MICHAEL A. TELESCA, District Judge.
Represented by counsel, Ana Maria Cordero ("Plaintiff") instituted this action pursuant to Titles II and XVI of the Social Security Act ("the Act"), seeking review of the final decision of the Acting Commissioner of Social Security ("the Commissioner") denying her applications for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI"). This Court has jurisdiction over the matter pursuant to 42 U.S.C. §§ 405(g), 1383(c).
On March 6, 2012, and March 12, 2012, Plaintiff protectively filed applications for SSI and DIB, respectively. Plaintiff, 48 years-old and with past work as an assistant teacher, an eldercaregiver, and a secretary, alleged disability beginning December 15, 2010, due to back pain, neck pain, migraine headaches, and carpal tunnel syndrome. After her claims were denied on August 3, 2012, Plaintiff requested a hearing, which was held via videoconference on October 21, 2013, before Administrative Law Judge Curtis Axelson ("the ALJ"). Plaintiff appeared with her attorney and testified. The ALJ did not call any expert witnesses. On January 8, 2014, the ALJ issued an unfavorable decision. The Appeals Council denied Plaintiff's request for review on July 27, 2015, making the ALJ's decision the final decision of the Commissioner. Plaintiff then timely commenced this action.
The parties have cross-moved for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure. The Court adopts and incorporates by reference the comprehensive factual summaries provided by the parties in their supporting briefs. The medical evidence will be discussed in more detail below, as necessary to the Court's resolution of the issues presented on this appeal.
For the reasons that follow, the Commissioner's decision is reversed, and the matter is remanded for further administrative proceedings consistent with this opinion.
When considering a claimant's challenge to the Commissioner's decision denying benefits under the Act, a district court must accept the Commissioner's findings of fact, provided that such findings are supported by "substantial evidence" in the record.
At step two of the sequential evaluation, the ALJ found that Plaintiff had the following "severe" impairments: lumbar disc disease, early degenerative changes of the cervical spine, carpal tunnel syndrome, asthma and depression. (T.35).
The record indicates that when Plaintiff had a consultative physical examination on July 16, 2012, with Nikita Dave, M.D., she described suffering from headaches twice weekly that included burring of her vision, and sensitivity to light and sound. (T.325). "Headaches" was one of the diagnoses Dr. Dave assigned to Plaintiff, and she noted that Plaintiff "[m]ay have moderate limitations for all activity during acute bout of headache, likely to be transient over a few hours." (T.329).
About five months later, on January 9, 2013, Plaintiff underwent a neurologic consultation with Dr. Laszlo Mechtler (T.858-62), to whom she complained of left-sided hip and leg pain, as well as constant muscle pains, neck pain and headaches, which had been worsening over time. At present, Dr. Mechtler noted, Plaintiff was having daily headaches, rated as 8 out of 10 in severity, that lasted a few minutes. About 4 to 5 times a month, Plaintiff suffered more intense headaches, rated as 10 out of 10 in severity; these were accompanied by photophobia, nausea, neck stiffness, and blurred vision. Headache triggers included sleep disturbances, weather changes, menstrual cycles, and depression. Plaintiff reported that she smoked cannabis on a daily basis for pain relief. Dr. Mechtler diagnosed Plaintiff with migraine without aura, with intractable migraine with status migrainosus;
As noted above, the ALJ did not include headaches among the "severe impairments" he found at step two. "Impairments" are "anatomical, physiological, or psychological abnormalities . . . demonstrable by medically acceptable clinical and laboratory techniques." 20 C.F.R. §§ 404.1508, 416.908. "Severe" impairments are those that "significantly limit" physical or mental abilities to do basic work activities.
The ALJ clearly erred in not finding Plaintiff's migraine headaches to be severe impairments at step two. As an initial matter, severe headaches were diagnosed by at least two "acceptable medical sources," treating physician Dr. Mechtler and consultative physician Dr. Dave.
Plaintiff argues that the ALJ, in electing to give treating physician Dr. James Lawrence's opinion only minimal weight, misapplied the treating physician rule.
On November 8, 2013, Dr. Lawrence completed a physical RFC questionnaire (T.953-54), indicating that in an 8-hour day Plaintiff could sit for 3 hours at a time, and could sit for a total of 4 to 5 hours in an 8-hour day. She could stand and walk for 1 hour at a time, and for 3 hours total in an 8-hour day. She could frequently lift up to 25 pounds but could only occasionally bend, squat, crawl, or climb. She had moderate restriction involving unprotected heights, being around moving machinery, exposure to marked changes in humidity and temperature, driving automotive equipment and exposure to dust, fumes and gasses. Dr. Lawrence opined that Plaintiff's pain and side-effects from her medications would only interfere with work tasks requiring sustained concentration. Dr. Lawrence stated that Plaintiff experienced exacerbations of pain symptoms that would make it impossible for her to function in a work setting. Her symptoms would cause her to miss work three days per month. She had been limited in this way since July 17, 2012. Dr. Lawrence opined Plaintiff could work only 4 to 6 hours a day before her pain would prevent performance of even simple work tasks.
"[T]he treating physician rule generally requires deference to the medical opinion of a claimant's treating physician[.]"
Although the ALJ gave multiple reasons for discounting Dr. Lawrence's opinion, the Court agrees that none of them qualify as "good reasons." First, the ALJ stated that Dr. Lawrence's opinion was "without substantial support from the other evidence of record, which obviously renders it less persuasive." (T.41). The ALJ did not identify, much less allude to, which evidence of record failed to offer "substantial support" for Dr. Lawrence's opinion. This was error, and it precludes the Court from conducting a meaningful review of whether the ALJ's decision is supported by substantial evidence.
