Court Opinion

ID: 4697993
Source: CourtListenerOpinion
Date Created: 2021-06-23 19:00:47.076755+00
Date Added: 2024-06-11T08:05:50.073652
License: Public Domain

UNPUBLISHED

                       UNITED STATES COURT OF APPEALS
                           FOR THE FOURTH CIRCUIT

                                      No. 19-2415

KIMBERLY TRIPLETT,

                    Plaintiff − Appellant,

             v.

ANDREW SAUL, Commissioner of Social Security Administration,

                    Defendant – Appellee.

Appeal from the United States District Court for the Eastern District of Virginia, at
Richmond. M. Hannah Lauck, District Judge. (3:19−cv−00104−MHL)

Argued: March 9, 2021                                             Decided: June 23, 2021

Before DIAZ, THACKER, and HARRIS, Circuit Judges.

Vacated and remanded by unpublished per curiam opinion.

ARGUED: Clifford Michael Farrell, MANRING & FARRELL, Columbus, Ohio, for
Appellant. Jonathan Tyler Lucier, OFFICE OF THE UNITED STATES ATTORNEY,
Richmond, Virginia, for Appellee. ON BRIEF: G. Zachary Terwilliger, United States
Attorney, OFFICE OF THE UNITED STATES ATTORNEY, Alexandria, Virginia, for
Appellee.

Unpublished opinions are not binding precedent in this circuit.
PER CURIAM:

       Kimberly Triplett appeals the district court’s order affirming the Social Security

Administration’s denial of her application for disability insurance benefits.       Triplett

contends that the administrative law judge (“ALJ”) erred by (1) according little weight to

three medical opinions, including her treating physician’s opinion; and (2) concluding that

two of the three opinions classified her impairments as not severe, when all three doctors

opined that her impairments were severe.

       We agree with Triplett that the ALJ erred by misreading the severity findings in two

of the three medical opinions. The ALJ also erred by failing to consider each of the factors

listed in 20 C.F.R. § 404.1527(c) before affording only negligible weight to Triplett’s

treating physician’s medical opinion. Because these errors frustrate our judicial review,

we vacate the district court’s judgment and remand for further administrative proceedings.

                                             I.

       On February 27, 2015, Triplett applied for Social Security Disability Insurance

benefits, alleging disability based on fibromyalgia 1 and chronic fatigue syndrome. Triplett

alleged that her disability began on January 4, 2014.          After the Social Security

Administration denied Triplett’s claim initially and upon reconsideration, Triplett

       1
         Fibromyalgia is “a disorder of unknown cause characterized by chronic
widespread soft-tissue pain particularly in the neck, shoulders, back, and hips, which is
aggravated by use of the affected muscles and accompanied by weakness, fatigue, and sleep
disturbances.” Arakas v. Comm’r, 983 F.3d 83, 91 (4th Cir. 2020) (cleaned up).

                                             2
requested and received a hearing before an ALJ. The ALJ denied Triplett’s claim in a

written decision, and the Appeals Council denied Triplett’s request for review.

       Triplett then filed suit in the United States District Court for the Eastern District of

Virginia. She argued that “the ALJ erred by: (1) finding . . . that none of [Triplett’s]

medically determinable impairments qualified as severe; and, (2) making an inconsistent

and confusing residual functional capacity . . . finding to justify her conclusion that

[Triplett] did not suffer from any severe impairments.” Triplett v. Saul, No. 3:19CV104

(MHL), 2019 WL 6122022, at *1 (E.D. Va. Aug. 15, 2019). Triplett also argued that the

ALJ erred in failing to provide the required reasons for assigning less than controlling

weight to her treating physician’s opinion. A magistrate judge issued a report and

recommendation, which recommended granting summary judgment to the agency and

affirming its decision. Id.

       Triplett filed an objection solely to the magistrate judge’s holding affirming the

ALJ’s determination that “all of her medically determinable impairments were non-

severe.” Triplett v. Saul, No. 3:19CV104, 2019 WL 5190884, at *3 (E.D. Va. Oct. 15,

2019) (cleaned up). Triplett didn’t raise any additional arguments before the district court.

The district court overruled Triplett’s objection, adopted the report and recommendation,

and granted summary judgment to the agency. Id. at *1.

