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Hansley v. Commissioner of Social Security, 3:17-CV-00267. (2018)

Court: District Court, M.D. Pennsylvania Number: infdco20180323g66 Visitors: 7
Filed: Feb. 23, 2018
Latest Update: Feb. 23, 2018
Summary: REPORT AND RECOMMENDATION KAROLINE MEHALCHICK , Magistrate Judge . This is an action brought under Section 1383(c) of the Social Security Act and 42 U.S.C. 405(g), seeking judicial review of the final decision of the Commissioner of Social Security (hereinafter, "the Commissioner") denying Plaintiff David Edgar Hansley, Jr.'s claims for a period of disability and disability insurance benefits ("DIB") under Titles II and XVI of the Social Security Act. (Doc. 1). The matter has been referr
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REPORT AND RECOMMENDATION

This is an action brought under Section 1383(c) of the Social Security Act and 42 U.S.C. § 405(g), seeking judicial review of the final decision of the Commissioner of Social Security (hereinafter, "the Commissioner") denying Plaintiff David Edgar Hansley, Jr.'s claims for a period of disability and disability insurance benefits ("DIB") under Titles II and XVI of the Social Security Act. (Doc. 1). The matter has been referred to the undersigned United States Magistrate Judge to prepare a report and recommendation pursuant to the provisions of 28 U.S.C. § 636(b) and Rule 72(b) of the Federal Rules of Civil Procedure. For the reasons expressed herein, and upon detailed consideration of the arguments raised by the parties in their respective briefs, it is respectfully recommended that the Commissioner's decision be VACATED.

I. BACKGROUND AND PROCEDURAL HISTORY

On April 30, 2013, Plaintiff David Edgar Hansley, Jr. ("Hansley") filed applications for Title II and Title XVI benefits, respectively. (Doc. 8-2, at 22). In these applications, Hansley claimed disability beginning January 2, 2012. (Doc. 8-2, at 22). The Social Security Administration initially denied Hansley's claims on October 2, 2013. (Doc. 8-2, at 22). Hansley filed a request for a hearing before an Administrative Law Judge ("ALJ") on October 17, 2013. (Doc. 8-2, at 22). The hearing was held on March 26, 2015, before ALJ Joseph M. Hillegas. (Doc. 8-2, at 22). At the hearing, Hansley's counsel requested amendment of the alleged onset date from January 2, 2012 to June 7, 2014. (Doc. 8-2, at 22). Counsel attributed the change to Hansley turning 50.1 (Doc. 8-2, at 41-42). In a written opinion dated June 19, 2015, the ALJ determined that Hansley was not disabled and therefore not entitled to the benefits sought. (Doc. 8-2, at 33). Hansley appealed the decision of the ALJ to the Appeals Council, who, on December 16, 2016, denied Hansley's request for review. (Doc. 8-2, at 3).

In January of 2017, Hansley passed away. (Doc. 12, at 2). On February 13, 2017, Hansley's father, David E. Hansley, Sr., filed the instant action. (Doc. 1). The Commissioner responded on April 14, 2017, providing the requisite transcripts from the disability proceedings the same day. (Doc. 7; Doc. 8). The parties then filed their respective briefs, with the Plaintiff declining to file a reply brief. (Doc. 12; Doc. 13; Doc. 16). Plaintiff alleges three errors warranted reversal or remand. (Doc. 12, at 4).

II. THE ALJ'S DECISION

In a decision dated June 19, 2015, the ALJ determined Hansley "has not been under a disability, as defined in the Social Security Act, from June 7, 2014, through the date of this decision." (Doc. 8-2, at 33). The ALJ reached this conclusion after proceeding through the five-step sequential analysis required by the Social Security Act. See 20 C.F.R. § 404.1520. The ALJ determined that Hansley met the insured status requirements of the Social Security Act through December 31, 2015. (Doc. 8-2, at 24).

