MARIAN W. PAYSON, United States Magistrate Judge.
Plaintiff Rachael Marie Gualano ("Gualano") brings this action pursuant to Section 205(g) of the Social Security Act, 42 U.S.C. § 405(g), seeking judicial review of a final decision of the Commissioner of Social Security (the "Commissioner") denying her application for Supplemental Security Income Benefits ("SSI"). Pursuant to the Standing Order of the United States District Court for the Western District of New York regarding Social Security cases dated June 1, 2018, this case has been reassigned to, and the parties have consented to the disposition of this case by, the undersigned. (Docket # 16).
Currently before the Court are the parties' motions for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure. (Docket ## 9, 14). For the reasons set forth below, I hereby vacate the decision of the Commissioner and remand this claim for further administrative proceedings consistent with this decision.
This Court's scope of review is limited to whether the Commissioner's determination is supported by substantial evidence in the record and whether the Commissioner applied the correct legal standards. See Butts v. Barnhart, 388 F.3d 377, 384 (2d Cir. 2004) ("[i]n reviewing a final decision of the Commissioner, a district court must determine whether the correct legal standards were applied and whether substantial evidence supports the decision"), reh'g granted in part and denied in part, 416 F.3d 101 (2d Cir. 2005);
To determine whether substantial evidence exists in the record, the court must consider the record as a whole, examining the evidence submitted by both sides, "because an analysis of the substantiality of the evidence must also include that which detracts from its weight." Williams ex rel. Williams v. Bowen, 859 F.2d 255, 258 (2d Cir. 1988). To the extent they are supported by substantial evidence, the Commissioner's findings of fact must be sustained "even where substantial evidence may support the claimant's position and despite the fact that the [c]ourt, had it heard the evidence de novo, might have found otherwise." Matejka v. Barnhart, 386 F.Supp.2d 198, 204 (W.D.N.Y. 2005) (citing Rutherford v. Schweiker, 685 F.2d 60, 62 (2d Cir. 1982), cert. denied, 459 U.S. 1212, 103 S.Ct. 1207, 75 L.Ed.2d 447 (1983)).
A person is disabled for the purposes of SSI and disability benefits if he or she is unable "to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." 42 U.S.C. §§ 423(d)(1)(A) & 1382c(a)(3)(A). When assessing whether a claimant is disabled, the ALJ must employ a five-step sequential analysis. See Berry v. Schweiker, 675 F.2d 464, 467 (2d Cir. 1982) (per curiam). The five steps are:
20 C.F.R. §§ 404.1520(a)(4)(i)-(v) & 416.920(a)(4)(i)-(v); Berry v. Schweiker, 675 F.2d at 467. "The claimant bears the burden of proving his or her case at steps one through four[;] ... [a]t step five the burden shifts to the Commissioner to `show there is other gainful work in the national
Gualano contends that the ALJ's determination that she is not disabled is not supported by substantial evidence and is the product of legal error. (Docket ## 9-1, 15). In his decision, the ALJ determined that Gualano retained the RFC to perform light work involving simple, routine tasks requiring only simple work-related decisions and occasional contact with supervisors and coworkers, but was unable to perform positions requiring tandem work, contact with the public, assembly lines or conveyor belts. (Tr. 20). Gualano challenges this determination on the grounds that the ALJ failed to properly apply the treating physician rule to the opinion rendered by her licensed mental health therapist Cortney Bota ("Bota"), which was cosigned by her treating psychiatrist, Viktor Yatsynovich ("Yatsynovich"), MD. (Docket ## 9-1 at 12-22; 15 at 1-4). According to Gualano, the ALJ treated the opinion as one from an unacceptable medical source rather than from a treating psychiatrist. (Id.). Further, Gualano maintains that the ALJ failed to consider the requisite factors in determining to give the opinion "little weight" and failed to provide good reasons for discounting the opinion. (Id.). Gualano also contends that the ALJ's RFC assessment is not supported by any of the medical opinions contained in the record. (Docket ## 9-1 at 23-28; 15 at 5-6). Finally, Gualano challenges the ALJ's RFC determination on the grounds that he failed to evaluate an opinion submitted by her primary care physician Sami A. Raphael ("Raphael"), MD. (Docket ## 9-1 at 28-29; 15 at 6-7).
