Opinion ID: 2979476
Heading Depth: 2
Heading Rank: 1

Heading: The ALJ’s Evaluation of the Medical Evidence

Text: Severe impairments are impairments that significantly limit a claimant’s “physical or mental ability to do basic work activities.” 20 C.F.R. § 404.1520(c). Although the ALJ mentioned -13- No. 09-2076 Kalmbach v. Commissioner of Social Security Kalmbach’s diagnosis of fibromyalgia in the course of discussing the medical evidence, he neither identified it as a severe impairment nor explained why he believed it was not one. That oversight is gaping given that Kalmbach’s disability application is premised primarily upon the pain and fatigue she experiences as a result of her fibromyalgia, and in light of the fact that she was diagnosed with the condition by a specialist in rheumatology, and both the specialist and her primary care physician agreed that Kalmbach’s fibromyalgia symptoms are the primary cause of her inability to engage in sustained work activity. Moreover, this Circuit has expressly recognized that fibromyalgia can be a “severe impairment.”2 Rogers, 486 F.3d at 243; Preston v. Sec’y of Health & Human Servs., 854 F.2d 815, 820 (6th Cir. 1998). In that regard, Dr. Ognenovski, Kalmbach’s treating rheumatologist since May 2001, has consistently opined that Kalmbach has been unable to perform sustained work activity since April 2005 due to her fibromyalgia and its attendant chronic pain and fatigue, complicated by other comorbid factors including obesity and sleep apnea. Dr. Beison, the plaintiff’s primary care physician, agreed with Dr. Ognenovski’s assessment that Kalmbach is incapable of performing any type of substantial gainful activity as a result of the symptoms associated with fibromyalgia. 2 Fibromyalgia, also called fibrositis, “is a medical condition marked by ‘chronic diffuse widespread aching and stiffness of muscles and soft tissues.’ Stedman’s Medical Dictionary for the Health Professions and Nursing at 541 (5th ed. 2005). We note also that ours is not the only circuit to recognize the medical diagnosis of fibromyalgia as well as the difficulties associated with this diagnosis and the treatment for this condition.” Rogers v. Comm’r of Soc. Sec., 486 F.3d 234, 244 n.3 (6th Cir. 2007) (most internal citations omitted). -14- No. 09-2076 Kalmbach v. Commissioner of Social Security In assessing the medical evidence supporting a claim for disability benefits, the ALJ is bound by the so-called “treating physician rule,” which generally requires the ALJ to give greater deference to the opinions of treating physicians than to the opinions of non-treating physicians. Blakley v. Comm’r of Soc. Sec., 581 F.3d 399, 406 (6th Cir. 2009). The rationale behind the rule is that treating physicians are likely to be the medical professionals most able to provide a detailed, longitudinal picture of [the claimant’s] medical impairment(s) and may bring a unique perspective to the medical evidence that cannot be obtained from the objective medical findings alone or from reports of individual examinations, such as consultative examinations or brief hospitalizations. 20 C.F.R. § 404.1527(d)(2). The ALJ must give a treating source opinion “controlling weight” if the treating source opinion is “well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in [the] case record.” Id. Even if the ALJ does not give controlling weight to a treating physician’s opinion, he must still consider how much weight to give it; in doing so, the ALJ must take into account the length of the treatment relationship, frequency of examination, the extent of the physician’s knowledge of the impairment(s), the amount of relevant evidence supporting the physician’s opinion, the extent to which the opinion is consistent with the record as a whole, whether or not the physician is a specialist, and any other relevant factors tending to support or contradict the opinion. 