Miller v. Comm'r of Soc. Sec.

• Decision Date: 29 January 2016
• Docket Number: No. 15–1405.,15–1405.
• Parties: Rondal MILLER, Plaintiff–Appellant v. COMMISSIONER OF SOCIAL SECURITY, Defendant–Appellee.
• Court: U.S. Court of Appeals — Sixth Circuit

811 F.3d 825

Rondal MILLER, Plaintiff–Appellant

v.COMMISSIONER OF SOCIAL SECURITY, Defendant–Appellee.

No. 15–1405.

United States Court of Appeals, Sixth Circuit.

Decided and Filed: Jan. 29, 2016.

ON BRIEF:Ronald D. Glotta, Glotta & Associates, P.C., Detroit, Michigan, for Appellant. Steven A. Budde, Social Security Administration, Chicago, Illinois, for Appellee.

BEFORE: STRANCH, DONALD, LIPEZ,^* Circuit Judges.

OPINION

LIPEZ, Circuit Judge.

Claimant Ronald Miller seeks review of a denial of his application for Social Security benefits. On remand from the Appeals Council, an administrative law judge (ALJ) determined that Miller was not disabled within the meaning of the Social Security Act and therefore did not qualify for benefits. Miller appealed the decision again, but the Appeals Council declined to review it. Miller sought judicial review in the district court, where Miller and the Commissioner cross-motioned for summary judgment. Accepting the magistrate judge's recommendation in part and denying it in part, the district court denied Miller's motion for summary judgment and granted the Commissioner of Social Security's motion, affirming the Commissioner's denial of benefits. Miller's timely appeal followed.

The ALJ's decision is flawed in multiple respects. Hence we cannot conclude that the decision is supported by substantial evidence. We therefore vacate the district court's ruling and remand with instructions that the case be returned to the Commissioner for further proceedings.

I.

Because Miller's treatment record both precedes and follows his administrative proceedings, we present his treatment history and his claim's procedural trajectory together in chronological order below. We divide this chronology into sections that reflect the information contained in the record at each stage of consideration.

A. The Record Preceding the First ALJ Decision (2006–2008)

Miller is a single father who, before his alleged disability, held positions as a security guard, machine operator, material handler, and a night-club bouncer. In January 2006, Miller visited a hospital emergency department with an injured left knee. Miller presented with mild degenerative changes and a contusion. Immediately following the injury, Miller did not return to work as a night-club bouncer. In May 2006, Miller submitted an application for a period of disability, disability insurance benefits, and supplemental security income. Miller alleged disability based on "leg/knee/foot problems" on his left side, with an onset date of February 1, 2006.

In July 2006, Sonia Ramirez, M.D., and Mohammad Azimi, M.D., completed assessments of Miller in accordance with the Social Security benefits claim process. Dr. Ramirez examined Miller and concluded that Miller was obese and had a "[f]oot drop of the left foot, probably secondary to injury and trauma." Dr. Azimi reviewed Miller's records and completed a physical residual functional capacity (RFC) assessment of Miller. Dr. Azimi listed diagnoses of left foot drop and obesity

, and he determined that Miller could occasionally climb, balance, stoop, kneel, crouch, and crawl; stand for at least two hours and sit for at least six hours of an eight-hour day; and occasionally lift 20 pounds and frequently lift ten pounds.

Later that year, Miller attempted to return to work at the night club, but eventually, in 2007, his employer fired him because he was not able to carry out his responsibilities. Subsequently, Miller alleged disability due to depression, as well. In 2008, Miller sought treatment for depression at Southwest Counseling Solutions. There, Leslie Leemgraven, L.L.M.S.W., recommended that Miller receive a psychiatric evaluation "due to the severity of this [sic] depressive symptoms" and diagnosed Miller with a depressive disorder

; adjustment disorder with depressed mood ; and unspecified drug dependence, in remission. Leemgraven assigned Miller a global assessment of functioning (GAF) score of 49. David Vila, M.D., then completed a psychiatric examination of Miller, observing that Miller was "tearful and depressed." Dr. Vila diagnosed Miller with "[m]ajor [d]epression, recurrent, moderate," assigned Miller a GAF score of 50, and recommended a prescription for Paxil and Desyrel.

In December 2008, an ALJ considered Miller's claim and determined that he could perform a significant number of jobs in the national economy, and therefore he was not disabled within the meaning of the Social Security Act. Miller appealed the decision to the Appeals Council.

