THÉRÈSE WILEY DANCKS, Magistrate Judge.
Presently before the Court in this action, in which Plaintiff seeks judicial review of an adverse administrative determination by the Commissioner, pursuant to 42 U.S.C. §405(g), are cross-motions for judgment on the pleadings.
After due deliberation, and based up the Court's oral bench decision, which has been transcribed, is attached to this Order and is incorporated in its entirety by reference herein, it is hereby,
ORDERED, as follows:
SO ORDERED.
Transcript of a
(In Chambers, Counsel present by telephone.)
THE COURT: So I have before me a request for judicial review of an adverse determination by the Acting Commissioner under 42 United States Code Section 405(g). The background is as follows: Plaintiff was born in August of 1969 and is currently 49 years old. She was 43 years old at the onset of her alleged disability. She completed high school and last worked in 2008 when she stopped working to care for her younger son. Her past jobs have included bank teller and a self-employed home care aide.
In her application for benefits, she indicated she had a right torn ACL, or anterior cruciate ligament, and fractured tibia that had not healed correctly, plantar fasciitis and also right knee arthrofibrosis.
Procedurally, for purposes of this matter, plaintiff filed for Title II benefits on September 9, 2014. She alleged an onset date of disability beginning March 1, 2013. A hearing was conducted by Administrative Law Judge David Begley on October 4, 2016, wherein the plaintiff testified, as did a vocational expert. The hearing was held open for the receipt of further medical information.
ALJ Begley issued a decision on March 7, 2017, noting that per plaintiff's earnings records, her last date insured was March 31, 2013. The ALJ then found plaintiff was not disabled during the relevant time. The Social Security Administration made that a final determination of the agency by the Appeals Council's denial of plaintiff's request for review dated February 1, 2018. This District Court action followed.
ALJ Begley applied the required five-step sequential test for determining disability. At step one he found plaintiff had not engaged in any substantial gainful activity during the period from the alleged onset date of March 1, 2013 through the date last insured of March 31, 2013.
At step two, he concluded plaintiff suffers from the severe condition of right knee arthrofibrosis.
At step three, the ALJ concluded that the plaintiff's impairment does not meet or medically equal any of the listed presumptively disabling conditions. Then, after a review of the record evidence, the ALJ determined plaintiff is capable of performing a full range of sedentary work with additional limitations.
At step four, the ALJ concluded plaintiff is unable to perform any past relevant work, and at step five the ALJ applied the Medical Vocational Guidelines as well as obtained the testimony from a vocational expert and concluded that plaintiff was not disabled.
As relevant to the time period in question and per the administrative record, plaintiff treated with her primary care provider Dr. Mathew Ulahannan and orthopedists Dr. Andrew Wickline and Dr. James Dennison as well as physician assistants at Genesee Orthopedic and Plastic Surgery Associates. Dr. Mathew Ulahannan was a private practitioner and not associated with Genesee Orthopedic. Plaintiff also received treatment by Dr. Russell LaFrance at Hamilton Orthopedic Surgery and Sports Medicine for her right knee beginning January 27, 2014. She obtained physical therapy at Adirondack Sports Medicine and Physical Therapy beginning in April of 2013 through August of 2013.
I've reviewed the record carefully and in light of the arguments of counsel and what counsel have presented in their briefs, I've applied the requisite deferential standard which requires me to determine whether proper legal principles were applied and whether the result is supported by substantial evidence.
Plaintiff argues the Appeals Council failed to consider additional medical evidence submitted after the ALJ's decision and failed to remand the claim to the ALJ for consideration of the additional medical evidence under the treating physician rule. Plaintiff also argues the RFC is not supported by the medical evidence, and that the step five determination was improper.
I'll turn first to the Appeals Council's determination not to consider the additional evidence. Under the regulations, a plaintiff is expressly authorized to submit new evidence to the Appeals Council without demonstrating good cause. Also under the regulations, the Appeals Council must consider new and material evidence if it relates to the period on or before the date of the administrative law judge's hearing decision and there is a reasonable probability that the additional evidence would change the outcome of the ALJ's decision.
9 New evidence is any evidence that has not been considered previously during the administrative process. Thus, the Administration need not consider any evidence that is cumulative to that which was already contained in the record prior to the ALJ's decision.