At step one, an ALJ must determine whether the claimant is engaging in substantial gainful activity ("SGA"). 20 C.F.R § 404.1520(a)(4)(i). If a claimant is engaging in SGA, the Regulations deem them not disabled, regardless of age, education, or work experience. 20 C.F.R. § 404.1520(b). SGA is defined as work activity—requiring significant physical or mental activity—resulting in pay or profit. 20 C.F.R. § 404.1572. In making this determination, the ALJ must consider only the earnings of the claimant. 20 C.F.R. § 404.1574. The ALJ determined Hansley "has not engaged in [SGA] since June 7, 2014, the alleged onset date." (Doc. 8-2, at 24). Thus, the ALJ's analysis proceeded to step two.

At step two, the ALJ must determine whether the claimant has a medically determinable impairment that is severe or a combination of impairments that are severe. 20 C.F.R. § 404.1520(a)(4)(ii). If the ALJ determines that a claimant does not have an "impairment or combination of impairments which significantly limits [the claimant's] physical or mental ability to do basic work activities, [the ALJ] will find that [the claimant] does not have a severe impairment and [is], therefore, not disabled." 20 C.F.R. § 404.1520(c). If a claimant establishes a severe impairment or combination of impairments, the analysis continues to the third step.

The ALJ found Hansley "has the following severe impairments: morbid obesity (testified 300 pounds currently and 5'5" tall and was referred by PCP for evaluation with bariatric surgeon) [sic]; coronary arteriosclerosis status-post stenting; diabetes mellitus without complication [sic]; non-alcoholic fatty liver; benign essential hypertension; and obstructive sleep apnea (does not use C-pap every night)." (Doc. 8-2, at 24-25). The ALJ did not identify any non-severe impairments.

At step three, the ALJ must determine whether the severe impairment or combination of impairments meets or equals the medical equivalent of an impairment listed in 20 C.F.R. Part 404, Subpt. P, App. 1 (20 C.F.R. §§ 404.1520(d); 404.1525; 404.1526). If the ALJ determines that the claimant's impairments meet these listings, then the claimant is considered disabled. 20 C.F.R. § 404.1520(a)(4)(iii). The ALJ determined that none of Hansley's impairments, considered individually or in combination, met or equaled a Listing. (Doc. 8-2, at 24). Specifically, the ALJ considered Listings 1.00 (musculoskeletal), 4.00 (cardiovascular), and 6.00 (genitourinary). (Doc. 8-2, at 25).

Between steps three and four, the ALJ determines the claimant's residual functional capacity ("RFC"), crafted upon consideration of the medical evidence provided. The ALJ determined that Hansley:

has the [RFC] to perform to lift up to ten pounds frequently and twenty pounds occasionally and stand/walk for up to six hours out of an eight-hour workday and sit for up to six hours (i.e., he can perform light work as defined by 20 CFR 404.1567(b) and 416.967(b). He is further limited to tasks requiring no more than occasional climbing, balancing, stooping, kneeling, crouching, or crawling. Due to insulin dependence, he cannot maintain a commercial driver's license and needs to take a five-minute break every hour to accommodate urinary frequency. (Doc. 8-2, at 25).

Having assessed a claimant's RFC, at step four the ALJ must determine whether the claimant has the RFC to perform the requirements of their past relevant work. 20 C.F.R. § 404.1520(a)(4)(iv). A finding that the claimant can still perform past relevant work requires a determination that the claimant is not disabled. 20 C.F.R. § 404.1520(a)(4)(iv). Past relevant work is defined as work the claimant has done within the past 15 years, that was substantial gainful activity, and that lasted long enough for the claimant to learn how to do it. 20 C.F.R. § 404.1560(b). If the claimant cannot perform past relevant work or has no past relevant work, then the analysis proceeds to the fifth step. The ALJ determined Hansley was unable to perform past relevant work. (Doc. 8-2, at 32). The ALJ noted past relevant work as a truck driver, but determined that the exertional requirements of the job exceeded Hansley's RFC. (Doc. 8-2, at 32).

