JOHN GLEESON, District Judge.
Nalia Milien seeks review, pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3), of the Commissioner of Social Security's denial of her application for a period of disability and disability insurance benefits. The parties have cross-moved for judgment on the pleadings. I +heard oral argument on December 3, 2010. Because the Commissioner's decision is not supported by substantial evidence in the record, I deny the Commissioner's motion, grant Milien's motion, and remand for further proceedings.
On September 12, 2007, Milien filed an application for disability and disability insurance benefits, alleging that she had been disabled since June 27, 2007.
On July 31, 2009, ALJ Cofresi concluded that Milien was not disabled within the meaning of the Social Security Act on the ground that she retained the residual functional capacity to perform limited light work as defined in 20 C.F.R. § 416.967(b). The Appeals Council denied Milien's request for review on March 29, 2010, making the ALJ's adverse decision the final decision of the Commissioner. See DeChirico v. Callahan, 134 F.3d 1177, 1179 (2d Cir. 1998).
Milien was born in 1957 and received an eighth grade education in her native Haiti. She immigrated to the United States in 1983. She worked in 1984 and 1985, and the following year she began working as a school bus escort, assisting disabled children in getting on and off school buses and carrying their school bags. Milien held that position from 1986 until the alleged onset of her disability in 2007. She lived independently prior to the onset date, but now lives with a cousin in Queens. Milien has six children, of whom five are adults; the sixth, a 14-year-old daughter, was sent to live with Milien's 25-year-old son in Atlanta when Milien's condition worsened. She is separated from her husband.
Milien suffers from HIV, hypertension, fatigue, obesity, and depression. Her HIV and hypertension are well-controlled by medication, but the medications' side effects have negatively impacted her health. She now regularly takes Atripla, amlodipine-benazepril, hydrochlorothiazide ("HCTZ"), Norvasc, and Sustiva. Her current symptoms arose shortly after a change in her HIV medication in the first half of 2007, which added Atripla to her daily regimen.
In her testimony at the hearing before ALJ Cofresi, Milien complained that the medications prescribed by her doctor in early 2007 caused her to be "so sedated [at night] that if there were a fire she did not believe she would be able to wake up." (Milien Mem. at 3; R. 33.) She claims the medications also cause severe fatigue that persists for two to three hours after awakening each morning, and leaves her "sleepy" all day. (R. 33-34.) She noted at the hearing before ALJ Cofresi that she had skipped her medicine the night before in order to be sufficiently alert for the hearing. (R. 34.)
Milien is dizzy throughout the day, which prevents her from sitting more than 30-40 minutes at a time. (R. 29.) It also prevents her from taking the subway, because she feels it would be unsafe for her to exit at her destination in that condition. (R. 28.) Her dizziness began after the medication switch in early 2007. (R. 25.)
Milien testified that she is able to perform basic activities of personal maintenance, such as grooming, washing, and hairdressing. However, her dizziness and fatigue make her unable cook, clean, or shop. She can use public transportation, but is restricted to travel on the bus. (R. 27-28.) Her social activity is adequate, including weekly church attendance and meetings with family and friends.
Milien has consistently been diagnosed with HIV, hypertension (poorly controlled), obesity, diabetes mellitus type 2, and depression. Other diagnoses throughout the relevant period have included fatigue (medically and virally induced), pterygia,
Milien's medical record begins with an admission to Long Island Jewish Hospital on October 17, 2005, for treatment of hemoptysis. (R. 145.) At the time she was taking the prescription drugs Norvasc, Sustiva, Trivada, Lisinopril, and HCTZ. (Id.) An x-ray taken at the hospital revealed an opacity in the right lung "which may represent atelectasis,
On October 28, 2005, shortly after being released from the hospital, Milien was examined by her treating physician, Dr. Yvan Mardy.
