Kuhaneck v. Comm'r of Soc. Sec.
Kuhaneck v. Comm'r of Soc. Sec.
Opinion of the Court
INTRODUCTION
Represented by counsel, Plaintiff Kathryn L. Kuhaneck ("Plaintiff") brings this *243action 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 the matter pursuant to
BACKGROUND
Plaintiff protectively filed her application for DIB on August 20, 2014. (Dkt. 7 at 42, 110).
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 ,
*244II. Disability Determination
An ALJ follows a five-step sequential evaluation to determine whether a claimant is disabled within the meaning of the Act. See Parker 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: "anxiety; depression; left knee arthritis status post-surgery; fibromyalgia ; complex regional pain syndrome ; obesity ; Ehlers-Danlos syndrome ; and history of herniated discs status post spinal fusion." (Id. ). The ALJ further found that Plaintiff's medically determinable impairments of endometriosis and migraine headaches were non-severe. (Id. at 44-45).
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 45). The ALJ particularly considered the criteria of Listings 1.04, 12.04, and *24512.06 in reaching her conclusion. (Id. at 45-47).
Before proceeding to step four, the ALJ determined that Plaintiff retained the RFC to perform a range of sedentary work as defined in
is limited to occasional climbing of ramps or stairs; occasional climbing of ladders, ropes, or scaffolds; and occasional balancing, stooping, crouching, kneeling, and crawling; able to sit for one hour, and then stand for 15 minutes, alternating throughout the workday; is limited to occasional exposure to unprotected heights; occasional exposure to moving mechanical parts; occasional operating a motor vehicle; occasional exposure to temperature extremes; able to perform simple, routine, repetitive tasks.
(Id. at 47). At step four, the ALJ found that Plaintiff was unable to perform any past relevant work. (Id. at 53).
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 information clerk, machine tender, and order clerk. (Id. at 53-54). Accordingly, the ALJ found that Plaintiff was not disabled as defined in the Act. (Id. at 54-55).
II. Remand of this Matter for Further Proceedings is Necessary
Plaintiff asks the Court to remand this matter to the Commissioner, arguing: (1) the ALJ failed to adequately explainer her reasons for rejecting opinion evidence in the record, including the opinion of Plaintiff's treating physician, Cynthia Teerlinck, M.D; (2) the ALJ assessed the RFC in absence of a supporting medical opinion; and (3) the Appeals Council failed to properly address new evidence submitted by Plaintiff's treating surgeon and primary care physician. (Dkt. 11-1 at 33-40). For the reasons set forth below, the Court finds that the ALJ erred in evaluating the opinion evidence of Dr. Teerlinck, and that this error necessitates remand for further administrative proceedings.
A. Assessment of Opinion Evidence
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; (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.
*246Scitney v. Colvin ,
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."
Dr. Teerlinck completed a physical medical source statement on January 13, 2015. (Dkt. 7 at 793-96). Dr. Teerlinck identified Plaintiff's tender fibromyalgia points and limited range of motion in her back as objective signs of her impairments. (Id. at 793). Dr. Teerlinck opined that Plaintiff could walk less than one city block without rest or severe pain. (Id. at 794). Plaintiff could sit for thirty minutes at one time, stand for fifteen minutes at one time, and could sit or stand/walk for about two hours in an eight-hour day. (Id. ). Plaintiff required a job that permitted her to shift positions at will from sitting, standing, or walking, and needed to walk for five minutes, every forty-five minutes. (Id. ). Further, due to her muscle weakness, chronic fatigue, and pain, Plaintiff would need to take three to four unscheduled breaks of ten minutes in length. (Id. ). Plaintiff did not need a cane or assistive device. (Id. at 795). Dr. Teerlinck further opined that Plaintiff could occasionally lift ten pounds and never lift twenty pounds or more. (Id. ). Plaintiff could never twist, and rarely stoop (bend), crouch/squat, climb stairs, or climb ladders. (Id. ). She did not have any significant limitations for reaching, handling, or fingering. (Id. ). According to Dr. Teerlinck, Plaintiff would be "off task" fifteen percent of the workday and was capable of performing low-stress work. (Id. at 796). Plaintiff's impairments were likely to produce "good days" and "bad days," and she would be absent from work as a result of her impairments or treatment more than four days per month. (Id. ).
