GARY L. SHARPE, Chief District Judge.
Plaintiff Elizabeth A. Brown challenges the Commissioner of Social Security's denial of Disability Insurance Benefits (DIB) and Supplemental Security Income (SSI), seeking judicial review under 42 U.S.C. §§ 405(g) and 1383(c)(3). (Compl., Dkt. No. 1.) After reviewing the administrative record and carefully considering Brown's arguments, the Commissioner's decision is reversed and remanded.
On February 24, 2011, Brown filed applications for DIB and SSI under the Social Security Act ("the Act"), alleging disability since January 1, 2011. (Tr.
Brown commenced the present action by filing her complaint on July 30, 2013 wherein she sought review of the Commissioner's determination. (Compl.) The Commissioner filed an answer and a certified copy of the administrative transcript. (Dkt. Nos. 8, 10.) Each party, seeking judgment on the pleadings, filed a brief. (Dkt. Nos. 12, 14.)
Brown contends that the Commissioner's decision is tainted by legal error and is not supported by substantial evidence. (Dkt. No. 12 at 10-17.) Specifically, Brown claims that the ALJ erred in: (1) improperly evaluating her residual functional capacity (RFC); and (2) failing to obtain the testimony of a vocational expert (VE). (Id.) The Commissioner counters that the appropriate legal standards were used by the ALJ and her decision is also supported by substantial evidence. (Dkt. No. 14 at 4-16.)
The court adopts the parties' undisputed factual recitations. (Dkt. No. 12 at 2-9; Dkt. No. 14 at 1.)
The standard for reviewing the Commissioner's final decision under 42 U.S.C. § 405(g)
Among other arguments, Brown contends that the ALJ did not apply the proper legal standards when determining Brown's RFC. (Dkt. No. 12 at 10-15.) Specifically, Brown argues that the ALJ should have afforded controlling weight to the opinion of treating physician Michael Lax. (Id.) Further, Brown claims that the opinion of consultative examiner Kalyani Ganesh was impermissibly vague, and, thus, does not constitute substantial evidence supporting the ALJ's RFC determination. (Id. at 11, 15.) Brown also asserts that the ALJ failed to "properly evaluate or make accommodations for [her] mental deficits resulting from her pain," as found by consulting examiner Christina Caldwell and non-examining psychological consultant T. Harding. (Id.) The court agrees that remand is required here.
A claimant's RFC "is the most [she] can still do despite [her] limitations." 20 C.F.R. § 404.1545(a)(1). In assessing a claimant's RFC, an ALJ must consider "all of the relevant medical and other evidence," including a claimant's subjective complaints of pain. Id. § 404.1545(a)(3). An ALJ's RFC determination must be supported by substantial evidence
In this case, the ALJ concluded that Brown retains the RFC to perform light work
As Brown points out, the ALJ discounted the opinion of Dr. Lax, who treated Brown for cervical disc disease, cervical and thoracic strains, a shoulder impingement, and mid back pain. (Id. at 18.) In January 2012, Dr. Lax completed a medical source statement and, rather than answering questions with respect to Brown's functioning, repeatedly noted that Brown was unable to work at that time. (Id. at 322-24.)
Here, the ALJ explained that she gave Dr. Lax's exceedingly restrictive opinion little weight because it was inconsistent with the clinical and diagnostic evidence of record, as well as Brown's "extensive activities of living." (Tr. at 18.) Moreover, the ALJ noted that, because it was an opinion on the ultimate issue of disability, as opposed to a functional assessment, Dr. Lax's opinion was not deserving of any special significance. (Id.); see 20 C.F.R. § 404.1527(d)(1), (3). Thus, the ALJ considered the relevant factors and properly explained her reasoning for discounting the weight given to Dr. Lax's opinion. 20 C.F.R. § 404.1527(c)(3), (4).
Although it is clear that the ALJ followed the correct legal standard to be applied in analyzing Dr. Lax's opinion, it is not at all clear that the ALJ's RFC determination is supported by other, substantial evidence. Brown's treatment providers consistently indicated that Brown exhibited decreased range of motion in her cervical and lumbar spine, decreased sensation in her right upper extremity, reduced grip and arm strength on her right side, a positive impingement sign on the right shoulder, and tenderness in her cervical and thoracic spine, as well as shoulders. (Tr. at 258-60, 263, 307-08, 316-17, 330, 332-33, 337-38, 343.) On several occasions, straight leg raising was positive on the right and it was noted that Brown's gait was stiff or she had difficulty getting on and off of the exam table. (Id. at 258, 263, 333, 338.) In March 2011, an MRI of Brown's cervical spine revealed narrowing of multiple left foramina and multiple annular bulges, but no spinal cord compression. (Id. at 307.) Thereafter, x-rays showed a reversed cervical lordosis, diffuse disc degeneration, and moderate hypertrophic spurring at C2-C7. (Id. at 308.)
