JEREMIAH J. McCARTHY, Magistrate Judge.
This is an action brought pursuant to 42 U.S.C. § 405(g) to review the final determination of defendant Commissioner of Social Security that plaintiff was not entitled to disability insurance benefits ("DIB"). Before the court are the parties' cross-motions for judgment on the pleadings [9, 12].
The parties' familiarity with the 2,430-page administrative record [5] is presumed. The plaintiff filed an application for DIB on November 15, 2013. [5-2], p. 21; [5-5], p. 190. He alleged a disability beginning on June 22, 2009, the date he was injured at work when he fell from a piece of equipment. [5-2], p. 61. Plaintiff declined to file an application for Supplemental Security Income. [5-5], p. 190. Plaintiff was last insured for DIB on December 31, 2014. [5-2], p. 21. His claim was initially denied. [5-4], p. 128. Administrative Law Judge ("ALJ") Bryce Baird conducted a hearing on October 14, 2016. [5-2], pp. 21, 41. Plaintiff appeared with his attorney.
Following the hearing, ALJ Baird held the record open to further develop the evidence and permit plaintiff's attorney to submit additional evidence and briefing. [5-2], pp. 118-19; [5-6], pp. 308-09, 310, 311, 315-16. On October 19, 2016, ALJ Baird requested that Dr. Capicotto provide the Social Security Administration ("SSA") with a residual functional capacity statement, and forwarded to Dr. Capicotto a form medical source statement for that purpose. [5-6], pp. 297-307.
In addition, John Schwab, D.O. performed a consultative orthopedic examination on November 4, 2016. See [5-11], pp. 2402-12. Dr. Schwab submitted both a narrative report and a completed medical source statement to the SSA.
Plaintiff's attorney submitted additional medical and other evidence for ALJ Baird's consideration, including a March 23, 2017 report from Dr. Capicotto. See [5-10], pp. 2129-36; 2137-38; 2139-44; 2145-49; 2150-2228; 2229-2400; 2413-16; 2418-24; and 2425-30. Dr. Capicotto did not return the medical source statement to the SSA or provide an opinion concerning plaintiff's functional abilities, save for the statements in his March 23, 2017 report.
On April 12, 2017, ALJ Baird issued his Notice of Decision denying plaintiff's claim. [5-2], pp. 21-40.
Several independent medical examiners ("IMEs") examined plaintiff between August of 2009 and January of 2015 at the request of his employer's workers' compensation carrier. Anthony Leone, M.D., an orthopedic surgeon, first examined plaintiff on August 18, 2009. [5-8], p. 811. He stated that plaintiff could not return to his regular job, but "could do modified type work. No bending. No twisting. No overhead activity. No lifting, pushing, pulling, or carrying of more than 25 pounds." [5-8], p. 814. Dr. Leone examined plaintiff again on May 18, 2010. He opined that plaintiff "could return to work with restrictions; no repetitive bending, twisting, or overhead activity; no lifting, pushing, pulling or carrying of over 20 pounds."
Walter J. Levy, M.D., a neurosurgeon, examined plaintiff on February 10, 2011.
Melvin Brothman, M.D., an orthopedic surgeon, examined plaintiff on May 4, 2011. He found that plaintiff "could return to work on a modified basis to avoid excessive bending or lifting over 10 pounds."
Dr. Brothman re-examined plaintiff on December 11, 2012. He stated in a form IME Report of Permanent Impairment that, with respect to plaintiff's "residual functional capacities for any work", plaintiff could sit frequently (defined as "1/3 to 2/3 of the time").
Plaintiff underwent his first spinal surgery on November 18, 2013. [5-7], pp. 393-98. Dr. Brothman examined plaintiff a fourth time on March 24, 2014. He noted plaintiff was using a cane and had a "marked loss of flexion". [5-8], p. 678. Dr. Brothman stated that plaintiff could "only return to sedentary work to avoid bending or lifting more than 10 pounds."
James W. Faulk, M.D., an orthopedic surgeon, examined plaintiff on January 14, 2015 — soon after plaintiff's last insured date of December 31, 2014.
Plaintiff had a second spinal surgery on November 9, 2015. [5-10], pp. 2227-28. Dr. Faulk re-examined plaintiff on April 13, 2016. [5-8], p. 2000. He concluded that plaintiff had a "marked-to-total (80%) degree of disability" and that "[t]he only type of work he could currently do would be a sedentary type of work, no lifting over 5 pounds, no bending, climbing, or kneeling."
