KENDALL J. NEWMAN, Magistrate Judge.
Plaintiff seeks judicial review of a final decision of the Commissioner of Social Security ("Commissioner") denying plaintiff's application for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") under Titles II and XVI, respectively, of the Social Security Act ("Act").
Plaintiff was born on July 26, 1963, has a limited eleventh grade education, is able to communicate in English, and previously worked in various positions in the construction industry.
In a decision dated May 13, 2010, the ALJ determined that plaintiff had not been under a disability, as defined in the Act, from September 30, 2005, through the date of that decision. (AT 14-26.) The ALJ's decision became the final decision of the Commissioner when the Appeals Council denied plaintiff's request for review on January 20, 2012. (AT 1-6.) Thereafter, plaintiff filed this action in federal district court on March 14, 2012, to obtain judicial review of the Commissioner's final decision. (ECF No. 1.)
Plaintiff has raised the following issues: (1) whether the ALJ erred in not finding plaintiff's shoulder impairments to be severe at step two of the sequential evaluation process; (2) whether the ALJ improperly weighed the medical opinion evidence; (3) whether the ALJ improperly discounted plaintiff's credibility and subjective complaints; and (4) whether the ALJ erred in failing to obtain testimony by a vocational expert.
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 and SSI pursuant to the Commissioner's standard five-step analytical framework.
Before proceeding to step four, the ALJ assessed plaintiff's residual functional capacity ("RFC"), finding that plaintiff was capable of performing sedentary work with additional limitations to simple repetitive tasks and limited public contact. (AT 18.) At step four, the ALJ found that plaintiff was unable to perform any past relevant work. (AT 25.) Finally, at step five, the ALJ determined, in reliance on the "Grids" (
Accordingly, the ALJ concluded that plaintiff had not been under a disability, as defined in the Act, from September 30, 2005, through the date of the ALJ's decision. (AT 26.)
Under the Commissioner's regulations, an impairment or combination of impairments is deemed to be severe at step two if it "significantly limits your physical or mental ability to do basic work activities." 20 C.F.R. §§ 404.1520(c), 404.1521(a). As the Ninth Circuit Court of Appeals has explained, "the step-two inquiry is a de minimis screening device to dispose of groundless claims. An impairment or combination of impairments can be found not severe only if the evidence establishes a slight abnormality that has no more than a minimal effect on an individual's ability to work."
In this case, the ALJ provided no meaningful explanation as to why he found that plaintiff's shoulder impairments had no more than a minimal effect on plaintiff's ability to work. Although the Commissioner argues that plaintiff has offered no objective evidence regarding shoulder impairments apart from his subjective complaints, there are numerous references to plaintiff's prior rotator cuff surgeries in the medical records. (
However, even if the ALJ technically erred at step two by not finding plaintiff's shoulder impairments to be severe, such error may nonetheless be harmless if the ALJ proceeded to consider the effects of that impairment at subsequent steps.
Plaintiff primarily contends that the ALJ improperly relied on the opinions of the consultative examining physicians to reject the opinion of plaintiff's treating physician, Dr. David McKinney, with respect to plaintiff's physical limitations.
