Opinion
Civil Action No. 04-2005-KHV.
December 20, 2004
MEMORANDUM AND ORDER
Roger M. Lund appeals the final decision of the Commissioner of Social Security to deny him disability benefits under Title II of the Social Security Act, 42 U.S.C. §§ 401 et seq. This matter is before the Court on Plaintiff's Social Security Brief (Doc. #5) filed May 11, 2004, which the Court construes as a motion for judgment. For reasons set forth below, the Court sustains plaintiff's motion in part.
Procedural Background
On March 12, 2001, plaintiff filed his disability application with the Social Security Administration. He alleged a disability on set date of January 1, 1998. Plaintiff's benefit application was denied initially and on reconsideration. On July 11, 2003, the administrative law judge ("ALJ") concluded that plaintiff was not under a disability as defined in the Social Security Act and that he therefore was not entitled to disability benefits. On November 6, 2003, the Appeals Council denied plaintiff's request for review. The decision of the ALJ stands as the final decision of the Commissioner. See 42 U.S.C. § 405(g), § 1383(c)(3).
Factual Background
The following is a brief summary of the evidence presented to the ALJ.
Roger M. Lund was born on April 26, 1975. Transcript Of Proceedings Before The Social Security Administration ("Tr.") at 401, attached to defendant's Answer (Doc. #3) filed March 12, 2004. At the time of his hearings before the ALJ, plaintiff was 28 years old. Tr. 401. Plaintiff has a high school education plus a business degree in marketing. Tr. 401.
Plaintiff suffers from obesity; panhypopituitary deficiency, corrected byhormone replacement; nonspecific pain syndrome; obstructive sleep apnea, corrected by C-PAP; marijuana abuse; past suspected Lyme disease with no active disease process; and a non-severe mood disorder. Tr. 15.
I. Medical History
On April 13, 2000, Dr. Jackie Springer completed a physical examination. She noted panhypopituitary, adult HGH deficiency (severe), hypogonadism (severe), gyneconastia, and organic brain disease. Tr. 324. Dr. Springer prescribed testosterone cypionate and ArmourThyroid. Tr. 324.
On July 6, 2000, plaintiff underwent a split night sleep study at Total Sleep Diagnostics, Inc. Tr. 304-10. Michael Nelson, Ph.D., noted that the study involved a split night with the first portion used to document sleep apnea and the second portion used to titrate C-PAP therapy. Tr. 304. Dr. Nelson noted that the study was consistent with severe sleep apnea and recommended weight loss and a C-PAP pressure of 11cm H2O to decrease respiratory events associated with sleep disruption to normal levels. Tr. 304. On July 12, 2000, Total Sleep Diagnostics, Inc., set plaintiff up on a nasal C-PAP unit. Tr. 303.
On April 18, 2001, plaintiff saw Dr. Cedric B. Fortune for a consultative examination. Tr. 341. Dr. Fortune diagnosed plaintiff with fibromyalgia and sleep apnea under treatment with C-PAP and arthralgia. Tr. 342. He also noted that plaintiff was overweight. Tr. 342. He opined that plaintiff's intelligence was well above average and that plaintiff could perform reasonable activities including sitting, standing and walking. Tr. 342. On May 25, 2001, Dr. George Drasin reviewed x-rays of plaintiff's knees and lumbar spine, and concluded that both were normal. Tr. 343.
On January 16, 2002, G. Thomas Colpitts, D.D.S., wrote a letter to Social Security which stated that he had been treating plaintiff for osteonecrosis of the jaw. Tr. 369. On January 22, 2002, Dr. Colpitts wrote a letter which stated that plaintiff had been seen for osteonecrotic surgery of the jaw. Tr. 368. Dr. Colpitts stated that patients with osteonecrotic lesions "have extreme loss of energy and are unable to function in a normal way." Tr. 368.
On May 2, 2002, Dr. Arnold Katz evaluated plaintiff for musculoskeletal pain. Tr. 372. Dr. Katz concluded that plaintiff did not have classic trigger points seen with fibromyalgia and thus stated he did not diagnose plaintiff with fibromyalgia.Id. He noted that plaintiff has pain of myofascial etiology and numerous athletic injuries. Id. Dr. Katz surmised that depression and anxiety may contribute to plaintiff's chronic pain. Id.
