DAVID N. HURD, District Judge.
Plaintiff Donna Lewis ("Lewis" or "plaintiff") brings this action, pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3), seeking review of defendant Commissioner of Social Security's ("Commissioner" or "defendant") final decision denying her application for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI"). The parties have filed their briefs as well as the Administrative Record on Appeal and the motion will be considered on the basis of these submissions without oral argument.
On November 30, 2010, Lewis filed applications for DIB and SSI claiming a period of disability beginning on July 1, 2009. R. at 115-128.
On May 31, 2012, the ALJ rendered a written decision concluding that Lewis was not disabled within the meaning of the Social Security Act from July 1, 2009 through the date of his decision. R. at 9-19. Plaintiff timely appealed this unfavorable disability determination to the Appeals Council. Id. at 5.
On September 20, 2013, the ALJ's decision became the final decision of the Commissioner when the Appeals Council denied Lewis's request for review. R. at 1-3. Plaintiff filed this action on November 1, 2013, seeking judicial review of the Commissioner's denial of benefits. Because the parties are familiar with the underlying facts, they are discussed only to the extent necessary to address plaintiff's appeal.
A court's review of the Commissioner's final decision is limited to determining whether the decision is supported by substantial evidence and the correct legal standards were applied. Poupore v. Astrue, 566 F.3d 303, 305 (2d Cir.2009) (per curiam). "Substantial evidence means `more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.'" Id. (quoting Consol. Edison Co. v. NLRB, 305 U.S. 197, 229, 59 S.Ct. 206, 83 L.Ed. 126 (1938)).
"To determine on appeal whether an ALJ's findings are supported by substantial evidence, a reviewing court considers the whole record, examining the evidence from both sides, because an analysis
However, "where there is a reasonable basis for doubting whether the Commissioner applied the appropriate legal standards," the decision should not be affirmed even though the ultimate conclusion reached is arguably supported by substantial evidence. Martone v. Apfel, 70 F.Supp.2d 145, 148 (N.D.N.Y.1999) (citing Johnson v. Bowen, 817 F.2d 983, 986 (2d Cir.1987)).
The Social Security Act defines "disability" as the "inability to engage in any substantial gainful activity by reason of any medically determinable 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). In addition, the Act requires that a claimant's:
Id. § 423(d)(2)(A).
The ALJ must follow a five-step evaluation process in deciding whether an individual is disabled. See 20 C.F.R. §§ 404.1520, 416.920. At step one, the ALJ must determine whether the claimant has engaged in substantial gainful activity. A claimant engaged in substantial gainful activity is not disabled, and is therefore not entitled to benefits. Id. §§ 404.1520(b), 416.920(b).
If the claimant has not engaged in substantial gainful activity, then step two requires the ALJ to determine whether the claimant has a severe impairment or combination of impairments which significantly restricts his physical or mental ability to perform basic work activities. Id. §§ 404.1520(c), 416.920(c).
If the claimant is found to suffer from a severe impairment or combination of impairments, then step three requires the ALJ to determine whether, based solely on medical evidence, the impairment or combination of impairments meets or equals an impairment listed in Appendix 1 of the regulations (the "Listings"). Id. §§ 404.1520(d), 416.920(d); see also id. Pt. 404, Subpt. P, App. 1. If the claimant's impairment or combination of impairments meets one or more of the Listings, then the claimant is "presumptively disabled." Martone, 70 F.Supp.2d at 149 (citing Ferraris v. Heckler, 728 F.2d 582, 584 (2d Cir.1984)).
If the claimant is not presumptively disabled, step four requires the ALJ to assess whether — despite the claimant's severe impairment — he has the residual functional capacity ("RFC") to perform his past relevant work. 20 C.F.R. §§ 404.1520(f),
If it is determined that the claimant cannot perform his past relevant work, the burden shifts to the Commissioner for step five. Perez, 77 F.3d at 46. This step requires the ALJ to examine whether the claimant can do any type of work. 20 C.F.R. §§ 404.1520(g), 416.920(g). The regulations provide that factors such as a claimant's age, physical ability, education, and previous work experience should be evaluated to determine whether a claimant retains the RFC to perform work in any of five categories of jobs: very heavy, heavy, medium, light, and sedentary. Perez, 77 F.3d at 46 (citing 20 C.F.R. § 404, Subpt. P, App. 2). "[T]he Commissioner need only show that there is work in the national economy that the claimant can do; [she] need not provide additional evidence of the claimant's residual functional capacity." Poupore, 566 F.3d at 306 (citing 20 C.F.R. § 404.1560(c)(2)).