An individual's RFC is his or her "maximum remaining ability to do sustained work activities in an ordinary work setting on a regular and continuing basis." Melville v. Apfel, 198 F.3d 45, 52 (2d Cir. 1999) (quoting SSR 96-8p, 1996 WL 374184, *2 (July 2, 1996)). When making an RFC assessment, the ALJ should consider "a claimant's physical abilities, mental abilities, symptomology, including pain and other limitations which could interfere with work activities on a regular and continuing basis." Pardee v. Astrue, 631 F.Supp.2d 200, 221 (N.D.N.Y. 2009) (citing 20 C.F.R. § 404.1545(a)). "To determine RFC, the ALJ must consider all the relevant evidence, including medical opinions and facts, physical and mental abilities, non-severe impairments, and [p]laintiff's subjective evidence of symptoms." Stanton v. Astrue, 2009 WL 1940539, *9 (N.D.N.Y. 2009) (citing 20 C.F.R. §§ 404.1545(b)-(e)), aff'd, 370 F. App'x 231 (2d Cir. 2010).
An ALJ should consider "all medical opinions received regarding the claimant." See Spielberg v. Barnhart, 367 F.Supp.2d 276, 281 (E.D.N.Y. 2005) (citing 20 C.F.R. § 404.1527(d)
"An ALJ who refuses to accord controlling weight to the medical opinion of a treating physician must consider various `factors' to determine how much weight to give to the opinion." Halloran v. Barnhart, 362 F.3d 28, 32 (2d Cir. 2004). The ALJ must explicitly consider the "Burgess factors":
Gunter v. Comm'r of Soc. Sec., 361 F. App'x 197, 199 (2d Cir. 2010); see also Estrella v. Berryhill, 925 F.3d at 95-96 ("[f]irst, the ALJ must decide whether the opinion is entitled to controlling weight[;]... if the ALJ decides the opinion is not entitled to controlling weight, it must determine how much weight, if any, to give it[;] [i]n doing so, it must `explicitly consider' the ... nonexclusive `Burgess factors'"). "At both steps, the ALJ must `give good reasons in its notice of determination or decision for the weight it gives the treating source's medical opinion.'" Estrella, 925 F.3d at 96 (quoting Halloran v. Barnhart, 362 F.3d at 32); Burgess v. Astrue, 537 F.3d 117, 129-30 (2d Cir. 2008) ("[a]fter considering the above factors, the ALJ must comprehensively set forth [his] reasons for the weight assigned to a treating physician's opinion[;] ... [f]ailure to provide such `good reasons' for not crediting the opinion of a claimant's treating physician is a ground for remand") (citations and quotations omitted); Wilson v. Colvin, 213 F.Supp.3d 478, 482-83 (W.D.N.Y. 2016) ("an ALJ's failure to follow the procedural requirement of identifying the reasons for discounting the opinions and for explaining precisely how those reasons affected the weight given denotes a lack of substantial evidence, even where the conclusion of the ALJ may be justified based on the record") (alterations, citations, and quotations omitted). "This requirement allows courts to properly review ALJs' decisions and provides information to claimants regarding the disposition of their cases, especially when the dispositions are unfavorable." Ashley v. Comm'r of Soc. Sec., 2014 WL 7409594, *1 (N.D.N.Y. 2014) (citing Snell v. Apfel, 177 F.3d 128, 134 (2d Cir. 1999)).
The record in this case demonstrates that Bota provided mental health counseling to Gualano on a monthly basis beginning in October 2015 and continuing through the time of the administrative hearing in May 2017. (Tr. 29, 364-78). Gualano also received psychiatric treatment, including medication management, from Yatsynovich during that same general time period. (Tr. 340-49, 370-78). On April 20, 2017, Bota authored an opinion assessing Gualano's work-related mental limitations. (Tr. 355-60). In the opinion, Bota opined that Gualano suffered from post-traumatic stress disorder, panic disorder with agoraphobia, and unspecified depressive disorder. (Id.). According to Bota, Gualano's
Bota opined that Gualano had no useful ability to function
In the opinion, Bota indicated that Gualano's limitations were caused by her "significant anxiety and panic attack symptoms," which presented a barrier to Gualano's thought process, interaction with others, and daily functioning. (Id.). Bota also opined that Gualano's symptoms prevented her from leaving her home except for medical appointments. (Id.). Bota indicated that Gualano's psychiatric impairments caused headaches, chest pain, shortness of breath and arm pain, and she expected that Gualano would be absent from work more than four days per month. (Id.). According to Bota, Gualano suffered from marked limitations in her ability to engage in activities of daily living and maintain social functioning and concentration, persistence and pace. (Id.). She opined that Gualano was unable to function independently outside the home and was unable to engage in full-time competitive employment. (Id.). On April 25, 2017, Yatsynovich "read and approved" the opinion authored by Gualano.