On February 9, 2006, Milien was evaluated by state agency psychologist Rochelle Sherman. Sherman noted that Milien had taken a leave of absence for health reasons in October and November 2005, and that though she had since returned to work, she was "having difficulty completing work tasks." (R. 159.) Milien displayed an unremarkable appearance, had "clear, fluent, and intelligible" speech with no evidence of thought disorder, a full range of affect, and a neutral mood. (R. 160.) Sherman also observed "mildly deficient" attention and concentration (id.), and "mildly impaired" memory (R. 161). Milien had below average cognitive functioning, but "good" insight and judgment. (Id.) She was independent in her living and able to follow directions, but had difficulty coping with stress. (Id.) Sherman concluded that her results "appear to be consistent with psychiatric and cognitive problems, which may interfere with the claimant's ability to function on a daily basis." (Id.) Milien was diagnosed with depression and given a guarded prognosis, though Sherman noted Milien would be able to manage her own funds. (R. 162.)
On the same date, Milien saw Dr. Steven Rocker, who appears to be a state agency physician.
Dr. Nisha Sethi, Milien's treating infectious disease specialist, filled out an undated disability questionnaire stating that she had last seen Milien on September 18, 2007, and that she had begun seeing her every two to three months on August 20, 2004.
On December 19, 2007, Dr. Scott Weinstein performed a consultative medical examination on Milien. He stated that Milien had reported a three-to-four year history of severe fatigue "as a result of antiretroviral therapy." (R. 175.) The fatigue caused her to be "`very, very tired when [she awakes] in the morning and at night.'" (Id.) Milien also told Weinstein of "episodic lightheadedness" that appeared to be related to her blood pressure. (Id.) Weinstein recorded a largely normal physical workup, but noted "mild to moderate obesity" and "mild conjunctival hyperemia bilaterally" with "bilateral pterygia." (R. 177.) In addition to pterygia, he diagnosed fatigue, HIV, hypertension (poorly controlled), conjunctivitis, neutropenia, lymphocytosis, thrombocytopenia, and microcytic anemia, and declared Milien's prognosis "stable." (R. 178.)
On January 9, 2008, Milien's case was referred for a psychiatric consultation to Dr. Robert McClintock. Asked to comment on Milien's potential diagnosis of depression, he wrote "Clmt alledges [sic] Depression, which has to be developed as part of determining the claim." (R. 196.) He did not give any weight to Dr. Sethi's report, as Sethi was "not a Psychiatrist." (Id.) He recommended that "psych forms . . . be completed . . . and a psych CE [consultative examination] . . . be obtained." (Id.)
On January 15, 2008, Milien's case was referred for medical advice to Dr. P. Seitzman, who noted that "[t]here is no evidence secured of initial HIV diagnosis." He went on to state that there was currently "no evidence of HIV at all."
On January 21, 2008, Milien received a psychiatric consultative evaluation by state agency psychologist Dr. Kenneth Cochrane. Cochrane observed that Milien's demeanor and responsiveness to questions was cooperative, but that her manner of relating, social skills, and overall presentation were "poor" due to her "inability to concentrate." (R. 201.) She was disheveled, poorly groomed, lethargic, and had poor eye contact. (Id.) Her affect was depressed and anxious, and her mood was dysthymic. (Id.) Her attention, concentration, and memory were impaired "due to limited intellectual functioning," and her insight and judgment were poor. (R. 202.) Although she was "able to follow and understand simple directions and instructions . . . [and] simple tasks," she was only minimally able to maintain attention and concentration. Cochrane noted that her "[c]urrent vocational difficulties are caused by medical problems and probable cognitive deficits." (Id.) He concluded that her prognosis was "guarded," and that her results appeared to be "consistent with cognitive problems [which] may significantly interfere with the claimant's ability to function on a daily basis." (Id.) He further concluded that Milien should seek further psychiatric treatment to rule out cognitive disorder and HIV-related dementia. (R. 203).
