SHASHI H. KEWALRAMANI, Magistrate Judge.
Plaintiff Marvin J. Cannon ("Plaintiff") seeks judicial review of the final decision of the Commissioner of the Social Security Administration ("Commissioner" or the "Agency") denying his application for disability insurance benefits ("DIB"), under Title II of the Social Security Act (the "Act"). This Court has jurisdiction, under 42 U.S.C. § 405(g), and, pursuant to 28 U.S.C. § 636(c), the parties have consented to the jurisdiction of the undersigned United States Magistrate Judge. For the reasons stated below, the Commissioner's decision is REVERSED and this action is REMANDED for further proceedings consistent with this Order.
Plaintiff filed an application for DIB on October 31, 2012,
The reviewing court shall affirm the Commissioner's decision if the decision is based on correct legal standards and the legal findings are supported by substantial evidence in the record. 42 U.S.C. § 405(g);
"`When evidence reasonably supports either confirming or reversing the ALJ's decision, [the Court] may not substitute [its] judgment for that of the ALJ.'"
To establish whether a claimant is disabled under the Act, it must be shown that:
The ALJ employs a five-step sequential evaluation process to determine whether a claimant is disabled within the meaning of the Act.
The five steps are:
Dr. Lane was one of two treating physician's whose opinions the ALJ considered. Dr. Lane, however, appears to have been the physician who treated Plaintiff the longest, from, at least, December 2007 through December 2014. See Tr. 379, 874. During this seven-year span, it appears that Dr. Lane treated and/or evaluated Plaintiff on, at least, 37 occasions. Tr. 379, 385, 386, 391-97, 406-35, 672, 682, 694, 695, 747, 752, and 873.
Following Plaintiff's spine surgery in March 2012 by neurosurgeon Dr. Ostrup, Dr. Lane treated Plaintiff on at least 17 occasions. Tr. 415-35, 672, 694, 695, 747-52, and 873. Though Dr. Lane indicates that Plaintiff stated he was doing well after the surgery, and indicated on July 6, 2012, that Plaintiff had "moderate improvement of his lumbar back pain[,]" by November 2012, Dr. Lane's findings began to reveal that Plaintiff's condition was deteriorating. Tr. 416, 419.
For example, on November 30, 2012, Dr. Lane issued a more comprehensive report in which he indicated that he "spent an additional 1 ½ hours reviewing [Plaintiff's] chart and medical records and ha[s] assessed the issues with respect to the A.M.A. Guides." Tr. 420 (emphasis in original). Dr. Lane also noted that Plaintiff "initially did well but then began to perform more vigorous activities and his symptoms returned." Tr. 421. In the "Discussion" portion of the report, Dr. Lane compared Plaintiff's condition prior to his back surgery and after his surgery and concluded "there has been new and additional impairment." Tr. 423.
Though Dr. Lane indicated Plaintiff was at a "maximal level of improvement," he stated that Plaintiff's limitations included "difficulty dressing, as well as with standing, sitting, reclining, walking, climbing stairs, lifting, riding, driving, erection, and restful and nocturnal sleep patterns."
Dr. Lane next appeared to examine Plaintiff in March 23, 2013 and in his remarks stated that Plaintiff has "ongoing back pain and pain into the [right] leg." Tr. 428. This report also notes that Plaintiff was trying to do exercises to improve his condition.
On April 23, 2013, and on June 4, 2013, Dr. Lane again treated Plaintiff. Tr. 433-34. In the June 4, 2013, notes, Dr. Lane provided various diagnoses and concluded that "[d]ue to ongoing pain; [Plaintiff] would benefit from a trial of acupuncture." Tr. 434. In addition to these notes, on June 4, 2013, Dr. Lane completed a "Physical Capacities Evaluation" where Dr. Lane concluded that Plaintiff could sit/stand/walk for 2 hours in an eight-hour workday and stated that Plaintiff "needs to alternate position to avoid pain." Tr. 672-74.
Dr. Lane again treated Plaintiff on July 16, 2013, August 27, 2013, and October 18, 2013, for Plaintiff's ongoing pain. Tr. 435, 682, and 694. At the October 18, 2013, visit, Dr. Lane again referred Plaintiff to the neurosurgeon, Dr. Ostrup, "[d]ue to persistent stenosis which has been progressively worse [and Plaintiff] needs reevaluation." Tr. 694. On a November 25, 2013, visit, Dr. Lane noted that Plaintiff met with Dr. Ostrup on December 12 and Plaintiff's "gait: assisted with a cane." Tr. 695.
