Opinion
6:20-CV-06713 EAW
2022-03-16
JAMES H., Plaintiff, v. COMMISSIONER OF SOCIAL SECURITY, Defendant.
Scot G. Miller, Coughlin & Gerhart, LLP, Binghamton, NY, for Plaintiff. Graham Morrison, Social Security Administration Office of General Counsel, New York, NY, Kathryn L. Smith, U.S. Attorney's Office, Rochester, NY, for Defendant.
Scot G. Miller, Coughlin & Gerhart, LLP, Binghamton, NY, for Plaintiff.
Graham Morrison, Social Security Administration Office of General Counsel, New York, NY, Kathryn L. Smith, U.S. Attorney's Office, Rochester, NY, for Defendant.
DECISION AND ORDER
ELIZABETH A. WOLFORD, Chief Judge
INTRODUCTION
Represented by counsel, Plaintiff James H. ("Plaintiff") brings this action pursuant to Title XVI of the Social Security Act (the "Act"), seeking review of the final decision of the Commissioner of Social Security (the "Commissioner," or "Defendant") denying his application for supplemental security income ("SSI"). (Dkt. 1). This Court has jurisdiction over the matter pursuant to 42 U.S.C. § 405(g). Presently before the Court are the parties’ cross-motions for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure. (Dkt. 14; Dkt. 15). For the reasons discussed below, Plaintiff's motion (Dkt. 14) is granted to the extent that the matter is remanded for further administrative proceedings, and the Commissioner's motion (Dkt. 15) is denied.
BACKGROUND
Plaintiff protectively filed his application for SSI on September 12, 2016. (Dkt. 13 at 23, 65). In his application, Plaintiff alleged disability beginning January 1, 2005, due to the following impairments: schizophrenia, paranoid type; post-traumatic stress disorder ; dysthymia ; high blood pressure ; asthma ; arthritis ; thyroid; anxiety; and mood disorder. (Id. at 23, 52-53). Plaintiff's application was initially denied on January 10, 2017. (Id. at 23, 69-74). A video hearing was held before administrative law judge ("ALJ") Stanley K. Chin on October 11, 2018. (Id. at 23, 36-51). Plaintiff appeared in Horseheads, New York, and the ALJ presided over the hearing from Baltimore, Maryland. (Id. ). On November 20, 2018, the ALJ issued an unfavorable decision. (Id. at 20-31). Plaintiff requested Appeals Council review; his request was denied on August 13, 2020, making the ALJ's determination the Commissioner's final decision. (Id. at 5-7). This action followed.
When referencing the page number(s) of docket citations in this Decision and Order, the Court will cite to the CM/ECF-generated page numbers that appear in the upper righthand corner of each document.
LEGAL STANDARD
I. District Court Review
"In reviewing a final decision of the [Social Security Administration ("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." Talavera v. Astrue , 697 F.3d 145, 151 (2d Cir. 2012) (quotation omitted); see also 42 U.S.C. § 405(g). The Act holds that a decision by the Commissioner is "conclusive" if it is supported by substantial evidence. 42 U.S.C. § 405(g). "Substantial evidence means more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Moran v. Astrue , 569 F.3d 108, 112 (2d Cir. 2009) (quotation omitted). It is not the Court's function to "determine de novo whether [the claimant] is disabled." Schaal v. Apfel , 134 F.3d 496, 501 (2d Cir. 1998) (quotation omitted); see also Wagner v. Sec'y of Health & Human Servs. , 906 F.2d 856, 860 (2d Cir. 1990) (holding that review of the Secretary's decision is not de novo and that the Secretary's findings are conclusive if supported by substantial evidence). However, "[t]he deferential standard of review for substantial evidence does not apply to the Commissioner's conclusions of law." Byam v. Barnhart , 336 F.3d 172, 179 (2d Cir. 2003) (citing Townley v. Heckler , 748 F.2d 109, 112 (2d Cir. 1984) ).
II. Disability Determination
An ALJ follows a five-step sequential evaluation to determine whether a claimant is disabled within the meaning of the Act. See Bowen v. City of New York , 476 U.S. 467, 470-71, 106 S.Ct. 2022, 90 L.Ed.2d 462 (1986). At step one, the ALJ determines whether the claimant is engaged in substantial gainful work activity. See 20 C.F.R. § 416.920(b). If so, the claimant is not disabled. If not, the ALJ proceeds to step two and determines whether the claimant has an impairment, or combination of impairments, that is "severe" within the meaning of the Act, in that it imposes significant restrictions on the claimant's ability to perform basic work activities. Id. § 416.920(c). If the claimant does not have a severe impairment or combination of impairments, the analysis concludes with a finding of "not disabled." If the claimant does have at least one severe impairment, the ALJ continues to step three.
