Opinion ID: 20701
Heading Depth: 3
Heading Rank: 3

Heading: ALJ's Failure to Give Treating Physician's Opinions Proper Weight

Text: 31 The ALJ correctly placed the burden on Newton at the fourth step of the five-step process. It appears, however, that the ALJ did not properly place the burden on the Commissioner at the fifth step. The ALJ stated that Pertusi's opinions regarding the claimant's residual functional capacity, specifically his opinion that Newton could not perform even sedentary work during the period of claimed disability, were not entitled to great weight. In actuality, the ALJ gave Pertusi's opinions no weight. The ALJ found Pertusi's opinion regarding residual functional capacity was not reliable because it was insufficiently substantiated by clinical or diagnostic evidence, and thus was conclusory. The ALJ also faulted Pertusi for failing to include work restrictions for Newton in his medical notes and contemporaneous records during the 1989-1994 period, finding that this omission undermined Pertusi's credibility as to his assessment of claimant's residual functional capacity. The ALJ also rejected Pertusi's opinions because of the inconsistency between Pertusi's January 30, 1995 opinion that Newton was totally disabled and the fact that at the time of Pertusi's opinion Newton was working 25-35 hours per week. 3 32 Requirements for Giving Weight to Treating Physicians' Opinions. -- The opinion of the treating physician who is familiar with the claimant's impairments, treatments and responses, should be accorded great weight in determining disability. See Leggett v. Chater, 67 F.3d 558, 566 (5th Cir. 1995); Greenspan v. Shalala, 38 F.3d 232, 237 (5th Cir. 1994), cert. denied, 514 U.S. 1120 (1995). A treating physician's opinion on the nature and severity of a patient's impairment will be given controlling weight if it is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with . . . other substantial evidence. Martinez, 64 F.3d at 176 (citing 20 C.F.R. 404.1527(d)(2)). The opinion of a specialist generally is accorded greater weight than that of a non-specialist. Paul v. Shalala, 29 F.3d 208, 211 (5th Cir. 1994). 33 Even though the opinion and diagnosis of a treating physician should be afforded considerable weight in determining disability, the ALJ has sole responsibility for determining a claimant's disability status. Id. '[T]he ALJ is free to reject the opinion of any physician when the evidence supports a contrary conclusion.' Id. The treating physician's opinions are not conclusive. See Brown, 192 F.3d at 500. The opinions may be assigned little or no weight when good causeis shown. Greenspan, 38 F.3d at 237. Good cause may permit an ALJ to discount the weight of a treating physician relative to other experts where the treating physician's evidence is conclusory, is unsupported by medically acceptable clinical, laboratory, or diagnostic techniques, or is otherwise unsupported by the evidence. See, e.g., Brown, 192 F.3d at 500; Greenspan, 39 F.3d at 237; Paul, 29 F.3d at 211. 34 Factors to be Considered Before Declining to Give Treating Physicians' Opinions Controlling Weight. -- SSA Regulations provide that the SSA will always give good reasons in [its] notice of determination or decision for the weight [it gives the claimant's] treating source's opinion and list factors an ALJ must consider to assess the weight to be given to the opinion of a treating physician when the ALJ determines that it is not entitled to controlling weight. See 20 C.F.R. 404.1527(d)(2). Specifically, this regulation requires consideration of: 35
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41 The regulation is construed in Social Security Ruling (SSR) 96-2p, which states: 42 [A] finding that a treating source medical opinion is not well supported by medically acceptable clinical and laboratory diagnostic techniques or is inconsistent with the other substantial evidence in the case record means only that the opinion is not entitled to controlling weight, not that the opinion should be rejected. 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. In many cases, a treating source's medical opinion will be entitled to the greatest weight and should be adopted even if it does not meet the test for controlling weight. 43 SSR 96-2p, 61 F.R. 34490, 34491 (July 2, 1996) (emphasis added). SSR 96-5p provides, with respect to Residual Functional Capacity Assessments and Medical Source Statements, that Adjudicators must weigh medical source statements under the rules set out in 20 C.F.R. 404.1527 . . . , providing appropriate explanations for accepting or rejecting such opinions. SSR 96-5p, 61 F.R. 34471, 34474 (July 2, 1996). 44 Several federal courts have concluded that an ALJ is required to consider each of the 404.1527(d) factors when the ALJ intends to reject or give little weight to a treating specialist's opinion. See Clark v. Commissioner of Social Security, 143 F.3d 115, 118 (2d Cir. 1998); Goatcher v. U.S. Department of Health & Human Servs., 52 F.3d 288, 290 (10th Cir. 1995); Dwyer v. Apfel, 23 F. Supp. 2d 223, 228 (N.D.N.Y. 1998); Amidon v. Apfel, 3 F. Supp. 2d 350, 355-56 (W.D.N.Y. 1998); McDonald v. Apfel, No. CA 3-97-CV-2035R, 1998 WL 159938,  (N.D. Tex. Mar. 31, 1998). This court now similarly holds that an ALJ is required to consider each of the 404.1527(d) factors before declining to give any weight to the opinions of the claimant's treating specialist. The ALJ failed to perform this analysis, which should be conducted on remand. 