KENDALL J. NEWMAN, Magistrate Judge.
Plaintiff seeks judicial review of a final decision of the Commissioner of Social Security ("Commissioner") denying plaintiff's application for Disability Insurance Benefits ("DIB") under Title II of the Social Security Act ("Act").
For the reasons that follow, the court grants plaintiff's motion for summary judgment in part, denies the Commissioner's cross-motion for summary judgment, and remands the case for further proceedings under sentence four of 42 U.S.C. § 405(g).
Plaintiff was born on January 26, 1961; has completed two years of college and a paralegal certificate; and previously worked as a legal secretary/legal assistant and a bank teller.
In a decision dated November 2, 2012, the ALJ determined that plaintiff had not been under a disability, as defined in the Act, from September 11, 2010, plaintiff's alleged disability onset date, through the date of the ALJ's decision. (AT 19-32.) The ALJ's decision became the final decision of the Commissioner when the Appeals Council denied plaintiff's request for review on March 15, 2013. (AT 1-6.) Plaintiff then filed this action in federal district court on May 14, 2013, to obtain judicial review of the Commissioner's final decision. (ECF No. 1.)
Plaintiff raises the following issues: (1) whether the ALJ improperly evaluated the medical opinion evidence; (2) whether the ALJ erroneously found that plaintiff did not meet a listing; and (3) whether the ALJ improperly discounted plaintiff's testimony regarding the nature and extent of her functional limitations.
The court reviews the Commissioner's decision to determine whether (1) it is based on proper legal standards pursuant to 42 U.S.C. § 405(g), and (2) substantial evidence in the record as a whole supports it.
The ALJ evaluated plaintiff's entitlement to DIB pursuant to the Commissioner's standard five-step analytical framework.
(AT 25.)
At step four, the ALJ found that plaintiff was capable of performing her past relevant work as a legal secretary. (AT 30.) Alternatively, at step five, after considering plaintiff's age, education, work experience, and RFC, the ALJ found, based on the VE's testimony, that there were jobs that existed in significant numbers in the national economy that plaintiff could perform, including occupations such as receptionist, appointment clerk, and billing clerk. (AT 31.) Therefore, the ALJ concluded that plaintiff had not been under a disability, as defined in the Act, from September 11, 2010, plaintiff's alleged disability onset date, through the date of the ALJ's decision. (AT 32.)
Plaintiff contends that the ALJ improperly discounted the opinions of plaintiff's treating physicians, Dr. Croasdale and Dr. Kashani, and erroneously relied on the opinion of state agency physician, Dr. Leah Holly.
The weight given to medical opinions depends in part on whether they are proffered by treating, examining, or non-examining professionals.
To evaluate whether an ALJ properly rejected a medical opinion, in addition to considering its source, the court considers whether (1) contradictory opinions are in the record; and (2) clinical findings support the opinions. An ALJ may reject an uncontradicted opinion of a treating or examining medical professional only for "clear and convincing" reasons.
In this case, plaintiff's treating physicians, Dr. Croasdale and Dr. Kashani, each submitted a "Dizziness Medical Source Statement" on May 18, 2012, and May 21, 2012, respectively. (AT 428-31, 432-35.)
Dr. Croasdale diagnosed plaintiff with Meniere's disease and hearing loss due to vertigo, indicating that plaintiff would have about 3-4 dizziness episodes per week lasting from several minutes to hours, with precipitating factors listed as stress, sudden movements, and up and down motion. (AT 428.) Associated symptoms were noted to be nausea/vomiting, malaise, sensitivity to noise, hot flashes, mood changes, mental confusion/inability to concentrate, fatigue/exhaustion, and falling, with after effects such as confusion, exhaustion, irritability, and anxiety lasting from minutes to hours. (AT 429.) Dr. Croasdale opined that plaintiff could operate a motor vehicle, but could not work at heights or with power machines; would require unscheduled breaks during an 8-hour workday, each lasting a minimum of 30 minutes; would likely be off task 25% or more of the workday; was incapable of even low stress work; and would be absent from work more than four days per month. (AT 429-30.) He added that, as a result of vertigo spells, plaintiff was "unable to stand, walk, lift, bend, stoop, sit for long periods of time. Patient has profound hearing loss, noise sensitivity." (AT 431.)
