HOLLY B. FITZSIMMONS, Magistrate Judge.
Plaintiff Michelle R. Green brings this action pursuant to 42 U.S.C. §405(g), seeking review of a final decision of the Commissioner of Social Security which denied her application for Disability Insurance Benefits ("DIB") under Title II Social Security, 42 U.S.C. §401
For the reasons set forth below, plaintiff's Motion for Judgment on the Pleadings
The procedural history of this case is not disputed. Plaintiff protectively filed an application for DIB on June 11, 2013, alleging disability as of January 23, 2013.
On March 29, 2016, Administrative Law Judge ("ALJ") Carl E. Stephan held a hearing, at which plaintiff appeared with a paralegal and testified. [Tr. 38-62]. No Vocational Expert testified at the hearing. [Tr. 38]. On June 10, 2016, the ALJ found that plaintiff was not disabled, and denied her claim. [Tr. 19-37]. Plaintiff filed a timely request for review of the hearing decision on July 19, 2016. [Tr. 123-24]. On September 14, 2017, the Appeals Council denied review, thereby rendering ALJ Smith's decision the final decision of the Commissioner. [Tr. 1-6]. The case is now ripe for review under 42 U.S.C. §405(g).
Plaintiff, represented by counsel, timely filed this action for review and moves to reverse and/or remand the Commissioner's decision.
The review of a social security disability determination involves two levels of inquiry.
The Court does not reach the second stage of review — evaluating whether substantial evidence supports the ALJ's conclusion — if the Court determines that the ALJ failed to apply the law correctly.
"[T]he crucial factors in any determination must be set forth with sufficient specificity to enable [a reviewing court] to decide whether the determination is supported by substantial evidence."
It is important to note that in reviewing the ALJ's decision, this Court's role is not to start from scratch. "In reviewing a final decision of the SSA, this Court is limited to determining whether the SSA's conclusions were supported by substantial evidence in the record and were based on a correct legal standard."
Under the Social Security Act, every individual who is under a disability is entitled to disability insurance benefits.
To be considered disabled under the Act and therefore entitled to benefits, Ms. Green must demonstrate that she is unable to work after a date specified "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). Such impairment or impairments must be "of such severity that [s]he is not only unable to do h[er] previous work but cannot, considering h[er] age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy." 42 U.S.C. §423(d)(2)(A);
There is a familiar five-step analysis used to determine if a person is disabled.
"Through the fourth step, the claimant carries the burdens of production and persuasion, but if the analysis proceeds to the fifth step, there is a limited shift in the burden of proof and the Commissioner is obligated to demonstrate that jobs exist in the national or local economies that the claimant can perform given his residual functional capacity."
Following the above-described five step evaluation process, ALJ Stephan concluded that plaintiff was not disabled under the Social Security Act. [Tr. 19-37]. At step one, the ALJ found that plaintiff had not engaged in substantial gainful activity since January 23, 2013, the alleged onset date. [Tr. 24].
At step two, the ALJ found that plaintiff had cervical sprain and strain; cervical spondylosis; cervical disc herniation without myelopathy; and lumbar strain, all of which are severe impairments under the Act and regulations. [Tr. 24-28]
At step three, the ALJ found that plaintiff's impairments, either alone or in combination, did not meet or medically equal the severity of one of the listed impairments in 20 C.F.R. Pt. 404, Subpart P, Appendix 1. [Tr. 28]. The ALJ specifically considered Listing 1.04 (disorders of the spine). [Tr. 28]. The ALJ also conducted a psychiatric review technique and found that plaintiff had a no restriction in activities of daily living or social functioning, and a mild restriction in concentration, persistence or pace. [Tr. 26-27]. The ALJ found no episodes of decompensation. [Tr. 27].
Before moving on to step four, the ALJ found plaintiff had the RFC "to perform the full range of light work, as defined in 20 C.F.R. 404.1567(b)." [Tr. 28].
