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Knapp v. Colvin

United States District Court, W.D. Virginia, Roanoke Division

August 1, 2016

CAROLYN W. COLVIN, Commissioner of Social Security, Defendant.


          Robert S. Ballou United States Magistrate Judge

         Plaintiff 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.


         This 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.[1] 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).


         Knapp applied for SSI and DIB on February 21, 2012, claiming that his disability began on September 15, 2010.[2] 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. Id.

         On December 23, 2013, the ALJ entered his decision analyzing Knapp's claim under the familiar five-step process, [3] and 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.


         Knapp 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.

         Treating Physician's Opinion

         Knapp 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.

         While a 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.

         First, 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 opinion.

         Second, 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 ...

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