JOHN W. LUNGSTRUM, District Judge.
Plaintiff seeks review of a decision of the Commissioner of Social Security (hereinafter Commissioner) denying Social Security Disability(SSD) benefits under sections 216(i) and 223 of the Social Security Act. 42 U.S.C. §§ 416(i) and 423 (hereinafter the Act). Finding error in the Administrative Law Judge's (ALJ) consideration of Dr. Koprivica's medical opinion, the court ORDERS that the decision shall be REVERSED, and that judgment shall be entered pursuant to the fourth sentence of 42 U.S.C. § 405(g) REMANDING this case for further proceedings.
Plaintiff applied for SSD on April 21, 2009, alleging disability beginning April 24, 2007. (R. 25, 140-43). The applications were denied initially and upon reconsideration, and Plaintiff requested a hearing before an ALJ. (R. 25, 80-81, 102-03). Plaintiff's request was granted, and Plaintiff appeared with counsel for a hearing before ALJ Debra Bice on November 30, 2010. (R. 25, 40-42). At the hearing, testimony was taken from Plaintiff and from a vocational expert. (R. 25, 40-79).
ALJ Bice issued her decision on February 22, 2011 finding that although Plaintiff has impairments that are severe within the meaning of the Act and is unable to perform his past relevant work, he has sufficient residual functional capacity (RFC) to perform other jobs that exist in significant numbers in the economy and is therefore not disabled within the meaning of the Act. (R. 25-35). Consequently, she denied Plaintiff's application for DIB.
The court's jurisdiction and review are guided by the Act.
When deciding if substantial evidence supports the ALJ's decision, the mere fact that there is evidence in the record which might support a contrary finding will not establish error in the ALJ's determination. "The possibility of drawing two inconsistent conclusions from the evidence does not prevent an administrative agency's findings from being supported by substantial evidence. [The court] may not displace the agency's choice between two fairly conflicting views, even though the court would justifiably have made a different choice had the matter been before it de novo."
An individual is disabled only if he can establish that he has a physical or mental impairment which prevents him from engaging in
The Commissioner uses a five-step sequential process to evaluate disability. 20 C.F.R. § 404.1520 (2010);
The Commissioner next evaluates steps four and five of the sequential process— determining at step four whether, in light of the RFC assessed, claimant can perform his past relevant work; and at step five whether, when also considering the vocational factors of age, education, and work experience, claimant is able to perform other work in the economy.
Plaintiff claims substantial record evidence does not support the Commissioner's decision because the ALJ erroneously evaluated the medical opinions and because the Commissioner failed properly to consider the additional medical evidence presented to the Appeals Council. He claims the ALJ failed to assess the credibility of Plaintiff's allegations of symptoms properly. The Commissioner argues that the ALJ properly considered the credibility of Plaintiff's allegations of symptoms, and properly considered the medical opinion evidence, and that the new evidence presented to the Appeals Council does not require remand.
The court finds that remand is necessary because the ALJ did not properly explain her evaluation of the medical opinions. Because the case must be remanded, the Commissioner will once again have the opportunity to consider the new medical evidence presented to the Appeals Council. Moreover, Plaintiff may make his arguments regarding the credibility of his allegations of symptoms to the Commissioner on remand. Therefore, the court need not address those issues here.
Plaintiff acknowledges that the ALJ accorded "substantial weight" to the treating source opinion of Dr. Stechschulte and to the non-treating source opinion of Dr. Koprivica. (Pl. Br. 21). But, she argues that the ALJ did not adopt these physicians' opinions and, in fact erred in ignoring the limitation to sedentary work included in Dr. Stechschulte's treatment records for almost a two year period, and Dr. Koprivica's opinion that Plaintiff be allowed to sit whenever necessary during periods of standing and walking work activity, and to stand whenever necessary during periods of seated work activity.
The Commissioner argues that the ALJ could appropriately omit Dr. Koprivica's sitting and standing option because the treating physician, Dr. Stechschulte did not find such a limitation. (Comm'r Br. 8) (citing
In his Reply Brief, Plaintiff argues that the Commissioner misconstrues the evidence and that the ALJ's RFC assessment does not accommodate Dr. Koprivica's requirement for a sit/stand option at will. (Reply 3). Finally, he argues that "Dr. Stechschulte's medical records strongly imply that Dr. Stechschulte was not using the term `light duty' as defined in the Social Security regulations," because Dr. Stechschulte "provided a work status of `Light Duty' for Mr. Tomlinson, yet at the same time restricted him to `desk work (sedentary) only.'"
In her decision, the ALJ discussed the limitations opined by Dr. Koprivica and by Dr. Stechschulte:
(R. 32). The ALJ accorded "substantial weight" to the opinions of Dr. Koprivica and Dr. Stechschulte because the physicians "examined the claimant and reviewed the medical evidence," and because "their opinions are specific and well supported and consistent with the weight of the medical evidence."
