UNITED STATES DISTRICT COURT 

SOUTHERN DISTRICT OF OHIO 

WESTERN DIVISION AT DAYTON 

LAURA ORT, 

Plaintiff, 

vs. 

COMMISSIONER OF THE SOCIAL 

SECURITY ADMINISTRATION, 

Defendant. 

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Case No. 3:18-cv-286 

Magistrate Judge Sharon L. Ovington 

(by full consent of the parties) 

DECISION AND ENTRY 

I. Introduction 

In July 2014, Plaintiff Laura Ort applied for period of disability, Disability 

Insurance Benefits, and Supplemental Security Income. Her applications were denied 

initially and upon reconsideration. After a hearing, Administrative Law Judge (ALJ) 

Deborah F. Sanders concluded that she was not eligible for benefits because she is not 

under a “disability” as defined in the Social Security Act. Plaintiff brings this case 

challenging the Social Security Administration’s denial of her applications benefits. 

The case is before the Court upon Plaintiff’s Statement of Errors (Doc. #8), the 

Commissioner’s Memorandum in Opposition (Doc. #11), Plaintiff’s Reply (Doc. #12), 

and the administrative record (Doc. #5). 
2

Plaintiff seeks a remand of this case for payment of benefits or, at a minimum, for 

further proceedings. The Commissioner asks the Court to affirm ALJ Sanders’s nondisability decision. 

II. Background 

Plaintiff asserts that she has been under a “disability” since January 31, 2014. She 

was forty-four years old at that time and was therefore considered a “younger person” 

under Social Security Regulations. See 20 C.F.R. §§ 404.1563(c), 416.963(c). She has at 

least a high school education. See id. §§ 404.1564(b)(4), 416.964(b)(4).1

A. Plaintiff’s Testimony 

Plaintiff testified at the hearing before ALJ Sanders that she stopped working 

because “[m]y body just literally quit. I worked until I dropped.” (Doc. #5, PageID

#221). She does not know the exact date she stopped working because she has some 

long-term memory issues from a motorcycle accident. Id. She was the passenger on a 

motorcycle that “hit a rock just the wrong way.” Id. at 222. She was “ejected and thrown 

about 20 feet.” Id. She sustained a head injury and broke her back. Id. As a result of the 

head injury, she began having seizures again (as a child, she was epileptic). Id. Her last 

seizure was in 2011. Id. at 223. 

Plaintiff explained that she in not able to work because of chronic pain. Id. She 

described her problem as a catch 22; “my body needs to rest, but if it rests too long with 

the arthritis that I have, and all the bone problems and joint problems, if I am inactive for 

 

1

 The remaining citations will identify the pertinent Disability Insurance Benefits Regulations with full 

knowledge of the corresponding Supplemental Security Income Regulations. 
3

more than 30 minutes at a time, it’s severe. The more I don’t move, the more I tighten 

up.” Id. When she moves, her arthritis causes her to pop, crack, and snap. Id. But she 

tries to keep going. Id. Plaintiff can sit in a chair for five to thirty-five minutes at a time, 

depending on her positioning and the chair. Id. at 223-24, 228. She can stand for five to 

ten minutes before she has to sit down. Id. at 229. She thought she could stand for a total 

of one hour in an eight-hour day. Id. at 240. Sometimes, she cannot sleep for a day or 

two at a time because she is in so much pain. Id. at 224. Other times, she can sleep for 

twelve to sixteen hours. Id. 

Plaintiff has fibromyalgia. At times, she can touch her skin and it feels bruised. 

Id. at 224. She takes several pain medications. Her seizure medicine, gabapentin, is 

considered a pain medication as well. Id. at 233. She uses lidocaine patches every day 

and takes methocarbamol as needed. Id. Her doctors sometimes prescribe Percocet. Id. 

Plaintiff has lower back pain that travels to the front of her left leg at the top and 

into her tailbone area. Id. at 231-33. On a scale from one to ten, her pain is typically at 

five to six. Id. at 233. She has difficulty bending over and stooping down. Id. at 231. 

She cannot crouch or crawl. Id. She uses a device to help put on her socks because of 

her SI joints and a steel bar in her back that prevents her from bending. Id. She also uses 

a long shoehorn to get her shoes on and off. Id. at 232. After her back surgery in 

February 2016, Plaintiff continued to see pain management but not on a regular basis. Id. 

She has also had to get injections in her back because of pain. Id. 

Additionally, Plaintiff has right shoulder pain. Id. at 234. Her doctors 

recommended surgery but she had to choose whether to have back surgery or shoulder 
4

surgery first, and she chose back surgery. Id. She has difficulty lifting her right arm over 

her shoulder, out to the front, and out to the side. Id. 

Plaintiff has problems with both ankles as well. Id. at 235. She has severe pain 

that starts three to five inches above her ankles and goes to the tops of her feet. Her 

doctors have not yet determined the cause. Id. She had pain in her heels but it stopped 

after she had injections. Id. 

One of her doctors prescribed Plaintiff a cane a year before the hearing to help her 

walk and prevent her from falling. Id. at 228-29. Plaintiff also used a walker with a seat 

before her back surgery. Id. at 228. Nonetheless, she falls every three to four weeks. 

She has issues with her hands. She has tendinitis and possibly carpal tunnel. Id. at 

239. Her hands ache, particularly between her index finger and thumb. Id. She has 

difficulty holding a pen. She drops things without realizing it is going to happen. Id. On 

her left hand, her index finger and thumb lock up in strange positions. Id. 

