McKenzie v. Commissioner of Social Security

Background

Justin Blane McKenzie sought judicial review under 42 U.S.C. §§ 405(g) and 1383(c) of the Commissioner of Social Security’s final decision denying his application for Supplemental Security Income benefits. McKenzie alleged disability based on depression, a learning disorder, and anxiety. After a hearing, Administrative Law Judge Vincent M. Cascio determined that McKenzie had not been disabled since the date of his application. The Appeals Council denied review, making the administrative judge’s decision final.

The parties filed competing motions for judgment on the pleadings. McKenzie argued that the administrative judge failed to provide “good reasons” for rejecting the opinion of his treating psychiatrist, Dr. Yvelene Abellard. The Commissioner argued that the administrative judge applied the correct legal standards and that substantial evidence supported the decision.

Dr. Abellard’s Opinion

Dr. Abellard reported that she had treated McKenzie monthly since February 2015. In a May 30, 2017 functional-capacity assessment, she described mood and behavior fluctuations, anxiety, inattentiveness, and other symptoms. She opined that McKenzie would miss work more than three times per month and had inadequate abilities in areas including maintaining attention, sustaining a routine, completing a normal workday, responding to workplace changes, and dealing with ordinary work stress. She also identified moderate restrictions in daily activities and social functioning, frequent deficiencies in concentration, persistence, or pace, and repeated episodes of deterioration in work or work-like settings. In a June 6, 2018 letter, she stated that McKenzie continued to show the symptoms and deterioration described in her assessment.

The administrative judge gave Dr. Abellard’s opinion “little weight,” finding that its severe limitations were inconsistent with therapy records and McKenzie’s reported daily activities. The administrative judge relied particularly on McKenzie’s reported ability to drive and to care for his mother.

Court’s Analysis

For claims filed before March 27, 2017, the treating-physician rule required the administrative judge first to decide whether a treating physician’s opinion deserved controlling weight. If the opinion was not given controlling weight, the administrative judge had to consider specified factors and provide good reasons for the weight assigned. Those factors, commonly called the Burgess factors, include the frequency, length, nature, and extent of treatment; the medical evidence supporting the opinion; the opinion’s consistency with the rest of the record; and whether the doctor was a specialist.

The court held that the administrative judge failed to expressly consider each of these factors when evaluating Dr. Abellard’s opinion. The court further found that the administrative judge had not otherwise supplied good reasons supporting the decision to give the opinion little weight.

The court found problems with the administrative judge’s reliance on treatment notes from social worker Mario Passaro because McKenzie ended that treatment more than a year before Dr. Abellard’s June 2018 letter and continued treatment with Dr. Abellard afterward. The court also found that the administrative judge inaccurately characterized Dr. Abellard’s later treatment notes as showing consistently good mental-status examinations. According to the court, those notes reflected frequent sleep, appetite, behavior, and mood problems, along with frequent abnormal affect, frequent hyperverbal speech, limited insight and judgment, and fair impulse control.

The court also rejected the administrative judge’s reliance on McKenzie’s ability to drive and help his mother. The record showed that McKenzie knew how to drive but had not driven for a couple of years because he did not have a car. The record also did not show that helping his mother reach the restroom at night and watching over her required the same mental abilities as regular work in a workplace setting.

Disposition

The court concluded that the administrative judge failed to follow the treating-physician rule and that the error could have affected the disability determination. The Commissioner’s motion was DENIED, McKenzie’s motion was GRANTED, and the case was REMANDED for further administrative proceedings under 42 U.S.C. § 405(g), sentence four. On remand, the administrative judge must apply all four Burgess factors when deciding what weight to give Dr. Abellard’s opinion. The clerk was directed to terminate the pending motions and close the case.