20 C.F.R. § 404.1527(d)(2)–(6). The ALJ’s decision as to how much weight to accord a medical opinion must be accompanied by “good reasons” that are “supported by the evidence in the case record, and must be -15- No. 09-2076 Kalmbach v. Commissioner of Social Security sufficiently specific to make clear to any subsequent reviewers the weight the adjudicator gave to the treating source’s medical opinion and the reasons for that weight.” Soc. Sec. Rul. 96-2p, 1996 WL 374188, at . This procedural “good reason” rule serves both to ensure adequacy of review and to permit the claimant to understand the disposition of her case. Rogers, 486 F.3d at 242. We will reverse and remand a denial of benefits, even though “substantial evidence otherwise supports the decision of the Commissioner,” when the ALJ fails to give good reasons for discounting the opinion of the claimant’s treating physician. Wilson, 378 F.3d at 543–46. A failure to follow the procedural requirement “of identifying the reasons for discounting the opinions and for explaining precisely how those reasons affected the weight accorded the opinions denotes a lack of substantial evidence, even where the conclusion of the ALJ may be justified based upon the record.” Rogers, 486 F.3d at 243; see also Wilson, 378 F.3d at 546 (a reviewing court “cannot excuse the denial of a mandatory procedural protection simply because . . . there is sufficient evidence in the record of the ALJ to discount the treating source’s opinion and, thus, a different outcome on remand is unlikely”). Thus, while a “lack of compatibility with other record evidence is germane to the weight [accorded] a treating physician’s opinion, an ALJ cannot simply invoke the criteria set forth in the regulations if doing so would not be ‘sufficiently specific’ to meet the goals of the ‘good reason’ rule.” Friend v. Comm’r of Soc. Sec., 375 F. App’x 543, 551 (6th Cir. 2010). In this case, the ALJ’s entire rationale for discounting the opinions of Drs. Ognenovski and Beison was summed up succinctly in two sentences: “[T]hey are not supported by the objective findings and appear to be based entirely on the claimant’s subjective complaints. Further, [the -16- No. 09-2076 Kalmbach v. Commissioner of Social Security determination of disability] is a conclusion reserved to the Commissioner.” (AR 22.) As a matter of law, these do not qualify as “good reasons” and therefore do not comport with the procedural requirement embodied in 20 C.F.R. § 404.1527(d)(2). First, the fact that the ultimate determination of disability, per se, is reserved to the Commissioner, 20 C.F.R. § 404.1527(e), did not supply the ALJ with a legitimate basis to disregard the physicians’, and particularly Dr. Ognenovski’s, assessment of Kalmbach’s abilities to perform work-related activities, including standing, walking, sitting, using her hands, and so forth. Dr. Ognenovski did not opine in a vacuum that Kalmbach was disabled. Rather, he opined that she was incapacitated by pain and fatigue from performing workrelated activities on a sustained basis. Moreover, both Dr. Ognenovski and Dr. Beison affirmatively stated that they did not believe their patient was a malingerer or someone who exaggerated her symptoms. Further, the ALJ’s rejection of the treating physicians’ opinions as unsupported by objective evidence in the record obviously stems from his fundamental misunderstanding of the nature of fibromyalgia. Cf. Rogers, 486 F.3d at 243 (observing that the ALJ’s failure to recognize fibromyalgia as a “severe impairment” “influenced the ALJ’s consideration of the medical evidence in the present case”). In his discussion of Dr. Ognenovski’s treatment notes and medical findings, the ALJ repeatedly emphasized the indications that Kalmbach retained mobility in her joints and had normal blood tests, bone, scans and MRIs with only minimal degenerative changes; he harkened back to these objective findings in asserting that Dr. Ognenovski’s assessment of the plaintiff’s abilities was not supported by the objective medical evidence. We have recognized on more than -17- No. 09-2076 Kalmbach v. Commissioner of Social Security one occasion, however, that fibromyalgia patients generally “present no objectively alarming signs.” Rogers, 486 F.3d at 243 (citing Preston v. Sec’y of Health & Human Servs., 854 F.2d 815, 820 (6th Cir. 1988) (per curiam) (noting that objective tests are of little relevance in determining the existence or severity of fibromyalgia); Swain v. Comm’r of Soc. Sec., 297 F. Supp. 2d 986, 990 (N.D. Ohio 2003) (observing that “[f]ibromyalgia is an ‘elusive’ and ‘mysterious' disease” which causes “severe musculoskeletal pain”). Rather, fibromyalgia patients, like Kalmbach here, typically “manifest