John Schwab, D.O., a family medicine physician, conducted his orthopedic consultative examination on November 4, 2016. [5-11], p. 2402. Dr. Schwab opined in his narrative report that plaintiff had a "marked restriction to bending, lifting, and carrying heavy objects."
ALJ Baird concluded that plaintiff was not disabled from June 9, 2009 through December 31, 2014. [5-2], pp. 22, 29. He analyzed the medical and other evidence in the context of the well-settled five-step test used to determine whether a claimant is entitled to disability benefits. [5-2], pp. 22-23, citing 20 C.F.R. 404.1520.
In order to continue his analysis at steps four and five, ALJ Baird determined that, through plaintiff's last insured date, he retained the residual functional capacity ("RFC") "to perform sedentary work as defined in 20 CFR 404.1567(a)" because plaintiff was able to, among other things, "stand and/or walk for two hours in an eight-hour workday, and sit for six hours in an eight-hour workday." [5-2], p. 26.
To arrive at his conclusions of plaintiff's RFC, ALJ Baird considered the statements in the record concerning plaintiff's ability to work and his degree of disability. He dismissed all of the statements in the record that plaintiff was "totally" disabled, or disabled to some other degree (i.e. "moderate" or "marked") or percentage (i.e. "75%" or "100%"). [5-2], p. 29. He reasoned that "[a]ny conclusory statements assessing disability under the workers' compensation guidelines or rules were not considered as they are based upon the Workers' Compensation Board's own rules and methodology; conclusory statements assessing disability under workers' compensation guidelines or rules are not binding in this forum and represent an opinion on an issue reserved to the Commissioner".
ALJ Baird also rejected Dr. Capicotto's March 23, 2017 statement that "it is unlikely that [plaintiff] will be able to return to the work force". [5-11], p. 2430. Dr. Capicotto did not provide any other assessment of plaintiff's functional abilities. ALJ Baird assigned "little weight" to Dr. Capicotto's statement because "it is not supported by an appropriate or specific function-by-function assessment" of plaintiff's work-related limitations, and because it "is inconsistent with the medical evidence prior to the date last insured", including Dr. Capicotto's other reports, and with Dr. Schwab's opinion. [5-8], p. 31.
ALJ Baird assigned "significant weight" to the functional assessments of Drs. Leone, Levy, Brothman, and Faulk "due to their expertise, their physical examinations of the claimant, and the relative consistency of their opinions with each other and the medical evidence through the date last insured". [5-2], p. 30. He also assigned "significant weight" to the opinion of Dr. Schwab for the same reasons, and because his opinion was consistent with those of Drs. Leone, Levy, Brothman, and Faulk.
Finally, ALJ Baird determined that "jobs existed in significant numbers in the national economy that the claimant could have performed" through his date last insured. [5-2], pp. 32-33. In order to arrive at this conclusion, ALJ Baird relied upon the testimony of vocational expert David A. Festa.
"A district court may set aside the Commissioner's determination that a claimant is not disabled only if the factual findings are not supported by `substantial evidence' or if the decision is based on legal error."
Plaintiff argues that ALJ Baird erred in four ways:
Plaintiff's Memorandum [9-1], pp. 17-33.
In response, the Commissioner argues that ALJ Baird's conclusions were supported by substantial evidence, and that he properly analyzed the available evidence, including the evidence of plaintiff's functional limitations. Further, the Commissioner argues the ALJ had no obligation to re-contact Dr. Capicotto. Commissioner's Brief [12-1], pp. 10-18.
A treating physician's opinion is accorded "controlling weight" if it is "well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in [the] record". 20 C.F.R. §§ 404.1527(c)(2); 416.927(c)(2).
I agree that ALJ Baird was entitled to reject the conclusory statements found throughout the medical records concerning plaintiff's degree of disability (i.e. "moderate", "marked", "total", along with various percentages) made in the context of plaintiff's workers' compensation claim. See
Further, ALJ Baird was entitled to reject Dr. Capicotto's March 23, 2017 statement that "it is unlikely that [plaintiff] will be able to return to the work force." [5-11], p. 2430. This is a conclusory statement that may, or may not, concern plaintiff's functional capacity to work. Accordingly, ALJ Baird was entitled to reject this statement. 20 C.F.R. §404.1527.
This is not, however, a case in which rejecting a statement concerning disability from a plaintiff's treating physician renders the record devoid of opinion evidence. When an ALJ rejects the only evidence in the record concerning a plaintiff's functional abilities, he or she has an obligation to further develop the record.