At step five of the sequential analysis process, an ALJ considers the claimant's age, education, and work experience to see if a claimant can make the adjustment to other work. 20 C.F.R. § 404.1520(a)(4)(v). These factors are not considered when evaluating a claimant's ability to perform past relevant work. 20 C.F.R. § 404.1560(b)(3). If a claimant has the ability to make an adjustment to other work, they will not be considered disabled. 20 C.F.R. § 404.1520(a)(4)(v).

The ALJ made vocational determinations that Hansley was 50 years old on the alleged onset date, defined as an individual closely approaching advanced age by the Regulations. 20 C.F.R. § 404.1563. (Doc. 8-2, at 32). The ALJ also noted that Hansley "has at least a high school education and is able to communicate in English" as considered in 20 C.F.R. § 404.1564. (Doc. 8-2, at 32). The ALJ determined that upon consideration of these factors, Hansley's RFC, and the testimony of a vocational expert, "there are jobs that exist in significant numbers in the national economy that the claimant can perform." (Doc. 8-2, at 32). The ALJ specifically identified delivery truck driver, with over 100,000 jobs nationally. (Doc. 8-2, at 33).

As a result of this analysis, the ALJ determined that Hansley was not disabled and denied Hansley's applications for benefits. (Doc. 8-2, at 33).

III. STANDARD OF REVIEW

In order to receive benefits under Title II or Title XVI of the Social Security Act, a claimant must demonstrate an "inability to engage in any substantial gainful activity 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), 1382c(a)(3)(A). To satisfy this requirement, a claimant must have a severe physical or mental impairment that makes it impossible to do his or her previous work or any other substantial gainful activity that exists in significant numbers in the national economy. 42 U.S.C. § 423(d)(2)(A); 20 C.F.R. § 404.1505(a). Additionally, to be eligible to receive benefits under Title II of the Social Security Act, a claimant must be insured for disability insurance benefits. 42 U.S.C. § 423(a); 20 C.F.R. § 404.131.

In evaluating whether a claimant is disabled as defined in the Social Security Act, the Commissioner follows a five-step sequential evaluation process. 20 C.F.R. § 404.1520(a); 20 C.F.R. § 416.920(a). Under this process, the Commissioner must determine, in sequence: (1) whether the claimant is engaged in substantial gainful activity; (2) whether the claimant has a severe impairment; (3) whether the claimant's impairment meets or equals a listed impairment; (4) whether the claimant is able to do past relevant work, considering his or her residual functional capacity ("RFC"); and (5) whether the claimant is able to do any other work that exists in significant numbers in the national economy, considering his or her RFC, age, education, and work experience. 20 C.F.R. § 404.1520(a); 20 C.F.R. § 416.920(a). The claimant bears the initial burden of demonstrating a medically determinable impairment that prevents him or her from doing past relevant work. 20 C.F.R. § 404.1512(a); 20 C.F.R. § 416.912(a). Once the claimant has established at step four that he or she cannot do past relevant work, the burden then shifts to the Commissioner at step five to show that jobs exist in significant numbers in the national economy that the claimant could perform that are consistent with his or her RFC, age, education, and past work experience. 20 C.F.R. § 404.1512(f); 20 C.F.R. § 416.912(f).