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, on December 17, 2006, plaintiff underwent a consultative examination by board certified internal medicine specialist, Dr. Mustafa Ammar, who did not review plaintiff's prior treatment records. (AT 267-70.) Plaintiff chief complaints were noted to be back pain, shoulder pain, and right hip pain, and plaintiff also described a history of fainting episodes with heat, a heart attack, and a mild stroke resulting in residual problems with memory, focus, and concentration. (AT 267.) Plaintiff stated that he could not do anything at home and mostly watched television. (
Dr. Ammar diagnosed plaintiff with a history of degenerative disease of the lower back with back pain; a history of bilateral shoulder pain status post surgical repair for rotator cuff injury; a history of right hip pain; and a history of mild heart attack and mild stroke with memory problems. (AT 270.) He opined that plaintiff could stand and walk for about 6 hours in an 8-hour workday (with more frequent breaks due to low back and right hip pain); sit for 6 hours in an 8-hour workday; lift and carry 20 pounds frequently and occasionally due to low back and shoulder pain; only occasionally bend, stoop, and crouch; and that plaintiff did not need an assistive device. (
On October 19, 2007, Dr. David McKinney completed a treating source statement and RFC evaluation form. (AT 321-24.) Based on a physical examination of plaintiff, a review of plaintiff's medical records, and plaintiff's surgical history, Dr. McKinney diagnosed plaintiff with lumbar stenosis and radiculopathy, coronary heart disease, bipolar disorder, and bilateral rotator cuff repair with chronic shoulder impingement, noting that plaintiff experienced symptoms of daily lumbar pain and pain with any overhead lifting. (AT 321.) He rated plaintiff's pain as 7 or 8 out of 10 chronically, and 9 to 10 out of 10 at worst, noting that plaintiff's pain complaints were credible and that plaintiff was at that time treated with medication, including 4-6 Vicodins per day, and lumbar spine epidural injections. (AT 324.)
Dr. McKinney opined that plaintiff could occasionally lift 6-10 pounds to his chest and rarely lift 6-10 pounds overhead; rarely lift overhead with either hand/arm; stand/walk for 10-15 minutes at a time for 4-5 times a day; sit for 15 minutes at a time for a total of 8 hours in a day; and occasionally bend, but never climb, balance, stoop, crouch, crawl, or kneel. (AT 322-23.) In support of his assessment, Dr. McKinney relied on his physical examination, findings of nerve impingement of L3 and moderate to severe canal stenosis at L4-L5 as shown by a May 11, 2007 CT scan of the lumbar spine, findings of bilateral degenerative hip arthritis, and plaintiff's prior two rotator cuff repair surgeries. (
Finally, on March 25, 2010, plaintiff was evaluated for his orthopedic concerns by Dr. R. Kelley Otani, a diplomate of the American Board of Physical Medicine and Rehabilitation. (AT 413-15.) Dr. Otani reviewed some of plaintiff's prior records, including Dr. Ammar's December 17, 2006 assessment; x-rays taken on April 13, 2007; and certain treatment notes from 2009. (AT 414.) Plaintiff reported that he was independent in terms of mobility and activities of daily living, but that he used a right-handed single point cane for long distances. (AT 413.) Upon physical examination, Dr. Otani found decreased lumbar lordosis, increased pain and sensitivity with axial loading and palpation of plaintiff's lumbar spine, and limited range of motion in plaintiff's shoulders and hips. (AT 414.) A straight leg raise test was positive on the right to 10 degrees and the left to 30 degrees, but plaintiff was able to "long sit" when distracted. (
Dr. Otani diagnosed plaintiff with low back pain with degenerative disk disease (as shown by the x-rays); degenerative osteoarthritis in the hips, bipolar disorder, hypercholesteromia, and bilateral rotator cuff surgery (with the right shoulder in 1997 and the left shoulder in 2003). (AT 414-15.) He noted that plaintiff did not have focal neurologic findings or evidence of a radicular component with regards to his pain symptomatology, and observed that there were non-physiologic inconsistencies in the physical examination, with subjective complaints that appeared to be greater than the objective findings. (AT 415.) Dr. Otani opined that plaintiff could sit for 1 hour at a time for a total of 6 hours in an 8-hour day; stand for 45 minutes at a time for a total of 2 hours in an 8-hour day; and lift/carry 20 pounds occasionally and 10 pounds frequently. (
The ALJ, in according minimal weight to treating physician Dr. McKinney's opinion, primarily relied on the opinions of the consultative examiners, and in particular the opinion of Dr. Otani. (AT 24.) Because Dr. Otani and Dr. Ammar both personally examined plaintiff and conducted thorough evaluations based on their examinations, resulting in independent clinical findings, their opinions would ordinarily constitute substantial evidence.