At step four, the ALJ found plaintiff was unable to perform any past relevant work. [Tr. 31]. At step five, after considering plaintiff's age, education, work experience and RFC, the ALJ found that jobs existed in significant numbers in the national economy that plaintiff could perform. [Tr. 31-32].
The ALJ concluded that plaintiff had not been under a disability from January 23, 2013, the alleged onset date of disability, through June 10, 2016, the date of the ALJ's decision. [Tr. 32].
An ALJ has the responsibility to determine a claimant's RFC based on all the evidence of record. 20 C.F.R. §§404.1545(a)(1), 416.945(a)(1). The RFC is an assessment of "the most [the disability claimant] can still do despite [his or her] limitations." 20 C.F.R. §404.1545(a)(1), 416.945(a)(1). Although "[t]he RFC determination is reserved for the commissioner . . . an ALJ's RFC assessment is a medical determination that must be based on probative evidence of record. . . . Accordingly, an ALJ may not substitute his own judgment for competent medical opinion."
Pursuant to 20 C.F.R. §§404.1527(c)(2) and 416.927(c)(2), a treating source's opinion will usually be given more weight than a non-treating source. If it is determined that a treating source's opinion on the nature and severity of a plaintiff's impairment is "well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in [the] case record," the opinion is given controlling weight. 20 C.F.R. §§404.1527(c)(2), 416.927(c)(2). If the opinion, however, is not "well-supported" by "medically acceptable" clinical and laboratory diagnostic techniques, then the opinion cannot be entitled to controlling weight.
Here, the ALJ found that plaintiff had the RFC to "perform the full range of light work, as defined in 20 C.F.R. §404.1567." [Tr. 28]. The regulations dictate the physical exertion requirements of light work:
20 C.F.R. §404.1567.
The administrative record in this case contains numerous detailed treatment records, and medical opinions from treating and other examining sources that relate the medical evidence to what plaintiff can and cannot do functionally. Plaintiff accurately points out that there are numerous disability assessments, supported by functional limitation, by her treating providers in the record and there is no dispute that plaintiff was disabled from returning to her work as a CNA. [Tr. 31]. It is also undisputed that plaintiff did not work after the first motor vehicle accident on January 23, 2013, that the injuries sustained were due to the accident, and that conservative treatment did not relieve her symptoms. After a second motor vehicle accident on February 20, 2014, it is also undisputed that plaintiff sustained injuries to her lumbar spine and this accident was an aggravating/activating event to a pre-existing cervical condition.
Notably, the ALJ did not assess the opinion of treating orthopedic surgeon Dr. Cameron Huckell in making his RFC determination, as conceded by defendant. [Doc. #22-1 at 19]. Defendant argues that "[a]lthough the ALJ did not
During the relevant period under review, there is no opinion of record by a treating physician or other medical provider that plaintiff was able to work and/or was ready to return to work. Rather, the ALJ's decision in large part indicates that he impermissibly assessed plaintiff's RFC on the basis of bare medical findings, and substituted his own judgment for competent medical opinion.
This is not a case where plaintiff suffers relatively little physical impairment, such that the ALJ may render a common sense judgment about plaintiff's functional capacity. The ALJ acknowledged as much by designating plaintiff's cervical sprain and strain; cervical spondylosis; cervical disc herniation without myelopathy; and lumbar strain "severe." [Tr. 24-28].
Moreover, throughout the treating relationship with Dr. Huckell, the doctor opined that plaintiff was temporarily totally disabled as a result of the motor vehicle accident in January 2013 and was unable to return to her job. [Tr. 244 (8/8/13), Tr. 234 (10/9/13), Tr. 228 (12/5/13), Tr. 222 (12/17/13). By March 2014, and after the second motor vehicle accident in February 2014, Dr. Huckell opined that he considered plaintiff to have a permanent partial disability. [Tr. 388 (3/21/14), Tr. 401 (6/18/14), Tr. 414 (8/7/14), Tr. 450 (10/4/14)].