The ALJ found Lewis had not engaged in substantial gainful activity since July 1, 2009, the alleged onset date. R. at 11. The ALJ next found plaintiff's bipolar disorder and panic disorder with agoraphobia to be severe impairments, but that this combination of severe impairments did not meet or equal any of the Listings.
Id. (footnote omitted).
Based on these findings and Lewis's age, education, and work experience, the ALJ determined jobs existed in significant numbers in the national economy that plaintiff could perform. R. at 18-19. Accordingly, the ALJ concluded plaintiff was not disabled within the meaning of the Act. Id. at 19.
On appeal, Lewis argues the ALJ: (1) erred in finding that she suffered from only "mild" difficulties in daily living and social functioning; (2) improperly weighed the medical evidence; (3) reached an unsupportable RFC determination; and (4) failed to elicit the testimony of a Vocational Expert.
Lewis first argues that the ALJ's findings of only "mild restriction" in her activities of daily living and only "mild difficulties" in her social functioning are not supported by substantial evidence. Pl.'s Mem., ECF No. 14, 10-11
As an initial matter, Lewis seems to argue that these particular findings are implicated in the ALJ's ultimate RFC determination. But as the Commissioner correctly points out, these findings were made at, and are relevant to, steps two
Where, as here, "mental impairments are at issue, the Commissioner directs administrative adjudicators to employ a `psychiatric review technique' (sometimes referred to as a `special technique')." Wilson v. Colvin, 2015 WL 1609727, at *4 (N.D.N.Y. Apr. 10, 2015) (Sharpe, C.J.) (adopting Report & Recommendation of Hines, M.J.) (citing 20 C.F.R. §§ 404.1520a(b)(e), 416.920a(b)-(e)).
"This technical method helps administrative law judges first determine whether claimants have medically-determinable mental impairments." Wilson, 2015 WL 1609727, at *4 (footnote omitted). "This technique also enables administrative law judges to determine subsequently whether medically-determinable mental impairments are severe (a Step 2 issue) and whether they meet or are equivalent in severity to any presumptively disabling mental disorder (a Step 3 issue)." Id.
As relevant here, ALJs determine whether a claimant's severe mental impairments meet or equal any of the presumptively disabling impairments listed in Appendix 1 of the Regulations
In Lewis's case, the ALJ considered these paragraph B criteria and concluded plaintiff: (1) suffered from mild restriction in activities of daily living; (2) experienced mild difficulties in social functioning; (3) experienced moderate difficulties in concentration, persistence, or pace; and (4) had suffered no episodes of decompensation of extended duration. R. at 12.
These findings are supported in the ALJ's written decision with a brief narrative discussion and include citations to various pieces of record evidence. With respect to activities of daily living, the ALJ noted that Lewis reported that she lived alone and is able to cook, do laundry, shop, shower herself, dress herself, and bathe daily.
Lewis attempts to challenge these findings on appeal by listing several pieces of "significant" evidence in the record that she concludes are "not the symptoms and indicia of someone with only mild difficulties in daily living or social function." Pl.'s Mem. at 11. In other words, plaintiff does not articulate how the challenged findings are the product of legal error or how the ALJ's proffered citations do not constitute substantial evidence, but rather "essentially invite[s] the court to re-weigh evidence and come to a different conclusion than did [the] ALJ." Wilson, 2015 WL 1609727, at *4.
That invitation must be declined, since a reviewing court "defer[s] to the Commissioner's resolution of conflicting evidence." Cage v. Comm'r of Soc. Sec., 692 F.3d 118, 122 (2d Cir.2012). Indeed, and as noted above, a district court's review of an administrative denial of benefits "is limited to determining whether the [Commissioner's] conclusions were supported by substantial evidence in the record and were based on a correct legal standard." Lamay v. Comm'r of Soc. Sec., 562 F.3d 503, 507 (2d Cir.2009). Lewis's citations to other pieces of record evidence, without more, are an insufficient basis on which to challenge the ALJ's findings at these early steps. Accordingly, this ground for appeal will be denied.
