Augustin v. Berryhill
Augustin v. Berryhill
Opinion of the Court
INTRODUCTION
Plaintiff Nirlande Augustin brings this action under
For the following reasons, the Court ALLOWS Plaintiff's motion to reverse the Commissioner's decision (Docket No. 12) and DENIES Defendant's motion to affirm the Commissioner's decision (Docket No. 13).
FACTUAL BACKGROUND
The following facts are taken from the administrative record. Plaintiff is a single, 62-year-old female. R. 40. She lives with one of her children in Everett, Massachusetts.
I. Educational and Work History
Plaintiff earned a high school diploma and received some vocational training. R.
*13740. She worked as a legal secretary at New England Life until the mid-1980s. R. 165. She stopped working due to her sickle cell disease, moved to Florida, and received disability benefits for ten years.
II. Medical History
At age sixteen, Plaintiff was diagnosed with sickle cell disease.
In March 2015, Plaintiff was diagnosed with breast cancer. R. 342. On April 29, 2015, she underwent a right modified radical mastectomy to remove the cancer. R. 374-75. There were no immediate complications from the procedure, and her surgeon indicated one week later that she exhibited full range of motion of her entire arm. R. 340-41.
On June 27, 2015, after moving to Boston, Plaintiff went to the Lawrence Memorial Hospital emergency room complaining of shortness of breath and right-sided chest pain. R. 382, 384. She informed the attending physician that she had been doing reasonably well since her surgery two months earlier. R. 386. The physician found that she was severely anemic. R. 382. Her symptoms improved after she was rehydrated and transfused with two units of blood.
Plaintiff met with oncologist Dr. Dejan Juric at the Massachusetts General Hospital ("MGH") on July 17, 2015 to discuss her breast cancer. R. 405-06. She reported some fatigue and intermittent tightness in her right chest wall, but denied any frank pain, shortness of breath, dyspnea on exertion, bone pain, or joint pain. R. 405. She declined chemotherapy to reduce her risk of recurrence because she worried that, in conjunction with her sickle cell disease, the chemotherapy would render her completely unable to function. R. 51, 406.
Plaintiff saw a hematologist at MGH, Dr. Rachel Rosovsky, on December 7, 2015 for her sickle cell disease. R. 440-43. She told Dr. Rosovsky that her energy levels were "okay" but had decreased over the past two years. R. 441. She reported no pain. R. 441-42. Plaintiff said she was not consistently taking her folic acid and iron to treat her sickle cell disease and did not know how many sickle cell crises she had per year.
Three weeks later, Plaintiff returned to Dr. Rosovsky. She reported that she had been taking her iron and folic acid daily since the last visit and that she was okay but felt fatigued often. R. 436. Plaintiff refused to take any pain medication stronger than Motrin. R. 439. Dr. Rosovsky encouraged Plaintiff to start taking a prescription drug called Hydra for her sickle cell disease, which she said she would consider.
On January 4, 2016, Plaintiff met with Dr. Anne Moulton, her primary care physician at MGH. R. 434-35. Plaintiff reported no pain, though she appeared tired. R. 434. She also saw Dr. Rosovsky the same day. R. 426-30. She reported feeling weak all over and had taken 600mg of Motrin the evening before to prevent a sickle cell *138crisis. R. 427. She stated that she was taking folic acid and iron more regularly.
On February 29, 2016, she visited a nurse practitioner complaining of fatigue, feeling like she was going to pass out after basic tasks, and right arm numbness. R. 462. The nurse practitioner noted that Plaintiff was inconsistently taking her folic acid. R. 463-64. She arranged for Plaintiff to receive a blood transfusion. R. 463.
On April 1, 2016, Plaintiff visited Dr. Juric to discuss her breast cancer. R. 452-54. She reported significant fatigue and intermittent chest wall tightness but no pain. R. 452-53. Dr. Juric counseled her to take Hydrea regularly for her sickle cell and advised her to undergo chemotherapy to reduce the risk of cancer recurrence ; again, she declined both. R. 454.