On October 2, 2002, plaintiff saw Dr. Springer for a follow-up visit. Tr. 381. Plaintiff told Dr. Springer that he had 30 of 60 symptoms of chronic Lyme disease and wanted a Lyme test. Additionally, he wanted to recheck HGH treatment. Dr. Springer recommended that plaintiff continue on Celexa. She suggested check chronio titer for Lyme disease, check morning cortisol, transcortin and DHEA at next visit. Tr. 381. On October 21, 2002, plaintiff had blood drawn for the Lyme test. Tr. 389. The IgM Western blot test was negative. Id. On November 12, 2002, plaintiff had blood drawn again. Tr. 386. The IgM Western blot results were again negative, but the IgG Western blot results were positive. Tr. 386-87. On November 27, 2002, Charles L. Crist, M.D., wrote a letter which stated that plaintiff has been diagnosed with Borreliosis (Lyme disease) and stated that plaintiff was disabled and not able to work at any job. Tr. 373.
On February 5, 2003, Dr. Springer wrote a letter which stated that plaintiff's complaints of body pain might be due to pituitary dysfunction. Tr. 375. She stated as follows:
Mr. Lund underwent stimulation testing for adult growth hormone deficiency. The tests revealed severe deficiency in all hormones of the hypothalamic/pituitary axis. Mr. Lund has total pituitary failure. Hormone replacement will prolong his life but he is unable to work at any job due to the damage his long-standing deficiency has caused.
Total pituitary failure has left Roger Lund totally disabled and he is unable to work at any job position.Id. On June 2, 2003, Dr. Springer completed a Fibromyalgia Residual Functional Capacity Questionnaire. Tr. 376. On the form, Dr. Springer marked that plaintiff met the American College of Rheumatology criteria for fibromyalgia. Id. She stated "pituitary insufficiency — panhypopituitary" as other diagnoses.Id. She noted that "I have not ascessed [sic] this patient for fibromyalgia. I diagnosed and treated his panhypopituitary disease. I believe this patient will not be able to hold a full-time or part-time job due to his severe emotional and cognitive limitations." Tr. 381. Dr. Springer's diagnoses on June 2, 2002, included panhypopituitary, Lyme disease, fibromyalgia, morbid obesity. Tr. 383.
On June 12, 2003, Dr. Crist wrote a letter to Sharon Meyers, plaintiff's attorney, disagreeing with Dr. DeMarco's testimony that plaintiff shows no evidence of active Lyme disease and stating that plaintiff has a positive IgG Western blot. Tr. 396. Dr. Crist stated that whether the blot is IgG or IgM, there is no difference in the response to antibiotic treatment. Id.
II. Testimony And Daily Activities
A. Plaintiff
Plaintiff testified that since 1995, he has had severe pain inside his body. He cannot point to a spot that does not hurt. Tr. 402. He reported that his doctor attributes the pain to chronic Lyme disease, which he believes stems from a tick bite in 1991. Id. Plaintiff stated that he had spinal meningitis in his senior year of high school. Id. Plaintiff testified that because he is very smart, he was able to attend college even though things were going down hill for him. Tr. 403. He rarely attended class, did not get good grades, was tired and irritable and had trouble connecting with people. Id. He started thinking about killing himself because he was in so much pain but has never made any suicide attempts. Id.
Plaintiff testified that he was diagnosed with sleep apnea and uses a C-PAP machine to keep from choking in his sleep. Id. He has not felt rested in ten years. Tr. 404. When plaintiff sleeps through the night, he gets eight to nine hours of sleep; when he wakes up early, he gets five to six hours of sleep. Id. Dr. Crist has recently prescribed Oxycontin for the pain. Id. Before that, plaintiff was taking Vioxx for pain. Tr. 404. Plaintiff stated that he resisted taking narcotics because they make him feel nauseous. Tr. 405. He described the pain as "like all my muscles are sour." Tr. 405. His hamstrings get tight, his back starts to hurt if he bends over to pick anything up. Id. He testified that he has TMJ and his jaw gets stiff. Id. Plaintiff testified that he does not breathe well and is very constipated. Tr. 406.
