CAROLYN K. DELANEY, Magistrate Judge.
Plaintiff seeks judicial review of a final decision of the Commissioner of Social Security ("Commissioner") denying an application for Supplemental Security Income ("SSI") under Title XVI of the Social Security Act ("Act"). The parties have consented to Magistrate Judge jurisdiction to conduct all proceedings in the case, including the entry of final judgment. For the reasons discussed below, the court will grant plaintiff's motion for summary judgment and deny the Commissioner's cross-motion for summary judgment.
Plaintiff, born January 1, 1966, applied on April 4, 2013 for SSI, alleging disability beginning October 22, 2012. Administrative Transcript ("AT") 196. Plaintiff alleged she was unable to work due to a left shoulder and neck injury, high blood pressure, a heart murmur, and a lower back injury. AT 111, 216. In a decision dated May 1, 2015, the ALJ determined that plaintiff was not disabled.
AT 22-30.
Plaintiff argues that the ALJ committed the following errors in finding plaintiff not disabled: (1) the ALJ failed to address the treating orthopedic opinions of Dr. Wisner from October through December 2012, and also failed to address the results of a January 2014 functional capacity evaluation; (2) the ALJ failed to provide specific and legitimate reasons for rejecting the opinion of psychologist Dr. Kalman; and (3) The ALJ improperly minimized the functional impact of plaintiff's left knee meniscal tear and bilateral carpal tunnel syndrome on her RFC and improperly relied on outdated medical evidence.
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 record as a whole must be considered,
Plaintiff contends that the ALJ failed to address multiple opinions by plaintiff's treating orthopedist, Dr. Wisner, who indicated between October 2012 and December 2012 that plaintiff was unable to work.
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 Aclear and convincing@ reasons.
Dr. Gary Wisner, an orthopedist, began treating plaintiff and filling out forms for her worker's compensation carrier in 2009. His progress notes document ongoing tests, examinations, medications, and follow-up. They report plaintiff's complaints of neck pain, stiffness, limited range of motion, and elbow pain radiating from the neck. AT 501-620. Prior to plaintiff's disability onset date of October 22, 2012, Dr. Wisner filled out numerous forms for the worker's compensation carrier, checking the box indicating that plaintiff could return to work.
On October 23, 2012, however, Dr. Wisner indicated for the first time that plaintiff could not return to work. AT 514. His progress notes from that day indicate: "Patient presents sooner than scheduled due to severe pain in neck. Patient states that her neck is causing migraines and has constant pain and spasms. Left shoulder is about the same. Left elbow continues to bother her and she wants surgery. Left elbow interferes with sleep/bad enough for surgery." AT 513. Similarly, Dr. Wisner indicated on November 13, 2012 that plaintiff should not return to work for an unknown period of time, noting neck pain and spasms, headaches, weakness in her arms, blurry vision, and increased elbow and shoulder pain. AT 511. He indicated that she should remain off work indefinitely on November 19, December 6, and December 12, 2012. AT 502-508. Dr. Wisner's December 12, 2012 notes indicate that plaintiff presented with severe neck pain, stiffness, a 50% range of motion, spasms, and constant pain in her shoulder and elbow due to radiating pain from her neck. AT 501. The treatment plan recommended an MRI, home traction unit, and surgery on her left elbow. AT 501. Dr. Wisner did not treat plaintiff after December 2012 and never indicated she could return to work.
The ALJ's decision stated: "Progress notes from Gary Wisner, M.D. from the alleged onset date through December 2012, note complaints of neck pain, stiffness, and limited range of motion. She also reports of constant elbow pain radiating from the neck [Exhibit 6F]." AT 25;
In determining plaintiff's physical RFC, the ALJ gave substantial weight to the opinions of three State Agency physicians "as they are supported by the objective evidence of `mild' and some moderate findings." AT 29;
Defendant argues that the opinions at issue "cover only a three-month period, and they do not reflect an opinion as to total disability nor that Plaintiff was permanently disabled for the required twelve continuous months as required" under the Social Security Act. (ECF No. 19 at 8.) While this may be a reason to discount Dr. Wisner's opinions, the ALJ did not offer it; nor did the ALJ seem aware that plaintiff's long-term treating doctor believed she was unable to work as of her alleged disability onset date. The ALJ is not bound by physician opinions on ultimate issues,
As to defendant's argument that Dr. Wisner's work-related opinions constitute check-box forms entitled to little weight, the forms were accompanied by detailed progress reports and written in the context of a long-term treating relationship. Dr. Wisner's progress notes from October through December 2012 indicate that plaintiff was experiencing "severe" and "constant" pain, stiffness, and a limited range of motion, among other symptoms. The court declines to find the ALJ's error harmless simply because the overlooked reports did not cover a twelve-month period.
Plaintiff also contends that the ALJ erred by ignoring a physical/functional evaluation performed on January 7, 2014 at the Sacramento Pain Clinic as part of a multi-disciplinary evaluation. AT 1554-1557. The report, which provided "the Physical Therapy component of the multidisciplinary evaluation," was signed by Rick Wurster, a physical therapist. AT 1554, 1557. It indicated that plaintiff had severe impairment of function and severe lack of effective control strategies due to constant pain and flare-ups. AT 1554. It also assessed multiple current functional deficits, including findings that plaintiff could rarely perform lifting from the ground, could only stand or walk for five minutes continuously, could only sit for 15 minutes continuously, and could seldom stoop, kneel, or reach. AT 1555. The report assessed severe impairments in daily activities such as cooking, cleaning, bathing, and dressing, and found plaintiff to have daily headaches and multiple physical deficits. AT 1555-1556. The report's summary noted that plaintiff had functional deficits precluding work. AT 1557.
Though the decision summarized other, mainly psychiatric records from the Sacramento Pain Clinic, the ALJ did not mention Mr. Wurster's January 2014 functional evaluation. AT 26. The ALJ discussed the opinions of State Agency physicians (AT 28-29) and other evidence, concluding: "The medical records do not demonstrate her claims of extremely limited functional capacity." AT 27.
"[L]ay witness testimony as to a claimant's symptoms or how an impairment affects ability to work is competent evidence, and therefore cannot be disregarded without comment."
Here, the ALJ erred by failing to provide germane reasons to disregard Mr. Wurster's January 2014 functional evaluation. Defendant argues that any such error is harmless, as the ALJ set forth a review of the objective medical evidence in the record and the opinion of Mr. Wurster, a lay witness, was inconsistent with that record. However, as discussed above, the ALJ also failed to address a treating physician's opinion that plaintiff was unable to work for months after her alleged onset date. In light of the incomplete discussion of record evidence bearing on plaintiff's ability to work, the court cannot conclude with certainty that the ALJ's error in disregarding the January 2014 functional evaluation was harmless.
Based on the foregoing, the undersigned concludes that plaintiff is entitled to summary judgment. The court does not reach the remaining issues.
With error established, the court has the discretion to remand or reverse and award benefits.
Here, the record as a whole creates serious doubt as to whether the claimant was, in fact, disabled during the relevant period. Thus the case is remanded to allow the ALJ an opportunity to re-examine the record, including evidence submitted by the Appeals Council.
For the reasons stated herein, IT IS HEREBY ORDERED that:
The claimant bears the burden of proof in the first four steps of the sequential evaluation process.