Plaintiff met with Dr. Rosovsky the same day. R. 455-60. She told her she was tired all the time and took naps a lot but her fatigue was better than before. R. 456. She noted that she was still inconsistent in taking her folic acid and iron.
Plaintiff returned to Dr. Juric on July 15, 2016. R. 477-80. He again tried to convince Plaintiff to undergo chemotherapy to reduce her risk of breast cancer recurrence, but she declined. R. 477. He also emphasized the importance of taking Hydrea daily for her sickle cell disease.
Five days later, Plaintiff followed up with Dr. Rosovsky. R. 469-75. She said she was feeling "quite well," although she was still not consistent with her medications. R. 470. She reported occasional back or neck pain and said she took Motrin when this occurred, which helped the flare-ups subside within three days.
Plaintiff saw Dr. Moulton on August 23, 2016 for left arm pain she first noticed while putting on coats in the late winter. R. 476. She told Dr. Moulton that her arm hurt whenever she reached for anything and that she had been unable to sleep on her left side for a month.
Plaintiff visited Dr. Juric again on October 4, 2016. R. 480-84. She reported some fatigue, intermittent chest wall tightness, and some left shoulder pain, but no other bone or joint pain. R. 482. Dr. Juric again discussed the utility of taking Hydrea to control her sickle cell disease, but Plaintiff refused to do so. R. 480. He again noted that Plaintiff was able to carry out work of a light or sedentary nature. R. 482.
On October 17, 2016, Plaintiff followed up with Dr. Rosovsky. R. 485-92. She reported feeling "quite well" but noted that she was tired all the time and took occasional naps during the day. R. 487. Dr. Rosovsky recorded her fatigue as "moderate to severe." R. 488. Plaintiff told Dr. Rosovsky that she was taking her folic acid and iron every day. R. 487. She stated that she took Motrin when she had neck and back pain that signaled a flare-up of her sickle cell disease.
III. Medical Opinions
In an undated letter, Dr. Moulton stated that Plaintiff has sickle cell disease"with all of the secondary manifestations," "exceedingly painful" aseptic necrosis of her left shoulder, "extreme fatigue," and "pain and decreased range of motion" in her right arm. R. 494. This problem was discussed at an October 5, 2016 office visit. She also noted Plaintiff's 2015 diagnosis of breast cancer, as well as the fact that Plaintiff "gets fatigued and short of breath with limited exertion and has difficulty performing many activities of daily living."
In an August 10, 2017 letter, Dr. Juric stated that Plaintiff has "a recent history of aggressive and poorly differentiated carcinoma of the right breast, requiring ride-sided modified radical mastectomy with extensive axillary lymph node dissection." R. 9. He also noted her "sickle cell anemia complicated by pain crises and avascular necrosis of the left humeral head."
On September 8, 2015, Dr. Lawrence Schaffzin, an ophthalmologist and state agency medical consultant, reviewed Plaintiff's medical records but did not examine her. R. 61-69. He opined that Plaintiff's sickle cell disease and breast cancer produced her pain and other symptoms. R. 65-66. Nevertheless, he found that she could occasionally lift or carry twenty pounds and climb ladders, ropes, or scaffolds; frequently lift or carry ten pounds, climb stairs or ramps, stoop, kneel, crouch, and crawl; and stand, walk, or sit for a total of six hours during an eight-hour workday. R. 66-67. He opined that these limitations would not prevent her from working in her former profession as a secretary. R. 68. On review on February 2, 2016, Dr. James Grim, a neurologist and state agency medical consultant, reached essentially the same result. R. 81-89.
IV. Vocational Expert's Testimony
At the hearing before the ALJ, Ruth Baruch, a vocational expert, testified about Plaintiff's work ability. She opined that a hypothetical person with the abilities Dr. Schaffzin and Dr. Grim ascribed to Plaintiff could work as a legal secretary or in other light clerical jobs. R. 56-57. She said *140that a similar person who was off task twenty percent of the workday due to fatigue and pain or absent from work two days per month would not be able to do any work in the local and national economy. R. 58-59.
