Opinion
99 C 7693.
March 28, 2001.
MEMORANDUM AND ORDER
Plaintiff Shirley Moore brings this action pursuant to 42 U.S.C. § 405(g) to review the final decision of the Commissioner of the Social Security Administration denying her claim for disability insurance benefits under the Social Security Act, 42 U.S.C. § 1381 et seq. Ms. Moore timely filed her complaint for judicial review in this Court and seeks an order reversing the Commissioner's final decision. The Commissioner has filed a cross-motion for summary judgment. The court has jurisdiction over this matter under 42 U.S.C. § 405(g) and 1383(c)(3). For the reasons set forth below, the decision of the Commissioner is reversed and this case is remanded for further proceedings consistent with this order.
Pleadings for judicial review of the final decision of the Commissioner are ordinarily denominated "Motions for Summary Judgment." The standard of review applied to these decisions, however, does not conform to that ordinarily used under Rule 56 of the Federal Rules of Civil Procedure or the local rules. Therefore, this court will construe both parties' motions as applications to the court for an order either reversing or affirming the Commissioner's final decision. See Vaile v. Chater, 916 F. Supp. 821, 823 n. 2 (N.D.Ill. 1996).
I. BACKGROUND
A. Procedural History
Ms. Moore applied for Title II Disability Insurance Benefits ("DIB") on January 18, 1996. (A.R. at 36-38). Her application for benefits was denied on August 23, 1996. (A.R. at 25). After she unsuccessfully sought reconsideration, she requested a hearing before an Administrative Law Judge (A.R. at 31, 34). The ALJ conducted a hearing on November 18, 1997, and issued a decision denying her claim on May 28, 1998. (A.R. at 20). The Commissioner's Appeals Council denied Ms. Moore's request for review on September 22, 1999. (A.R. at 3). Thus, the ALJ's decision stands as the Commissioner's final decision. See 20 C.F.R. § 404.981; Herron v. Shalala, 19 F.3d 329, 322 (7th Cir. 1994).
A. The Hearing Before the ALJ
At the time of her hearing before the ALJ, Ms. Moore was 54 years old, 5'2" tall, and weighed approximately 180 pounds. (A.R. at 170). Ms. Moore is a high school graduate and has completed two years of study at Wobanzi Community College, but has not yet earned a degree. (A.R. at 171). In 1997, Ms. Moore was living in Aurora, Illinois, with her husband and her 29 year old son. (A.R. at 169-170).
Ms. Moore has not worked since July 24, 1995. (A.R. at 171). She claims that she was physically unable to continue working after this date due to severe lower back pain. (A.R. at 181). Specifically, Ms. Moore has been diagnosed with "degenerative disk disease at L4/5 with disk space narrowing, osteophyte formation, severe facet joint degenerative disease bilaterally at L4/5," and moderate scoliosis. (A.R. at 163).
An osteophyte is "a bony excrescence or outgrowth, usually branched out in shape." Taber's Cyclopedic Medical Dictionary 1368 (18th ed. 1997).
A facet joint is "one of the zygapophyseal joints of the vertebral column between the articulating facets of each pair of vertebrae." Taber's Cyclopedic Medical Dictionary 700 (18th ed. 1997).
Scoliosis is "a lateral curvature of the spine." Taber's Cyclopedic Medical Dictionary 1727 (18th ed. 1997).
1. Testimony During the Hearing Before the ALJ
a. Ms. Moore
At her hearing, Ms. Moore testified regarding her symptoms and work history. The ALJ expressly noted that her testimony was credible, stating "that's not a question here." (A.R. at 217). In her written opinion, however, the ALJ stated that she would not fully credit Ms. Moore's subjective complaints of severe pain, stating that she thought that Ms. Moore had exaggerated. (A.R. at 17). According to Ms. Moore, her back pain is like a toothache and her back aches all of the time. (A.R. at 181). She also testified that she periodically experiences sharp pains radiating down her right leg as well as some numbness in that leg. (A.R. at 181).
During her hearing, Ms. Moore was wearing a back brace and was taking Voltaren, a nonsteroidal anti-inflammatory medication, to alleviate her back pain. (A.R. at 182). She stated that this medication numbed the pain, but did not alleviate it completely. (A.R. at 182). Ms. Moore also testified that she took Cyclobenzaprine, a muscle relaxant, to help her relax and sleep at night. (A.R. at 182). In addition to these medications, Ms. Moore testified that she generally took one bath per day and occasionally used a heating pad to help her relax. (A.R. at 184).