Moreover, the ALJ adequately discharged his obligation to further develop the record in this case. ALJ Baird attempted to obtain a functional assessment from Dr. Capicotto. [5-6], pp. 297-307. But Dr. Capicotto did not respond, except for the comment contained in the March 23, 2017 report. In addition, the ALJ ordered a consultative examination. See Report of Dr. Schwab [5-11], pp. 2402-10. Lastly, ALJ Baird held the record open for months before rendering his decision, and plaintiff's attorney submitted additional medical records (including Dr. Capicotto's March 23, 2017 report) and briefing. See [5-10], pp. 2129-36; 2137-38; 2139-44; 2145-49; 2150-2228; 2229-2400; 2413-16; 2418-24; and 2425-30.
Under these circumstances, the ALJ was entitled to reject Dr. Capicotto's conclusory statements, and adequately discharged his obligation to develop the record concerning plaintiff's functional abilities.
However, ALJ Baird failed to identify any evidence to support his finding that plaintiff was able to sit for up to six hours during an eight-hour workday. Both the Second Circuit and the SSA recognize that the ability to sit for long periods of time is a requirement for sedentary work. See
The RFC need "not perfectly correspond with any of the opinions of medical sources cited in his decision".
"As a result, an ALJ's determination of RFC without a medical advisor's assessment is not supported by substantial evidence."
I agree with plaintiff that ALJ Baird failed to properly support his findings concerning plaintiff's ability to sit. Plaintiff's Memorandum [9-1], pp. 22-25. ALJ Baird accorded Dr. Schwab's opinions "significant weight", but explicitly rejected his opinion that plaintiff was able to sit for only up to 4 hours in an 8-hour workday because "this sitting opinion is somewhat inconsistent with the balance of the evidence in the record, including the opinions of Dr. Leone, Dr. Levy, Dr. Brothman, and Dr. Faulk, and Dr. Schwab's own narrative medical source statement in which he did not assign any sitting limitations". [5-2], p. 30. ALJ Baird does not identify the portions of the opinions of Drs. Leone, Levy, Brothman, or Faulk that he believes are "inconsistent" with Dr. Schwab's opinion or otherwise explain the alleged inconsistency. Nor did he explain why he rejected the sitting limitations expressed by Drs. Brothman and Faulk. This was an error. "The plaintiff here is entitled to know why the ALJ chose to disregard the portions of the medical opinions that were beneficial to [his] application for benefits."
ALJ Baird also does not identify the portions of Drs. Leone, Levy, Brothman, or Faulk's opinions that affirmatively support his finding that plaintiff is able to sit for 6 hours in an 8-hour work day. Review of these opinions fails to settle the issue, as none of these doctors stated that plaintiff could sit for 6 hours in an 8-hour workday — an "essential" element of sedentary work.
Drs. Leone and Levy's reports are silent concerning plaintiff's ability to sit. [5-8], pp. 734, 773, 782, 814. Dr. Brothman stated in his December 11, 2012 IME Report of Permanent Impairment form that plaintiff can sit "frequently" with respect to work, defined as "1/3 to 2/3 of the time". [5-8], p. 719. Mathematically, this indicates the plaintiff can sit up to 5.3 hours, not 6, in an 8-hour work day. Dr. Brothman is silent in his narrative reports concerning plaintiff's ability to sit.
Neither ALJ Baird nor the Commissioner
Although the ALJ in
Here, the medical evidence relied upon by ALJ Baird to support his finding on sitting is similarly deficient. None of the opinions cited by ALJ Baird that comment on plaintiff's ability to sit state that plaintiff can sit for 6 hours out of an 8-hour day. The remaining reports cited by the ALJ are silent on the issue and there is no evidence that those doctors were asked to provide such an opinion. The absence of a statement concerning a limitation does "not express an opinion as to whether the claimant could perform all the activities and exertions necessary for sedentary employment."
"It is bedrock Social Security law that the responses of a vocational expert are relevant only to the extent offered in response to hypotheticals that correspond to medical evidence of record."
Accordingly, this matter is remanded to the Commissioner for a proper analysis of claimant's RFC, especially with reference to plaintiff's ability to sit and for how long, and further analysis concerning plaintiff's ability, through his date last insured, to perform sedentary work that existed in the national economy. See
For the reasons stated above, plaintiff's motion for judgment on the pleadings [9] is granted to the extent that this matter is remanded to the Commissioner for further proceedings consistent with this Decision and Order, and is otherwise denied. Accordingly, the Commissioner's motion for judgment on the pleadings [12] is also denied.