JOSEPH F. BIANCO, District Judge:
Plaintiff, Danny Johnson (hereinafter "plaintiff) brings this action, pursuant to 42 U.S.C. § 405(g) of the Social Security Act ("SSA"), challenging the final decision of defendant, Commissioner of the Social Security Administration (hereinafter "Commissioner"), denying the plaintiffs application for Disability Insurance Benefits or Supplemental Security Income. The Commissioner moves for judgment on the pleadings pursuant to Federal Rule of Civil Procedure 12(c). Plaintiff opposes the Commissioner's motion and cross-moves for judgment on the pleadings, alleging that the Administrative Law Judge ("ALJ") failed to develop the record and to properly assess plaintiff's credibility and violated the treating physician rule. For the reasons set forth below, the case is remanded to the ALJ for further proceedings consistent with this Memorandum and Order.
The following summary of facts is based upon the administrative record ("AR") as
Plaintiff was born on May 12, 1963. (AR at 74, 75.) He was educated through the ninth grade. (Id. at 124.) He last worked in 2006 as a car detailer and had performed that job between five and ten years. (Id. at 45-46, 121.)
Below, the Court outlines medical evidence of plaintiff's well-being in the period immediately prior to the alleged onset date of January 25, 2007 up until the date of the ALJ's decision.
Plaintiff was treated for human immunodeficiency virus ("HIV") from September 2006 until September 2009 at the Nassau University Medical Center, HIV Primary Care Clinic ("HIV Clinic"). Plaintiff received treatment at the HIV Clinic from Minou Absy, M.D. and nurse practitioner Wanda Evelyn. During that time, plaintiff's illness became more stabilized and his condition generally improved.
Plaintiff was diagnosed with HIV in approximately July 2006. (Id. at 185.) Before starting any medications, on September 1, 2006, plaintiff was seen at Nassau University Medical Center ("NUMC") for weakness, nausea, shortness of breath, intermittent chest pain, and exertional dyspnea, but he left without being examined. (Id. at 184-85.)
Plaintiff began treatment for HIV on October 11, 2006 at the HIV Clinic. (Id. at 186.)
On October 26, 2006, plaintiff returned to the HIV Clinic for a follow-up visit. He complained of diarrhea, rash by his eyes and between his legs. (Id. at 193.) Also, plaintiff was not taking his HIV medications and was referred to a treatment adherence program. (Id. at 194.) Plaintiff's CD4 count and viral load remained at 12 and 14,200. (Id. at 193.)
Plaintiff's returned to the HIV Clinic on January 31, 2007. (Id. at 197.) He weighed 64.7 kg and complained of a dry cough, visual changes and rash on his legs. (Id. at 197.) Plaintiff had not taken his medication for the prior two months due to what he explained were insurance complications and the importance of treatment adherence was stressed. (Id. at 197-98.) Plaintiffs CD4 count and viral load remained at 12 and 14,200 and he was considered unstable. (Id.)
Plaintiff's medical records from his February 2007 visit to the HIV Clinic indicate a CD4 count of 51 and a dramatically decreased viral load of 222 from his prior 14,200 in January 2007. (Id. at 183.) His medical records from April 5, 2007 reveal a CD4 count of 35 and a viral load of less than 75. (Id. at 183, 201.)
On April 9, 2007, plaintiff returned to the HIV Clinic and weighed 67.8 kg and complained of a sore throat, cough and slight night sweats. (Id. at 160.) His CD4 count was 35 and viral load was 222. (Id.) In addition, plaintiff indicated that he was taking his medications and it was noted that he was ninety-percent adherent with his medications. (Id. at 160-61, 202.) His physical examination revealed genital warts and he was prescribed a new regimen consisting of Reyataz, Norvir, and Truvada. (Id. at 160-61.) Plaintiff was not considered stable. (Id. at 161.)
On May 6, 2007, plaintiff was brought to the emergency department of NUMC because he reportedly expressed thoughts of suicide. (Id. at 203.)
Lab results from August 2007 show that plaintiff's CD4 count was 27 and his viral load was 940 and in October 2007, his CD4 count was 81 and his viral load less than 75. (Id. at 183; see id. at 156.) On December 13, 2007, plaintiff returned to the HIV Clinic and complained of a slight cough and backache. (Id. at 156.) Plaintiff reported that he had not taken his medications for one month and was counseled for treatment adherence. (Id. at 156.) Plaintiff weighed 75.6 kg and was deemed stable. (Id. at 156-57.)