According to Ms. Moore, she had an extremely limited ability to lift, as even lifting a gallon of milk or a bag of groceries caused discomfort. (A.R. at 184). She said that she could walk up and down her block, but that was it. (A.R. at 185). She described her troubles both sitting and standing, noting that 15 minutes of either would make her uncomfortable. (A.R. at 185). Because of these difficulties, she spent most of her time in bed. (A.R. at 185-86). She also testified that she could not perform household chores or maintain her garden, and had difficulty going up and down the stairs in her home. (A.R. at 187). Ms. Moore felt that her condition had deteriorated since she left her job in 1995. (A.R. at 188).
Ms. Moore last worked at the Elgin Mental Health Center between 1985 and 1995 as a mental health technician. (A.R. at 171, 174, 178). She was responsible for ensuring the well-being of patients, and regularly performed tasks such as grooming, transporting, and at times restraining the patients. (A.R. at 175-176). In addition, she was required to write reports regarding the patients' progress and behavior. (A.R. at 177).
On July 24, 1995, Ms. Moore was placed on administrative leave during an investigation of patient abuse. (A.R. at 172). She subsequently resigned from her position after several administrative hearings at the hospital, claiming that she had been harassed and treated unfairly. (A.R. at 172). Prior to working as a medical assistant in Elgin, Ms. Moore worked at Mercy Manor Retirement Home in a similar position. (A.R. at 178).
According to the ALJ, Ms. Moore's last relevant work experience was at Farmer's Insurance, where she was a "policy coder" for approximately five years, between 1978 and 1983. (A.R. at 56, 179-180). A policy coder's responsibilities include the entry of data from insurance policies into the company's computer system. (A.R. at 179). According to Ms. Moore, this job required her to sit for most of the day, and occasionally to carry files weighing between 10 and 30 pounds from the record room to her desk. (A.R. at 180).
Ms. Moore worked as a policy coder thirteen years before her application for disability. The administrative guidelines provide that "a gradual change occurs in most jobs in our national economy so that after 15 years it is no longer realistic to expect that skills (or proficiencies) and abilities acquired in these jobs continue to apply. The fifteen year guide is intended to insure that remote work experience which could not reasonably be expected to be of current relevance is not applied." 20 C.F.R. § 404.1565(a) 416.965(a). Thus, the court will not consider Ms. Moore's work experience prior to her policy coder job.
b. The Medical Expert — Dr. Newman
Dr. William Newman provided medical testimony regarding Ms. Moore's condition. (A.R. at 11). Dr. Newman was licensed to practice medicine in 1949 and specializes in orthopaedic surgery. (A.R. at 81). After examining the medical evidence provided by Ms. Moore, he concluded that Ms. Moore had degenerative disk disease at L4/5 with disk space narrowing, osteophyte formation, and severe facet joint degenerative disease bilaterally at L4/5, the degeneration at L4 being her most significant impairment. (A.R. at 163-164). He also noted that Ms. Moore's condition had worsened since her earlier examinations. (A.R. at 163). In addition, he stated that Ms. Moore has bilateral cervical ribs, a congenital anomaly that periodically produces numbness and paresthesias of the hand. (A.R. at 168).
After reviewing Ms. Moore's medical records, Dr. Newman found that her impairments did not meet or equal the severity or duration requirements to establish a disability under the Social Security regulations. (A.R. at 169). Nevertheless, Dr. Newman found that collectively, Ms. Moore's impairments were "severe" and clearly imposed limitations on her physical activities. (A.R. at 193). Dr. Newman recommended that Ms. Moore should not be required to strain her lower back by bending, repetitive bending, lifting heavy objects, or sitting for a prolonged period of time. (A.R. at 193).
Specifically, Dr. Newman recommended that Ms. Moore lift a maximum of 20 pounds occasionally, and not more than 8 pounds frequently. (A.R. at 194). He also recommended a maximum of 45 minutes of standing or walking at one time. (A.R. at 194). In addition, he said that Ms. Moore should not attempt any overhead work due to her cervical rib condition. (A.R. at 194). In an attempt to clarify Ms. Moore's physical limitations, Dr. Newman stated that he believed Ms. Moore could successfully perform the duties of a medical records clerk or a ward clerk in a hospital. (A.R. at 210).
c. The Vocational Expert — Lee Knutson
Lee Knutson is a Vocational Rehabilitation Consultant. He has a 1994 Master of Science degree from the University of Wisconsin-Stout in Vocational Rehabilitation with an emphasis in Vocational Evaluation and Work Adjustment. (A.R. at 84). Mr. Knutson prepared an evaluation of Ms. Moore's past relevant work for the ALJ, including Ms. Moore's positions as a mental health technician, a nurse's aide, and a policy coder. (A.R. at 196). In light of Ms. Moore's age, education and work experience, and with the restrictions Dr. Newman had placed upon Ms. Moore's activities, Mr. Knutson concluded that Ms. Moore could obtain a position as a policy coder or a similar "sedentary" job. (A.R. at 197-198).