Plaintiff has breathing issues. At times her oxygen level drops to dangerous 

levels. Id. at 225. When that happens, she gets disoriented and confused. Id. It first 

happened when she had back surgery and it happened again when she had gallbladder 

surgery. Id. at 226. 

Plaintiff’s pain has affected her mental health. “It makes me very depressed and 

angry, hateful. It makes me withdraw, I’ve lost people in my life, a lot of people.” Id. at 

238. She has depression and anxiety. She has crying spells at least once a week that last 

for a minute or a minute and a half. Id. at 237. Thoughts about her life—not having a 

boyfriend or normal life—trigger crying spells. Id. She has mood swings, “[m]ore on the 
5

negative side, the depressed side, angry.” Id. She described her energy level as “[v]ery 

poor and her ability to concentrate on a task as “[n]ot very well.” Id. Plaintiff sees her 

psychiatrist, Dr. Moody, once a month. Id. at 236. He prescribes Celexa and Xanax. Id. 

Plaintiff uses marijuana two to three times a week to take her mind off her pain. 

Id. at 230. She ingests it rather than smoking it. Id. She also smokes cigarettes, albeit 

not very often. Id. at 230-31. She smokes less than half a pack per month. Id. at 231. 

Plaintiff testified that she is “basically homeless” and “float[s] from friend to 

friend’s house.” Id. at 217. She does not have any responsibility for cleaning or chores. 

Id. at 219. She does laundry once per week. However, she only puts the clothes in the 

washer and folds them after they dry. Her friend takes them out, puts them in the dryer, 

and gets them out. Id. 

During the day, she watches TV, looks at Facebook, deals with her body, and 

keeps moving and resting. Id. at 218. She has a driver’s license but only drives to 

appointments and when necessary. Id. In an average week, Plaintiff has two to four 

appointments that last for up to an hour and sometimes more. Id. at 224. She sees a 

psychologist once a week, psychiatrist once a month, pulmonologist twice a month (at 

least for that month), and orthopedic doctors once or twice a month. Id. at 224-25, 227. 

She drives to the grocery store two to four times a week because she cannot carry heavy 

bags and she has no permanent place to live. Id. at 219. For example, she cannot carry a 

gallon of milk to she buys pints and half gallons. Id. 
6

B. Medical Opinions 

i. Barbara A. Bennett, D.O. 

Dr. Bennett, Plaintiff’s treating family-care physician since 2005, completed 

interrogatories and a medical assessment in August 2016. She has treated Plaintiff for 

anxiety, chronic pain, depression, osteoarthritis, arthritis, neuropathy, asthma, COPD, 

reflux, joint pain, muscle pain, fibromyalgia, seizures, fatigue, amnesia, headaches, and 

ankle, back, neck, and hip pain. Id. at 1061. 

Dr. Bennett opined Plaintiff could frequently carry up to five pounds. Id. at 1056. 

Plaintiff tremors, osteoarthritis, and back issues make it hard for her to lift or carry 

anything heavy or for a long period of time. Id. at 1055. She can stand and walk for five 

minutes at a time for a total of thirty minutes in an eight-hour day. Id. at 1056. She can 

sit for thirty minutes without interruption for a total of five hours in an eight-hour 

workday. Id. She cannot climb, balance, stoop, crouch, kneel, or crawl. Id. at 1057. Her 

ability to reach, handle, finger, feel, push, or pull are also affected by her impairments. 

Id. Specifically, she has trouble doing those things due to her chronic pain and tremors. 

Id. She should avoid all exposure to heights, moving machinery, chemical, temperature 

extremes, vibration, dust, fumes, and humidity because they could cause lung issues, 

coughing, an inability to breath, and increased pain. Id. at 1058. Dr. Bennett concluded 

Plaintiff does not have the residual functional ability on a sustained basis to do sedentary 

work. Id. She explained, “[Plaintiff] has [a] hard time getting to her appointments [and] 

sitting in our office, she is trying physical therapy but [is] still having chronic widespread 

pain.” Id. 
7

Additionally, Dr. Bennett opined that the combined effects of Plaintiff’s physical 

and mental impairments result in a greater degree of functional limitation than her 

physical impairments alone. Id. at 1061. She explained that Plaintiff “has suffered from 

chronic pain for several years and ... it has caused depression [and] anxiety that both 

[a]ffect her life now.” Id. at 1061. 

Because Plaintiff’s pain and depression affect her sleep, Dr. Bennett opined that 

Plaintiff could not be prompt and regular in attendance on a sustained basis. Id. at 1062. 

Further, she cannot demonstrate reliability because she has chronic pain and does not 

know when she will have flare ups. Id. at 1065. 

She cannot behave in an emotionally stable manner, relate predictably in social 

situations, or respond appropriately to supervision, co-workers, and customary work 

pressures. Id. at 1063-64. She does not like social situations and once she starts feeling 

uncomfortable, she could have a panic attack. Id. at 1064. She also would struggle to 

communicate with co-workers “because she would not want to communicate [with] 

anyone.” Id. at 1066. Pressure at work, including criticism from supervisors could cause 

her to have a breakdown. Id. at 1063, 1067. 