According to lab results from January 16 2008, plaintiff's blood tests revealed an improved CD4 count of 78 and viral load of 4,763. (Id. at 167; see id. at 155.) Eight days later, plaintiff went to the HIV Clinic and complained of a cough, dysphagia and visual changes. (Id. at 212.) Plaintiff weighed 75.8 kg. (Id.) At his annual physical examination conducted during the same visit, plaintiff complained of right hip pain "with long walk." (Id. at 154.) The examining doctor noted tenderness in the lower back and plaintiff was diagnosed with right hip pain secondary to aseptic necrotic osteoarthritis. (Id. at 154.) Other than genital warts, plaintiff's exam was relatively normal. (Id. at 153-55.)
On February 14, 2008, x-rays were taken of plaintiff's right hip and found that "[t]here is no evidence of fracture or dislocation... and no significant abnormality." (Id. at 164, 214, 216.) Later that month, on February 28, 2008, plaintiff returned to the HIV Clinic and complained of a cough and weight loss. Plaintiff weighed 72.6 kg, but he left before being examined. (Id. at 217.)
On May 1, 2008, plaintiff returned to the HIV Clinic. (Id. at 219.) Plaintiff weighed 72.3 kg and his CD4 count was 134 and viral load of less than 48. (Id. at 225, 226.) Plaintiff was noted to have missed four medication doses in the prior week and was seventy-five percent adherent with his medications. (Id. at 219, 220.) Medication adherence was stressed and plaintiff refused the treatment adherence program. (Id. at 220.)
Plaintiff returned to the HIV Clinic for a follow up on May 29, 2008. (Id. at 226.) Plaintiff complained of genital warts and shortness of breath. (Id. at 226.) He weighed 73 kg, and it was noted that he was one-hundred percent compliant with his medications, and his condition was deemed stable. (Id. at 226, 227.)
As discussed infra, on June 16, 2008, Dr. Linell Skeene conducted a consultative examination at the request of the Commissioner and concluded that plaintiff had no limitation for physical activity based upon the physical examination and noted that plaintiff may have some fatigue secondary to HIV that limits his physical activity. (Id. at 172.)
Six weeks later, on July 30, 2008, plaintiff returned to the HIV Clinic. (Id. at 172.) Plaintiff complained of hip and left arm pain for the past ten days and shortness of breath. (Id. at 228.) His examination
On October 25, 2008, plaintiff returned to the HIV Clinic. (Id. at 234.) Plaintiff complained of shortness of breath and weight loss and plaintiff's weight was recorded at 70.2 kg. (Id. at 234.) Plaintiff's CD4 count was 181 and his viral load was 646, and he was deemed stable. (Id. at 234.) Plaintiff was noted to be eighty-five percent compliant with his medications and refused the treatment adherence program. (Id. at 235.) That same day, plaintiff was a walk-in at the NUMC ambulatory unit and he complained of back pain. (Id. at 236.) The medical record shows that plaintiff was discharged from jail on Friday, October 10, 2008. (Id. at 236.) Plaintiff received a neurological referral to rule out peripheral neuropathy. (Id. at 237.)
Lab results from December 16, 2008 show plaintiff's CD4 count to be 169 and his viral load to be 665. (Id. at 242.) On December 17, 2008, plaintiff went to the HIV Clinic and complained of night sweats, diarrhea, and visual changes. (Id. at 238.) It was noted that plaintiff was 90% complaint with his medications and adherence to treatment was stressed. (Id. at 239.) Plaintiff weighed 72.3 kg, he was considered stable, and his medication was not changed. (Id. at 239.) Plaintiff reported for an appointment at the NUMC ambulatory unit that same day and reported "no new pain." (Id. at 240.)
Plaintiff returned to the HIV Clinic twice in February 2009. (Id. at 244-48.) On February 11, 2009, plaintiff complained of a slight cough and constipation, but no pain. (Id. at 244, 245.) Plaintiff weighed 71.5 kg and indicated he had stopped his medications several days earlier. (Id. at 244.) At his second visit on February 25, 2009, plaintiff indicated that he was "stressed [because] of his girlfriend." (Id. at 246.) Plaintiff weighed 72.9 kg. (Id. at 246.) Plaintiff stated that he was ninety-percent complaint with his medications and refused the treatment adherence program. (Id. at 247.) At his appointment with the NUMC ambulatory unit that same day, plaintiff complained of "body" pain and gave it a severity of three out of ten and described it as "shocks thru body." (Id. at 248.)
