KENDALL J. NEWMAN, Magistrate Judge.
Plaintiff Brenda Kaye Deadwiley seeks judicial review of a final decision by the Commissioner of Social Security ("Commissioner") denying plaintiff's application for Disability Insurance Benefits ("DIB") under Title II of the Social Security Act ("Act").
After carefully considering the record and the parties' briefing, the court GRANTS IN PART plaintiff's motion for summary judgment, DENIES the Commissioner's cross-motion for summary judgment, and REMANDS the action for further administrative proceedings consistent with this order.
Plaintiff was born on December 31, 1959; attended 12 years of education and obtained a high school diploma; can communicate in English; and previously worked as a baker. (Administrative Transcript ("AT") 40-41.)
On appeal, plaintiff raises the following issues: (1) whether the ALJ failed to properly assess the medical opinion evidence; (2) whether the ALJ improperly discounted plaintiff's subjective complaints; and (3) whether the ALJ failed to fully develop the record when questioning the vocational expert ("VE") regarding plaintiff's residual functional capacity ("RFC") for alternative employment.
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 RFC, finding that plaintiff could perform light work as defined in 20 C.F.R. § 404.1567(b) along with the following additional limitations:
(AT 37.) At step four, the ALJ determined that plaintiff was unable to perform any past relevant work. (AT 40.) However, at step five the ALJ found that, in light of plaintiff's age, education, work experience, RFC, and the vocational expert's testimony, there were jobs that existed in significant numbers in the national economy that plaintiff could have performed. (AT 41.)
Thus, the ALJ concluded that plaintiff had not been under a disability, as defined in the Act, from August 21, 2009, plaintiff's alleged disability onset date, through September 30, 2011, plaintiff's date last insured. (AT 42.)
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.
As an initial matter, the ALJ properly discounted a portion of the opinion of Dr. Steven L. McIntire, who examined plaintiff on August 23, 2013, that plaintiff is TTD (temporarily totally disabled). (AT 362.) Dr. McIntire examined plaintiff in the context of a worker's compensation case where disability criteria are defined differently than under the Social Security Act. (AT 39.)
Plaintiff also asserts that the ALJ erred by failing to give weight to the September 30, 2009 opinion of plaintiff's treating physician, Dr. Roderick Sanden, that plaintiff avoid activities of reaching/lifting/using arms above the shoulders. (AT 350.) The ALJ gave that opinion little weight, because it "does not indicate specific exertional or postural limitations," lacked an "intended duration," and "appear[ed] only once" in the record. (AT 40.) However, there is no medical evidence in the record that contradicts Dr. Sanden's assessed overhead reaching limitation, and the limitation does not appear to be without any foundation, especially given plaintiff's cervical degenerative disk disease and herniation. Thus, the ALJ was required to provide clear and convincing reasons to discount the limitation. For the reasons discussed below, the court is not persuaded that such reasons were provided.
Contrary to the ALJ's finding, Dr. Sanden's recommendation is an exertional and postural limitation: plaintiff was not to reach overhead at all with any amount of weight. Furthermore, while Dr. Sanden's assessment did not specify exactly how long the limitation would last, and appeared only once in the record, the ALJ does not point to substantial evidence suggesting that the limitation had ceased or other substantial evidence contradicting such a limitation. To the contrary, the non-examining state agency physician, Dr. Jaituni, who reviewed plaintiff's records on April 24, 2013, likewise opined that plaintiff had a limitation of "No OHR B UE," i.e., no overhead reaching with the bilateral upper extremities. (AT 96.) Although the ALJ generally credited Dr. Jaituni's opinion that plaintiff could do a limited range of light work, the ALJ never explained why Dr. Jaituni's no overhead reaching limitation was not adopted. (AT 40.)
Therefore, the ALJ erred in not providing clear and convincing reasons for declining to adopt the no overhead reaching limitation assessed by treating physician Dr. Sanden and state agency physician Dr. Jaituni. Moreover, based on the present record, the court cannot find that the ALJ's error was harmless. At the administrative hearing, the ALJ questioned the VE regarding a limitation to occasional overhead reaching, but not regarding a limitation to no overhead reaching. (AT 76-82.) As such, the court is unable to determine to what extent a no overhead reaching limitation would have eroded the number of jobs that plaintiff could have performed during the relevant period.
Consequently, the court finds it appropriate to remand the action for further administrative proceedings; more specifically, for further consideration of the opinions of Dr. Sanden and Dr. Jaituni that plaintiff was limited to no overhead reaching. Importantly, the court does not instruct the ALJ to credit that particular limitation or any specific opinion in the record. The ALJ may choose to further develop the record by obtaining a consultative evaluation, medical expert testimony, and/or supplemental vocational expert testimony. Indeed, the court expresses no opinion regarding how the evidence should ultimately be weighed, and any ambiguities or inconsistencies resolved, on remand, provided that the ALJ's decision is based on proper legal standards and supported by substantial evidence in the record as a whole.
In light of the court's conclusion that the case should be remanded for further consideration of the medical opinion evidence, the court declines to reach plaintiff's remaining issues concerning plaintiff's credibility and the vocational expert testimony. On remand, the ALJ will have an opportunity to reconsider those matters, if appropriate.
For the foregoing reasons, IT IS HEREBY ORDERED that:
1. Plaintiff's motionfor summary judgment (ECF No. 13) is GRANTED IN PART.
2. The Commissioner's cross-motion for summary judgment (ECF No. 14) is DENIED.
3. The final decision of the Commissioner is REVERSED, and the case is REMANDED for further administrative proceedings consistent with this order pursuant to sentence four of 42 U.S.C. § 405(g).
4. 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.