United States District Court, D. Minnesota
ORDER REJECTING REPORT AND RECOMMENDATION
C. TOSTRUD JUDGE
Mai V. appealed the decision of the Acting Commissioner of
Social Security (“the Commissioner”) denying Mai
V.'s application for disability insurance benefits and
supplemental security income benefits. The Parties filed
cross-motions for summary judgment. ECF Nos. 12, 15. This
matter is before the Court on a Report and Recommendation
issued by Magistrate Judge David T. Schultz. ECF No. 18
(“R&R”). Magistrate Judge Schultz recommends
granting the Commissioner's summary-judgment motion [ECF
No. 15] and denying Mai V.'s summary-judgment motion [ECF
No. 12]. R&R at 14. Mai V. filed objections to the Report
and Recommendation [ECF No. 20], to which the Commissioner
has responded [ECF No. 22]. Because Mai V. has objected, the
Court is required to review de novo “those portions of
the report or specified proposed findings or recommendations
to which objection is made.” 28 U.S.C. §
636(b)(1); see also Local Rule 72.2(b)(3). Based on that
review, and for the reasons described below, the Report and
Recommendation will be rejected, the Commissioner's
decision will be reversed, and the case will be remanded for
further administrative proceedings as described below.
only issue Mai V. raises in her objection relates to two
medical source statements of her treating psychotherapist,
Nicole Ward, Psy.D. Obj. at 1. In addition to Dr. Ward's
opinion letter dated March 16, 2016, see Tr. 2047,
which the ALJ did discuss, see Tr. 224, Dr. Ward offered the
two medical source statements containing her opinions
regarding Mai V.'s limitations-the first dated December
8, 2014, and the second dated July 14, 2016, see Tr.
2498-2500 and 2591-93, respectively-that the ALJ did not
reference. Mai V. argues that this failure to discuss the
opinions of her treating psychotherapist was improper. Obj.
at 1; see also Ex. To Obj. [ECF No. 21] (copy of Exzabrian W.
v. Berryhill, No. 17-cv-4688 (ADM/BRT), 2018 WL 6980875 (D.
Minn. Dec. 20, 2018), R&R adopted, 2019 WL 135702 (D.
Minn. Jan. 8, 2019)). She also made this argument in her
summary-judgment brief, contending that “[t]he
ALJ's failure to evaluate every medical opinion received
violates 20 C.F.R. § 404.1527(c).” ECF No. 13 at
V.'s argument is correct. Because the ALJ did not discuss
how much, if any, weight she gave to the December 2014 and
July 2016 opinions of Dr. Ward, and did not give any reasons
for her determination of how to appropriately weigh those
opinions, the Court cannot determine whether substantial
evidence exists in the record to support the ALJ's
decision. See Harles-Wilson v. Berryhill, No. 16-cv-02758
(FLN), 2018 WL 1525728, at *6 (D. Minn. Mar. 28, 2018)
(citing Dewald v. Astrue, 590 F.Supp.2d 1184, 1201 (D.S.D.
2008)). Accordingly, the appropriate remedy is to remand the
case to permit the ALJ an opportunity to determine what
weight to give to Dr. Ward's opinions, as required by 20
C.F.R. § 404.1527(c)(2).
Security regulations define “medical opinions” as
“statements from acceptable medical sources that
reflect judgments about the nature and severity of [a
claimant's] impairment(s), including [the claimant's]
symptoms, diagnosis and prognosis, what [the claimant] can
still do despite impairment(s), and [the claimant's]
physical or mental restrictions.” 20 C.F.R. §
404.1527(a)(1). Ordinarily, a treating physician's
medical opinion is entitled to substantial weight. Dixon v.
Barnhart, 353 F.3d 602, 606 (8th Cir. 2003) (citation
omitted). When such an opinion is not given controlling
weight, the ALJ must determine what weight to afford the
opinion based on factors enumerated in the regulations. 20
C.F.R. § 404.1527(c)(2). An ALJ must “always give
good reasons . . . for the weight [she] give[s] [a] treating
source's medical opinion.” Id.
“Failure to provide ‘good reasons' for not
crediting the opinion of a claimant's treating physician
is a ground for remand.” Snell v. Apfel, 177 F.3d 128,
133 (2d Cir. 1999) (citation omitted); see also LaRiccia v.
Comm'r of Soc. Sec., 549 Fed.Appx. 377, 387 (6th Cir.
2013) (“Failure to provide ‘good reasons' for
rejecting the opinion of a treating source generally requires
remand, even if ‘a different outcome on remand is
unlikely.'” (quoting Wilson v. Comm'r of Soc.
Sec., 378 F.3d 541, 546 (6th Cir. 2004))); Wilson, 378 F.3d
at 546 (“A court cannot excuse the denial of a
mandatory procedural protection simply because [. . .] there
is sufficient evidence in the record for the ALJ to discount
the treating source's opinion and, thus, a different
outcome on remand is unlikely.”); Harles-Wilson, 2018
WL 1525728, at *5 (“Failure to provide a good reason
for discrediting a treating physician's opinion is
grounds for remand.” (citing Snell, 177 F.3d at 133)).
Report and Recommendation addresses various ratings contained
in Dr. Ward's December 2014 and July 2016 opinions, notes
that the ALJ “extensively evaluated and discussed the
underlying . . . records, ” and observes that Dr.
Ward's opinions “are not new or different medical
records in and of themselves, ” but rather were based
on the same records the ALJ considered in her decision.
