Opinion ID: 181679
Heading Depth: 3
Heading Rank: 1

Heading: SSR 96-5p Recontact Requirement

Text: The gravamen of Ferguson's first claim is that the ALJ improperly rejected the opinion of one of her treating physicians. The record indicates that Ferguson received treatment from a psychiatrist, Dr. Ruth Erulkar, M.D., from March 2003 until November 2005. The record of Dr. Erulkar's treatment is limited to handwritten office notes, reflecting Ferguson's reported history and subjective complaints, as well as medications prescribed. Among these notes is one statement of opinion by Dr. Erulkar: [Patient] will not be able to work due to her agoraphobia and panic attacks. Paranoia present. A.R. 428, Note 11/16/05. This note was entered just twelve days before the second hearing conducted by the ALJ and was addressed in his decision as follows: On November 16, 2005, Dr. Erulkar stated, Patient will not be able to work due to her agoraphobia and panic attacks. Paranoia present. (Exhibit 25F, page 2). I reject Dr. Erulkar's opinion, which is not supported by Dr. Erulkar's own objective findings. Dr. Erulkar's notes are handwritten and only partially legible. Generally, they consist of phrases, not complete sentences. It is often difficult to discern when Dr. Erulkar is merely recording the history and complaints offered to her by the claimant and when she is noting objective mental status abnormalities that she has observed. However, they appear to contain mostly the claimant's history and complaints. In any event, viewing the record as a whole, including the paucity of objective abnormalities recorded by the examiners who have evaluated the claimant, along with the claimant's daily activities, social functioning, and general tendency to exaggerate her symptoms, I reject Dr. Erulkar's opinion of disability. A.R. 69, Decision p. 51. Ferguson construes the ALJ's treatment of Dr. Erulkar's notes as reflecting the ALJ's failure to understand the bases for her opinion that Ferguson was unable to work. In such a circumstance, Ferguson contends, where the bases for a treating source's opinion are not clear, the ALJ was obliged, pursuant to Social Security Ruling 96-5p, to make every reasonable effort to recontact the source for clarification. Instead, she argues, the ALJ chose to throw up his hands and disregard the notes entirely. The district court did not specifically address Ferguson's charge that the ALJ had a duty to recontact Dr. Erulkar. Rather, the court held the ALJ complied with SSR 96-5p by basing his assessment of Ferguson's residual functional capacity upon the record as a whole after conducting an extensive examination of numerous opinions, including that of Dr. Erulkar. On appeal, the district court's ruling on Ferguson's claim that the ALJ failed to apply the correct legal standard is reviewed de novo. Valley v. Comm'r of Soc. Sec., 427 F.3d 388, 390 (6th Cir.2005). Social Security Ruling 96-5p purports to clarify Social Security Administration policy on how we consider medical source opinions on issues reserved to the Commissioner, including ... whether an individual is `disabled' under the Social Security Act. Soc. Sec. Rul. 96-5p, 1996 WL 374183 at  (July 2, 1996). [1] For purposes of SSR 96-5p, medical opinions are defined as statements from physicians and psychologists or other acceptable medical sources that reflect judgments about the nature and severity of [the claimant's] impairment(s). Id., 1996 WL 374183 at . The provision at issue recognizes that even though some issues, such as whether an individual is disabled, are case-dispositive administrative issues reserved to the Commissioner, adjudicators must always carefully consider medical source opinions about any issue, including 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. Id. The Ruling goes on to identify two conditions that must both be met to trigger the duty to recontact: the evidence does not support a treating source's opinion... and the adjudicator cannot ascertain the basis of the opinion from the record. Id. at  (emphasis added). [2] While the former of these requirements is met in this case, the latter is not. First, however, we reject Ferguson's characterization of the ALJ's error. While the ALJ said he rejected Dr. Erulkar's opinion of disability, the language and analysis of his thorough decision clearly refutes the charge that he threw up his hands and ignored or disregarded Dr. Erulkar's notes entirely. The ALJ explicitly referred to and quoted from Dr. Erulkar's notes extensively. Further, he actually relied on Dr. Erulkar's office notes in rejecting other medical opinions of record. Specifically, he rejected the opinions of Michael D. Wagner, M.D., John M. Miga, Ph.D., and Roseann F. Umana, Ph.D., who all concluded in 2002 that Ferguson's mental impairments were not severe. With reference to Dr. Erulkar's notes, the ALJ found, despite the scarcity of objective evidence relating to the claimant's mental status, ... that she has some mental impairments that cause a significant restriction in her ability to perform basic work-related activities. A.R. 69, Decision p. 51. Thus, the suggestion that the ALJ outright dismissed, ignored and disregarded Dr. Erulkar's notes is groundless. Further, to the extent the ALJ rejected Dr. Erulkar's opinion of disability, he did so not because the bases for her opinion were unclear to him, but because those bases, Ferguson's self-reported history and subjective complaints, were not supported by objective medical evidence: The claimant's complaints are not fully supported by the objective and psychological evidence, as has been described in detail above. The most striking aspect of this case