JOANNA SEYBERT, District Judge.
Plaintiff Brian Bowler ("Plaintiff") brings this action pursuant to Section 205(g) of the Social Security Act (the "Act"), 42 U.S.C. § 405(g), challenging the Commissioner of Social Security's (the "Commissioner") denial of his application for Social Security Disability Insurance Benefits. (Compl., D.E. 1, ¶¶ 1, 8.) Presently pending before the Court are the parties' cross-motions for judgment on the pleadings. (Pl. Mot., D.E. 9; Comm'r Mot., D.E. 13.) For the following reasons, Plaintiff's motion is GRANTED and the Commissioner's motion is DENIED.
On July 13, 2015, Plaintiff completed an application for disability insurance benefits alleging that since December 31, 2014, chronic obstructive pulmonary disease ("COPD"), emphysema, chronic pneumonia, lumber spine pain, osteoarthritis, venus insufficiency, hepatitis C, and cellulitis rendered him disabled. (R. 187-88, 245.) After Plaintiff's claim was denied (R. 108-19), he requested a hearing before an Administrative Law Judge ("ALJ") (R. 120-21). On February 20, 2018, Plaintiff, accompanied by counsel, appeared for a video hearing before the ALJ. (R. 34-56.) A vocational expert also testified at the hearing. (R. 47-55.)
In a decision dated March 8, 2018, the ALJ found that Plaintiff was not disabled. (R. 12-33.) On July 6, 2018, the Social Security Administration's Appeals Council denied Plaintiff's request for review and the ALJ's decision became the final decision of the Commissioner. (R. 1-4.)
Plaintiff initiated this action on September 7, 2018 (
In reviewing the ruling of an ALJ, the Court does not determine
Here, the ALJ found that Plaintiff met the insured-status requirements of his claim through December 31, 2017. (R. 18.) Next, the ALJ applied the familiar five-step disability analysis and concluded that Plaintiff was not disabled from December 31, 2014, the alleged disability-onset date, through December 31, 2017, the last date insured. (R. 18-29);
The ALJ then determined that Plaintiff had the residual functional capacity ("RFC") "to perform light work (per the jobs identified by the vocational expert) as defined in 20 CFR 404.1567(b)." (R. 20-27.) The vocational expert testified that Plaintiff could find gainful employment as (1) an inspector hand packager, (2) an electrical accessories assembler, (3) a cashier, (4) a photo copy machine operator, and (5) a hand trimmer. (R. 28.) The ALJ found that Plaintiff "could lift/carry fifty pounds occasionally and twenty pounds frequently; sit eight hours, up to four hours at a time; stand eight hours, up to two hours at a time; and walk eight hours, up to two hours at a time" and that Plaintiff could "change positions at the workstation, with no interruption of the work." (R. 20.) The ALJ further found Plaintiff (1) "should never climb ladders or scaffolds and should not work at unprotected heights," (2) "could frequently tolerate humidity and wetness," (3) "should avoid concentrated exposure to pulmonary irritants (
Proceeding to steps four and five, the ALJ found that while (4) Plaintiff was unable to perform his past relevant work as a recycling worker (R. 27), (5) considering his RFC, age, education, and work experience, Plaintiff could make a successful adjustment to work existing in significant numbers in the national economy as an inspector hand packager, electrical accessories assembler, cashier, photo copy machine operator, and hand trimmer (R. 27-28). As a result, the ALJ determined that Plaintiff was not disabled.
The ALJ addressed Plaintiff's alleged claims of disability due to "COPD, lumbar spine (pain), emphysema, osteoarthritis, venous insufficiency, hepatitis C, cellulitis, and chronic pneumonia" and referenced his testimony that he is unable to work "due to breathing problems and pain in his back." (R. 20, 24.) However, the ALJ found that Plaintiff "does not appear to have a disabling physical condition" even though Plaintiff's impairments could "reasonably be expected to cause the alleged symptoms" but that "these symptoms are not entirely consistent with the medical evidence and other evidence in the record." (R. 24.)
In deciding Plaintiff's RFC, the ALJ considered Plaintiff's testimony (R. 20-21), the ALJ's determination from the Prior Disability Claim (R. 21), and the "objective record evidence" (R. 21). The ALJ detailed her review of the "objective record evidence" (R. 21-23) and cited to records from Dr. Aftab Chaudhri, Plaintiff's primary care physician (R. 21), Dr. Jerome Caiati, who performed a consultative examination (R. 22), Dr. Anil Mongia, who performed consultative examination and conducted pulmonary testing (R. 22), Dr. Steve Mermelstein, Plaintiff's treating pulmonologist (R. 22-23), Dr. Gregory Ajemian, Plaintiff's treating internist (R. 23), and Plaintiff's ear nose and throat medical records (R. 23).