At plaintiff's March 25, 2009 visit to the HIV Clinic, plaintiff stated he had recently been hospitalized for pneumonia and was "feeling better." (Id. at 249.) Plaintiff's lab results from that day show a CD4 count was 304 and his viral load was 753 and he weighed 70.4 kg. (Id. at 249, 252.) Plaintiff reported that he was ninety-percent compliant with his medications and he refused treatment adherence counseling. (Id. at 250.)
Plaintiff returned to the HIV Clinic on May 28, 2009. (Id. at 255.) Plaintiff complained of night sweats, was deemed stable, and weighed 72.7 kg. (Id. at 255-56.) Plaintiff reported to be eighty-five percent compliant with his medications. (Id. at 256.) At his follow-up with the NUMC ambulatory unit that same day, plaintiff reported no pain. (Id. at 258.)
On July 29, 2009, plaintiff returned to the HIV Clinic. (Id. at 259.) Plaintiff reported that he had been released from jail the day before his visit after being incarcerated for two months. (Id. at 259, 263.) Plaintiff complained of occasional numbness/tingling and weighed 68.9 kg. (Id.) His most recent lab results from June 22, 2009 show a CD4 count of 207 and a viral load of less than 48. (Id.) Plaintiff reported that he was 100% complaint with
On August 6, 2009, plaintiff walked-in requesting refills for his medications due to his incarceration. (Id. at 264-65.) His scripts were sent to his pharmacy for pickup the next day. (Id. at 265.) On August 27, 2009, plaintiff returned to the HIV Clinic. (Id. at 266.) Plaintiff weighed 73.5 kg and reported that he was 100% complaint with his medications. (Id. at 266-67.)
A little more than two weeks after his latest follow-up visit to the HIV Clinic, Dr. Linell Skeene conducted a consultative internal medicine examination at the behest of the Commissioner on June 16, 2008. (Id. at 169-172.) Plaintiffs chief complaint was lower back pain, which he described as sharp and constant, radiating down the right leg without any associative numbness. (Id. at 169.)
(Id.)
With respect to plaintiffs musculoskeletal examination, Dr. Skeene observed that plaintiffs "[c]ervical spine shows full flexion, extension, lateral flexion bilaterally, and full rotary movement bilaterally. No scoliosis, kyphosis, or abnormality in thoracic spine." (Id. at 171.) In addition, plaintiff had "full [range of motion] of hips, knees, and ankles bilaterally. Strength 5/5 in upper and lower extremities.... Joints stable and nontender. No redness, heat, swelling, or effusion." (Id.) Furthermore, Dr. Skeene noted that there were no motor or sensory deficits (id.), and plaintiffs "[h]and and finger dexterity intact. Grip strength 5/5 bilaterally." (Id. at 171-72.) Finally, Dr. Skeene diagnosed: (1) probable arthritis of the lumbar spine; (2) HIV; (3) status post pneumonia; and (4) venereal warts, and in his medical source statement noted that "the claimant has no limitation for physical activity based on the physical exam. The claimant may have some fatigue secondary to HIV that limits his physical activity." (Id. at 172.)
On March 11, 2008, claims representative H. Delia completed a Disability Report, Form SSA-3367, after a face-to face interview with plaintiff. (Id. at 115-18.) Within the Observations section, Delia answered that plaintiff has no difficulty with hearing, reading, breathing, understanding, coherency, concentrating, talking, answering, sitting, standing, walking, seeing, using his hands and writing. (Id. at 116-17.)
On July 17, 2008, based upon the medical evidence contained in the record at that time, including Dr. Skeene's consultative examination, disability analyst A. Tolliver completed a Physical Residual Functional Capacity Assessment ("disability assessment") of plaintiff. (Id. at 173-78.)
(Id. at 174.)
In addition, Tolliver stated that his findings were not significantly different from the treating source conclusions. (Id. at 177.)
Plaintiff was forty-six years old at the time he testified at his hearing on October 14, 2009. (Id. at 45.) As noted supra, plaintiff had worked as a car detailer and stopped working in 2006. (Id. at 45-46.) He performed the job mostly while standing and he stopped working because he found out he had HIV and he could not stand for very long due to a back problem, which he identified as scoliosis. (Id. at 46-47; see Id. at 50.) Plaintiff elaborated further that he was laid off due to his HIV medical appointments. (Id. at 48.) ("I kept having to go to my appointments ... and they couldn't have me going to my appointments because I had to do cars so they laid me off.") Responding to a question about whether he has tried to go back to work, plaintiff explained "I tried but the appointments just got in the way so I told them about it and some of the people just can't use me." (Id. at 48-49.)
