DAVID E. PEEBLES, Chief Magistrate Judge.
Currently pending before the court in this action, in which plaintiff seeks judicial review of an adverse administrative determination by the Acting Commissioner, pursuant to 42 U.S.C. § 405(g), are cross-motions for judgment on the pleadings.
After due deliberation, and based upon the court's oral bench decision, a transcript of which is attached and incorporated herein by reference, it is hereby
ORDERED, as follows:
(1) Plaintiff's motion for judgment on the pleadings is GRANTED.
(2) The Acting Commissioner's determination that plaintiff was not disabled at the relevant times, and thus is not entitled to benefits under the Social Security Act, is VACATED.
(3) The matter is hereby REMANDED to the Acting Commissioner, without a directed finding of disability, for further proceedings consistent with this determination.
(4) The clerk is respectfully directed to enter judgment, based upon this determination, remanding the matter to the Acting Commissioner pursuant to sentence four of 42 U.S.C. § 405(g) and closing this case.
(In chambers, counsel present by telephone. Time noted: 10:16 a.m.)
THE COURT: I have before me a request for a judicial review of an adverse determination by the Acting Commissioner of Social Security pursuant to 42, United States Code, Section 405(g).
The background is as follows: The plaintiff was born in August of 1964. He was 49 years old at the alleged onset date and 51 years of age at the time of the hearing in this matter. The plaintiff stands 5'8" in height and weighs 200 pounds. He lives with his wife and three children. At the time of the hearing they were ages 19, 16, and 12. He lives in North Syracuse. Plaintiff is ambidextrous. He's a high school graduate.
Plaintiff last worked in July of 2013 with the exception of the driving, which we'll talk about in a moment. He worked as a warehouse worker for Rite Aid, a position that he began in February of 1989. Plaintiff was laid off from work and drew unemployment. According to Administrative Transcript pages 43 and 214, plaintiff drove for approximately one month for a medical transport company in 2014 and 2015, but they stopped calling him.
Physically, plaintiff suffers from degenerative disc disease at the cervical and lumbar levels, ankylosing spondylitis — which I will not try to pronounce — rheumatoid arthritis, osteoarthritis, asthma, sleep apnea, hypothyroidism, hypertension, and obesity. Plaintiff has treated with several sources, Stephan Alkins for his sleep apnea; James Blanchfield, who apparently is his general physician. He also treated at Arthritis Health Associates from September 2013 to August 2015, at least for his rheumatoid arthritis, including with Physician's Assistant April Summerfield and Dr. Ramzi Khairallah.
He has been to Total Chiropractic of North Syracuse with Dr. Scott Kozlowski from August 2013 to October 2014. He has undergone physical therapy at Crouse Hospital, October 2013 to April 2014. He has seen Syracuse Gastroenterological Associates for his pancreatic condition, and Internist Associates James Blanchfield, who I mentioned earlier, and Dr. Collin Harris, who issued a medical source statement in May of 2012. It's unclear what his treatment relationship was with the plaintiff.
Plaintiff has been prescribed various medications, including Advair, Asmanex, Humira, Meloxicam, Prednisone, Symbicort, and Synthroid. Daily activities of the plaintiff includes cooking, cleaning, laundry, shopping, showering, watching television, listening to the radio, reading. He mows his lawn, he walks three times a week, visits family and friends, and goes to church weekly. That's at page 237 and 547 of the Administrative Transcript.
Procedurally, plaintiff applied for Title II disability insurance benefits on March 20, 2014, alleging an onset date of July 15, 2013. A hearing was conducted by Administrative Law Judge Marie Greener on October 19, 2015. ALJ Greener held a supplemental hearing with a vocational expert on — I can't read my notes — either January or February 21, 2016 — it's actually January 21, 2016. On February 22, 2016, Administrative Law Judge issued an unfavorable decision, which became a final determination of the agency on March 29, 2017, when the Social Security Administration Appeals Council denied plaintiff's request for a review. In her decision, ALJ Greener applied the five-step sequential test for determining disability after concluding that he was insured through December 31, 2018.
At step one, she concluded plaintiff had not engaged in substantial gainful activity since July 15, 2013, although she noted that he did briefly work as a driver.
At step two, ALJ Greener concluded that plaintiff suffers from severe impairments, including degenerative disc disease of the cervical spine, degenerative disc disease of the lumbar spine with herniated nucleus pulpous contacting the right S1 nerve root, and ankylosing spondylitis. At page 24 — and I won't recite them all — ALJ Greener rejected a host of other conditions, including, significantly, rheumatoid arthritis suffered by the plaintiff claiming that there is no indication in the record that they rose to a level of a severe impairment, which would significantly limit plaintiff's ability to perform basic work functions.
At step three, the ALJ determined that the plaintiff's conditions did not meet or medically equal any of the listed presumptively disabling impairments set forth in the Commissioner's regulations, specifically considering listing 1.04. She then surveyed the record and determined that despite his conditions, plaintiff essentially retains the residual functional capacity to perform unskilled light work with exceptions, including a provision for alternating positions between sitting and standing throughout the workday and only occasionally stoop and frequently reach.
