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 April 30, 1979, has a high school education, and previously worked as a construction laborer.
In a decision dated September 19, 2011, the ALJ determined that plaintiff had not been under a disability, as defined in the Act, from August 5, 2007, plaintiff's alleged disability onset date, through March 30, 2011, the date last insured. (AT 26-36.) The ALJ's decision became the final decision of the Commissioner when the Appeals Council denied plaintiff's request for review on May 8, 2013. (AT 5-11.) Thereafter, plaintiff filed this action in federal district court on October 9, 2014, to obtain judicial review of the Commissioner's final decision. (ECF No. 1.)
Plaintiff raises the following issues: (1) whether the ALJ's residual functional capacity determination ("RFC") was supported by substantial evidence and whether the ALJ improperly failed to consider the treating opinions of Dr. Senegor when making that determination; (2) whether the ALJ improperly assessed plaintiff's subjective testimony regarding the severity of the functional limitations caused by his impairments; and (3) whether the Appeals Council failed to properly consider an additional treating opinion issued by Dr. Senegor that was submitted into the record by plaintiff in connection with his application for review of the ALJ's decision.
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.
Before proceeding to step four, the ALJ assessed plaintiff's residual functional capacity ("RFC") for the relevant time period as follows:
(AT 30.)
At step four, the ALJ found that plaintiff was unable to perform any past relevant work. (AT 35.) Finally, at step five, the ALJ determined, through the VE's testimony, that considering plaintiff's age, education, work experience, and RFC, there were jobs that existed in significant numbers in the national economy that plaintiff could have performed, specifically, the representative occupations of small products assembler, lens-block gauger, and charge-account clerk. (AT 36, 58-59.)
Accordingly, the ALJ concluded that plaintiff had not been under a disability as defined in the Act from August 5, 2007, the alleged onset date, through March 30, 2011, the date last insured. (AT 36.)
First, plaintiff argues that the ALJ erred in determining that plaintiff had the RFC to perform a reduced range of light work because that determination was not based on substantial evidence and did not properly address the medical opinion evidence in the record.
With regard to the medical opinion evidence, plaintiff argues that the ALJ completely disregarded and failed to assign weight to the treating opinions Dr. Senegor developed in connection with the treatment he provided plaintiff, including two spinal fusion surgeries, between April 16, 2009, and January 21, 2011. Plaintiff claims that these treating records demonstrate that Dr. Senegor provided multiple functional opinions regarding plaintiff's physical capacity that the ALJ failed to address in a meaningful fashion in her decision. However, the treating records plaintiff highlights in support of his argument provide no opinion regarding plaintiff's functional limitations. Indeed, the two treating notes plaintiff specifically highlights in his briefing as containing Dr. Senegor's opinions that the ALJ supposedly ignored are merely Dr. Senegor's post-surgery recommendations to plaintiff upon discharge from the hospital after his two spinal fusion surgeries.
Furthermore, the ALJ's written decision demonstrates that she specifically considered Dr. Senegor's treating records that plaintiff draws into contention along with the rest of the medical and non-medical evidence in the record, including all of the opinion evidence available to her. (AT 31-35.) Therefore, the ALJ did not err in considering Dr. Senegor's treating notes when deciding plaintiff's RFC.
Nevertheless, even though the court finds that the ALJ did not err in considering Dr. Senegor's treatment notes, it agrees with plaintiff's more general assertion that the ALJ's RFC determination regarding plaintiff's physical functioning was not based on substantial evidence from the record. In her discussion regarding the impact of plaintiff's physical impairments, the ALJ considered the opinions of Dr. Boparai, an examining consultative physician who had examined plaintiff just eight days after his second spinal fusion surgery, and two state agency non-examining physicians, Dr. Brodsky and Dr. Fracchia. (AT 34.) The ALJ assigned "no weight" to Dr. Boparai's opinion because Dr. Boparai's examination took place just after plaintiff underwent his second spinal surgery and, therefore, did "not provide an appropriate assessment of the claimant's functional capacity after recovery." (
Dr. Brodsky issued his opinion on October 7, 2010, about a month after plaintiff had undergone his second spinal fusion surgery, and based his opinion entirely on a review of the record that had been developed prior to that operation, with the exception of Dr. Boporai's examining opinion, which Dr. Brodsky dismissed as an inaccurate assessment of plaintiff's actual physical RFC because Dr. Boporai had examined plaintiff just days after he had undergone the surgery. Dr. Brodsky specifically noted in his opinion that plaintiff "may well be severely limited by 9/17/11 (twelve months S/P surgery), but it is too early to make a specific assessment," and that "a reasonable assumption is that [plaintiff] will be able to sustain LIGHT pRFC performance by 9/17/11." (AT 287 (italics added).)
Not only did Dr. Brodsky opine limitations based on an assumption of what plaintiff's physical condition would likely be as of September 17, 2011, nearly 6 months after the end of the relevant period, as a result of an assumed successful second surgery, but his opinion also entirely failed to address plaintiff's physical functional capacity prior to the time he underwent his second surgery — a span of time which comprised the large majority of the relevant period at issue. To be sure, the medical evidence in the record from before the date of the second surgery generally indicates that the symptoms of plaintiff's degenerative disc disease continued to progressively worsen even after plaintiff underwent his first spinal fusion surgery and generally caused plaintiff debilitating pain throughout the portion of the relevant period prior to his second surgery.