Plaintiff stated that Dr. Springer served as his endocrinologist but did not treat him for pain. Tr. 407. She prescribes growth hormone and Vioxx, which plaintiff stated did not help. Id. Dr. Crist treats plaintiff for pain. Id. Plaintiff experiences tingling in his legs and sometimes in his hands and forearms maybe ten or 20 times a week. Tr. 407-08.
Plaintiff testified that on an average day, he wakes up around 3:00 p.m. if he has slept well. Because of pain, it takes him 30 minutes to get out of bed. He stated that he tries to do one thing a day because that is about all he can handle. Tr. 408-09. Plaintiff spends his day trying to move in ways to shift the pain. Tr. 409. He watches TV, listens to music or listens to Pastor Murray on the Internet. He spends the whole day resisting thoughts of suicide. Id. He has difficulty dealing with people because they do not understand his pain. Tr. 410. He stays up late so he has the house to himself and does not have to deal with the phone ringing, answering the door, or letting his dog out. Id.
Plaintiff testified that he feels like he is in a constant state of panic. Tr. 411. His associated physical symptoms include constriction in breath, moving his eyes and slurred speech. Id. He "freaks out" when asked to repeat what he says and starts yelling and swearing. Id. His attention span is short and he is sensitive to light. Tr. 412. He experiences hand tremors. Tr. 413. Plaintiff testified that he has never been hospitalized for his pain. Id. He stated that he cannot work because he cannot do any kind of repetitive physical or mental activity. Tr. 414. He does not receive mental health treatment because people at a mental health clinic told him that his problems were physical. Tr. 415. He has not sought treatment for suicide ideation because his problems are symptoms of Lyme disease and talking to someone about his childhood will not make the pain go away. Tr. 416.
Plaintiff completed four Activities of Daily Living questionnaires — on May 9 and August 27, 2000 and on March 18 and July 22, 2001 (plaintiff's mother completed the third and fourth and plaintiff signed them). Tr. 133-40, 148-54, 188-94, 227-35. Plaintiff stated that he lives with both parents, his grandmother, a sister and (on the last questionnaire) his brother. On the first questionnaire, plaintiff stated that he does not have energy to invest much time in grooming or dressing. Tr. 134. On the third and fourth questionnaires, plaintiff indicated that his condition does not affect his ability to care for personal needs. Tr. 189, 228. Plaintiff reported that he does not cook, do laundry or help with housecleaning chores. Tr. 134, 149, 189, 228. On the first questionnaire, plaintiff reported that he handles his own money/pays his own bills, but he has no bills because he has no money. Tr. 135. In subsequent questionnaires, plaintiff indicated that he does not handle his own money/pay his own bills and reiterated that he has no money. Tr. 150, 190, 231. He does no shopping but occasionally drives to the doctor. Tr. 135, 150, 190, 231. He watches TV, sometimes two to three hours per day. Tr. 135, 150, 190, 231. On the first two questionnaires, plaintiff reported that he reads. Tr. 136, 151. On the third and fourth questionnaires, plaintiff reported that he no longer reads because he cannot concentrate and needs to constantly massage himself to relieve pain. Tr. 191, 232. He reported that he rarely leaves the house. Tr. 136, 151, 191, 232. Initially, he noted that he sleeps about ten hours each day. Tr. 137, 152. Plaintiff later reported getting about eight hours of sleep each night. Tr. 192, 233. Plaintiff noted that his quality of sleep is "horrible" and that he wakes up exhausted. Tr. 192.
B. Alice Lund
Alice Lund, plaintiff's mother, testified that plaintiff lives with her. Tr. 417. She believes that he has symptoms of Lyme disease, extreme fibromyalgia and pain all over his body. Id. She testified that he cannot do simple everyday things that normal people can do, including sitting, walking, standing and bending. Id. Ms. Lund reported that plaintiff is difficult to get along with. Tr. 418. She testified that plaintiff has "tried everything" for his pain, including morphine, deep tissue massage, Oxycontin and Aleve. Tr. 420. Ms. Lund described plaintiff as "extremely bright, creative, intelligent, and extremely active." Id. He played football in high school and college and graduated early from college. Id. Plaintiff had meningitis at age 16, after which the family began to see small changes in him. Tr. 421. The family has spent around $100,000 to help plaintiff. Id. Ms. Lund has not recommended that plaintiff see a psychiatrist. Tr. 422. Dr. Springer has prescribed Celexa. Tr. 423.