She cannot understand, remember, and carry out simple work instructions without 

requiring close supervision. Id. at 1064. She has a history of amnesia and she could 

forget simple instructions. Id. She cannot maintain concentration and attention for 

extended periods because she has issues remembering things (due to her motor vehicle 

accident) and cannot focus on something for two hours. Id. at 1065. 
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Plaintiff has extreme restrictions of activities of daily living; extreme difficulties 

in maintaining social functioning; and extreme deficiencies in concentration, persistence 

or pace resulting in failure to complete tasks in a timely manner. Id. at 1068. 

ii. Debra K. Sowald, Psy.D. 

Plaintiff’s treating psychologist, Dr. Sowald, completed a mental impairment 

questionnaire in October 2016. She diagnosed Major Depressive Disorder; Post 

Traumatic Stress Disorder; Generalized Anxiety Disorder; Panic Disorder with 

Agoraphobia; Somatic Symptom Disorder; Attention Deficit Hyperactivity Disorder, 

Combined Type; and Pain Disorder with related psychological factors. Id. at 1145. 

Further, Dr. Soward indicated that other conditions affect Plaintiff’s psychological status, 

including chronic back and neck pain, back surgery, tailbone pain, fibromyalgia, bursitis, 

leg and hip problems, chronic obstructive pulmonary disease, ADHD, irritable bowel 

syndrome, gall bladder issue (polyp is blocking it), heel and ankle pain, and seizures. Id.

at 1145-47. 

Plaintiff’s symptoms include poor memory, sleep disturbance, personality change 

(with health problems and pain), recurrent panic attacks, paranoia or inappropriate 

suspiciousness, difficulty thinking or concentrating, social withdrawal or isolation (Laura 

is working on this in therapy), decreased energy, intrusive recollections of atraumatic 

experience, generalized persistent anxiety, somatization unexplained by organic 

disturbance, depression, severe and chronic pain. Id. at 1147-48. Plaintiff also struggles 

with personal hygiene and “cannot get herself to shower regularly, only when she is 

going to a medical appointment.” Id. at 1148. 
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Dr. Sowald indicated that Plaintiff’s symptoms are severe—45 to 50 out of 100. 

She explained, “Laura is unable to work, avoidant of crowds, unable to take adequate 

care of herself or her environment; and she is anxious in small groups. Her pain rules out 

most activities. She seldom even watches television. She sleeps most of the day. Her 

PTSD keeps her avoidant of many situations and relationships, and makes her anxious 

when driving.” Id. at 1147. 

Dr. Sowald opined, “Laura’s many disorders leave her immobilized at times ....” 

Id. at 1148. “[Her] anxiety causes her to shake visibly, and increases all of her other pain 

disorders. Her depression leaves her unable to take care of her personal care and her 

environment, and leaves her exhausted by limited exertion.” Id. at 1150. Because she 

cannot work, she has struggled with her finances. Id. at 1148. She stopped opening her 

mail for years because she could not pay any bills. Id. She was homeless and had to stay 

with friends because the State of Ohio repossessed her grandmother’s condominium, 

where Plaintiff lived. Id. And, her inability to work “makes her feel terrible, as if she has 

no purpose in life, and leaves her hoping that her next life will be better. She visualizes 

about it.” Id. 

Plaintiff’s treatment includes individual and group psychotherapy as well as 

psychotropic medications. Id. at 1149. She also uses an Alpha-Stim AID unit2

 to help 

 

2

 According to its website, “The Alpha-Stim electrotherapy device relieves post-traumatic, acute and 

chronic pain through painless electrical stimulation delivered via two handheld Smart Probes.” ALPHASTIM, www.alpha-stim.com (last visited Sept. 18, 2019). 
10

control her frequent anxiety, decrease her depression, assist her in relaxing to sleep, and 

aid in decreasing her pain level. Id. at 1150. 

Dr. Sowald noted that Plaintiff has “weird reactions to medications.” Id. at 1149. 

“With her adult ADHD, Laura has a unique response to Xanax of it energizing her and 

helping her focus to get tasks done .... Unfortunately, with the State of Ohio pressuring 

physicians to decrease prescribing Benzodiazepines, Laura’s Xanax has been decreased 

to a level where she is getting immobilized again. With the decrease, Laura’s feeling 

functional has decreased.” Id. at 1149-50. 

Dr. Sowald opined that, overall, Plaintiff has made steady progress and her 

prognosis is good. Id.at 1150. However, “she has quite a distance to go to be functioning 

at the level she needs to be at.” Id. Dr. Sowald opined that, on average, Plaintiff would 

be absent from work more than three times a month because of her impairments and 

treatment. Id. at 1151. Further, she has extreme restrictions of activities of daily living; 

extreme difficulties in maintaining social functioning; extreme deficiencies in 

concentration, persistence or pace resulting in failure to complete tasks in a timely 

manner; and extreme episodes of deterioration or decompensation in work. Id. 

iii. Fred Greaves, Ed.D., & Juliette Savitscus, Ph.D. 

Dr. Greaves reviewed Plaintiff’s records in December 2014 and found she had 

several severe impairments: disorders of back–discogenic and degenerative; 

dysfunction–major joints; peptic ulcer; chronic liver disease; COPD; asthma; disorders of 

muscle, ligament, and fascia; fibromyalgia; affective disorders; and anxiety disorders. Id.

at 261. He opined that she has a mild restriction of activities of daily living; moderate 
11

difficulties in maintaining social functioning; moderate difficulty in maintaining 

concentration, persistence or pace; and no episodes of deterioration or decompensation. 

