Richardson v. Comm'r of Soc. Sec.
Richardson v. Comm'r of Soc. Sec.
Opinion of the Court
Represented by counsel, Plaintiff Ramona L. Richardson ("Plaintiff") brings this action pursuant to Title II of the Social Security Act (the "Act"), seeking review of the final decision of the Commissioner of Social Security (the "Commissioner," or "Defendant") denying her application for disability insurance benefits ("DIB"). (Dkt. 1). This Court has jurisdiction over this matter pursuant to
BACKGROUND
Plaintiff protectively filed her application for DIB on April 5, 2013. (Dkt. 7-3 at 12).
Hearings on Plaintiff's claim were held before ALJ Sharon Seeley in Buffalo, New York, on November 24, 2014, and September 18, 2015. (Dkt. 7-2 at 39-78). Plaintiff's attorney amended Plaintiff's claim for a closed period of disability from October 10, 2012, to October 25, 2013, when Plaintiff returned to work full-time. (Id. at 43-44). On March 22, 2016, the ALJ issued an unfavorable decision. (Id. at 8-23). Plaintiff requested Appeals Council review; that request was denied on June 28, 2017, making the ALJ's determination the Commissioner's final decision. (Id. at 2-4). This action followed.
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,
*112(quotation omitted); see also Wagner v. Sec'y of Health & Human Servs.,
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 Bowen 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 cervical disc herniation, degenerative disc *113disease of the lumbar spine, and chronic migraine headaches. (Id. at 14). The ALJ also identified non-severe impairments, including right knee contusion, bronchitis, goiter, obesity, and hypertension. (Id. at 14-15).
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 15). The ALJ particularly considered the criteria of Listings 1.04 and 11.00 in reaching her conclusion. (Id. at 26).
Before proceeding to step four, the ALJ determined that Plaintiff retained the RFC to perform less than a full range of light work as defined in
can lift and carry 20 pounds occasionally and 10 pounds frequently; sit six hours in an eight-hour workday and stand and/or walk four hours in an eight-hour workday, alternating every 15 minutes between sitting and standing. The claimant can also frequently stoop, kneel, crouch or crawl and occasionally reach overhead with the bilateral upper extremities.
(Id. at 15). At step four, the ALJ found that Plaintiff was unable to perform any past relevant work. (Id. at 21).
At step five, the ALJ relied on the testimony of a vocational expert 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 storage facility clerk, furniture rental consultant, and machine tender. (Id. at 22). Accordingly, the ALJ found that Plaintiff was not disabled as defined in the Act. (Id. at 22-23).
II. Remand of this Matter for Further Proceedings is Necessary
Plaintiff asks the Court to reverse the Commissioner's decision, or in the alternative, to remand the Commissioner's decision for further proceedings, arguing that: (1) the Commissioner erred in failing to give good reasons for rejecting the opinion of William M. Capicotto, M.D., Plaintiff's treating orthopedic surgeon, that Plaintiff had a "temporary total disability," and failed to fully develop the record; and (2) the Commissioner erred in failing to do a full and proper credibility assessment of Plaintiff. (Dkt. 8-1 at 18-34). For the reasons set forth below, the Court finds that the ALJ failed to properly support her assessment of Plaintiff's RFC and failed to develop the record, and that this error necessitates remand for further administrative proceedings.
A. Assessment of Medical Opinions of Record
Because Plaintiff's claim was filed before March 27, 2017, the ALJ was required to apply the treating physician rule, under which a treating physician's opinion is entitled to "controlling weight" when it is "well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in [the] case record[.]"
(i) the frequency of examination and the length, nature and extent of the treatment relationship; (ii) the evidence in support of the treating physician's opinion;
*114(iii) the consistency of the opinion with the record as a whole; (iv) whether the opinion is from a specialist; and (v) other factors brought to the Social Security Administration's attention that tend to support or contradict the opinion.
Whatever weight the ALJ assigns to the treating physician's opinion, he must "give good reasons in [his] notice of determination or decision for the weight [he gives to the] treating source's medical opinion."