Dr. Huckell's treatment notes include detailed notations of physical examination of plaintiff's musckuloskeletal system (including gait, physical inspection, range of motion, strength, straight leg raises), neurologic system (including deep tendon reflexes, sensation and pathologic reflexes), and her psychiatric status. [Tr. 218, 233, 243, 384, 394-95, 405-06, 442-43]. Beginning in December 2013, Dr. Huckell noted that conservative care, including chiropractic, massage and physical therapy, did not improve her symptoms. [Tr. 217, 226]. On examination, Dr. Huckell noted that plaintiff's "left grip strength is 25% less than a right grip strength indicating that the spinal cord compression and nerve root compression left side is starting to cause some neurological problems that are objective." [Tr. 217, 226]. At that time, plaintiff provided a consent to surgery. [Tr. 221]. The doctor stated, Michelle is now developing some early signs of myelopathy and there is an indication for surgery. I explained to her that she is a candidate for anterior cervical discectomy and fusion and allograft bone cage and plate C5-7. There is no indication for further physical therapy since she has had neurological worsening.
[Tr. 222, 228]. In March and June 2014, Dr. Huckell noted that "[w]e are planning on proceeding with surgery relatively soon." [Tr. 388, 401], However, despite providing consent to surgery, Dr. Huckell noted in August and October 2014, that plaintiff "is not ready to commit [to] any surgical intervention yet which is reasonable." [Tr. 404, 441].
After the second MVA in February 2014, Dr. Huckell stated
[Tr. 388-89 (3/21/14), 401 (6/18/14), 414 (8/17/14)]. A functional capacity evaluation was not performed or, if done, is not part of the record.
In the last treatment record in October 2014, on physical examination Dr. Huckell noted paravertebral muscle rigidity. Cervical range of motion revealed, flexion 45 degrees/0-60 degrees, extension 40 degrees/0-75 degrees, bending to right 15 degrees/0-45 degrees, rotation to right 65 degrees/0-80 degrees, rotation to left 50 degrees/0-80 degrees. Thoracic range of motion revealed flexion 40 degrees/0-50 degrees, rotation 15 degrees/10-30 degrees, rotation to left 15 degrees/10-30 degrees. Lumbar range of motion revealed flexion 40 degrees/0-60 degrees, extension 10 degrees/0-25 degrees, bending to right 20 degrees/0-25 degrees, bending to left 20 degrees/0-25 degrees. The doctor noted functional range of motion of shoulders, elbows, wrists, hips, knees, and ankles. Strength was 5/5 bilaterally for the upper extremities including intrinsic muscles of hands. Grip strength was firm bilaterally. However, in objective grip strength testing, the doctor noted that plaintiff's right hand achieved a crit of 28 kg of force and her left hand was 25% less than 22 kg of force, "which is clearly objective evidence of weakness in a left-handed individual." [Tr. 443]. Straight leg raises were positive on the left side at approximately 50 degrees. Deep tendon reflexes 2+ at the bilateral knees and ankles, 3+ at the bilateral upper extremities and plaintiff has spreading to other muscle groups at proximal joints. Sensation was intact to light touch bilaterally to upper and lower extremities. Finally, pathologic reflexes showed Hoffman sign were bilaterally positive. [Tr. 443].
On October 7, 2014, Dr. Huckell added, that while "[s]he was not working at the time of her second MVA (02/23/2014) the second accident activated/aggravated her pre-existing condition and continued her loss of work to some extent." [Tr. 450]. The doctor "recommended against lumbar surgery for her condition although she might be helped by lumbar epidural steroids." [Tr. 441;
Dr. Huckell provided the following disability opinion on October 7, 2014,
[Tr. 453].
Instead of addressing Dr. Huckell's opinion, the ALJ ignored it, writing that
[Tr. 30]. Plaintiff correctly states that "the ALJ did not address Dr. Huckell's opinion, as he assumed the reports from Pinnacle indicating that Ms. Green is totally disabled came from the physician assistant Mr. Joslyn (Tr. 30) and thus are not governed by 20 C.F.R. §404.1527." [Doc. #15-1 at 34]. As set forth above, Dr. Huckell examined plaintiff, reviewed the diagnostic imaging and co-signed these reports.
