DOUGLAS F. McCORMICK, Magistrate Judge.
Plaintiff Deborah Carmen Williams ("Plaintiff") appeals from the final decision of the Administrative Law Judge ("ALJ") denying her application for Social Security disability insurance benefits. The Court concludes that the ALJ erred by discounting the opinion of Plaintiff's treating physician without providing specific and legitimate reasons. Accordingly, the ALJ's decision is reversed and the matter is remanded for further proceedings consistent with this opinion.
Plaintiff filed her application for benefits on August 17, 2010, alleging disability beginning June 30, 2009. Administrative Record ("AR") 26. The ALJ found that Plaintiff had the severe impairments of right carpal tunnel syndrome and complaints of neck and back pain. AR 28. Notwithstanding these severe impairments, the ALJ determined that Plaintiff retained the residual functional capacity ("RFC") to perform a full range of light work. AR 29. The ALJ concluded that Plaintiff was not disabled because there was work available in the national economy in significant numbers that she could perform despite her impairments. AR 37.
The parties dispute whether the ALJ erred in: (1) evaluating and weighing the opinion of Plaintiff's treating physician; and (2) assessing Plaintiff's credibility.
Plaintiff contends that the ALJ erred in failing to give controlling weight to the opinion of her treating orthopedist, Dr. Rajiv Puri. JS at 4-12. Plaintiff was injured on the job in May 2007 while working as a truck driver. AR 367. Plaintiff began treatment with Dr. Puri in March 2008 due to back and right shoulder pain caused by the work injury. AR 373-440.
The ALJ rejected Dr. Puri's opinion as follows:
AR 35.
An ALJ should generally give more weight to a treating physician's opinion than to opinions from non-treating sources.
Considering the record as a whole, including the medical records submitted by Plaintiff to the Appeals Council, the Court finds that the ALJ did not provide specific and legitimate reasons for rejecting Dr. Puri's opinion. First, the ALJ's conclusion that Dr. Puri "did not have a longitudinal treatment record" is belied by the treatment records submitted to the Appeals Council. These records demonstrate that Plaintiff saw Dr. Puri on a fairly regular basis for treatment of back and shoulder pain from March 2008 to March 2009.
Second, the ALJ's conclusion that Dr. Puri relied solely upon Plaintiff's "subjective complaints and history" in reaching his opinion is not supported by the evidence when the medical records submitted by Plaintiff to the Appeals Council are considered. In August 2008, Dr. Puri found that Plaintiff had "limited" range of motion in her right shoulder. AR 399. A month later, Dr. Puri's notes reflect that an MRI of Plaintiff's right shoulder "shows tendonitis" and a cortisone injection was administered. AR 395.
Third, the fact that Plaintiff did not report shoulder pain to her medical providers for more than a year after Dr. Puri's March 2009 evaluation does not undermine Dr. Puri's opinion. Rather, this fact seems more probative of Plaintiff's credibility than the weight to give Dr. Puri's opinion.
Finally, the ALJ stated that Dr. Puri did not intend for the limitations he imposed in his March 9, 2009 report to last more than 12 months. However, the Court cannot determine whether Dr. Puri intended the limitations to be temporary or permanent. All of the other work injury status reports prepared by Dr. Puri include a notation that Plaintiff is "totally temporar[ily] disabled until next exam," with a follow up date four weeks later.
Moreover, the Court cannot conclude that the ambiguity about whether Dr. Puri intended Plaintiff's lifting and reaching limitations to last at least 12 months is inconsequential to the ultimate issue of disability. The examining physician, Dr. Enriquez, provided similar lifting and reaching limitations in June 2011, more than two years later.
Nor can the Court conclude that any error is harmless. If the ALJ credited Dr. Puri's and Dr. Enriquez's reaching limitations, then Plaintiff would not be able to perform the job of home health care companion, an occupation identified by the vocational expert as compatible with Plaintiff's RFC, because that job requires frequent reaching.
In sum, the Court finds that the reasons offered by the ALJ for rejecting the opinion of Plaintiff's treating physician are not specific and legitimate, especially in light of the additional records submitted to the Appeals Council. The decision whether to remand for further proceedings is within this Court's discretion.
A remand is appropriate, however, where there are outstanding issues that must be resolved before a determination of disability can be made and it is not clear from the record that the ALJ would be required to find the claimant disabled if all the evidence were properly evaluated.
For the reasons stated above, the decision of the Social Security Commissioner is REVERSED and the action is REMANDED for further proceedings consistent with this opinion.