MICHAEL A. TELESCA, District Judge.
Plaintiff Mary E. Marullo ("Plaintiff"), who is represented by counsel, brings this action pursuant to the Social Security Act ("the Act"), seeking review of the final decision of the Commissioner of Social Security ("the Commissioner") denying her application for Supplemental Security Income ("SSI"). This Court has jurisdiction over the matter pursuant to 42 U.S.C. §§ 405(g), 1383(c). Presently before the Court are the parties' motions for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure. Dkt. ##9,11.
Plaintiff protectively applied for SSI on March 21, 2008, alleging disability beginning January 17, 2008 due to neuropathy in both legs and nerve damage. T. 97-100, 108.
In applying the familiar five-step sequential analysis, as contained in the administrative regulations promulgated by the Social Security Administration ("SSA"),
The ALJ's determination became the final decision of the Commissioner when the Appeals Council denied Plaintiff's request for review on July 20, 2012. T. 1-4, 6-7. Plaintiff then filed this action seeking judicial review of the Commissioner's decision pursuant to 42 U.S.C. § 405(g). Dkt.#1.
In the present motion, Plaintiff alleges that the ALJ's decision is erroneous because it is not supported by substantial evidence contained in the record, or is legally deficient and therefore she is entitled to judgment on the pleadings. Pl. Mem. (Dkt.#10) 7-14. The Commissioner cross-moves for judgment on the pleadings on the grounds that the ALJ's decision is correct, is supported by substantial evidence, and was made in accordance with applicable law. Comm'r Mem. (Dkt.#11-1) 17-25.
For the following reasons, Plaintiff's motion is denied, and the Commissioner's cross-motion is granted.
42 U.S.C. § 405(g) grants jurisdiction to district courts to hear claims based on the denial of Social Security benefits. Section 405(g) provides that the District Court "shall have the power to enter, upon the pleadings and transcript of the record, a judgment affirming, modifying, or reversing the decision of the Commissioner of Social Security, with or without remanding the cause for a rehearing." 42 U.S.C. § 405(g) (2007). The section directs that when considering such a claim, the Court must accept the findings of fact made by the Commissioner, provided that such findings are supported by substantial evidence in the record. Substantial evidence is defined as "`more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.'"
When determining whether the Commissioner's findings are supported by substantial evidence, the Court's task is "to examine the entire record, including contradictory evidence and evidence from which conflicting inferences can be drawn."
Under Rule 12(c), judgment on the pleadings may be granted where the material facts are undisputed and where judgment on the merits is possible merely by considering the contents of the pleadings.
Beginning April 20, 2007, Plaintiff began treatment at DENT Neurologic Institute ("DENT") for back pain, pain in the lower extremities, and gait problems. T. 154. In June, 2007, an EMG/nerve conduction study revealed severe peripheral neuropathy with features of chronic axonal loss and probable demyelination in her right extremities and lower left extremities. T. 156-57.
Dr. Harnath Clerk, M.D., Plaintiff's primary care provider at the time, issued a treating source opinion that Plaintiff could sit, stand, and walk for a total of one hour per eight hour workday; that she could lift up to twenty pounds occasionally; needed a cane to ambulate; and that she should only occasionally climb, balance, stoop, kneel, crouch, or crawl. T. 214. Dr. Clerk further opined that Plaintiff should not be exposed to more than a moderate noise level; should only occasionally be exposed to unprotected heights, moving mechanical parts, operating a motor vehicle; humidity and wetness, dusts, odors, fumes, and pulmonary irritants, extreme cold or heat; and vibrations. T. 214-15.
On August 4, 2008, Plaintiff was consultatively examined by Kathleen Kelley, M.D., who diagnosed her with probable cerebral palsy with spastic dysplasia, hyper-reflexia of the lower extremities, and nonspecific ankle and knee pain with full range of motion T. 180. The doctor reported that Plaintiff showered, bathed, dressed herself, cooked, cleaned, did laundry, shopped, and watched television, but did not perform childcare activities. T. 177-78. The physical examination revealed spastic diplegic gait with inability to walk on heels, wide stance, positive Romberg test, and inability to walk tandem heel-to-toe. Babinski test was negative, muscle tone was normal, Plaintiff needed no help changing for exam or getting on and off the exam table, and was in no acute distress. T. 178. Plaintiff had no cyanosis, clubbing, or edema, no significant varicosities or trophic changes, and no evident muscle atrophy. T. 179. She had full range of motion in hips, knees, and ankles bilaterally, with full strength in her upper and lower extremities.
Dr. Kelley opined that Plaintiff would have difficulty walking long distances, climbing stairs, standing for long periods, and that she would need breaks secondary to her spastic gait. T. 180. Lifting, carrying, or reaching for markedly heavy objects or pushing and pulling markedly heavy objects from a standing position would cause balance issues.
On August 28, 2009, I. Larios, a non-physician state agency review analyst, evaluated Plaintiff's medical record. T. 199-204. Larios found that Plaintiff was limited to sedentary work (able to lift ten pounds occasionally; able to sit for six hours and stand for two hours in an eight-hour day), with the additional restrictions that Plaintiff was only frequently able to stoop, kneel, crouch, and crawl, and occasionally able to climb and balance.
