HENRY PITMAN, Magistrate Judge.
TO THE HONORABLE GEORGE B. DANIELS, United States District Judge:
Plaintiff Nancy Rivera brings this action pursuant to Section 205(g) of the Social Security Act (the "Act"), 42 U.S.C. § 405(g), seeking judicial review of a final decision of the Commissioner of Social Security ("Commissioner") denying her application for disability insurance benefits ("DIB"). The Commissioner and plaintiff have both moved for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure. For the reasons set forth below, I respectfully recommend that plaintiff's motion (Docket Items ("D.I.") 17, 22) be granted and that the Commissioner's motion (D.I. 24) be denied.
Plaintiff filed an application for DIB on July 25, 2012, alleging that she had been disabled since January 9, 2012 (Tr. 124-30). Plaintiff completed a "Disability Report" in support of her claim for benefits (Tr. 151-57). Plaintiff claimed that she was disabled because her "[r]ight knee is very swollen," she had "chronic pain" and she "walk[s] with a cane" (Tr. 152). Plaintiff reported that she took the following medications: 400 milligrams of Etodolac for inflammation and 50 milligrams of Tramadol for pain, as prescribed by the East Tremont Medical Center (Tr. 154). Plaintiff also reported that she went to physical therapy for her knee and had undergone an arthroscopy
On August 22, 2012, the Social Security Administration ("SSA") denied plaintiff's application, finding that she was not disabled (Tr. 51-54). Plaintiff timely requested and was granted a hearing before an Administrative Law Judge ("ALJ") (Tr. 57-59). ALJ Sean P. Walsh scheduled a hearing on April 7, 2014, but it was postponed so that plaintiff could obtain representation (Tr. 35-40). The ALJ subsequently held a hearing on August 1, 2014 (Tr. 20-34). The ALJ reviewed the claim
Plaintiff was born in 1958 and was 56 years old at the time of her hearing before the ALJ (Tr. 22-23). She attended the University of Puerto Rico but did not graduate (Tr. 23).
At her hearing before the ALJ, plaintiff testified that she stopped working in 2011 because she suffered a fall that injured her knee (Tr. 23). At that time, she had been working as a tutor (Tr. 23). Prior to becoming a tutor, plaintiff was a receptionist and a counselor at a social services agency (Tr. 23-24).
According to a September 2012 Federation Employment & Guidance Service ("F.E.G.S.") report, plaintiff reported feeling depressed because of her knee injury (Tr. 235). Plaintiff also said that she received emotional support from her daughter (Tr. 236).
An x-ray of plaintiff's knees taken on October 6, 2011, after plaintiff's fall, showed early osteoarthritis
Dr. Stuart S. Remer, M.D., an orthopedist, examined plaintiff on December 21, 2011. Plaintiff reported intermittent, moderate-to-severe pain, which she said was exacerbated by walking (Tr. 182). Plaintiff also reported that physical therapy had helped for a short period (Tr. 182). Dr. Remer's physical examination of plaintiff revealed tenderness, swelling and a restricted range of motion in her right knee (Tr. 182). Dr. Remer recommended that plaintiff undergo an arthroscopy (Tr. 182).
Dr. Remer performed an arthroscopy on plaintiff's right knee on January 9, 2012 (Tr. 174-75). After the arthroscopy, Dr. Remer diagnosed the following conditions in plaintiff's right knee: torn medial meniscus posterior horn, extensive synovitis
At a follow-up appointment with Dr. Remer on January 19, 2012, plaintiff reported that her movement was improving, but that she was still experiencing moderate pain (Tr. 180). Plaintiff also stated that she was using a cane to walk (Tr. 180). Dr. Remer removed plaintiff's sutures and referred her to a physiatrist for treatment (Tr. 180). Plaintiff's physiatrist noted that plaintiff could walk and stand for 15 minutes and sit for one hour, and recommended further physical therapy (Tr. 202, 204).
After completing approximately three months of physical therapy, plaintiff saw Dr. Remer on May 16, 2012 (Tr. 225). Although plaintiff reported that physical therapy and pain medication offered some relief for her right knee pain, it did not provide complete relief (Tr. 225). Dr. Remer's physical examination revealed no edema
On June 21, 2012, plaintiff reported increased pain in her right knee (Tr. 173). An examination of the knee showed crepitus, swelling and a restricted range of motion (Tr. 173). Dr. Remer determined that plaintiff had severe degenerative joint disease in her right knee and recommended a right knee replacement (Tr. 173).
