LANDYA McCAFFERTY, District Judge.
Pursuant to 42 U.S.C. § 405(g), Jonathan McCormick moves to reverse the Acting Commissioner's decision to deny his applications for Social Security disability insurance benefits, or DIB, under Title II of the Social Security Act, 42 U.S.C. § 423, and for supplemental security income, or SSI, under Title XVI, 42 U.S.C. § 1382. The Acting Commissioner, in turn, moves for an order affirming her decision. For the reasons that follow, this matter is remanded to the Acting Commissioner for further proceedings consistent with this order.
The applicable standard of review in this case provides, in pertinent part:
42 U.S.C. § 405(g) (setting out the standard of review for DIB decisions);
As for the statutory requirement that the Acting Commissioner's findings of fact be supported by substantial evidence, "[t]he substantial evidence test applies not only to findings of basic evidentiary facts, but also to inferences and conclusions drawn from such facts."
The parties have submitted a Joint Statement of Material Facts. That statement, document no. 11, is part of the court's record and is summarized here, rather than repeated in full.
McCormick worked as a self-employed carpenter until June of 2012. His medical records include diagnoses of physical conditions affecting his left elbow (bursitis), his left hip (osteoarthritis), his shoulders (high-grade acromioclavicular shoulder separations/instability), his right wrist (joint pain), and his lower back (thoracic or lumbosacral neuritis or radiculitis, unspecified;
McCormick applied for both DIB and SSI in June of 2013. Because he submitted insufficient evidence, the initial review of his applications included no assessment of either his physical or mental residual functional capacity ("RFC").
In January of 2014, McCormick saw Dr. Shawn Harrington for a re-evaluation of his back pain. Several weeks later, Dr. Harrington completed an RFC Questionnaire on McCormick. In it, Dr. Harrington identified diagnoses of lower back pain, spinal stenosis, shoulder pain, and hip osteoarthritis. Dr. Harrington stated that McCormick's impairments resulted in pain, numbness, and back stiffness and that those symptoms were often "severe enough to interfere with the attention [and] concentration required to perform simple work-related tasks." Administrative Transcript (hereinafter "Tr.") 372. Dr. Harrington opined that McCormick: (1) needed to recline or lie down more often than would by permitted by the breaks typically given during a normal workday; (2) could sit and could stand/walk for 30 minutes at a time; (3) could sit and could stand/walk for a total of two hours each in an eight-hour workday; (4) needed a job that permitted shifting positions at will from sitting, standing, or walking; (5) needed to take hourly unscheduled breaks of unknown duration; (6) could frequently lift and carry less than 10 pounds; (7) could never lift and carry any more than that; (8) had unspecified limitations on his capacity for repetitive reaching, handling, or fingering due to wrist arthritis; and (9) was likely to be absent from work more than four times a month due to his impairments or treatment for them.
In March of 2014, McCormick's primary care physician, Dr. Lora McClintock, completed an RFC Questionnaire on McCormick. In it, she identified diagnoses of severe degenerative disc disease of the lumbosacral spine, a condition affecting both shoulders, and a condition affecting McCormick's left hip.
The record also includes a Mental Capacity Assessment completed by Jan Manwaring, a licensed clinical social worker. In it, she considered 23 specific abilities and determined that McCormick had: (1) unknown limitations in two abilities; (2) moderate limitations in six abilities; (3) marked limitations in nine abilities; and (4) extreme limitations in six abilities.
After McCormick's applications were denied at the initial level of review, he received a hearing before an Administrative Law Judge ("ALJ"). At the hearing, the ALJ took telephonic testimony from Dr. Arthur Brovender, a board certified orthopedic surgeon who had neither treated nor examined McCormick, but had reviewed McCormick's medical records. After describing the medical records he reviewed, Dr. Brovender stated that McCormick had been diagnosed with degenerative disc disease of the lumbosacral spine, grade one spondylosis, and "osteoarthritis of the set."