       This appeal followed.

                                              3
                                             II.

       The Social Security Act defines a “disability” as the “inability to engage in any

substantial gainful activity by reason of any medically determinable physical or mental

impairment . . . which has lasted or can be expected to last for a continuous period of not

less than 12 months.” 42 U.S.C. § 423(d)(1)(A). ALJs use the five-step sequential

evaluation process set forth in 20 C.F.R. § 404.1520(a)(4) to determine whether a claimant

is disabled under the Act.

       Step one requires the ALJ to determine whether the claimant has been working

during the relevant period. § 404.1520(a)(4)(i). Step two asks whether the claimant’s

medically determinable impairments meet the regulations’ severity and duration

requirements. § 404.1520(a)(4)(ii). “An impairment . . . is not severe if it does not

significantly limit [the claimant’s] physical or mental ability to do basic work activities.”

20 C.F.R. § 404.1522(a); See also Evans v. Heckler, 734 F.2d 1012, 1014 (4th Cir. 1984)

(“An impairment can be considered as not severe only if it is a slight abnormality which

has such a minimal effect on the individual that it would not be expected to interfere with

the individual’s ability to work, irrespective of age, education, or work experience.”)

(cleaned up). To meet the duration requirement, the impairment “must have lasted or must

be expected to last for a continuous period of at least 12 months.” § 404.1509. “If the

claimant has been working, or if the claimant’s impairments do not meet the severity and

duration requirements, the ALJ must find the claimant not disabled.” Arakas, 983 F.3d at

90.

                                             4
         At step three, the ALJ considers the medical severity of the claimant’s impairments

and determines whether they (1) are equivalent to the impairments listed in the regulations

and (2) meet the duration requirement.             § 404.1520(a)(4)(iii).   If the claimant’s

impairments meet both requirements, the ALJ must find that the claimant is disabled. Id.

         But if the step three analysis is inconclusive, the ALJ next considers the claimant’s

“residual functional capacity” and her “past relevant work.” § 404.1520(a)(4)(iv). “To

assess the claimant’s Residual Functional Capacity, the ALJ must first identify the

claimant’s functional limitations or restrictions and assess the claimant’s ability to do

sustained work-related activities on a regular and continuing basis—i.e., 8 hours a day, for

5 days a week, or an equivalent work schedule.” Arakas, 983 F.3d at 90 (cleaned up).

“After the Residual Functional Capacity assessment, the ALJ proceeds to step 4, which

asks whether the claimant can still perform past relevant work despite the limitations

identified.” Id. If the answer is yes, then the claimant is not disabled. § 404.1520(a)(4)(iv).

         If the claimant can’t perform her past relevant work, the ALJ moves to step five and

considers the claimant’s residual functional capacity, age, education, and work experience

to determine whether she can adjust to other work available in the national economy.

§ 404.1520(a)(4)(v). If so, the claimant is not disabled. Id. Though the claimant bears the

burden of proof at the first four steps, the burden shifts to the Commissioner at step five,

during which the ALJ typically relies on a vocational expert’s testimony. Arakas, 983 F.3d

at 90.

                                               5
                                           III.

       Triplett was 49 years old when she first applied for disability insurance benefits.

She holds a graduate degree and worked for the entire relevant period as a vocational

evaluator, a position which required her to drive throughout Virginia. She also regularly

commuted between her home in Fredericksburg and her office in Richmond.

       Due to her alleged disability, Triplett resigned from her position in January 2014

and hasn’t worked since.

                                           A.

       Triplett first complained of fatigue during a September 2013 appointment with Dr.

Daniel Gray, her primary care physician, reporting that she began experiencing fatigue

three years prior and also experienced “headache[s], muscle weakness and sleepiness” in

conjunction with fatigue.    A.R. 337.    Triplett told Gray that her fatigue occurred

intermittently and “at random,” that she occasionally experienced “weakness in her upper

body and neck,” and that her symptoms improved “after she t[ook] a day or so off work

and sle[pt] a lot.” Id.