On July 18, 2012, plaintiff reported continuing right knee pain to Dr. Remer (Tr. 222). An x-ray taken of plaintiff's knee showed advanced osteoarthritis changes with severe synovitis (Tr. 222). A physical examination of the knee showed tenderness, pain, swelling and a reduced range of motion (Tr. 222).
On September 5, 2012, plaintiff was assessed at the F.E.G.S. health care facility (Tr. 227-45). Her Patient Health Questionnaire-9 ("PHQ-9") score was a nine, which represents mild depression (Tr. 235). The report indicated that plaintiff came to the appointment by herself by bus and that plaintiff reported having difficulty traveling on the subway due to pain in her right knee (Tr. 235). Plaintiff also reported that she could wash dishes and clothes, sweep and mop floors, vacuum, watch television, make beds, shop for groceries, cook meals, read, socialize, get dressed, bathe, use the toilet and groom herself (Tr. 235-36). Plaintiff also reported that she could only walk one to two blocks (Tr. 242). During an examination with F.E.G.S. hospital physician Robert Marc Romanoff, plaintiff reported right knee pain (Tr. 240-41). Dr. Romanoff noted that plaintiff's level of pain was a three on a scale of one to ten and was a five at its worst (Tr. 241). Moreover, a physical examination showed no abnormal results in plaintiff's musculoskeletal system or elsewhere (Tr. 241).
Plaintiff had a total right knee replacement in August 2013 (Tr. 25). On May 20, 2014, Julia Kaci, M.D. performed a consultative orthopedic examination on plaintiff (Tr. 258-61). Plaintiff reported that she could not cook, clean, do laundry, shop or care for children because of pain (Tr. 259). A physical examination showed a limited range of motion in the right knee, pitting edema in the right lower leg and joint effusion and inflammation bilaterally (Tr. 260). Dr. Kaci diagnosed plaintiff with right knee pain status post total knee replacement, left knee pain and low back pain (Tr. 260). Dr. Kaci stated that plaintiff could not walk on her heels and toes and needed help getting on and off the examination table (Tr. 259). Additionally, Dr. Kaci noted that plaintiff had marked limitations in walking, climbing stairs, kneeling, squatting and standing, as well as moderate limitations in bending, lifting and carrying (Tr. 260).
Dr. Kaci also completed a corresponding functional assessment, in which she concluded that plaintiff could lift and carry up to twenty pounds frequently and up to fifty pounds occasionally, sit for thirty minutes at a time and for four hours total in an eight-hour workday, stand for fifteen minutes at a time and for two hours total in a workday and walk for ten minutes at a time and for one hour total in a workday (Tr. 262-63). Dr. Kaci also found that plaintiff could not walk more than twenty to thirty feet without use of a cane and that she could not climb, balance, stoop, kneel, crouch or crawl (Tr. 263, 265). Finally, Dr. Kaci found that while plaintiff could not shop, travel without a companion or walk a block at a reasonable pace on rough or uneven surfaces, plaintiff could use standard public transportation and climb a few steps at a reasonable pace with the use of a single hand rail (Tr. 267).
After the ALJ issued his decision, physician Marc Silverman, M.D. assessed plaintiff (Tr. 41-44). He opined that plaintiff could occasionally lift and/or carry less than ten pounds in an eight-hour workday, stand and/or walk for less than two hours in a workday, sit for less than six hours in a workday and push and/or pull with some restrictions (Tr. 42-44). Although Dr. Silverman's assessment was submitted to the Appeals Council, the Appeals Council declined to consider it because it post-dated the relevant time period (Tr. 2)
An attorney represented plaintiff at the August 1, 2014 hearing before ALJ Walsh (Tr. 10, 22). Plaintiff testified at the hearing. She explained that in 2011, she slipped and fell (Tr. 24-25). As a result of that accident, plaintiff's right knee "started bothering" her and she stopped working (Tr. 24). Plaintiff testified that she first had an arthroscopy for the knee, and then underwent a total knee replacement in August 2013 (Tr. 25). After the knee replacement, plaintiff explained that she stayed in rehabilitation for one month and then had physical therapy, but that her knee remains symptomatic (Tr. 25-28).
Plaintiff testified that she requires a prescribed cane to walk and that she takes Naproxen (Tr. 30). Plaintiff reported that her pain was a seven on a scale of one to ten (Tr. 31). She stated that she could stand for approximately five to ten minutes without a cane, and fifteen to twenty minutes with a cane (Tr. 31). Plaintiff also testified that "sitting is not good" because of swelling in both of her knees (Tr. 31). Plaintiff said that because of the pain caused by sitting, she needs to change from sitting to standing every ten to fifteen minutes (Tr. 31-32). She also noted that her doctor referred her for more physical therapy because her right knee remains symptomatic (Tr. 32).
