ALLISON CLAIRE, Magistrate Judge.
Plaintiff seeks judicial review of a final decision of the Commissioner of Social Security ("Commissioner"), denying her application for disability insurance benefits ("DIB") under Title II of the Social Security Act ("the Act"), 42 U.S.C. §§ 401-34.
Plaintiff protectively filed an application for DIB on June 8, 2011.
On August 30, 2013, the ALJ found plaintiff "not disabled" under Sections 216(i) and 223(d) of Title II of the Act, 42 U.S.C. §§ 416(i), 423(d). AR 12-21 (decision), 22-25 (exhibit list). On March 25, 2015, after receiving a Representative Brief as an additional exhibit, the Appeals Council denied plaintiff's request for review, leaving the ALJ's decision as the final decision of the Commissioner of Social Security. AR 1-4 (decision and additional exhibit list).
Plaintiff filed this action on April 30, 2015. ECF No. 1; see 42 U.S.C. § 405(g). The parties consented to the jurisdiction of the magistrate judge. ECF Nos. 8, 9. The parties' cross-motions for summary judgment, based upon the Administrative Record filed by the Commissioner, have been fully briefed. ECF Nos. 14 (plaintiff's summary judgment motion), 16 (Commissioner's summary judgment motion), 18 (plaintiff's reply).
Plaintiff was born on September 1, 1962. AR 19. Plaintiff worked as a kitchen manager from 2000 to 2010, and as a home attendant before that. AR 19, 47, 247. Plaintiff was, at age 47, a "younger person" under the regulations, when she filed her application for DIB.
The Commissioner's decision that a claimant is not disabled will be upheld "if it is supported by substantial evidence and if the Commissioner applied the correct legal standards."
Substantial evidence is "more than a mere scintilla," but "may be less than a preponderance."
"The ALJ is responsible for determining credibility, resolving conflicts in medical testimony, and resolving ambiguities."
The court will not reverse the Commissioner's decision if it is based on harmless error, which exists only when it is "clear from the record that an ALJ's error was `inconsequential to the ultimate nondisability determination.'"
Disability Insurance Benefits and Supplemental Security Income are available for every eligible individual who is "disabled." 42 U.S.C. §§ 402(d)(1)(B)(ii) (DIB), 1381a (SSI). Plaintiff is "disabled" if she is "`unable to engage in substantial gainful activity due to a medically determinable physical or mental impairment. . . .'"
The Commissioner uses a five-step sequential evaluation process to determine whether an applicant is disabled and entitled to benefits. 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4);
20 C.F.R. § 404.1520(a)(4)(i), (b).
The claimant bears the burden of proof in the first four steps of the sequential evaluation process. 20 C.F.R. §§ 404.1512(a) ("In general, you have to prove to us that you are blind or disabled"), 416.912(a) (same);
The ALJ made the following findings:
AR 14-20 (excerpted).
As noted, the ALJ concluded that plaintiff was "not disabled" under Sections 216(i) and 223(d) of Title II of the Act, 42 U.S.C. §§ 416(i), 423(d). AR 21.
Plaintiff argues that the ALJ erred by rejecting the opinions of two treating doctors and two reviewing doctors, who all concurred that plaintiff was limited to sedentary or less than sedentary work, and finding to the contrary that plaintiff could engage in light work. Plaintiff requests that the matter be remanded to the Commissioner for additional proceedings.
"To reject [the] uncontradicted opinion of a treating or examining doctor, an ALJ must state clear and convincing reasons that are supported by substantial evidence."
Lyudmila V. Salomalina, M.D., was a treating doctor.
The ALJ gave this opinion "little weight" because it is "conclusory in nature providing no objective evidence to support [the] opinion." AR 19. This was not error.
The opinion of a treating doctor is generally given special weight — and under certain circumstances, is "controlling" — because a treating doctor is in a unique position to know the plaintiff as an individual, and because the continuity of such a doctor's dealings with plaintiff enhances her ability to obtain a "longitudinal" assessment of plaintiff's problems.