       After a referral from Gray, Triplett sought treatment from Dr. Avnit Ahuja, a

rheumatologist. During a June 2014 appointment, Ahuja determined that Triplett had

normal range of motion and normal strength in her extremities. Ahuja provided Triplett

information about Lyrica and Cymbalta, prescription medications used to treat

fibromyalgia and chronic fatigue syndrome.         But during a July 2014 follow-up

appointment, Triplett expressed concerns about using these medications (due to their

possible side effects) and stated that she treated her pain with Tylenol.          Ahuja

                                            6
recommended that Triplett use the pain reliever Tramadol-Acetaminophen (“Ultracet”) to

manage her symptoms and again noted that Triplett had normal range of motion and normal

strength in her extremities.

       Triplett next saw Ahuja in September 2014. She again exhibited normal strength

and range of motion and reported that Ultracet helped her manage her symptoms. Triplett

remained “[h]esitant . . . to use Cymbalta and Lyrica due to possible side effects,” and

Ahuja recommended that Triplett “[c]ontinue to exercise as tolerated.” A.R. 297.

       During a July 2015 appointment with Ahuja, Triplett reported that she “takes

[T]ramadol every night now,” “cannot tolerate more than 2 hours of activity a day,” and

requires 20 minutes “at times to get out of bed.” A.R. 418. But Triplett also reported that

she went to the gym three times a week, where she used a stationary bike and did “stren[g]th

training and weights.” Id. A month later, Triplett told Ahuja that she was “feeling better

and doing well with [T]ramadol and would prefer not to add further medications.” A.R.

456. Ahuja also found that Triplett continued to have normal range of motion and strength

in her extremities. Ahuja sent his notes from Triplett’s appointments with him to Dr. Gray.

       Several non-treating consultants assessed Triplett’s physical and mental limitations

as part of the agency’s consideration of her disability claim. Dr. Richard Surrusco

reviewed Triplett’s medical records during the initial review of her application for benefits.

Surrusco found that Triplett wasn’t disabled but was limited to sedentary work. He also

found that Triplett had a severe medically determinable impairment and that her

“statements about the intensity, persistence, and functionally limiting effects of the

symptoms [were] substantiated by the objective medical evidence alone.” A.R. 98. But

                                              7
he opined that Triplett could stand or walk for a total of two hours and sit for a total of six

hours in an eight-hour workday. And he answered “no” to questions asking whether

Triplett had “postural,” “manipulative,” “visual,” “communicative,” or “environmental

limitations.” A.R. 99.

       Dr. William Rutherford, Jr. evaluated Triplett’s records as part of the

reconsideration of her application for benefits. Rutherford similarly concluded that Triplett

had a severe medically determinable impairment and was limited to sedentary work but

wasn’t disabled. Dr. Joseph Leizer, Ph.D. separately reviewed Triplett’s records to assess

her psychological condition and limitations, if any. He determined that Triplett had no

severe mental impairments and concluded that, though Triplett complained of difficulty

concentrating and focusing, “she is able to clean, do laundry, organize and help her son

with homework.” A.R. 109.

       In April 2017, Triplett complained to her orthopedist of lower back pain following

a fall. But her pain improved after she completed physical therapy. And by November

2017, Triplett had normal muscle tone, “painless range of motion with full flexion” in her

torso, and “no pain with back extension.” A.R. 689. During this appointment, Triplett

didn’t report taking either Ultracet or Tramadol, stating that she was then taking Lisinopril

(a hypertension medication), Flonase (a seasonal allergy medication), Timolol (a glaucoma

medication), and a multivitamin and iron supplement. See A.R. 688. She also reported

that fatigue was “[n]ot [p]resent.” A.R. 689.

       Also in November 2017, Dr. Gray filled out a fibromyalgia residual function

questionnaire, indicating that Triplett could bend and twist at the waist only occasionally.

                                              8
Gray marked that Triplett wasn’t limited in reaching, handling or fingering, but he also

wrote that she could grasp, turn and twist objects only 50 percent of the time during a

workday, finger only 50 percent of the time and reach for objects only 15 percent of the

time. Gray stated that Triplett had a “fair” prognosis, but wrote that her fibromyalgia had

lasted, or could be expected to last, at least twelve months. A.R. 671. Gray also opined

that Triplett experienced chronic and widespread pain, which worsened with stress, fatigue,

minimal activity, and changing weather.