The ALJ's examination of Dr. Brovender continued in the following manner:
Tr. 46-47.
When McCormick's attorney asked Dr. Brovender about the discrepancy between the RFC he gave McCormick and the RFCs assessed by Drs. Harrington and McClintock, Dr. Brovender explained that McCormick's "physical examinations show that his motor neurological and sensory examinations were normal, his reflexes were normal, he had no sensory changes, he had no muscle weakness." Tr. 47. In response to another question from McCormick's attorney, Dr. Brovender testified that McCormick's ability to use his upper extremities was unlimited.
After taking testimony from Dr. Brovender, the ALJ took testimony from a vocational expert ("VE"). He began by asking the VE about a hypothetical individual with the following limitations:
Tr. 68-69. According to the VE, a person with the foregoing limitations could do carpentry, as that job is generally performed, i.e., at the medium exertional level. The VE also testified that a person with those limitations could do the job of cleaner, kitchen helper, and packer, all of which are unskilled jobs at the medium exertional level. The applicable regulations provide that "[m]edium work involves lifting no more than 50 pounds at a time with frequent lifting or carrying of objects weighing up to 25 pounds." 20 C.F.R. §§ 404.1567(c) & 416.967(c). In addition, "[a] full range of medium work requires standing or walking, off and on, for a total of approximately 6 hours in an 8-hour workday in order to meet the requirements of frequently lifting or carrying objects weighing up to 20 pounds." Social Security Ruling 83-10, 1983 WL 31251, at *6 (S.S.A. 1983).
In response to a hypothetical question that incorporated Dr. Harrington's limitations, the VE testified there are no jobs that a person with that RFC would be able to perform. In response to a hypothetical question that incorporated Dr. McClintock's limitations, the VE testified that, at most, a person with that RFC could perform the job of surveillance system monitor, but that "if this individual is going to require unscheduled breaks [of] unknown duration or frequency, that could be problematic in terms of performing any work," Tr. 71.
The VE's testimony concluded with a question from McCormick's counsel:
Tr. 72.
After the hearing, the ALJ issued a decision in which he gave little weight to Dr. Harrington's opinion, little weight to Dr. McClintock's opinion, and great weight to Dr. Brovender's opinion. The ALJ's decision also includes the following relevant findings of fact and conclusions of law:
Tr. 15, 17, 18, 25. In addition to determining that McCormick was capable of performing the skilled job of carpenter, as generally performed, the ALJ also determined, in the alternative, that McCormick could perform the jobs of cleaner, kitchen helper, and packer.
To be eligible for disability insurance benefits, a person must: (1) be insured for such benefits; (2) not have reached retirement age; (3) have filed an application; and (4) be under a disability. 42 U.S.C. §§ 423(a)(1)(A)-(D). To be eligible for supplemental security income, a person must be aged, blind, or disabled, and must meet certain requirements pertaining to income and assets. 42 U.S.C. § 1382(a). The only question in this case is whether the ALJ correctly determined that McCormick was not under a disability from June 30, 2012, through March 17, 2015.
To decide whether a claimant is disabled for the purpose of determining eligibility for either DIB or SSI benefits, an ALJ is required to employ a five-step process.
The claimant bears the burden of proving that he is disabled.
McCormick claims that the ALJ: (1) erred in assessing his RFC by giving too little weight to the opinions of Drs. Harrington and McClintock and by giving too much weight to the opinion of Dr. Brovender; and (2) failed to properly consider his mental impairments. The court agrees that the ALJ did not give good reasons for discounting the opinions of Drs. Harrington and McClintock.
Under the applicable regulations, the opinions of treating sources such as Drs. Harrington and McClintock are entitled to controlling weight if they are "well-supported by medically acceptable clinical and laboratory diagnostic techniques and [are] not inconsistent with the other substantial evidence in [a claimant's] case record." 20 C.F.R. §§ 404.1527(c)(2) & 416.927(c)(2). Given that the opinions offered by Drs. Harrington and McClintock are not consistent with Dr. Brovender's opinions, there is no good argument to be made that the opinions of McCormick's two treating sources are entitled to controlling weight.