At step four, plaintiff, she concluded, could not perform his past relevant work as a warehouse worker. It exceeds the exertional limitations of the RFC.
At step five, after determining that if a full range of light work could be performed by the plaintiff, the Medical-Vocational Guidelines or the grids would prescribe a finding of no disability, and that would be grid Rules 202.20 and 202.13. ALJ Greener then consulted with a vocational expert, and based on the vocational expert's testimony, concluded that plaintiff can perform the functions of a photocopy machine operator, an order caller, and a router, all three being light SVP 2 positions and, thus, concluded that plaintiff was not disabled at the relevant times.
As you know, my task is limited to determining whether the correct legal principles were applied by the Administrative Law Judge and the determination is supported by substantial evidence. It is an extremely deferential scope of review.
In terms of context, in addressing the arguments, I bear in mind that plaintiff bears the burden of proof through step four, including at the residual functional capacity stage, but at step five, the burden shifts to the Commissioner to determine that plaintiff is capable of performing work available in the national economy.
First, I'll talk about the treating source statement of Dr. Blanchfield. It is true that ordinarily the opinion of a treating physician concerning the nature and severity of an impairment is entitled to considerable deference, provided it is supported by medically acceptable clinical and laboratory diagnostic techniques and not inconsistent with other substantial evidence. Dr. Blanchfield's medical source statement contains opinions that are extremely limiting and, frankly, not supported by the record evidence. For example, at 652, question 12, how many city blocks can your patient walk without rest or severe pain? He notes zero, which is contrary to plaintiff's own statements indicating that walking is one of his hobbies and that walking is not affected by his conditions, and those are at pages 459 and 491.
The limitation to ten percent use of hands is not well supported, as well, and contrary to plaintiff's ability to drive as indicated in his self-report and based on the fact that he did, in fact, engage in limited driving for a living briefly, but that's not to say that the entirety of Dr. Blanchfield's opinion should be rejected.
The two major issues here, in my view, are the treatment of plaintiff's neck condition and hand condition. In terms of neck, the X-rays in the records support the existence of a condition which could reasonably be limiting in the ability to maneuver the plaintiff's head. Dr. Jenouri notes limitations in plaintiff's range of motion during his consultative exam. The plaintiff notes some limitations at 459 and 491 in his ability to maneuver his head. The Administrative Law Judge found at step two that his cervical degenerative disc disease did constitute a severe impairment, and Dr. Blanchfield indicates that plaintiff can only occasionally turn his head and look up at page 64.
I agree with plaintiff's counsel that there should have been a fuller discussion and consideration of any neck limitations, and any such limitation should have been included in the RFC upon which the vocational expert based his opinions. And I agree that this case is, to a large degree, controlled by District Judge Suddaby's decision in Hopkins vs. Commissioner of Social Security at 2015 WL 4508630 from July 13, 2015, and I'm unable to conclude with certainty based on Hopkins that this would constitute a harmless error.
I also think that there should have been a discussion of plaintiff's rheumatoid arthritis and the affect on his ability to perform fine manipulation and use his hands. It is true that Dr. Jenouri did find grip strength 5/5 and hand and finger dexterity intact at 549, but that occurred in April of 2014 and it was, therefore, considerably earlier than Dr. Blanchfield's opinions in September of 2015. As counsel indicated, the rheumatoid arthritis appears to be a degenerative condition, as indicated at page 638, for example, which showed moderate degenerative changes in the hands in December of 2014. There's considerable evidence in the record to address the hands at page 392. In September 2013, Dr. Khairallah made the statement that plaintiff's hands continued to bother him and affect his daily activities and ability to work. Similarly, at page 386, the doctor makes the same statement.
At page 385, in November of 2013, PA Summerfield notes both severely limited range of motion of the cervical spine and osteoarthritic changes in the hands. At page 559 on March 19, 2014, Physician's Assistant Summerfield notes degenerative changes in the hands, as well as the limited motion of cervical lumbar spine. And at page 643, September 17, 2014, Physician's Assistant Summerfield notes degenerative changes in the hands, as well as the moderate limitation of range of motion of the cervical spine.
There's really little discussion of the ability to use the hands in the Administrative Law Judge's decision. Both the neck and hand conditions could well have considerable impact on the RFC finding and the vocational expert's opinions. And so although I think that there's conflicting evidence, and it could well be that after this is reviewed that it's determined that the plaintiff is not disabled, I think a more robust discussion to permit meaningful judicial review is necessary.
So I will grant judgment on the pleadings to the plaintiff. I don't find persuasive evidence of disability, and so there will be no directed finding. I'll remand the matter to the Commissioner for further proceedings consistent with this opinion.
Again, thank you both for excellent presentations. Have a good weekend.
MR. DOLSON: Thank you, your Honor.
MR. JEWETT: Thank you, Judge.
(Time noted: 10:32 a.m.)
I, HANNAH F. CAVANAUGH, Official Court Reporter, in and for the United States District Court for the Northern District of New York, DO HEREBY CERTIFY that pursuant to Section 753, Title 28, United States Code, that the foregoing is a true and correct transcript of the stenographically reported proceedings held in the above-entitled matter and that the transcript page format is in conformance with the regulations of the Judicial Conference of the United States.