However, those reasons do not apply to Dr. Salomalina's opinion. As discussed above, Dr. Salomalina examined plaintiff only once, on December 3, 2012. The second time Dr. Salomalina saw plaintiff, there is no evidence that she examined plaintiff, reviewed any laboratory or clinical tests, or did anything other than receive plaintiff's own "report" of her condition, and complete a check-off form. Nothing in the record indicates how Dr. Salomalina even reached most of her diagnoses of plaintiffs' conditions. The court could possibly infer that the diagnosis of back pain was reached after a physical examination, since the doctor reports that plaintiff had "tenderness and spasm of her paralumbar area." However, there is no indication that any examination, or even observation, of plaintiff's joints or left foot was carried out. In addition, Dr. Salomalina does nothing to connect plaintiff's alleged conditions — back pain, joint pain and left foot pain — to the limitations she checked off on the March 2013 form, nor to her conclusion that plaintiff could only do "less than sedentary" work.
Given the conclusory nature of Dr. Salomalina's opinion, and its lack of support, the ALJ did not err in rejecting it:
Joanne Mu Chao, M.D. is another treating physician, and specializes in orthopedics. AR 319-408. Dr. Chao examined and treated plaintiff, and ordered lab tests, on November 2, 2010, and limited plaintiff to "Sit down work; Patient may stand and walk with cane 5 minutes per hour," through November 30, 2010. AR 323, 385-90, 405-08. Dr. Chao examined and treated plaintiff, and ordered lab tests, on November 18, 2010, and limited plaintiff to "Sit down work; Patient may stand or walk with cane 10 minutes per hour," through January 3, 2011. AR 335, 404. Dr. Chao examined and treated plaintiff on December 14, 2010, and recommended surgery ("knee arthoscopy"), scheduled for December 27, 2010, with an "expected return to usual activities at about 6 weeks post op. . . ." AR 351. Dr. Chao examined and treated plaintiff on January 6, 2011, for a "postoperative exam." AR 356. She placed plaintiff on "Sit down work; May stand walk 10 minutes at a time with cane," with a return to "full duty" date of February 7, 2011. AR 358. Dr. Chao referred plaintiff to physical therapy on January 6, 2011. AR 361.
The ALJ decision does not mention Dr. Chao, nor any of her opinions, lab tests or clinical findings. Plaintiff argues that this was error. ECF No. 14-1 at 14. Defendant argues that the ALJ was not required to discuss Dr. Chao's opinion because it was "not probative of [plaintiff's] long-term condition and fail[ed] to reflect the effects of the surgery." ECF No. 16 at 10. Dr. Chao never opines that plaintiff's limitations — even if measured from the alleged onset date of June 3, 2010 — have lasted more than 12 months or that they are expected to last for 12 months. See 20 C.F.R. § 404.1509 ("Unless your impairment is expected to result in death, it must have lasted or must be expected to last for a continuous period of at least 12 months. We call this the duration requirement."). To the contrary, Dr. Chao's opinion is that plaintiff's impairment was expected to be resolved by February 2011, which is less than 12 months from the alleged onset date of June 3, 2010. Plaintiff identifies no evidence in the record showing that despite Dr. Chao's expectation, the impairments lasted beyond the 12 month period starting June 3, 2010.
Therefore even if it was error to fail to mention Dr. Chao's opinion, it was harmless error, since this opinion does not provide evidence of plaintiff's disability for a 12 month period (even if combined with other opinions).
Plaintiff very briefly mentions that in July 2011, plaintiff "was ordered to remain `off work.'" ECF No. 14-1 at 16. This mention is not connected to any argument plaintiff makes, but plaintiff may mean to argue that this is evidence that plaintiff's limitations continued into July 2011, providing the 12-month period of disability. Indeed, a treating doctor, Robert Walker, D.C. ("Specialty: Chiropractic"), examined plaintiff on July 8, 2011, and instructed plaintiff to "Remain off-work." AR 432. This very general instruction, however, does not provide evidence that any of the specific limitations identified by Dr. Chao (or even by Dr. Salomalina) were still in effect in July 2011. Rather, this is evidence only that Dr. Walker believed plaintiff could not return to work, which at the time was performed at the "medium" exertional level. See AR 19 (past relevant work was kitchen manager and home attendant, and both were at the "medium" exertional level). The ALJ already incorporated this restriction into his RFC, where he found that plaintiff "is unable to perform past relevant work," and that she could only perform work at the "light" exertional level. AR 19.
