MICHAEL A. TELESCA, District Judge.
Kenneth Renard Wright ("Plaintiff"), represented by counsel, brings this action pursuant to Title II of the Social Security Act ("the Act"), seeking review of the final decision of the Commissioner of Social Security ("the Commissioner") denying his application for disability insurance benefits ("DIB"). The Court has jurisdiction over this matter pursuant to 42 U.S.C. § 405(g). Presently before the Court are the parties' motions for judgment on the pleadings pursuant to Federal Rule of Civil Procedure 12(c).
Plaintiff protectively filed an application for DIB on April 25, 2011, alleging disability since June 9, 2009, due to diabetes mellitus, high blood pressure, emotional distress, high cholesterol, and respiratory problems. T.189, 205.
At step one, the ALJ found that Plaintiff, who met the insured status requirements through December 31, 2014, had not performed substantial gainful activity during the relevant period (June 9, 2009, through June 27, 2012). T.14. At step two, the ALJ found that Plaintiff had the following severe impairments: diabetes mellitus II, polyarthritis of the right knee, and depressive disorder, not otherwise specified ("NOS"). T.14, 16. The ALJ found that Plaintiff's alleged respiratory problems did not constitute a severe impairment because the medical records showed no complaints or clinical findings of, e.g., shortness of breath, coughing, or wheezing. T.14. Although Plaintiff alleged arthritis in his hands and carpal tunnel syndrome, the ALJ found that the record did not support this. The ALJ declined to find Plaintiff's hypertension and hyperlipidemia to be severe impairments because there was no indication that these conditions had resulted in more than minimal limitations in his ability to perform work-related activities. Also, his high cholesterol was adequately controlled with medication. Finally, although Plaintiff included back pain as one of his disabling impairments, Plaintiff had not reported this impairment at the time he filed his application. Plaintiff's primary care physician, David Stornelli, M.D., consistently diagnosed lumbago or joint pain at multiple sites, but none of Dr. Stornelli's progress notes showed objective musculoskeletal or neurological findings. T.16. Finally, consultative internist Dr. Sirotenko, who provided a detailed report on June 14, 2010, found that Plaintiff's physical examination was completely unremarkable in terms of his lower back. In particular, Plaintiff's lumbar spine showed full flexion, extension, lateral flexion, and rotation; and his lumbar x-rays showed no significant abnormalities. T.16.
The ALJ then considered Plaintiff's medically determinable severe impairments in light the following listed impairments: 12.04 (affective disorders); 1.02 (major dysfunction of a joint (i.e., the knee)); and 9.00 (endocrine disorders). At the hearing, the ALJ heard testimony from an impartial psychiatrist, Dr. Ramon Fortuno; and an impartial internist, Dr. German Malaret. T.46-56. Both Dr. Fortuno and Dr. Malaret testified that Plaintiff's physical and mental impairments, either singly or in combination, did not meet or medically equal any listed impairment. T.16-18. With regard to his depressive disorder NOS, the ALJ found that Plaintiff had mild limitations in activities in daily living, no limitations in social functioning, moderate difficulties in maintaining concentration, persistence, or pace, and no episodes decompensation. T.16-18. Thus, because his mental impairment did not cause at least two "marked" limitations or one "marked" limitation and "repeated" episodes of decompensation, the "paragraph B" criteria of Listing 12.04 were not met. As to Listing 1.02 (major dysfunction of a joint), the ALJ found that although Plaintiff has chronic right knee pain secondary to arthritis with some joint-space narrowing in the medial and lateral compartments, there was no indication of gross anatomical deformity, stiffness, or bony destruction of the joint. The ALJ acknowledged that Plaintiff's gait consistently has been described as antalgic and that he uses a cane, but he found that Plaintiff did not have the severe degree of difficulty ambulating that is required by Listing 1.02.
The ALJ next determined that Plaintiff retained the residual functional capacity ("RFC") to perform light work,
At step four, the ALJ found that given his RFC of less than the full range of light work, Plaintiff could no longer perform his past employment, which included clean-up worker (heavy and unskilled) and security guard (light and semiskilled). T.28.
At step five, based upon both the Medical-Vocational Guidelines and the vocational expert testimony, the ALJ found that Plaintiff could perform such representative occupations as addresser, document preparer, and telephone-answering/service operator. T.30. Accordingly, the ALJ entered a finding of "not disabled."
Title 42 U.S.C., § 405(g) authorizes district courts "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." This Court's function is not to determine
Plaintiff asserts that remand is required because the ALJ failed to fulfill his obligation to develop the record when he did not send Plaintiff for further testing, despite the independent medical expert's clinical impression of diabetic neuropathy. Defendant argues that the Social Security Administration is not a health management organization, and therefore the ALJ had no duty to send Plaintiff for diagnostic testing.