Furthermore, plaintiff's treatment records developed after his second spinal fusion surgery indicate that plaintiff's physical condition generally did not improve and may have even begun to decline further in the months after he underwent that second operation. On November 11, 2010, roughly 2 months after plaintiff underwent his second spinal fusion surgery, Dr. Senegor, plaintiff's treating physician, noted that plaintiff felt that his surgery had "worked out well," plaintiff's pain had been reduced, and "x-rays appear satisfactory for this stage of recovery." (AT 308.) However, on January 12, 2011, Dr. Senegor issued a report regarding his 4-month follow-up examination of plaintiff that noted that while plaintiff had initially done well after the surgery, he had "recently . . . developed new lumbar radicular symptoms," including "low back pain and pain radiating down the right leg towards the foot in a fairly typical L5 radicular distribution with numbness in the big toe of the right foot." (AT 363.) Dr. Senegor further noted that plaintiff's pain had "been severe enough that [plaintiff] has once again taken to the use of a cane and recently appeared in an emergency room." (
Despite the fact that Dr. Brodsky's opinion was based only on a consideration of evidence developed prior to the date on which plaintiff underwent his second spinal fusion surgery, did not address plaintiff's functional capacity prior to that surgery, was based on an admitted speculation as to what plaintiff's physical RFC would likely be a year after that surgery, and was generally not supported by the objective medical evidence developed both prior to and after that surgery, the ALJ still accorded great weight to Dr. Brodsky's opinion and largely adopted the functional limitations contained therein. (AT 34.) That determination was in error.
The ALJ's reliance on Dr. Fracchia's non-examining opinion also did not constitute substantial evidence in support of her RFC determination. Unlike Dr. Brodsky, Dr. Fracchia had the benefit of reviewing the first post-operation treating report that Dr. Senegor issued in November of 2010 that indicated that plaintiff's second surgery was successful and he was recovering at a satisfactory rate. (AT 343.) However, Dr. Fracchia did not have an opportunity to review plaintiff's treating records developed thereafter, in early-to-mid 2011, that indicated that plaintiff began to again suffer from severe symptoms as a result of his physical impairments soon after that first follow up visit with Dr. Senegor and continued to experience those symptoms in the months after he underwent his second spinal fusion surgery. (
In sum, the non-examining opinions of Dr. Brodsky and Dr. Fracchia did not constitute substantial evidence in support of the ALJ's RFC determination because they were not supported by the other medical evidence in the record from throughout the relevant period.
Furthermore, while the ALJ correctly highlighted the fact that Dr. Boporai's examining opinion likely did not accurately reflect plaintiff's physical RFC throughout the course of the relevant period because his orthopedic examination of plaintiff was conducted while plaintiff was still recovering from his second spinal fusion surgery, this invalid examination was entirely the Commissioner's own doing because it was the Administration that had scheduled it to take place in such close temporal proximity to plaintiff's surgery.
When the court finds that the ALJ committed prejudicial error, it has the discretion to remand or reverse and award benefits.
Here, plaintiff argues that the ALJ's error requires this matter to be remanded for further administrative proceedings. The court agrees. As discussed above, the opinion evidence in the record regarding plaintiff's spinal impairments has not been adequately developed such that the ALJ could make a proper RFC determination regarding the functional impact of those impairments on plaintiff's ability to perform physical work-related activities throughout the course of the relevant period. Accordingly, development of the record through further administrative proceedings is warranted.
On remand, the ALJ shall obtain a consultative examination of plaintiff by a physician who has
In light of the court's conclusion that the case must be remanded for further development of the record, the court provides no opinion at this time regarding whether the ALJ failed to properly consider plaintiff's testimony when assessing plaintiff's RFC. The ALJ is free to reevaluate her analysis with respect to this issue, or any other aspect of her decision. On remand, the ALJ will have an opportunity to further consider the issues, and address the medical evidence and non-medical testimony, including plaintiff's testimony, in context of the record as a whole. The court also finds plaintiff's final argument — that the Appeals Counsel failed to consider the entire opinion issued by Dr. Senegor on October 24, 2011, in connection with its consideration of plaintiff's request to review the ALJ's decision — is moot due to the above order directing the ALJ to consider Dr. Senegor's opinion on remand.
Accordingly, for the reasons outlined above, IT IS HEREBY ORDERED that:
1. Plaintiff's motion for summary judgment (ECF No. 15) is GRANTED IN PART.
2. The Commissioner's cross-motion for summary judgment (ECF No. 18) is DENIED.
3. The case is remanded for further administrative proceedings consistent with this order pursuant to sentence four of 42 U.S.C. § 405(g).
4. Judgment is entered for plaintiff.
5. The Clerk of Court shall close this case.
The claimant bears the burden of proof in the first four steps of the sequential evaluation process.