V. Plaintiff's Testimony
At the hearing, Plaintiff testified that she feels pain and numbness almost every day in her arm. R. 42. She does not lift anything because of the pain and finds it difficult to reach for a towel in the bathroom or overhead with her hands. R. 44. She takes Motrin to control her pain. R. 48-49. She also testified that she feels very fatigued, needs a few hours to get out of bed every morning, and must lie down most of the day. R. 43, 54. She cannot make all her meals for herself and requires an hour or two to make a simple breakfast of eggs when she does cook. R. 43-44, 53. She does not do many errands or chores around the house, such as laundry or grocery shopping. R. 44. She cannot stand or walk for long periods of time, and she needs someone to help her return to her room after taking a shower. R. 43. She also regularly has shortness of breath and other breathing problems. R. 53. Plaintiff stated that she does not use stronger pain medication, Hydrea, or chemotherapy because she does not want to throw up and feel even more fatigued all the time. R. 51.
LEGAL STANDARD
Under the Social Security Act, a claimant seeking benefits must prove that she is disabled, i.e., unable "to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment... for a continuous period of not less than twelve months."
1) if the applicant is engaged in substantial gainful work activity, the application is denied; 2) if the claimant does not have, or has not had within the relevant time period, a severe impairment or combination of impairments, the application is denied; 3) if the impairment meets the conditions for one of the "listed" impairments in the Social Security regulations, then the application is granted; 4) if the applicant's "residual functional capacity" ["RFC"] is such that he or she can still perform past relevant work, the application is denied; and 5) if the applicant, given his or her [RFC], education, work experience, and age, is unable to do any other work, the application is granted."
Purdy,
The claimant bears the burden of proof for steps one through four. Purdy,
AGENCY DECISION
Plaintiff filed her applications for Social Security Disability Insurance and Supplemental Security Income benefits on June 11, 2015, claiming disability beginning January 1, 2013. R. 17. The claim was denied on September 24, 2015 and again upon reconsideration on February 19, 2016. R. 17, 101-03. ALJ Sujata Rodgers held a hearing on March 22, 2017. R. 34.
On May 23, 2017, the ALJ issued her decision, which again denied Plaintiff's disability claim. R. 17-29. At step one of the five-step disability evaluation process, the ALJ found that Plaintiff had not engaged in substantial gainful activity since January 1, 2013, the alleged onset date. R. 19. At step two, she found that Plaintiff's sickle cell anemia, status post breast cancer, and left shoulder subtotal tear constituted severe impairments. R. 19-20. At step three, she found that none of Plaintiff's impairments, alone or in combination, met or equaled a listed impairment under 20 C.F.R. Part 404, Subpart P, Appendix 1. R. 20. She specifically ruled out impairments under Listing 7.05, which includes sickle cell disease, and Listing 13.10, which includes breast cancer.
The ALJ proceeded to determine Plaintiff's RFC. R. 20-27. She accorded great weight to the assessments of the state agency non-examining medical physicians that Plaintiff was able to do light exertional work, which she found consistent with the evidence in the medical records. R. 25-26. She rejected the assessment of Dr. Moulton, Plaintiff's primary care physician, that Plaintiff could not work because her letter was conclusory and did not list any specific physical residual functional limitations.
[T]he claimant has the [RFC] to perform light work as defined in 20 CFR 404.1567(b) and 416.967(b) except that she can occasionally lift and carry 20 pounds and frequently lift and carry 10 pounds. She can sit, stand, or walk for 6 hours each in an 8-hour workday. She can frequently climb ramps and stairs, balance, stoop, kneel, crouch, and crawl. She can occasionally climb ladders, ropes, and scaffolds. She can occasionally reach overhead with bilateral upper extremities.