       Gray further opined that Triplett experienced several symptoms, including: multiple

tender points, nonrestorative sleep, chronic fatigue, morning stiffness, cognitive

impairment, and numbness and tingling. Ultimately, Gray opined that Triplett couldn’t

work a full eight-hour workday and would need a job that allowed her to shift positions at

will and lie down for unpredictable intervals during the workday. He estimated that Triplett

would likely have to miss work more than three days per month.

                                            B.

       Before the ALJ, Triplett testified that she began her typical day by preparing her

then eight-year-old son for school. Said Triplett, “I make sure he gets dressed, has his

backpack[] packed, and then I walk him up the street[] to the bus stop and stay with him

until he gets on the bus.” A.R. 33. Triplett testified that she did laundry or other light

housework in the morning and rested in the afternoon before getting her son off the bus.

She went grocery shopping once a week, which tired her so much that it was the only

activity she could do that day. In the evenings, Triplett helped her son with his homework

                                             9
and took him to taekwondo practice, a five-minute drive from her house. Triplett also took

her son to the movies and played games with him. 2

       In August 2017, Triplett traveled with her husband and son to Florida on vacation.

Her husband drove the entire way in a single day, a trip which took 14 hours, including “a

lot of breaks.” A.R. 35. The vacation included a visit to Disney World, although she didn’t

say—and wasn’t asked—how much time she spent there or which activities she engaged

in. Her husband also drove for the entire return trip.

       When asked why she didn’t believe she could work, Triplett said:

       The symptoms that I have are on a daily basis. I’m in pain constantly and
       the more activity I have, the more pain, more fatigue, difficulty thinking,
       remembering, short-term memory gets impaired, and I have a lot of problems
       with the blood sugar dropping as well. And once I get fatigued, I have
       problems with vertigo. When I was working, I had to travel from Richmond
       to Fredericksburg every day, just to go back and forth to home, and when I
       was very fatigued, my blood sugar would drop and I would have to pull off
       and wait until I could get my blood sugar restabilized. So the – that really
       impacted my ability to function in my job. So all of that, together – that
       whole picture together is the reason why I can't work.

A.R. 37–38. Triplett explained that the best way for her to control her pain and other

symptoms was by limiting her schedule. She could perform about two hours of activities

each day, not counting time spent with her son, and would then need to rest to be able to

help her son with homework and other activities. While she could drive, she did so only

around Fredericksburg “because of the difficulty . . . for [her] to multitask and the fatigue

. . . and the pain.” A.R. 40. And Triplett testified that she would have a “bad day” three

       2
        Triplett didn’t testify, and wasn’t asked, about which games she played with her
son or whether any of them required physical exertion.

                                             10
or four times a month, when she couldn’t get out of bed because she experienced “severe

vertigo, severe pain, [and] severe fatigue.” A.R. 41.

         Following Triplett’s testimony, a vocational expert testified concerning Triplett’s

ability to work considering her age, education, past work, and impairments. The ALJ

presented the vocational expert with two hypotheticals. In the first hypothetical, the ALJ

asked:

         [A]ssume a person of the Claimant’s age, education, and work experience
         with the residual functional capacity to perform sedentary work. The
         hypothetical individual is able to occasionally stoop, kneel, crouch, crawl or
         climb ramps, stairs, ladders, ropes, and scaffolds. Must avoid concentrated
         exposure to hazardous (sic) and noise. Would such a hypothetical individual
         be able to perform the Claimant’s past work?

A.R. 49. The vocational expert answered yes. For the second hypothetical, the ALJ asked:

         [A]ssume a person of the Claimant’s age, education, and work experience
         with the residual functional capacity, as indicated in hypothetical #1, but in
         addition, the hypothetical individual will be off task 15% of the day and or
         miss work, leave early or arrive late two days per month. . . . Would the
         hypothetical individual be able to perform the Claimant’s past work?

Id.   The vocational expert answered no and testified that the person in the second

hypothetical couldn’t perform “any other jobs.” Id. The ALJ explained that she asked the

vocational expert about the hypothetical individual being “off task and the missed work,

based on the Claimant’s testimony about the need for breaks during the day, as well as, the

– I think she said about three really bad days per month.” A.R. 50

                                              C.