When an ALJ does not give controlling weight to a treating source's opinion, he must still determine how much weight to give that opinion by considering the following factors: (1) the length of the treatment relationship and the frequency of examination; (2) the nature and extent of the treatment relationship; (3) the supportability of the opinion; (4) the consistency of the opinion with the record as a whole; (5) the specialization of the source offering the opinion; and (6) any other relevant factors.
Finally, an ALJ must give "good reasons in [his] decision for the weight [he] give[s] [a claimant's] treating source's opinion." 20 C.F.R. §§ 404.1527(c)(2) & 416.927(c)(2).
Having outlined the applicable legal principles, the court turns to the opinions of Drs. Harrington, McClintock, and Brovender.
In his RFC Questionnaire, Dr. Harrington identified: (1) limitations on sitting, standing, and walking that, according to the VE, would preclude any work; (2) a limitation on lifting and carrying and a limitation on standing and walking that would preclude work at the medium exertional level; and (3) a likelihood of absences from work with a frequency that, according to the VE, would preclude all unskilled work.
After describing the opinions in Dr. Harrington's RFC Questionnaire, the ALJ gave the following evaluation of those opinions:
Tr. 23-24. There are several problems with the ALJ's explanation for the weight he gave Dr. Harrington's opinions.
First of all, while he addressed Dr. Harrington's opinion that McCormick: (1) had limitations on his capacity for repetitive reaching, handling, or fingering; and (2) was likely to be absent from work more than four times a month, he said nothing about Dr. Harrington's opinions on Harrington's capacity for sitting, standing, and walking and his capacity for lifting and carrying. The ALJ was obligated to give good reasons for the weight he gave those opinions,
To be sure, the ALJ stated that Dr. Harrington's opinion, as a whole, was "not well supported by or consistent with the evidence of record," Tr. 23, which echoes two of the factors for evaluating treating source opinions. But without identifying either a particular opinion, such as the limitation on sitting, standing, and waking, and without identifying particular contradictory record evidence, the ALJ's blanket assessment of Dr. Harrington's opinion is insufficiently specific to qualify as a good reason.
Not only are the ALJ's explanations thin on specificity, the specific explanations he did provide are not persuasive. For example, he discounted Dr. Harrington's opinion on McCormick's capacity for repetitive reaching, handling, or fingering because McCormick "did not endorse any difficulty using his hands," Tr. 23, in a function report he completed several months before Dr. Harrington gave his opinions. That function report asked McCormick to indicate any areas that his condition affected. He did not check the box for "Using Hands," but he
The ALJ's reason for discounting Dr. Harrington's opinion that McCormick was likely to be absent from work more than four times a month due to his impairments or treatment for them is even less persuasive. Leaving aside the ALJ's failure to offer any citations to the record to support his observation that McCormick has been able to attend all of his medical appointments, there is a logical problem with the ALJ's explanation. The ALJ does not say how many medical appointments McCormack has attended without mishap.
In sum, the ALJ has not given good reasons for giving little weight to Dr. Harrington's opinions. His explanation generally lacks specificity, and when there is a link between a specific opinion and evidence that purportedly undermines it, the explanation is either unsupported by the record or logically flawed. Given that Dr. Harrington offered several opinions that, if credited, would preclude McCormick's employment, the ALJ's failure to give good reasons for discounting those opinions merits a remand.
In his RFC Questionnaire, Dr. McClintock identified: (1) limitations on lifting and carrying and limitations on standing and walking that would preclude work at the medium exertional level; (2) a need for unscheduled breaks that would preclude McCormick from any work; and (3) a likelihood of absences from work that, according to the VE, would preclude all unskilled work.