Evidence is material in this context if it is relevant to the plaintiff's condition during the time period at issue and it is probative. The Administration thus need not consider evidence related to plaintiff's condition after the last date insured.
Here, the additional evidence submitted to the Appeals Council includes a treatment note from Dr. Ulahannan dated March 11, 2013. However, this treatment note was already contained in the administrative record that was before the ALJ and therefore is not new medical evidence. Other treatment notes from Dr. Ulahannan submitted to the Appeals Council dated February 13, 2014 to December 13, 2016 all concern treatment rendered after the last date insured, which is, as I've said, March 31, 2013, and the notes do not relate back to the relevant period. While the additional notes after the date last insured may show continued treatment and that her knee condition may have worsened over that later time period, plaintiff must show she became disabled on or before the last date insured. She has not done so with those additional records.
I also find that the Appeals Council was correct in determining that the resubmission of Dr. Ulahannan's medical source statement dated February 15, 2017 with the physician's name now printed under the signature does not change the outcome of the decision or the RFC finding. The ALJ had already reviewed this evidence, which only noted one date of treatment of March 13, 2013, during the period at issue, and the statement does not note when the limitations noted in it were initially present. Notably, the functional limitations listed by Dr. Ulahannan are generally consistent with sedentary work and with the additional limitations as determined by the ALJ in the RFC.
I also reject plaintiff's argument that Dr. Ulahannan's letter dated July 20, 2017, wherein he revised his February 15, 2017 source statement after reviewing other physicians' medical records for the period of March 13, 2013 to May 12, 2014, required the Appeals Council to grant review. I find the Appeals Council did not err in finding that the July 20, 2017 letter would not have reasonable — have a reasonable probability of changing the outcome of the decision of the ALJ. The opinion is not supported by the findings in Dr. Ulahannan's treatment note of March 13, 2013, nor is it supported by the exam findings of the orthopedic physicians at Genesee Orthopedics, Dr. Wickline and Dr. Dennison, between the date of onset and the last date insured, especially since those medical records were contained in the administrative record at the time of the ALJ's decision and were considered by the ALJ. Additionally, physical therapy records in July and August of 2013, which were also part of the administrative record considered by the ALJ, show plaintiff's right knee was less stiff and less painful, her knee was feeling looser and seemed straighter and she was walking easier. She still had some diminished extension and strength in the right knee but only a slight antalgic gait.
All in all, I find the Appeals Council did not err in denying plaintiff's request for review, nor did they err in their explanation of their denial.
Next the plaintiff argues the RFC is not supported by the medical evidence and that the ALJ substituted his own opinion in determining the RFC. I also find this argument unpersuasive. A plaintiff's RFC is the most she can do despite her limitations and the determination is ultimately left up to the ALJ, who must consider all medical — all relevant medical and nonmedical evidence. The RFC need not perfectly track any one opinion but must be supported by the evidence of record as a whole.
I have done a thorough and searching review of the record and find that the RFC is supported by substantial evidence. There were no gaps in the record for the relevant time period. The ALJ thoroughly discussed the medical evidence and other evidence of record, formulated the RFC based upon an assessment of all the medical and nonmedical evidence as a whole for the relevant time period, and thoroughly explained his analysis in arriving at the RFC. Based upon the treatment during the relevant time period and the other nonmedical evidence of record, the ALJ found plaintiff capable of sedentary work and provided other limitations including no use of ladders, ropes, or scaffolds, no climbing, kneeling, or crawling, and no more than occasional climbing of ramps or stairs and occasional balancing, stooping, and crouching.
Here the relevant period correctly determined by the ALJ was from March 1, 2013 to March 31, 2013, and the administrative record before the ALJ contained all of the medical and nonmedical evidence for that period and beyond. A March 11, 2013 treatment note of Dr. Ulahannan indicates that plaintiff complained of right knee pain and the exam revealed tenderness with swelling and fluid thrill. He diagnosed a sprained right knee with effusion. The x-rays were negative for fracture and he referred her for orthopedic evaluations with directions to use cold compresses and pain medications.