         In her decision denying Triplett’s claim at step two, the ALJ found that Triplett

“does not have an impairment or combination of impairments that has significantly limited

                                              11
(or is expected to significantly limit) the ability to perform basic work-related activities for

12 consecutive months.” A.R. 18. The ALJ thus found that Triplett’s impairments met

neither the severity nor the duration requirements. The ALJ also found that Triplett had

multiple medically determinable impairments, including “fibromyalgia/chronic fatigue

kind syndrome.”      Id.   And the ALJ found that Triplett’s “medically determinable

impairments could reasonably be expected to produce the alleged symptoms.” A.R. 19.

But the ALJ determined that Triplett’s testimony about the “intensity, persistence and

limiting effects of [her] symptoms [was] not entirely consistent with the medical evidence

and other evidence in the record.” Id.

       According to the ALJ, Triplett “received either brief, routine, conservative

treatment, or, at times, more involved treatment, but in either case, there is no evidence that

these impairments resulted in lasting sequelae.” Id. The ALJ noted that Triplett reported

in 2014 that treatment with Ultracet helped her manage her fibromyalgia symptoms and

that “[s]he continued to report improvement with Ultracet and Tramadol throughout 2015.”

A.R. 20. The ALJ pointed out that Triplett “had maintained normal strength and range of

motion, and she admitted that exercise helps her pain.” Id. The ALJ also noted that Triplett

“remained able to drive, do laundry, housecleaning, go grocery shopping, get her son up,

ready for school, and on the bus, and she [was] able to help with homework and get him to

Tae Kwon Do practice on time.” Id.

       The ALJ then described the state agency physicians’ findings and limitation of

Triplett to sedentary work. But she gave their opinions “little weight,” because she

believed them to be “internally inconsistent.” A.R. 21. The ALJ deemed them inconsistent

                                              12
because “[i]t was determined that [Triplett] did not have a severe impairment, but then she

was reduced to sedentary exertion.” Id.

       The ALJ also pointed to an apparent inconsistency in Dr. Gray’s opinion, stating:

“Dr. Gray said the claimant has no significant limitations in reaching, handling, or

fingering, but then states the claimant can perform bilateral handling 50%, bilateral

fingering 50%, and bilateral reaching (including overhead) 15% each.” Id. The ALJ then

gave Dr. Gray’s opinion “little to no weight, as the evidence does not support this level of

limitation. The evidence supports relatively mild intermittent symptoms that resolve with

routine treatment.” Id. And, said the ALJ, no evidence in the record substantiated Gray’s

(or Triplett’s) claim that Triplett would miss three or more days of work a month because

of her symptoms.

       Finally, the ALJ determined that, even if Triplett’s impairments were severe, she

would still not be disabled at step four, because Triplett could perform her previous or a

similar job while restricted to sedentary activity. The ALJ based this finding on the

vocational expert’s testimony that, “with a reduction to less than sedentary work with the

above-named limitations, [Triplett] could return to this past relevant work as generally

performed.” A.R. 22. The ALJ didn’t address the second hypothetical, aside from her

statement that she didn’t credit Triplett’s testimony (on which the hypothetical was based)

concerning the intensity, persistence, and limiting effects of her symptoms.

                                            13
                                            IV.

       We review a district court’s grant of summary judgment de novo, “applying the

same legal standards as the district court.” Martin v. Lloyd, 700 F.3d 132, 135 (4th Cir.

2012). In disability benefits cases, we “affirm the Social Security Administration’s

disability determination when [the] ALJ has applied correct legal standards and [her]

factual findings are supported by substantial evidence.” Mascio v. Colvin, 780 F.3d 632,

634 (4th Cir. 2015) (cleaned up). “Substantial evidence is such relevant evidence as a

reasonable mind might accept as adequate to support a conclusion.” Johnson v. Barnhart,

434 F.3d 650, 653 (4th Cir. 2005).

       “In reviewing for substantial evidence, we do not undertake to re-weigh conflicting

evidence, make credibility determinations, or substitute our judgment for that of the ALJ.”

Id. (cleaned up). Rather, “[w]here conflicting evidence allows reasonable minds to differ

as to whether a claimant is disabled, the responsibility for that decision falls on the ALJ.”