The ALJ then addressed Plaintiff's back impairment and found that "consultative examination did not reveal any disabling findings." (R. 24.) The ALJ next turned to Plaintiff's pulmonary impairments and found that the "record does not reveal a work-precluding pulmonary impairment." (R. 24.)
The ALJ next considered statements and opinion evidence (R. 25-26) and ultimately adopted and afforded significant weight to the opinion of Dr. Edwin Cruz, a non-examining medical expert who is board certified in internal medicine, pulmonary medicine, and critical care (R. 26). Based solely on a review of medical records, Dr. Cruz provided answers to medical interrogatories and filled out a medical source statement of Plaintiff's ability to do work-related activities. (R. 680-92.) Among other things, Dr. Cruz opined that Plaintiff (1) could occasionally lift/carry up to 50 pounds (R. 681); (2) stand and walk for two hours at a time, and sit, stand, and walk for eight hours in an eight-hour work day (R. 682); and (3) climb stairs continuously (R. 684). Dr. Cruz also stated that "PFTs [pulmonary function tests] suggest sufficient reserve to perform mild-moderate activities." (R. 690.)
With respect to Plaintiff's back impairments, (1) the ALJ afforded some weight to spine specialist Dr. Sebastian Lattuga's assessment that Plaintiff should refrain from any activity that exacerbates his symptoms (R. 25, 255-56) and (2) the ALJ afforded some weight to the opinion of consultative examiner Dr. Caiati (R. 25), who submitted an orthopedic medical source statement (R. 401-04). Dr. Caiati opined that (1) Plaintiff was unrestricted in "sitting, standing, walking, reaching, pushing, and pulling" from a "musculosketal point of view," (2) Plaintiff had minimal to mild limitations to bend due to low back pain, (3) Plaintiff had minimal limitations to climb due to bilateral knee pain, and (4) Plaintiff had mild limitations to lift due to low back and bilateral knee pain. (R. 404.)
As for Plaintiff's pulmonary impairments, Dr. Mongia, a consultative examiner who conducted pulmonary testing, opined, among other things, that Plaintiff "was restricted from activities requiring mild or greater exertion because of chronic pneumonia, emphysema, and chronic bronchitis. He has mild to moderate restriction for standing and walking, and moderate restriction for squatting and kneeling because of knee problems." (R. 410.) Dr. Mongia also indicated that Plaintiff's pulmonary function tests revealed "mild to moderate restrictive pattern" and "moderate obstruction" (R. 409) and that Plaintiff's "chest exam does not correlate with test result" (R. 411). The ALJ afforded Dr. Mongia's opinion "limited weight" and described it as "overly restrictive and not consistent with the overall record." (R. 25.) Instead, the ALJ found that "[t]he overall record evidence is consistent with a range of work included in the [RFC], per" Dr. Cruz. (R. 25.)
In addition to his treatment notes, Dr. Mermelstein, Plaintiff's treating pulmonologist, submitted a "Pulmonary Medical Source Statement" (R.532-35) and opined that Plaintiff is incapable of even "low stress" jobs (R. 535) and that Plaintiff could rarely lift 10 pounds, could only sit for 30 minutes, up to two hours at a time, before needing to get up, could stand/walk less than two hours, would take several unscheduled breaks during a working day, and will be "off task" fifteen percent of the time in a competitive eight-hour work day (R. 533-34).
The ALJ recognized that Dr. Mermelstein has treated Plaintiff since 2012 but assigned Dr. Mermelstein's pulmonary medical source statement "limited weight" as "inconsistent with Dr. Mermelstein's own reports and the overall record evidence." (R. 26.) In support, the ALJ articulated that "treatment notes reflect that [Plaintiff] was doing reasonably well," that "[s]ome dyspnea was due to weight gain," Plaintiff was "only to continue with monitoring and medications, including inhalers and nebulizer," "[f]ollow up was in six months," and Dr. Mermelstein's "assessment appears to be based on the [Plaintiff]'s self-reports, as the overall record does not corroborate such extreme limitations." (R. 26.) Instead, the ALJ found the record evidence "more consistent with the opinions of Dr. Cruz," the non-examining medical expert, "for a range of medium to light work." (R. 26.)