After describing the opinions in Dr. McClintock's RFC Questionnaire, the ALJ gave the following evaluation of those opinions:
Tr. 24.
The ALJ's evaluation of Dr. McClintock's opinions suffers from the same shortcomings as his evaluation of Dr. Harrington's opinions. Again, the ALJ did not address the limitation on lifting and carrying or the limitation on standing and walking, either of which would preclude work at the medium exertional level, nor did he address Dr. McClintock's opinion that McCormick would require unscheduled breaks that would preclude any work. Moreover, apart from the ALJ's discussion of the limitation related to McCormick's capacity for repetitive reaching, handling, or fingering, discussed above, the ALJ provided only two other explanations that are specific enough for the court to review,
The ALJ challenged Dr. McClintock's opinion that McCormick can only stand/walk for 30 minutes at a time, but even without that limitation, the remaining limitations in Dr. McClintock's RFC Questionnaire would support a determination that McCormick is disabled. Similarly, the ALJ stated that "[t]reatment notes also show that the claimant did not complain of or present with side effects from medication," Tr. 24, but Dr. McClintock did not assess any limitations based upon side effects of medication. Rather, she simply responded to a question asking her to "[i]dentify the side effects of any medications which may impact [claimant's] capacity for work,
To sum up, the ALJ's failure to give good reasons for discounting the opinions in Dr. McClintock's RFC Questionnaire also merits a remand.
The lack of good reasons for discounting the opinions provided by McCormick's two treating sources is enough to warrant a remand. However, there also appear to be problems with the ALJ's evaluation of Dr. Brovender's opinion.
In two different spots in his decision, the ALJ described his evaluation of Dr. Brovender's opinion and his decision to give that opinion great weight.
Tr. 24. Claimant takes issue with the foregoing statement, and his point is well taken, for two reasons.
First, it is not so clear that Dr. Brovender actually said what the ALJ says he said. With respect to neurological and sensory findings, Dr. Brovender's testimony consists of the following:
. . . .
Tr. 45-46, 47. That testimony is difficult to follow, and the court does not understand Dr. Brovender's acknowledgement of a medical record documenting "talk about sensory changes" in conjunction with his subsequent statement that "physical examinations . . . show . . . no sensory changes." In light of that apparent contradiction, and the somewhat garbled nature of Dr. Brovender's testimony as reported in the hearing transcript, the court simply cannot tell whether Dr. Brovender actually said that McCormick's sensory and neurological findings were normal.
However, if Dr. Brovender did say that McCormick's sensory and neurological findings were normal (except for weakness in a big toe), that appears to be a mischaracterization of the medical record. A January 6, 2014, physical examination resulted in the following finding: "
In addition, a report on a battery of tests conducted at the Monadnock Neurology Center includes the following findings:
Tr. 443 (Ex. 14F). Without knowing the full ramifications of those findings, the court feels safe in concluding that the "slight chronic changes" and "mild active changes" documented in McCormick's radiology report fall short of being completely normal sensory and neurological findings.
Based upon the foregoing, the court must conclude that to the extent that Dr. Brovender testified that McCormick's sensory and neurological findings were normal, he could only have done so by ignoring evidence from multiple physical examinations that uncovered signs of peripheral neuropathy, an impairment that the ALJ deemed severe but Dr. Brovender did not even mention, much less identify as a medically determinable impairment. In light of the problems with Dr. Brovender's appraisal of the medical record, his opinion does not appear to qualify as substantial evidence in support of the ALJ's RFC assessment.
For the reasons described above, the Acting Commissioner's motion for an order affirming her decision, document no. 11, is denied, and McCormick's motion to reverse that decision, document no. 9, is granted to the extent that the case is remanded to the Acting Commissioner for further proceedings, pursuant to sentence four of 42 U.S.C. § 405(g). The clerk of the court shall enter judgment in accordance with this order and close the case.
SO ORDERED.