On May 8, 2001, Ms. Lund completed an Activities of Daily Living questionnaire. Tr. 119-24. She reported that plaintiff cooks for himself about half the time. Tr. 120. He does no household chores because he is "incapable of doing chores — he is inconstant pain." Id. Plaintiff has a driver's license and sometimes borrows his mother's car, but he seldom leaves the house. Tr. 121. He occasionally plays the guitar, writes songs and listens to tapes. Id. He reads the Bible and Christian books but cannot handle the stress of news or newspapers. Id. Ms. Lund described plaintiff as "hard to be around," stating that he is impatient, has an explosive temper, and is irritable, intolerant and unreasonable. Id. He occasionally attends a movie with his parents or a concert with his brother. Tr. 122. Ms. Lund reported that she has seen a great change in plaintiff as he used to be active in sports, had friends and went out socially. Id. He now has a short attention span and cannot complete tasks because of pain. Id. She also described plaintiff as "somewhat paranoid." Tr. 123.
C. Testimony Of Medical Expert Lynn I. DeMarco, M.D.
At the request of the ALJ, Lynn I. DeMarco, M.D., testified at plaintiff's hearing. Tr. 424. Dr. DeMarco testified that he was board certified in internal medicine and allergy menology, and that he has experience treating people who have the type of problems described in the record. Id.
Based on his review of the written evidence, Dr. DeMarco testified that plaintiff suffered from obesity; panhypopituitary deficiency, corrected by hormone replacement; non-specific pain syndrome; obstructive sleep apnea, corrected by C-PAP; non-specific mood disorder; substance abuse; and suspected Lyme disease. Tr. 425, 426, 428. The record reflected a diagnosis of fibromyalgia, which Dr. DeMarco did not think was well substantiated. Tr. 426. Dr. DeMarco testified that evidence in the record did not support a diagnosis of active Lyme disease. Tr. 428.
Dr. DeMarco testified that the record reflects no medical basis for severe pain, extreme stiffness and concentration deficits of which plaintiff complains. Tr. 429. He also testified that the record contains no medical basis for plaintiff's fatigue/exhaustion which would make him non-functional during normal work hours. Id.
Dr. DeMarco testified that the psychiatric review technique form in the record did not show a major depressive, manic or bipolar disorder. Tr. 430. Furthermore, Dr. DeMarco stated that plaintiff had not received significant treatment for his mood disorder or sought consistent psychiatric or psychological help, but that he had received anti-depressants. Id. Dr. DeMarco testified that based on the objective record, plaintiff was slightly limited in daily living activities. Tr. 431. In Dr. DeMarco's opinion, plaintiff suffers from a non-severe mood disorder. Id.
Dr. DeMarco testified that plaintiff should experience no limitations on his ability to sit, stand and walk. Tr. 432. He testified that in lifting an object with both hands and carrying it 15 feet, plaintiff would be limited to 30 to 50 pounds of weight. Id. He also testified that plaintiff should have no limitations on bending at the waist or gripping/grasping. Tr. 433. He agreed that plaintiff's stair climbing should be limited to three or four flights. Id.
D. Testimony Of Vocational Expert Amy Salva
Vocational expert Amy Salva testified at the request of the ALJ. Tr. 434. Salva read the written evidence of record. Id. Salva testified that plaintiff had never had a relevant job.Id. The ALJ asked Salva which jobs an individual could perform if he had a history of obesity, corrected panhypopituitary deficiency, non-specific pain syndrome, corrected obstructive sleep apnea, non-severe mood disorder and suspected Lyme disease (with no evidence of an active Lyme disease process of consequence), if he was restricted to climbing three to four flights of stairs at a time and lifting a 30-50 pound object and carrying it 15 feet ten to 12 times in an hour with both hands. Tr. 435-36. Salva testified that such a person would be able to perform a full range of sedentary and light level work, such as car porter, housekeeper, assembly worker, and telephone solicitor. Tr. 437.