Lewis next argues the ALJ erred in assigning "great weight" to a March 1, 2011 report by M. Apacible, a state agency psychiatric consultant who never actually examined her and reached his conclusions on the basis of an incomplete record. Pl.'s Mem. at 11.
First, insofar as Lewis appears to argue an ALJ lacks discretion to ever afford anything more than limited weight to the opinion of a state agency consultant, she is incorrect. Although this may have once been the case, the current Regulations "recognize that the Commissioner's consultants are highly trained physicians with expertise in evaluation of medical issues in disability claims" whose "opinions may constitute substantial evidence in support of residual functional capacity findings." Delgrosso v. Colvin, 2015 WL 3915944, at *4 (N.D.N.Y. June 25, 2015) (Suddaby, J.) (adopting Report & Recommendation of Hines, M.J.) (rejecting similar "global objection to reliance on nonexamining medical advisers' opinions" by same plaintiffs' counsel).
However, that does not end the inquiry into the propriety of the ALJ's reliance on Dr. Apacible. Lewis also claims that since Dr. Apacible's report was issued in March 2011, it failed to take into account a large degree of relevant medical evidence subsequent to that date. Pl.'s Mem. at 12-13. Importantly, Dr. Apacible's opinion appears to have been rendered before the opinion of plaintiff's long-time mental health care provider and Licensed Clinical Social Worker ("LCSW") Valerie Jones-Giles was made part of the record.
It is true, as Lewis readily concedes and as the Commissioner is quick to point out, that LCSW Jones-Giles is considered an "other source" under the Regulations and is therefore not entitled to the generous presumption of "controlling weight" ordinarily afforded to a claimant's treating physician. See Caron v. Colvin, 2014 WL 3107959, at *7 (N.D.N.Y. July 8, 2014) (noting "the Commissioner's regulations do not require an ALJ to assign the same presumption of controlling weight to these ancillary treatment providers"), aff'd, 600 Fed.Appx. 43 (2d Cir.2015) (summary order). However, given that Dr. Apacible's opinion was rendered early in the disability review process on the basis of an incomplete record that lacked LCSW Jones-Giles's valuable medical opinion, the ALJ's decision to nevertheless assign it "great weight" constitutes error warranting remand.
Lewis's remaining challenges are predicated on conclusions drawn by the ALJ that will necessarily be impacted by his reconsideration of the relative weight to be assigned to her treating and consulting sources and therefore will not be addressed at this time. However, the ALJ is also specifically directed to revisit at least three other aspects of his written decision on remand.
First, the ALJ should clarify his findings with respect to the February 2011 evaluation completed by Mary Ann Moore, Psy. D. The ALJ afforded "some weight" to this opinion, partially discounting it on the basis of her allegedly faulty conclusion that "the claimant's treatment notes appear to show that the claimant's condition is more stable than Dr. Moore appears to believe." R. at 16.
Of course, "[t]here is no requirement that an administrative law judge blindly accept [the] opinion of a consultative examiner concerning a claimant's limitations when substantial evidence supports a decision to give less weight to such opinion." Griffin v. Colvin, 2014 WL 296854, at *7 (N.D.N.Y. Jan. 27, 2014) (Sharpe, C.J.) (adopting Report & Recommendation of Hines, M.J.).
Nevertheless, the appropriate amount of weight to be afforded to medical opinion evidence is properly determined by applying the same general criteria to each one: (1) the length of the treatment relationship and the frequency of examination; (2) the nature and extent of the treatment relationship; (3) evidence supporting the opinion; (4) consistency with the record as a whole; (5) the source's specialization in the area of treatment; and (6) other significant factors. 20 C.F.R. §§ 404.1527(c), 416.927(c).
Presumably, the ALJ's statement about Dr. Moore's February 2011 opinion was a permissible reference to an inconsistency between Dr. Moore's conclusions and other substantial evidence in the record. Read otherwise, it might be viewed as an impermissible attempt by the ALJ to substitute
Second, the ALJ discounted the March 2012 opinion of Dr. Moore "because it appears based somewhat on the claimant's alleged symptoms." R. at 17. But "a patient's complaints or reports of his or her history are `an essential diagnostic tool.'" McGregor, 993 F.Supp.2d at 139. This finding should therefore be clarified, since it could be fairly read as indicative of the ALJ impermissibly discrediting Dr. Moore's opinion on the basis of only his lay judgment that the medical report reflected resulting from her consultative examination improperly considered some, or all, of Lewis's complaints to be credible.