In reviewing the Commissioner's final decision denying a claimant's application for benefits, the Court's review is limited to determining whether the findings of the final decision-maker are supported by substantial evidence in the record. See 42 U.S.C. § 1383(c)(3) (incorporating 42 U.S.C. § 405(g) by reference); Johnson v. Comm'r of Soc. Sec., 529 F.3d 198, 200 (3d Cir. 2008); Ficca v. Astrue, 901 F.Supp.2d 533, 536 (M.D. Pa. 2012). Substantial evidence "does not mean a large or considerable amount of evidence, but rather such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Pierce v. Underwood, 487 U.S. 552, 565 (1988) (internal quotations omitted). Substantial evidence is less than a preponderance of the evidence but more than a mere scintilla. Richardson v. Perales, 402 U.S. 389, 401 (1971). A single piece of evidence is not substantial evidence if the ALJ ignores countervailing evidence or fails to resolve a conflict created by the evidence. Mason v. Shalala, 994 F.2d 1058, 1064 (3d Cir. 1993). In an adequately developed factual record, however, substantial evidence may be "something less than the weight of the evidence, and the possibility of drawing two inconsistent conclusions from the evidence does not prevent [the ALJ's decision] from being supported by substantial evidence." Consolo v. Fed. Maritime Comm'n, 383 U.S. 607, 620 (1966). "In determining if the Commissioner's decision is supported by substantial evidence the court must scrutinize the record as a whole." Leslie v. Barnhart, 304 F.Supp.2d 623, 627 (M.D. Pa. 2003). The question before the Court, therefore, is not whether Hansley is disabled, but whether the Commissioner's finding that Hansley is not disabled is supported by substantial evidence and was reached based upon a correct application of the relevant law. See Arnold v. Colvin, No. 3:12-CV-02417, 2014 WL 940205, at *1 (M.D. Pa. Mar. 11, 2014) ("[I]t has been held that an ALJ's errors of law denote a lack of substantial evidence."); Burton v. Schweiker, 512 F.Supp. 913, 914 (W.D. Pa. 1981) ("The [Commissioner]'s determination as to the status of a claim requires the correct application of the law to the facts."); see also Wright v. Sullivan, 900 F.2d 675, 678 (3d Cir. 1990) (noting that the scope of review on legal matters is plenary); Ficca v. Astrue, 901 F.Supp.2d 533, 536 (M.D. Pa. 2012) ("[T]he court has plenary review of all legal issues decided by the Commissioner.").

IV. DISCUSSION

Hansley raises three points of error in his brief. He argues that the ALJ erred: in finding standing/walking limitations contradicted by a treating physician and two agency experts; by failing to realize that the RFC found falls below two exertional levels, and; in his credibility analysis by failing to find Hansley credible based on his stellar work history. (Doc. 12, at 4).

A. THE ALJ ERRED IN THEIR EVALUATION OF OPINION EVIDENCE

Hansley argues that the ALJ erred by crediting the opinion offered by a State agency examining physician over the opinions of Hansley's treating physician and two later State agency opinions. (Doc. 12, at 5-6). He argues that the standing/walking restrictions identified in the RFC, based on the examining agency physician's opinion, overstate his abilities as reflected in the other three opinions afforded lesser deference. (Doc. 12, at 8). He continues, stating the ALJ: erred in choosing this opinion over three other opinions; fails to properly identify good reasons for discounting Hansley's treating source; offers facts in support that are inconsistent with the record, and; improperly credited an opinion rendered without the benefit of the entire record. (Doc. 12, at 8-13).

The first of these opinions — that of consultative examiner Dr. A. Cuozzo — was crafted August 3, 2012, in conjunction with a separate disability proceeding that Hansley abandoned before filing the instant action. (Doc. 8-12, at 21-31). In the relevant portion of his opinion, Dr. Cuozzo opined that Hansley could stand and walk six hours or more in an eight-hour workday. (Doc. 8-12, at 23).

The second opinion comes from the current disability application. The opinion is authored by Dr. Ryan Deblis, who examined Hansley on September 14, 2013. (Doc. 8-7, at 62). Dr. Deblis opined that Hansley could stand four hours at one time, walk two hours at one time, stand two hours in an eight-hour workday, and walk three hours in an eight-hour workday. (Doc. 8-7, at 69). In the narrative portion of his opinion, Dr. Deblis opined that Hansley would be able to stand two hours in an eight-hour workday and walk about two hours in an eight-hour workday. (Doc. 8-7, at 66).