With respect to his weighing of Bota's opinion, the ALJ stated:
(Tr. 22).
Gualano challenges the ALJ's weighing of the opinion authored by Bota and cosigned by Yatsynovich on the grounds that the ALJ failed to properly treat the opinion as one from a treating psychiatrist. (Docket ## 9-1 at 12-22; 15 at 1-4). The government does not appear to dispute — nor should it — that the opinion should be assessed under the treating physician rule because Gualano's treating psychiatrist reviewed and cosigned the report. (Docket # 14-1 at 16-18); see Fritty v. Berryhill, 2019 WL 289779, *4 (W.D.N.Y. 2019) ("where the opinion is co-signed by a treating physician, ... the opinion should be evaluated as having been the treating physician's opinion") (internal quotations omitted); King v. Comm'r of Soc. Sec., 350 F.Supp.3d 277, 282 (W.D.N.Y. 2018) ("medical source statements cosigned by a treating physician should be evaluated as having been the treating physician's opinion") (quotation omitted). Rather, the government maintains that, in accordance with the treating physician rule, the ALJ provided good reasons for declining to give the opinion controlling weight. (Docket # 14-1 at 16-18).
The fallacy in the government's position is that it assumes, without discussion or support, that the ALJ did in fact apply the treating physician rule to the opinion. Little in the decision, however, supports that assumption. For instance, the ALJ does not mention or recite the treating physician rule or its considerations in the decision. Although the failure "to refer explicitly to each regulatory factor in determining the weight to assign to a treating physician's opinion" does not warrant remand where the decision, read in its entirety, supports the conclusion that the ALJ "conscientiously applied the substance of the treating physician rule," Jasen v. Comm'r of Soc. Sec., 2017 WL 3722454, *11 (W.D.N.Y. 2017); see Estrella, 925 F.3d at 96 ("failure to `explicitly' apply the Burgess factors when assigning weight... is a procedural error" but does not
Not only is any explicit reference to the treating physician considerations absent from the decision, but so too is any discussion demonstrating that the ALJ was aware of and weighed those considerations. For example, nowhere in the decision does the ALJ discuss the "frequency, length, nature and extent of treatment" that Yatsynovich provided to Gualano. See, e.g., Estrella, 925 F.3d at 97 (failure to address relationship between treating source and claimant is "especially relevant" because this factor "is of heightened importance" in cases involving mental illness). In fact, the ALJ refers to Yatsynovich merely as a "doctor," rather than as a psychiatrist with specialized knowledge relating to mental health impairments.
As the ALJ made clear, an opinion from Bota was not entitled to controlling weight because Bota was an "unacceptable medical source." (Tr. 22). He discounted her opinion because it was rendered in a "checklist" format
In the absence of any further discussion of the significance of Yatsynovich's signature, it is unclear whether the ALJ considered the opinion to be from an acceptable medical source and entitled to assessment under the treating physician rule. See Johnson v. Colvin, 2016 WL 659664, *3 (D. Conn. 2016) ("the co-signing of [the] opinions by a physician raises the prospect that they should be evaluated under the treating physician rule[,] ... [and] the ALJ
Having concluded that remand is warranted, I decline to reach Gualano's remaining contentions. See Erb v. Colvin, 2015 WL 5440699, *15 (W.D.N.Y. 2015) (declining to reach remaining challenges to the RFC and credibility assessments where remand requiring reassessment of RFC was warranted).
For the reasons stated above, the Commissioner's motion for judgment on the pleadings (