United States District Court, W.D. Virginia, Roanoke Division
REPORT AND RECOMMENDATION
S. Ballou United States Magistrate Judge
Charles Edward Knapp (“Knapp”) filed this action
challenging the final decision of the Commissioner of Social
Security (“Commissioner”) determining that he was
not disabled and therefore not eligible for supplemental
security income (“SSI”), and disability insurance
benefits (“DIB”) under the Social Security Act
(“Act”). 42 U.S.C. §§ 401-433,
1381-1383f. Specifically, Knapp alleges that the ALJ (1)
improperly afforded less weight to the opinion of his
treating physician and (2) erroneously found his testimony to
be less than credible. I find that the ALJ failed to provide
a sufficient explanation for the weight given to the treating
physician's opinion. As such, I RECOMMEND that
Knapp's motion for summary judgment (Dkt. No. 15) be
GRANTED in part, the Commissioner's motion for summary
judgment (Dkt. No 19) be DENIED, and that the case be
REMANDED for further consideration by the ALJ.
court limits its review to a determination of whether
substantial evidence exists to support the Commissioner's
conclusion that Knapp failed to demonstrate that he was
disabled under the Act. Mastro v. Apfel, 270 F.3d 171,
176 (4th Cir. 2001). “Substantial evidence is such
relevant evidence as a reasonable mind might accept as
adequate to support a conclusion; it consists of more than a
mere scintilla of evidence but may be somewhat less than a
preponderance.” Craig v. Chater, 76 F.3d 585,
589 (4th Cir. 1996) (internal citations omitted). The final
decision of the Commissioner will be affirmed where
substantial evidence supports the decision. Hays v.
Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990).
applied for SSI and DIB on February 21, 2012, claiming that
his disability began on September 15, 2010. The Commissioner
denied the application at the initial and reconsideration
levels of administrative review. R. 77-102, 105-24. On
October 31, 2013, ALJ Steven A. DeMonbreum held a hearing to
consider Knapp's disability claim. R. 29-76. Knapp was
represented by an attorney at the hearing, which included
testimony from Knapp and vocational expert Ashley Wells.
December 23, 2013, the ALJ entered his decision analyzing
Knapp's claim under the familiar five-step process,
denying Knapp's claim for benefits. R. 11-22. The ALJ
found that Knapp suffered from the severe impairments of
fibromyalgia, osteoarthritis, gout/gouty arthritis in the
knees, ankles, and feet, obesity, hypertension, chronic
obstructive pulmonary disease (COPD), asthma, history of
cervical strain, and diabetes. R. 13-14. The ALJ found that
these impairments did not meet or medically equal a listed
impairment (R. 15) and further found that Knapp had the
residual function capacity (“RFC”) to perform
light work. R. 16. Specifically, the ALJ found that Knapp
could occasionally operate foot controls with both lower
extremities; occasionally climb ramps and stairs, but never
ladders, ropes, or scaffolds; frequently balance and
occasionally kneel, stoop, bend, crouch, and crawl; that he
should avoid all exposure to temperature extremes and
humidity, as well as dust, fumes, odors, chemicals, and
gases; and that he should avoid all exposure to vibrations
and to hazards such as moving machinery and unprotected
heights. Id. The ALJ determined that Knapp could
return to his past relevant work as a retail manager and
insurance agent (R. 21) and that he could also work at other
jobs that exist in significant numbers in the national
economy, such as cafeteria attendant and sales attendant. R.
22. Thus, the ALJ concluded that he was not disabled. On May
8, 2015, the Appeals Council denied Knapp's request for
review (R. 1-5), and this appeal followed.
alleges that the ALJ erred by failing to properly evaluate
and explain the weight he gave to the opinion of Knapp's
treating physician, Robert C. Patten, Jr., M.D. and that the
ALJ improperly found Knapp to be less than credible in his
complaints of pain and its limiting effect on his abilities.
asserts that the ALJ erred by giving “very limited
weight” to the opinion of his treating physician, Dr.
Patten, who submitted a letter explaining Knapp's
diagnoses and his resulting physical limitations. R. 740-41.
The October 29, 2013 letter states that Knapp suffers from
“extensive osteoarthritis and fibromyalgia” and
that he experiences pain in most of his joints, but
specifically in his knees, hips, feet, wrists, and hands. R.
740. Dr. Patten concludes that Knapp is unable to maintain
employment, sit, walk, or “do any type of repetitive
motion on a regular basis” due to his pain and
discomfort and that his pain makes concentration difficult.