At step three, the ALJ examines whether a claimant's impairment meets or medically equals the criteria of a listed impairment in Appendix 1 of Subpart P of Regulation No. 4 (the "Listings"). Id. § 416.920(d). If the impairment meets or medically equals the criteria of a Listing and meets the durational requirement (id. § 416.909), the claimant is disabled. If not, the ALJ determines the claimant's residual functional capacity ("RFC"), which is the ability to perform physical or mental work activities on a sustained basis, notwithstanding limitations for the collective impairments. See id. § 416.920(e).
The ALJ then proceeds to step four and determines whether the claimant's RFC permits the claimant to perform the requirements of his or her past relevant work. Id. § 416.920(f). If the claimant can perform such requirements, then he or she is not disabled. If he or she cannot, the analysis proceeds to the fifth and final step, wherein the burden shifts to the Commissioner to show that the claimant is not disabled. Id. § 416.920(g). To do so, the Commissioner must present evidence to demonstrate that the claimant "retains a residual functional capacity to perform alternative substantial gainful work which exists in the national economy" in light of the claimant's age, education, and work experience. Rosa v. Callahan , 168 F.3d 72, 77 (2d Cir. 1999) (quotation omitted).
DISCUSSION
I. The ALJ's Decision
In determining whether Plaintiff was disabled, the ALJ applied the five-step sequential evaluation set forth in 20 C.F.R. § 416.920. At step one, the ALJ determined that Plaintiff had not engaged in substantial gainful work activity since September 12, 2016, the application date. (Dkt. 13 at 25).
At step two, the ALJ found that Plaintiff suffered from the severe impairments of: "anxiety, depression, conduct disorder, adjustment disorder, asthma, tobacco use disorder, and obesity." (Id. at 25). The ALJ further found that Plaintiff's medically determinable impairments of hypertension, hypothyroidism, hyperlipidemia, and alleged arthritis were non-severe. (Id. ).
At step three, the ALJ found that Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of any Listing. (Id. at 26). The ALJ particularly considered the criteria of Listings 3.00, 12.04, and 12.06 in reaching his conclusion. (Id. at 26-27).
Before proceeding to step four, the ALJ determined that Plaintiff retained the RFC to perform medium work as defined in 20 C.F.R. § 416.967(c), with the additional limitations that Plaintiff:
must frequently avoid exposure to environmental irritants such as fumes, odors, dusts, gases, and poorly ventilated areas. He can perform short and simple routine instructions and tasks performed in a work environment free of fast-paced production requirements involving only simple work related decisions
and infrequent and gradual work place changes. He can tolerate occasional interaction with coworkers, supervisors, and the public.
(Id. at 27). At step four, the ALJ found that Plaintiff was unable to perform any past relevant work. (Id. at 30).
At step five, the ALJ relied on the testimony of a vocational expert ("VE") to conclude that, considering Plaintiff's age, education, work experience, and RFC, there were jobs that exist in significant numbers in the national economy that Plaintiff could perform, including the representative occupations of hospital cleaner, warehouse worker, and laundry laborer. (Id. at 30-31). Accordingly, the ALJ found that Plaintiff was not disabled as defined in the Act. (Id. at 31).
II. Remand of this Matter for Further Proceedings is Necessary
Plaintiff asks the Court to remand this matter to the Commissioner, arguing (1) the Commissioner did not properly evaluate the medical evidence in the record, including because the ALJ did not properly assess the opinion offered by his treating psychiatrist John Deines, M.D., and the Appeals Council did not properly assess the opinion offered by Quinn David Olan Austin-Small, Ph.D., and (2) the decision is not supported by substantial evidence, including because the hypothetical question posed to the vocational expert did not account for all of Plaintiff's limitations, and the ALJ failed to develop the record. (Dkt. 14-1 at 2, 13-22). As further explained below, because the ALJ did not properly weigh the opinion offered by Dr. Deines, remand for further proceedings is necessary.
A. Weighing of Dr. Deines's Opinion
Plaintiff's first argument is that the ALJ failed to properly weigh the opinion evidence in the record. (Dkt. 14-1 at 13). In response, the Commissioner argues that the ALJ is free to choose between medical opinions, that Plaintiff seeks a mere re-weighing of the medical opinions in the record, and the ALJ properly weighed the opinion offered by Dr. Deines. (Dkt. 15-1 at 6).
