KENDALL J. NEWMAN, Magistrate Judge.
Plaintiff Ashot Shiboyan seeks judicial review of a final decision by the Commissioner of Social Security ("Commissioner") denying plaintiff's application for Disability Insurance Benefits ("DIB") under Title II of the Social Security Act ("Act").
After carefully considering the record and the parties' briefing, the court GRANTS IN PART plaintiff's motion for summary judgment, DENIES the Commissioner's cross-motion for summary judgment, and REMANDS the action for further administrative proceedings.
Plaintiff was born on March 11, 1954; completed 2 years of college in the United States; speaks Armenian with limited ability to communicate in English; and previously worked as a bus driver and case worker. (Administrative Transcript ("AT") 29, 32-36, 46-47, 200, 202.)
On appeal, plaintiff raises the following issues: (1) whether the ALJ improperly discounted the opinion of plaintiff's treating physician; (2) whether the ALJ failed to properly consider plaintiff's obesity; (3) whether the ALJ erred at step four of the sequential disability analysis; and (4) whether the ALJ improperly discounted plaintiff's credibility.
The court reviews the Commissioner's decision to determine whether (1) it is based on proper legal standards pursuant to 42 U.S.C. § 405(g), and (2) substantial evidence in the record as a whole supports it.
The ALJ evaluated plaintiff's entitlement to DIB pursuant to the Commissioner's standard five-step analytical framework.
Before proceeding to step four, the ALJ assessed plaintiff's RFC as follows:
(AT 12.) At step four, the ALJ determined that plaintiff was capable of performing his past relevant work as a caseworker. (AT 14.) Thus, the ALJ concluded that plaintiff had not been under a disability, as defined in the Act, from November 1, 2013, plaintiff's alleged disability onset date, through August 28, 2015, the date of the ALJ's decision. (AT 15.)
Whether the ALJ improperly discounted the opinion of plaintiff's treating physician
The weight given to medical opinions depends in part on whether they are proffered by treating, examining, or non-examining professionals.
To evaluate whether an ALJ properly rejected a medical opinion, in addition to considering its source, the court considers whether (1) contradictory opinions are in the record; and (2) clinical findings support the opinions. An ALJ may reject an uncontradicted opinion of a treating or examining medical professional only for "clear and convincing" reasons.
In this case, the ALJ provided several specific and legitimate reasons for discounting the opinion of plaintiff's treating physician, Dr. Michael Bass, who suggested, inter alia, that plaintiff could only stand and walk for 1-2 hours per day, sit for less than 1 hour a day, lift a maximum of 5-10 pounds, concentrate sufficiently to perform simple tasks less than 50% of the day, and would be absent from work more than 4 days per month. (AT 282-85, 313-14.)
As an initial matter, Dr. Bass's opinion is brief, conclusory, and unsupported by any detailed clinical findings or rationale. (AT 13.) Given the severity of the opinion, one would expect greater substantiation and justification for the extreme limitations assessed. As such, the ALJ permissibly gave the opinion little weight.
Additionally, the ALJ rationally observed that Dr. Bass's opinion was inconsistent with the imaging studies. (AT 13.) For example, a March 31, 2014 x-ray of the lumbar spine was essentially normal, except for "slight narrowing of the disc space at L3-4 where there are anterior osteophytes" suggestive of degenerative disc disease at L3-4. (AT 281.) A subsequent x-ray performed on October 2, 2014, revealed some "degenerative changes of the lower thoracic spine with bridging osteophytes," but was ultimately described by the radiologist as unremarkable. (AT 317-18.) Such mild objective findings are not what one would expect from a person who allegedly has disabling functional limitations.
Furthermore, the ALJ reasonably relied on the opinion of consultative examiner and board certified orthopedic surgeon, Dr. Dale Van Kirk, who reviewed plaintiff's medical records, personally examined plaintiff on March 29, 2014, and prepared a detailed report of his clinical findings. (AT 273-80.) Dr. Van Kirk opined that plaintiff could lift and carry 20 pounds occasionally and 10 pounds frequently; stand and walk for up to 6 hours a day; sit without restriction; and climb, balance, stoop, kneel, crouch, and crawl occasionally. He should not be required to work in extremely cold and/or damp environments. (AT 278-79.) Because Dr. Van Kirk is an orthopedic specialist who personally examined plaintiff and made independent clinical findings, his opinion unquestionably constitutes substantial evidence on which the ALJ was entitled to rely.
