Biro v. Comm'r of Soc. Sec.
Biro v. Comm'r of Soc. Sec.
Opinion of the Court
INTRODUCTION
Represented by counsel, Plaintiff Laszlo Biro ("Plaintiff") brings this action pursuant to Title XVI of the Social Security Act (the "Act"), seeking review of the final decision of the Commissioner of Social Security (the "Commissioner," or "Defendant") denying his application for supplemental security income ("SSI"). (Dkt. 1). This Court has jurisdiction over the matter pursuant to
BACKGROUND
Plaintiff initially filed an application for SSI on March 29, 2007. (Dkt. 8-8 at 15).
*467(Id. ). As a result of this incarceration, Plaintiff's SSI benefits were suspended. (Id. ).
Plaintiff protectively filed a new application for SSI on March 30, 2011, alleging disability from March 29, 2007, due to gout, severe lower back pain, hypertension, pancreatitis, and anxiety. (Dkt. 8-6 at 2-3). Plaintiff's application was initially denied on July 12, 2011. (Dkt. 8-4 at 2-5). At Plaintiff's request, a hearing on his claim was held before an administrative law judge ("ALJ"), and on September 26, 2012, the ALJ issued an unfavorable decision. (Dkt. 8-2 at 12-28). The Appeals Council denied Plaintiff's request for review on December 11, 2013 (Id. at 2-4), and an action was commenced in this court. See Civil Action No. 6:14-CV-06061. Pursuant to a stipulation between Plaintiff and the Commissioner, the court remanded the matter for further administrative proceedings. (Dkt. 8-9 at 27).
On remand, the Appeals Council vacated the Commissioner's prior decision and remanded the case to the ALJ to: (1) further develop the record regarding Plaintiff's impairments; (2) give further consideration to treating and nontreating source opinions; and (3) further evaluate Plaintiff's subjective complaints in accordance with the applicable regulations. (Id. at 27-28).
A remand hearing was held before ALJ John P. Ramos on January 26, 2016. (Dkt. 8-8 at 78-118). On April 18, 2016, ALJ Ramos issued an unfavorable decision. (Id. at 14-48). The Appeals Council declined to assume jurisdiction, rendering ALJ Ramos' decision the Commissioner's final determination. (Id. at 2).
LEGAL STANDARD
I. District Court Review
"In reviewing a final decision of the [Social Security Administration ("SSA") ], this Court is limited to determining whether the SSA's conclusions were supported by substantial evidence in the record and were based on a correct legal standard." Talavera v. Astrue ,
II. Disability Determination
An ALJ follows a five-step sequential evaluation to determine whether a claimant is disabled within the meaning of the Act. See *468Bowen v. City of New York ,
At step three, the ALJ examines whether a claimant's impairment meets or medically equals the criteria of a listed impairment in Appendix 1 of Subpart P of Regulation No. 4 (the "Listings").
The ALJ then proceeds to step four and determines whether the claimant's RFC permits the claimant to perform the requirements of his or her past relevant work.
DISCUSSION
I. The ALJ's Decision
In determining whether Plaintiff was disabled, the ALJ applied the five-step sequential evaluation set forth in
At step two, the ALJ found that Plaintiff suffered from the severe impairments of degenerative disc disease of the cervical and lumbar spine, degenerative joint disease of the left knee, history of gout, asthma, and panic disorder with agoraphobia. (Id. ). The ALJ further found that Plaintiff had the non-severe impairments of hypertension, hyperlipidemia, duodenal cancer, pancreatitis, digestive disorders, and obesity. (Id. at 19-20). The ALJ also concluded that Plaintiff's claimed enlarged liver and borderline diabetes did not constitute medically determinable impairments. (Id. at 21).
At step three, the ALJ found that Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of any Listing. (Id. at 25-26). The ALJ particularly considered the criteria of Listings 1.02, 1.03, 1.04, 12.02, 12.04, 12.06, 12.09, and 14.09 in reaching his conclusion. (Id. at 21-22).