On September 26, 2013, Dr. Leo Potera evaluated Hansley's file, including the opinion of Dr. Deblis but not Dr. Cuozzo, and authored a corresponding opinion of his own. Dr. Potera, who did not examine Hansley personally, opined that Hansley could stand/walk for four hours in an eight-hour workday with normal breaks. (Doc. 8-3, at 26).

The last opinion cited is that of Hansley's treating physician Dr. Lorna B. Stuart, who saw Hansley "intermittently" beginning in August 2012 up until her opinion dated July 1, 2013. (Doc. 8-7, at 14). Dr. Stuart did not make specific durational findings on Hansley's ability to stand/walk during the workday. (Doc. 8-7, at 14). Instead, she opined that "Hansley is unable to do any job which requires much sitting/standing/walking secondary to his weight." (Doc. 8-7, at 14). She stated however that "[d]esk work would be possible." (Doc. 8-7, at 14).

The ALJ summarized and afforded weight as follows:

[t]he undersigned has assigned great weight to the opinions of the consultative examiners, Dr. A. Cuozzo and Dr. Ryan Deblis, who performed physical evaluations in August 2012 and September 2013, respectively, at the request of the Bureau of Disability Determination in conjunction with the claimant's disability application (Exhibits B13F and B5F). Both physicians noted that the claimant's motor power was full in bilateral lower extremities and that there were no reflex or sensory deficits, with no atrophy upon physical examination. In fact, the claimant's ability to sit, bend, stand, walk, or lift was limited only by his obesity. Both physicians also indicated that the claimant could lift/carry at least 20 pounds occasionally, although Dr. Deblis indicated that the claimant was limited to a total of 4 or 5 hours standing/walking rather than the 6 hours postulated by Dr. Cuozzo (Exhibits B5F/10 and B13F/5). The undersigned finds that the 5-hour limitation imposed by Dr. Deblis is unsupported by any clinical evidence and has therefore give greater weight to Dr. Cuozzo's opinion since there are no clinical findings suggesting such limitation. Their opinions are generally consistent with that of the State Agency Medical Consultant who reviewed the file at a lower level of adjudication and concluded that the claimant was able to lift/carry ten pound frequently and twenty pounds occasionally and could stand/walk for up to four hours in an eight-hour workday with occasional posturals (Exhibit B5A). This opinion has been afforded less weight than the opinion of Dr. Cuozzo since the standing limitations are simply not consistent with all evidence of record, including recent evidence indicating that the claimant has lost fifty pounds over two years and is essentially asymptomatic with respect to ischemic heart disease as noted above. Very little weight has been assigned to the opinion of Dr. Stuart who recommended that the claimant be confined to a "desk job" since her opinion is inconsistent with the other substantial evidence of record and has no clinical findings which would support such a limitation (Exhibit B3F). (Doc. 8-2, at 31).

The mere fact that an ALJ credits a non-treating source over a treating one, while not preferred, is not error without more. It is well established that the opinion of a treating source is afforded controlling weight where well-supported by objective medical evidence and not inconsistent with substantial evidence in the record. See 20 C.F.R. § 404.1527; Morales v. Apfel, 225 F.3d 310, 316 (3d Cir. 2000); Dunkle v. Comm'r of Soc. Sec., 829 F.Supp.2d 307, 317 (W.D. Pa. 2011) ("A cardinal principle guiding disability eligibility determinations is that the ALJ accord treating physicians' reports great weight, especially `when their opinions reflect expert judgment based on a continuing observation of the patient's condition over a prolonged period of time.'"). Where a conflict exists between a treating source and another medical source, an ALJ may accept, reject, or weigh each opinion, so long as "good reasons" are provided for doing so. 20 C.F.R. § 404.1527(c)(2). It is the duty of the ALJ to explain the rationale for the weight afforded. Plummer v. Apfel, 186 F.3d 422, 429 (3d Cir. 1999). The purpose of this is to allow for meaningful judicial review. Burnett v. Comm'r Soc. Sec. Admin., 220 F.3d 112, 119 (3d Cir. 2000). Hansley's challenge is not the fact that a non-treating source received more weight than a treating source, but the manner in which weight was afforded.