Id. Plaintiff is able to perform simple routine tasks in an environment that does not 

require fast pace or high production demands. Id. at 266. She is able to have brief, 

superficial contact with others and can adapt to minor, infrequent changes in the 

workplace. Id. at 267. 

In August 2015, Dr. Savitscus reviewed Plaintiff’s records and agrees with the 

majority of Dr. Greaves’ findings. However, she found that Plaintiff had one additional 

severe impairment—ADD/ADHD. Id. at 280. Further, she has a moderate restriction of 

activities of daily living. Id. Plaintiff “retains the ability to understand and remember 1-

3 step tasks consistently and 4-5 step tasks occasionally.” Id. at 285. 

iv. Elizabeth Das, M.D., & Leon D. Hughes, M.D. 

Dr. Das reviewed Plaintiff’s records in December 2014. She opined that Plaintiff 

could lift and/or carry twenty pounds occasionally and ten pounds frequently. Id. at 263. 

She can stand for a total of six hours in an eight-hour workday and can sit for six hours 

total. Id. She can occasionally push and/or pull with her upper and lower left 

extremities. Id. She cannot climb ladders, ropes, or scaffolds. Id. She can occasionally 

climb ramps/stairs, stoop, kneel, crouch, and crawl. Id. at 263-64. She can frequently 

balance. Id. at 264. She is limited to occasional overhead reaching. Id. She should 

avoid concentrated exposure to extreme heat or cold; and humidity; fumes, odors, dusts, 

gases, poor ventilation. Id. at 264-65. She should avoid even moderate exposure to 
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hazards such as machinery or heights. Id. at 265. Dr. Das concluded that Plaintiff is not 

under a disability. Id. at 269. 

In May 2015, Dr. Hughes reviewed Plaintiff’s records and affirmed Dr. Das’ 

assessment. Id. at 289. 

III. Standard of Review 

The Social Security Administration provides Disability Insurance Benefits and 

Supplemental Security Income to individuals who are under a “disability,” among other 

eligibility requirements. Bowen v. City of New York, 476 U.S. 467, 470 (1986); see 42 

U.S.C. §§ 423(a)(1), 1382(a). The term “disability”—as defined by the Social Security 

Act—has specialized meaning of limited scope. It encompasses “any medically 

determinable physical or mental impairment” that precludes an applicant from 

performing a significant paid job—i.e., “substantial gainful activity,” in Social Security 

lexicon. 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A); see Bowen, 476 U.S. at 469-70. 

Judicial review of an ALJ’s non-disability decision proceeds along two lines: 

“whether the ALJ applied the correct legal standards and whether the findings of the ALJ 

are supported by substantial evidence.” Blakley v. Comm’r of Soc. Sec., 581 F.3d 399, 

406 (6th Cir. 2009); see Bowen v. Comm’r of Soc. Sec., 478 F.3d 742, 745-46 (6th Cir. 

2007). Review for substantial evidence is not driven by whether the Court agrees or 

disagrees with the ALJ’s factual findings or by whether the administrative record 

contains evidence contrary to those factual findings. Gentry v. Comm’r of Soc. Sec., 741 

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

2007). Instead, the ALJ’s factual findings are upheld if the substantial-evidence standard 
13

is met—that is, “if a ‘reasonable mind might accept the relevant evidence as adequate to 

support a conclusion.’” Blakley, 581 F.3d at 407 (quoting Warner v. Comm’r of Soc. 

Sec., 375 F.3d 387, 390 (6th Cir. 2004)). Substantial evidence consists of “more than a 

scintilla of evidence but less than a preponderance ....” Rogers, 486 F.3d at 241 

(citations and internal quotation marks omitted); see Gentry, 741 F.3d at 722. 

The other line of judicial inquiry—reviewing the correctness of the ALJ’s legal 

criteria—may result in reversal even when the record contains substantial evidence 

supporting the ALJ’s factual findings. Rabbers v. Comm’r of Soc. Sec., 582 F.3d 647, 

651 (6th Cir. 2009); see Bowen, 478 F.3d at 746. “[E]ven if supported by substantial 

evidence, ‘a decision of the Commissioner will not be upheld where the SSA fails to 

follow its own regulations and where that error prejudices a claimant on the merits or 

deprives the claimant of a substantial right.’” Rabbers, 582 F.3d at 651 (quoting in part 

Bowen, 478 F.3d at 746, and citing Wilson v. Comm’r of Soc. Sec., 378 F.3d 541, 546-47 

(6th Cir. 2004)). 

IV. The ALJ’s Decision 

 As noted previously, it fell to ALJ Sanders to evaluate the evidence connected to 

Plaintiff’s applications for benefits. She did so by considering each of the five sequential 

steps set forth in the Social Security Regulations. See 20 C.F.R. §§ 404.1520, 416.920. 

She reached the following main conclusions: 

 Step 1: Plaintiff has not engaged in substantial gainful employment since 

January 31, 2014. 

 Step 2: She has the severe impairments of degenerative joint disease, cervical 

radiculopathy, osteoarthritis, degenerative disc disease, lumbar, 
14

peripheral neuropathy, fibromyalgia, bilateral plantar fasciitis, chronic 

hepatitis C, major depressive disorder, generalized anxiety disorder, 

cannabis disorder, gastroesophageal reflux disease, chronic 

obstructive pulmonary disease, and asthma. 