With respect to his back problem, plaintiff testified that he never had surgery on his back and has not had any injections. (Id. at 56, 68.) Plaintiff was wearing a
With respect to HIV, plaintiff testified that his primary symptoms were feeling weak and tired and difficulty sleeping. (Id. at 51.) Plaintiff also stated that he sometimes had "night sweats" and when that occurred sleeping without his t-shirt stops the sweating. (Id. at 61.) In addition, plaintiff testified that he has trouble concentrating and sometimes he forgets things such as his appointments. (Id. at 60.)
Plaintiff testified that he lives with his mother, his sister and his two nephews, ages ten and eighteen. (Id. at 54-55.) As noted supra, although plaintiff testified that he sometimes has trouble zipping a zipper or buttoning a shirt (Id. at 63-64), plaintiff is generally independent in his personal care. He lives in the bedroom in the basement of his mother's house and he can open the door to his bedroom and walk up and down the stairs. (Id. at 66-67.) When plaintiff wakes up in the morning, he first stretches and then washes and brushes his teeth. (Id. at 55.) He is able to open a drawer to take something out and open a closet to take out clothes. (Id. at 67.) It takes plaintiff about twenty minutes to dress himself and longer if he has to tie shoes. (Id. at 70.) Plaintiff is able to open an envelope, write with a pen, shower, get a haircut, pull a t-shirt over his head, use utensils, use a phone, hold up a cup of coffee, pick up coins, and squeeze a tube of toothpaste. (Id. at 62, 66-68.) Plaintiff goes shopping for food with his mother (Id. at 64; see id. at 130), but otherwise most other household chores are performed by his mother or friend. (Id. at 64-66.)
On March 11, 2008, plaintiff filed applications for disability insurance benefits and supplemental security income, alleging disability beginning January 25, 2007 due to HIV and lower back problems. (Id. at 102-106, 120.) The applications were denied on July 28, 2008. (Id. at 76.) On October 23, 2008, plaintiff requested a hearing (id. at 83), and appeared with his representative before ALJ Seymour Rayner on October 14, 2009. (Id. at 42.) By decision dated November 16, 2009, ALJ Rayner found that plaintiff was not disabled. (Id. at 32-40.) Plaintiff then filed a timely appeal to the Appeals Council, which was denied on March 19, 2010. (Id. at 1-3.) Plaintiff then filed this action on May 21, 2010, and the Commissioner served the administrative record on September 21, 2010, and filed his answer on September 22, 2010. On February 25, 2011, the parties bundled their papers: Commissioner moved the Court for a judgment on the pleadings and plaintiff responded and cross-moved for a judgment on the pleadings; Commissioner replied and plaintiff submitted a reply on his cross-motion. The motions are fully submitted and the Court has carefully considered the parties' arguments.
A district court may only set aside a determination by an ALJ that is based upon legal error or that is unsupported by substantial evidence. Balsamo v. Chater, 142 F.3d 75, 79 (2d Cir.1998) (citing Berry v. Schweiker, 675 F.2d 464, 467 (2d Cir. 1982)). The Supreme Court has defined "substantial evidence" in Social Security
A claimant is entitled to Social Security benefits under the Social Security Act ("SSA") if the claimant is unable to "engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to last for a continuous period of not less than twelve months." 42 U.S.C. § 1382c(a)(3)(A). An individual's physical or mental impairment is not disabling under the SSA unless it is "of such severity that he is not only unable to do his previous work but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy." 42 U.S.C. § 1382c(a)(3)(B).
The Commissioner has promulgated regulations establishing a five-step procedure for evaluating disability claims. See 20 C.F.R. §§ 404.1520, 416.920. The Second Circuit has repeatedly summarized this evaluative process:
Brown v. Apfel, 174 F.3d 59, 62 (2d Cir. 1999) (quoting Perez v. Chater, 77 F.3d 41, 46 (2d Cir.1996)). The claimant bears the burden of proof with regard to the first four steps; the Commissioner bears the burden of proving the last step. Brown, 174 F.3d at 62.