R&R at 13. According to the Report and Recommendation,
the ALJ “rejected any basis for [Dr. Ward's
ratings-based] limitations [in the December 2014 and July
2016 opinions] . . . for the same reasons and based on the
same records on which she relied when discounting Dr.
Ward's March 26, 2016 opinion.” Id. The
Commissioner similarly characterizes the ALJ's discussion
of Dr. Ward's underlying treatment records as
“extensive, ” and further argues that, because
the limitations discussed in Dr. Ward's December 2014 and
July 2016 “checklist opinions” were
“essentially identical to” those described in a
March 2016 opinion letter from Jonathan Hoistad, Ph.D.,
another provider at the same clinic as Dr. Ward, the ALJ did,
at least in essence, evaluate the medical opinions provided
by Dr. Ward in the December 2014 and July 2016 documents.
Resp. to Obj. at 2-3.
ALJ is not required to discuss every piece of evidence
submitted, ” and the mere failure to cite specific
evidence does not indicate that it was not considered. Black
v. Apfel, 143 F.3d 383, 386 (8th Cir. 1998) (citations
omitted). On review, a failure to discuss a treating
physician's medical opinion may not require reversal if
the Court concludes, in light of the evidence the ALJ does
discuss, that “it is highly unlikely that the ALJ did
not consider and reject” the treating physician's
opinion. Id. But here, the ALJ's discussion of
Dr. Ward's underlying treatment records creates doubt
regarding whether the ALJ did in fact give reasonable
consideration to the evidence underlying these two opinions
from Dr. Ward. For example, of the six pages of treatment
notes the ALJ attributes to Dr. Ward, two of those pages do
not reflect Dr. Ward's notes at all, but those of other
providers providing complementary care to Mai V. at the same
clinic as Dr. Ward. Compare Tr. 224 (citing Ex. C26F at 18,
20, 24, 36, and 88), with Tr. 2239-40 (Ex. C26F at 20-21,
treatment notes signed by Dr. Hoistad) and Tr. 2255-56 (Ex.
C26F at 36-37, treatment notes signed by Vickie Wilhelm, MS,
LPC). And although the ALJ discounted the opinion of Mai
V.'s group-therapy facilitator that Mai V. experienced
racing thoughts and difficulty concentrating in the group
session, explaining that the opinion “is completely
unsupported by the group notes, ” Tr. 224, the ALJ did
not mention that Dr. Ward also observed similar issues in her
treatment of Mai V., see, e.g., Tr. 2592 (observing in her
July 2016 opinion that Mai V. had “some trouble
focusing during session and becomes distracted by other
thoughts. Can become somewhat defensive and irritable. She
often has trouble organizing her thoughts.”). That the
ALJ misattributed other providers' opinions to Dr. Ward
and failed to identify instances where Dr. Ward's
treatment records and opinions might bolster other
providers' opinions that the ALJ rejected as lacking
support raises doubts as to whether the ALJ did in fact
consider either Dr. Ward's December 2014 and July 2016
medical opinions or the underlying medical records from Dr.
Ward in adjudicating Mai V.'s claim.
the March 2016 opinion explicitly considered by the ALJ
differs from the December 2014 and July 2016 opinions not
referenced by the ALJ in ways that are relevant to Mai
V.'s claim. The two non-referenced opinions contain more
detailed opinions and more thorough discussions for the bases
of those opinions, and they also touch on topics that are not
addressed at all in the March 2016 opinion. For example, the
March 2016 opinion does not discuss any impairments in Mai
V.'s ability to drive, to maintain stable work
attendance, or to keep on pace in the workplace; by contrast,
in the December 2014 and July 2016 opinions, Dr. Ward
identifies each of those as capabilities affected by Mai
V.'s condition and points to medical and clinical
findings in support of those assessments. Tr. 2047, 2499,
2592. Those assessments appear to be consistent with at least
some of Dr. Ward's treatment notes. See, e.g., Tr. 1074
(April 2013 notes reflecting transportation limitations),
1496 (August 2014 notes reflecting issues with pace,
cognitive function, ability to remember clinical appointments
without assistance, and transportation), 1488 (September 2014
notes reflecting racing thoughts and problems with focus),
1486 (October 2014 notes reflecting difficulty maintaining
focus), 2300 (June 2015 notes reflecting difficulty
maintaining focus), 2559 (May 2016 notes reflecting
difficulty with memory). Accordingly, the ALJ's
determination that Dr. Ward's March 2016 opinion was not
entitled to any weight, see Tr. 224, says very little about
how to appropriately weigh the December 2014 or July 2016
opinions on a broader set of topics.
the Court is not persuaded by the Commissioner's argument
that because the ALJ discussed the March 2016 opinions of Dr.
Hoistad, and because those “opined limitations were
essentially identical” to those described by Dr. Ward
in December 2014 and July 2016, the ALJ has already evaluated
the limitations in a backdoor sort of way. See Resp. to Obj
at 2-3. The first reason given by the ALJ for giving Dr.
Hoistad's opinion no weight is that he “is not a
treating source and . . . has only seen the claimant on two
occasions for a diagnostic assessment.” Tr. 225. By
contrast, Dr. Ward is a treating source, and the ALJ was
required to give “good reasons” for the weight
assigned to her opinions. 20 C.F.R. § 404.1527(c)(2).
foregoing reasons, and based upon all of the files, records,
and proceedings in the above-captioned matter, IT IS
HEREBY ORDERED that:
Plaintiff's Objection to the Report and Recommendation is
SUSTAINED [ECF No. 20];
Report and Recommendation [ECF No. 18] is
Plaintiff's summary-judgment motion [ECF No. 12] is
GRANTED insofar as it seeks reversal of the