Dr. Lane continued to treat Plaintiff on May 12, 2014, noting "[b]ack pain continues and has worsened," Tr. 747; June 9, 2014, which included a questionnaire where Plaintiff indicated "no" to needing assistance with transportation, shopping/errands, and domestic chores, Tr. 752; and December 22, 2014. Tr. 873. In this, what appears to be a latest visit considered by the ALJ, on December 22, 2014, Dr. Lane opined that Plaintiff can stand/walk/sit for less than 2 hours during a normal 8-hour day.
The ALJ determined that "[Plaintiff] meets the insured status requirements of the . . . Act through December 31, 2017." Tr. 23. The ALJ then found at step one, that "[Plaintiff] has not engaged in [SGA] since September 17, 2012, the alleged onset date (20 C.F.R. 404.1517
At step two, the ALJ found that "[Plaintiff] has the following severe impairments: degenerative disc disease of the lumbar spine, [and] status post laminectomy on March 28, 2012 (20 CFR 404.1520(c))."
At step three, the ALJ found that "[Plaintiff] does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in [the Listings]." Tr. 24.
In preparation for step four, the ALJ found that Plaintiff has the residual functional capacity ("RFC") to "perform a range of sedentary work" and that he could specifically "lift and/or carry 10 pounds occasionally and less than 10 pounds frequently . . . stand and/or walk for two hours out of an eight-hour workday with regular breaks . . . [and] sit for six hours out of an eight-hour workday with regular breaks."
The ALJ made the following observations about Plaintiff's medical records. Plaintiff injured his back in May 2007 after a well fell onto him.
In July 2012, Plaintiff "was noted to be doing well . . . to have mild back pain . . . [with] no significant leg pain or weakness[,]" and was discharged from the care of his neurosurgeon, Dr. Ostrup.
In August 2012, Plaintiff reported to doctors that he was doing well, and he again "acknowledged that he only took pain medication on an as-needed basis." Tr. 28. Physical examination notes from August 2012 revealed that Plaintiff had tenderness in his lumbar spine and a sensory deficit in his right thigh.
On November 30, 2012, Plaintiff's treating orthopedic surgeon, Dr. Lane, examined Plaintiff and found that Plaintiff had tenderness and a decreased range of motion in his spine, decreased sensation in his thighs, and "moderately significant degenerative disc disease . . . with multiple spurring throughout the lumbar area" of his spine.
On December 6, 2013,
On January 9, 2013, consultative examiner Larry Dodge, M.D., noted that Plaintiff had a decreased range of motion in his spine and that a "straight-leg-raising test caused pain in the back at [sixty] degrees in the supine and seated positions."
On March 5, 2013, consultative examiner Frederick Close, M.D., reported that Plaintiff had tenderness in his back, a "moderately severe bilateral lumbar spasm[,]" numbness in his right thigh, and a decreased range of motion in his lumbar spine and shoulder.
On June 4, 2013, Dr. Lane opined that Plaintiff could "perform less than a full range of sedentary exertional work; he could sit, stand, and/or walk for two hours out of an eight-hour workday; he was precluded from crawling; he needed to alternate positions; and he could occasionally bend."
On December 22, 2014, Dr. Lane opined that Plaintiff "could perform a limited range of sedentary exertional work; he could sit, stand and/or walk for less than two hours out of an eight-hour day; and he needed to change positions every five minutes."
After summarizing the medical evidence, the ALJ assigned weight to the various medical source opinions in the record. Tr. 29-31. The ALJ began his analysis by giving "little weight" to Dr. Lane's June 2013 and December 2014 opinions because "Dr. Lane failed to set forth the specific clinical and/or objective evidence that support the limitations assessed . . . [and] the record does not support limiting [Plaintiff] to sitting for two hours per day." Tr. 29. The ALJ added that these two opinions were due little weight because it also "appears that Dr. Lane was sympathetic to [Plaintiff] . . . [and] assessed limitations that are greater than that what is supported by the record as a whole."
The ALJ then assigned "partial weight" to Dr. Lane's opinion from November 2012, that Plaintiff could lift up to ten pounds and could occasionally bend and stoop.
The ALJ gave "minimal weight" to Dr. Lane's assessment from 2008 that Plaintiff "could perform a range of light exertional work" and that Plaintiff "was precluded from weight bearing for more than six hours in an eight-hour workday." Tr. 31. The ALJ similarly gave "minimal weight" to Dr. Shoemaker's opinion from 2007 that Plaintiff could perform sedentary exertional work.
