WILLIAM M. SKRETNY, District Judge.
1. Plaintiff Jessica Cassick challenges the determination of an Administrative Law Judge ("ALJ") that she is not disabled within the meaning of the Social Security Act ("the Act"). Plaintiff alleges that she has been disabled since June 24, 2011 due to injuries sustained in a car accident on January 6, 2011. Plaintiff contends that her impairments render her unable to work, and thus, she is entitled to disability benefits under the Act.
2. Plaintiff filed an application for disability insurance benefits on March 29, 2014, which the Commissioner denied on May 19, 2014. Plaintiff thereafter requested a hearing before an ALJ. On May 12, 2016, ALJ Michael A. Lehr held a hearing via videoconference from Kansas City, Missouri, at which Plaintiff appeared with counsel and testified. A vocational expert also appeared and testified. After considering the case de novo, the ALJ denied Plaintiff's application for benefits in a written decision on July 26, 2016. The Appeals Council denied Plaintiff's request for review on July 31, 2017. Plaintiff filed the instant action on October 4, 2017, challenging the Commissioner's final decision.
3. On October 10, 2018, Plaintiff filed a Motion for Judgment on the Pleadings under Rule 12(c) of the Federal Rules of Civil Procedure. (Docket No. 13). On December 10, 2018, the Commissioner filed a Motion for Judgment on the Pleadings. (Docket No. 15). Plaintiff filed a reply on December 28, 2018 (Docket No. 16), at which time this Court took the matter under advisement without oral argument. For the following reasons, Plaintiff's motion is granted, Defendant's motion is denied, and this case will be remanded.
4. A court reviewing a denial of disability benefits may not determine de novo whether an individual is disabled.
5. "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 of the substantiality of the evidence must also include that which detracts from its weight."
6. The Commissioner has established a five-step sequential evaluation process to determine whether an individual is disabled under the Act.
7. The five-step process is as follows:
8. Although the claimant has the burden of proof on the first four steps, the Commissioner has the burden of proof on the fifth and final step.
9. In this case, the ALJ made the following findings with regard to the five-step process set forth above: (1) Plaintiff did not engage in substantial gainful activity during the period from her alleged onset date of June 24, 2011, through her date last insured ("DLI") of June 30, 2013 (R. at 12);
10. Plaintiff's brief challenges the ALJ's decision on two grounds. First, she contends that the ALJ erred by improperly substituting his judgment for that of the medical opinions of record. Second, she argues that the ALJ failed to properly evaluate the opinion of her treating physician. (Docket No. 13-1 at 15-24). Having reviewed the ALJ's decision in light of Plaintiff's arguments, the Court finds reversible error on both grounds.
11. First, Plaintiff argues that "the ALJ erred by rejecting all RFC [medical] opinions and then formulating a function-by-function physical RFC without any medical authority," creating "a gap in the record" requiring remand. (Docket No. 13-1 at 17). The Commissioner concedes that there is no medical opinion "directly supporting the ALJ's RFC assessment," (Docket No. 15-1 at 16), but nonetheless defends the ALJ's RFC determination on the ground that "the ALJ found that he could sufficiently weigh the relevant evidence, resolve the inconsistencies, and determine whether Plaintiff was disabled based on the evidence of record"—without identifying what evidence lends support to the RFC finding. (Docket No. 15-1 at 17). As discussed in detail below, the ALJ's RFC determination does not rest on substantial evidence.
12. The ALJ concluded that Plaintiff "had the [RFC] to perform light work." (R. at 14). The Regulations define "light work" as follows:
20 C.F.R. § 404.1567(b).
13. In deciding a disability claim, an ALJ is tasked with "weigh[ing] all of the evidence available to make an RFC finding that [is] consistent with the record as a whole."