*469Before proceeding to step four, the ALJ determined that Plaintiff retained the RFC to perform sedentary work as defined in
should avoid frequent pushing and pulling with either upper extremity; can occasionally perform postural activities, such as bending, stooping, kneeling, crouching, and crawling; may need the use of a cane to ambulate, but retains the ability to carry small objects such as files in his free hand; and should avoid exposure to concentrated respiratory irritants or extremes of temperature. The claimant also retains the ability to understand and follow simple instructions and directions; can perform simple tasks with supervision and independently; can maintain attention/concentration for simple tasks; can regularly attend to a routine and maintain a schedule; can relate to and interact with others to the extent necessary to carry out simple tasks, but should avoid work requiring more complex interaction or joint efforts with others to achieve work goals and should not have interaction with the public; and can handle reasonable levels of simple work-related stress in that he can make simple decisions directly related to the completion of his tasks, work in a position where he is not responsible for the work of others, and in work that involves little change in daily routine, work duties, or processes.
(Id. at 24). At step four, the ALJ found that Plaintiff had no past relevant work. (Id. at 39).
At step five, the ALJ relied on the testimony of a vocational expert ("VE") to conclude that, considering Plaintiff's age, education, work experience, and RFC, there were jobs that exist in significant numbers in the national economy that Plaintiff could perform, including the representative occupations of document preparer, addresser, and touch-up screener. (Id. at 39-41). Accordingly, the ALJ found that Plaintiff was not disabled as defined in the Act. (Id. at 41-42).
II. Remand of this Matter for Further Proceedings is Necessary
Plaintiff asks the Court to reverse the Commissioner's decision, arguing that: (1) the ALJ's RFC finding was unsupported by substantial evidence, because the ALJ relied upon a medical opinion predating Plaintiff's 2013 knee injury ; and (2) the ALJ improperly relied on a questionnaire completed in 2011 in assessing the credibility of Plaintiff's subjective complaints. For the reasons set forth below, the Court finds that the ALJ's assessment of Plaintiff's RFC was unsupported by substantial evidence and that this error necessitates remand for further administrative proceedings.
A. Assessment of Plaintiff's RFC
In deciding a disability claim, an ALJ is tasked with "weigh[ing] all of the evidence available to make an RFC finding that [is] consistent with the record as a whole." Matta v. Astrue ,
Of particular relevance to this case, "medical source opinions that are *470conclusory, stale, and based on an incomplete medical record may not be substantial evidence to support an ALJ finding." Camille v. Colvin ,
Here, Plaintiff argues that the ALJ's RFC finding was not supported by substantial evidence because it was based on the stale medical opinion of consultative examiner Dr. Harbinder Toor and otherwise unsupported by any competent medical opinion. The Court agrees, for the reasons discussed below.
Dr. Toor examined Plaintiff on June 21, 2011, shortly after his application was filed and nearly five years before the ALJ issued his decision. (Dkt. 8-7 at 182-85). Dr. Toor performed a physical examination of Plaintiff, during which Plaintiff had a normal gait and stance, used no assistive devices, and was able to rise from a chair without difficult. (Id. at 183). Plaintiff did have slight difficulty getting on and off the examination table and walking on his heels and toes, and was able to squat to only 50% of full. (Id. ). Plaintiff had slight discomfort in his knees bilaterally, but exhibited a full range of motion. (Id. at 184). Based on this examination, Dr. Toor opined that Plaintiff had "moderate" limitations in standing, walking, sitting, bending, lifting, pushing, and pulling. (Id. at 185).
More than two years after Dr. Toor's examination, in September 2013, Plaintiff twisted his left knee and fell. (See Dkt. 8-13 at 237). Plaintiff was determined to have a tear of the medial cartilage or meniscus of his left knee and underwent a left knee arthroscopy on October 17, 2013. (Id. at 108-110). Plaintiff continued to suffer left knee pain in 2013 and 2014. (See, e.g. , Dkt. 8-14 at 47, 66). In July 2014, he reported that he had experienced only a 50% improvement in his symptoms since his surgery. (Id. at 66).
In August 2014, Plaintiff was instructed to begin wearing a left knee brace. (Id. at 78). Plaintiff's treating physician's assistant noted that Plaintiff might require a total knee replacement if his symptom continued to worsen. (Id. ).
In November 2015, Plaintiff again complained of significant left knee pain and asked his treatment providers about possible options to alleviate it. (Id. at 127). An x-ray of Plaintiff's left knee was taken and showed tricompartmental joint disease, most advanced in the medial compartment, and a small effusion. (Id. at 108). On December 20, 2015, Plaintiff reported to his physician that his knee pain continued to worsen and that he was experiencing swelling, occasional popping, and clicking. (Id. at 151). On examination, Plaintiff had a limited range of motion in his left knee, with positive pain and crepitus on patellofemoral grind testing and positive pain over the patellar tendon. (Id. at 152). Plaintiff declined further conservative care and expressed interest in a second arthroscopy. (Id. at 153).