R. 20.
At step four, the ALJ relied on the vocational expert's testimony to find that Plaintiff was capable of returning to her past relevant work as a legal secretary. R. 27. Alternatively, at step five, the ALJ found that Plaintiff could perform a significant number of jobs existing in the national economy, such as office clerk, file clerk, or mail clerk. R. 27-28. The ALJ determined Plaintiff was not disabled and denied her claim. R. 29.
Plaintiff made a timely request for review of the ALJ's decision by the Appeals Council of the Social Security Administration. R. 11. The Appeals Council denied the request on February 20, 2018, making the ALJ's decision the final decision of the Commissioner. R. 1-6. The case is now ripe *142for review under
STANDARD OF REVIEW
A district court reviews an ALJ's decision "to determine 'whether the final decision is supported by substantial evidence and whether the correct legal standard was used'." Coskery v. Berryhill,
In reviewing for legal error, "[f]ailure of the [ALJ] to apply the correct legal standards as promulgated by the regulations or failure to provide the reviewing court with the sufficient basis to determine that the [ALJ] applied the correct legal standards are grounds for reversal." Weiler v. Shalala,
DISCUSSION
Plaintiff assails the ALJ's decision in four respects: 1) failing to find that she has a listed impairment that qualifies her as disabled under step three; 2) giving too much weight to the non-examining state agency medical consultants' opinions and insufficient weight to the opinion of Dr. Moulton, her primary care physician; 3) ignoring her chronic pain syndrome; and 4) finding that she has an RFC to perform light work. The Court concludes that the ALJ failed to properly weigh the medical opinions, which requires the case be remanded for a new hearing. Therefore, the Court does not address Plaintiff's other three arguments.
Under the applicable regulations, a "medical source" is "an individual who is licensed as a healthcare worker by a State and working within the scope of practice permitted under State or Federal law."
The ALJ must give "[c]ontrolling weight ... to a treating physician's opinion on the nature and severity of a claimant's impairments if the opinion is 'well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence' in the record." Johnson,
That said, a number of factors determine the appropriate weight to give to the opinions of treating and other medical sources.
The ALJ did not provide good reasons for her weighing of the medical opinions. She gave great weight to the opinions of the non-examining state agency medical consultants because they were consistent with Plaintiff's medical records. She accorded little weight to the opinions of Dr. Moulton, Plaintiff's primary care physician and a treating source, which she deemed inconsistent with the medical records. The ALJ did not mention, however, that Dr. Schaffzin and Dr. Grim provided their opinions based on incomplete medical records that did not reflect Plaintiff's condition as of the date of Dr. Moulton's opinion
In Soto-Cedeño v. Astrue, the First Circuit held that an assessment performed by the claimant's treating physician could not be "reasonably characterized as 'inconsistent' with the other medical evidence in record" where the assessment and other medical evidence were from "different time periods."
Plaintiff did not submit an opinion from Dr. Juric until she appealed her case to the Appeals Council, so the ALJ did not consider it. For the purposes of remand, however, the Court notes that the record contains even less evidence to discount Dr. Juric's opinion since he wrote his letter in August 2017, almost two years after Dr. Schaffzin's report.
Since the ALJ did not sufficiently justify giving little weight to Dr. Moulton's opinion, remand is required. Lemieux v. Berryhill,
ORDER
Accordingly, the Court ALLOWS Plaintiff's motion to reverse the Commissioner's decision (Docket No. 12) and DENIES Defendant's motion to affirm the Commissioner's decision (Docket No. 13).
SO ORDERED.
Hydrea, also known as Hydroxyurea, is an antimetabolite medication used to treat certain types of cancer and reduce the frequency of crises in patients with sickle cell anemia.
The Court notes that Plaintiff has consistently refused to take Hydrea or follow other treatment recommendations from her physicians because she is worried the medication will make her fatigued and nauseous. On remand, the ALJ may consider this justification in determining the weight to give to her treating sources' opinions, see Johnson,
Reference
- Full Case Name
- Nirlande AUGUSTIN v. Nancy A. BERRYHILL, Acting Commissioner of Social Security Administration
- Cited By
- 1 case
- Status
- Published