SUZANNE H. SEGAL, Magistrate Judge.
Brandy Renay Brammer ("Plaintiff") seeks review of the final decision of the Commissioner of the Social Security Administration (the "Commissioner" or the "Agency") denying her application for Disability Insurance Benefits ("DIB") and Supplement Security Income ("SSI"). The parties consented, pursuant to 28 U.S.C. § 636(c), to the jurisdiction of the undersigned United States Magistrate Judge. For the reasons stated below, the decision of the Commissioner is REVERSED and REMANDED for further administrative proceedings consistent with this decision.
On May 21, 2009, Plaintiff filed for DIB and SSI, claiming that she became disabled on September 25, 1999. (Administrative Record ("AR") 264-67, 277-83). Plaintiff based her alleged disability on "[l]ower back injury, bu[l]ging disc, deg[enerative] disc,[]nerve pain, failed surgery, pinched nerves." (AR 313). The Agency denied Plaintiff's applications on August 22, 2009 (AR 131-37) and upon reconsideration on March 18, 2010. (AR 140-44).
Plaintiff requested a hearing, which was held before Administrative Law Judge ("ALJ") Jay E. Levine on May 12, 2011. (AR 81-107). On June 24, 2011, ALJ Levine determined that Plaintiff was not disabled. (AR 113-22).
Plaintiff filed a request for review of ALJ Levine's decision, which the Appeals Council (the "Council") granted. (AR 127). On November 16, 2012, the Council vacated the ALJ's decision and remanded the matter for further proceedings. (AR 127-29). Upon remand, the Council directed the ALJ to further consider whether Plaintiff was capable of performing any of her past relevant work, further evaluate Plaintiff's mental impairment, and give further consideration to Plaintiff's maximum RFC during the entire period at issue. (AR 128). Further, if necessary the ALJ was required to obtain evidence from a vocational expert. (AR 129).
On April 25, 2013, ALJ Tamara Turner-Jones (the "ALJ") conducted a hearing following the Council's remand order. (AR 41-80). On June 14, 2013, the ALJ issued an unfavorable decision. (AR 13-28). Plaintiff sought review before the Council (AR 7-9), which the Council denied on February 20, 2015. (AR 1-4). The ALJ's determination thus became the final decision of the Commissioner. Plaintiff filed the instant action on April 17, 2015.
Plaintiff was born on February 20, 1980. (AR 26). She was nineteen years old as of the alleged disability onset date and twenty-three years old at the time of her hearing before the ALJ. (AR 43). In September 1999, Plaintiff suffered a work-related injury. (AR 434). Plaintiff's last-insured date was June 30, 2003. (AR 15).
Dr. Timothy P. Gray, an orthopaedic surgeon, provided Plaintiff treatment of one to two sessions per month between January 2000 to April 2002 in connection with her 1999 workers' compensation claim. (AR 370-441). Dr. Gray primarily treated Plaintiff for her complaints of low back pain with disk degeneration and bilateral leg pain. (
Dr. Thomas Haider, Plaintiff's more recent treating physician, who also treated Plaintiff in connection with her workers' compensation claim, saw Plaintiff at least sixty times between October 2004 to April 2013 for complaints of low back and leg pain. (AR 567-673, 799-864). On November 2, 2006, Dr. Haider performed on Plaintiff a laminotomy, discectomy, and foraminotomy at L4-5 on the right side. (AR 494-95). After the surgery, Plaintiff reported worsening of symptoms. (AR 581, 587, 591, 597, 603-04, 606, 613-14, 619, 621). Dr. Haider reported that a January 2008 radiograph of Plaintiff's cervical spine showed "straightening as well as reversal of cervical lordosis [and] spondylosis of the C2-C4 levels." (AR 599). A July 2008 MRI of Plaintiff's lumbar spine showed "continuation of prominent posterior disc bulge measuring 4 mm in size at the level of L4-5," "bilateral foraminal stenosis," "disc dessication" at L4-5, "mild bilateral facet arthropathy" at L3-4 and L5-S1, and "diffuse disc desiccation" at L3-4, L4-5, and L5-S1. (AR 582).
Between 2004 and 2008, Dr. Haider treated Plaintiff with
On April 23, 2013, Dr. Haider completed a "Physical Residual Capacity Question." (AR 860-64). In the questionnaire, Dr. Haider diagnosed Plaintiff with "status post laminectomy lumbar surgery in 2006." (AR 860). He noted his clinical and objective findings included positive MRI, nerve conduction, and x-ray findings. (
To qualify for disability benefits, a claimant must demonstrate a medically determinable physical or mental impairment that prevents her from engaging in substantial gainful activity and that is expected to result in death or to last for a continuous period of at least twelve months.