On July 2, 2009, Plaintiff underwent an MRI of the brain which was negative for any serious abnormality. T. 218-19. Based on the negative MRI and the previous EMG study, Plaintiff's specialists at DENT diagnosed Charcot-Marie-Tooth disease (also known as hereditary motor and sensory neuropathy), an inherited neurological disorder characterized by weakness of the foot and lower leg muscles.
Charcot-Marie-Tooth is a slow-progressing and non-fatal disease, with symptoms varying greatly among individuals, and pain ranging from mild to severe.
Treatment notes from DENT dated September 17, 2009, indicate that Plaintiff complained of worsening weakness in her lower extremities and hands, difficulty walking, and burning sensation in her legs. T. 246. Dr. Malti Patel's impression was motor sensory perihpheral neuropathy in uppper and lower extremity, and blood work was recommended.
Plaintiff was prescribed leg braces but was not compliant in using them. T. 262, 275. She also underwent physical therapy, which she discontinued after five weeks. T. 272, 299-317. She was also not compliant with using a recommended cane. T. 178, 200, 212.
Plaintiff is a high-school graduate who completed one year of college and was 30 years-old at the time of her hearing. T. 27, 112. She has past work experience as a certified nursing assistant, dishwasher, and factory line worker. T. 109.
On May 2, 2008, Plaintiff completed a Function Report as part of her SSI application, in which she stated her daily activities included bathing, dressing and feeding her children, washing dishes, doing laundry with breaks, preparing lunch and dinner, watching television, vacuuming, and shopping. Her hobbies included walking and bicycle riding. T. 118-121.
At the hearing, Plaintiff testified that she could only stand for a half-hour before her legs would begin to shake, that she had difficulty sitting for longer than an hour, and had loss of feeling and muscle in her hands, which caused her to drop whatever she might be holding at the time. T. 34, 37, 38. Her daily activities included dressing, bathing, washing dishes, doing laundry, cleaning her home (making beds, vacuuming, sweeping, mopping, taking out the trash), shopping, and occasionally visiting family members. T. 35-37. She told the ALJ she would lie during the day when she had "major" back pain. T. 43-44.
The ALJ also heard testimony from Vocational Expert ("VE") Jay Steinberg. T. 44-50. The ALJ asked the VE to assume an individual of Plaintiff's age, education, and vocational background, with the limitations outlined in the RFC findings. T. 45-46. The VE testified that such an individual could work as a telephone survey worker or telemarketer, which is unskilled, sedentary work that exists in significant numbers in the national economy. T. 45-47.
Plaintiff first contends that the ALJ committed reversible error by failing to give Plaintiff's treating source opinion controlling weight or to provide an explanation as to why controlling weight was not given. Pl. Mem. (Dkt.#10) 7-8.
Under the Regulations, a treating physician's opinion is entitled to "controlling weight" when it is "well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with substantial evidence in [the] case record." 20 C.F.R. § 404.1527(c)(2);
The ALJ considered Dr. Clerk's November 2008 functional assessment and afforded it "some weight." T. 18. A review of the evidence in the record supports this determination.
Dr. Clerk's residual functional capacity assessment indicated that Plaintiff could lift/carry up to 20 pounds, sit/stand/walk for one hour each, and could perform all postural and environmental activities occasionally. T. 211-16. Though he noted that Plaintiff "required a cane to ambulate," he also indicated that a cane was not "medically necessary." T. 212. In assessing Plaintiff's ability to use her hands and feet, the doctor wrote the notation, "NA," presumably indicating that Plaintiff had no functional restrictions. T. 213. He did not explain his responses on the medical source statement despite questions requesting identification of supporting medical or clinical findings. T. 212, 213, 215.
The ALJ reviewed and referenced the medical record, medical source statements, and Plaintiff's activities of daily living, which were only partially consistent with Dr. Clerk's assessment. T. 16-19. For example, Plaintiff's non-compliance with physical therapy and leg braces and her extensive daily activities undermine the doctor's extreme limitations. T. 18. Dr. Clerk's own treatment notes from September and December, 2008, indicate unremarkable physical findings, normal upper and lower extremities with full range of motion bilaterally, no evidence of clubbing or cyanosis, normal peripheral circulation, and no apparent acute distress. T. 18, 239-40, 241-42. His assessment was also inconsistent with that of the consultative examiner, Dr. Kelley, whose physical examination yielded largely normal results, and who opined that Plaintiff would have difficulty walking long distances, climbing stairs, standing for long periods, and would require breaks. T. 17, 178-80. The ALJ assigned equal weight to Dr. Clerk's and Dr. Kelley's reports. T. 17-18. Finally, Dr. Clerk's RFC assessment was partially consistent with the SSA non-physician reviewer's opinion that Plaintiff could frequently lift less than ten pounds, occasionally lift ten pounds, stand/walk for two hours, sit for six hours, and had no restrictions pushing or pulling, including operation of hand and/or foot controls.