Salva testified that a person who needs to lie down frequently during the day because of fatigue and severe pain would not be competitively employable. Tr. 437. She also testified that a person who experienced significant deficits in concentration, persistence or pace, could not focus and stay on task for an extended period of time could not be competitively employable. Tr. 438. In addition, she testified that a person who misses more than one sick day per month would be unable to maintain employment. Id. Further, a person who had to be away from his work station more frequently than a 30-minute lunch break and two 15-minute breaks would be unable to maintain employment. Finally, a person with a concentration deficit which happens up to one-third of the workday could not compete for employment.
III. ALJ Findings
In his order of July 11, 2003, the ALJ made the following findings:
1. Claimant has not engaged in substantial gainful activity since the alleged onset of disability.
2. Claimant has the following severe impairments: obesity; panhypopituitary deficiency, corrected by hormone replacement; non-specific pain syndrome; obstructive sleep apnea, corrected by C-PAP; marijuana abuse; past suspected Lyme disease with no active disease process; and a non-severe mood disorder.
3 Claimant's medically determinable impairments do not meet or medically equal one of the listed impairments in Appendix 1, Subpart P, Regulation No. 4.
4. The Administrative Law Judge finds the allegations and testimony of claimant and his mother regarding claimant's limitations are not credible for the reasons set forth in the body of this decision.
5. The Administrative Law Judge has carefully considered all of the medical opinions in the record regarding the severity of claimant's impairments ( 20 CFR § 416.927).
6. Claimant has the following physical residual functional capacity: is capable of lifting and carrying an object weighing 30-50 pounds, 15 feet, 10-12 times an hour, using both hands; is not limited with regard to sitting, standing, walking on a level surface, bending, gripping or grasping;, [sic] and can climb 3-4 flights of stairs. Moreover, he retains the following mental residual functional capacity: mild restriction of activities of daily living; mild difficulties maintaining social functioning; mild difficulties maintaining concentration, persistence, or pace; and no episodes of decompensation of extended duration.
7. Claimant has no past relevant work ( 20 CFR § 416.965).
8. Claimant is a "younger" individual ( 20 CFR § 416.963).
9. Claimant has more than a "high school" education ( 20 CFR § 416.964).
10. Claimant has the residual functional capacity to perform a significant range of work ( 20 CFR § 416.967).
11. Claimant has not been under a "disability," as defined in the Social Security Act, as amended, at any time through the date of this decision ( 20 CFR § 416.920(f)).
Tr. 21-22.
Standard Of Review
The ALJ decision is binding on the Court if supported by substantial evidence. See 42 U.S.C. § 405(g); Dixon v. Heckler, 811 F.2d 506, 508 (10th Cir. 1987). The Court must determine whether the record contains substantial evidence to support the decision and whether the ALJ applied the proper legal standards. See Castellano v. Sec'y of HHS, 26 F.3d 1027, 1028 (10th Cir. 1994). While "more than a mere scintilla," substantial evidence is only "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 401 (1971). Evidence is not substantial" if it is overwhelmed by other evidence — particularly certain types of evidence (e.g., that offered by treating physicians) — or if it really constitutes not evidence but mere conclusion." Knipe v. Heckler, 755 F.2d 141, 145 (10th Cir. 1985) (citation omitted).
Analysis
Plaintiff bears the burden of proving disability under the Social Security Act. See Ray v. Bowen, 865 F.2d 222, 224 (10th Cir. 1989). The Social Security Act defines "disability" as the inability to engage in any substantial gainful activity for at least twelve months due to a medically determinable impairment. See 42 U.S.C. § 423(d)(1)(A). To determine whether a claimant is under a disability, the Commissioner applies a five-step sequential evaluation: (1) whether the claimant is currently working; (2) whether the claimant suffers from a severe impairment or combination of impairments; (3) whether the impairment meets an impairment listed in Appendix 1 of the relevant regulation; (4) whether the impairment prevents the claimant from continuing his past relevant work; and (5) whether the impairment prevents the claimant from doing any kind of work.See 20 C.F.R. §§ 404.1520, 416.920. If a claimant satisfies steps one, two and three, he will automatically be found disabled; if a claimant satisfies steps one and two, but not three, he must satisfy step four. If step four is satisfied, the burden shifts to the Commissioner to establish that the claimant is capable of performing work in the national economy. See Williams v. Bowen, 844 F.2d 748, 751 (10th Cir. 1988).