Id. Dr. Patten also wrote that Knapp's condition
is chronic and will likely not improve with time.
Id. The ALJ gave “very limited weight”
to Dr. Patten's opinions because his conclusions were
“inconsistent with [his] own clinical findings and
unsupported by the medical evidence of the record as a whole
including Dr. Humphries' consultative examination report,
the state agency consultants' assessments, and the
claimant's activities of daily living.” R. 20. The
ALJ's accompanying explanation for this decision found
the opinions “inconsistent with his own clinical
findings (e.g. virtually unremarkable physical examinations
revealing clear lungs, benign extremities, etc.) as well as
failing to correlate functionally with other clinical
findings in the record including Dr. Humphries and the State
agency consultants.” Id. Though the ALJ
references general exhibits or reports that may substantiate
his findings, he omits from his analysis any specific reasons
why or how the evidence in the record contradicts Dr.
Patten's opinion. Knapp argues that the ALJ committed
error because he did not specifically state what evidence in
the record contradicts Dr. Patten's opinions in violation
of SSR 96-2p. Pl.'s Br. Summ. J., 19-20.
treating physician's opinion is not automatically
entitled to controlling weight, the Social Security
regulations require that an ALJ give such an opinion
controlling weight if he finds the opinion
“well-supported by medically acceptable clinical and
laboratory diagnostic techniques” and “not
inconsistent with the other substantial evidence in [the]
case record.” 20 C.F.R. § 416.927(c)(2). The ALJ
must give “good reasons” for not affording
controlling weight to a treating physician's opinion. The
Fourth Circuit recently reiterated in Monroe v.
Colvin, that an ALJ's failure to “‘build
an accurate and logical bridge from the evidence to his
conclusion'” is grounds for remand.
Monroe, 2016 WL 3349355, at *10 (4th Cir. Jun. 16,
2016). The failure of an ALJ to specify what treatment
history or evidence does not support a particular opinion
means “the analysis is incomplete and precludes
meaningful review.” Id. at *11.
Monroe confirms the ALJ's obligation to explain
his conclusions and point to the record evidence to support
those conclusions. Only then can a court engage in a
meaningful review to determine whether substantial evidence
supports the ALJ's decision.
as to Dr. Patten's opinion and its consistency with his
clinical findings, the ALJ recounts in detail Knapp's
medical records, including information that both supports and
rebuts Knapp's claim that he is disabled. For example,
the ALJ notes that Dr. Patten diagnosed hypertension,
diabetes mellitus, anxiety state, gout, fibromyalgia, and
osteoarthritis (R. 19), all of which may tend to support Dr.
Patten's opinion that Knapp's complaints of pain were
genuine, that he needed a cane to walk, that his pain would
cause frequent interruptions in concentration, that his
symptoms would require missing work, and that he would need
time for breaks at work beyond those normally given in a
workday to elevate his lower extremities and rest. R. 741. In
the same paragraph of his opinion, the ALJ notes Dr.
Patten's clinical findings of “negative ENT and
heart, clear lungs, and benign extremities with no
edema” (R. 19, citing R. 652-57) and his
“virtually unremarkable” findings that Knapp had
“obesity and scattered rhonchi due to bronchitis, but
negative ENT, supple neck, no lung rales or wheezing, regular
heart, and benign A/P.” R. 19, citing R. 662-65.
However, in the section of the opinion explaining the weight
given to Dr. Patten's opinion, the ALJ makes conclusory
statements that Dr. Patten's conclusions are not
supported by his own clinical findings without pointing to
which clinical findings do not support the opinion.
Monroe requires that, to the extent the ALJ
determines that Dr. Patten's findings are benign or
otherwise normal and thus, inconsistent with the limitations
described, the ALJ must identify those findings and analyze
how the conclusion of disabling limitations is inconsistent
with those findings. Pointing to “unremarkable”
findings from a particular doctor's visit (such as a
negative ENT or a supple neck) does not, without more pointed
analysis, mean that Dr. Patten's opinion is unsupported
by his clinical findings when his clinical findings also
include diagnoses and records that would tend to support his
the ALJ discredits Dr. Patten's opinion because it is
inconsistent with the conclusions reached by the consultative
examiner and the state agency physicians. Again, however, the
ALJ fails to specifically analyze how Dr. Patten's
opinion is inconsistent with the other medical opinions or