On January 25, 2008, Milien was evaluated by Dr. Wlodek Skranovski, a psychiatrist. Skranovski evaluated Milien under Listing 12.02 of the Listing of Impairments, 20 C.F.R. § 404 subpt. P. app. 1 (hereinafter "Listing"), which denotes the symptoms of organic mental disorders. (R. 212.) He indicated that "[a] medically determinable impairment is present that does not precisely satisfy the diagnostic criteria" set forth by Listing 12.02. (R. 213.) He determined that Milien had moderate difficulty in maintaining concentration, persistence or pace, but determined that there were no restrictions on her activities of daily living, no difficulties in maintaining social functioning, and no episodes of decompensation (collectively, the "B criteria"). (R. 222.) He determined that she met neither the B criteria nor the C criterion (a medically documented history of a disorder of at least two years' duration "that has caused more than a minimal limitation of ability to do any basic work activity"). (R. 223.)
In a more detailed form also completed on January 25, 2008, Dr. Skranovski concluded that Milien had no significant limitation in her ability to: remember locations and work-like procedures; understand, remember, and carry out very short and simple instructions; maintain a schedule; interact appropriately with the general public; ask questions; or adapt to a work environment. (R. 226-27.) She had moderate limitations on her ability to: understand, remember, and carry out detailed instructions; maintain attention and concentration for extended periods; work closely with others without being distracted by them; complete a normal workday and workweek without interruptions from psychological symptoms or without having to take an "unreasonable number and length" of rest periods; and maintain socially appropriate behavior. (Id.) Skranovski found no evidence that she was limited in her ability to accept instructions, respond appropriately to criticism, or get along with coworkers or peers. (R. 227.)
On April 14, 2009, Dr. Mardy filled out a "treating doctor's patient functional assessment to do sedentary work." He opined that Milien could stand, walk, and sit less than four hours a day, and that she could lift less than five pounds for one-third of the day but less than three pounds for two-thirds of the day. (R. 232.) He stated that Milien required medications that interfered with her ability to function in the work setting, that she would have difficulty concentrating on her work, and that she would require more than two sick days per month. (R. 233.) He stated that she feels "`dizzy' when wake up in the AM secondary to medication taken at night." (Id.) He further noted that Milien was "clinically weak secondary to underlying disease and the various drugs taken ie HTN meds, etc." (Id.)
To be found eligible for disability benefits, Milien must show that, "by reason of any medically determined physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months," 42 U.S.C. § 423(d)(1)(A), she "is not only unable to do [her] previous work but cannot, considering [her] age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy," id. § 423(d)(2)(A).
The Social Security regulations direct a five-step analysis for evaluating disability claims:
DeChirico, 134 F.3d at 1179-80 (2d Cir. 1998) (internal quotation marks omitted); see also 20 C.F.R. § 404.1520. The claimant bears the burden of proof in the first four steps, the Commissioner in the last. See Green-Younger v. Barnhart, 335 F.3d 99, 106 (2d Cir. 2003).
The ALJ followed the five-step procedure outlined above. He determined that Milien had not engaged in substantial gainful activity since June 27, 2007, her date of onset, and that she would continue to meet the insured status requirements of the Social Security Act through December 31, 2011. (R. 10.) He determined that she had several "severe impairments:" HIV, high blood pressure (hypertension), fatigue, obesity, and depressive disorder. (Id.) He evaluated her HIV under Sections 14.00D and 14.08D of the Listing, her hypertension under Section 4.00 of the Listing, and her mental impairment under Listing 12.04,
The ALJ next determined that Milien retained the residual functional capacity to perform her past relevant work. (Id.) Although he was not required to proceed to the fifth step, having answered the fourth question in the affirmative, he did so "assuming, arguendo, that the claimant was unable to perform her past relevant work." (R. 16.) At the fifth step, the ALJ concluded that Milien was not disabled under the Social Security Act because she retained the residual functional capacity to perform the statutory range of "light work," with a restriction to "simple rote tasks" only. (R. 12.) See 20 C.F.R. § 416.967(b) ("Light work involves lifting no more than 20 pounds at a time with frequent lifting or carrying of objects weighing up to 10 pounds. Even though the weight lifted may be very little, a job is in this category when it requires a good deal of walking or standing, or when it involves sitting most of the time with some pushing and pulling of arm or leg controls.").