In his summary sheet of Ms. Moore's relevant work history, Mr. Knutson wrote that Ms. Moore's job as a policy coder was equivalent to positions as a medical voucher clerk and/or data entry clerk. (A.R. at 152). These positions require an individual to examine vouchers forwarded to an insurance company or to enter data into a computer via a keyboard. (A.R. at 152). These positions, according to the SSA regulations, are sedentary. (A.R. at 152).
2. Medical Evidence
Ms. Moore presented records from the Dreyer Medical Clinic. These records reflect examinations by physicians associated with the Department of Disability Services. The relevant medical records are as follows:
a. Dr. Lindahl
Ms. Moore visited the Dreyer Medical Clinic on numerous occasions between 1989 and 1997. Dr. Lindahl, a specialist in internal medicine, was her examining physician on the majority of her visits to the clinic. (A.R. at 90-103). Ms. Moore first seriously injured her back on or about May 8, 1989. (A.R. at 103). During an examination on May 11, 1989, Dr. Lindahl indicated that Ms. Moore "did not have any terrible immediate pain, but after going home she remained in bed with discomfort localized as low back discomfort. No neurological symptoms in the legs. Low back pain came on somewhat later. She has had some past history of previous back injuries. She does have quite a bit of spasm in the lumbar musculature and markedly limited range of lumbar flexion, only a few degrees, secondary to pain. She moves somewhat gingerly." (A.R. at 103).
Dr. Lindahl determined that Ms. Moore's injury was a lumbar strain. (A.R. at 103). He advised Ms. Moore to stay off her feet and to use a heating pad to aid recovery. (A.R. at 103). He also prescribed Anaprox to relieve her pain, and Flexoril for her muscle spasms. (A.R. at 105). A CAT scan of Ms. Moore's back taken in 1990 showed that she had bulging discs. (A.R. at 98). Between 1990 and her alleged onset of disability in 1995, Ms. Moore complained of back pain on two other occasions. First, she reported back pain during her examinations in October of 1994, (A.R. at 95) and in November of 1990 (A.R. at 101). Then, in November of 1995, her record show that she was "most bothered by having a lot of trouble with stress at work and with her back. She said she had low back pain ever since she hurt it at work back in 1989 . . . Tends to respond to Anacin and a rubdown . . . Unable to touch her toes by about three or four inches. Back seems to have some right-sided muscle prominence; possibly right lower thoracic or upper lumbar scoliosis . . . Possibly some muscle relaxers, Flexeril would benefit her." (A.R. at 92).
Dr. Lindahl subsequently treated Ms. Moore's back pain on several other occasions. In November of 1996, his examination notes state that Ms. Moore's "disks have shown some degenerative spondylosis and some bulging disks on an old CT scan. No neurological symptoms. She does walk a treadmill at home for about half an hour . . . she has had bilateral cervical ribs. She had some muscle contraction pains in the neck in the past, but nothing currently . . . Back has limited range of lumbar flexion. She is unable to touch her toes by about 4-6 inches . . . chronic low back pain. X-rays have shown some degenerative change and some scoliosis. I recommend that we treat this conservatively." (A.R. at 90-91).
The most recent medical records from the Dreyer clinic are dated August 29, 1997. (A.R. at 89). During that examination, the doctor spoke with Ms. Moore about different treatments, prescribed Voltaren for her pain, and indicated that she should arrange a program of physical therapy. (A.R. at 89).
In a Dreyer Medical Clinic intake form filled out by Ms. Moore on February 4, 1997, Ms. Moore wrote that she was not working and that she could not do much that involved lots of standing or bending. (A.R. at 123). She also noted that pain would awaken her at night. (A.R. at 123). Notes from an exam that day by a physical therapist (whose name is illegible) indicate that Ms. Moore's condition was worsening. (A.R. at 124). The examiner also noted that Ms. Moore had not been diligently following her physical therapy plan, although she was walking regularly on the treadmill at home at that time and performing some work around the household. (A.R. at 124). The examiner also noted that Ms. Moore was in constant pain. (A.R. at 124).