The ALJ also discussed Dr. Lane's June 2008 opinion from within Plaintiff's workers' compensation medical records, where Dr. Lane found that Plaintiff was "temporarily totally disabled" ("TTD").
The ALJ then gave "some weight" and "little weight" to the opinions of the State agency medical consultants and Drs. Dodge, Ostrup, and Close, who all opined that Plaintiff retained the capacity to perform work at the medium exertional levels and could lift between twenty-five and thirty-five pounds, in part, because the RFC "assessed in [his] decision gives greater limitations based upon the totality of the evidence." Tr. 30-31.
The ALJ concluded his assessment of the medical evidence by noting that although "the record shows [that Plaintiff] had some continuing back problems, the records convey that [Plaintiff] has responded fairly well to his lumbar spine surgery in 2012" and "the longitudinal evidence does not reflect that [Plaintiff] has neurological deficits because of his back impairments." Tr. 30.
At step four, the ALJ found that "[Plaintiff] is capable of performing [his] past relevant work [("PRW")] as an administrative assistant" "as generally and actually performed." Tr. 31, 32. The ALJ concluded that because Plaintiff was able to return to his PRW, "[Plaintiff] has not been under a disability, as defined in the . . . Act, from September 17, 2012, through [May 29, 2015,] the date of th[e] decision." Tr. 32. Having concluded that Plaintiff was not disabled at step four, the ALJ did not assess whether Plaintiff could perform other work at step five.
In this appeal, Plaintiff argues that the ALJ erred by: (1) rejecting the opinion from his treating orthopedic surgeon, Dr. Lane; (2) rejecting his subjective symptom statements concerning the extent and severity of his impairments without considering Plaintiff's "stellar work history"; and (3) failing to rule on post hearing objections to the VE's testimony about the nature of Plaintiff's PRW. ECF No. 29, Joint Stipulation at 4-5. The Court finds that the ALJ improperly rejected Dr. Lane's opinion when finding that Plaintiff could perform "his past relevant work of an administrative assistant as generally and actually performed." Tr. 32.
There are three types of medical opinions in Social Security cases: those from treating physicians, examining physicians, and non-examining physicians.
"`To reject [the] uncontradicted opinion of a treating or examining doctor, an ALJ must state clear and convincing reasons that are supported by substantial evidence.'"
"`If a treating or examining doctor's opinion is contradicted by another doctor's opinion, an ALJ may only reject it by providing specific and legitimate reasons that are supported by substantial evidence.'"
As set forth previously, Dr. Lane was one of two treating physician's whose opinions the ALJ considered. The ALJ provided several reasons for discounting each of Dr. Lane's opinions. First, the ALJ noted contradictions between the limitations Dr. Lane endorsed—that Plaintiff could perform less than a full-range of sedentary work and could lift up to only ten pounds, as well as the opinions of Drs. Dodge, Ostrup, and Close—that Plaintiff could perform work at the medium exertional levels and could lift between twenty-five and thirty-five pounds. Because limitations endorsed by Dr. Lane were contradicted by the opinions of three other doctors, the Court must determine whether the ALJ's conclusion— that Dr. Lane's opinions were due reduced weight—was supported by specific and legitimate reasons and substantial evidence in the record. The Court addresses each of the ALJ's assignments of weight to Dr. Lane's opinions in turn, starting with the ALJ's analysis of Dr. Lane's earliest opinions.
The ALJ found that the limitation Dr. Lane endorsed in 2008—that Plaintiff had the capability to perform a range of light exertional work, and that Plaintiff could bear weight for up to six hours per day—was due minimal weight because it predated Plaintiff's alleged disability onset date by four years, was from before Plaintiff's back surgery, which the ALJ found that Plaintiff responded well to, was from before Plaintiff reached maximum medical improvement, and was made at a time when Dr. Lane did not have access to all the evidence in the record. This Court finds that these reasons are specific and legitimate and are supported by substantial evidence in the record.
Moreover, the limitations that Dr. Lane endorsed in this assessment, that Plaintiff had the capability to perform a range of light exertional work, were less restrictive than the limitations the ALJ endorsed in the RFC, which limited Plaintiff to performing a range of sedentary work and to standing and/or walking for only two hours per day. Finally, Plaintiff appears to concede that the ALJ's limitations were more restrictive than those assessed by Dr. Lane in this assessment.