Dr. Stechschulte treated Plaintiff after he injured his right knee in a work injury on March 10, 2007, and the record includes treatment notes from Dr. Stechschulte dated from April 24, 2007 through August 18, 2009. (R. 552-656). As the ALJ cited, the final treatment note from Dr. Stechschulte on August 18, 2009 indicates that Plaintiff's work status is "Light Duty," and his permanent restrictions are "No kneeling, squatting, climbing, [or] crawling." (R. 552). Six months earlier, on February 3, 2009, Dr. Stechschulte assigned a work status of "Light Duty," and restrictions of "No kneeling, squatting, climbing, [or] crawling," and for the first time stated that the restrictions are permanent. (R. 555). Moreover, as the parties agree, during the time he treated Plaintiff, Dr. Stechschulte generally stated Plaintiff's work status was light duty, and usually included a temporary "restriction" to "Desk Work (sedentary) only." (R. 558, 561, 568, 571, 577, 589, 592, 599, 602, 605, 608, 611, 614, 621, 624, 631, 634, 637, 640, 645, 652).
Dr. Koprivica examined Plaintiff and reviewed his medical records on March 17, 2009 and provided an "independent medical evaluation" of Plaintiff's condition dated April 20, 2009. (R. 403-27). As the ALJ noted, "Dr. Koprivica opined that the claimant can sit for less than two hours at a time and stand or walk for one to two hours at a time, but he should avoid stairs and he cannot crawl, kneel, squat, or climb." (R. 32) (citing R. 418). Moreover, as the parties agree, Dr. Koprivica opined that Plaintiff "should be allowed the opportunity to change posture." (R. 418). Specifically, he opined that Plaintiff should have "the flexibility of sitting whenever necessary" during his standing and walking intervals, and stated, "Captive sitting intervals should be limited to less than two hours with the flexibility of getting up when necessary." (R. 418).
With regard to Dr. Stechschulte's opinion, Plaintiff is correct that the physician restricted Plaintiff to "Light Duty" with an additional restriction to "Desk Work (sedentary) only" for more than a year and a half from May 31, 2007 through December 23, 2008. (R. 558-640,
Plaintiff's argument that Dr. Stechschulte's records imply that he was not using "light duty" as the term is defined in the Social Security regulations is a reasonable alternative view of Dr. Stechschulte's records compared to the view expressed by the ALJ. But the ALJ's view is also reasonable and is also supported by substantial record evidence. Plaintiff has not show that the ALJ's view is erroneous. Therefore, the court may not substitute its judgment for that of the ALJ. It "may not displace the agency's choice between two fairly conflicting views, even though the court would justifiably have made a different choice had the matter been before it de novo."
As to Dr. Koprivica's opinion regarding the need to change at will from sitting to standing or from standing to sitting, as Plaintiff suggests, the court finds error in the ALJ's failure to discuss that opinion or to explain why he did not adopt it. The Commissioner argues only that "the ALJ could appropriately omit this restriction" from the RFC assessed because "Dr. Stechschulte, Plaintiff's treating physician, did not find Plaintiff limited to this degree." (Comm'r Br. 8) (citing
The Commissioner is correct that an ALJ need not provide a pinpoint citation for each RFC finding, but the court is at a loss to see how that fact is sufficient to justify an ALJ's failure to discuss or explain why she did not adopt a medical opinion which is contrary to her RFC assessment, especially when the contrary medical opinion was provided by a physician whose opinion the ALJ purported to give "substantial weight." It is likewise true that Dr. Stechschulte did not find that Plaintiff needed the option to sit or stand at will. However, although Dr. Stechschulte is a treating physician and Dr. Koprivica is a non-treating physician, the ALJ did not give Dr. Stechschulte's opinion controlling weight, but purported to give both physicians' opinions equal weight— substantial weight. (R. 32).
An administrative agency must give reasons for its decisions.
Here, the ALJ asserted that she gave "substantial weight" to Dr. Koprivica's opinion, suggesting that the opinion is significantly probative evidence. However, she rejected the portion of the opinion requiring that Plaintiff be allowed to stand or sit at will. But, she did not discuss that significantly probative evidence she rejected. That is error. Additionally, the ALJ's RFC assessment that Plaintiff does not need the option to sit or stand at will conflicts with Dr. Koprivica's opinion that Plaintiff must be allowed to stand or sit at will, but the ALJ did not explain why she did not adopt Dr. Koprivica's opinion. That is also error.
Remand is necessary for the Commissioner to discuss Dr. Koprivica's opinion and to explain how the evidence supports the determination that Plaintiff does not need to be allowed the option to sit or to stand at will.