PAMELA K. CHEN, District Judge.
Plaintiff Bernice Yu ("Yu") commences this action under 42 U.S.C. § 405(g)
Yu was an attorney with 17 years of experience and a law degree from Fordham. (R. 43, 424.) A series of events — a back injury in February 2004, reinjury to her back in early 2005, and subsequent
Before Yu became disabled, she earned a six-figure salary working in-house at an international conglomerate of advertising and marketing agencies, including McCann Erickson. (R. 32, 135.) In this position, Yu advised clients, drafted contracts, conducted negotiations, supervised lawsuits and government investigations, and dealt with outside law firms. (R. 136.) This position required Yu to stand for approximately six hours and sit for approximately six hours each day and to frequently lift or carry files weighing ten pounds or more. (Id.) Yu held this position until February 2002, when she was terminated. (R. 32-33.) After her termination, in around 2003, Yu tried but failed to find other positions as an in-house attorney.
Yu was 45 years old in February 2004, when her disability started. (R. 119, 131.) Yu continued to satisfy the Social Security Act's insured status requirement until December 2008, when she was 50 years old.
On October 21, 2004, as requested by Yu's primary physician, Dr. Diana Santini (R. 223, 335), Dr. Leila Rafla-Demetrious saw Yu for an ophthalmology consultation, because Yu complained about "floaters" in her eyes. (R. 224, 238.) At this consultation, Dr. Rafla-Demetrious recited Yu's history of type II diabetes, hepatitis B, hypertension, and a cataract in the left eye,
On January 4, 2005, Dr. Rafla-Demetrious prescribed Xalatan to treat Yu's potential glaucoma. (R. 235.) Three weeks later, Dr. Rafla-Demetrious found that Yu had exhibited a "good response" to Xalatan, but additionally diagnosed Yu with a cataract in the right eye. (R. 231.)
On March 22, 2005, Dr. Rafla-Demetrious newly diagnosed Yu with an after-cataract
On October 17, 2006, Dr. Rafla-Demetrious also prescribed Lumigan to treat Yu's open-angle glaucoma, because the amount of pressure in her eyes was "poor." (R. 252.) One month later, Dr. Rafla-Demetrious found that Yu's eye pressure was "better ... on Lumigan, though still a bit higher than optimal." (R. 256.)
On January 23, 2007, Dr. Rafla-Demetrious found that Yu's eye pressure was "poor ... on Lumigan" and "higher than optimal," so prescribed Istalol instead. (R. 258.) Yu also complained about blurriness, and indeed her vision had deteriorated to 20/100 in the right eye and 20/80 in the left eye. (R. 257.) Two months after that, Dr. Rafla-Demetrious found that Yu's eye pressure was "still higher than optimal" on Istalol. (R. 261.) Yu's vision, however, had improved in both eyes: 20/50 in the right eye and 20/40 in the left eye. (R. 260.)
On June 5, 2007, Dr. Rafla-Demetrious also prescribed Azopt, in addition to the Istalol that Yu was already prescribed, as Yu's eye pressure was still too high. (R. 263.) A month later, Dr. Rafla-Demetrious took Yu off Azopt and prescribed Travatan Z as an alternative, because the combination of Azopt and Istalol had not lowered Yu's eye pressure. (R. 266.)
On December 13, 2007, Dr. Rafla-Demetrious suddenly discovered that Yu had a "good" amount of eye pressure. (R. 277.) Yu's vision was nearly the same: 20/60 in the right eye and 20/40 in the left eye. (R. 276.) Two months later, Dr. Rafla-Demetrious again found that Yu had a "fair/good" amount of eye pressure. (R. 285.) Yu's vision had improved slightly to 20/40 in the right eye and 20/25 in the left eye. (R. 284.) Further follow-ups led to similar findings. (See R. 287 (May 29, 2008), 290 & 292 (Aug. 26, 2008), 295-96 (Dec. 22, 2008), 301-302 (Feb. 3, 2009).)
On February 3, 2009, Yu discussed with Dr. Rafla-Demetrious and agreed to proceed with surgery for the cataract in Yu's right eye. (R. 300, 302.)