Notes from follow-up physical therapy exams on February 10th and 25th of 1997 indicate that Ms. Moore reported pain in her lower back at a higher intensity. (A.R. at 128). She did not continue physical therapy sessions after February 25, 1997. (A.R. at 129).
A report of an x-ray taken at the Dreyer Clinic on August 29, 1997 stated that Ms. Moore exhibited degenerative disk disease at L4-5 with disk space narrowing and osteophyte formation. (A.R. at 145). An exam performed by Dr. Edwin Dolin at this time also showed "severe facet joint degenerative disease bilaterally at L4-5 and L5-S1. (A.R. at 145). An x-ray in 1990 found that Ms. Moore had "bulging disks at L4-5 and L5-S1. (A.R. at 146). An x-ray report from May of 1989 found "minimal spurring present in the spine" and indicated that Ms. Moore had minimal spondylosis deformans. (A.R. at 147).
b. Review Performed by State Physicians
Two physicians reviewed Ms. Moore's medical records for the state. Dr. Mohammad Irshad examined Ms. Moore's records and filled out a "Disability Determination and Transmittal" for the Social Security Administration on August 16, 1996. (A.R. at 23). Dr. Irshad diagnosed Ms. Moore with chronic lumbar myalgia. (A.R. at 23). Dr. Paul LaFata agreed with this diagnosis after reviewing Ms. Moore's records on September 24, 1996. (A.R. at 24). Dr. Francis LaFata specializes in geriatric medicine and general surgery and was licensed to practice in 1941. (A.R. at 74).
Dr. LaFata also completed a residual functional capacity assessment for the SSA on August 14, 1996. (A.R. at 63). Although the writing on the form is virtually illegible, it appears that Dr. LaFata affirmed the previous examiner's determinations that Ms. Moore could work. (A.R. at 63-70). Dr. Earl Donelan affirmed this assessment on September 30, 1996. (A.R. at 63). Dr. Donelan is a family practice physician who was licensed to practice in 1943. (A.R. at 73).
C. Questionnaires and Application Information.
In a "disability report" dated June 7, 1996, Ms. Moore described her physical condition for the SSA. (A.R. 48-55). She reported having a slipped disk which caused extreme pain when she attempted to perform even the simplest of tasks. (A.R. at 48). According to the report, the condition first began on December 21, 1989 and forced her to stop working on July 24, 1995. (A.R. at 48).
At the time she applied for disability, Ms. Moore saw Dr. Metcalf of the Dreyer Medical Clinic three to four times each week for physical therapy treatments. (A.R. at 49). She received outpatient treatment at the Dreyer Clinic where she was treated with oral medication and physical therapy including hot and cold treatments and ultrasounds. (A.R. at 50). She also noted that she had limited social contacts because she experienced back pain when she attempted to use the pedals in her car. (A.R. at 51).
II. THE ALJ'S DECISION
In a decision issued on May 28, 1998, the ALJ applied the Commissioner's sequential evaluation of "disability" under 20 C.F.R. § 416.920(b)-(f) and found that Ms. Moore was not disabled. (A.R. at 12). The ALJ found that Ms. Moore had not worked or performed any substantial gainful activity since her disability application in July of 1995. (A.R. at 19). The ALJ next found that Ms. Moore suffered from severe spinal disorders but that this impairment did not "meet or equal any section of the Listing of Impairments." Id.
20 C.F.R. § 416.920(b) provides that "[i]f you are working and the work you are doing is substantial gainful activity, we will find that you are not disabled regardless of your medical condition or your age, education, and work experience." Sections 416.920(c)-(f) address impairments and ask whether an impairment is severe (i.e., whether it significantly limits the physical or mental ability to do basic work activities), meets or equals an impairment listed in Appendix 1, prevents the applicant from doing past relevant work, or prevents the applicant from doing other work.
In reaching this determination, the ALJ determined that Ms. Moore's treating source's medical opinions were not entitled to controlling weight. (A.R. at 16). The ALJ cited Soc. §. Rul. 96-2p (July 2, 1996) and determined that because "no treating source has opined that the claimant is disabled, the treating source rule is inapplicable." (A.R. at 16). The ALJ then assessed Ms. Moore's residual functional capacity and found that as a result of her severe impairment, Ms. Moore's "maximum sustained work capability was limited to less than a full range of light work." (A.R. at 19).