The Commissioner "must consider" the following in determining a claimant's entitlement to benefits: "(1) objective medical facts; (2) diagnoses or medical opinions based on such facts; (3) subjective
Here, in reaching his conclusion that plaintiff was not disabled under the SSA, the ALJ adhered to the five-step sequential analysis for evaluating applications for disability benefits. (Id. at 35-40.) At the first step, the ALJ found that plaintiff had not engaged in substantial gainful activity since his alleged disability onset date of January 25, 2007. (Id. at 36.) At step two of the analysis, the ALJ found that plaintiff had severe impairment consisting of "a lumbar spinesprain/strain which results in pain in the lower back." (Id. at 36.) Although the ALJ did not explicitly find plaintiff's HIV to be a severe impairment, the ALJ considered plaintiff's HIV at steps three and four of the inquiry. In other words, if plaintiff's HIV was not a severe impairment under step two, that would end the ALJ's inquiry with respect to plaintiff's HIV and there would be no need for the ALJ to proceed to determine whether it is a listed impairment under step three and whether plaintiff possesses the residual functional capacity to perform her past relevant work under step four. Thus, the Court concludes that the ALJ found plaintiff's HIV to be a severe impairment and its absence from the decision is an inadvertent typographical error.
Plaintiff argues that the ALJ failed to develop the record. Specifically, plaintiff argues that the ALJ failed to obtain RFC assessments from NUMC treating physician and treating nurse practitioner, Minou Absy, M.D. and Wanda Evelyn ("treating sources"), respectively.
It is well-established that the ALJ must affirmatively "develop the record in light of the essentially non-adversarial nature of a benefits proceeding" Tejada v. Apfel, 167 F.3d 770, 774 (2d Cir.1999) (quoting Pratts v. Chater, 94 F.3d 34, 37 (2d Cir.1996)). The ALJ's regulatory obligation to develop the administrative record exists even when the claimant is represented by counsel or by a paralegal at the hearing. Rosa v. Callahan, 168 F.3d 72, 79 (2d Cir.1999); Pratts, 94 F.3d at 37. The regulations provide that the lack of a statement from plaintiff's treating source regarding how plaintiff's impairments affect his or her ability to perform workrelated activities will not render a report incomplete. 20 C.F.R. § 404.1513(b)(6). However, the regulations also provide that the Commissioner will first request such a statement. See Perez v. Chater, 77 F.3d 41, 47 (2d Cir.1996) ("[B]efore we make a determination that you are not disabled, we will develop your complete medical history... [and] will make every reasonable effort to help you get medical reports from your own medical sources when you give us permission to request the reports." (quoting 20 C.F.R. § 404.1512(d))); see also Robins v. Astrue, No. CV-10-3281 (FB), 2011 WL 2446371, at *3 (E.D.N.Y. June 15, 2011) ("Although the regulation provides that the lack of such a statement will not render a report incomplete, it nevertheless promises that the Commissioner will request one.").
Here, as noted above, the Court conducted a thorough and careful review of the administrative record. The record contains over one-hundred pages of well documented medical source documents from NUMC and its HIV Clinic over a three-year period from September 2006 until September 2009 (AR at 153-68, 182-270), exceeding the regulations' requirements for a complete medical history under 20 C.F.R. § 416.912(d). In addition, the record includes a report from consultative examiner, Dr. Skeene, disability analyst A. Tolliver, and plaintiff's detailed testimony at the hearing, regarding his functional capacity. However, there is no reference in the decision or the record as a whole that the ALJ requested RFC assessments from plaintiff's treating sources.
The Commissioner contends that the medical records obtained were sufficient to make a disability determination. (See Comm'r's Reply at 2 (citing Rosa v. Callahan, 168 F.3d at 79 n. 5 ("[W]here there are no obvious gaps in the administrative record, and where the ALJ already possesses
For the reasons set forth above, the case is remanded to the ALJ for further proceedings consistent with this Memorandum and Order. Specifically, on remand, the ALJ must request RFC assessments from plaintiff's treating sources. Then, the ALJ must reassess plaintiff's RFC taking into account any RFC assessments provided in response to his request, in accordance with the applicable regulations. In addition, as discussed supra, the ALJ should also consider whether his reevaluation of the evidence alters his assessment of plaintiff's credibility and his finding that plaintiff did not meet or equal the regulations listing for HIV. Furthermore, to the extent that the ALJ relies upon the disability analyst's assessment, the ALJ should reconsider it in accordance with the applicable regulations. Finally, as noted supra, it appears the ALJ made an inadvertent typographical
SO ORDERED.