Similarly, the Court finds no error in the ALJ's analysis of Dr. Lane's June 2008 opinion from Plaintiff's workers' compensation records. In addition to the reasons discussed above for rejecting Dr. Lane's other 2008 opinion—that the opinion evidence from 2008 was essentially stale—as the ALJ correctly found here, a determination that someone is TTD for workers' compensation purposes is not relevant to a DIB analysis because the criteria for making each determination are different.
The Court next turns to the ALJ's analysis of Dr. Lane's opinions that were rendered after Plaintiff's March 2012 surgery. The ALJ gave partial weight to Dr. Lane's opinion from November 2012, that Plaintiff could only occasionally bend and stoop, lift up to ten pounds, and had reached maximum medical improvement. Tr. 29-30. Specifically, the ALJ found that the longitudinal evidence did not support Dr. Lane's opinion that Plaintiff could only occasionally bend and stoop.
The ALJ supported his conclusion that Plaintiff had fewer restrictions in his ability to bend and stoop than Dr. Lane opined in November 2012 by discussing the contradicting opinions and diagnostic findings of other doctors, that Plaintiff had no limitations in his ability to bend and stoop. Tr. 28-31. Specifically, the ALJ cited reports indicating that Plaintiff: had a "full range of motion and no bony tenderness in his spine"; was "neurologically normal"; was "able to ambulate across the examining room without difficulty, limp, or antalgic gait"; displayed "normal" motor testing and sensory examination; was able to "frequently" kneel, crouch, and crawl; was "able to perform a full range of medium exertional work" without any postural limitations; and displayed "possible symptom magnification."
Moreover, contrary to Plaintiff's assertion that the ALJ's reporting of the record was highly selective, the ALJ also noted opinions from other doctors that Plaintiff had a "decreased range of motion" in his "spine" and his "thoracolumbar spine"; was "precluded from repetitive bending and stooping"; and was limited to only "occasional" stooping.
Finally, the Court addresses the ALJ's weighing of Dr. Lane's June 2013 and December 2014 opinions, which provide the greatest limitations on Plaintiff's abilities. The ALJ gave reduced weight to these opinions because, the ALJ found, they were unsupported by objective evidence, were inconsistent with the rest of the medical record, and it appeared Dr. Lane was sympathetic to Plaintiff because he endorsed limitations that were not supported by the record as a whole. Tr. 29. The Court finds that these conclusions by the ALJ were not supported by substantial evidence and require a closer review by the ALJ of these and other diagnoses by Dr. Lane.
First, there is no basis to believe that Dr. Lane's opinions regarding Plaintiff were biased and the ALJ does not point to anything in any of the numerous notes or reports by Dr. Lane that Dr. Lane was guided by anything other than his objective medical analysis. Second, the record as a whole supports Dr. Lane's findings that Plaintiff's pain, though initially abated, continued to get worse.
The ALJ also improperly discounts the June 4, 2013, and December 22, 2014, reports because there was no "specific clinical and or objective evidence that supports the limitations assessed." Tr. 29. This conclusion ignores the numerous diagnosis notes in 2013 and 2014 that were made and presumably considered by Dr. Lane as part of his conclusions. These opinions by Dr. Lane should, therefore, have been given greater deference.
The ALJ also appeared to cite to the neurosurgeon's opinion, to whom Dr. Lane referred Plaintiff, in support of his decision to diminish the impact of Dr. Lane's opinions when he stated that "the claimant's neurosurgeon noted that claimant was neurologically intact." Tr. 29. This does not mean that Plaintiff had a controlled level of pain. In fact, a full reading of the neurosurgeon's report of December 13, 2013, provides: "[Plaintiff] states that he continues to have significant back pain. This is not positionally related. He may get some benefit when he lies prone, but for the most part, the back pain is an ongoing issue." Tr. 701. The ALJ's failure to consider this aspect of the report should be corrected on remand.
Finally, these two later opinions by Dr. Lane were later than all but one of the other opinions and allowed Dr. Lane to consider the most recent medical evidence.
In conclusion, though the ALJ properly discounted several earlier opinions by the treating physician, Dr. Lane, the discounting of Dr. Lane's later opinions which indicated greater limitations than the RFC was improper based on the analysis provided by the ALJ.
Because the record was not fully developed as result of the ALJ's failure to consider the bases for the treating physician's later medical opinions regarding Plaintiff's limitations in his ability to sit, stand, and walk, IT IS ORDERED that the Commissioner's decision is REVERSED and this case is REMANDED for further administrative proceedings as set forth above.