Nevertheless, the court finds that the opinions of Dr. Otani and Dr. Ammar here cannot qualify as substantial evidence to support the ALJ's assessment of plaintiff's functional limitations, because these examiners did not have access to all of plaintiff's pertinent medical records, and in particular, the May 11, 2007 CT scan of plaintiff's lumbar spine on which Dr. McKinley heavily relied in his assessment. Unlike the April 13, 2007 x-rays and a December 10, 2007 lumbar spine MRI, which were reviewed by Dr. Otani and contained mostly mild to moderate findings, the May 11, 2007 CT scan of plaintiff's lumbar spine contained more severe findings. (AT 304-05, 397, 414.) In particular, that CT scan contained the following impression:
(AT 304.)
The regulations require that a consultative examiner be given any necessary background information about the plaintiff's condition. 20 C.F.R. § 404.1517. Background information is essential because consultative exams are used to try to resolve inconsistencies or ambiguities in the evidence. 20 C.F.R. § 404.1519a(b). An opinion on a documented medical problem given after only a one-shot examination, without recourse to the plaintiff's available medical records, is not one which can generally be relied upon. This conclusion is especially true when the medical records contain results from important objective tests, such as the above-mentioned CT scan, which the treating physician used to support his opinion.
Although the May 11, 2007 CT scan was only performed after Dr. Ammar examined plaintiff on December 17, 2006, there is no indication that the CT scan results were somehow unavailable at the time of Dr. Otani's examination on March 25, 2010. The May 11, 2007 CT scan results, on which Dr. McKinney heavily relied in his assessment, were more severe than the other objective test results on which Dr. Otani relied, suggesting, for example, that there may be possible impingement of nerve roots. Dr. Otani and Dr. Ammar did not have access to the May 11, 2007 CT scan results, and it is unclear how these examiners would have weighed the potentially conflicting objective test results. Importantly, the court cannot independently determine whether and/or how review of those results would have changed Dr. Otani's and Dr. Ammar's opinions, if at all, with respect to plaintiff's functional limitations.
Accordingly, remand for a consultative evaluation by an examining orthopedic specialist, or other appropriate health professional, with full access to plaintiff's prior treatment records and objective test results, is necessary to adjudicate plaintiff's claims. Depending on the results of the consultative examination, the ALJ may also consider conducting a supplemental hearing with vocational expert testimony regarding any limitations found, if necessary.
Plaintiff requests that the case be remanded for payment of benefits. However, an award of benefits is only appropriate where "no useful purpose would be served by further administrative proceedings," "the record has been thoroughly developed," and "there are no outstanding issues that must be resolved before a proper disability determination can be made."
Therefore, the court finds that the better course of action is to remand the case for further proceedings as outlined above. Indeed, the court expresses no opinion regarding the weight ultimately to be given to any particular evidence on remand, and leaves it to the sound discretion of the ALJ to evaluate the record as a whole within the confines of the applicable law.
In light of the court's conclusion that the case should be remanded for further development of the medical opinion evidence, the court declines to address plaintiff's remaining issues regarding plaintiff's credibility and vocational expert testimony at this time. Upon remand, the ALJ will have an opportunity to consider whether his analysis regarding plaintiff's credibility should or should not be revised in light of further development of the record, and whether vocational expert testimony is appropriate, subjects on which the court expresses no opinion here.
For the foregoing reasons, IT IS HEREBY ORDERED that:
1. Plaintiff's motion for summary judgment (ECF No. 15) is GRANTED IN PART.
2. The Commissioner's cross-motion for summary judgment (ECF No. 18) is DENIED.
3. The action is REMANDED for further proceedings consistent with this order pursuant to sentence four of 42 U.S.C. § 405(g).
4. Judgment is entered for plaintiff.
5. The Clerk of Court is directed to close this case and vacate all dates.
The claimant bears the burden of proof in the first four steps of the sequential evaluation process.