Here, the ALJ discussed Dr. Clerk's opinion along with other medical evidence, including his own treatment notes, and the record as a whole. Although the ALJ did not explicitly state his reasoning for affording Dr. Clerk's opinion less than controlling weight, the omission was harmless error. The Second Circuit has explained that "[w]here application of the correct legal principles to the record could lead [only to the same] conclusion, there is no need to require agency reconsideration."
Plaintiff next claims that the ALJ violated Social Security Ruling ("SSR") 96-8p by failing to provide a narrative in support of his RFC finding. Pl. Mem. 8-10.
Residual functional capacity is "what an individual can still do despite his or her limitations."
In making the RFC determination, the ALJ must consider a claimant's physical abilities, mental abilities, symptomology, including pain and other limitations which could interfere with work activities on a regular and continuing basis. 20 C.F.R. § 404.1545(a). The ALJ must consider all the relevant evidence, including medical opinions and facts, physical and mental abilities, non-severe impairments, and plaintiff's subjective evidence of symptoms. 20 C.F.R. §§ 404.1545(b)-(e). Pursuant to 20 C.F.R. § 404.1527(C)(1), every medical opinion, regardless of its source, must be evaluated. The RFC assessment must include a narrative discussion describing how the evidence supports each conclusion, citing specific medical facts (e.g., laboratory findings) and nonmedical evidence (e.g., daily activities, observations). SSR 96-8p, 1996 WL 374184, at *7.
Here, the ALJ gave "some weight" to Plaintiff's treating physician and the consultative examiner, whose opinions were conflicting. T. 17-18. Contrary to Plaintiff's assertion, this was permissible.
Plaintiff cites to
Though the ALJ afforded equal weight to the consultative examiner's and the treating physician's opinions, it is easily gleaned which portions of those opinions were rejected. For example, Dr. Kelley diagnosed Plaintiff with "probably cerebral palsy," which the ALJ did not find to be a severe impairment. T. 16, 180. It is apparent from considering the total decision that ALJ carefully considered all of the opinions in the medical record.
Thus, the ALJ's RFC determination is supported by substantial evidence.
Plaintiff also argues that the ALJ erred in relying on the VE's testimony because it was based on an incomplete hypothetical. Pl. Mem. 10-12.
For the opinion of a VE to constitute substantial evidence, the hypothetical questions posed to the VE must include all of the claimant's limitations that are supported by medical evidence in the record.
In making his step five finding that jobs existed in the national economy that Plaintiff could perform, the ALJ relied on the testimony of VE Jay Steinberg. He initially asked the VE to assume an individual that could,
The ALJ appears to have misstated the standing and sitting limitations, as his hypothetical indicated standing for six hours and sitting for two hours, which is inconsistent with sedentary work.
Because the hypothetical questions were based upon an RFC that realistically and accurately described Plaintiff's limitations, the VE's testimony provided substantial evidence to support the finding of no disability.
Plaintiff avers that the ALJ failed to consider cerebral palsy a severe impairment and provided no explanation as to why it was non-severe in his step two analysis. Pl. Mem. 14-15.
For an impairment to be considered severe, it must more than minimally limit the claimant's functional abilities, and it must be more than a slight abnormality. 20 C.F.R. § 416.9249(c). It must also be "medically determinable," established through medically acceptable clinical or laboratory diagnostic techniques demonstrating the existence of a medical impairment.
On the outset, there is no diagnosis of cerebral palsy by Plaintiff's treating physicians (Dr. Michael Grey, Dr. Patel, Dr. Holmlund) in a record spanning several years of treatment. T. 233-42, 244-60. Moreover, Plaintiff's May, 2007 EMG and July, 2009 MRI were unremarkable for cerebral palsy. T. 156, 219. The diagnosis of "probable cerebral palsy" was made by Dr. Kelley during a consultative examination on August 4, 2008 and was therefore not supported by the medical records or the clinical findings, and it is Plaintiff's burden to come forward with evidence to support her disability claim.
Plaintiff urges the Court to find reversible error on the basis that the ALJ failed to develop the record as to Dr. Kelley's diagnosis. Pl. Mem. 13. The two cases cited by Plaintiff,
Here, the medical record does not support a diagnosis of "probable cerebral palsy," resulting from a one-time examination, but does support the diagnoses of Charcot-Marie-Tooth disease, motor sensory polyneuropathy, and hereditary spastic paraplegia. These disorders are consistent with Plaintiff's documented symptoms of gait abnormality and neuropathy in her lower extremities, supported by the diagnostic testing, and were diagnosed by her treating physicians during an extended course of treatment.
Based on the evidence cited above and in the record as a whole, the ALJ's finding that Plaintiff's "probable cerebral palsy" was not a severe impairment was supported by substantial evidence. Moreover, because the ALJ concluded that Plaintiff had established other impairments considered severe under the Act and continued with the sequential analysis, any arguable errors in the findings at step two of the analysis were harmless.
For the foregoing reasons, Plaintiff's motion for judgment on the pleadings (Dkt.#9) is denied, and the Commissioner's cross-motion for judgment on the pleadings (Dkt.#11) is granted. The Complaint is dismissed in its entirety with prejudice.
ALL OF THE ABOVE IS SO ORDERED.