H. RUSSEL HOLLAND, District Judge.
This is an action for judicial review of the denial of disability benefits under Title II and Title XVI of the Social Security Act, 42 U.S.C. §§ 401-434, 1381-1383f. Plaintiff Randy Dell Newland has timely filed his opening brief,
On March 7, 2013, plaintiff filed applications for disability benefits under Title II and Title XVI of the Social Security Act, alleging that he became disabled on February 20, 2013. Plaintiff alleged that he was disabled due to back injury, torn rotator cuffs, learning disability, his elbow, and depression. Plaintiff's applications were denied initially, and plaintiff requested a hearing. After an administrative hearing on September 3, 2014, an administrative law judge (ALJ) denied plaintiff's application. Plaintiff sought review of the ALJ's January 5, 2015 unfavorable decision. On June 20, 2016, the Appeals Council granted plaintiff's request for review and remanded the matter to the ALJ.
Plaintiff was born on July 15, 1964. Plaintiff was 48 years old on his alleged onset date. Plaintiff has an 11th grade education. Plaintiff's past relevant work includes work as a production line welder, a production line assembler, a material handler, a production line maintenance mechanic, and a cook.
The ALJ first determined that plaintiff met "the insured status requirements of the Social Security Act through June 30, 2017."
The ALJ then applied the five-step sequential analysis used to determine whether an individual is disabled.
At step one, the ALJ found that plaintiff had "not engaged in substantial gainful activity since February 20, 2013, the alleged onset date. . . ."
At step two, the ALJ found that plaintiff had "the following severe impairments: right rotator cuff repair, status post bilateral carpal tunnel releases, status post cervical fusion, and lumbar degenerative disc disease. . . ."
At step three, the ALJ found that plaintiff did "not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1. . . ."
"Between steps three and four, the ALJ must, as an intermediate step, assess the claimant's RFC."
The ALJ found plaintiff's pain and symptom statements less than credible because they were inconsistent with the objective medical evidence and his daily activities.
The ALJ gave Dr. Sklaroff's January 2018 opinion great weight.
At step four, the ALJ found that plaintiff "is unable to perform any past relevant work. . . ."
At step five, the ALJ found that "there are jobs that exist in significant numbers in the national economy that the claimant can perform" including working as a kitchen helper, an airport maintenance laborer, or a store laborer.
Thus, the ALJ concluded that plaintiff had "not been under a disability, as defined in the Social Security Act, from February 20, 2013, through the date of this decision. . . ."
Pursuant to 42 U.S.C. § 405(g), the court has the "power to enter, upon the pleadings and transcript of the record, a judgment affirming, modifying, or reversing the decision of the Commissioner. . . ." The court "properly affirms the Commissioner's decision denying benefits if it is supported by substantial evidence and based on the application of correct legal standards."
As an initial matter, defendant complains that plaintiff did not raise some of his arguments in the "argument" section of his opening brief, instead raising them in the "summary of pertinent evidence" section. While it would have been preferable had plaintiff raised his arguments in the actual argument section of his opening brief, that he did not does not mean that the court cannot consider these arguments. Defendant was able to discern what arguments plaintiff was making and respond to those arguments in his opposing brief.
Turning then to plaintiff's arguments, plaintiff first argues that the ALJ erred in giving Dr. Christensen's opinion great weight. Dr. Christensen examined plaintiff on August 15, 2013. Dr. Christensen's discussion was as follows:
The ALJ gave great weight to Dr. Christensen's opinion that plaintiff was "capable of at least light activity" and in her discussion mentioned that Dr. Christensen believed that perhaps there was "`quite a bit of magnification of symptoms.'"
To the extent this is what plaintiff is arguing, this argument fails, in large part because the majority of the medical records in this case came in
To the extent that plaintiff is arguing that the ALJ focused too heavily on Dr. Christensen's comment about symptom magnification, it should be noted that Dr. Christensen was not the only medical provider who believed that there might be some magnification of symptoms here. In September 2016, Dr. Eule noted some concerns about "secondary gain issues."
All that said, there is still a problem with the ALJ's treatment of Dr. Christensen's opinion, although this is not an issue that plaintiff raised. The ALJ gave great weight to Dr. Christensen's opinion that plaintiff could perform "light activity" but Dr. Christensen put some limitations on this "light activity." Specifically, Dr. Christensen opined that plaintiff was "generally functional and capable of at least light activity within the parameters mentioned above."
As for the fact that plaintiff had shoulder surgery in 2016, defendant has argued that there was no reason for the ALJ to bifurcate the assessment of plaintiff's residual functional capacity pre- and post-surgery because plaintiff testified that his limitations were the same both before and after surgery. More specifically, plaintiff testified that he could still not lift his arms after surgery.
The ALJ erred as to Dr. Christensen's opinion. Although the ALJ gave this opinion great weight, she did not include some of the limitations assessed by Dr. Christensen and she failed to give legitimate reasons for not including the assessed limitations.