The Court first considers whether Hansley's treating physician was entitled to controlling or at least more significant weight. As stated above, the ALJ afforded very little weight to the opinion of Dr. Stuart because of inconsistency with the record and a lack of clinical findings to support her opinion. (Doc. 8-2, at 31). Dr. Stuart's opinion contains a one-page summary of Hansley's visits at the Clinic over the prior year, as well as a diabetes flow sheet from an unknown source and date and two pages of bloodwork results from Hansley's visit two months prior. (Doc. 8-7, at 15-17). Dr. Stuart summarized the treatment history as spanning four prior visits, without discussion of ongoing or prescribed treatment regimens. (Doc. 8-7, at 14). Dr. Stuart recorded Hansley's weight (ranging from 326 in August 2012, down to 311 in May 2013, and back up to 317 in June 2013), blood pressure (150/101, 120/88, and 140/84 across the same), and blood sugar (>500 on May 2, 2013; 264-408 on May 9, 2013). (Doc. 8-7, at 14).

The ALJ's conclusions that limited the weight of Dr. Stuart's opinion are within the permissible bounds of the Regulations. Dr. Stuart opined that Hansley was could not sit/stand/walk "much" due to his weight, however the extent of "much" leaves much to the imagination. No other source found significant sitting restrictions, nor is it clear whether the four to five hour limitations on standing/walking would be considered much and therefore inconsistent with Dr. Stuart's opinion. Further, Hansley testified that in 2012, when he was at his heaviest over the course of his visits with Dr. Stuart, he remained able to work as a CDL driver. (Doc. 8-2, at 45). This directly contradicts Dr. Stuart's opinion that Hansley's weight precludes any work requiring significant sitting due to his weight, consistent with her opinion that he would be limited to a desk job. In the year following this visit Hansley's weight decreased slightly. Thus, the weight afforded to treating source Dr. Stuart was permissibly found to be below a controlling standard.

Doubt remains as to the appropriateness of affording greater weight to examining source Dr. Cuozzo over subsequent opinions authored by a treating source, examining source, and non-treating, non-examining source. Under SSR 96-6p, a State agency medical consultant's opinion may be:

entitled to greater weight than the opinions of treating or examining sources. For example, the opinion of a State agency medical or psychological consultant or other program physician or psychologist may be entitled to greater weight than a treating sources medical opinion if the State agency medical or [psychological] consultant's opinion is based on a review of a complete case record that includes a medical report from a specialist in the individual's particular impairment which provides more detailed and comprehensive information than what was available to the individual's treating source. SSR 96-6p.

The ALJ credited Dr. Cuozzo's opinion over the others in the record because the "standing limitations are simply not consistent with all evidence of record, including recent evidence indicating that the claimant has lost fifty pounds over two years and is essentially asymptomatic with respect to ischemic heart disease[.]" (Doc. 8-2, at 31).

The Plaintiff states that the ALJ's finding on Hansley's weight loss of fifty pounds over the two years preceding the ALJ's opinion is simply "untrue." (Doc. 12, at 12). The Plaintiff notes that in April of 2013 — two years and three months before the ALJ's opinion — Hansley weighed 315 pounds.2 (Doc. 12, at 12; Doc. 8-9, at 32). At the disability hearing, Hansley testified that he weighed about 300 lbs. (Doc. 8-2, at 43). "[E]ven at his heaviest weight on record, 342 pounds on January 6, 2011, Plaintiff was only 40 pounds away from his present weight." (Doc. 12, at 13; Doc. 8-13, at 10). The Court has not found evidence corroborating the weight loss articulated by the ALJ. On the date of Dr. Deblis' opinion — 22 months before the ALJ's decision — Hansley weighed 314 pounds; a weight consistent with the date of Dr. Cuozzo's opinion. (Doc. 8-7, at 64). In February of 2015, one month before the hearing and five months before the ALJ's decision, Hansley weighed 302 pounds. (Doc. 8-25, at 3). Thus, over the two years before the decision, Hansley appeared to lose only around 15 pounds as opposed to the fifty stated by the ALJ. The only reference to fifty pounds of weight loss appears to relate to a five year period beginning in 2010. (Doc. 8-25, at 7, 21). Thus, the weight loss justification for affording greater weight to Dr. Cuozzo's opinion appears belied by the evidence of the record.