Here, the ALJ found that plaintiff does not suffer impairments which meet or equal any criteria contained in the Listing of Impairments in Appendix 1. Tr. 21. In reaching his conclusion, the ALJ determined that "no treating or examining physician has mentioned findings equivalent in severity to the criteria of any listed impairment." Tr. 15.
The ALJ next found, under step four, that plaintiff had no past relevant work. At step five, the ALJ denied benefits because he found that plaintiff could perform work in the national economy. In the step five analysis, the ALJ must determine whether — in view of his age, education and work experience — plaintiff has the residual capacity to perform other work in the national economy. Bowen v. Yuckert, 482 U.S. 137, 148 (1987). The ALJ bears the burden of proof at step five. See id. at 146 n. 5. To meet this burden, the ALJ must find that plaintiff can perform work "in the claimant's residual functional capacity category."Talbot v. Heckler, 814 F.2d 1456, 1462 (10th Cir. 1987).
The ALJ found plaintiff capable of performing a significant range of work. Plaintiff challenges the ALJ's decision, arguing that (1) the ALJ erred in rejecting the opinion of his treating physician, Dr. Springer; and (2) the ALJ erred in relying on vocational expert testimony that plaintiff could perform other substantial gainful activity because the hypothetical did not include limiting effects of claimant's nonexertional impairments.Plaintiff's Social Security Brief (Doc. #5) filed May 11, 2004, at 11, 16, 20.
I. Opinion Of Treating Sources
Plaintiff argues that the ALJ assessment of plaintiff's residual functional capacity is not supported by substantial evidence. Specifically, plaintiff argues that the ALJ relied on the testimony of a nonexamining, non-treating physician and assigned no weight to the opinions of plaintiff's treating physician regarding plaintiff's ability to work.
According to the Tenth Circuit, a treating physician's opinion is not dispositive on the ultimate issue of disability. White v. Massanari, 271 F.3d 1256, 1259 (10th Cir. 2001) (citingCastellano v. Sec'y of Health Human Servs., 26 F.3d 1027, 1029 (10th Cir. 1994)). A treating physician's opinion is not entitled to controlling weight if it is not "well-supported by medically acceptable clinical and laboratory diagnostic techniques" if it is inconsistent with other substantial evidence in the record, 20 C.F.R. § 404.1527(d)(2); see also Watkins v. Barnhart, 350 F.3d 1297, 1300 (10th Cir. 2003) (quotation omitted), or if it is brief, conclusory and unsupported by medical evidence, Frey v. Bowen, 816 F.2d 508, 513 (10th Cir. 1987).
The ALJ must give substantial weight to the opinion of a treating physician "unless good cause is shown to disregard it."Goatcher v. United States Dep't of HHS, 52 F.3d 288, 289-90 (10th Cir. 1995). When a treating physician opinion is inconsistent with other medical evidence, the ALJ task is to examine reports of other physicians to see if they outweigh the reports of the treating physician. See id. The ALJ must consider the following specific factors to determine what weight to give any medical opinion: (1) the length of the treatment relationship and the frequency of examination; (2) the nature and extent of the treatment relationship, including the treatment provided and the kind of examination or testing performed; (3) the degree to which the physician's opinion is supported by relevant evidence; (4) consistency between the opinion and the record as a whole; (5) whether the physician is a specialist in the area upon which an opinion is rendered; and (6) other factors brought to the ALJ's attention which tend to support or contradict the opinion. Id. at 290 (citing 20 C.F.R. § 404.1527(d)(2)-(6)). The ALJ must give specific, legitimate reasons for disregarding the treating physician's opinion that a claimant is disabled. See Goatcher, 52 F.3d at 290.