 Step 3: She does not have an impairment or combination of impairments that 

meets or equals the severity of one in the Commissioner’s Listing of 

Impairments, 20 C.F.R. Part 404, Subpart P, Appendix 1. 

 Step 4: Her residual functional capacity, or the most she could do despite her 

impairments, see Howard v. Comm’r of Soc. Sec., 276 F.3d 235, 239 

(6th Cir. 2002), consists of “sedentary work ... except occasionally 

push and pull[;] stand and/or walk 2 [hours] of an 8-hour day, 

changing position from standings and/or walking to sitting after every 

20 minutes of standing and/or walking, sit 6 hours of 8-hour day, 

shifting positions after 45 minutes of sitting for a couple of minutes 

before resuming sitting, occasionally use foot controls and hand 

controls, occasionally climb ramps and stairs, never climb 

ladders/ropes/scaffolds, frequently balance, occasionally stoop, kneel, 

crouch, crawl, occasionally engage in overhead reach, never work at 

unprotected heights, around moving mechanical parts, never operating 

a motor vehicle, avoid concentrated exposure to extreme 

heat/cold/humidity, avoid concentrated exposure to irritants such as 

fumes, odors, dusts, gases, and poorly ventilated areas; capable of 

performing simple, routine, repetitive tasks but not at a production 

rate pace[;] occasional interaction with coworkers but no shared 

tasks[;] no over-the-shoulder supervision, no work in customer service 

capacity, can adapt to minor infrequent changes that are explained in 

advance, and may be off-task 5% daily.” 

 Step 4: She is unable to perform any of her past relevant work. 

 Step 5: She could perform a significant number of jobs that exist in the 

national economy. 

(Doc. #5, PageID #s 56-74). These main findings led the ALJ to ultimately conclude that 

Plaintiff was not under a benefits-qualifying disability. Id. at 73. 
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V. Discussion 

Plaintiff contends that the ALJ erred in evaluating the medical source opinions and 

medical evidence. The Commissioner maintains that substantial evidence supports the 

ALJ’s decision. 

A. Medical Opinions 

Social Security Regulations require ALJs to adhere to certain standards when 

weighing medical opinions. “Key among these is that greater deference is generally 

given to the opinions of treating physicians than to those of non-treating physicians, 

commonly known as the treating physician rule.” Rogers, 486 F.3d at 242 (citations 

omitted). The rule is straightforward: 

Treating-source opinions must be given “controlling weight” 

if two conditions are met: (1) the opinion “is well-supported by 

medically acceptable clinical and laboratory diagnostic 

techniques”; and (2) the opinion “is not inconsistent with the 

other substantial evidence in [the] case record.” 

Gayheart v. Comm’r of Soc. Sec., 710 F.3d 365, 376 (6th Cir. 2013) (quoting in part 20 

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

If the treating physician’s opinion is not controlling, “the ALJ, in determining how 

much weight is appropriate, must consider a host of factors, including the length, 

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

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

other relevant factors.” Rogers, 486 F.3d at 242 (citing Wilson, 378 F.3d at 544). 

 The Regulations also require ALJs to provide “good reasons” for the weight 

placed upon a treating source’s opinions. Wilson, 378 F.3d at 544. This mandatory 
16

“good reasons” requirement is satisfied when the ALJ provides “specific reasons for the 

weight placed on a treating source’s medical opinions.” Id. (quoting Soc. Sec. R. 96-2p, 

1996 WL 374188, at *5 (Soc. Sec. Admin. July 2, 1996)). The goal is to make clear to 

any subsequent reviewer the weight given and the reasons for that weight. Id. 

Substantial evidence must support the reasons provided by the ALJ. Id. 

The ALJ first addressed the opinions of Plaintiff’s treating physician, Dr. Bennett. 

The ALJ concluded that Dr. Bennett’s “pre-alleged onset statements (albeit a few 

months)” were not entitled to controlling weight or any weight at all. (Doc. #5, PageID 

#71); see Doc. #5, PageID #873. The ALJ next addressed Dr. Bennett’s August 2016 

opinion. However, in evaluating her later opinion, it is not clear if the ALJ considered 

either condition of the treating physician rule. 

The ALJ did not directly address the first condition of the treating physician 

rule—whether Dr. Bennett’s opinions were well-supported by medically acceptable 

clinical and laboratory diagnostic techniques. As a result, it is difficult to determine 

whether the ALJ considered the first condition of the treating physician rule or 

supportability as a factor. Specifically, the ALJ discounted Dr. Bennett’s opinion that 

Plaintiff can never climb, balance, stoop, reach, or do sedentary work on a sustained basis 

because “these are not realistic limitations based on physical exams from this provider 

and other providers throughout the record.” (Doc. #5, PageID #71). The ALJ did not 

give any further explanation. However, earlier in her decision, she discussed medical 

evidence, including objective evidence of Plaintiff’s severe impairments—evidence that 

supports Dr. Bennett’s opinion. For example, in April 2014, shortly after Plaintiff’s 
17

alleged disability onset date, x-rays revealed mild osteoarthritic changes to her sacroiliac 

joints and prominent degenerative changes to her lower lumbar spine. Id. at 515. 