Finally, and on the subject of credibility, the ALJ is also directed to clarify his evaluation of Lewis's subjective complaints. "An [ALJ] may properly reject [subjective complaints] after weighing the objective medical evidence in the record, the claimant's demeanor, and other indicia of credibility, but must set forth his or her reasons `with sufficient specificity to enable us to decide whether the determination is supported by substantial evidence.'" Lewis v. Apfel, 62 F.Supp.2d 648, 651 (N.D.N.Y.1999) (quoting Gallardo v. Apfel, No. 96-CV-9435, 1999 WL 185253, at *5 (S.D.N.Y. Mar. 25, 1999)).
Where the record evidence does not support a claimant's testimony, the ALJ must employ a two-step analysis to evaluate the claimant's reported symptoms. See 20 C.F.R. § 404.1529; SSR 96-7p. First, the ALJ must determine whether, based on the objective medical evidence, a claimant's medical impairments "could reasonably be expected to produce the pain or other symptoms alleged." 20 C.F.R. § 404.1529(a); SSR 96-7p. Second, if the medical evidence establishes the existence of such impairments, the ALJ must evaluate the intensity, persistence, and limiting effects of those symptoms to determine the extent to which the symptoms limit the claimant's ability to do work. See id.
At this second step, the ALJ must consider: (1) the claimant's daily activities; (2) the location, duration, frequency, and intensity of the claimant's pain or other symptoms; (3) precipitating and aggravating factors; (4) the type, dosage, effectiveness, and side effects of any medication the claimant takes or has taken to relieve his pain or other symptoms; (5) other treatment the claimant receives or has received to relieve his pain or other symptoms; (6) any measures that the claimant takes or has taken to relieve his pain or other symptoms; and (7) any other factors concerning claimant's functional limitations and restrictions due to his pain or other symptoms. 20 C.F.R. § 416.929(c)(3)(I)-(vii); SSR 96-7p.
Importantly, an ALJ "must discuss the relationship between the plaintiff's medically determinable impairment, the plaintiff's reported symptoms, his conclusions
Here, the entirety of the ALJ's discussion of Lewis's credibility in his written decision stated that:
R. at 14.
Of course, "reviewing courts do not demand perfect decisions, and `[w]hile this sort of boilerplate is inadequate, by itself, to support a credibility finding, ... its use[] does not make a credibility determination invalid.'" Crofoot v. Comm'r of Soc. Sec., 2013 WL 5493550, at *11 (N.D.N.Y. Sept. 30, 2013) (Sharpe, C.J.) (adopting Report & Recommendation of Hines, M.J.) (condemning this boilerplate language as "gobbledygook" that "is, at best, gibberish insusceptible to meaningful judicial review").
Rather, "[t]he determinative question is not whether [the] ALJ [] used meaningless and opaque language when expressing his credibility choice, but whether he explained how [the claimant's] subjective testimony is not supported or undermined by other evidence, and whether the ultimate credibility finding is supported by substantial evidence." Crofoot, 2013 WL 5493550, at *11.
Even so, that question must be answered in the negative here. A careful review of the ALJ's written decision reveals no further explicit discussion on this topic or any kind of detailed narrative of the sort ordinarily contemplated by the Regulations, which suggests that "the ALJ `made a determination with respect to plaintiff's overall RFC and then used that RFC to discount plaintiff's non-conforming allegations and resulting limitations.'" Barnwell v. Colvin, 2014 WL 4678259, at *14 (S.D.N.Y. Sept. 19, 2014) (quoting Norman v. Astrue, 912 F.Supp.2d 33, 86 (S.D.N.Y.2012)). Because the Regulations require an ALJ to detail specific reasons supporting his determination of a plaintiff's credibility, his mere recitation of the language of the Regulations frustrates meaningful review.
The deficiencies in the ALJ's written decision leave a reasonable basis for doubting whether the Commissioner applied the appropriate legal standards.
Therefore, it is
ORDERED that
1. Lewis's motion for judgment on the pleadings is GRANTED;
2. The Commissioner's motion for judgment on the pleadings is DENIED;
3. The Commissioner's decision is VACATED; and
4. This matter is remanded to the Commissioner for further administrative proceedings consistent with this opinion.
The Clerk of the Court is directed to close the case.
IT IS SO ORDERED.