The ALJ afforded Dr. Teerlinck's opinion "some weight." (Id. at 52). The ALJ explained that while she agreed with Dr. Teerlinck that Plaintiff was capable of performing a low-stress job and could lift ten pounds, there was "little evidence in Dr. Teerlinck's records to support her opinions that the claimant would need breaks three to four times a day or miss more than four days of work a month." (Id. ). The ALJ did not address Dr. Teerlinck's assessment of Plaintiff's ability to walk, sit, stoop, crouch, climb stairs and ladders, or her need to shift positions at will.
The Court has reviewed the medical record, which contains visit notes from Dr. Teerlinck from January 2015 through January 2016. (Id. at 873-81, 977-84). The visit notes reveal ongoing complaints of pain, including pain while sitting, standing, and walking, difficulty walking, and Plaintiff's complaints of needing to reposition frequently. (Id. at 873, 876, 879, 880, 979). The records also reveal that Plaintiff received *247a steroid injection in her back and a nerve block in her left foot, and required visits to urgent care and the emergency room. (Id. at 873, 878, 979). At the administrative hearing, Plaintiff testified that she has had fourteen surgeries. (Id. at 76). In other words, Dr. Teerlinck's treatment notes, as well as other information in the record, appear to support Dr. Teerlinck's assessment of Plaintiff's limitations, including her need for breaks and absences.
Further, the ALJ failed to address certain portions of Dr. Teerlinck's opinion, including Plaintiff's ability to walk, sit, stoop, crouch, climb stairs and ladders, or her need to shift positions at will, despite the fact that Dr. Teerlinck's opinion as to Plaintiff's ability to perform these activities diverges with the assessed RFC.
The Court further notes that the ALJ failed to consider the consistency of Dr. Teerlinck's opinion with the record as a whole, a consideration that is required by the treating physician rule. Halloran ,
In sum, Dr. Teerlinck, one of Plaintiff's treating physicians, submitted a detailed medical source statement, which the ALJ largely rejected with the conclusory statements that "I do not find much support for some of the opinions of Dr. Teerlinck," and "there is little evidence in Dr. Teerlinck's records to support her opinions that the claimant would need breaks three to four times a day or miss more than four days of work a month." (See Dkt. 7 at 52). Further explanation is required before rejecting an opinion by a treating source, particularly where information in the treatment notes document Plaintiff's complaints, and the treating source identifies objective findings for Plaintiff's impairments. Accordingly, remand is required. On remand, the ALJ is directed to more thoroughly consider Dr. Teerlinck's opinion in light of the treating physician rule and, should she decide not to adopt that opinion, offer good reasons supporting her decision.
B. 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),
CONCLUSION
For the foregoing reasons, Plaintiff's motion for judgment on the pleadings (Dkt. 11) is granted to the extent that the matter is remanded for further administrative proceedings. Defendant's motion for judgment on the pleadings (Dkt. 15) 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/LCF-generated page numbers that appear in the upper righthand corner of each document.
Both the ALJ and Plaintiff refer to a treatment record at Exhibit B33F/2, found at page 1078 of the medical record, contending that Dr. Teerlinck found that Plaintiff had a normal range of motion in all major joints except her ankle. (See Dkt. 7 at 52; Dkt. 15-1 at 16). However, this record is not from Dr. Teerlinck; rather, it is a record from Hemant Kalia, M.D., of the Unity Spine Center. (See id. at 1082-86).
Although not specifically addressed in the written determination, the ALJ appears to have adopted Dr. Teerlinck's opinion that Plaintiff is able to stand for fifteen minutes at one time and for about two total hours per day, as the RFC provides that Plaintiff is able to stand for fifteen minutes, every hour, during an eight-hour workday.
Reference
- Full Case Name
- Kathryn L. KUHANECK v. COMMISSIONER OF SOCIAL SECURITY
- Cited By
- 12 cases
- Status
- Published