Plaintiff next argues that the ALJ erred as to Dr. Granholm's opinion. Dr. Granholm was plaintiff's PCP from April 5, 2013 through December 18, 2014. On March 20, 2014, Dr. Granholm opined that plaintiff could not work because he needed surgery and had inadequate pain management, primarily because he could not afford treatment.
Dr. Granholm was a treating physician. Because Dr. Granholm's opinion was contradicted by Dr. Christensen's and Dr. Sklaroff's opinions, the ALJ was required to give specific and legitimate reasons for only giving some weight to Dr. Granholm's opinion.
The ALJ gave some weight to Dr. Granholm's opinion because Dr. Granholm had "a treatment relationship with" plaintiff but did not give it more weight because it "appears to be essentially a record of the claimant's subjective allegations/beliefs."
The court agrees. As plaintiff points out, Dr. Granholm cited to objective medical evidence in support of her opinion. Dr. Granholm noted that plaintiff had rotator cuff tears, limited back range of motion, and leg pain, all of which was documented/supported by a 2013 MRI.
Plaintiff next argues that the ALJ erred as to PA-C Crowley's opinion. On November 2, 2015, Jennifer Crowley, PA-C, opined that plaintiff could lift/carry 5 pounds frequently, lift/carry 50 pounds occasionally, and could occasionally grasp, do fine manipulation, and reach overhead.
The ALJ gave great weight to Crowley's opinion "because it comes from a treating source and is not inconsistent with the other medical evidence of record, which does not document any significant subsequent treatment for associated symptoms."
Defendant again argues that there was no reason for the ALJ to bifurcate the assessment of plaintiff's residual functional capacity because plaintiff testified that his hands/wrists were worse after surgery.
Plaintiff next argues that the ALJ erred as to Dr. Martinez's February 2017 opinion. Dr. Martinez was plaintiff's PCP from August 2, 2015 through November 28, 2017. On February 27, 2017, Dr. Martinez opined that plaintiff could sit less than one hour; stand less than one hour; would need to get up and move around every 15-20 minutes; could occasionally lift/carry 5 pounds; could never/rarely grasp objects, use hands for fine manipulations and overhead reach; would frequently experience pain severe enough to interfere with attention and concentration; would need an unscheduled break every 15-30 minutes; and would miss more than three days of work a month.
Dr. Martinez was a treating physician, whose opinion was contradicted. Thus, the ALJ was required to give specific and legitimate reasons for rejecting his opinion. The ALJ rejected Dr. Martinez's opinion because it was "not consistent with the other evidence of record including a subsequent examination by Dr. Martinez that notes negative findings in key areas. This includes a normal gait and stance, no sensory abnormalities, normal deep tendon reflexes, and normal muscle tone and strength. . . ."
However, the treatment note in question, which is for plaintiff's visit with Dr. Martinez on November 28, 2017, states that on exam, "[t]he cranial nerves were normal, no sensory abnormalities were noted, gait and stance were normal, and the deep tendon reflexes were normal. . . . [T]he muscle tone was normal, and motor strength was normal."
Nonetheless, the ALJ erred as to Dr. Martinez's February 2017 opinion. The ALJ cited to one treatment note from Dr. Martinez in support of her rejection of his February 2017 opinion. One portion of one treatment note is not substantial evidence. The ALJ did not identify any other evidence in the record that was not consistent with Dr. Martinez's opinion. "An ALJ must provide `sufficiently specific reasons' for rejecting the opinion of a treating physician.
Next, plaintiff argues that the ALJ failed to consider Dr. Eule's treatment notes and that by doing so, the ALJ ignored the critical nature of his cervical spine issue prior to his surgery. Plaintiff also seems to suggest that the ALJ should have obtained a residual functional capacity opinion from Dr. Eule since he did plaintiff's cervical spine surgery in 2017.
This argument fails because the ALJ did cite to some of Dr. Eule's treatment notes as well as noting that plaintiff had cervical spine surgery in 2017.
Finally, plaintiff argues that the ALJ erred because she failed to fully and fairly develop the record. "The ALJ in a social security case has an independent `duty to fully and fairly develop the record and to assure that the claimant's interests are considered.'"
Plaintiff argues that the ALJ failed to fully and fairly develop the record because the ALJ failed to order the two consultative exams that Dr. Sklaroff recommended at the 2017 administrative hearing. At that administrative hearing, Dr. Sklaroff testified that plaintiff needed consultative exams by a neurologist and an orthopod in order to determine what limitations he might have as a result of his impairments.
Defendant argues that the ALJ did not fail to fulfill her duty to full and fairly develop the record given that an additional 650 pages of medical evidence came into the record after the 2017 administrative hearing, including treatment records from a neurologist.
While defendant is correct that there was additional medical evidence that came into the record after the 2017 administrative hearing, Dr. Sklaroff testified at the 2018 hearing that there were still gaps in the record. For example, Dr. Sklaroff testified that "you need a workup for" the peripheral neuropathy
Plaintiff requests that this matter be remanded for further proceedings and because of the gaps in the record, such a remand is appropriate here. Plaintiff also requests that the court require that his claim be adjudicated "elsewhere than the Anchorage hearing office."
The decision of the Commissioner is reversed and this matter is remanded for further proceedings.