On February 23, 2009, during a pre-operative examination requested by Dr. Rafla-Demetrious, Dr. Santini noted that Yu was unable to read with the right eye which was blurry, but otherwise had no pain in that eye. (R. 380.)
On March 2, 2009, Dr. Rafla-Demetrious performed the surgery, which involved cataract extraction and lens implantation in the right eye. (R. 311.) Yu went home the same day as the surgery. (Id.) After the surgery, Dr. Rafla-Demetrious described Yu as either "doing well" or "doing great." (R. 323 (Mar. 3, 2009), 318 (Mar. 10, 2009), 326 (Apr. 7, 2009), 329 (May 19, 2009).) Her vision, a month after the surgery,
On May 19, 2009, Dr. Rafla-Demetrious's impression was that, with respect to Yu's open-angle glaucoma, the amount of pressure was "ok" in the right eye, but "borderline" in the left eye. (R. 329.)
After Yu started feeling pain precipitated by the injury and reinjury to her back in 2004 and 2005, Dr. Santini referred Yu to an unnamed orthopedist. (R. 158.) This orthopedist ordered an MRI, which revealed a herniated disc in Yu's lumbar (lower back) spine
On June 14, 2005, pain management specialist, Dr. Joel Kreitzer, began seeing Yu. (Id.) Dr. Kreitzer noted at this time that, due to the herniated disc, Yu felt pain in her left buttock down to her ankle and cramping in her legs.
Thus, on April 21, 2006,
On May 11, 2006, Yu underwent surgery on her lumbar spine, performed by Dr. Casden: laminotomy
On May 22, 2006, during Yu's first post-operative follow-up, Dr. Casden's nurse practitioner noted that "[t]he pain [Yu] had before surgery is mostly resolved, although she does get occasional cramping." (R. 189.) At another follow-up a week after, Dr. Casden summarily stated that Yu "has had a nice result from surgery," and was "doing well and looks good." (R. 188.) At a July 11, 2006 follow-up, Dr. Casden briefly noted that Yu was "doing nicely" with "no significant problems" after the surgery. (R. 187.)
On March 13, 2007, Dr. Casden repeated that Yu was "doing nicely" after the surgery on her lumbar spine, but now noted that she sometimes suffered pain, which was "quite bad," in and around the thoracic (upper-and-middle-back) spine. (R. 186.) Accordingly, Dr. Casden ordered an MRI of Yu's thoracic spine. (Id.) This MRI, taken on March 21, 2007, revealed that, though Yu's thoracic spine seemed fine, her lower cervical (neck) spine had "extensive" osteophytes
On March 30, 2007, Dr. Casden again repeated that Yu was "doing nicely" after the surgery. (R. 185.) In contrast to his last set of notes, however, Dr. Casden noted this time that Yu had "some minor aches and pains with complaints here and there but nothing really too bad." (Id.)
On September 2, 2008, Dr. Casden prepared a letter in support of Yu's claim before the Internal Revenue Service ("IRS") that Yu was disabled when she withdrew funds from her qualified retirement
On September 19, 2008, when Yu returned to Dr. Casden for the last time, Dr. Casden noted that Yu had pain "all over" which was difficult to pinpoint and, as such, recommended that she visit a rheumatologist. (R. 184, 409.)
On November 25, 2008, as recommended by Dr. Casden, a rheumatologist, Dr. Jessica Berman, saw Yu for a consultation. (R. 208.) As Dr. Berman noted, Yu reported tension in her neck, "sharp pain" in her torso from turning, some stiffness in her hands when performing specific tasks, occasional sciatica,
Upon referral by Dr. Santini (R. 359), Yu also began a series of physical therapy sessions. The therapist's notes from these sessions referenced the surgery on Yu's lumbar spine in 2006, and that her physician had determined that Yu suffered pain and weakness in her legs and feet. (E.g., R. 337.) The therapist found that Yu "tolerated... well" her first two sessions in late January 2009. (R. 337, 339.) At the second session, the therapist even noted that Yu supposedly felt better. (R. 339.)