In her evaluation, the ALJ did not find Ms. Moore's testimony as to her pain or her functional limitations fully credible. (A.R. at 17). Finally, noting the testimony of both the medical and vocational experts who testified at the hearing, the ALJ determined that Ms. Moore was able to perform her past relevant work as a policy coder despite her impairments. (A.R. at 19). Therefore, the ALJ concluded that Ms. Moore was not disabled.
III. ANALYSIS
A. Contentions of the Parties
Ms. Moore makes four principal arguments. First, she contends that the Commissioner's decision should be reversed or remanded because the ALJ committed an error of law by failing to give her treating physician's opinions and evidence "controlling weight" as prescribed by 20 C.F.R. § 404.1527(d)(2). (Pltf. Br. at 14). Second, Ms. Moore contends that the ALJ's credibility determination was patently wrong because her testimony was essentially consistent with the objective medical record. (Pltf. Br. at 11). Third, Ms. Moore argues that her due process rights were violated when the ALJ relied upon Dr. Newman's testimony regarding the responsibilities of a medical records clerk in reaching a decision as to Ms. Moore's capacity to work. (Plft. Br. at 19). Finally, Ms. Moore contends that the ALJ's determination is not supported by substantial evidence. (Pltf. Br. at 18-20).
In response, the Commissioner asserts that the ALJ properly applied the "treating physician rule" and, even if the ALJ did erroneously apply the rule, Ms. Moore's treating physician's opinions do not support a finding of disability. (Def. Br. at 11). Next, the Commissioner contends that the ALJ properly evaluated the medical and vocational experts' testimony regarding Ms. Moore's residual functional capacity. (Def. Br. at 13-15). Furthermore, the Commissioner maintains that the remainder of the ALJ's findings were supported by substantial evidence, including her credibility assessment. (Def. Br. at 7). Finally, the Commissioner posits that, even if Ms. Moore's arguments are successful, Ms. Moore can still perform other jobs in the economy and, therefore, is not disabled. (Def. Br. at 15).
A. Standard of Review
In reviewing the Commissioner's decision, we are obliged to review all of the evidence in the record. Delgado v. Bowen, 782 F.2d 79, 82 (7th Cir. 1985). Judicial review of the Commissioner's final decision is governed by 42 U.S.C. § 405(g) which provides that "the findings of the commissioner of Social Security as to any fact, if supported by substantial evidence, shall be conclusive . . ." Thus, a reviewing court may not decide the facts anew, reweigh the evidence, or substitute its own judgment for that of the Commissioner. Delgado, 782 F.2d at 82.
Instead, judicial review is limited to determining whether the ALJ applied the correct legal standards in reaching a decision and whether there is substantial evidence in the record to support the findings. 42 U.S.C. § 405(g); see also Scivally v. Sullivan, 966 F.2d 1070, 1075 (7th Cir. 1992). Substantial evidence is "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 401 (1971). The ALJ's decision must be affirmed if the findings and inferences reasonably drawn from the record are supported by substantial evidence, even though some evidence may also support the claimant's argument. 42 U.S.C. § 405(g). A credibility determination made by the ALJ will not be disturbed unless it is patently wrong. Powers v. Apfel, 207 F.3d 431, 435 (7th Cir. 2000). The ALJ's conclusions of law, however, are not entitled to such deference. If the ALJ committed an error of law, "reversal is required without regard to the volume of the evidence in support of the factual findings." Imani v. Heckler, 797 F.2d 508, 510 (7th Cir. 1986).
A. Establishing a Disability
Under the Social Security Act, an individual is disabled "if he is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than twelve months." 42 U.S.C. § 1382c(a)(3)(A). In addition, an individual is disabled "only if his physical or mental impairment or impairments are of such severity that he is not only unable to do his previous work but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy, regardless of whether such work exists in the immediate area in which he lives, or whether a specific job vacancy exists for him, or whether he would be hired if he applied for work. . . ." 42 U.S.C. § 1382c(a)(3)(B).
The Commissioner uses a five-step process to determine whether an individual is disabled. See 20 C.F.R. § 416.920. The ALJ must determine in sequence: (1) whether the claimant is presently working and whether that work constitutes substantial gainful activity; (2) whether the claimant's impairment is "severe"; (3) whether the impairment meets or equals one of the list of specified impairments, see 20 C.F.R. Part 404, Subpart P, Appendix 1; (4) whether the claimant is able to perform her past relevant work; and (5) whether the claimant's age, education, and past work experience, in relation to her residual functional capacity, enable her to do other work. Id.