B. The Appeals Council's Decision to Remand

In February 2011, the Appeals Council vacated the ALJ's 2008 decision and remanded the case for further proceedings. The Appeals Council determined that the ALJ's decision did not adequately evaluate Miller's mental impairments

, in part, because a GAF scale rating of 49 "could indicate a serious impairment in social and occupational functioning."¹ The Appeals Council also found that the ALJ's conclusions about Miller's RFC—that he could "perform light work except for standing/walking for a maximum of 2 hours in an 8–hour day"—were not consistent with the record or with Social Security Administration rulings and regulations.² The Appeals Council ordered an ALJ, on remand, to obtain a consultative mental status evaluation and a consultative medical examination of Miller, further develop the vocational evaluation, rule in accordance with SSA rulings and regulations, and obtain updated medical records.

C. The Remainder of the Record Preceding the Second ALJ Decision (2009–2011)

From 2009 to 2011, Miller continued to seek treatment for his physical and mental impairments

. This treatment, along with Miller's consultative examinations ordered by the Appeals Council, make up the remainder of the record available to the ALJ who considered Miller's claim on remand.

In February 2009, Miller received a prescription for a walking cane to address his foot drop. The record also includes monthly progress notes for Miller that span a period from December 2009 to July 2011. The notes detail Miller's "leg pain" and "anxiety," as well as his coping methods and his children's status in school. The identity of the evaluating source is unclear.

In February 2011, "James White, M.D.," completed a mental RFC assessment of Miller. White determined that Miller was either "moderately limited" or "markedly limited"—the most severe limitation level—in all but two of the assessment categories. The assessment categories measure understanding and memory, sustained concentration and persistence, social interaction, and adaptation. In his remarks, White indicated that Miller's condition required "repetition and very close supervision." The record also reflects that, in 2010, "James White, NP," ordered laboratory testing on Miller. Additional notes reflect treatment in 2009, 2010, and 2011 but do not clearly reflect the identity of the provider.

In March 2011, and in accordance with the Appeals Council's order, Miller underwent two consultative examinations—one from internal medicine physician Ernesto Bedia, M.D., and another from psychiatrist Luzbella Imasa, M.D. Dr. Bedia diagnosed Miller with left foot drop, hypertension

, and type 2 diabetes. Dr. Bedia reported that Miller was "[a]mbulatory with a cane," but that he could "walk without the cane." Dr. Bedia also noted that Miller had "difficulty walking on his toes and heels on the left" and was obese. Dr. Bedia completed a medical source statement detailing Miller's ability to perform work-related activities. Dr. Bedia determined that Miller could stand for four hours without interruption and for six hours, with breaks, in an eight-hour workday, and that Miller could frequently use both his right foot and his left foot. Psychiatrist Imasa recorded that Miller sees a therapist and that his primary care physician prescribes antidepressants and hypertension medication. Dr. Imasa indicated that Miller needed "therapeutic intervention and support services," but also that he was able to manage funds. Dr. Imasa diagnosed Miller with "[m]ajor depressive disorder

and [a] history of poly substance dependence in remission" and assigned Miller a GAF score of 50. In a mental medical source statement, Dr. Imasa also indicated that Miller had no restrictions interacting appropriately with the public, supervisors, or co-workers, but that he had a marked restriction responding "appropriately to usual work situations and to changes in a routine work setting." Dr. Imasa attributed this limitation to Miller's physical impairments.

In July 2011, Karen Jordan, M.S.W., completed a mental RFC assessment of Miller. Jordan determined that Miller was either moderately limited or markedly limited in approximately two-thirds of the assessment categories and that he was either not significantly limited or exhibited no evidence of a limitation in the remaining categories.

D. The 2011 ALJ Hearing and Decision

In August 2011, Miller attended a hearing before a second ALJ to re-consider his claim for benefits. At the hearing, Miller testified that he lives with his two young children,³ who assist with household chores such as vacuuming and doing the laundry; that he helps his children with their kindergarten and first-grade homework; and that every Sunday, he and his children take the church-provided bus to attend services. Miller testified that his brother gave him a car so he could drive his kids to school, because "everybody knew I was in pain walking the kids back and forth to school." Miller also testified that standing for 45 minutes caused him back and leg pain and that, with regard to his depression, he often finds himself crying and takes medication to treat his depression. Miller said that he does not stay in close touch with members of his family, other than his mother and children, and that he does not have contact with friends.

A vocational expert (VE) also testified at the 2011 hearing and provided estimates of the available jobs...