On February 23, 2009,
At another physical therapy session on April 22, 2009, the therapist found that Yu had pain and weakness in her right knee, noting that she felt this pain when taking stairs and slightly when walking and that this pain registered as an eight on a ten-point scale. (R. 343.) At subsequent sessions, the therapist found that, in addition
In an undated questionnaire, Dr. Casden cited the fact that, from April 21, 2006 to September 19, 2008, he had examined Yu every four to six weeks. Dr. Casden indicated that, during these prior examinations, Yu (i) primarily exhibited pain and fatigue as her symptoms and (ii) demonstrated limited range of motion, tenderness, spasms, and swelling.
On July 12, 2006, two months after the surgery on Yu's lumbar spine, Yu went to the emergency room with tenderness in her lower right abdomen. (R. 160.) Weill Cornell physicians conducted a CT scan, which revealed that Yu had (i) appendicitis with a ruptured appendix,
On August 18, 2006, Yu sought a second opinion from surgeon, Dr. Michael Lieberman, who confirmed that she had appendicitis with a ruptured appendix. (R. 165-66; see R. 174.) Dr. Lieberman ordered a second CT scan, and recommended an appendectomy.
On October 19, 2006, Dr. Lieberman performed the appendectomy laparoscopically, with tubes inserted in the abdomen through small incisions,
After the appendectomy, Dr. Lieberman saw Yu again for follow-ups on October 30, 2006 and January 29, 2007. (R. 174.) During Yu's final visit, Dr. Lieberman advised that Yu see an "internist" about the untraceable pain in her side and chest. (Id.)
In July or August 2007, Yu started seeing Dr. James Lax, a gastroenterologist, regarding her "persistent GI problems," including those stemming from the appendectomy. (R. 149, 176.) On September 14, 2007, based on an endoscopy, Dr. Lax newly diagnosed Yu with esophagitis with Barrett's metaplasia,
On February 13, 2010, Dr. Lax stated, in a letter, that Yu's hepatitis B, liver issues, and GI problems "for which I have seen her in the past" had not contributed to her disability. (R. 396.) Rather, in Dr. Lax's opinion, Yu's disability was "more related to her diabetes, hypertension, herniated disks, and ... related to a complicated ruptured appendix and ensuing surgery, before she became my patient." (Id. (emphasis added).)
On February 26, 2011, in response to questions regarding Yu's "ability to do work-related activities," Dr. Lax represented that he was unable to answer any of the questions, among which were questions about the length of time for which Yu could stand or sit and the amount of weight that Yu could lift or carry. (R. 404-407.)
On May 7, 2011, a psychologist, Dr. Ronald Sherman, saw Yu for the first and only time. (R. 416.) As Dr. Sherman noted, Yu explained that she had previously never visited any psychiatrists, because "Chinese never visit ... psychiatrist[s]." (R. 424 (quotations omitted).) Dr. Sherman found that Yu exhibited the following symptoms, evidence of which existed as early as November 25, 2008
(R. 424; see R. 417-18 (additionally naming "[r]ecurrent panic attacks" and "[o]bsessions or compulsions" as symptoms).)
In light of these findings, Dr. Sherman clinically diagnosed Yu with generalized
On July 2, 2009, in a disability report, Yu stated that, even though her last employer terminated her before she became disabled, Yu's set of impairments — including glaucoma, spinal issues, GI problems, diabetes, hepatitis B, and hypertension — had prevented her from further employment. (R. 134-35, 143.) Yu claimed that these impairments caused her "constant fatigue and pain all the time," such that she could no longer stand or sit for long periods of time. (R. 135.)
On May 12, 2011, at the hearing before the ALJ, Yu similarly testified that "chronic health problems[,] stemming initially from the back injury" in February 2004, kept her from working again. (R. 34.) Yu denied her ability to resume her past work as an in-house attorney, as she could not "sustain the periods of time that I need to do documents," let alone handle the "mere physical strain" of going to work for eight hours at a desk. (R. 43, 46.) Yu admitted that, in spite of her inability to work, she was able to care for her daughter, volunteer at her daughter's school, perform chores around the house, and do light shopping for groceries across the street. (R. 47.) Yu also admitted that she could casually walk up to five blocks. (R. 47-48.)