To decide if a claimant is entitled to benefits, an ALJ conducts a five-step inquiry. 20 C.F.R. §§ 404.1520, 416.920. The steps are:
The claimant has the burden of proof at steps one through four, and the Commissioner has the burden of proof at step five.
The ALJ employed the five-step sequential evaluation process. At step one, the ALJ found that Plaintiff had not engaged in substantial gainful employment since her alleged onset date of September 25, 1999. (AR 15). At step two, the ALJ found that Plaintiff had the severe impairments of degenerative disc disease of the lumbar spine, status post laminotomy and diskectomy, sprain/strain of the cervical spine, asthma, and obesity. (AR 16).
At step three, the ALJ found that Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1 (20 C.F.R. §§ 404.1520(d), 404.1525, 404.1526, 416.920(d), 416.925 and 416.926). (AR 18). The ALJ then found that Plaintiff had the following RFC:
(
In making this finding, the ALJ considered Plaintiff's subjective allegations, but did not find them fully credible. (AR 20-25). The ALJ also noted that:
(AR 26).
At step four, the ALJ found that Plaintiff has no past relevant work. (
Under 42 U.S.C. § 405(g), a district court may review the Commissioner's decision to deny benefits. The court may set the decision aside when the ALJ's findings are based on legal error or are not supported by substantial evidence in the record as a whole.
To determine whether substantial evidence supports a finding, the court must "`consider the record as a whole, weighing both evidence that supports and evidence that detracts from the [Commissioner's] conclusion.'"
Plaintiff contends that the Commissioner's decision should be overturned for two reasons. First, Plaintiff contends the ALJ did not properly consider the opinion of treating physicians, Dr. Gray and Dr. Haider, in determining Plaintiff's RFC. (Plaintiff's Memorandum in Support of Complaint (the "MSC"), Dkt. No. 14, at 4-9; Plaintiff's Reply Memorandum in Support of Complaint ("Reply"), Dkt. No. 16, at 3-5). Second, Plaintiff claims that the ALJ did not properly consider her subjective pain testimony. (MSC at 9-13; Reply at 5-7). Because the Court concludes that the ALJ did not properly consider Plaintiff's treating physicians' opinion, it is unnecessary to address the remaining issue raised by Plaintiff.
Social Security regulations require the ALJ to consider all relevant medical evidence when determining whether a claimant is disabled. 20 C.F.R. §§ 404.1520b, 416.927(c). The opinions of treating physicians are entitled to special weight because the treating physician is hired to cure and has a better opportunity to know and observe the claimant as an individual.
Plaintiff argues that the "ALJ was correct in stating that Dr. Gray's records indicate that [Plaintiff] was released to perform primarily sedentary work," however, the ALJ failed to properly consider Dr. Gray's conclusion that Plaintiff would be limited to working at that level only for two to four hours per day. (MSC at 4-9; Reply at 3-5). The Court agrees.
In determining Plaintiff's RFC, the ALJ noted that she gave "significant weight, but not controlling weight to the opinions expressed by Dr. Gray." (AR 25). The ALJ explained that although Dr. Gray "felt throughout the workers' compensation records that [Plaintiff] could perform at least sedentary work. . . [s]ince his assessments of [Plaintiff's] capacity was done within the workers' compensation setting and do not reflect the specific function-by-function residual functional capacity required by the Regulations, it is not accorded controlling weight." (
The ALJ also has a duty to translate Dr. Gray's workers' compensation findings into Social Security terms.
Because the ALJ failed to provide specific and legitimate reasons for rejecting Dr. Gray's opinion, the case must be remanded to remedy this defect. Upon remand, the ALJ must translate Dr. Gray's workers' compensation findings into appropriate social security terminology, and then either provide specific and legitimate reasons to reject Dr. Gray's opinions or incorporate the limitations provided by Dr. Gray into the RFC determination.
Plaintiff contends that the ALJ failed to articulate legally sufficient reasons for rejecting Dr. Haider's opinions. (MSC at 7-9; Reply at 5). The Court agrees.