Additionally, x-rays showed moderate diffuse degenerative changes to her lower lumbar 

spine “appearing stable” and severe disc narrowing with grade 1 anterior spinal listhesis 

of L5 on S1 with associated severe degenerative disc disease changes—all stable. Id. at 

514. 

Despite the objective evidence, the ALJ focused on evidence in the record that 

does not support Dr. Bennett’s opinions (such as normal examinations). If the ALJ was 

addressing the first condition of the treating physician rule, she erred to the extent that 

she required Dr. Bennett’s opinion to be fully supported by objective evidence. This is 

because, “For a medical opinion to be well-supported by medically acceptable clinical 

and laboratory diagnostic techniques, it is not necessary that the opinion be fully 

supported by such evidence.” Soc. Sec. R. 96-2P, 1996 WL 374188, *2 (July 2, 1996) 

(emphasis added). To the extent the ALJ was addressing supportability as a factor, this 

constitutes error because “these factors are properly applied only after the ALJ has 

determined that a treating-source opinion will not be given controlling weight.” 

Gayheart, 710 F.3d at 376 (citing 20 C.F.R. § 404.1527(c)(2)). 

Next, the ALJ discounted Dr. Bennett’s August 2016 assessment because it “does 

not comport with the record.”3

 (Doc. #5, PageID #71). The ALJ similarly did not 

 

3

 She only gave one example. According to the ALJ, Dr. Bennett’s opinion that Plaintiff can only stand 

for 20 to 30 minutes conflicts with Plaintiff’s admission that she takes her pets for walks for 20 to 25 

minutes. (Doc. #5, PageID #s 70-71). This is somewhat puzzling because Dr. Bennett opined Plaintiff 

could stand for almost the exact amount of time Plaintiff walks. Because there is no conflict between her 

opinion and Plaintiff’s walks, substantial evidence does not support the ALJ’s conclusion. 
18

directly refer to the second condition of the treating physician rule—whether the opinion 

is not inconsistent with the other substantial evidence in your case record. 

To the extent the ALJ intended to discuss the second condition, she failed to 

determine whether Dr. Bennett’s opinions were “not inconsistent” with the record. This 

distinction is important because, the Social Security Administration defines “not 

inconsistent:” as “a term used to indicate that a well-supported treating source medical 

opinion need not be supported directly by all of the other evidence (i.e., it does not have 

to be consistent with all the other evidence) as long as there is no other substantial 

evidence in the case record that contradicts or conflicts with the opinion.” Soc. Sec. R. 

96-2p, 1996 WL 374188, at *3 (Soc. Sec. Admin. July 2, 1996). 

The ALJ found that Plaintiff’s largely normal physical exams conflicted with Dr. 

Bennett’s extreme limitations. Yet, substantial evidence does not support this conclusion. 

Why? Because “persons suffering from fibromyalgia ‘manifest normal muscle strength 

and neurological reactions and have a full range of motion.’” Germany-Johnson v. 

Comm’r of Soc. Sec., 313 F. App’x 771, 778 (6th Cir. 2008) (quoting Preston v. Sec’y of 

Health & Human Servs., 854 F.2d 815, 820 (6th Cir.1988)). The ALJ found fibromyalgia 

to be a severe impairment but then ignored its symptoms. This constitutes error. 

Even if Dr. Bennett’s opinions are not entitled to controlling weight, “Treating 

source medical opinions are still entitled to deference and must be weighed using all of 

the factors provided in 20 C.F.R. §§ 404.1527 and 416.927.” Soc. Sec. R. 96-2P, 1996 

WL 374188, at *4. In the present case, the ALJ ignored or overlooked several factors. 

For example, the ALJ did not acknowledge that Dr. Bennett has treated Plaintiff for over 
19

twenty-five years. (Doc. #5, PageID #526); see 20 C.F.R. § 404.1527(c)(2)(i) 

(“Generally, the longer a treating source has treated you and the more times you have 

been seen by a treating source, the more weight we will give to the source’s medical 

opinion. When the treating source has seen you a number of times and long enough to 

have obtained a longitudinal picture of your impairment, we will give the medical 

source’s medical opinion more weight than we would give it if it were from a nontreating 

source.”). 

The ALJ likewise did not acknowledge that Dr. Bennett’s treatment notes include 

multiple reports from specialists. See 20 C.F.R. § 404.1527(c)(2)(ii) (Generally, the more 

knowledge a treating source has about your impairment(s) the more weight we will give 

to the source’s medical opinion. We will look at the treatment the source has provided 

and at the kinds and extent of examinations and testing the source has ... ordered from 

specialists and independent laboratories.”). For example, in July 2016, Jeffrey S. Rogers, 

D.O., examined Plaintiff upon Dr. Bennett’s referral. And his notes support Dr. 

Bennett’s opinions. For instance, he noted that, upon exam, Plaintiff was “frustrated with 

[her] pain.” (Doc. #5, PageID #841). She had an antalgic gait, unsteady station, and 

decreased balance. Id. Her spinal range of motion was limited due to pain; she had pain 

with flexion and extension; and her sacroiliac joints were tender. Id. Further, the was 

tenderness over her left and right lumbar area and bilateral paravertebral muscle spasms. 

Id.