Finally, the ALJ properly relied on the opinions of the state agency physicians, who essentially opined that plaintiff was capable of performing light work with postural limitations. (AT 58-59, 71-73.)
Therefore, the court finds that the ALJ's evaluation of Dr. Bass's opinion is supported by the record and by the proper analysis.
Plaintiff's argument that the ALJ failed to properly consider plaintiff's obesity lacks merit. At step two, the ALJ specifically calculated plaintiff's body mass index and listed plaintiff's obesity as a severe impairment. (AT 11.) There is no reason to believe that the ALJ did not consider all of plaintiff's impairments, severe and non-severe, in formulating the RFC, and plaintiff fails to point to any specific functional limitation attributable to plaintiff's obesity that was omitted from the RFC. Indeed, although consultative examiner and orthopedic specialist Dr. Van Kirk expressly noted that plaintiff was "markedly overweight," he still opined that plaintiff was capable of performing essentially light work with postural limitations. (AT 276, 278-79.) As such, plaintiff's obesity was properly considered.
A claimant is deemed not disabled at step four if he is found capable of performing his past work either as actually performed or as generally performed in the national economy. 20 C.F.R. § 404.1560(b)(2). Here, the ALJ found that plaintiff was capable of performing plaintiff's past relevant work of caseworker as he actually performed it. (AT 15.) However, at the hearing, plaintiff testified that he actually had to lift items weighing up to 70-80 pounds as part of that job, and the VE testified that plaintiff would consequently not be able to do his past work as actually performed. (AT 34-35, 44, 48.)
The Commissioner posits that any such error was harmless, because the VE testified that plaintiff could nonetheless do his prior work as generally performed in the national economy. (AT 47.) However, the VE also testified that the position of caseworker, as generally performed in the economy, had a specific vocational profile ("SVP") of 7, which would at least arguably be inconsistent with the findings of the consultative psychiatrist, Dr. Michael Zoglio, who opined that plaintiff may have low to borderline intellectual functioning: "The claimant would probably have difficulty managing his funds. I do not think he seems to have the intellectual capacity to write checks and do his bank account." (AT 291.) To be sure, Dr. Zoglio's opinion is somewhat ambiguous; despite ostensibly finding low to borderline intellectual functioning, he also opined that plaintiff could perform simple and repetitive tasks without limitation and was only mildly limited in completing detailed and complex tasks. (AT 292.) However, the ALJ never addressed and resolved those ambiguities, and instead purported to give substantial weight to Dr. Zoglio's opinion, but without incorporating any specific mental limitations into the RFC. Such unresolved ambiguities and inconsistencies preclude the court from finding harmless error at step four.
Therefore, the court finds it appropriate to remand the action for further administrative proceedings. On remand, the ALJ shall give further consideration to Dr. Zoglio's opinion and whether any additional mental limitations should be incorporated into the RFC. After such clarification, the ALJ shall also reconsider his step four determination, and if necessary, proceed to step five of the sequential disability analysis, utilizing supplemental vocational expert testimony as appropriate. The ALJ is also free to develop the record in any other respects deemed appropriate. Importantly, the court does not instruct the ALJ to credit any particular opinion or evidence on remand. Indeed, the court expresses no opinion regarding how the evidence should ultimately be weighed, and any ambiguities or inconsistencies resolved, at any particular step on remand, provided that the ALJ's decision is based on proper legal standards and supported by substantial evidence in the record as a whole.
The court declines to reach the issue of plaintiff's credibility at this juncture. On remand, the ALJ will have an opportunity to re-examine his credibility findings on the supplemented record, if appropriate.
For the foregoing reasons, IT IS HEREBY ORDERED that:
1. Plaintiff's motion for summary judgment (ECF No. 18) is GRANTED IN PART.
2. The Commissioner's cross-motion for summary judgment (ECF No. 23) is DENIED.
3. The Commissioner's final decision is REVERSED, and the action is REMANDED for further administrative proceedings consistent with this order pursuant to sentence four of 42 U.S.C. § 405(g).
4. The Clerk of Court shall close this case.
The claimant bears the burden of proof in the first four steps of the sequential evaluation process.