An ALJ faced with an HIV-related disability must evaluate the claimant's allegations under Listings 14.00 (immune system disorders) and 14.08 (HIV infection). Listing 14.08 contains an extensive list of HIV symptoms and HIV-related conditions, each of which, if found, would call for a finding of disability. Among those symptoms and conditions, a claimant's HIV status meets the listing where the claimant has suffered "[r]epeated . . . manifestations of HIV infection . . . resulting in significant, documented symptoms or signs (for example, severe fatigue . . .), and one of the following at the marked level: 1. Limitations of activities of daily living. 2. Limitation in maintaining social functioning. 3. Limitation in completing tasks in a timely manner due to deficiencies in concentration, persistence, or pace." Listing 14.08K. Listing 14.00, which provides general instructions regarding the ALJ's evaluation of a claimant's HIV symptoms, states that the side effects of HIV medication are to be given the same weight as effects of the disease itself. Id. § 14.00G(5)(a) ("The symptoms of HIV infection and the side effects of medication may be indistinguishable from each other. We will consider all of your functional limitations, whether they result from your symptoms or signs of HIV infection or the side effects of your treatment.").
ALJ Cofresi's conclusion that "[t]he record does not show that the claimant's HIV positive status has advanced to the point of causing secondary medical complications" (R. 11), disregarded what the ALJ had already termed a "severe impairment" — Milien's fatigue. Even if the fatigue was related to Milien's medications (a finding ALJ Cofresi did not make),
Moreover, ALJ Cofresi did not properly evaluate the three areas of functional impairment laid out in Listing 14.08K: activities of daily living, social functioning, and completing tasks. Milien's condition meets at least one appropriate listing: Listing 14.00I states that the Commissioner "will find that you have a marked limitation of activities of daily living if you have a serious limitation in your ability to maintain a household or take public transportation because of symptoms, such as pain, severe fatigue, anxiety, or difficulty concentrating, caused by your immune system disorder (including manifestations of the disorder) or its treatment, even if you are able to perform some self-care activities."). Listing 14.00I(6) (quotation marks omitted and emphasis added). Milien testified that she is unable to take the subway and was restricted to buses (R. 28); that she is no longer able to maintain her independent household or properly care for her minor child (R. 27, 34-35); and that she cannot cook, clean, or shop (R. 27). Dr. Cochrane stated that due to her cognitive deficits, Milien would not be able to manage her own money and pay her own bills. (See R. 202, Listing 14.00I(6) ("Activities of daily living include .. . paying bills."); see also infra Part B.2.b.) The ALJ did not take into account this testimony, and thus failed to consider the substantial weight of the evidence with regard to Milien's functional limitations. The ALJ's failure to properly evaluate Milien's HIV status according to Listings 14.00 and 14.08 requires a remand.
Under the regulations, a treating physician's opinion about a claimant's impairments is entitled to "controlling weight" if it is "well [] supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in [the] case record." 20 C.F.R. § 404.1527(d)(2); see also Schisler v. Sullivan, 3 F.3d 563, 568 (2d Cir. 1993) (upholding these regulations). The Commissioner must set forth "good reasons" for refusing to accord the opinions of a treating physician controlling weight. He must also give "good reasons" for the weight actually given to those opinions if they are not considered controlling. 20 C.F.R. § 404.1527(d)(2); see also Halloran v. Barnhart, 362 F.3d 28, 33 (2d Cir. 2004) ("We do not hesitate to remand when the Commissioner has not provided `good reasons' for the weight given to a treating physician[']s opinion and we will continue remanding when we encounter opinions from ALJs that do not comprehensively set forth reasons for the weight assigned to a treating physician's opinion."); Snell v. Apfel, 177 F.3d 128, 133 (2d Cir. 1999) ("Under the applicable regulations, the Social Security Administration is required to explain the weight it gives to the opinions of a treating physician."). When the Commissioner does not give a treating physician's opinion controlling weight, the weight given to that opinion must be determined by reference to: "(i) the frequency of examination and the length, nature, and extent of the treatment relationship; (ii) the evidence in support of the opinion; (iii) the opinion's consistency with the record as a whole; (iv) whether the opinion is from a specialist; and (v) other relevant factors." Schaal v. Apfel, 134 F.3d 496, 503 (2d Cir. 1998) (citing 20 C.F.R. § 416.927(d)(2)).
