield as 

an active mother, Mansfield indicated that she has difficulty driving long 

distances because sitting for too long hurts her back; that she cannot stand 

for too long; that she needs help to lift her children and other heavy objects, 

and/or she experiences pain; that she can do a few chores around the 

house, but washing a sink full of dishes, vacuuming and sweeping hurt her 

back; that she often has help preparing food; that she needs breaks while 

performing household chores; and that she shops only a couple of times a 

month. [R. 9-2, Tr. 65-66, 70-71; R. 9-6, Tr. 219-222]. Mansfield did 

32

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 32 of 36 Pg ID 1073
represent that she could walk for a long time, but that was in a 

questionnaire that she signed on August 18, 2008, well before she began 

treating with Dr. Yong and well before the January 4, 2012 hearing. [R. 9-

6, Tr. 224]. Regardless, Mansfield unequivocally described limitations on 

her ability to sit or stand for long periods of time and to lift much weight, so

the ALJ’s ostensible reliance on Mansfield’s description of her daily 

activities to justify a RFC allowing for the sitting, standing and demands of 

light work cannot be justified.

5

For these reasons, this Court recommends that this matter be 

remanded in order for the ALJ to clarify whether or not Mansfield’s treating 

physicians believe that her back ailments allow for walking, standing and 

sitting without limitation, and for lifting up to 20 pounds and up to 10 pounds 

frequently. If not, and if there is no medical evidence to the contrary, the 

ALJ should pose a new hypothetical to the VE that incorporates the 

necessary additional limitations.

C. Mansfield’s Other Alleged Errors

The Court notes for the record that Mansfield’s other alleged errors 

5 The Court also disagrees with the ALJ’s statement that Mansfield’s 

boyfriend’s is “entirely inconsistent” with her statements regarding her 

limitations. [AR 9-2, Tr. 46-47]. While there are some distinctions between 

their statements, John Taylor’s description of Mansfield’s daily activities, 

and difficulties with standing, cleaning and lifting have some consistency 

with Mansfield’s testimony. [AR 9-6, Tr. 291-298]. 

33

 

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 33 of 36 Pg ID 1074
do not warrant reversal. First, her claims that the ALJ erred in not 

considering various doctors’ GAF scores is without merit. The Sixth Circuit 

has routinely held that while GAF scores are helpful, they are not required 

to be incorporated into an RFC in order for it to be accurate. Howard v. 

Comm’r of Soc. Sec., 276 F.3d 235, 241 (6th Cir. 2002); White v. Comm’r 

of Soc. Sec., 572 F.3d 272, 276 (6th Cir. 2009); see also 65 Fed. Reg. 

50746, 50764-65 (2000). 

The ALJ also did not err in not imposing any specific limitations 

regarding Mansfield’s headaches. Mansfield herself noted that these 

headaches had decreased in frequency over time, and the medical records 

showed she was last treated for them in 2010, almost two years prior to the 

hearing, [R. 9-2, Tr. 75-77] and none of Mansfield’s doctors mentioned her 

headaches or issued limitations as a result of them. 

IV. CONCLUSION

The Court finds that the ALJ erred insofar as she failed to follow the 

treating physician rule with regard to Dr. Tadeo’s opinion evidence, and 

that substantial evidence does not support an RFC that includes light work. 

For this reason, the Court RECOMMENDS that Mansfield’s Motion for 

Summary Judgment [R. 16] be GRANTED IN PART to the extent it seeks 

remand but DENIED IN PART to the extent it seeks reversal and award of 

34

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 34 of 36 Pg ID 1075
benefits, the Commissioner’s Motion [R. 19] be DENIED and this case be 

REMANDED for further consideration consistent with this Report and 

Recommendation.

s/Elizabeth A. Stafford

ELIZABETH A. STAFFORD

United States Magistrate Judge

Dated: April 17, 2015

NOTICE TO THE PARTIES REGARDING OBJECTIONS

Either party to this action may object to and seek review of this 

Report and Recommendation, but must act within fourteen days of service 

of a copy hereof as provided for in 28 U.S.C. § 636(b)(1) and Fed.R.Civ.P. 

72(b)(2). Failure to file specific objections constitutes a waiver of any 

further right of appeal. Thomas v. Arn, 474 U.S. 140 (1985); Howard v. 

Secretary of HHS, 932 F.2d 505 (6th Cir. 1991); United States v. Walters, 

638 F.2d 947 (6th Cir. 1981). Filing objections which raise some issues but 

fail to raise others with specificity will not preserve all objections that party 

might have to this Report and Recommendation. Willis v. Secretary of 

HHS, 931 F.2d 390, 401 (6th Cir. 1991); Smith v. Detroit Fed'n of Teachers 

Local 231, 829 F.2d 1370, 1373 (6th Cir. 1987). A copy of any objection 

must be served upon this Magistrate Judge. E.D. Mich. LR 72.1(d)(2).

35

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 35 of 36 Pg ID 1076
Each objection must be labeled as “Objection #1,” “Objection #2,” 

etc., and must specify precisely the provision of this Report and 

Recommendation to which it pertains. Not later than fourteen days after 

service of objections, the non-objecting party must file a response to 

the objections, specifically addressing each issue raised in the objections in 

the same order and labeled as “Response to Objection #1,” “Response to 

Objection #2,” etc. The response must be concise and proportionate in 

length and complexity to the objections, but there is otherwise no page 

limitation. If the Court determines that any objections are without merit, it 

may rule without awaiting the response.

CERTIFICATE OF SERVICE

The undersigned certifies that the foregoing document was served 

upon counsel of record and any unrepresented parties via the Court’s ECF 

System to their respective email or First Class U.S. mail addresses 

disclosed on the Notice of Electronic Filing on April 17, 2015.

s/Marlena Williams

MARLENA WILLIAMS

Case Manager

36

2:14-cv-11766-AJT-EAS Doc # 21 Filed 04/17/15 Pg 36 of 36 Pg ID 1077