14. The ALJ's decision references the medical opinions of Dr. Mikhail Strut, Plaintiff's treating physician and pain management specialist, Dr. Eric Puestow,
15. Dr. Strut treated Plaintiff 20 times from November 2012 through November 2015. (R. at 394-407, 480). Dr. Strut evaluated Plaintiff on November 13, 2012. (R. at 287). He observed that Plaintiff experiences an increase in pain when performing daily activities such as bending, twisting, and lifting. (R. at 287). He noted that Plaintiff's "pain is constant [and] variable in intensity." (R. at 287). His notes also reflect that he ordered an MRI of Plaintiff's lumbar spine to confirm his diagnosis of lumbar radiculopathy and L5-S1 disc herniation. (R. at 289). Dr. Strut's December 6, 2012 evaluation concluded that Plaintiff had "decreased active range of motion in [her] lumbar spine approximately 50% in all planes," had "multiple muscle spasm[s] and [her] bilateral lumbar paraspinals adjacent muscles right [were] much more involved than [the] left," had "decreased medial hamstring reflex on the right side and decreased sensation over right L5 dermatome," and "decreased strength [in her] right dorsiflexion and left plantar flexion." (R. at 396). Dr. Strut's January 23, 2014 evaluation reflects that Plaintiff's "symptoms [were] so severe [that] she is no longer able to write or type on the computer," that her "previous physical exam demonstrated weakness in the right shoulders abduction and forward flexion and right elbow extension," and that a "recent physical exam demonstrated significant weakness in her bilateral intrinsic hand muscles." (R. at 394). Dr. Strut also wrote that "[Plaintiff's] pathology is severe and will qualify for surgical intervention." (R. at 395). The record also includes Dr. Strut's treating source statement dated May 9, 2016, where he noted that Plaintiff "suffers from numerous impairments which significantly limit her functional capacity and her ability to fulfill her activity of daily living[]" that "stem from [the motor vehicle accident] which occurred on 1/6/2011." (R. at 480). He concluded: "In my opinion, based upon the MRI and EMG reports and my clinical examinations, [Plaintiff] cannot sustain any full[-]time employment" nor can she "lift anything more than 2 to 3 pounds due to the severe nature of her injuries." (R. at 480-481).
16. The ALJ did not discuss the above evidence when deciding what weight to afford Dr. Strut's opinion. Instead, the ALJ concluded that Dr. Strut's opinion deserved "limited weight" for two reasons: Dr. Strut "is not known to have a good understanding of the disability program and its requirements"; and "his opinions are not supported by the evidence as a whole, including the [Plaintiff's] previously discussed extent of day-to-day activities." (R. at 16). He also concluded that the record lacked objective evidence supporting Dr. Strut's conclusion that Plaintiff had the capacity "for only sedentary exertion with lifting of no more than 2-3 pounds maximum." (R. at 16).
17. The flaw in the ALJ's analysis here is two-fold. First, it is well settled that "[t]here is a critical difference between activities of daily living (which one can do at his own pace when he is able) and keeping a full time job,"
18. But second, the ALJ significantly mischaracterized Plaintiff's testimony in reaching his RFC determination, and misrepresented Plaintiff's ability to perform day-today activities. Plaintiff testified that daily activities such as "grocery shopping, lifting laundry," "vacuuming," "sweeping," and "mopping" caused her pain. (R. at 39). When asked how she was able to care for her son and engage in daily activities with her injuries, Plaintiff responded: "Some days it's a lot harder than others. My son has had to pretty much become a lot more independent than maybe some other [4]-year olds might need to"; "he can accommodate himself, and then I accommodate him as much as I can." (R. at 41). She also testified that she is unable to lift her son. (R. at 41-42). She described her lower back pain as "feel[ing] like there's a knife in it all the time," preventing her from "lay[ing], sit[ting], stand[ing], [or] doing anything"; she "can't really hold, or do anything with [her] left arm"; she "can't write," "can't pick, pull, or anything" with her left hand— finally admitting that she could not use her left hand "at all." (R. at 43-44). Plaintiff testified that her accident and resulting injuries altered the course of her education, prompting her to switch to a major that did not require "actual writing," and one that would lead her to a career in which she could "accommodate [her] own self." (R. at 50-51). She also stated that the school provided her "certain accommodations"; for example, some professors would send her their PowerPoint presentations from lectures so that Plaintiff "didn't have to do a lot of note taking." (R. at 52). Contrary to the ALJ's conclusion, Plaintiff's testimony appears to be consistent with the functional limitations outlined in Dr. Strut's evaluations.
19. In further analyzing what weight to afford Dr. Strut's opinion, the ALJ found "no objective evidence" supporting Dr. Strut's conclusion that Plaintiff retained the capacity "for only sedentary exertion with lifting of no more than 2-3 pounds maximum." (R. at 16). In so concluding, the ALJ ignored Dr. Strut's extensive treatment notes discussed above, which relied on diagnostic testing and Plaintiff's own testimony at her hearing, and instead cherry-picked other record evidence, some of which lie outside of the period of alleged disability.
