DAVID N. HURD, District Judge.
Plaintiff Luis Felipe Diaz Sanjurjo ("Sanjurjo" or "plaintiff") brings this action, pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3), seeking review of defendant Commissioner of Social Security's ("Commissioner" or "defendant") final decision denying his application for Supplemental Security Income ("SSI"). The parties have filed their briefs as well as the Administrative Record on Appeal and the motions will be considered on the basis of these submissions without oral argument.
On January 22, 2008, Sanjurjo filed an application for SSI claiming a period of disability beginning on December 1, 2006. R. at 334-36. This application was initially denied on March 31, 2008.
On April 21, 2010, the ALJ rendered a written decision concluding that Sanjurjo was not disabled within the meaning of the Social Security Act (the "Act") from January 8, 2008 through the date of this decision. R. at 113-20. Plaintiff timely appealed this unfavorable disability determination to the Appeals Council, who granted his request for review, vacated the ALJ's decision, and remanded the claim for further consideration.
On April 19, 2012, the ALJ held a supplemental hearing in accordance with the remand order issued by the Appeals Council. R. at 35-58. Plaintiff, represented by an attorney, again testified through a Spanish interpreter.
On May 22, 2012, the ALJ rendered another written decision, again concluding Sanjurjo was not disabled within the meaning of the Act. R. at 17-25. This administrative denial became the final decision of the Commissioner on December 5, 2013, when the Appeals Council denied plaintiff's renewed request for review.
On January 27, 2014, Sanjurjo filed this action seeking judicial review of the Commissioner's denial of benefits. Because the parties are familiar with the underlying facts, they are discussed only to the extent necessary to address plaintiff's appeal.
A court's review of the Commissioner's final decision is limited to determining whether the decision is supported by substantial evidence and the correct legal standards were applied.
"To determine on appeal whether an ALJ's findings are supported by substantial evidence, a reviewing court considers the whole record, examining the evidence from both sides, because an analysis of the substantiality of the evidence must also include that which detracts from its weight."
However, "where there is a reasonable basis for doubting whether the Commissioner applied the appropriate legal standards," the decision should not be affirmed even though the ultimate conclusion reached is arguably supported by substantial evidence.
The Act defines "disability" as the "inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." 42 U.S.C. § 423(d)(1)(A). In addition, the Act requires that a claimant's:
The ALJ must follow a five-step evaluation process in deciding whether an individual is disabled.
If the claimant has not engaged in substantial gainful activity, then step two requires the ALJ to determine whether the claimant has a severe impairment or combination of impairments which significantly restricts his physical or mental ability to perform basic work activities.
If the claimant is found to suffer from a severe impairment or combination of impairments, then step three requires the ALJ to determine whether, based solely on medical evidence, the impairment or combination of impairments meets or equals an impairment listed in Appendix 1 of the regulations (the "Listings").
If the claimant is not presumptively disabled, step four requires the ALJ to assess whether—despite the claimant's severe impairment—he has the residual functional capacity ("RFC") to perform his past relevant work. 20 C.F.R. §§ 404.1520(f), 416.920(f). The burden of proof with regard to these first four steps is on the claimant.
If it is determined that the claimant cannot perform his past relevant work, the burden shifts to the Commissioner for step five.
The ALJ found Sanjurjo had not engaged in substantial gainful activity since January 8, 2008, the application date. R. at 19. The ALJ next found plaintiff's back impairments, respiratory impairments, and diabetes mellitus to be severe impairments.
Based on these findings and Sanjurjo's age, education, and work experience, the ALJ determined jobs existed in significant numbers in the national economy that plaintiff could perform. R. at 24. Accordingly, the ALJ concluded plaintiff was not disabled within the meaning of the Act.
Sanjurjo argues the ALJ: (1) improperly weighed, or failed to discuss, certain medical opinions in the record; (2) incorrectly assessed his credibility; and (3) posed an incorrect hypothetical to the VE.
Sanjurjo first argues that the ALJ's RFC determination is not supported by substantial evidence because he failed to weigh, or even discuss, the opinions of several medical sources in the record in formulating his ultimate RFC assessment.