normal muscle strength and neurological reactions and have a full range of motion.” Preston, 854 F.2d at 820. In the absence of other objectively ascertainable manifestations, the process of diagnosing fibromyalgia includes (1) the testing of a series of focal points for tenderness and (2) the ruling out of other possible conditions through objective medical and clinical trials. Id.; Swain, 297 F. Supp. 2d at 990. Dr. Ognenovski noted on multiple occasions that Kalmbach tested positive for tenderness at 18 of 18 focal points, and he ruled out the possibility of other causes for Kalmbach’s symptoms. Thus, the ALJ’s contention that the treating physicians’ assessments and opinions were unsupported by other objective medical evidence was simply beside the point. Nor can it be said that the ALJ’s failure to give good reasons—a legal error—was in any sense harmless, because his rejection of the treating physicians’ opinions is not supported by substantial evidence in the record either. In particular, there are no countervailing or contradictory medical opinions in the record to which the ALJ pointed in support of his wholesale rejection of the treating physicians’ opinions. As indicated above, an ALJ must accord “controlling weight” to a treating physician’s opinion if that opinion is “well-supported by medically acceptable clinical and -18- No. 09-2076 Kalmbach v. Commissioner of Social Security laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in [the] case record.” 20 C.F.R. § 404.1527(d)(2). Here, Dr. Ognenovski’s diagnosis of fibromyalgia is supported by medically acceptable clinical and diagnostic techniques that pertain to the diagnosis for that particular condition, and his opinion regarding the plaintiff’s capacity to perform workrelated activities as a result of the symptoms she suffered in connection with her fibromyalgia is not inconsistent with the other evidence in the record. There effectively is no other evidence in the record, besides the plaintiff’s own testimony, discussed in greater detail below. In sum, the ALJ’s failure to give good reasons for his rejection of the treating physicians’ opinions constituted legal error, apparently stemming from his failure to recognize the plaintiff’s fibromyalgia as a “severe impairment.” Cf. Preston, 854 F.2d at 820 (finding reversible error where the ALJ failed to credit the plaintiff’s treating physician’s fibromyalgia diagnosis based on the absence of objective medical evidence to support it). Finally, the ALJ’s failure to accord controlling—or indeed any—weight to Dr. Ognenovski’s assessment of Kalmbach’s ability to perform work-related activities was error in light of the fact that the medical opinion was consistent with the overwhelming weight of the evidence in this case, and not contradicted by any other medical evidence in the record. These errors alone warrant remand, but they are further compounded by the ALJ’s inadequately supported assessment of Kalmbach’s credibility, as discussed below. B. The ALJ’s Evaluation of Kalmbach’s Credibility -19- No. 09-2076 Kalmbach v. Commissioner of Social Security The ALJ found that Kalmbach’s statements regarding the effect of her impairments on her ability to work were not fully credible. We have recognized that disability claims related to fibromyalgia are related to the symptoms associated with the condition—including complaints of pain, stiffness, fatigue, and inability to concentrate—rather than the underlying condition itself. Rogers, 486 F.3d at 247 (citing 20 C.F.R. § 416.929); Wyatt v. Sec’y of Health & Human Servs., 974 F.2d 680, 686 (6th Cir. 1992) (noting that subjective complaints of pain may support a claim for disability). Where the symptoms and not the underlying condition form the basis of the disability claim, we employ a two-part analysis in evaluating complaints of disabling pain. 20 C.F.R. § 416.929(a); Rogers, 486 F.3d at 247; Felisky v. Bowen, 35 F.3d 1027, 1038-39 (6th Cir.1994). First, the ALJ should ask whether the there is an underlying medically determinable physical impairment that could reasonably be expected to produce the claimant’s symptoms. 