As I've already discussed above, the ALJ reviewed Dr. Ulahannan's source statement which only noted one date of treatment of March 13, 2013 during the period at issue. And the statement does not note when the limitations noted in it were initially present. Again, the functional limitations listed by Dr. Ulahannan are generally consistent with sedentary work and the additional limitations as determined by the ALJ in the RFC. I find the weight given to that statement and the reasons for it as explained by the ALJ were proper.
Plaintiff also saw orthopedist Dr. Wickline on May 13, 2013, and he diagnosed a right knee injury. He ordered an MRI, and he directed the plaintiff to rest, weight bear as she could on crutches, and use ice and antiinflammatory medications as well as elevate the leg. The MRI revealed she had an ACL tear and tibial fracture. She was then seen by physician assistant Christopher Jones in Dr. Dennison's office on March 20, 2013 and she reported to him that she was able to walk on the knee with little to no problem. The PA, whose note was countersigned by Dr. Dennison, noted plaintiff's gait was mildly antalgic with some swelling and decreased flexion and extension of the right knee but no quadriceps atrophy. Strength was four out of five in the right leg. He gave her a brace to use to keep her non-weight bearing for a short period of time, from four to eight weeks.
On March 29, 2013, just prior to the date last insured, plaintiff was again seen by a PA and Dr. Dennison. At that time, plaintiff had some swelling and effusion with full extension but decreased flexion in the knee. She was told to work on range of motion and continue icing the knee and continue antiinflammatory medications.
Although Dr. LaFrance did not begin treating plaintiff until after the date last insured, the ALJ gave some weight to his suggestion that plaintiff was capable of some work after an initial six-month period after the March 2013 injury. Dr. LaFrance noted in January of 2014 that plaintiff currently enjoyed outdoor activities, walking, and swimming. She ambulated with a limp and needed no assistive devices. Her knee was tender but improving with physical therapy and he recommended she continue the therapy. Further notes in 2014 indicate her range of motion was improving and she should continue with icing and continue the antiinflammatory medication.
I find all of the treatment outlined above was thoroughly reviewed by the ALJ and the records provide clear and substantial evidence to support the RFC determination such that meaningful judicial review is possible. Only where the reviewing court is unable to fathom the ALJ's rationale in relation to the evidence in the record would remand be appropriate for further findings or clearer explanation for the decision. Here I find the ALJ's analysis regarding plaintiff's functional limitations and restrictions affords an adequate basis for meaningful judicial review, applies the proper standards, and is supported by substantial evidence such that additional analysis would be unnecessary or superfluous.
Further, the plaintiff's activities of daily living also support the RFC. She testified she could drive about four months after the March 2013 injury, and she noted in her function report that she was able to do some cooking daily, help her children get ready for school, do household activities, and light housekeeping. She could go out alone and walk a little bit. She shopped for groceries and spent time with her family. Thus, I find the ALJ properly evaluated the opinion evidence and gave good reasons for the weight given to the opinions and also properly evaluated the other medical and nonmedical evidence and properly explained the reasons for the RFC.
In light of the foregoing and considering the entire record and the ALJ's determination, I find that the ALJ applied the appropriate legal standards of review in determining plaintiff's RFC and the RFC is supported by substantial evidence. I also find that the ALJ had a complete record for the time period in question.
Regarding plaintiff's step five argument, I find it to be without merit. Since I have found the RFC to be supported by substantial evidence and since the vocational expert's testimony was based upon a hypothetical that was the same as the RFC, the ALJ properly relied on a vocational expert's testimony that plaintiff could perform jobs that exist in significant numbers in the national economy. The RFC, which I have found properly supported and determined, simply does not indicate that plaintiff would be off task 25 percent or more of the workday or that she would need unscheduled breaks during the workday. Therefore, the Commissioner met her burden at step five and correctly determined the plaintiff was not disabled.
So I grant defendant's motion for judgment on the pleadings, I will enter a judgment dismissing plaintiff's complaint in this action. A copy of the transcript of my decision will be attached to the order should any appeal be taken from my determination.
I, JODI L. HIBBARD, RPR, CRR, CSR, Federal Official Realtime Court Reporter, in and for the United States District Court for the Northern District of New York, DO HEREBY CERTIFY that pursuant to Section 753, Title 28, United States Code, that the foregoing is a true and correct transcript of the stenographically reported proceedings held in the above-entitled matter and that the transcript page format is in conformance with the regulations of the Judicial Conference of the United States.
