615 F. App'x 315
6th Cir.2015Background
- Cynthia Winn applied for Title II disability insurance benefits alleging disability beginning March 3, 2008; claim denied by SSA and an ALJ found her not disabled.
- ALJ found severe physical impairments (degenerative joint/disc disease, ankle surgery effects, obesity) and assigned sedentary RFC, but concluded Winn did not prove a severe, continuous mental impairment for 12 months.
- Winn received outpatient mental-health treatment (therapy and psychiatry) at Daymont beginning 2009–2010, was prescribed Depakote, Lexapro, Xanax, and had GAF scores around 55 with episodic mood swings, depression, anxiety, occasional suicidal ideation, and auditory symptoms.
- State consultative examiners (Dr. Jones) and state reviewers (Drs. Haskins, Chambly) found moderate limitations and recommended non-public, simple repetitive work with minimal social interaction; one found marked limitation interacting with the public.
- Treating psychiatrist Dr. Amparo Wee later opined marked limitations in activities of daily living, social functioning, and concentration/persistence/pace, and significant workplace functional impairments.
- The district court affirmed the ALJ; the Sixth Circuit reversed, holding the ALJ improperly discounted the treating psychiatrist and erred on the severity finding, and remanded to SSA.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether the ALJ properly applied the treating-physician rule to Dr. Wee's opinion | Winn: ALJ failed to give controlling or adequate weight to treating psychiatrist Dr. Wee; ALJ misread treatment notes and substituted her own judgment for medical opinion | Commissioner/ALJ: treatment notes show improvement after therapy/medication and Dr. Wee's opinions are not borne out by the record | Court: ALJ did not provide substantial evidence or the required "good reasons" to discount Dr. Wee; remand required |
| Whether Winn had a "severe" mental impairment lasting 12 continuous months | Winn: medical records, state reviewers, and treating psychiatrist show ongoing, episodic but severe mental limitations meeting the minimal second-step threshold | Commissioner/ALJ: improvements with treatment after state evaluations render the state opinions non-representative of longitudinal functioning | Court: ALJ’s conclusion that mental impairments were not severe was not supported by substantial evidence; error reversible |
| Whether ALJ’s RFC and step‑4 analysis adequately accounted for mental limitations | Winn: ALJ failed meaningfully to incorporate mental limitations into RFC or consider them at step 4 after rejecting treating opinion | Commissioner/ALJ: because at least one severe physical impairment existed, RFC and subsequent steps suffice | Court: Error was not harmless under Maziarz because mental limitations were not meaningfully considered in RFC; remand required |
Key Cases Cited
- Cole v. Astrue, 661 F.3d 931 (6th Cir. 2011) (standard of appellate review of SSA decisions and treating-source weight discussion)
- Gayheart v. Comm’r of Soc. Sec., 710 F.3d 365 (6th Cir. 2013) (record must be considered as a whole; assessing sustained functional capacity)
- Wilson v. Comm’r of Soc. Sec., 378 F.3d 541 (6th Cir. 2004) (requirements for ALJ’s "good reasons" when discounting treating source opinions)
- Maziarz v. Sec’y of Health & Human Servs., 837 F.2d 240 (6th Cir. 1987) (when ALJ finds another severe impairment, error at step two may be harmless if RFC accounts for all limitations)
- Higgs v. Bowen, 880 F.2d 860 (6th Cir. 1988) (step-two "severe" impairment threshold is de minimis)
- Rogers v. Comm’r of Soc. Sec., 486 F.3d 234 (6th Cir. 2007) (everyday activities are not necessarily comparable to work activity; limits on ALJ inference from activities)