45 ALJ's Improper Reliance on Non-Treating, Non-Examining Physician. -- The ALJ expressly relied for her findings on the testimony of the medical expert, Willbanks, and her own disbelief of portions of Newton's own testimony. There is no indication that Willbanks had any training in rheumatology. Willbanks, who did not examine Newton personally, agreed that Newton suffered from SLE. Willbanks's opinion was based primarily on his review of Pertusi's assessments and answersto interrogatories. While Willbanks apparently had access to Pertusi's treatment notes, he did not have all the significant hospitalization records, including records of a five-day hospitalization in 1993. Willbanks's opinion also did not take into account other medical opinions supporting Newton's claim of disability, such as a hospital note from Dr. Fehl that Newton's pain was due to her progressively increasing and spreading joint pain secondary to her lupus and the July 28, 1996, statement from Dr. Carrera, another examining physician, that Newton could not perform even sedentary work due to her lupus. Willbanks commented that the records were insufficient for him to determine the severity and frequency of the symptoms, but he did not testify that Pertusi's findings or answers should be discredited because they were conclusory. Willbanks found that Newton's symptoms were typical for a patient with SLE, and that generally the symptoms were responsive to treatment. Willbanks, however, failed to consider the side-effects of the treatments. 46 The ALJ nevertheless relied on Willbanks's conclusory and unsubstantiated opinion that Newton was not disabled. Under these circumstances, the ALJ's finding that Newton had sufficient residual functional capacity to perform sedentary work is not supported by substantial evidence. 47 Requirement to Obtain Supplemental Information. -- SSR 96-2p admonishes: 48 [I]n some instances, additional development required by a case - for example to obtain more evidence or to clarify reported clinical signs or laboratory findings - may provide the requisite support for a treating source's medical opinion that at first appeared to be lacking or may reconcile what at first appeared to be an inconsistency between a treating source's medical opinion and the other substantial evidence in the case record. . . . 49 SSR 96-2p, 61 F.R. at 33491. SSA Regulation 20 C.F.R. 404.1512(e) provides in pertinent part: 50 (e) Recontacting medical sources. When the evidence we receive from your treating physician or psychologist or other medical source is inadequate for us to determine whether you are disabled, we will need additional information to reach a determination or a decision. To obtain the information, we will take the following actions. 51 (1) We will first recontact your treating physician or psychologist or other medical source to determine whether the additional information we need is readily available. We will seek additional evidence or clarification from your medical source when the report from your medical source contains a conflict or ambiguity that must be resolved, the report does not contain all the necessary information, or does not appear to be based on medically acceptable clinical and laboratory diagnostic techniques. . . . 52 20 C.F.R. 404.1512(e). Subsection (d) of 404.1512 provides in part: 53 Our responsibility. Before we make a determination that you are not disabled, we will develop your complete medical history for at least the 12 months preceding the month in which you file your application unless there is a reason to believe that development of an earlier period is necessary or unless you say that your disability began less than 12 months before you filed your application. We will make every reasonable effort to help you get medical reports from your own medical sources when you give us permission to request the reports. 54 20 C.F.R. 404.1512(d). 55 The Second Circuit has held that an ALJ cannot reject a treating physician's diagnosis without first attempting to fill any clear gaps in the administrative record. Rosa v. Callaghan, 168 F.3d 72, 79 (2d Cir. 1999) (citing Schaal v. Apfel, 134 F.3d 496, 505 (2d Cir. 1998) ([E]ven if theclinical findings were inadequate, it was the ALJ's duty to seek additional information from [the treating physician] sua sponte.). The Fifth Circuit also imposes a duty on an ALJ to develop the facts fully and fairly relating to an applicant's claim for disability benefits. See Ripley, 67 F.3d at 557. If the ALJ does not satisfy his duty, his decision is not substantially justified. Id. In this case, the ALJ expressed doubts about Pertusi's opinions based on Willbanks's criticisms and Newton's later part-time work, but did not request additional information to eliminate those doubts before rejecting the opinion of the treating physician. 56 Reversal, however, is appropriate only if the applicant shows prejudice from the ALJ's failure to request additional information. Id. Prejudice can be established by showing that additional evidence would have been produced if the ALJ had fully developed the record, and that the additional evidence might have led to a different decision. Id. at 557 n.22. 57 Newton has made a sufficient showing that additional evidence could have been produced, if requested. The ALJ was faced with what she deemed an incomplete medical history. The ALJ, without obtaining the supplemental information, made medical determinations as to claimant's abilities to do specific jobs. The ALJ erred when she found, with virtually no meaningful analysis of the specific medical records, that omissions from the treating specialist's assessment or answers to interrogatories left gaps preventing a finding as to the proper weight to accord Pertusi's opinion of Newton's residual functional capacity over the four year period in issue. 58 Conclusion Regarding ALJ's Failure to Give Proper Weight to Treating Physician's Opinions 59 This is not a case where there is competing first-hand medical evidence and the ALJ finds as a factual matter that one doctor's opinion is more well-founded than another. See and compare, e.g., Spellman v. Shalala, 1 F.3d 357 (5th Cir. 1993). Nor is this a case where the ALJ weighs the treating physician's opinion on disability against the medical opinion of other physicians who have treated or examined the claimant and have specific medical bases for a contrary opinion. See and compare, e.g., Prosch v. Apfel, 201 F.3d 1010 (8th Cir. 2000). Instead, this is a case where the ALJ summarily rejected the opinions of Newton's treating physician, based only on the testimony of a non-specialty medical expert who had not examined the claimant. At best, the record was incomplete, and Pertusi could have provided clarification or supplementation, if requested. This case is reversed and remanded for further consideration consistent with this decision. 60