A. Did the ALJ Err by Not Considering Dr. Lindhal's Records?
Ms. Moore first contends that the ALJ committed an error of law by declining to give the opinion of her treating physician, Dr. Lindahl, controlling weight as to the issue of whether she is disabled. For the following reasons, the court finds that the ALJ should not have completely rejected Dr. Lindahl's opinion as to Ms. Moore's condition and that this error requires us to remand this case for further proceedings.
1. The Treating Source Rule
A treating physician is any physician who "has provided [the claimant] with medical treatment or evaluation and who has or has had an ongoing treatment relationship with [the claimant]." 20 C.F.R. § 404.1502. Under the "treating source" rule:
[M]ore weight is generally given to the opinion of a treating physician because of his greater familiarity with the claimant's conditions and circumstances. A treating physician's opinion regarding the nature and severity of a medical condition is entitled to controlling weight if it is well-supported by medical findings and not inconsistent with other substantial evidence in the record. A claimant, however, is not entitled to disability benefits simply because a physician finds that the claimant is `disabled' or unable to work.' Under the Social Security regulations, the Commissioner is charged with determining the ultimate issue of disability."
Clifford v. Apfel, 227 F.3d 863, 870 (7th Cir. 2000) (citations omitted). see also 20 C.F.R. § 404.1527(d)(1) (2).
Medical opinions from treating sources are granted this deference because "these sources are likely to be the medical professionals most able to provide a detailed, longitudinal picture of [a claimant's] medical impairment(s) and may bring a unique perspective to the medical evidence that cannot be obtained from the objective medical findings alone or from reports of individual examinations, such as consultative examinations or brief hospitalizations." 20 C.F.R. § 404.1527(d)(2). Thus, the regulations provide that, "[i]f we find that a treating source's opinion on the issue(s) of the nature and severity of your impairment(s) is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in your case record, we will give it controlling weight." Id.
When the Commissioner does not give controlling weight to the treating source's opinion, a detailed explanation of the reasons why this opinion was discredited is required. Id. The Commissioner is required to examine factors such as the length of the treatment relationship, the frequency of examination, the nature and extent of the treatment relationship, the evidence which supports the opinion, the opinion's consistency, and the physician's specialization. 20 C.F.R. § 1527(d)(2)-(6).
Because the treating source rule revolves around medical opinions from treating physicians, the definition of a "medical opinion" is also critical. According to the regulations, "[m]edical opinions are statements from physicians and psychologists or other acceptable medical sources that reflect judgments about the nature and severity of your impairment(s), including your symptoms, diagnosis and prognosis, what you can still do despite impairment(s), and your physical or mental restrictions." 20 C.F.R. § 404.1527(a)(2).
A treating source's "opinion" that a claimant is disabled, however, is not a "medical opinion" as defined under the regulations. See 20 C.F.R. § 404.1527(e). Such opinions "are, instead, opinions on issues reserved to the Commissioner because they are administrative findings that are dispositive of a case; i.e., that would direct the determination or decision of disability." 20 C.F.R. § 404.1527(e); see also Clifford v. Apfel, 227 F.3d at 870. Thus, a medical source need not state that a claimant is "disabled" in order for the ALJ to determine that a claimant is disabled, as this determination is explicitly left to the Commissioner. Id.
In this case, the ALJ correctly identified the regulation containing the "treating source rule." (A.R. at 16). Nevertheless, citing Social Security Ruling 96-2p (July 2, 1996), she found that, because "no treating source has opined that the claimant is disabled, the treating source rule is inapplicable." Id. According to Ms. Moore, the ALJ failed to apply the treating source rule correctly and thereby committed reversible error. (Plaintiff. Br. at 14).
Specifically, Ms. Moore contends that the ALJ should have examined the opinions of Dr. Lindahl, her treating physician, and found that she is disabled. Ms. Moore also contends that the ALJ erred by rejecting an entire line of evidence — Dr. Lindahl's medical records — without sufficiently articulating reasons for doing so. In response, the Commissioner asserts that Dr. Lindahl's reports and notes do not constitute a medical opinion about the severity of Ms. Moore's medical condition. Alternatively, the Commissioner contends that, even if Dr. Lindahl did offer a medical opinion, he implicitly indicated that her back condition was, at most, of moderate severity. Thus, the Commissioner asserts that, at worst, the Commissioner's decision to reject Dr. Lindahl's opinion entirely was harmless error.