20 C.F.R. § 416.929(a).3 Second, if the ALJ finds that such an impairment exists, then he must evaluate the intensity, persistence, and limiting effects of the symptoms on the individual’s ability to do basic work activities. Id. Relevant factors for the ALJ to consider in his evaluation of symptoms include the claimant’s daily activities; the location, duration, frequency, and intensity of symptoms; factors that precipitate and aggravate symptoms; the type, dosage, effectiveness, and side effects of any medication taken to alleviate the symptoms; other 3 The ALJ stated that “the claimant’s medically determinable impairments could reasonably be expected to produce the alleged symptoms” (AR 21) but, because he did not list fibromyalgia as a severe impairment, it is unclear whether he took that condition into consideration in assessing Kalmbach’s pain allegations. -20- No. 09-2076 Kalmbach v. Commissioner of Social Security treatment undertaken to relieve symptoms; other measures taken to relieve symptoms, such as lying on one’s back; and any other factors bearing on the limitations of the claimant to perform basic functions. Id.; see also Soc. Sec. Rul. 96-7p, 1996 WL 374186, at -3 (July 2, 1996) (Policy Interpretation Ruling Titles II and XVI: Evaluation of Symptoms in Disability Claims: Assessing the Credibility of an Individual’s Statements). The ALJ, of course, and not the reviewing court, is tasked with evaluating the credibility of witnesses, including that of the claimant. Walters v. Comm’r of Soc. Sec., 127 F.3d 525, 531 (6th Cir. 1997); Crum v. Sullivan, 921 F.2d 642, 644 (6th Cir.1990). However, the ALJ is not free to make credibility determinations based solely upon an “intangible or intuitive notion about an individual’s credibility.” Soc. Sec. Rul. 96-7p, 1996 WL 374186, at . Rather, such determinations must find support in the record. Whenever a claimant’s complaints regarding symptoms, or their intensity and persistence, are not supported by objective medical evidence, the ALJ must make a determination of the credibility of the claimant in connection with her complaints based on a consideration of the entire case record. The entire case record includes any medical signs and laboratory findings, the claimant’s own complaints of symptoms, any information provided by the treating physicians and others, as well as any other relevant evidence contained in the record. Consistency of the various pieces of information contained in the record should be scrutinized. Consistency between a claimant’s symptom complaints and the other evidence in the record tends to support the credibility of the claimant, while inconsistency, although not necessarily defeating, should have the opposite effect. -21- No. 09-2076 Kalmbach v. Commissioner of Social Security Social Security Ruling 96-7p also requires that the ALJ explain the credibility determinations in his decision with sufficient specificity as “to make clear to the individual and to any subsequent reviewers the weight the adjudicator gave to the individual’s statements and the reasons for that weight.” In other words, blanket assertions that the claimant is not believable will not pass muster, nor will explanations as to credibility which are not consistent with the entire record and the weight of the relevant evidence. And, as the court noted in Rogers, “given the nature of fibromyalgia, where subjective pain complaints play an important role in the diagnosis and treatment of the condition, providing justification for discounting a claimant’s statements is particularly important.” 486 F.3d at 248 (citing Hurst v. Sec’y of Health & Human Servs., 753 F.2d 517, 519 (6th Cir. 1985)). In the present case, the ALJ’s consideration of Kalmbach’s subjective pain complaints and assessment of her credibility do not comport with the Administration’s requirements. The ALJ’s discounting of Kalmbach’s credibility was based on (1) the absence of objective medical evidence; (2) the absence of more aggressive treatment; and (3) the ALJ’s conclusion that Kalmbach engaged in “essentially normal daily and social activities.” (AR 21.) As discussed above, however, the absence of objective medical evidence to substantiate the diagnosis of fibromyalgia or its severity is basically irrelevant, and more “aggressive” treatment is not recommended for fibromyalgia patients. In other words, the first two bases for the ALJ’s discounting Kalmbach’s credibility are irrelevant. Further, his conclusion that Kalmbach