In this case, Dr. Capicotto, an orthopedic surgeon, began treating Plaintiff in December 2012 for neck and low back pain, precipitated as a result of Plaintiff's October 2012 motor vehicle accident. (Dkt. 7-7 at 187). At the December 2012 visit, Plaintiff complained of significant neck and lower back pain, with lower back pain aggravated by prolonged sitting or standing, repetitive twisting, turning, lifting, bending, pushing, or pulling. (Id. at 188). An examination of Plaintiff's neck revealed diminished strength of 4/5; limited range of motion; and tenderness at C5-7. (Id. at 189). An examination of Plaintiff's spine revealed tenderness at L4-S1; loss of normal lumbar lordosis ; limited range of motion; negative straight leg raise tests; and painful bilateral heel walk. (Id. ). Dr. Capicotto noted that x-rays performed by his office of Plaintiff's cervical spine showed a loss of lordosis with disc space narrowing and osteophyte formation at the C5-6 level, and x-rays of the lumbar spine appeared mostly normal. (Id. at 190). Dr. Capicotto diagnosed cervical disc herniation with myelopathy at the C5-6 level, and advised Plaintiff that she may want to consider surgery if her pain did not improve over the next month. (Id. at 191). Dr. Capicotto assessed Plaintiff's disability status as "Total, temporary." (Id. ).
Plaintiff continued treatment with Dr. Capicotto on February 11, 2013, April 11, 2013, and May 14, 2013. (Id. at 172-186). During these visits, Plaintiff reported some improvement in her back and neck pain, and Dr. Capicotto's clinical findings remained the same. At the May 14, 2013 visit, Dr. Capicotto assessed Plaintiff's disability as "Moderate, temporary." (Id. at 176). Dr. Capicotto further noted that Plaintiff reported she was examined in employee health by a Kaleida Heath physician, who opined that, if she continued work as an LPN, she would have to go back to work with significant restrictions. (Id. ).
In her written determination relating to the assessment of Plaintiff's RFC, the ALJ noted that Dr. Capicotto's opinion was the *115only opinion in the record from a treating source. (Dkt. 7-2 at 20). The ALJ found that Dr. Capicotto's opinions that Plaintiff had a "total temporary" and "moderate temporary" disability were "of limited value in assessing the claimant's residual functional capacity because they do not state specific limitations and [Dr. Capicotto] does not appear to consider anything other than the claimant's back impairment." (Id. ). Despite the "limited value" of Dr. Capicotto's opinions, the ALJ gave them "substantial weight", on the sole basis that these opinions were consistent with the fact that Plaintiff's RFC had improved by May 2013. (Id . ). Specifically, the ALJ found that "Dr. Capicotto's May 2013 opinion that the claimant had a 'moderate' disability at that point is consistent with the residual functional capacity, which allows for only a limited range of light work level." (Id. ). The ALJ gave "some weight" to a June 2013 opinion of the consultative examiner, Donna Miller, D.O., as the medical records suggested more substantial limitations than those indicated by Dr. Miller. (Id. ). The ALJ incorporated Dr. Miller's limitations, but to a "greater extent than she suggested." (Id. ).
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,
An ALJ is prohibited from 'playing doctor' in the sense that 'an ALJ may not substitute his own judgment for competent medical opinion.... This rule is most often employed in the context of the RFC determination when the claimant argues either that the RFC is not supported by substantial evidence or that the ALJ has erred by failing to develop the record with a medical opinion on the RFC.
Quinto v. Berryhill, No. 3:17-cv-00024 (JCH),
Here, the assessed RFC is not supported by substantial evidence. As noted by the ALJ, Dr. Capicotto's opinion is the only opinion in the record from a treating source, and the ALJ found that Dr. Capicotto's opinions as to Plaintiff's disability were of "limited value" because they were vague. (Dkt. 7-2 at 20 (Dr. Capicotto's opinions "do not state specific functional limitations") ). The ALJ further found that Dr. Capicotto's opinions were incomplete. (Id. at 20 (Dr. Capicotto's opinions "[do] not appear to consider anything other than the claimant's back impairment") ). Despite these identified inadequacies in Dr. Capicotto's opinions, the ALJ assigned them "significant weight." (Id. ). However, it is unclear which portion of Dr. Capicotto's vague and incomplete opinions informed the ALJ's RFC, which is quite specific, in that it addresses Plaintiff's ability to lift and carry; sit, stand, and walk; and stoop, kneel, crouch, crawl, and reach. (Id. at 15). The ALJ therefore failed to adequately explain the reasons for the weight given to Dr. Capicotto's opinions.
