Jackson v. Commissioner of Social Security
MEMORANDUM-DECISION AND ORDER: The Court hereby ORDERS that Plaintiff's # 15 motion for judgment on the pleadings is DENIED. The Court further ORDERS that Defendant's # 21 motion for judgment on the pleadings is GRANTED. The Court furth er ORDERS that the Commissioner's decision is AFFIRMED and Plaintiff's complaint is DISMISSED. The Court further ORDERS that the Clerk of the Court shall enter judgment in favor of Defendant and close this case. Signed by Senior Judge Frederick J. Scullin, Jr. on 2/10/2017. (nmk)
UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF NEW YORK
CARRIE L. JACKSON, a/k/a CARRIE L. DAVIS,
COMMISSIONER OF SOCIAL SECURITY,
LEGAL SERVICES OF CENTRAL
221 South Warren Street, Suite 300
Syracuse, New York 13202
Attorneys for Plaintiff
CHRISTOPHER J. CADIN, ESQ.
SOCIAL SECURITY ADMINISTRATION
OFFICE OF REGIONAL
GENERAL COUNSEL – REGION II
26 Federal Plaza – Room 3904
New York, New York 10278
Attorneys for Defendant
MICHELLE L. CHRIST, ESQ.
SCULLIN, Senior Judge
MEMORANDUM-DECISION AND ORDER
Plaintiff Carrie L. Jackson, a/k/a Carrie L. Davis, brought this action pursuant to the
Social Security Act, 42 U.S.C. § 405(g) (“Act”), seeking judicial review of a final decision of the
Commissioner of Social Security (the “Commissioner”), denying her application for benefits.
See generally Dkt. Nos. 1, 15. Pending before the Court are the parties’ cross-motions for
judgment on the pleadings under Rule 12(c) of the Federal Rules of Civil Procedure. See Dkt.
Nos. 15, 21.
II. PROCEDURAL HISTORY AND BACKGROUND
Plaintiff protectively applied for benefits on March 27, 2012, alleging disability as of
March 1, 2012. See Administrative Record (“AR”) at 123. The Social Security Administration
denied Plaintiff’s application on June 26, 2012. See id. at 62. Plaintiff filed a timely request for
a hearing on July 13, 2012. See id. at 98-99. A video hearing was held on June 18, 2013, before
Administrative Law Judge Marie Greener (“ALJ”). See id. at 18. On November 27, 2013, the
ALJ held a supplemental video hearing. See id. At this hearing, David A. Festa, an impartial
vocational expert, testified. See id. Attorney Cindy Domingue-Hendrickson represented Plaintiff
at both hearings. See id.
On February 19, 2014, the ALJ issued a written decision in which she made the following
findings “[a]fter careful consideration of the entire record . . . .”
1) Plaintiff had not “engaged in substantial gainful activity since March 27, 2012,
the application date.”
2) Plaintiff “has the following severe impairments: AC deformity; depression; and
3) Plaintiff “does not have an impairment or combination of impairments that
meets or medically equals the severity of one of the listed impairments in 20
CFR Part 404, Subpart P, Appendix 1.”
4) Plaintiff “has the residual functional capacity to perform unskilled light work
as defined in 20 CFR 416.967(b) with no overhead lifting, and performing low
stress work meaning routine daily tasks which do not significantly change in
pace or location on a daily basis; and tasks which do not require working in
conjunction or cooperation with others.”
5) “Considering [Plaintiff’s] age, education, work experience, and residual
functional capacity, there are jobs that exist in significant numbers in the
national economy that the claimant can perform.”
6) Plaintiff “has not been under a disability, as defined in the Social Security Act,
since March 27, 2012, the date the application was filed.”
See AR at 20-26 (citations omitted).
The ALJ’s decision became the Commissioner’s final decision on June 29, 2015, when
the Appeals Council of the Social Security Administration denied Plaintiff’s request for review.
See AR at 6-8. Plaintiff then commenced this action on September 2, 2015, filing a supporting
brief on June 16, 2016. See Dkt Nos. 1, 15. Defendant filed a response brief on August 29,
2016. See Dkt. No. 21.
In support of her motion, Plaintiff argues that the ALJ erred by not finding her
Muenke/Crouzon syndrome, carpal tunnel syndrome, and migraine headaches to be severe at
step two of the disability analysis. Moreover, Plaintiff argues that there is not substantial
evidence to support the ALJ’s findings with respect to her residual functional capacity (“RFC”).
In particular, Plaintiff argues that the ALJ erred by not finding in her RFC analysis that she is
limited to occasional reaching and lifting in all directions, not just overhead. Finally, Plaintiff
argues that the ALJ improperly weighed medical source opinions. See generally Dkt. No. 15,
A. Standard of review
Absent legal error, a court will uphold the Commissioner’s final determination if there is
substantial evidence to support it. See 42 U.S.C. § 405(g). The Supreme Court has defined
substantial evidence to mean “‘more than a mere scintilla’” of evidence and “‘such relevant
evidence as a reasonable mind might accept as adequate to support a conclusion.’” Richardson
v. Perales, 402 U.S. 389, 401 (1971) (quotation omitted). Accordingly, a reviewing court “‘may
not substitute [its] own judgment for that of the [Commissioner], even if [it] might justifiably
have reached a different result upon a de novo review.’” Cohen v. Comm’r of Soc. Sec., 643 F.