is the gulf between the claimant's complaints of extreme mental symptoms (e.g., panic attacks that last all day long, auditory hallucinations, communications from her television and computer directed specifically to her, and paranoid ideation) and the almost complete lack of objective evidence to support her dramatic complaints. A.R. 64, Decision p. 46. Again, the ALJ stated specifically: I reject Dr. Erulkar's opinion, which is not supported by Dr. Erulkar's own objective findings. A.R. 69, Decision p. 51. At the time of the ALJ's Decision, the record was largely devoid of objective medical evidence substantiating the complained-of severity of Ferguson's anxiety and paranoia. To this day, Ferguson has not even argued that Dr. Erulkar's opinion of disability was in fact based on undisclosed objective medical evidence that would have been forthcoming if only the ALJ had inquired. This striking gulf, as the ALJ put it, between Ferguson's subjective complaints and the objective medical evidence, is all the more striking in light of the chronology of the administrative proceedings. When the ALJ made his final decision in July 2006, Ferguson had been granted a second bite at the apple. She had been advised in the ALJ's first decision, in May 2005, that her subjective complaints were insufficient to establish disability and there was no objective medical evidence indicating that she could not still perform her past relevant work. When this decision was vacated by the Appeals Council and the case remanded for a more thorough evaluation, Ferguson was afforded another opportunity to remedy the identified shortcomings in her claims by supplementing the record and making a more credible showing in a second hearing. Indeed, Ferguson did supplement the record with additional medical evidence, including additional notes from Dr. Erulkar. Yet, though she was represented by counsel, she failed to adduce additional objective medical evidence substantiating the severity of her mental impairments. Dr. Erulkar's office notes are fairly characterized in the ALJ's second opinion as consisting mostly of the claimant's history and complaints. Dr. Erulkar's only statement of opinion is encapsulated in the one handwritten statement that Ferguson will not be able to work due to her agoraphobia and panic attacks. This disability opinion is not explained in any way, is not tied to any physical examination findings or empirical testing results, and is not justified by reference to findings made by other physicians. Though she treated Ferguson for some two years during the pendency of her application for disability benefits, Dr. Erulkar appears not have conducted any testing or prepared any report or letter explaining any objective medical bases for her opinion. As a consequence, the supplemental evidence furnished by Dr. Erulkar amounted, in material part, to no more than a statement of her opinion, based on Ferguson's own self-reporting, that Ferguson was disabledi.e., an opinion that relates to an issue reserved to the Commissioner; an opinion that is never entitled to controlling weight or special significance. Soc. Sec. Rul. 96-5p, 1996 WL 374183 at . See also Warner v. Comm'r of Soc. Sec., 375 F.3d 387, 390 (6th Cir.2004) (determination of disability is prerogative of Commissioner, not treating physician, and treating physician's opinion is entitled to substantial deference only if supported by objective medical evidence). Because Dr. Erulkar's opinion on this issue reserved to the Commissioner was not supported by the objective medical evidence, the first precondition triggering the ALJ's recontact obligation was arguably met. As to the second precondition, however, the bases for Dr. Erulkar's opinion cannot be said to be unclear. Ferguson's reported history and subjective complaints were the bases for Dr. Erulkar's opinion. These bases were not unclear. They were in fact sufficient, in light of the other record evidence, to persuade the ALJ that Ferguson suffered from severe mental impairments. But they were insufficient to persuade the ALJ that Ferguson was disabled. This determination, whether Ferguson had carried her burden of showing that she is disabled, is the case dispositive issue reserved to the ALJ. In this respect, Dr. Erulkar's opinion was deemed unpersuasive not because its bases were unclear, but because they were not corroborated by objective medical evidence. It follows that the ALJ's SSR 96-5p duty to make every reasonable effort to recontact Dr. Erulkar was not triggered and therefore not violated. See Poe v. Comm'r of Soc. Sec., 342 Fed.Appx. 149, 156 n. 3 (6th Cir.2009) ([A]n ALJ is required to re-contact a treating physician only when the information received is inadequate to reach a determination on claimant's disability status, not where, as here, the ALJ rejects the limitations recommended by that physician.); DeBoard v. Comm'r of Soc. Sec., 211 Fed.Appx. 411, 416 (6th Cir.2006) (same). [3] In sum, we find no error. The burden lies with the claimant to prove that she is disabled. Foster v. Halter, 279 F.3d 348, 353 (6th Cir.2001). The ALJ has discretion to determine whether additional evidence is necessary. Id. at 355. Here, the ALJ's thorough opinion demonstrates that he carefully considered the entire record in this case, including Dr. Erulkar's notes; that he identified substantial evidence supporting the determination that Ferguson was not disabled; and that he did not abuse his discretion in failing to recontact Dr. Erulkar, because the bases for her opinion, though wanting, were not unclear or ambiguous. We therefore uphold the district court's rejection of Ferguson's claim that the ALJ violated SSR 96-5p.