In fact, there is objective evidence in the record that supports Dr. Lawrence's opinion. For instance, on September 7, 2012, Dr. Lawrence reviewed Plaintiff's low back MRI (T.844), which revealed L5-S1 disc space narrowing and dehydration; a broad based central disc herniation; and a separate far left lateral disc herniation encroaching on the left foramen. At L4-5, there was a mild disc bulge with a small left paracentral disc herniation, a far right lateral annular tear, and a small disc herniation which had decreased in size. At L3-4 there was a mild disc bulge.
A subsequent MRI in July of 2013, revealed a straightening/slight reversal of normal cervical lordosis which may have been secondary to muscle spasm; multi-level loss of signal and ventral osteophytes involving mild cervical spine slight anterolisthesis of C2 over C3; and slight retrolisthesis of C5 over C6 suspected on the lateral neutral projections. (T.867). At C2-C3, there was a mild posterior broad based disc bulge/left posterolateral asymmetric disc bulging/protrusion associated with mild bilateral facet joint arthropathy and uncovertebral joint hypertrophy more prominent on the left resulting in mild neural foraminal narrowing on the left. At C3-4, there was a posterior broad based disc herniation with mild indentation of the ventral aspect of the spinal cord, and mild bilateral uncovertebral joint hypertrophy resulting in mild neural foraminal narrowing bilaterally. At C4-5, there was a mild posterior disc bulge and central focal disc protrusion flattening the ventral aspect of the spinal cord. At C5-6, there was a broad based disc herniation and posterior spurring flattening the ventral aspect of the spinal cord, mild bilateral facet joint arthorpathy, and uncovertebral joint hypertrophy resulting in mild bilateral neural foraminal narrowing. At C6-7, there was a mild posterior disc bulge and mild central focal subligamenious protrusion. When Plaintiff consulted with Dr. Zair Fishkin on October 24, 2013, he reviewed Plaintiff's MRIs and assessed her with a tentative diagnosis of C3-6 herniated nucleus pulpous, L5-S1 herniated nucleus pulposus, left hip greater trochanteric bursitis and left hip origin of pain. (T.949-50). He opined that she was a "poor candidate" for discectomy to correct the "fairly large left-sided disc herniation at L5-S1" with associated degenerative changes and loss of disc space height at L5-S1. Instead, she would require a "near-complete facetectomy." (T.950). Dr. Fishkin cautioned that even with this surgery, there was a risk that the disc level would continue to collapse. (
The ALJ also discounted Dr. Lawrence's opinion because he found Plaintiff's treatment history with him to be "quite brief." (T.41). Under the Commissioner's Regulations, a treating source is afforded greater weight once he has examined the claimant "`a number of times and long enough to have obtained a longitudinal picture of [the alleged] impairment.'" 20 C.F.R. §§ 404.1527(c)(2)(i), 416.927(c)(2)(i). "Importantly, there is no arbitrary, minimum period of treatment by a physician before this standard is considered met."
The ALJ additionally characterized Dr. Lawrence's opinion as speculative, stating that when Dr. Lawrence said Plaintiff was "disabled," it was "possible that the doctor was referring solely to an inability to perform the claimant's past work, which is consistent with the conclusions reached in this decision." (T.41). There are at least two grounds for discarding this statement as a "good reason." First, as the Court and the parties are well aware, the ultimate question as to whether a claimant is disabled is reserved to the Commissioner. Dr. Lawrence, however, did not simply pronounce that Plaintiff is disabled and leave it that. Instead, his report details the specific functional limitations attributable to Plaintiff's severe impairments and the resultant symptoms, and offers his opinion as to how her capacity to perform full-time gainful employment would be affected. Specifically, the sitting limitations (four to five hours) Dr. Lawrence assigned would preclude Plaintiff from performing sedentary work, and the standing/walking limitations (three hours) would exclude light work as an option.
Finally, the ALJ faulted Dr. Lawrence's opinion as being internally inconsistent because he "opined that [Plantiff] could work 4-6 hours if limited to part time work." (T.41). However, this statement does not contradict Dr. Lawrence's opinion that Plaintiff is unable to perform "full-time competitive employment five days per week, eight hours per day on a sustained basis," i.e., she could not work 40 hours a week on a "regular and continuing basis."
The fourth sentence of Section 405(g) of the Act provides that a "[c]ourt shall have power to enter, upon the pleadings and transcript of the record, a judgment affirming, modifying, or reversing the decision of the Commissioner. . ., with or without remanding the case for a rehearing." 42 U.S.C. § 405(g). Although it is less typical, reversal without remand is the appropriate disposition when the record contains "persuasive proof of disability,"
Here, that standard is met. Beginning at step two, with the omission of Plaintiff's medically determinable migraine headaches as a "severe impairment," the ALJ's sequential evaluation was marred by legal errors and mischaracterizations of the record. Of particular note is the ALJ's failure to properly apply the treating physician rule, and the corollary "good reasons" rule, when weighing the medical source statement of Plaintiff's treating specialist, Dr. Lawrence. None of the regulatory factors support a decision not to afford controlling weight to Dr. Lawrence's opinion, which is consistent with the evidence of record, as discussed further above in this Decision. If Dr. Lawrence's opinion were given controlling weight, Plaintiff would be unable to maintain competitive gainful employment.
For the foregoing reasons, the Commissioner's motion for judgment on the pleadings is denied, and Plaintiff's motion for judgment on the pleadings is granted. The Commissioner's decision is reversed, and the matter is remanded solely for the calculation and payment of benefits. The Clerk of Court is directed to close this case.