ALJ Cofresi's failure to state the amount of weight he assigned to Dr. Mardy's opinion was erroneous. If he chose not to accept Mardy's observations as controlling, he should have undertaken the analysis required by Schaal in order to determine the weight Mardy's opinions would be given — including, for example, a discussion of the frequency with which Mardy treated Milien. Instead, ALJ Cofresi stated that he gave "no controlling weight to the medical source statement set forth by treating physician [Mardy because he] finds limits that far exceed the evidence of record. This opinion is based on the claimant's subjective complaints. There is no objective clinical or laboratory diagnostic findings that support this functional assessment." (Id.) Because the ALJ failed to conduct a proper Schaal analysis, thus applying an incorrect standard to Mardy's potentially dispositive report, the case must be remanded. See Schaal, 134 F.3d at 503 ("Because it is not entirely clear what legal standard the ALJ applied, and because we find that the ALJ . . . failed to follow SSA regulations requiring a statement of valid reasons for not crediting the opinion of plaintiff's treating physicians, we conclude that a remand is necessary in order to allow the ALJ to reweigh the evidence.").
In resolving whether a plaintiff is disabled, the Commissioner must consider subjective evidence of pain or disability testified to by the claimant.
Because the ALJ concluded that the objective medical evidence could reasonably give rise to Milien's symptoms, a dispositive reason for the ALJ's denial of benefits was his opinion that Milien's testimony about the extreme nature and limiting effects of her dizziness and fatigue was not credible. (R. 14, 22.) As explained below, I conclude that his adverse credibility determination is not supported by substantial evidence on the record, and thus requires a reversal.
The reasons for ALJ Cofresi's adverse credibility determination were threefold. First, he stated that Milien "has had very limited medical evaluation and treatment for her complaints of pain and depression." (R. 15.) Second, the ALJ observed that "despite [Milien's] allegations suffering from physical and mental impairments, throughout the period of time in issue she has continued to live independently and take care of all her personal needs, own household chores, shopping and cooking. Moreover she continues to socialize." (Id.) Finally, he found that Milien's statements were not "consistent with the medical evidence of record or that her allegations of pain and depression [were] not supported by the record." (Id.) With regard to Milien's depression, the ALJ's negative inference from her lack of treatment was improper. The record reflects that her depression did not arise until "a few months" before she met with Dr. Sethi in the Fall of 2007 — in other words, very close in time to her alleged onset date, when she stopped working and presumably lost her insurance. (R. 183.) At her hearing, Milien testified that she no longer had medical insurance and had stopped seeing doctors because she could not pay.
Second, the record is clear that Milien neither "continued to live independently" nor could she "take care of all her personal needs, own household chores, shopping and cooking." (R. 15.) To the contrary, the testimony reflects that she had substantial limitations in her independence and in the activities of daily life:
(R. 27.) Milien also testified that she had no money at all and was frequently dependent on her cousin for transportation. (R. 28.) As in Horan, the ALJ's adverse credibility determination was based at least in part on testimony Milien did not give. See Horan, 350 Fed. App'x at 484. ALJ Cofresi's misapprehension of Milien's testimony on the subject of daily living, and thus his erroneous determination of her credibility with regard to the severity of her symptoms, requires a remand.
Finally, the ALJ failed to properly consider Milien's 24-year work history. "A claimant with a good work record is entitled to substantial credibility when claiming an inability to work because of a disability." Rivera v. Schweiker, 717 F.2d 719, 725 (2d Cir. 1983); see Horan, 350 Fed. App'x at 485 (reversing and remanding in part because "the ALJ committed legal error in failing to consider [the claimant's] work history"). Milien had an extensive track record of consistent employment, 22 years of which were at the same company. Further, she testified that she left her job only when "they changed my medication" (R. 25), at which point she "[could not] get up to go into work" because she felt "dizzy . . . and [her] heart ke[pt] beating so fast."
The Commissioner's motion for judgment on the pleadings is denied, Milien's is granted, and the case is remanded to the Commission for further proceedings.
So ordered.