The ALJ did not err by failing to mention this opinion, since it does not provide evidence of plaintiff's disability.
On August 4, 2011, P.N. Ligo, M.D., a state agency reviewing doctor, reviewed plaintiff's Medical Evidence of Record ("MER") for the period from November 23, 2009 through June 9, 2011. AR 59-60. Dr. Ligo's RFC for plaintiff states that plaintiff can never lift more than 10 pounds, can stand/walk for no longer than 2 hours, has limited left overhead reaching, has limited push/pull capability, must avoid concentrated exposure to extreme cold, and must avoid even moderate exposure to "hazards" such as machinery and heights. AR 61-63.
The ALJ gave these opinions "reduced weight" to the extent they conflict with his own RFC, because "these opinions are not based upon direct examination and are inconsistent with the evidence of record as a whole." AR 19. On appeal the Commissioner argues that "the ALJ properly discounted" the reviewing doctors' opinions because they "did not have a chance to evaluate Plaintiff personally" and because "the evidence of record as a whole failed to support their opinions." The court rejects the Commissioner's surprising argument that the state agency doctors' opinions should be given "reduced weight" because they are "not based upon direct examination." The Commissioner's own rules require the ALJ to consider the opinion of non-examining state agency doctors, and those rules already account for the fact that those doctors do not have an examining or treating relationship with the plaintiff. The Commissioner's rules provide that "because nonexamining sources have no examining or treating relationship with you, the weight we will give their opinions will depend on the degree to which they provide supporting explanations for their opinions." 20 C.F.R. § 404.1527(c)(3) (emphasis added);
The ALJ also gave the agency doctors' opinions "reduced weight" because they were "inconsistent with the evidence of record as a whole." AR 19. However, the ALJ does not explain what evidence he is referring to. Moreover, the ALJ decision makes no reference to any evidence that would explain why the ALJ's RFC should be accepted over the state agency doctors' RFC. Specifically, it identifies no evidence to support the ALJ's conclusion that plaintiff can lift 20 pounds occasionally, rather than 10 pounds; why plaintiff can walk/stand for 6 hours rather than 2 hours; why she has no push/pull limitations; why she has no limited overhead reaching with the left upper extremity limitations; and why she has no environmental limitations. Indeed, none of these limitations are discussed in the ALJ's decision except to indicate that they are rejected.
Finally, the ALJ identifies no medical source opinions that contradict the state agency doctors' opinions, nor which state that the limitations the ALJ adopted are correct. Indeed, it is not clear how the ALJ's decision arrived at the RFC it did, given that it fails to discuss, or even identify, any medical source opinion that supports that RFC.
In short, the ALJ erred in rejecting, or giving "reduced weight," to the state agency doctors' opinions. This error is not harmless, because if the ALJ had credited those opinions, plaintiff would not be able to perform the jobs identified by the Vocational Expert that were otherwise available:
AR 54-55.
Plaintiff requests that this matter be remanded to the Commissioner for additional proceedings. ECF No. 14-1 at 23. That is the correct remedy here. Even if the agency doctors are correct about plaintiffs' limitations, it has not been established that there are no jobs available that plaintiff could do, but rather, that she could not do the ones that the Vocational Expert specified at the hearing.
For the reasons set forth above, IT IS HEREBY ORDERED that:
1. Plaintiff's motion for summary judgment (ECF No. 14), is GRANTED;
2. The Commissioner's cross-motion for summary judgment (ECF No. 16), is DENIED;
3. This matter is REMANDED to the Commissioner under sentence four of 42 U.S.C. § 405(g), for further proceedings consistent with this decision; and
4. The Clerk of the Court shall enter judgment for plaintiff, and close this case.