In assessing a disability claim, an ALJ must consider and weigh the various medical opinions of record. Pursuant to the Commissioner's regulations:
the ALJ must consider various factors in deciding how much weight to give to any medical opinion in the record, regardless of its source, including: (i) the frequency of examination and the length, nature and extent of the treatment relationship; (ii) the evidence in support of the ... physician's opinion; (iii) the consistency of the opinion with the record as a whole; (iv) whether the opinion is from a specialist; and (v) other factors brought to the Social Security Administration's attention that tend to support or contradict the opinion.
Pike v. Colvin , No. 14-CV-159-JTC, 2015 WL 1280484, at *5 (W.D.N.Y. Mar. 20, 2015) (quotation and alterations omitted).
Because Plaintiff's claim was filed before March 27, 2017, the ALJ was required to apply the treating physician rule, under which a treating physician's opinion is entitled to "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] case record[.]" 20 C.F.R. § 404.1527(c)(2). Under the treating physician rule, if the ALJ declines to afford controlling weight to a treating physician's medical opinion, he or she "must consider various factors to determine how much weight to give to the opinion." Halloran v. Barnhart , 362 F.3d 28, 32 (2d Cir. 2004) (internal quotation marks omitted). An ALJ's failure to explicitly apply the requisite factors is a "procedural error." Estrella v. Berryhill , 925 F.3d 90, 96 (2d Cir. 2019) (quotation omitted). However, such error is harmless if "a searching review of the record" confirms "that the substance of the treating physician rule was not traversed." Id. (quotations omitted).
Whatever weight the ALJ assigns to the treating physician's opinion, he must "give good reasons in [his] notice of determination or decision for the weight [he gives to the] treating source's medical opinion." 20 C.F.R. § 404.1527(c)(2) ; see also Harris v. Colvin , 149 F. Supp. 3d 435, 441 (W.D.N.Y. 2016) ("A corollary to the treating physician rule is the so-called ‘good reasons rule,’ which is based on the regulations specifying that ‘the Commissioner "will always give good reasons’ " for the weight given to a treating source opinion." (quoting Halloran , 362 F.3d at 32 )). "Those good reasons must be supported by the evidence in the case record, and must be sufficiently specific...." Harris , 149 F. Supp. 3d at 441 (internal quotation marks omitted).
Finally, for mental health impairments—which are at issue in this case—the opinions offered by treating providers are "all the more important," given those impairments are "not susceptible to clear records such as x-rays or MRIs," and "depend almost exclusively on less discretely measurable factors, like what the patient says in consultations." Flynn v. Comm'r of Soc. Sec. , 729 F. App'x 119, 122 (2d Cir. 2018) ; see also Olejniczak v. Colvin , 180 F. Supp. 3d 224, 228 (W.D.N.Y. 2016) (explaining that "the treating physician rule is even more relevant in the context of mental disabilities, which by their nature are best diagnosed over time" (quotations and citation omitted)).
Dr. Deines began treating Plaintiff at least as early as August 2016. (Dkt. 13 at 405-11). On January 30, 2018, Dr. Deines completed a "Mental Residual Functional Capacity Questionnaire." (Id. at 502). Dr. Deines opined that Plaintiff was "seriously limited, but not precluded" (meaning that his "ability to function in this area is seriously limited and less than satisfactory, but not precluded in all circumstances") in his ability to maintain regular attendance and be punctual within customary, usually strict tolerances. (Id. ). Dr. Deines further found that Plaintiff was "unable to meet competitive standards" (meaning that he "cannot satisfactorily perform this activity independently, appropriately, effectively and on a sustained basis in a regular work setting"), in the following areas of mental functioning: maintain attention for two hour segment; sustain an ordinary routine without special supervision; work in coordination with or proximity to others without being unduly distracted; complete a normal workday and workweek without interruptions from psychologically based symptoms; accept instructions and respond appropriately to criticism from supervisors; get along with co-workers or peers without unduly distracting them or exhibiting behavioral extremes; and deal with normal work stress. (Id. ). Dr. Deines anticipated that, due to his impairments or treatment, Plaintiff would be absent from work more than four days per month. (Id. ).
The ALJ discussed the opinion offered by Dr. Deines in the written determination:
I considered the medical source statement from John Deines, M.D., the claimant's psychiatrist. This was a conclusory checkbox form suggesting marked restriction in most areas of function without articulating any rationale and including no description of the claimant's impairments or symptoms. These suggested restrictions were disproportionate to Dr. Deine's own treatment records. Those records generally
described the claimant as having questionable reliability with objective exams noting mood deficits, restlessness, and some mild memory impairments. Accordingly, I have given little weight to this opinion.
(Id. at 29 (citations omitted)).
