JEREMIAH J. McCARTHY, Magistrate Judge.
This is an action brought pursuant to 42 U.S.C. §§405(g) and 1383(c)(3) to review the final determination of defendant Nancy A. Berryhill, the Acting Commissioner of Social Security, that plaintiff was not entitled to Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI"). Before me are the parties' cross-motions for judgment on the pleadings [15, 18].
On August 29, 2012 and October 31, 2012, plaintiff filed applications for DIB and SSI respectively (R. 137-38, 139-142).
"A district court may set aside the Commissioner's determination that a claimant is not disabled only if the factual findings are not supported by `substantial evidence' or if the decision is based on legal error".
An adjudicator determining a claim for Social Security benefits employs a five-step sequential process.
The sole issue presented by plaintiff is whether ALJ Lewandowski erred by giving no weight to the August 1, 2013 letter from NP Lolita Small (R. 524) stating that plaintiff was limited to working "4 hour shifts" and lifting no more than ten pounds. Plaintiff's Brief [15-1], p. 14. In rejecting NP Small's opinion, ALJ Lewandowski stated that "there is no support in this record for a limitation to a 4 hour shift" and noted that NP Small saw the plaintiff on the day the assessment was written (R. 19). Further, he noted that the letter failed include or refer to any objective findings supporting the limitations.
"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".
Further, the ALJ should also "explain the weight given to opinions from . . . `other sources,' or otherwise ensure that the discussion of the evidence in the determination or decision allows a claimant or subsequent reviewer to follow the [ALJ]'s reasoning". S.S.R. 06-03p, at *6.
Here, it does not appear that NP Small had a long-standing treatment relationship with plaintiff at the time she wrote the letter. Although plaintiff had been seen at the Evergreen Medical Group since February of 2013 (R. 426), the treatment notes reflect that NP Small's first examination of plaintiff was on August 1, 2013, the date she wrote the letter in question (R. 459). Moreover, NP Small's treatment note of that date states that she wrote the letter because plaintiff requested "a letter for work with limitations while he is under workup for his back pain".
The record does not reflect that NP Small is an orthopedic specialist. While plaintiff's treatment from Evergreen reflect varying issues relating to back pain, they do not include findings reflecting the functional limitations stated in NP Small's August 1, 2013 letter. On February 12, 2013 his back pain was thought to be due to a muscle sprain (R. 430); on March 25, 2013, his pain was noted as getting "progressively worse" and affecting his mobility (R. 435); on June 3, 2013, he continued to have pain in back (R. 451). Plaintiff commenced a course of physical therapy to deal with the back pain on June 4, 2013 (R. 582). On June 11, 2013, the visit just prior to his August 1, 2013 examination by NP Small, an examination of plaintiff by Dr. Tyler Evans was "negative for arthralgias, back pain and myalgias" (R. 456). Upon musculoskeletal examination on that date, Dr. Evans noted that plaintiff had "full, painless range of motion of all major muscle groups and joints".
Thus, it appears that plaintiff's back pain waxed and waned. Indeed, the report from plaintiff's initial physical therapy session notes that plaintiff stated that his pain ranged from a zero out of ten, to a seven out of ten (R. 582). While plaintiff was ultimately discharged from physical therapy due to a failure to make progress on August 23, 2013 (R. 586), on August 14, 2013 he reported that he took Ibuprofen "with good relief" for his back pain (R. 467).
In any event, the four-hour shift and ten-pound lifting limitations stated in NP Small's August 1, 2013 letter are not reflected or supported elsewhere in the record. Although the record contains objective findings which would support the fact that plaintiff suffers from some back pain, the degree of limitation stated by NP Small does not appear to be consistent with those findings. Moreover, her opinion is flatly contradicted by that of plaintiff's treating physician at Evergreen, Dr. Fatai Gbadamosi,
In sum, in light of the fact that NP Small did not have a long-standing treating relationship with plaintiff at the time she wrote the August 1, 2013 letter, and because the limitations stated that letter were not supported by clinical findings, are not consistent with plaintiff's overall medical record, and were contradicted by plaintiff's treating physician, ALJ Lewandowski did not err by failing to give weight to NP Small's August 1, 2013 letter.
For these reasons, plaintiff's motion for judgment on the pleadings [15] is denied and the Acting Commissioner's motion for judgment on the pleadings [18] is granted.