Id. (cleaned up). However, “we do not reflexively rubber-stamp an ALJ’s findings.” Lewis

v. Berryhill, 858 F.3d 858, 870 (4th Cir. 2017).

                                             A.

       Here, the ALJ misread the severity findings in Drs. Surrusco’s and Rutherford’s

opinions and incorrectly deemed them internally inconsistent on that basis. Drs. Surrusco

and Rutherford both found that Triplett suffered from a severe impairment that limited her

to sedentary work, though both also found that she wasn’t disabled and could continue to

perform her former job. We thus hold that the ALJ erred in giving these opinions little

weight based on a nonexistent internal inconsistency.

                                             14
                                              B.

       The ALJ then compounded this error when she failed to consider all the factors in

20 C.F.R. § 404.1527(c) before assigning little to no weight to the opinion of Triplett’s

treating physician, Dr. Gray. 3 This circuit observes the “treating physician rule,” which

“requires that ALJs give ‘controlling weight’ to a treating physician’s opinion on the nature

and severity of the claimant’s impairment if that opinion is (1) ‘well-supported by

medically acceptable clinical and laboratory diagnostic techniques’ and (2) ‘not

inconsistent with the other substantial evidence’ in the record.” Arakas, 983 F.3d at 106

(quoting 20 C.F.R. § 404.1527(c)(2)). “By negative implication, if a physician’s opinion

is not supported by clinical evidence or if it is inconsistent with other substantial evidence,

it should be accorded significantly less weight.” Craig v. Chater, 76 F.3d 585, 590 (4th

Cir. 1996).

       We have also explained how the ALJ is to assess a treating physician’s opinion that

is not controlling:

       [I]f a medical opinion is not entitled to controlling weight under the treating
       physician rule, an ALJ must consider each of the following factors to
       determine the weight the opinion should be afforded: (1) the length of the
       treatment relationship and the frequency of examination; (2) the nature and
       extent of the treatment relationship; (3) supportability, i.e., the extent to

       3
          Triplett arguably waived any challenge to the ALJ’s analysis of her treating
physician’s opinion by failing to raise it before the district court. But the agency hasn’t
pressed waiver before us. As we have observed, “the purpose of the waiver doctrine is to
avoid unfairness to an appellee and minimize the risk of an improvident or ill-advised
opinion being issued on an unbriefed issue.” Brown v. Nucor Corp., 785 F.3d 895, 920
(4th Cir. 2015) (cleaned up). Because Triplett argued both before the magistrate judge and
before us that the ALJ violated the treating physician rule, we find no prejudice to the
Social Security Administration in excusing her waiver.

                                              15
       which the treating physician presents relevant evidence to support the
       medical opinion; (4) consistency, i.e., the extent to which the opinion is
       consistent with the evidence in the record; (5) the extent to which the treating
       physician is a specialist opining as to issues related to his or her area of
       specialty; and (6) any other factors raised by the parties which tend to support
       or contradict the medical opinion.

Dowling v. Comm’r, 986 F.3d 377, 384–85 (4th Cir. 2021) (cleaned up).

       Here, substantial evidence supports the ALJ’s decision not to give controlling

weight to Dr. Gray’s medical opinion. This is because a reasonable mind could conclude

that Dr. Gray’s opinion conflicts with other medical evidence in the record.

       We briefly describe that evidence. Triplett’s last appointment with Dr. Ahuja, her

rheumatologist, was in August 2015, during which she reported that she was “feeling better

and doing well with [T]ramadol and would prefer not to add further medications.” A.R.

456. The record doesn’t indicate any additional specialized treatment for fibromyalgia.

       Triplett also declined to try Lyrica or Cymbalta, prescription medications frequently

used to treat fibromyalgia symptoms, because she was concerned about possible side

effects. Although these concerns were not entirely unfounded given that, in 2016, she

suffered an allergic reaction to prescription pain medication, which landed her in the

emergency room, 4 it also supports the ALJ’s conclusion that, contrary to Dr. Gray’s

opinion, Triplett’s “pain and fatigue is well controlled” with her then existing medication

regimen. A.R. 20.

       4
        Triplett went to the emergency room to seek treatment for an allergic reaction to
Celebrex in March 2016. See A.R. 558. But as discussed above, she began expressing
concerns over taking Lyrica and Cymbalta due to their possible side effects in 2014. The
record doesn’t indicate whether she had a history of allergic reactions to medications.