Chiropractic treatment records reveal trigger points in the right upper trapezius and a mild degree of hypertonicity of the suboccipital muscles, cervical paraspinal muscles, upper thoracic muscles, and mid thoracic muscles bilaterally. (Id. at 309-14, 319.) Brown's chiropractor repeatedly reported that Brown suffered a marked partial disability and opined that she should not perform work requiring repeated bending or lifting, prolonged neck flexion, or pushing, pulling, or carrying over ten pounds. (Id. at 309.) Notably, the ALJ did not explicitly consider this opinion in her decision.
Given the above cited clinical findings, the overlooked functional assessment of Brown's treating chiropractor, and the vague nature of Dr. Ganesh's opinion, the court remands this case for further consideration of Brown's RFC. See Burgess v. Astrue, 537 F.3d 117, 128-29 (2d Cir. 2008). Although the ALJ stated that Brown's "extensive" daily activities supported her RFC determination, Brown's reports to her treating and examining medical sources suggest that she had difficulty performing household chores such as cooking, cleaning, washing laundry, and shopping, as well as caring for her personal hygiene. (Tr. at 16, 18, 260, 266, 329, 331, 335, 336, 338.) Brown returned to work after her alleged onset date, but was only able to work two days per week, after which she required two days to recover. (Id. at 262.) Thus, standing alone, these activities do not support the ALJ's conclusion that Brown can perform light work. The Commissioner argues that Brown's conservative treatment regimen, and the recommendation from her vocational rehabilitation counselor that she consider alternative positions, are inconsistent with Dr. Lax's opinion and consistent with the ALJ's RFC finding. (Dkt. No. 14 at 9.) In addition, the Commissioner contends that records first submitted to the Appeals Council demonstrate that Brown's vocational rehabilitation counselors were "helping her to navigate the `system'" by exaggerating her limitations to her doctors and postponing enrollment in school until after she began receiving benefits. (Id.) While the ALJ should consider Brown's course of treatment and the new evidence submitted to the Appeals Council on remand, the court notes that a thorough reading of the records from Brown's vocational rehabilitation counselor reveals that, in her opinion, Brown had been understating her limitations to Dr. Lax. (Tr. at 368, 374.) Further, the vocational evaluation completed for Brown is not an assessment of her physical capabilities, but, rather, appears to be based on an earlier functional assessment completed by Dr. Lax. (Id. at 369, 376-80.) Indeed, the records submitted to the Appeals Council contain a functional assessment completed by Dr. Lax, in October 2010, two months before Brown's alleged onset date, restricting her to working only two eight-hour days a week. (Id. at 393-94.) On remand, the ALJ should consider this opinion, and, if necessary, re-contact Dr. Lax or obtain expert opinion as to Brown's functional capabilities.
With respect to the ALJ's finding that Brown is only limited from performing "highly complex tasks," (Id. at 16), after reviewing the administrative record the court concludes that this determination is supported by substantial evidence. Specifically, the ALJ's mental RFC determination is supported by the opinions of Dr. Caldwell and psychological consultant Harding, as well as Brown's lack of treatment for mental health impairments. (Id. at 264, 266, 288-91.) In May 2010, Brown reported to her treating doctor that she was experiencing some anxiety and concentration deficits, but she was "able to enjoy things" and was not depressed. (Id. at 254.) At this time, Brown did not want to take daily medication for anxiety. (Id. at 255.) Thereafter, in July 2011, Brown denied significant anxiety or depression and her treating physician assistant concluded that her anxiety was mild and did not require medication. (Id. at 352-53.) Her treatment notes are devoid of complaints regarding difficulty relating to others, and Brown reported that she had no problems getting along with bosses, teachers, or other people in authority. (Id. at 186.) Thus, the ALJ's determination with respect to Brown's mental limitations is supported by substantial evidence.
Because Brown's remaining contentions, (Dkt. No. 12 at 15-17), may be impacted by the subsequent proceedings directed by this Order, it would be premature of the court to address them at this juncture.