A second arthroscopy was performed on Plaintiff's left knee on January 21, 2016.
*471(Id. at 207-208). Plaintiff's post-operative diagnoses were chondral defect medial femoral condyle, posterior horn root tear lateral meniscus, lateral osteophyte in notch causing impingement, and patellofemoral degenerative changes. (Id. at 207). In February 2016, Plaintiff reported he was continuing to experience knee pain post-surgery. (Id. at 172).
In assessing Plaintiff's RFC, the ALJ accorded "significant weight" to Dr. Toor's 2011 opinion, stating that it was "generally supported by the objective medical evidence[.]" (Dkt. 8-8 at 30). The ALJ acknowledged that there had been a "worsening of [Plaintiff's] left knee disorder following an injury in September 2013," but concluded that "greater exertional and non-exertional limitations [than identified by Dr. Toor] are not supported by the objective clinical and laboratory findings from various treating and examining sources." (Id. ).
The Court finds the ALJ's consideration of Plaintiff's knee impairment unsupported by substantial evidence. First, Dr. Toor's opinion, which was rendered nearly five years before the ALJ's decision and before Plaintiff's September 2013 knee injury and two subsequent surgeries, was stale and not based on the complete medical record. See, e.g., Pagano v. Comm'r of Soc. Sec. , No. 16-CV-6537-FPG,
The ALJ also did not rely on any other competent medical opinion in considering Plaintiff's left knee condition. Only two opinions of record were issued after Plaintiff's September 2013 injury. First, nurse practitioner ("NP") Aileen Colunio issued an opinion on February 12, 2016, stating that she had "never been provided medical evidence that would suggest [Plaintiff] is disabled." (Dkt. 8-13 at 305-306). However, NP Colunio, who worked for a pain management clinic, acknowledged that she had not treated Plaintiff for his knee and ankle pain. (Id. at 305). Accordingly, NP Colunio's opinion does not provide any meaningful information regarding the impact of Plaintiff's knee condition on his functional limitations. Second, physician's assistant Diane Legendre issued an opinion on September 15, 2014, in which she stated that Plaintiff's conditions, which were chronic and not expected to improve, prevented him from working. (Id. at 227). The ALJ gave this opinion "little weight," stating that it was not supported by the clinical findings of record. (Dkt. 8-8 at 32). It is therefore clear that the ALJ could not have relied on either of these opinions in assessing Plaintiff's RFC in light of his worsening left knee symptoms.
Defendant contends that the ALJ's RFC finding was supported by the "voluminous medical record," including "extensive progress notes" and "diagnostic testing." (Dkt. 16 at 27). However, as the Court noted above, an ALJ may not "ma[ke] an RFC determination in the absence of supporting expert medical opinion[.]" Henningsen v. Comm'r of Soc. Sec. Admin. ,
Because the ALJ in this matter failed to rely on any competent medical opinion in assessing Plaintiff's RFC following his September 2013 knee injury and subsequent surgeries, his decision was unsupported by substantial evidence. Remand of this matter for further administrative proceedings, during which the record can be appropriately developed (including by obtaining an updated function-by-function medical assessment of Plaintiff), is necessary.
B. Plaintiff's Remaining Argument
Plaintiff also argues that the ALJ improperly relied on a questionnaire from 2011 in assessing the credibility of his subjective complaints. However, because the Court has already determined, for the reasons previously discussed, that remand of this matter for further administrative proceedings is necessary, the Court declines to reach this issue. See, e.g., Bell v. Colvin , No. 5:15-CV-01160 (LEK),
CONCLUSION
For the foregoing reasons, Plaintiff's motion for judgment on the pleadings (Dkt. 12) is granted to the extent that the matter is remanded for further administrative proceedings. Defendant's motion for judgment on the pleadings (Dkt. 16) is denied. The Clerk of Court is directed to enter judgment and close this case.
SO ORDERED.
When referencing the page number(s) of docket citations in this Decision and Order, the Court will cite to the CM/ECF-generated page numbers that appear in the upper righthand corner of each document.
The Act "requires the termination of eligibility for SSI benefits after a claimant is ineligible for 12 consecutive months." Singletary v. Astrue , No. 11-CV-6055,
Reference
- Full Case Name
- Laszlo BIRO v. COMMISSIONER OF SOCIAL SECURITY
- Cited By
- 101 cases
- Status
- Published