Were that the only issue, the Court may consider it to be harmless error. However, the ALJ also stated that Hansley was essentially asymptomatic with respect to ischemic heart disease. (Doc. 8-2, at 31). Ischemic heart disease is a "disease of the heart marked by a deficient supply of blood to the myocardium (the muscular walls of the heart). The most common cause of this disease is disease of the coronary arteries, usually atherosclerosis." J.E. SCHMIDT, ATTORNEYS' DICTIONARY OF MEDICINE AND WORD FINDER I-209 (3rd ed. 2008). Ischemic heart disease may present itself in several forms or syndromes, depending on the rate at which the coronary arteries became obstructed and on the extent of the obstruction. There are four types: (1) angina pectoris; (2) myocardial infarction; (3) chronic form of ischemic heart disease; and (4) sudden death. J.E. SCHMIDT, ATTORNEYS' DICTIONARY OF MEDICINE AND WORD FINDER I-209 (3rd ed. 2008).

Hansley testified that he had been to the emergency room twice in 2015 before the March hearing, and five times the year prior, mostly due to feeling the onset of symptoms from his heart condition. (Doc. 8-2, at 52). On November 29, 2012, Hansley saw Dr. Paul Casey of the Cardiology Consultants of Philadelphia, P.C., for a follow-up for atypical chest pain, coronary artery disease, hyperlipidemia, and morbid obesity. (Doc. 8-25, at 32). At this visit, occurring after three source opinions in this matter including Dr. Cuozzo's, Dr. Casey stated that there was no evidence for any active ischemia. (Doc. 8-25, at 32). Hansley returned to the practice in March and April of 2014. (Doc. 8-25, at 29). During the April visit, Dr. Casey again noted no symptoms of active ischemia. (Doc. 8-25, at 30). A June visit with Dr. Casey repeated the same findings. (Doc. 8-25, at 27). These findings support the ALJ's conclusion that Hansley was asymptomatic.

However on November 12, 2014, Hansley saw Dr. Gentry G. King for chest pain. (Doc. 8-25, at 21). While unclear on the relationship of the recurring chest pain to the stents placed in 2010, Dr. King discussed the option of a cardiac catheterization; the same procedure leading to the stents in 2010. (Doc. 8-25, at 21-23). Hansley underwent the procedure, which revealed "a critical lesion in a bifurcating circumflex marginal branch." (Doc. 8-25, at 11). Treatment notes from Dr. Casey dated February 25, 2015, reflect that Hansley had a critical lesion in the distal main circumflex which was dilated and stented; consistent with Hansley's testimony at the hearing that he had received another stent just months before the hearing. (Doc. 8-25, at 2; Doc. 8-2, at 49).

Requiring surgical intervention for the placement of a new stent due to chronic heart problems hardly supports the ALJ's conclusion that Hansley was "essentially asymptomatic." Both of the reasons offered by the ALJ for affording greater weight to the opinion of Dr. Cuozzo — weight loss and the asymptomatic nature of Hansley's heart condition — both appear unsupported by objective evidence.