The Commissioner argues that since the ALJ found that plaintiff could perform light or sedentary work, that this is consistent with Dr. Huckell's October 7, 2014 opinion precluding her work as a certified nurse assistant. [Doc. #22-1 at 19-20]. However, Dr. Huckell did not specifically state why Ms. Green could not perform her past work. The doctor documented "objective" evidence of weakness to plaintiff's dominant left hand and arm, left upper and lower extremities with neurological worsening throughout the treatment history. [Tr. 217, 222, 226-27, 383, 388, 393, 400-01, 404, 406, 441, 443, 450]. However, the ALJ's RFC determination makes no mention of additional functional limitations due to plaintiff's dominant left hand/arm radicular symptoms. Nor did the ALJ include any manipulative or postural limitations to account for these radicular symptoms to plaintiff's left dominant hand or other neurological worsening to her left upper and lower extremities.
"Because the ALJ failed to cite to any medical opinion to support his RFC findings, the Court is unable to determine if the ALJ improperly selected separate findings from different sources, without relying on any specific medical opinion."
Because the ALJ failed to assess Dr. Huckell's opinion and dismissed the opinions from other treating medical sources there is no medical opinion regarding Green's functional capacity to complete the activities for a full range of light work or sedentary work.
While the Commissioner is free to decide that the opinions of acceptable medical sources and other sources are entitled to no weight or little weight, those decisions should be thoroughly explained.
"In light of the ALJ's affirmative duty to develop the administrative record, an ALJ cannot reject [or ignore] a treating physician's [opinion] without first attempting to fill any clear gaps in the administrative record."
Because there is no medical source opinion or functional assessment supporting the ALJ's finding that Ms. Green can perform the full range of light work, the Court concludes that the RFC determination is without substantial support in the record and a remand for further administrative proceedings is appropriate.
On remand, the ALJ should develop the record as necessary to obtain opinions as to plaintiff's functional limitations from treating and/or examining sources, obtain a consultative physical examination and/or a medical expert review, obtain a functional capacity evaluation, and obtain emergency room treatment records from Erie County Medical Center and/or Kenmore Mercy Hospital for neck or low back pain [Tr. 61-62 (plaintiff testifying that she has sought emergency care approximately ten times for pain related issues), Tr. 510-11 (August 9, 2015, emergency room treatment records noting plaintiff presented with "worsening neck pain that is radiating down into her left arm." On examination noting "symptoms suggestive of a C6 C7 radiculopathy likely secondary to muscle spasm after sprain of the neck.")].
The Commissioner on remand should thoroughly explain his findings in accordance with the regulations.
As noted earlier, the Court's role in reviewing a disability determination is not to make its own assessment of the plaintiff's functional capabilities; it is to review the ALJ's decision for reversible error. Because the Court has found the ALJ erred in failing to evaluate the opinion of treating orthopedic surgeon Dr. Huckell, it need not reach the merits of plaintiff's remaining arguments. Therefore, this matter is remanded to the Commissioner for further administrative proceedings consistent with this ruling. On remand the Commissioner will address the other claims of error not discussed herein.
The Court offers no opinion on whether the ALJ should or will find plaintiff disabled on remand. Rather the Court finds remand is appropriate to permit the ALJ to evaluate Dr. Huckell's opinion and develop the record accordingly.
For the reasons stated, plaintiff's Motion for Judgment on the Pleadings
In light of the Court's findings above, it need not reach the merits of plaintiff's other arguments. Therefore, this matter is remanded to the Commissioner for further administrative proceedings consistent with this opinion. On remand, the Commissioner shall address the other claims of error not discussed herein.
This is not a Recommended Ruling. The parties consented to proceed before a United States Magistrate Judge [doc. #11] on September 25, 2018, with appeal to the Court of Appeals. Fed. R. Civ. P. 73(b)-(c).
SO, ORDERED.