The ALJ addressed Dr. Bennett’s opinion on Plaintiff’s mental impairments 

separately. She assigned “no weight” to Dr. Bennett’s opinions regarding Plaintiff’s 
20

mental status. (Doc. #5, PageID #71). Dr. Bennett opined that Plaintiff had extreme 

limitations in several areas of mental functioning. According to the ALJ, “[t]he record 

only supports mild and moderate limitations in mental functioning as further explained 

above and is fully supported by generally good mental status exams and the claimant’s 

course of mental health treatment.” Id. Substantial evidence does not support the ALJ’s 

conclusion that the record only supports mild and moderate limitations. For example, the 

ALJ failed to mention that Dr. Bennett’s opinions are consistent with Plaintiff’s treating 

psychologist, Dr. Sowald. 

Turning to Dr. Sowald’s opinions, ALJ Sanders assigned them “little weight.” 

Like the ALJ’s evaluation of Dr. Bennett’s opinion, she did not discuss the treating 

physician rule. Indeed, she does not acknowledge that Dr. Sowald is a treating 

psychologist. The ALJ refers to her as a “provider.” Id. at 71-72. 

However, the ALJ gave reasons for discounting Dr. Sowald’s opinion. She found, 

“This questionnaire is internally consitent [sic] as well as inconsistent with the rest of the 

record.” (Doc. #5, PageID #71). The ALJ explained that Dr. Sowald’s opinion that 

Plaintiff has extreme limitations is inconsistent with GAF (Global Assessment of 

Functioning) scores of 45-50 because those scores fall “slightly below the moderate 

range.”4

 Id. Slightly below moderate is also known as serious. The ALJ then assigned 

 

4

 GAF scores are not necessarily reliable. Indeed, the fifth and most recent edition of the Diagnostic and 

Statistical Manual of Mental Disorders (DSM-5) no longer uses the GAF scale, in part due to “its lack of 

conceptual clarity (i.e., including symptoms, suicide risk, and disabilities in its descriptors) and 

questionable psychometrics in routine practice.” Liza H. Gold, DSM-5 and the Assessment of 

Functioning: The World Health Organization Disability Assessment Schedule 2.0, 42 J. Am. Acad. 

Psychiatry & Law 173, 174 (2014) (footnote omitted) (available at http://www.jaapl.org. Search by 

article title). 
21

“little weight” to three exhibits because they included GAF scores of 35-45 and, 

according to the ALJ, the record and Plaintiff’s mental status exams do not support lower 

GAF scores. Id. at 71-72 (citing Exhibits 7F, 9F, and 17F/1-24). This is somewhat 

puzzling because these lower GAF scores of 35-45 are consistent with Dr. Sowald’s 

opinion that Plaintiff has severe limitations. The ALJ’s attempt to divide GAF scores and 

selectively apply them constitutes error. See Brooks v. Comm’r of Soc. Sec., 531 F. 

App’x 636, 641 (6th Cir. 2013) (“[A] substantiality of evidence evaluation does not 

permit a selective reading of the record. ‘Substantiality of the evidence must be based 

upon the record taken as a whole. Substantial evidence is not simply some evidence, or 

even a great deal of evidence. Rather, the substantiality of evidence must take into 

account whatever in the record fairly detracts from its weight.’”) (quoting Garner v. 

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

omitted). 

The ALJ also discounted Dr. Sowald’s opinion because Plaintiff “serves as her 

grandmother’s power of attorney, which would be unusual for someone with extreme 

limitations in concentration, persistence or pace.” (Doc. #5, PageID #71) (citation 

omitted). The ALJ cites one of Dr. Sowald’s treatment notes: “Laura was very 

concerned this week about her grandma (94) who fell and broke her femur and was at 

Grandview Hospital. Laura’s grandma needs a blood infusion. Laura is her grandma’s 

Power of Attorney and has to go sign for her grandma’s treatment....”5

 Id. at 782. 

 

5

 Coincidently, her grandmother’s doctor, Dr. Urse, was the same doctor who operated on Plaintiff’s knee. 

Indeed, Plaintiff hoped to see Dr. Urse for future treatment. (Doc. #5, PageID #782) 
22

Although Dr. Sowald does not indicate the length of time it took for Plaintiff to sign off 

on her grandmother’s treatment, there is no suggestion that it required her to maintain 

concentration, persistence, and pace on a sustained basis for any significant period of 

time. See Gayheart, 710 F.3d at 377 (“But the ALJ does not contend, and the record does 

not suggest, that [the claimant] could do any of these activities on a sustained basis, 

which is how the functional limitations of mental impairments are to be assessed.”) 

(citing 20 C.F.R. § 404.1520a(c)(2); 20 C.F.R. Part 404, Subpart P, Appendix 1, at 

12.00). 

The ALJ likewise pointed to a trip to Gatlinburg with friends and a family outing 

as evidence that Plaintiff is not as limited as opined by Dr. Sowald. However, these 

outlying events fail to show that Plaintiff is able to perform full time work on a sustained 

basis. The ALJ also pointed out that Plaintiff reported that she never left the cabin in 

Gatlinburg because of her physical impairments, not her mental ones. This is immaterial. 

Both Dr. Sowald and Dr. Bennett emphasized the important relationship between 

Plaintiff’s physical and mental impairments. Namely, Plaintiff’s physical impairments 

affect her psychological status. Dr. Bennett opined, for instance, that her chronic pain 

caused her depression and anxiety. (Doc. #5, PageID #s 1061, 1145-46). The ALJ 

ignored or overlooked this relationship. 