The Court thus finds error in the weight afforded to medical source opinions. Under SSR 96-6p, greater weight may be afforded to the medical consultant if, for example, the "consultant's opinion is based on a review of a complete case record that includes a medical report from a specialist in the individual's particular impairment which provides more detailed and comprehensive information than what was available to the individual's treating source." SSR 96-6p. The necessity of surgical intervention and two years of treatment notes are both particularly relevant considerations for a State agency medical opinion. Dr. Cuozzo had neither on the date his opinion was rendered. Dr. Cuozzo did not have the benefit of the three subsequently rendered medical opinions in this case. While there is no indication that Dr. Cuozzo did not have all the available information at the time, it cannot be stated that Dr. Cuozzo's opinion was based on the "complete case record" at the time of the ALJ's decision. Given the changes over the course of the intervening years, it was paramount to consider Hansley's conditional change, including the need for an additional stent in his heart, which may have affected Dr. Cuozzo's findings.

Based on a review of the ALJ's decision and supporting medical evidence, substantial evidence does not support the weight afforded to the four medical opinions. The rationale cited by the ALJ for affording great weight to the State agency medical consultant is specifically contradicted by the evidence itself, and the completeness of the examining physician changed over the nearly three years elapsing between examination and the date of the decision. Accordingly, the weight afforded runs afoul of the policy interpretation outlined in SSR 96-6p. As a result, the decision should be VACATED.

V. REMEDY

The Court has authority to affirm, modify or reverse the Commissioner's decision "with or without remanding the case for rehearing." 42 U.S.C. § 405(g); Melkonyan v. Sullivan, 501 U.S. 89, 100-01 (1991). However, the Third Circuit has advised that benefits should only be awarded where "the administrative record of the case has been fully developed and when substantial evidence in the record as a whole indicates that the claimant is disabled and entitled to benefits." Morales v. Apfel, 225 F.3d 310, 320 (3d Cir. 2000). See generally Fla. Power & Light Co. v. Lorion, 470 U.S. 729, 744 (1985) ( "[T]he proper course, except in rare circumstances, is to remand to the agency for additional investigation or explanation."). Because the Court concludes that the ALJ erred in the weight afforded to opinion evidence, the undersigned United States Magistrate Judge respectfully recommends that the decision of the Commissioner be VACATED and that the case be CLOSED.

VI. RECOMMENDATION

Based on the foregoing, it is recommended that the Commissioner's decision be VACATED, and that the case be REMANDED to the Commissioner to fully develop the record, conduct a new administrative hearing, and appropriately evaluate the evidence pursuant to sentence four of 42 U.S.C. § 405(g). It is further recommended that the Clerk of Court be directed to CLOSE this case.

NOTICE

NOTICE IS HEREBY GIVEN that the undersigned has entered the foregoing Report and Recommendation dated February 23, 2018.

Any party may obtain a review of the Report and Recommendation pursuant to Rule 72.3, which provides:

Any party may object to a magistrate judge's proposed findings, recommendations or report addressing a motion or matter described in 28 U.S.C. § 636(b)(1)(B) or making a recommendation for the disposition of a prisoner case or a habeas corpus petition within fourteen (14) days after being served with a copy thereof. Such party shall file with the clerk of court, and serve on the magistrate judge and all parties, written objections which shall specifically identify the portions of the proposed findings, recommendations or report to which objection is made and the basis for such objections. The briefing requirements set forth in Local Rule 72.2 shall apply. A judge shall make a de novo determination of those portions of the report or specified proposed findings or recommendations to which objection is made and may accept, reject, or modify, in whole or in part, the findings or recommendations made by the magistrate judge. The judge, however, need conduct a new hearing only in his or her discretion or where required by law, and may consider the record developed before the magistrate judge, making his or her own determination on the basis of that record. The judge may also receive further evidence, recall witnesses or recommit the matter to the magistrate judge with instructions.

FootNotes


1. Per 20 C.F.R. § 404.1563, a person aged 49 is considered a "younger person" under the Regulations while a person aged 50 is considered a "person closely approaching advanced age." Age, as a vocational factor, affects the determinations at step five of the sequential analysis process on whether a claimant has the ability to adjust to other work.
2. In the document cited, Hansley's weight is noted as 143 kg, which converts to 315.261 lbs.
Source:  Leagle

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