In terms of impairments, Yu cited the cataracts and glaucoma in her eyes, and testified that she had trouble seeing the computer screen. (R. 43.) Yu further testified that (i) before the surgery on her lumbar spine in May 2006, she had weakness in her left leg, which forced her to walk with a baby stroller, and sharp pain in her buttocks and down her leg, and that
On July 2, 2009, Yu applied for Social Security disability insurance benefits. (Compl. ¶ 6; R. 13, 119.) The Social Security Administration ("SSA") denied Yu's application. (Compl. ¶ 7; R. 13, 53-56.) Yu then requested a hearing before the ALJ, which took place on May 12, 2011. (Compl. ¶¶ 7-8; R. 13, 61-62.)
On June 14, 2011, the ALJ also denied Yu's application. (R. 21.) In his decision, the ALJ found, inter alia, that:
Based on these findings, the ALJ concluded that Yu was not disabled for the relevant period covered by her application under the Social Security Act. (R. 20-21.)
On July 15, 2011, in a letter to the Appeals Council for the SSA's Office of Disability Adjudication and Review (the "Council"), Yu requested review of the ALJ's decision. (R. 7.) On January 5, 2012, the Council refused to conduct such a review. (R. 1-3.)
Accordingly, on February 17, 2012, Yu commenced this action. (Compl., at 1.)
This Court may reverse the Commissioner's final decision, issued by the
Whereas the "substantial evidence" standard of review for the ALJ's factual findings is deferential, the standard of review for his legal conclusions is not. "Where an error of law has been made that might have affected the disposition of the case, this court cannot fulfill its statutory and constitutional duty to review the decision of the administrative agency by simply deferring to the factual findings of the ALJ." Townley v. Heckler, 748 F.2d 109, 112 (2d Cir.1984) (quoting Wiggins v. Schweiker, 679 F.2d 1387, 1389 n. 3 (11th Cir.1982)). Thus, even if this Court can defer to the ALJ's factual findings, it cannot permit legal errors in the decision below.
Yu's "disability" must have (i) started no later than the date she last satisfied the insured status requirement and (ii) ended no sooner than one year from the date she applied for Social Security disability insurance benefits. 42 U.S.C § 416(i)(2)(C), (E); see 20 C.F.R. § 404.315(a). As Yu had maintained insured status until December 2008 and applied for benefits in July 2009, the ALJ appropriately considered whether Yu's period of disability began before December 2008 and lasted until at least July 2008. (R. 18.) Periods of disability starting in May 2011 or ending in August 2007, for instance, would have been irrelevant.
In making his factual findings regarding Yu's "disability,"
At the second step in the five-step analysis, with respect to Yu's mental impairments, the ALJ should have also applied a "special technique" in assessing whether such impairments were severe: first finding if Yu had "medically determinable" impairments, then finding her "degree of functional limitation" stemming from these impairments. Kohler v. Astrue, 546 F.3d 260,
In his decision, the ALJ merely cited the fact that Yu's "medically determinable" mental impairments were diagnosed by Dr. Sherman in May 2011, "well after" December 2008, and concluded that therefore such impairments did not exist during the relevant period. (R. 15-16; see Dkt. No. 13 ("Def. Br."), at 17-19.) The ALJ erred in his conclusion. (See Pl. Br., at 17-20.)
Despite not having examined Yu during the relevant period, Dr. Sherman determined that she had developed generalized anxiety disorder, major depressive disorder, and hypochondriasis, rendering her "totally disabled," as early as November 2008. The date of Dr. Sherman's examination should not have been the dispositive reason for rejecting this diagnosis. Rather than rejecting Dr. Sherman's "retrospective diagnosis," the ALJ should have assessed the basis for this diagnosis by developing the record. See Rogers v. Astrue, 895 F.Supp.2d 541, 550-52 (S.D.N.Y. 2012) (collecting cases).
In Rogers, the court held that the ALJ should have "attempt[ed] to fill the gaps in the administrative record," rather than stressing the absence of "mental health treatment records" from the relevant period and refusing to consider the psychiatrist's "retrospective diagnosis" for the plaintiff's post-traumatic stress disorder. Id. "[I]t was legal error for the ALJ to rely on Plaintiff's lack of evidence from the relevant time period to deny benefits without first attempting to adequately develop the record, or to `pursue or consider the possibility of retrospective diagnosis.'" Id. at 552 (quoting Martinez v. Massanari, 242 F.Supp.2d 372, 378 (S.D.N.Y.2003)); accord Agnese v. Chater, 934 F.Supp. 59, 62-63 (E.D.N.Y.1996) (Wexler, J.) (finding that the ALJ incorrectly ignored that the psychiatrist had diagnosed the plaintiff with panic disorder "dating back to 1972," where no additional evidence had been adduced to contradict this diagnosis).