The Court finds that the ALJ's evaluation of Dr. Deines's January 2018 opinion is not sufficient. While the ALJ acknowledged that Dr. Deines was Plaintiff's treating psychiatrist, he declined to discuss the specific functional limitations assessed by Dr. Deines and instead wholesale rejected the opinion, noting that it was completed on a "checkbox form." (Id. at 29). While the ALJ may consider the form of Dr. Deines's opinion, he may not reject the opinion "based on the naked fact that it was provided in a check-box form." Colgan v. Kijakazi , 22 F.4th 353, 361 (2d Cir. 2022). The only other reason offered by the ALJ for rejecting the limitations assessed by Dr. Deines is because they were "disproportionate" to his treatment records, which described "questionable reliability with objective exams noting mood deficits, restlessness, and some mild memory impairments." (Dkt. 13 at 29). However, the ALJ failed to explain why the information contained in these treatment records contradict Dr. Deines's assessed limitations, including those for maintaining attention, maintaining attendance, sustaining a routine, completing a normal workday, accepting instructions from supervisors, interacting with co-workers, and dealing with work stress, which are not necessarily contradicted by treatment records describing "questionable reliability with objective exams noting mood deficits, restlessness, and some mild memory impairments."
The ALJ's failure to address the limitations relating to Plaintiff's ability to maintain regular attendance and completing a normal workday is particularly problematic, given that the ALJ also failed to address Dr. Deines's opinion that Plaintiff would be absent from work for more than four days per month. See, e.g. , Lesterhuis v. Colvin , 805 F.3d 83, 88 (2d Cir. 2015) (remanding case because "nothing in the record contradicts [the treating physician's] conclusion about the number of days each month that [the plaintiff] is likely to be absent from work"); Rugless v. Comm'r of Soc. Sec. , 548 F. App'x 698, 700 (2d Cir. 2013) (remanding for "some explanation of why there was no discussion in the ALJ's decision of Dr. Carroll's opinion that appellant would have to miss more than four days per month, would require unscheduled ten to fifteen minute breaks on a daily basis, and would be off-task more than twenty percent of the workday because of his limitations"). The Court further notes that Dr. Deines's opinion relating to Plaintiff's ability to maintain regular attendance at work is consistent with the opinion offered by Amanda Slowik, Psy.D., the consultative examiner, who opined that Plaintiff's "ability to maintain a regular schedule and appropriately deal with stress is moderately to markedly limited." (Dkt. 13 at 329).
In response to Plaintiff's argument that the ALJ's evaluation of Dr. Deines's opinion was inadequate, the Commissioner argues that the ALJ discussed Dr. Deines's observations and treatment history in the written determination. (Dkt. 15-1 at 8). While the Court agrees that the ALJ cited to portions of Dr. Deines's treatment notes in the written determination (see, e.g. , Dkt. 13 at 28), those discussions provide no meaningful explanation as to why the ALJ found the notes contradicted the specific functional limitations assessed by Dr. Deines on January 30, 2018.
At the administrative hearing on October 11, 2018, the vocational expert testified that an individual absent from work three days per month would be unable to perform any job existing in the national economy. (See id. at 49-50). In other words, the ALJ would have found Plaintiff disabled had he credited Dr. Deines's opinion relating to absences. Accordingly, remand is required on this basis. On remand, the ALJ should discuss each of the specific functional limitations assessed by Dr. Deines, including by considering the various factors provided by the treating physician rule. Should the ALJ decline to adopt the limitations assessed by Dr. Deines, he must provide good reasons for his failure to do so, including by citing to specific evidence in the record supporting his determination.
B. Plaintiff's Remaining Arguments
As set forth above, Plaintiff has identified additional reasons why he contends the ALJ's decision was not supported by substantial evidence. However, because the Court has already determined, for the reasons previously discussed, that remand of this matter for further administrative proceedings is necessary, the Court declines to reach these issues. See, e.g., Bell v. Colvin , No. 5:15-CV-01160 (LEK), 2016 WL 7017395, at *10 (N.D.N.Y. Dec. 1, 2016) (declining to reach arguments "devoted to the question whether substantial evidence supports various determinations made by [the] ALJ" where the court had already determined remand was warranted); Morales v. Colvin , No. 13cv06844 (LGS) (DF), 2015 WL 13774790, at *23 (S.D.N.Y. Feb. 10, 2015) (the court need not reach additional arguments regarding the ALJ's factual determinations "given that the ALJ's analysis may change on these points upon remand"), adopted , 2015 WL 2137776 (S.D.N.Y. May 4, 2015).
CONCLUSION
For the foregoing reasons, Plaintiff's motion for judgment on the pleadings (Dkt. 14) is granted to the extent that the matter is remanded for further administrative proceedings, and the Commissioner's motion for judgment on the pleadings (Dkt. 15) is denied. The Clerk of Court is directed to enter judgment and close this case.
SO ORDERED.