                                             16
       Triplett’s daily activities also support the ALJ’s conclusion that she wasn’t as

limited as Dr. Gray opined. As discussed above, Triplett got her son ready for school, took

him to and picked him up from the bus stop, took him to taekwondo practice in the

evenings, sometimes took him to the movies and played games with him, and was able to

do various household chores and shop for groceries. Triplett also could drive (at least

locally). And she went to the gym three times a week to exercise, as recommended by Dr.

Ahuja. Her exercise routine involved strength training and weights. Finally, she was able

to travel with her family to Disney World in August 2017.

       On this record, “we accept the ALJ’s conclusion that Dr. [Gray’s] medical opinion

was not entitled to controlling weight.” See Dowling, 986 F.3d at 385. But “it does not

follow that the ALJ had free reign to attach whatever weight to that opinion that [she]

deemed fit.” Id. Instead, “[t]he ALJ was required to consider each of the six 20 C.F.R.

§ 404.1527(c) factors before casting Dr. [Gray]’s opinion aside.” Id. Here, as in Dowling,

“[t]he ALJ plainly failed to do so.” Id.

       The ALJ afforded “little to no weight” to Dr. Gray’s opinion because “[t]he evidence

supports relatively mild intermittent symptoms that resolve with routine treatment.” A.R.

21. This explanation, however, touches on only one of the § 404.1527(c) factors—

supportability. True, the ALJ mentioned that Gray had seen Triplett for approximately five

years and was her family physician. But the ALJ failed to explain whether she considered

either the length or the nature of the treating relationship, as she was required to do under

§ 404.1527(c), before discounting Gray’s opinion.        And her analysis failed even to

acknowledge the other three § 404.1527(c) factors.

                                             17
       “While an ALJ is not required to set forth a detailed factor-by-factor analysis in

order to discount a medical opinion from a treating physician, it must nonetheless be

apparent from the ALJ’s decision that [she] meaningfully considered each of the factors

before deciding how much weight to give the opinion.” Dowling, 986 F.3d at 385. Here,

as in Dowling, it is not at all apparent that the ALJ considered, or was even aware of, all

the § 404.1527(c) factors.

       And just as in Dowling, we conclude that this error requires a remand. We note that

the first two § 404.1527(c) factors arguably cut in Triplett’s favor. Dr. Gray was Triplett’s

family physician, and he treated her for five years from July 2013, see A.R. 331–32, until

November 2017, when he filled out the fibromyalgia residual function questionnaire, see

A.R. 671.    During that time, Gray saw Triplett eleven times, and several of these

appointments were related to her fibromyalgia and chronic fatigue. See, e.g., A.R. 337

(documenting a September 30, 2013 appointment during which Triplett reported “fatigue,

headache, muscle weakness and sleepiness”); A.R. 348 (documenting a December 18, 2013

appointment during which Triplett sought treatment for sleep apnea but also reported

“headache, non-restorative sleep, . . . fatigue, [and] muscle pain”); A.R. 358 (documenting

a follow-up appointment concerning Triplett’s fatigue during which Gray noted that

Triplett’s symptoms “have remained unchanged” and “are aggravated by exertion, lack of

sleep and stress”). The ALJ’s brief dismissal of Gray’s opinion does not give us confidence

that she considered, or even reviewed, any of these records.

       In sum, the ALJ’s failure to engage meaningfully with the § 404.1527(c) factors in

dismissing Triplett’s treating physician’s opinion, combined with her error in the weight

                                             18
she assigned to the non-treating agency consultants’ testimony, frustrates our judicial

review. See Dowling, 986 F.3d at 386 (“[I]t is an elemental principle of administrative law

that agency determinations must be made in accordance with certain procedures that

facilitate judicial review.”) (cleaned up).

       A remand is therefore in order. 5

                                       *      *    *

       For the foregoing reasons, we vacate the district court’s judgment and remand the

case to the district court with instructions that it remand to the agency for further

administrative proceedings consistent with this opinion.

                                                           VACATED AND REMANDED

       Our opinion shouldn’t be read to suggest any particular result on remand regarding
       5

whether Triplett is disabled.

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