The ALJ concluded, “Overall, the opinions appear to be based on subjective 

complaints of the claimant and not objective mental status exams and observations.” Id.

at 71. Substantial evidence does not support the ALJ’s conclusion. The ALJ overlooks 
23

that it can be considerably more difficult to substantiate psychiatric impairments by 

objective laboratory testing: 

[W]hen mental illness is the basis of a disability claim, clinical 

and laboratory data may consist of the diagnosis and 

observations of professionals trained in the field of 

psychopathology. The report of a psychiatrist should not be 

rejected simply because of the relative imprecision of the 

psychiatric methodology or the absence of substantial 

documentation, unless there are other reasons to question the 

diagnostic techniques. 

Blankenship v. Bowen, 874 F.2d 1116, 1121 (6th Cir. 1989) (citing Poulin v. Bowen, 817 

F.2d 865, 873-74 (D.C. Cir. 1987), quoting Lebus v. Harris, F.Supp. 56, 60 (N.D. Cal. 

1981)). 

There is no reason to question Dr. Sowald’s diagnostic techniques. At the time 

she gave her assessment, she had treated Plaintiff approximately once a week for over 

two years. (Doc. #5, PageID #1145); see 20 C.F.R. § 404.1527(c)(2)(i) (“Generally, the 

longer a treating source has treated you and the more times you have been seen by a 

treating source, the more weight we will give to the source’s medical opinion.”). It is 

consistent with the assessments she provided in April 2015. (Doc. #5, PageID #s 748-51, 

754-56). In addition, it is supported by treatment notes from Ramakrishna Gollamudi, 

M.D., who consistently noted that Plaintiff’s mood was anxious and depressed. Id. at 

1546, 1548, 1550. 

In sum, the ALJ failed to provide good reasons, supported by substantial evidence, 

for rejecting Dr. Bennett’s opinions and Dr. Sowald’s opinions. “Because the reasongiving requirement exists to ‘ensur[e] that each denied claimant receives fair process,’ we 
24

have held that an ALJ’s ‘failure to follow the procedural requirement of identifying the 

reasons for discounting the opinions and for explaining precisely how those reasons 

affected the weight’ given ‘denotes a lack of substantial evidence, even where the 

conclusion of the ALJ may be justified based upon the record.’” Blakley, 581 F.3d at 407 

(quoting Rogers, 486 F.3d at 243). 

Accordingly, for the above reasons, Plaintiff’s Statement of Errors is well taken.6

B. Remand 

A remand is appropriate when the ALJ’s decision is unsupported by substantial 

evidence or when the ALJ failed to follow the Administration’s own regulations and that 

shortcoming prejudiced the plaintiff on the merits or deprived the plaintiff of a substantial 

right. Bowen, 478 F.3d at 746. Remand may be warranted when the ALJ failed to 

provide “good reasons” for rejecting a treating medical source’s opinions, see Wilson, 

378 F.3d at 545-47; failed to consider certain evidence, such as a treating source’s 

opinions, see Bowen, 478 F.3d at 747-50; failed to consider the combined effect of the 

plaintiff’s impairments, see Gentry, 741 F.3d at 725-26; or failed to provide specific 

reasons supported by substantial evidence for finding the plaintiff lacks credibility, see 

Rogers, 486 F.3d at 249. 

Under sentence four of 42 U.S.C. § 405(g), the Court has authority to affirm, 

modify, or reverse the Commissioner’s decision “with or without remanding the cause for 

rehearing.” Melkonyan v. Sullivan, 501 U.S. 89, 99 (1991). Consequently, a remand 

 

6

 In light of the above discussion, and the resulting need to remand this case, an in-depth analysis of 

Plaintiff’s other challenges to the ALJ’s decision is unwarranted. 
25

under sentence four may result in the need for further proceedings or an immediate award 

of benefits. E.g., Blakley, 581 F.3d at 410; Felisky v. Bowen, 35 F.3d 1027, 1041 (6th 

Cir. 1994). The latter is warranted where the evidence of disability is overwhelming or 

where the evidence of disability is strong while contrary evidence is lacking. Faucher v. 

Sec’y of Health & Human Servs., 17 F.3d 171, 176 (6th Cir. 1994). 

A judicial award of benefits is unwarranted in the present case because the 

evidence of disability is not overwhelming and the evidence of disability is not strong 

while contrary evidence is lacking. However, Plaintiff is entitled to an Order remanding 

this case to the Social Security Administration pursuant to sentence four of § 405(g) due 

to the problems discussed above. On remand, the ALJ should be directed to evaluate the 

evidence of record, including the medical source opinions, under the applicable legal 

criteria mandated by the Commissioner’s Regulations and Rulings and by case law; and 

to evaluate Plaintiff’s disability claim under the required five-step sequential analysis to 

determine anew whether Plaintiff was under a disability and whether her applications for 

Disability Insurance Benefits and Supplemental Security Income should be granted. 

IT IS THEREFORE ORDERED THAT: 

1. The Commissioner’s non-disability finding is vacated; 

2. No finding is made as to whether Plaintiff Laura Ort was under a 

“disability” within the meaning of the Social Security Act; 

3. This matter is REMANDED to the Social Security Administration under 

sentence four of 42 U.S.C. § 405(g) for further consideration consistent 

with this Decision and Entry; and 
26

4. The case is terminated on the Court’s docket. 

Date: September 30, 2019 s/Sharon L. Ovington 

 Sharon L. Ovington 

 United States Magistrate Judge