Had the ALJ fulfilled his duty to develop the record in this action, he might have found that Dr. Sherman's "retrospective diagnosis" was accurate and that Yu had been suffering from mental impairments all along, but avoided seeking treatment for cultural or other reasons. Accordingly, this Court remands this action, instructing the ALJ to reassess Yu's mental impairments after developing the record.
Throughout the five-step analysis, the ALJ was obligated to give "controlling weight" to opinions from treating physicians regarding Yu's impairments, except if these opinions were (i) inconsistent with "other substantial evidence" in the record or (ii) not supported by "medically acceptable clinical and laboratory diagnostic techniques." Green-Younger v. Barnhart, 335 F.3d 99, 106 (2d Cir.2003) (quoting 20 C.F.R. § 404.1527).
If the ALJ did not give these opinions "controlling weight," he needed to consider the following four factors:
Clark v. Comm'r of Soc. Sec., 143 F.3d 115, 118 (2d Cir.1998). Upon consideration of these factors, the ALJ had to specify the weight that he would give to these opinions and provide "good reasons" for giving them such weight. Id. (quotations omitted). See also Shaw, 221 F.3d at 134 (same).
First, Dr. Casden's earlier letter and treatment notes were not substantially inconsistent with his opinions in the undated questionnaire. The letter simply suggested that, because of the surgery on Yu's lumbar spine, Yu had been unable to work between June 2005 and August 2007; it did not imply that she was able to work after August 2007. As reflected in the treatment notes, Yu recovered after the surgery, but also developed significant pain in her cervical spine and eventually pain "all over."
Even if Dr. Casden's earlier letter and treatment notes were inconsistent with his opinions in the undated questionnaire, the ALJ should not have selectively relied on the former, insofar as they supported his conclusion and the latter did not. See Shaw, 221 F.3d at 135 (holding that the district court's reliance on and rejection of inconsistent opinions from the same doctor were "inconsistent use[s]" that "undermine[d] any argument that [this doctor's] opinion was so unreliable that it should not have been assigned controlling weight"). Rather, the ALJ had a duty to develop the record to resolve any conflict in the respective opinions from Dr. Casden. See Rosa v. Callahan, 168 F.3d 72, 76, 79-80 (2d Cir.1999) (Sotomayor, J.) (holding that the ALJ should have supplemented the record, instead of rejecting the treating physician's opinion as inconsistent with his "sparse notes," offering "incomplete information that was necessarily conclusive of very little" (quotations omitted)); Clark, 143 F.3d at 117-18 (holding that the doctor could have explained the "perceived inconsistencies between [his] two reports," had the ALJ developed the record rather than discrediting one of the reports); see also Hartnett v. Apfel, 21 F.Supp.2d 217, 221 (E.D.N.Y.1998) (Gleeson, J.) ("[I]f an ALJ perceives inconsistencies in a treating physician's reports, the ALJ bears an affirmative duty to seek out more information from the treating physician and to develop the administrative record accordingly.").
Second, the remaining medical evidence in the record was not substantially
Additionally, the ALJ cited the other physicians' opinions, without even specifying how they contradicted Dr. Casden's opinions. (R. 19-20.) The ALJ's conclusory statement — that the other physicians' opinions "did not indicate significant problems associated with the claimant's musculoskeletal system" (R. 19) — failed to substantiate his reliance on the other physicians' opinions and rejection of Dr. Casden's opinions on inconsistency grounds. See Smollins v. Astrue, No. 11-cv-424, 2011 WL 3857123, at *10 (E.D.N.Y. Sept. 1, 2011) (Gleeson, J.) ("[The ALJ's] perfunctory explanation for his reliance on such opinions and his rejection of the treating physicians' evaluations cannot withstand judicial scrutiny. For this reason alone, I would remand."); Santiago v. Barnhart, 441 F.Supp.2d 620, 630 (S.D.N.Y.2006) (holding that, because "it is unclear how the clinical notes [by other physicians] contradict [the treating physician's] view," the ALJ's determination of inconsistency was "too vague and conclusory").