At the hearing, independent medical expert ("IME") Dr. Malaret specifically noted during his testimony as follows:
T.46 (emphasis supplied). When questioned by Plaintiff's attorney, the following exchange clarified Dr. Malaret's position:
T.50-51 (emphasis supplied).
In his decision finding Plaintiff not disabled, although he gave significant weight to Dr. Malaret's testimony overall, the ALJ disregarded Dr. Malaret's clinical opinion that Plaintiff was suffering from diabetic neuropathy, stating, "Although the medical expert's diagnostic impression might be correct, I am forced to reject it, as it is based on the claimant's subjective complaints, not on the objective medical evidence." T.26.
In drawing this conclusion, the ALJ erred. The ALJ's rejection of the diagnostic impression because it allegedly had no basis other than Plaintiff's subjective complaints (burning sensations in his feet, hands and face) reflects a misapplication of the pertinent caselaw and regulations. In
Dr. Malaret also testified that if Plaintiff did suffer from diabetic neuropathy, it could potentially affect his ability to stand, do fine manipulations with his fingers, and do larger movements with his hands and arms. T.50-51. This, in turn, could have led to a more restrictive RFC, including, but not limited to, greater limitations on the total amount of time Plaintiff would be able to stand, during an 8-hour workday as well as limitations on reaching, handling, and fingering. Two of the jobs that the VE found Plaintiff could perform required frequent reaching, handling, and fingering, and one of the jobs required constant reaching, handling, and fingering. The Court notes that, fairly read, Dr. Malaret's testimony indicates that, in light of Plaintiff's symptoms of diabetic neuropathy, objective diagnostic testing should have been performed. T.46 (noting that "unfortunately there have been no tests for diabetic neuropathy" such as "electromyograms or nerve conduction studies"). However, the ALJ relied on this gap in the administrative record to demonstrate support for his rejection of Plaintiff's subjective complaints that were consistent with diabetic neuropathy. The Court notes that this gap in the record was not attributable to,
Plaintiff contends that the ALJ's RFC assessment was erroneous because the ALJ did not take into account Plaintiff's possible diagnosis of diabetic neuropathy, failed to include a shifting-ofpositions option, and failed to take into consideration that Plaintiff ambulates with a hand-held assistive device.
With regard to the possible diabetic neuropathy diagnosis based on IME Dr. Malaret's comments at the hearing, the Court has discussed this
The Court also finds that the ALJ's failure specifically to include a shifting-of-positions option was erroneous. As Plaintiff argues, such a limitation was implied in the testimony of ME Dr. Malaret, who opined that, with regard to standing, Plaintiff "probably couldn't do more than one to two hours at a time in an eight-hour day, maybe up to four hours in an eight-hour day." T.48, 51.
Finally, the Court agrees that the ALJ failed to properly consider the medical necessity of Plaintiff using a cane. Social Security Ruling ("SSR") 96-9P provides that "[t]o find that a hand-held assistive device is medically required, there must be medical documentation establishing the need for a hand-held assistive device to aid in walking or standing, and describing the circumstances for which it is needed (i.e., whether all the time, periodically, or only in certain situations; distance and terrain; and any other relevant information)." SSR 96-9P, 1996 WL 374185, at *7 (S.S.A. July 2, 1996). Here, Plaintiff testified that about 3 years ago a doctor whom he had seen prior to Dr. Stornelli recommended that he use a cane to more evenly distribute his weight. Plaintiff's use of a cane and his gait abnormality since that time is well-supported by the record.
Although the ALJ found Plaintiff capable of doing less than the full range of light work, he did not place any additional limitations on the amount Plaintiff was required to lift or the frequency with which he was required to perform lifting activities. As noted above, the regulations provided that light work "involves lifting no more than 20 pounds at a time with frequent lifting or carrying of objects weighing up to 10 pounds." 20 C.F.R. § 416.967(b). A job may also be in this category "when it requires a good deal of walking or standing, or when it involves sitting most of the time with some pushing and pulling of arm or leg controls."
Because all of Plaintiff's limitations were not included in the RFC assessment, the Court cannot find that it was supported by substantial evidence, and remand is required.
For the foregoing reasons, the Commissioner's denial of DIB was erroneous as a matter of law. Therefore, the Commissioner's motion for judgment on the pleadings is denied. Plaintiff's motion for judgment on the pleadings is granted to the extent that the Commissioner's decision is reversed, and the matter is remanded for further administrative proceedings consistent with this Decision and Order. In particular, Plaintiff should undergo objective medical testing for diabetic neuropathy, and the ALJ should incorporate the results of that testing, as well the necessity of Plaintiff's use of a handheld assistive device into a revised RFC assessment.