A claimant's RFC is an assessment of "what an individual can still do despite his or her limitations."
In his written decision, the ALJ first gave "great weight" to the opinion of John W. Axline, M.D., a medical consultant who had reviewed "all available evidence in the medical record" as of October 2011. R. at 22; 833-43. The ALJ then discussed the opinion of consultative examiner Amelita Balagtas, M.D., finding her opinion on Sanjurjo's limitations to be consistent with Dr. Axline's "more detailed and specific opinion."
Sanjurjo argues that the ALJ's discussion of the medical evidence fails to include any mention of, let alone any narrative discussion regarding, the medical opinions of two of plaintiff's treating providers as well as the opinion of at least one consultative examiner whose opinion allegedly diverges from that of the doctors discussed above.
Sanjurjo first identifies Physician's Assistant John Sullivan, who opined in March 2009 that plaintiff was "moderately limited" in walking, standing, and sitting, and "very limited" in sitting, lifting, carrying, pushing, pulling, and bending. R. at 525. PA Sullivan treated plaintiff from June 2008 through January 2010.
Sanjurjo next identifies Denia Pedreira, M.D., who opined in June 2011 that plaintiff was "moderately limited" in walking and standing and "very limited" in lifting, carrying, pushing, pulling, bending, and climbing. R. at 818. Dr. Pedreira treated plaintiff from November 2010 to June 2011.
Third, Sanjurjo identifies Farag Aboelsaad, M.D., who opined in February 2009 that plaintiff "needs to avoid bending, twisting, [or] lifting heavy objects." R. at 447. Dr. Aboelsaad examined plaintiff at least three times between February and November 2009.
The Commissioner retorts that Sanjurjo's contention regarding these medical opinions—namely, that the ALJ completely omitted any discussion of them in his written decision—is "simply wrong." Def.'s Mem., ECF No. 15, at 15.
There is a good reason the Commissioner has been forced to pursue this tactic on review: the ALJ completely neglected this trio of medical professionals in his written decision. And defendant implicitly concedes this fact, going on to argue that "[i]n any event, that an ALJ must consider all relevant evidence does not mean that the ALJ must specifically address each piece of evidence in his decision." Def.'s Mem. at 16. Defendant closes this portion of argument by noting that PA Sullivan "is not an acceptable medical source and, as such, his opinion is not entitled to deference."
After careful consideration, it is concluded that the ALJ's failure to discuss the opinions of PA Sullivan, Dr. Pedreira, or Dr. Aboelsaad necessitates remand. First, "the ALJ committed reversible error when he failed to mention, consider, or discuss plaintiff's treatment" with Dr. Pedreira, a treating physician.
Second, although the Commissioner argues that PA Sullivan "is not an acceptable medical source and, as such, his opinion is not entitled to def erence," Def.'s Mem. at 16, the ALJ still had a "duty to address and discuss the opinion."
Further, Sanjurjo correctly argues that the ALJ failed to assign any particular quantum of weight to Dr. Balagtas's opinion. "Unless there is a treating source opinion, which is given controlling weight, an ALJ's failure to explain the weight given to the opinion of a State agency medical consultant is legal error."
In sum, remand is necessary so that the ALJ can evaluate and weigh all of the relevant medical opinion evidence in this matter in accordance with the appropriate factors found in the Regulations. Because Sanjurjo's remaining challenges are predicated on conclusions drawn by the ALJ that may be impacted by his reconsideration of the medical evidence, they will not be directly addressed at this time. However, the ALJ is specifically directed to articulate whether, and to what extent, a thorough re-evaluation of the medical evidence alters his assessment of plaintiff's credibility.
The deficiencies in the ALJ's written decision leave a reasonable basis for doubting whether the Commissioner applied the appropriate legal standards.
Therefore, it is
ORDERED that
1. Sanjurjo's motion for judgment on the pleadings is GRANTED in part;
2. The Commissioner's motion for judgment on the pleadings is DENIED;
3. The Commissioner's decision is VACATED; and
4. This matter is remanded to the Commissioner for further administrative proceedings consistent with this opinion.
The Clerk of the Court is directed to close the case.
IT IS SO ORDERED.