engaged in “essentially normal daily and social activities” grossly mischaracterizes the available evidence. -22- No. 09-2076 Kalmbach v. Commissioner of Social Security Kalmbach indeed testified that she went to the grocery store, the pharmacy, and church, and that she was able to prepare her own meals most of the time, and usually able to dress herself without assistance. She was able to drive, but had to limit it to less than thirty minutes per day. These minimal activities are hardly consistent with eight hours’ worth of typical work activities. Cf. Rogers, 486 F.3d at 248–49 (finding that the plaintiff’s daily functions, including her ability to drive, clean her apartment, care for two dogs, do laundry, read, do stretching exercises, and watch the news, were not “comparable to typical work activities” and did not justify the ALJ’s discrediting her testimony). Kalmbach also testified that she suffered fatigue and pain basically all the time, that it took very little activity to “wear [her] out” to the point where she could not function or concentrate, and that she did not attempt to undertake more than one activity outside the home on any given day, because doing so would cause a flare-up in her symptoms. (AR 443, 452.) She testified that she spent most of her time sitting with her legs propped up, either reading or watching television. The ALJ’s determination that she engaged in essentially normal daily and social activities is not supported by substantial evidence in the record. Moreover, Kalmbach’s testimony was consistent with the available medical evidence. As early as October 2001, Dr. Ognenovski discussed with Kalmbach the possibility of her working fewer hours “as a way of coping with her [fibromyalgia] symptoms and fatigue.” (AR 309.) In February 2002, he observed that she was feeling much better and was less fatigued, in large part because she was working reduced hours, though she “of course” continued to take analgesics and muscle relaxants. (AR 310.) Over the next several years, her condition remained basically stable, -23- No. 09-2076 Kalmbach v. Commissioner of Social Security but Dr. Ognenovski noted that she periodically experienced flare-ups in her pain symptoms requiring her to increase her medications and rest for periods of three to five days before she was stable again. (AR 314.) These notations substantiate Kalmbach’s and both her physicians’ assessment that she would be required to be absent from any work she attempted a minimum of three days in any given month. Although Dr. Ognenovski noted in 2003 that it would be better “overall” for Kalmbach to “remain[] functional,” i.e., to work if she could, the context of his statements makes it clear he did not mean she should work full time. (AR 320.) And, although Kalmbach continued to work until April 2005, her testimonial evidence, the financial evidence in the record, and her physicians’ treatment notes indicate fairly conclusively that she was not working full time for the last few years she worked. (See, e.g., AR 388 (Dr. Ognenovski’s treatment note for September 30, 2004, indicating Kalmbach’s fibromyalgia was at “baseline,” that she “remain[ed] fairly functional” and “continued to work part-time”).) Nor can the fact that Dr. Kalmbach recommended weight loss and exercise be deemed to detract from Kalmbach’s credibility. Cf. Rogers, 486 F.3d at 249 (“[T]he fact that a patient is encouraged to remain active does not reflect the manner in which such activities may aggravate the patient’s symptoms. Notably, Rogers’ own treating physicians also recommended that she remain as active as possible, yet this did not alter their opinions as to her functional limitations and work restrictions.”). In sum, while credibility determinations regarding subjective complaints rest with the ALJ, those determinations must be reasonable and supported by substantial evidence. The decision in this -24- No. 09-2076 Kalmbach v. Commissioner of Social Security case does not contain specific reasons for discounting Kalmbach’s credibility; those reasons that are given are not supported by the evidence in the case record. The ALJ’s decision to reject Kalmbach’s subjective complaints and their effect on her ability to work is not supported by substantial evidence in the record and constitutes reversible error.