20. The only other record evidence that the ALJ relied on in reaching his RFC determination were the medical opinions of Dr. Puestow and Dr. Mangold. The ALJ afforded "little weight" to Dr. Mangold's opinion, the consultative psychologist, (R. at 16-17), who concluded that there was "insufficient evidence to establish the presence of a psychiatric impairment which would preclude the
21. After Plaintiff's merits hearing, the ALJ sent an interrogatory to Dr. Puestow, a board-certified specialist in internal medicine, asking him to evaluate the record evidence and draw a conclusion with respect to Plaintiff's impairments (if any) and any functional limitations that result from the impairments. (R. at 209). Dr. Puestow completed the interrogatory, concluding that none of Plaintiff's impairments combined or separately met or equaled any impairment described in the Listing of Impairments in the regulations. (R. at 497). The ALJ gave "significant weight" to this portion of Dr. Puestow's interrogatory, (R. at 14), but discounted the portion of the interrogatory where Dr. Puestow stated: "I do not consider the record sufficient for determination" as to whether Plaintiff's impairments resulted in any functional limitations or restrictions. (R. at 498). Dr. Puestow "believe[d] a comprehensive [clinical evaluation] [was] warranted" and stated that he "would be happy to review the case again after the [clinical evaluation]." (R. at 498). The ALJ disagreed with Dr. Puestow, countering that there was, in fact, "extensive evidence available, including the [Plaintiff's] presentation and testimony at the disability hearing" "sufficient to support the functional assessment set forth" in the ALJ's decision. (R. at 16). By picking and choosing portions of Dr. Puestow's interrogatory that supported the ALJ's conclusion but discounting the portions that did not, the ALJ committed error.
22. Because "the ALJ clearly misunderstood or exaggerated the degree to which plaintiff could independently perform daily activities such as housework and personal care," "which significantly altered and influenced her RFC finding,"
23. Plaintiff also argues that the ALJ failed to properly evaluate the medical opinion of Dr. Strut, her treating pain management specialist. (Docket No. 13-1 at 19-24). "Social Security Administration regulations, as well as [Second Circuit] precedent, mandate specific procedures that an ALJ
24. "First, the ALJ must decide whether the opinion is entitled to controlling weight."
25. "Second, if the ALJ decides the opinion is not entitled to controlling weight, it must determine how much weight, if any, to give it. In doing so, it must `explicitly consider' the following, nonexclusive `
(4) whether the physician is a specialist.'"
26. "At both steps, the ALJ must `give good reasons in [its] notice of determination or decision for the weight [it gives the] treating source's [medical] opinion."
27. At first glance, it appears that the ALJ followed the regulatory requirements of 20 C.F.R. § 404.1527(c)(2) in assigning "limited weight" to Dr. Strut's opinion. (R. at 16). The ALJ accounted for the (1) "frequen[cy], length, nature, and extent of treatment,"
28. However, even assuming "substantial evidence supports the ALJ's decision at step one to assign less-than-controlling weight to [Dr. Strut's] opinion, the same is not true of its decision at step two to assign `little weight' thereto."
29. Here, the ALJ assigned "limited weight" to Dr. Strut's opinions because, according to the ALJ, Dr. Strut "is not known to have a good understanding of the disability program and its requirements" and because "his opinions are not supported by the evidence as a whole, including [Plaintiff's] previously discussed extent of day-to-day activities." (R. at 16). As explained in detail above, the ALJ mischaracterized Plaintiff's testimony and downplayed the extent to which her injuries and symptoms limited her daily activities. Regardless, the Second Circuit has made clear that "[c]onsideration of such lay testimony is not a substitute for proper consideration of a treating physician's medical opinion."
30. After carefully examining the administrative record, this Court finds cause to remand this case to the ALJ for further administrative proceedings consistent with this decision. Plaintiff's Motion for Judgment on the Pleadings is therefore granted. Defendant's motion seeking the same relief is denied.
IT HEREBY IS ORDERED, that Plaintiff's Motion for Judgment on the Pleadings (Docket No. 13) is GRANTED.
FURTHER, that Defendant's Motion for Judgment on the Pleadings (Docket No. 15) is DENIED.
FURTHER, that this case is REMANDED to the Commissioner of Social Security for further proceedings consistent with this decision. FURTHER, that the Clerk of Court is directed to CLOSE this case.
SO ORDERED.