Treating Physician Opinion Rule: Narrative Requirement and Validation of Subjective Evidence in Mental Health Disability Determinations

Introduction

Krista Kay Miller filed applications for Disability Insurance Benefits (DIB) and Supplemental Security Income (SSI) on the ground that her diagnosed depression, anxiety, and post-traumatic stress disorder rendered her unable to work. The Social Security Administration’s Administrative Law Judge (ALJ) denied her claim, concluding that Miller’s treating psychiatrist’s opinion was not entitled to controlling weight, and the Magistrate Judge granted the Commissioner’s motion for summary judgment. Miller appealed to the Fourth Circuit, arguing that the ALJ failed to apply the “treating physician” rule correctly, overlooked key factors in evaluating the weight of medical opinions, and improperly discounted subjective testimony essential to mental-health diagnoses.

Summary of the Judgment

In an unpublished per curiam opinion issued May 15, 2025, the Fourth Circuit vacated and remanded the district court’s grant of summary judgment for the Commissioner. The appellate court held that:

The ALJ erred by refusing to give controlling weight to the opinion of Dr. Rajendra Lowtan, Miller’s long-time treating psychiatrist, on the ground that it was based on Miller’s subjective symptom reports;
The ALJ failed to identify the specific record evidence that was inconsistent with Lowtan’s opinion;
The ALJ did not meaningfully consider all six regulatory “weight factors” in 20 C.F.R. § 404.1527(c) when assigning “little weight” to the psychiatrist’s opinion, notably neglecting the length of the treating relationship.

For these reasons, the court concluded that the ALJ’s analysis did not conform to applicable regulations and was not supported by substantial evidence, necessitating remand for proper application of the treating-physician rule.

Analysis

Precedents Cited

Patterson v. Comm’r, 846 F.3d 656 (4th Cir. 2017): Standard of review—whether the ALJ’s decision is supported by substantial evidence and correct legal standards.
Dowling v. Comm’r, 986 F.3d 377 (4th Cir. 2021): Definition of “substantial evidence” and refusal to reweigh evidence on appeal.
Shinaberry v. Saul, 952 F.3d 113 (4th Cir. 2020): Deference to ALJ credibility findings when evidence allows reasonable minds to differ.
Radford v. Colvin, 734 F.3d 288 (4th Cir. 2013): Requirement that the ALJ build an “accurate and logical bridge” from evidence to conclusions.
Woods v. Berryhill, 888 F.3d 686 (4th Cir. 2018): Necessity of a narrative discussion explaining the weight given to conflicting medical opinions.
Shelley C. v. Comm’r, 61 F.4th 341 (4th Cir. 2023): Application of regulatory factors for weighing medical opinions and recognition of subjective evidence in mental impairments.
Easterbrook v. Kijakazi, 88 F.4th 502 (4th Cir. 2023): Importance of subjective patient reports in psychiatric diagnoses.
Arakas v. Comm’r, 983 F.3d 83 (4th Cir. 2020): Treating-physician rule—controlling weight when well supported and not inconsistent with record.
Mastro v. Apfel, 270 F.3d 171 (4th Cir. 2001): Opinions inconsistent with substantial evidence warrant less weight.

Legal Reasoning

Under 20 C.F.R. § 404.1527(c)(2), a treating source’s opinion must be given controlling weight if it is:

Well-supported by medically acceptable clinical and laboratory diagnostic techniques, and
Not inconsistent with other substantial evidence in the record.

The ALJ here denied controlling weight to Dr. Lowtan’s 2017 opinion on two flawed grounds:

That the opinion relied on Miller’s subjective reports—a basis the Fourth Circuit has explicitly rejected in mental-health cases.
That it conflicted with “unremarkable” mental-status examinations and “conservative” treatment, without specifying which pieces of evidence contradicted the psychiatrist’s conclusions about concentration, social interaction, and absenteeism.

Having denied controlling weight, the ALJ was required to consider six non-exclusive factors—examining relationship, treatment relationship (length and frequency), supportability, consistency, specialization, and any other relevant factor—and explain how each influenced the weight assigned. Although the ALJ mentioned some of these factors, he failed to recognize that Dr. Lowtan had treated Miller continuously since 2012 and did not provide the narrative bridging analysis mandated by Woods and Shelley C.

Impact

This decision reinforces two critical principles in Social Security disability adjudications:

Subjective symptom reports are valid diagnostic tools in mental-health cases and cannot be dismissed as a matter of regulatory routine.
ALJs must supply a thorough narrative explanation when assigning weight to medical opinions—identifying specific supporting or conflicting evidence and addressing each regulatory factor meaningfully.

Future claimants and decision-makers will rely on this ruling to challenge cursory or formulaic treatment-of-opinion analyses, particularly in psychiatric disability claims where objective testing is inherently limited.

Complex Concepts Simplified

Substantial Evidence: More than a “scintilla” of evidence—a reasonable mind must find the evidence adequate to support the conclusion.
Treating Physician Rule: A long-term caretaker’s medical opinion generally carries the greatest weight, so long as it is well supported and consistent with the record.
Narrative Discussion Requirement: ALJs must explain in words how they weighed each medical opinion—citing specific evidence for support or conflict.
Subjective Evidence: Patient-reported symptoms (e.g., mood swings, intrusive thoughts) are often the only tools available to diagnose and assess mental conditions like depression or PTSD.

Conclusion

The Fourth Circuit’s decision in Krista Miller v. Frank Bisignano emphatically upholds the principle that treating-physician opinions deserve rigorous, well-reasoned analysis and that subjective reports in mental-health disability cases are not to be dismissed out of hand. By vacating and remanding for failure to provide a controlling-weight determination or a compliant narrative discussion, the court has strengthened procedural safeguards for claimants with psychiatric impairments and clarified the degree of detail ALJs must employ in weighing medical opinions. This ruling is poised to shape future Social Security disability adjudications by demanding transparency, specificity, and respect for the unique nature of mental-health evidence.