2. Dr. Lindahl's Records
Ms. Moore visited Dr. Lindahl at the Dreyer Medical Clinic on at least thirteen occasions between 1989 and 1997. (A.R. at 90-103). So, do Dr. Lindahl's records of these visits contain "medical opinions" which the ALJ was required to examine and either adopt as controlling or reject? In other words, do Dr. Lindahl's examination notes reflect judgments about the nature and severity of Ms. Moore's back condition, including a diagnosis and prognosis, an assessment as to what Ms. Moore could still do, and an appraisal as to any physical or mental restrictions? See Soc. §. Rul.96-7p (July 2, 1996). And, if the records are "medical opinions," would consideration of these records altered the ALJ's decision? See Hughes v. Chater, 895 F. Supp. 985, 995 (N.D.Ill. 1995) ("if it is plain that the overlooked evidence could not have altered the result, the factfinder's error in failing to consider it would of course be harmless, and a remand would be pointless"). Here, the court finds that the ALJ should have considered Dr. Lindahl's' records and that the record does not support a finding that there is no reasonable probability that consideration of these records would have changed the outcome. See id.
Ms. Moore submitted several records of examinations performed at the Dreyer Medical Clinic prior to her alleged onset of disability in July of 1995. Ms. Moore first complained of back pain on May 11, 1989, when she visited the Dreyer Medical Clinic as a result of a work-related injury. (A.R. at 103). Dr. Lindahl reported during this examination that "she did not have any terrible immediate pain but Saturday she finished her work and went home. Has been in bed ever since then with discomfort, localized as low back discomfort. No neurological symptoms in the legs. Low back pain came on somewhat later, perhaps Saturday. She relates it to the slip on Friday, however." (A.R. at 103).
The notes from this examination continue, "[s]he has had some past history of previous back injuries. She does have quite a bit of spasm in the lumbar musculature and markedly limited range of lumbar flexion, only a few degrees, secondary to pain. She moves somewhat gingerly. Neurologic exam showed DTRs to be hypoactive (sic) in the lower extremities but I believe present. Could elicit everywhere except the left Achilles. Straight leg raising test was negative to about 60 degrees. Some discomfort with further extension." (A.R. at 103).
These notes reflect opinions as to the nature and severity of Ms. Moore's condition. Moreover, Dr. Lindahl told Ms. Moore to stay in bed and use a heating pad to help alleviate the pain. (A.R. at 103). He also prescribed Anaprox for her pain, and Flexoril for her muscle spasms. (A.R. at 103).
On October 6, 1989, Dr. Lindahl's exam notes indicate that Ms. Moore "has some intermittent back pains which bother her but currently asymptomatic lumbar strains." (A.R. at 102). Her examination on November 20, 1990 revealed that Ms. Moore complained that her back ached, and a CT scan taken at this visit showed bulging discs. (A.R. at 101). Following this examination, Ms. Moore apparently did not suffer any serious back pain again until November of 1995, as numerous records of visits to the Dreyer Clinic do not indicate any complaints of back pain. (A.R. 90-103).
Fousing on the medical records between Ms. Moore's alleged onset of disability and the issuance of the ALJ's decision, it is clear that Ms. Moore's treating physician's notes contain "medical opinions" that the ALJ was required to consider regardless of the fact that Dr. Lindahl never expressly opined that Ms. Moore was disabled. Ms. Moore claims that her disability began on July 24, 1995. On November 6, 1995, Ms. Moore told Dr. Lindahl that she was having a lot of trouble with her back. (A.R. at 92). Dr. Lindahl noted that she was unable to touch her toes by about three or four inches at this examination. (A.R. at 92). He also noted that her back had some "right-sided muscle prominence; possibly right lower thoracic or upper lumbar scoliosis" and that an x-ray showed bulging disks and scoliosis. (A.R. at 92). At this time, he concluded that Ms. Moore had "chronic low back pains." (A.R. at 92).
Similarly, Dr. Lindahl's notes from November 18, 1996 state that x-rays showed that Ms. Moore had generative spondylosis and that her CT scan showed bulging discs, but that she had "no neurological symptoms." (A.R. at 91). Dr. Lindahl recommended that Ms. Moore's back pain be treated "conservatively" and again noted that she suffered from chronic low back pain (A.R. at 90). On August 29, 1997, Dr. Lindahl opined that Ms. Moore had a "limited range of lumbar flexion," and that she had "been worse the past one or two years." (A.R. at 89). He also observed that she has a limited range of lumbar flexion and that she appeared to have a paraspinal muscle spasm in the lumbar area, and diagnosed her with chronic lower back pain accompanied by a history of degenerative spondylosis. (A.R. at 89).