In determining Plaintiff's RFC, the ALJ considered Dr. Haider's April 23, 2013 "Physical Residual Functional Capacity Questionnaire." (AR 860-64). As noted by the ALJ, Dr. Haider opined that Plaintiff could lift and carry up to ten pounds. (AR 25). Plaintiff was limited in her ability to perform manipulative maneuvers with her hands and she had marked limitation her ability to twist at the waist. (
Although the ALJ gave "great weight" to Dr. Haider's April 2013 assessment that Plaintiff could "lift and carry up to 10 pounds," she gave "minimal weight to the other limitations, as they are not well supported by the objective record as a whole." (AR 25). More specifically, the ALJ rejected Dr. Haider's opinion that Plaintiff would be "absent more than three times per month [because it] is speculative and without substantial support from the record." (
As an initial matter, because the ALJ specifically found Dr. Haider's opinion regarding Plaintiff's ability to sit and stand "unclear and confusing," the ALJ had a duty to re-contact Dr. Haider for clarification rather than simply rejecting his opinion.
Moreover, the ALJ erred in rejecting Dr. Haider's opinion as "speculative." As discussed above, Dr. Haider treated Plaintiff over the course of nearly nine years on a frequent and continual basis, and his opinion is supported by clinical findings and objective diagnostic testing. (AR 567-673, 799-864). Under these circumstances, the ALJ's assertion that Dr. Haider's opinion is "speculative" is not a specific and legitimate reason to reject his opinion.
Next, although the ALJ cites to moderate pathology in Plaintiff's lumbar spine, as well as mild to moderate sensory radiculopathy to reject Dr. Haider's opinion, the ALJ fails to explain how those findings are inconsistent with Dr. Haider's opinion.
The ALJ's next reasoning that the record "largely" shows that Plaintiff was able to ambulate effectively and there is nothing to indicate she was reliant on an assistive device for ambulation or stability lacks substantial support in the record. Numerous progress notes from Dr. Haider reflect that Plaintiff had "difficulty walking," "difficulty changing position and getting onto the examining table," "guarding with motion," "antalgic gate" and/or positive straight leg test. (AR 568, 572, 576, 578, 582, 585, 588, 592, 595, 598, 602, 604, 606, 610, 612, 614, 619, 629, 631, 635, 637, 640, 643, 647, 653, 655, 661, 665, 800, 802, 810, 812, 816, 818, 823, 828, 830, 832).
The ALJ's statement that there is "nothing in the record, except for [Plaintiff's] subjective complaints, showing any significant limitations in the cervical spine or the upper extremities" is contradicted by the record. Rather, the evidence reflects, Dr. Haider found on several occasions "tenderness in the cervical spine, left pericervical w/spasm, right pericervical w/spasm, and trapezius" and "evidence of muscle spasm at the cervical spine." (AR 572, 575, 581, 584, 587, 591, 594, 597). Dr. Haider also noted that "[r]adiographs of the cervical spine show cervical straightening as well as reversal of cervical lordosis as well as spondylosis of the C2-C4 level" and "severe muscle spasm." (AR 599). Thus, Dr. Haider did not base his opinions regarding Plaintiff's cervical spine or upper extremity limitations solely on Plaintiff's subjective complaints.
Finally, the finding that Plaintiff responded well to conservative non-narcotic pain medications is not entirely consistent with the record. As an initial matter, in 2008, Plaintiff underwent detoxification due to her inability to control the use of narcotic medications. As a result, Plaintiff was prescribed only non-narcotic medications after 2008. (AR 576, 579, 804). Dr. Haider's progress notes reflect that the non-narcotic medications were not effective in alleviating her pain because Plaintiff continually complained of increasing or severe pain, which Dr. Haider continued to treat through 2013. (AR 568, 571, 573, 800, 802, 810, 812, 823, 825, 828, 832, 837-38, 842-43, 845, 852-53). Plaintiff also requested, and was given several trigger point or nerve block injections to help alleviate her pain. (AR 568, 810, 812, 823-24, 828, 830, 843, 846, 853). Accordingly, the finding that Plaintiff "responded well to conservative nonnarcotic pain medications" is not supported by the medical evidence. Dr. Haider's progress notes chronicle Plaintiff's struggle with her back and leg pain, and at no point show sustained improvement or stabilization with conservative treatment. Thus, the ALJ's conclusion cannot be considered a specific and legitimate reason.
On remand, the ALJ should contact Dr. Haider, obtain clarification regarding his opinion, reconsider Dr. Haider's opinion, and as necessary, revise Plaintiff's RFC.
Accordingly, IT IS ORDERED that judgment be entered REVERSING the decision of the Commissioner and REMANDING this matter for further proceedings consistent with this decision. IT IS FURTHER ORDERED that the Clerk of the Court serve copies of this Order and the Judgment on counsel for both parties.