Dr. Kashani also diagnosed plaintiff with Meniere's disease and profound hearing loss due to vertigo, indicating that plaintiff would have about 3-4 dizziness episodes per week lasting from minutes to hours, which could manifest suddenly. (AT 432.) Associated symptoms were noted to be nausea/vomiting, malaise, photosensitivity, sensitivity to noise, hot flashes, mood changes, mental confusion/inability to concentrate, and falling, with after effects such as confusion, exhaustion, irritability, and anxiety lasting from minutes to hours. (AT 433.) Dr. Kashani opined that plaintiff could operate a motor vehicle, but could not work at heights or with power machines; needed more supervision at work than an unimpaired worker; would require unscheduled breaks during an 8-hour workday, each lasting from minutes to potentially "bedrest"; would likely be off task 25% or more of the workday; was incapable of even low stress work; and would be absent from work more than four days per month. (AT 433-34.) He further noted: "unable to balance herself, difficulty walking, cannot bend, stoop or lift which can bring on vertigo attack, sensitivity to noises." (AT 435.)
The ALJ legitimately discounted the opinions of Dr. Croasdale and Dr. Kashani. As an initial matter, the four-page form "Dizziness Medical Source Statements" completed by these physicians are conclusory and unsupported by any specific clinical findings, objective test results, or meaningful rationale in support of the severe limitations assessed.
Furthermore, as the ALJ observed, Dr. Croasdale's severe May 18, 2012 opinion conflicts with his previous October 10, 2011 treatment note in which he stated that, although plaintiff had chronic long-term Meniere's disease, she showed excellent stability adaptation and "may pursue employment." (AT 29, 417.) In January 2011, Dr. Kashani, whose treatment notes were largely cursory and illegible, also apparently told plaintiff that she did not have Meniere's disease, and curiously instructed her "not to worry about it and to continue treatment with Dr. Croasdale." (AT 344.) Additionally, the ALJ correctly observed that at least some of the symptoms noted on the "Dizziness Medical Source Statements" were not mentioned in the treatment records or were denied by plaintiff in the course of most doctor's visits. (AT 29-30.)
Finally, the ALJ also reasonably questioned the fact that the "Dizziness Medical Source Statements" completed by Dr. Croasdale and Dr. Kashani closely mirrored each other, given that some of the handwriting on the respective forms looked the same. (AT 30.) Contrary to plaintiff's argument, the ALJ did not need to be a handwriting expert to find that the same handwriting appeared on certain portions of both forms, which is obvious from a cursory review of the forms. (
Even though the court finds that the ALJ provided specific and legitimate reasons for discounting the opinions of Dr. Croasdale and Dr. Kashani, the court ultimately cannot conclude that the ALJ's RFC is supported by substantial evidence. The ALJ in this case did not request a consultative examination of plaintiff. In formulating plaintiff's RFC, the ALJ relied primarily on the opinion of a non-examining state agency physician, Dr. Leah Holly. (AT 29, 383-90.)
In light of the ambiguous record, the fact that Dr. Holly did not personally examine plaintiff or review the later test results obtained at Stanford, and the fact that Dr. Holly is a family/general practice physician with no specialized knowledge of ear disorders, the court finds that the case should be remanded for a consultative examination by an ear, nose, and throat specialist, or other appropriate specialist, with full access to plaintiff's prior medical records and test results. The ALJ may also conduct a supplemental hearing and develop the record in other respects, if necessary.
Importantly, although the court remands the case for further proceedings, the court expresses no opinion regarding how the medical opinions and other evidence should ultimately be weighed upon remand, nor any opinion regarding the ultimate question of whether plaintiff is disabled. The ALJ may well conclude that plaintiff is not disabled, provided that the decision is supported by substantial evidence.
In light of the court's conclusion that the case should be remanded for further development of the record, as outlined above, the court declines to reach plaintiff's remaining issues. On remand, the ALJ will have an opportunity to reconsider, if appropriate, his evaluation of plaintiff's credibility and whether plaintiff potentially meets or medically equals the criteria for any listing based on the augmented record.
For the foregoing reasons, IT IS HEREBY ORDERED that:
1. Plaintiff's motion for summary judgment (ECF No. 18) is granted in part.
2. The Commissioner's cross-motion for summary judgment (ECF No. 19) is denied.
3. This case is remanded for further proceedings consistent with this order pursuant to sentence four of 42 U.S.C. § 405(g).
4. The Clerk of Court is directed to enter judgment for plaintiff.
IT IS SO ORDERED.
The claimant bears the burden of proof in the first four steps of the sequential evaluation process.