Plaintiff testified that she also has other impairments. Specifically, plaintiff testified that she requires arthroscopy on her left knee (Tr. 26). Plaintiff also testified that she has "bad arthritis" in her hands, hypertension and asthma (Tr. 30).
The ALJ kept the record open for 30 days following the hearing so that plaintiff's attorney could submit additional records, including an RFC assessment from a treating source (Tr. 32-33). However, plaintiff's attorney did not submit any additional medical records (Tr. 10).
The Court may set aside the final decision of the Commissioner only if it is not supported by substantial evidence or if it is based upon an erroneous legal standard. 42 U.S.C. § 405(g);
The Court first reviews the Commissioner's decision for compliance with the correct legal standards; only then does it determine whether the Commissioner's conclusions were supported by substantial evidence.
"`Substantial evidence' is `more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.'"
Under Title II of the Social Security Act, 42 U.S.C. §§ 401
42 U.S.C. § 423(d)(2)(A). In addition, to obtain DIB, the claimant must have become disabled between the alleged onset date and the date on which she was last insured.
In making the disability determination, the Commissioner must consider: "`(1) the objective medical facts; (2) diagnoses or medical opinions based on such facts; (3) subjective evidence of pain or disability testified to by the claimant or others; and (4) the claimant's educational background, age, and work experience.'"
In determining whether an individual is disabled, the Commissioner must follow the five-step process required by the regulations. 20 C.F.R. § 404.1520(a)(4)(i)-(v);
If the claimant does not meet any of the listings in Appendix 1, step four requires an assessment of the claimant's RFC and whether the claimant can still perform her past relevant work given her RFC. 20 C.F.R. § 404.1520(a)(4)(iv);
RFC is defined in the applicable regulations as "the most [the claimant] can still do despite [her] limitations." 20 C.F.R. § 404.1545(a)(1). To determine RFC, the ALJ "`identif[ies] the individual's functional limitations or restrictions and assess[es] his or her work-related abilities on a function-by-function basis, including the functions in paragraphs (b),(c), and (d) of 20 [C.F.R. §§] 404.1545 and 416.945.'"
The claimant bears the initial burden of proving disability with respect to the first four steps. Once the claimant has satisfied this burden, the burden shifts to the Commissioner to prove the final step — that the claimant's RFC allows the claimant to perform some work other than her past work.
"It is the rule in [the Second] [C]ircuit that `the ALJ, unlike a judge in a trial, must [him]self affirmatively develop the record' in light of `the essentially non-adversarial nature of a benefits proceeding.'"
The ALJ is required "affirmatively to seek out additional evidence only where there are `obvious gaps' in the administrative record."
In considering the evidence in the record, the ALJ must give deference to the opinions of a claimant's treating physicians. A treating physician's opinion will be given controlling weight if it is "well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in [the] case record." 20 C.F.R. § 416.927(c)(2);
"[G]ood reasons" must be given for declining to afford a treating physician's opinion controlling weight. 20 C.F.R. § 416.927(c)(2);
As long as the ALJ provides "good reasons" for the weight accorded to the treating physician's opinion and the ALJ's reasoning is supported by substantial evidence, remand is unwarranted.
As an initial matter, the ALJ found that plaintiff last met the insured status requirements of the Act on June 30, 2012 (Tr. 12). The ALJ then conducted the analysis described above, relying on the evidence in the record to determine that plaintiff was not disabled during the relevant time period (Tr. 12-16).
At step one of the sequential analysis, the ALJ determined that plaintiff had not engaged in substantial gainful activity during the relevant time period (Tr. 12,
At step two, the ALJ found that plaintiff had the following severe impairments through June 30, 2012: osteoarthritis of both knees, hypertension and asthma (Tr. 12,
At step three, the ALJ found that plaintiff's disabilities did not meet the criteria of the listed impairments and that plaintiff was not, therefore, entitled to a presumption of disability (Tr. 12-13). Specifically, the ALJ found that plaintiff's "knee impairment" did not meet listing 1.02 (major dysfunction of a joint(s) due to any cause) because plaintiff's "ability to walk was not effectively precluded" (Tr. 13). Citing the September 2012 F.E.G.S. report, the ALJ noted that plaintiff "was able to do her household chores; her pain level was only `3' and her only restriction was to avoid public transportation" (Tr. 13). The ALJ found that plaintiff's asthma did not meet listing 3.03 (asthma) because there was no evidence that plaintiff was hospitalized or required emergency treatment for her asthma during the relevant time period (Tr. 13).