To the extent the ALJ relied on Dr. Capicotto's use of the term "moderate *116temporary" to inform the RFC (Dkt. 7-2 at 20), this was also improper, considering the lack of additional information in the record as to what Dr. Capicotto meant when he used that term. See Perozzi v. Berryhill,
The ALJ also considered the opinion of Dr. Miller. (Id. at 20). Dr. Miller opined that Plaintiff had "mild limitations for heavy lifting, bending, carrying, kneeling, and squatting. The claimant should also avoid any dust, irritants, or tobacco exposure which may exacerbate her pulmonary issue." (Dkt. 7-7 at 210-14). The ALJ gave Dr. Miller's opinion "some weight" but not "great weight." (Dkt. 7-2 at 20). Like the ALJ's assessment of Dr. Capicotto's opinions, it is unclear which portions of Dr. Miller's opinions informed Plaintiff's RFC, other than the inclusion of some degree of limitation on lifting, carrying, and kneeling. Dr. Miller did not offer any opinion on Plaintiff's ability to sit, stand and/or walk for certain durations. Further, Dr. Miller did not offer any opinion on Plaintiff's ability to stoop, crouch, crawl, or reach. However, these limitations are included in the assessed RFC, and the written determination is devoid of any opinion evidence as to what informed the limitations on these particular activities.
Defendant argues that there is no requirement that the ALJ's decision correspond perfectly with any medical opinion, and the Second Circuit has upheld RFC determinations with no corresponding functional assessment. The Commissioner cites to three Second Circuit opinions, including Wright v. Berryhill,
*117(RFC not supported by substantial evidence where ALJ's RFC assessment simply recited Plaintiff's testimony and the medical record without tying the evidence to specific RFC findings).
"While in some circumstances, an ALJ may make an RFC finding without treating source opinion evidence, the RFC assessment will be sufficient only when the record is 'clear' and contains 'some useful assessment of the claimant's limitations from a medical source.' " Muhammad v. Colvin, No. 6:16-cv-06369(MAT),
B. Duty to Develop the Record
The Court also agrees with Plaintiff that the ALJ failed to appropriately develop the record. "[W]here there are deficiencies in the record, an ALJ is under an affirmative obligation to develop a claimant's medical history...." Rosa v. Callahan,
Because it is unclear from the ALJ's written determination what medical opinions informed the assessed RFC, the case must be remanded for further development of the record. See Falcon v. Apfel,
C. Plaintiff's Remaining Arguments
As set forth above, Plaintiff has identified additional reasons why she contends the ALJ's decision was not supported by substantial evidence. 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 these issues. See, e.g., Bell v. Colvin, No. 5:15-CV-01160 (LEK),
*118Morales v. Colvin, No. 13cv06844 (LGS) (DF),
CONCLUSION
For the foregoing reasons, Plaintiff's motion for judgment on the pleadings (Dkt. 8) is granted to the extent that the matter is remanded for further administrative proceedings. Defendant's motion for judgment on the pleadings (Dkt. 12) 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.
In the written determination, the ALJ discusses medical records from Pratibha Bansal, M.D., a pain management specialist, which state that Plaintiff had to alternate between sitting and standing every 10 to 15 minutes. The ALJ discounted these statements in Dr. Bansal's records, as they "simply report the claimant's subjective statements." However, the ALJ noted that she incorporated Plaintiff's need to alternate between sitting and standing in the RFC, but not as frequently. (Dkt. 7-2 at 21). There is no further discussion as to what informed the assessed limitations on sitting and standing.
Reference
- Full Case Name
- Ramona L. RICHARDSON v. COMMISSIONER OF SOCIAL SECURITY
- Cited By
- 6 cases
- Status
- Published