Plaintiff first contends that the ALJ violated the treating physician rule by (1) failing to provide good reasons to discount Dr. Mermelstein's opinion that Plaintiff is incapable of even "low stress" jobs; (2) failing to identify the weight afforded to Dr. Mermelstein's opinion; and (3) failing to contact Dr. Mermelstein before according his opinion limited weight.
The Commissioner contends that the ALJ's RFC finding is supported by substantial evidence because (1) the ALJ properly afforded more weight to the consulting medical expert (Comm'r Br., D.E. 14, at 20-24), (2) Dr. Mermelstein's physical function opinion contradicted his treatment notes and was inconsistent with medical evidence (Comm'r Br. at 24-27), and (3) the ALJ properly considered Plaintiff's subjective complaints (Comm'r Br. at 28-30.)
The "treating physician rule" provides that the medical opinions and reports of a claimant's treating physicians are to be given "special evidentiary weight."
20 C.F.R. § 404.1527(c)(2) (emphasis supplied; second and third alterations in original). Thus, the opinion of a treating physician "need not be given controlling weight where [it is] contradicted by other substantial evidence in the record."
When an ALJ does not afford controlling weight to the opinion of a treating physician, the ALJ must consider several factors: "(1) the length of the treatment relationship and frequency of the examination; (2) the nature and extent of the treatment relationship; (3) the extent to which the opinion is supported by medical and laboratory findings; (4) the physician's consistency with the record as a whole; and (5) whether the physician is a specialist."
As a preliminary matter, Plaintiff's argument that the ALJ failed to specify the weight assigned to Dr. Mermelstein's opinion necessarily fails. The ALJ explicitly assigned Dr. Mermelstein "limited weight." (R. 26.) Thus, the ALJ was obligated to consider the above-referenced factors when deciding to assign Dr. Mermelstein's opinion less than controlling weight.
However, the ALJ failed to follow the treating physician rule. The ALJ assigned "little weight" to the opinions of Dr. Mermelstein and Dr. Mongia, the only physicians to treat and opine on Plaintiff's pulmonary impairments
Moreover, to the extent the ALJ's finding that Plaintiff was "
Thus, the ALJ traversed the treating physician rule and on remand the ALJ should "endeavor to obtain enough information to determine whether the opinion" of Dr. Mermelstein is entitled to controlling weight.
The Court also finds that Plaintiff's pulmonary-related RFC is not supported by substantial evidence. The Commissioner argues that the "ALJ's detailed RFC finding is supported by substantial evidence, in particular the opinions of medical expert pulmonologist Dr.Cruz and consulting physician Dr. Caiati. . . ." (Comm'r Br. at 21.) "In order for the Court to determine whether a treating physician's opinion is consistent with other substantial evidence in the administrative record, the Court must keep in mind that `genuine conflicts in the medical evidence are for the ALJ to resolve.'"
The ALJ also found that Dr. Mermelstein's opinion is "inconsistent with Dr. Mermelstein's own reports," including treatment notes that Plaintiff was doing "reasonably well." (R. 26.) However, Dr. Mermelstein's "records contain only raw medical evidence from each particular visit," such as that Plaintiff was doing "reasonably well," and "do not assess [Plaintiff's] ability to engage in competitive work on a regular and continuing basis despite" his impairments.
Nonetheless, "even if [Dr. Mermelstein's] treatment notes were inconsistent with his medical opinions, the ALJ inappropriately `cherry picked' the notes that supported his conclusion while ignoring those that did not."
With respect to Plaintiff's pulmonary impairments, Dr. Cruz cited unspecified pulmonary function tests to opine that Plaintiff has "sufficient reserve to perform mid-moderate activities." (R. 690.) Even assuming Dr. Cruz's opinion constitutes "substantial evidence," which it does not, this finding is nonetheless "unhelpful because [it was] vague regarding the Plaintiff's limitations."
Moreover, the Court recognizes that Dr. Cruz did not provide a "pulmonary medical source statement" (
Accordingly, "the ALJ's determination of [Plaintiff's] RFC was not supported by substantial evidence, and must be overturned."
In light of these findings, the Court need not address Plaintiff's additional contentions. Plaintiff may address those issues on remand.
Accordingly, Plaintiff's motion (D.E. 9) is GRANTED and the Commissioner's motion (D.E. 13) is DENIED. This matter is REMANDED for proceedings consistent with this Memorandum and Order. The Clerk of the Court is directed to mark this case CLOSED.
SO ORDERED.