On appeal, for the first time, the Commissioner seeks to explain the inconsistency between Dr. Casden's opinions and the other physicians' opinions, by specifying that both Dr. Santini and Dr. Berman determined, inter alia, that Yu exhibited normal ranges of motion. (Def. Br., at 13-14.) Such determinations were not, however, necessarily inconsistent with Dr. Casden's opinions in support of Yu's disability. The pain that rendered Yu disabled might have persisted, even though she was able to move about normally. Dr. Berman herself concluded that extension and side-to-side movement caused pain in Yu's cervical spine. In Zubizarreta v. Astrue, No. 08-cv-2723, 2010 WL 2539684 (E.D.N.Y. June 16, 2010) (Dearie, C.J.), the court found that another physician's assessment that the plaintiff possessed a "full range of motion" was not "substantial evidence" of inconsistency entitling the treating physician's opinions to less-than-controlling weight. Id. at *6; accord Dousewicz v. Harris, 646 F.2d 771, 775 (2d Cir.1981) (finding that the fact that the plaintiff "retained full range of motion" "fail[ed] to bear on the question of whether the plaintiff's chronic pain was disabling"). The Commissioner's belated explanation therefore is not convincing.
Finally, Dr. Casden's opinions in the undated questionnaire had a "medical basis." "Medically acceptable clinical and
Even if the ALJ, in referring to "additional medical findings" (R. 19), meant to indicate that Dr. Casden's opinions required more objective evidence, the ALJ should have attempted to acquire such evidence by developing the record. See Schaal v. Apfel, 134 F.3d 496, 505 (2d Cir.1998) ("[E]ven if the clinical findings [in support of the treating physician's opinion] were inadequate, it was the ALJ's duty to seek additional information from [the treating physician] sua sponte."); see also Clark, 143 F.3d at 118 (concluding that the treating physician could have offered clinical findings in support of his report, which stated that "[the plaintiff] could not sit for most of the workday," and that "[the treating physician's] failure to include this type of support for the findings in his report does not mean that such support does not exist").
Accordingly, this Court remands this action, instructing the ALJ to develop the record, determine whether Dr. Casden's opinions deserve controlling weight, and, if applicable, articulate reasons for according less-than-controlling weight to these opinions.
In assessing "residual functional capacity," the ALJ was also required to account for Yu's "reports of pain and other limitations," after analyzing the credibility of her statements through a "two-step process": (i) first, considering if Yu's impairments could "reasonably be expected to produce the symptoms" to which she had testified; and (ii) second, evaluating the extent to which these symptoms were "consistent" with the rest of the record. Genier v. Astrue, 606 F.3d 46, 49 (2d Cir.2010) (per curiam) (citing 20 C.F.R. § 404.1529).
The ALJ concluded that Yu's statements concerning the scope of her symptoms were not credible, as these statements failed to satisfy step two of this test "to the extent they [were] inconsistent with the above residual functional capacity assessment." (R. 17.) The ALJ's conclusion incorrectly assumed that any of Yu's statements that contradicted his "residual functional capacity" assessment lacked credibility. (See Pl. Br., at 21-22.) The ALJ was supposed to account for Yu's statements, after considering their credibility based in part on consistency with the rest of the record, and then assess "residual functional capacity." By putting the proverbial cart before the horse, the ALJ violated the "dictates of the Social Security regulations." Smollins, 2011 WL 3857123, at *11 (denouncing "acceptance as a foregone conclusion" of residual functional capacity in the ALJ's analysis of the plaintiff's credibility); see also Otero v. Colvin,
Accordingly, this Court remands this action, instructing the ALJ to re-analyze the credibility of Yu's statements before assessing whether she had the "residual functional capacity" to resume her past work.
For the foregoing reasons, this Court GRANTS Yu's motion and DENIES the Commissioner's cross-motion. The Commissioner's decision is REVERSED and REMANDED for further proceedings consistent with this Court's decision.
SO ORDERED.
