MICHAEL F. URBANSKI, District Judge.
This social security disability appeal is before the court for review of the Supplemental Report and Recommendation issued in this case by the magistrate judge on April 10, 2012. For the reasons set forth below, the Supplemental Report and Recommendation is
This matter was referred to the magistrate judge for proposed findings of fact and recommendations for disposition pursuant to 28 U.S.C. § 636(b)(1)(B) on June 9, 2011. The parties filed cross motions for summary judgment and supporting memoranda and the magistrate judge issued his Report and Recommendation on November 17, 2011. By Order dated April 3, 2012, the court referred this matter back to the magistrate judge for an assessment of the administrative law judge's ("ALJ") conclusion at step five of the sequential evaluation process. In a Supplemental Report and Recommendation issued April 10, 2012, the magistrate judge recommended once again that this case be remanded to the Commissioner pursuant to sentence four of 42 U.S.C. § 405(g) for further consideration. According to the magistrate judge, remand is necessary because the ALJ did not properly consider plaintiffs osteoporosis which caused work-related limitations. The magistrate judge placed significant emphasis on the medical report prepared by the consultative medical examiner, Christopher Newell, M.D., who found that plaintiff experienced postural limitations caused by the osteoporosis in her spine. The magistrate judge noted that the record reveals that the limitations caused by plaintiffs osteoporosis are more than minimal and significantly limit her ability to perform work activities. The magistrate judge recommended that the case be remanded to the Commissioner to appropriately consider plaintiffs osteoporosis.
Under 28 U.S.C. § 636(b)(1), the "court may accept, reject, or modify, in whole or in part, the findings and recommendations made by the magistrate judge." Federal Rule of Civil Procedure 72(b) provides the parties with an opportunity to file written objections to the proposed findings and recommendations, but neither party filed objections in this case to either the November 17, 2011 Report and Recommendation or to the April 10, 2012 Supplemental Report and Recommendation. Rule 72(b)(3) provides that the" district judge must determine de
474 U.S. at 154. Thus, even absent an objection, the court retains the ability to review
Having carefully reviewed the administrative record in this case, the court finds that the Supplemental Report and Recommendation should be adopted and the case remanded to the Commissioner for the following three reasons.
First, it is clear from plaintiffs treatment records that she suffers from severe osteoporosis, and this condition needs to be thoroughly evaluated by the Commissioner on remand. Plaintiffs medical records repeatedly refer to her osteoporosis. Each of the state agency physician reports indicate "[t]he medical evidence establishes medically determinable impairments of Osteoporosis and degenerative back disorder." (Administrative Record "R." at 353, 375, 394.) Plaintiffs treating physician ordered a DEXA bone densitometry
Second, this case is unusual in that there are conflicting opinions by multiple state agency physicians as to plaintiffs residual functional capacity. On September 11, 2007, Dr. R.S. Kadian concluded based on a review of plaintiff's medical records that plaintiff was capable of working at the light level of exertion. (R. 347-52.) Three months later, on December 14, 2007, Dr. Syed Hassan disagreed, finding that upon review of plaintiff's medical records that she was capable of working at the sedentary level with additional reaching and handling limitations. (R. 370-75.) Just four days later, Dr. William Amos, at the request of the SSA examiner, weighed in and reaffirmed Dr. Kadian's earlier residual functional capacity evaluation of light work with an additional limitation of no overhead lifting. (R. 377-78.)
The Commissioner then took the additional step of requesting that the Virginia Department of Rehabilitative Services perform a consultative examination. Dr. Christopher Newell examined plaintiff on January 8, 2008. Dr. Newell's examination report noted plaintiffs history of osteoporosis, osteoarthritis, chronic daily headaches and fibromyalgia. The report also noted a July 2007 lumbar MRI showing diffuse lumbar spondylosis and the result of a DEXA scan indicating osteoporosis in the lumbar spine and wrist. On examination, Dr. Newell found plaintiff to "have trigger points in the suboccipital, trapezius, SI, trochanteric, medial knee, anterior chest, medial elbow areas and over the bilateral forearm areas. This is consistent with fibromyalgia. I count 18/18 trigger points." (R. 385.) Dr. Newell's note continued:
(R. 385.) Based on his examination, Dr. Newell limited plaintiff to 2-4 hours of standing and walking in an 8 hour workday. He limited her sitting to 4-6 hours. He limited her lifting and carrying to 10 pounds frequently and 10-15 pounds occasionally. Dr. Newell included a postural limitation with respect to bending, stooping and squatting due to her osteoporosis in her spine. He limited her to occasional reaching, no overhead reaching and occasional handling, feeling, grasping and fingering. Finally, Dr. Newell opined that plaintiff could not do repetitive manipulations on a frequent basis due to her DEXA osteoporosis score. (R. 385-86.) Dr. Newell's report generally confirms the residual functional capacity found by Dr. Hassan.
Seven days later, on January 16, 2008, Dr. Amos signed another RFC form stating plaintiff had the capacity to perform light work. In the narrative portion of this RFC form, Dr. Amos is critical of Dr. Newell's evaluation, concluding that "[s]ome of the opinions cited in the report are viewed as an overestimate of the severity of the claimant's functional restrictions," (R. 394), and he suggests that Dr. Newell's report is "only a snapshot of the claimant's functioning and is an overestimate of the severity of her limitations." (R. 395.) At the end of the day, therefore, there are two state agency doctors who concluded that plaintiff could do light work and two, including the only examining doctor, who found that she is limited to less than sedentary work.
The ALJ "adopted the assessments of DDS Drs. Kadian and Amos because they are consistent with the other credible evidence of record," and concluded that "the opinions of Drs. Hassan and Newell are not supported by the weight of the evidence." (R. 88.) Given plaintiffs well documented history of osteoporosis, lumbar degenerative disc disease and migraine headaches throughout her treatment records, it is difficult to understand how the ALJ could have reached this conclusion. Certainly, the ALJ's decision provides no reasoned basis for accepting the opinions of Drs. Kadian and Amos over that of Dr. Newell, who actually examined plaintiff, and Dr. Hassan.
Given the dueling assessments of the state agency physicians, it is difficult as well to understand the ease with which the ALJ dismissed the opinions of plaintiff's long time treating physician, Dr. Danny L. Perry. The ALJ rejected Dr. Perry's disability opinions, dismissing his treatment notes as "boilerplate," (R. 79, 86), and speculating that his disability opinions were motivated by an "advocacy role." (R. 82.) In sum, in deciding that plaintiff could still perform light work, the ALJ adopted the opinions of two state agency doctors who never saw plaintiff over the views of three other doctors, one of whom examined plaintiff and one of whom treated her for several years. The ALJ's decision contains no persuasive reason for rejecting the views of the examining and treating physicians in this case, especially where those opinions are based on clinical judgments and objective reports such as the DEXA study and a 2007 lumbar MRI. Under these circumstances, the court is compelled to conclude that the ALJ's decision to assign a residual functional capacity at the light work level runs afoul of the treating physician rule and is not supported by substantial evidence.
Finally, the Appeals Council declined to consider the medical records submitted to it, concluding that they related to a period after the ALJ's decision on December 18, 2009. While that is true, the medical records, including a new lumbar spine MRI dated July 22, 2010, certainly reflect continuation of the chronic, degenerative issues plaintiff has struggled with for years before the ALJ's decision. As such, they should be considered by the Commissioner on remand.
For these reasons, the Supplemental Report and Recommendation dated April 10, 2012 is
An appropriate Order will be entered.