The ALJ then determined that plaintiff retained the RFC to perform "sedentary work" except that she should avoid "respiratory irritants secondary to her history of asthma" (Tr. 13). In reaching this determination, the ALJ examined plaintiff's subjective claims, as well as the F.E.G.S. report, Dr. Kaci's opinion and the rest of the record.
The ALJ found that plaintiff's "statements concerning the intensity, persistence and limiting effects of [her] symptoms [were] not entirely credible" (Tr. 13). The ALJ noted that while plaintiff reported depression, her PHQ-9 score at the time was a nine, indicating only mild depression (Tr. 14). Moreover, the ALJ noted that while plaintiff reported difficulty traveling by subway due to pain in her right knee, the F.E.G.S. report indicated that plaintiff was able to wash dishes and clothes, sweep, mop, vacuum, make beds, cook, shop, dress and socialize (Tr. 14-15). Additionally, plaintiff had reported that her level of pain was only a three on a scale of one to ten and her physical examination was normal (Tr. 14-15).
Next, the ALJ noted that although Dr. Remer recommended a right knee replacement in June 2012 and x-rays showed advanced osteoarthritis in July 2012, Dr. Remer reported on December 21, 2011 that plaintiff's pain was "only intermittent and moderate to severe, when walking" (Tr. 14). According to the ALJ, there was no indication that plaintiff had difficulty sitting or performing any postural activities at that time (Tr. 14-15).
The ALJ "decline[d] to accord Dr. Kaci's opinion much weight" because it was rendered two years after the relevant time period (Tr. 15). The ALJ stated that although plaintiff's RFC may have been limited at that time, the other evidence in the record failed to show that those same restrictions existed during the relevant time period (Tr. 15-16). He further noted that "there is little basis in this record to find that the claimant's ability to sit is restricted and that she cannot perform any postural activities" (Tr. 16).
At step four, the ALJ concluded that plaintiff was able to perform her past relevant work as a receptionist or counselor (Tr. 16). Accordingly, the ALJ found that plaintiff was not disabled and did not proceed to the fifth step of the analysis (Tr. 16).
Plaintiff contends that the ALJ's decision was not supported by substantial evidence and should be vacated (Memorandum of Law in Support of Plaintiff's Motion for Judgment on the Pleadings, dated May 9, 2016 (D.I. 23) ("Pl.'s Mem.").
As described above, the ALJ went through the sequential process required by the regulations. The ALJ's analysis at steps one and two were decided in plaintiff's favor, and the Government has not challenged those findings. I shall, therefore, limit my discussion to whether the ALJ's analysis at steps three and four complied with the applicable legal standards and were supported by substantial evidence.
Plaintiff contends that the ALJ's determination that plaintiff's right knee impairment did not meet listing 1.02 was erroneous and was not supported by substantial evidence (Pl.'s Mem., at 9). Plaintiff first asserts that the determination of whether a condition meets or equals a listing "requires the input of a medical expert" and argues that the ALJ should not have drawn his own conclusions (Pl.'s Mem., at 9). Second, plaintiff argues that the medical evidence demonstrates that plaintiff's ability to walk was seriously impaired during the relevant time period (Pl.'s Mem., at 9).
An ALJ is not required to consult a medical expert to determine whether a plaintiff meets a listing. The regulations contain permissive language, stating that an ALJ "
In addition, SSR 96-6p, 1996 WL 374180 (July 2, 1996) does not support plaintiff's argument. According to that ruling, although "longstanding policy requires that the judgment of a physician . . . designated by the Commissioner on the issue of equivalence . . . must be received into the record as expert opinion evidence and given appropriate weight," the "signature of a State agency medical . . . consultant on an SSA-831-U5 (Disability Determination and Transmittal Form) . . . ensures that consideration by a physician . . . designated by the Commissioner has been given to the question of medical equivalence." SSR 96-6p, 1996 WL 374180 at *3. The record here contains a Disability Determination and Transmittal Form, signed by a disability examiner (Tr. 50). Moreover, although SSR 96-9p further explains that an ALJ must obtain an "updated medical opinion from a medical expert" in two circumstances — (1) if the ALJ thinks that the record suggests that a "judgment of equivalence may be reasonable," if no additional medical evidence has been received, or (2) if additional medical evidence has been received that may change "the State agency medical . . . consultant's finding that the impairment(s) is not equivalent" to a listing, SSR 96-6p, 1996 WL 374180 at *4 — those circumstances are not present here because there is no evidence that the ALJ or a state medical consultant thought that plaintiff's knee impairment may have met Listing 1.02. Thus, the ALJ did not err by failing to call a medical expert.
The ALJ's determination that plaintiff's knee impairment did not meet Listing 1.02 is supported by substantial evidence.