Dr. Springer, an endocrinologist, has treated plaintiff for hormone deficiencies since April 2000. On February 5, 2003, she wrote a letter which stated:
Mr. Lund underwent stimulation testing for adult growth hormone deficiency. The tests revealed severe deficiency in all hormones of the hypothalamic/pituitary axis. Mr. Lund has total pituitary failure. Hormone replacement will prolong his life but he is unable to work at any job due to the damage his long-standing deficiency has caused.
Total pituitary failure has left Roger Lund totally disabled and he is unable to work at any job position.
Tr. 375. In June of 2003, Dr. Springer also completed a fibromyalgia RFC questionnaire and checked the box that plaintiff met the criteria for fibromyalgia, although she expressly noted on the form that she had not assessed plaintiff for pain or for fibromyalgia. She also wrote on the form that "this patient will not be able to hold a full-time or part-time job due to his severe emotional and cognitive limitations." Tr. 381. The ALJ discounted Dr. Springer's June 2003 opinion because
(1) Dr. Springer does not treat plaintiff for fibromyalgia; (2) Dr. Springer finds claimant is disabled due to "severe emotional and cognitive limitations", but Dr. Springer is an endocrinologist and this opinion is outside [her] area of expertise; (3) "severe emotional and cognitive limitations" are not treated nor substantiated by claimant's treatment records; and (4) Dr. Springer referred claimant to rheumatology specialist, Arnold Katz, M.D., on May 2, 2002 for an evaluation of claimant's musculoskeletal pain and it was reported claimant does NOT have the classic trigger points seen with fibromyalgia and therefore, this was not claimant's diagnosis.Id. The ALJ gave Dr. Katz' assessment great weight and found it consistent with objective medical evidence. The ALJ gave specific, legitimate reasons for discounting Dr. Springer's opinion of June 2003, and he did not err in doing so.
Notably, however, the ALJ did not discuss Dr. Springer's opinion of February 2003 that plaintiff was disabled due to total pituitary failure, whether he disregarded that opinion, or any specific reasons for disregarding the opinion. The Court recognizes that Dr. Springer's opinions from February of 2003 and June of 2003 were somewhat related. Evenso, the ultimate conclusion was different: (1) in February, Dr. Springer stated plaintiff was disabled due to damage from long-standing hormone deficiency, and (2) in June, Dr. Springer stated that plaintiff was disabled because of emotional and cognitive limitations. In his opinion, the ALJ did not discount both opinions. Instead, he discussed the June opinion without any mention of the February opinion. Such a procedure is inconsistent with Goatcher and 20 C.F.R. § 404.1527(d)(2)-(6). Therefore the Court must remand for the ALJ to (1) explain whether he rejects Dr. Springer's February 2003 opinion and (2) if so, upon what evidence and for what specific reasons.
Plaintiff asserts that the ALJ erred in not including in the hypothetical questions to the vocational expert his complaints of pain, mental impairments and limitations caused by these impairments. Because the Court finds that the ALJ improperly rejected the opinion of the treating physician, it need not reach this question.
The ALJ also found that plaintiff did not have active Lyme disease. Tr. 9. The ALJ noted that the medical evidence consisted of inconsistent lab results and a conclusory letter from Dr. Crist. The ALJ noted that Dr. Crist's letter stated that Lyme disease is characterized by good and bad days, while plaintiff alleges that he has been housebound for years due to constant pain. The ALJ afforded little weight to Dr. Crist's opinion because it was conclusory and did not provide positive findings that claimant currently has Lyme disease. The ALJ did not err in discounting the opinion of Dr. Crist. He gave specific, legitimate reasons for affording these opinions no weight.
II. Conclusion
For the reasons outlined above, the Court remands the case for further proceedings for the ALJ to further explain his ruling. In particular, the ALJ should explain upon what evidence he rejects Dr. Springer's opinion of February 2003, including specific reference to the factors outlined in Goatcher and 20 C.F.R. § 404.1527(d). IT IS THEREFORE ORDERED that Plaintiff's Social Security Brief (Doc. #5) filed May 11, 2004, be and hereby is SUSTAINED in part. The Court overrules plaintiff's request for an immediate award of benefits.
IT IS FURTHER ORDERED that the Judgment of the Commissioner is REVERSED and REMANDED pursuant to sentence four of 42 U.S.C. § 405(g) for further proceedings consistent with the memorandum and order.