3. Harmless Error
So, did the ALJ commit reversible error when she entirely jettisoned Dr. Lindahl's opinion because he did not specifically opine that Ms. Moore was disabled? The court finds that it must answer this question in the affirmative. Dr. Lindahl's notes reflect judgments about the nature and severity of Ms. Moore's impairments and reflect his assessment of her symptoms, his diagnosis and prognosis and her physical or mental restrictions. See 20 C.F.R. § 404.1527(a)(2). The ALJ was thus required to examine Dr. Lindahl's records and articulate reasons for accepting or rejecting his findings. 20 C.F.R. § 404.1527(d)(2) ("We will always give good reasons in our notice of determination or decision for the weight we give your treating source's opinion").
Instead, however, the ALJ focused solely on whether Dr. Lindahl had rendered an opinion as to whether Ms. Moore was, in fact, disabled. She then rejected Dr. Lindahl's opinion because he did not opine as to whether Ms. Moore was disabled. As noted above, a treating source's opinion regarding a claimant's disability is not a "medical opinion." 20 C.F.R. § 404.1527(e). Instead, this issue is reserved to the Commissioner because it is a dispositive administrative finding. 20 C.F.R. § 404.1527(e); see also Clifford v. Apfel, 227 F.3d at 870. Thus, Dr. Lindahl was not required to express an opinion as to the ultimate question of disability in order to convince the ALJ to consider his opinions as to Ms. Moore's condition under the treating source rule.
The court must thus evaluate whether there is a reasonable probability that consideration of Dr. Lindahl's opinion would have altered the outcome. See Hughes v. Chater, 895 F. Supp. at 995. To this end, it is important to note that the ALJ was obligated to consider all relevant evidence relating to disability. Clifford v. Apfel, 227 F.3d at 871. Medical evidence may be discounted if it is internally inconsistent or inconsistent with other evidence in the record, but Dr. Lindahl's records are consistent with the other medical evidence in the record. See id.
It is well-established that this court may not reweigh the evidence, resolve conflicts, decide questions of credibility, or substitute its own judgment for that of the Commissioner. Id. at 869; Godbey v. Apfel, 238 F.3d 803, 807-08 (7th Cir. 2000). Here, however, the ALJ did not address Dr. Lindahl's notes at all. Thus, the court cannot determine whether the evidence supports a finding of disability without stepping into the ALJ's shoes and reweighing the evidence afresh.
It is true that Dr. Lindahl's notes do not reflect a "smoking gun" piece of evidence that overwhelmingly supports a finding of disability. This does not mean, however, that the ALJ's error was necessarily harmless. This conclusion is supported by the Seventh Circuit's recent decision in Godbey v. Apfel, where the ALJ, among other things, did not address the claimant's abnormal electroencephalography readings. 238 F.3d at 810. A report by the claimant's doctor stated that the reading showed an abnormality but did not explain whether it impacted the claimant's ability to function. The Seventh Circuit found that the report could be considered contemporaneous evidence of an unresolved medical impairment supporting a finding of disability of "nothing at all." Id. it then concluded that, because the ALJ failed to discuss the abnormality, it could not be sure that the ALJ examined this evidence. Id.
Here, of course, we know that the ALJ did not consider Dr. Lindahl's records. Moreover, as with the abnormal electroencephalography readings in Godbey, the report at issue in this case could support a finding of disability, especially since Dr. Lindahl was Ms. Moore's treating physician. In short, although this court may "review the entire record, we may not decide the facts anew, reweigh the evidence, or substitute our own judgment for that of the Secretary." Herron v. Shalala, 19 F.3d 329, 333 (7th Cir. 1994).
The failure to evaluate Dr. Lindahl's records prevents this court from conducting "a meaningful review because we cannot establish if substantial evidence supported the denial of benefits." Id. at 337; see also Johnson v. Bowen, 817 F.2d 983 (2d Cir. 1987) (the misapplication of the treating source rule is proper grounds for a remand); Barnett v. Apfel, 13 F. Supp.2d 312 (N.D.N.Y. 1998) (remanding where the treating physician's opinion was well supported by medically acceptable clinical and laboratory diagnostic techniques and not inconsistent with other substantial evidence in the record). Accordingly, remand is appropriate so that the ALJ can consider all of the evidence relating to Ms. Moore's claimed disability.
IV. CONCLUSION
For the foregoing reasons, the Commissioner's decision is reversed and the case is remanded for further proceedings consistent with this order.