An applicant meets or equals Listing 1.02 if she has a major dysfunction of a joint, characterized by
20 C.F.R. Pt. 404, Subpt. P, App. 1 § 1.02. In turn, the Listings define "inability to ambulate effectively" as
20 C.F.R. Pt. 404, Subpt. P, App. 1 § 1.00(B)(2)(b)(1). To ambulate effectively,
20 C.F.R. Pt. 404, Subpt. P, App. 1 § 1.00(B)(2)(b)(2).
The ALJ properly determined that plaintiff did not meet or equal Listing 1.02 because she could ambulate effectively. Although plaintiff testified about her problems with standing and sitting (Tr. 31-32), and she reported that her condition affected her ability to walk (Tr. 242), there is substantial evidence in the record demonstrating that plaintiff's knee impairment did not "interfere[] very seriously with [her] ability to independently initiate, sustain, or complete activities." For instance, according to plaintiff and Dr. Remer, plaintiff required only one cane to stand and walk (Tr. 30, 180).
Dr. Kaci's assessment does not compel a contrary conclusion. Although Dr. Kaci noted that plaintiff was unable to walk on her heels and toes, needed help getting on and off the examination table, had marked limitations in walking, climbing stairs and standing and could not shop, travel without a companion or walk a block at a reasonable pace on rough or uneven surfaces (Tr. 259-60, 263, 265, 267), Dr. Kaci did not assess plaintiff until May 20, 2014 (Tr. 258), nearly two years after the date on which plaintiff was last insured.
Therefore, the ALJ's conclusion that plaintiff's impairment did not meet or equal Listing 1.02 is supported by substantial evidence.
Plaintiff objects to the ALJ's RFC assessment on two grounds. First, plaintiff asserts that the ALJ should not have relied on the F.E.G.S. report because F.E.G.S. is not a medical source (Pl.'s Mem., at 9). Second, plaintiff argues that the ALJ did not properly consider the objective medical evidence and that "[i]f there were any doubts regarding the plaintiff's capacity for work, the ALJ had an obligation to inquire of the treating source or otherwise to seek [a] medical opinion" (Pl.'s Mem., at 7-8). For the reasons stated below, I conclude that while the ALJ did not err in relying on the F.E.G.S. report, he did err by failing to develop the record. In addition, although not raised by the parties, I note that the ALJ failed to perform a function-by-function assessment of plaintiff's RFC.
In reaching his RFC determination, the ALJ relied on those portions of the F.E.G.S. report describing plaintiff's ability to perform certain activities, such as washing dishes and clothes, sweeping, mopping and vacuuming (Tr. 15). Moreover, he relied on that portion of the report noting a lack of abnormal musculoskeletal findings on examination and that plaintiff's level of pain was only a three on a scale of one to ten (Tr. 15).
The ALJ did not commit legal error by relying on the F.E.G.S. report. First, the ALJ was obligated to consider plaintiff's self-reported ability to perform household chores.
Second, the ALJ did not err in relying on the report merely because F.E.G.S. is not a medical source. Whether something is a medical source is relevant when that source is providing a medical opinion.
An ALJ is required to obtain necessary medical records in order to make a proper RFC assessment. 20 C.F.R. § 404.1513(b) ("Medical reports should include . . . (6) A statement about what you can still do despite your impairment(s) based on the acceptable medical source's findings . . . . [L]ack of the medical source statement will not make the report incomplete.");
The ALJ failed to support his RFC assessment with proper expert medical evidence. First, the list of activities plaintiff could perform did not come from a medical expert; rather, they came from plaintiff herself. Second, although the ALJ relied on Dr. Remer's reports in observing that "[t]here was no indication that the claimant had difficulty sitting or performing any postural activities [in December 2011]" (Tr. 14-15), Dr. Remer never specifically explained the scope of plaintiff's functional limitations.
Under such circumstances, and in the absence of other medical evidence in the record regarding plaintiff's functional limitations,
Therefore, because the ALJ failed in his duty to develop the record fully, remand is required.
Although not raised by the parties, I note that the ALJ did not perform a function-by-function assessment of plaintiff's RFC.
Although the failure to perform a function-by-function assessment of plaintiff's RFC does not require remand
For the foregoing reasons, I respectfully recommend that plaintiff's motion (D.I. 17, 22) be granted. I also recommend that the Commissioner's motion (D.I. 24) be denied and that this case be remanded to the SSA for further proceedings.
Pursuant to 28 U.S.C. § 636(b)(1)(C) and Rule 72(b) of the Federal Rules of Civil Procedure, the parties shall have fourteen (14) days from receipt of this Report to file written objections.