App’x 51, 52 (2d Cir. 2016) (summary order) (quoting Valente v. Sec’y of Health & Human
Servs., 733 F.2d 1037, 1041 (2d Cir. 1984)). In other words, “[t]he substantial evidence standard
means once an ALJ finds facts, [a reviewing court may] reject those facts ‘only if a reasonable
factfinder would have to conclude otherwise.’” Brault v. Soc. Sec. Admin., Comm’r, 683 F.3d
443, 448 (2d Cir. 2012) (quotation and other citation omitted).
To be eligible for benefits, a claimant must show that she suffers from a disability within
the meaning of the Act. The Act defines “disability” as an inability to engage in substantial
gainful activity (“SGA”) by reason of a medically determinable physical or mental impairment
that can be expected to cause death or last for at least twelve consecutive months. See 42 U.S.C.
§ 1382c(a)(3)(A). To determine if a claimant has sustained a disability within the meaning of the
Act, the ALJ follows a five-step process:
1) The ALJ first determines whether the claimant is engaged in SGA. See 20 C.F.R.
§§ 416.920(b), 416.972. If so, the claimant is not disabled. See 20 C.F.R.
2) If the claimant is not engaged in SGA, the ALJ determines if the claimant has a
severe impairment or combination of impairments. See 20 C.F.R. § 416.920(c). If
not, the claimant is not disabled. See id.
3) If the claimant has a severe impairment, the ALJ determines if the impairment
meets or equals an impairment found in the appendix to the regulations (the
“Listings”). If so, the claimant is disabled. See 20 C.F.R. § 416.920(d).
4) If the impairment does not meet the requirements of the Listings, the ALJ
determines if the claimant can do her past relevant work. See 20 C.F.R.
§ 416.920(e), (f). If so, the claimant is not disabled. See 20 C.F.R. § 416.920(f).
5) If the claimant cannot perform her past relevant work, the ALJ determines if she
can perform other work, in light of her RFC, age, education, and experience. See
20 C.F.R. § 416.920(f), (g). If so, then she is not disabled. See 20 C.F.R.
§ 416.920(g). A claimant is only entitled to receive benefits if she cannot perform
any alternative gainful activity. See id.
For this test, the burden of proof is on the claimant for the first four steps and on the
Commissioner for the fifth step if the analysis proceeds that far. See Balsamo v. Chater, 142
F.3d 75, 80 (2d Cir. 1998) (quotation omitted).
B. ALJ’s finding, at Step 2 of her analysis, that Plaintiff’s Muenke/Crouzon syndrome,
carpal tunnel syndrome, and migraine headaches were not severe impairments
At step two of the disability analysis, the ALJ must determine whether the claimant has a
severe impairment or combination of impairments. See 20 C.F.R. §§ 404.1520(c), 416.920(c).
In order to be severe, an impairment or combination of impairments must “significantly limit
your physical or mental ability to do basic work activities.” 20 C.F.R. § 404.1520(c). An
impairment or combination of impairments fails to meet this standard when the medical evidence
“establishes only a slight abnormality or a combination of slight abnormalities which would have
no more than a minimal effect on an individual’s ability to work . . . .” Social Security Ruling
(“SSR”) 85-28, 1985 WL 56856, *3 (1985). “[E]vidence about the functionally limiting effects
of an individual’s impairment(s) must be evaluated” and “symptom-related limitations and
restrictions must be considered at this step of the sequential evaluation process . . . .” SSR 96-3p,
1996 WL 374181, *2 (July 2, 1996). Furthermore, it is not error “when functional effects of
impairments erroneously determined to be non-severe at Step 2 are, nonetheless, fully considered
and factored into subsequent residual functional capacity assessments[.]” Snyder v. Colvin, No.
5:13-cv-585, 2014 WL 3107962, *5 (N.D.N.Y. July 8, 2014).
In this case, Plaintiff argues that the ALJ erroneously declined to find that her
Muenke/Crouzon syndrome, carpal tunnel syndrome (“CTS”), and migraine headaches
amounted to severe impairments. See Dkt. No. 15, Pl.’s Br., at 19-22. With respect to her
Muenke/Crouzon syndrome, she argues that the ALJ’s determination that her facial deformity
was corrected by surgery and now involves “barely minimal disfigurement” is contrary to the
record. See id. at 20; see also AR at 23. Furthermore, Plaintiff asserts that her Muenke/Crouzon
syndrome causes her depression and anxiety. See Dkt. No. 15 at 21.
Although Plaintiff’s Muenke/Crouzon syndrome may heighten her depression and
anxiety, it was not error for the ALJ to find that the Muenke/Crouzon syndrome did not
independently constitute a severe impairment. First of all, the ALJ considered Plaintiff’s
Muenke/Crouzon syndrome in relation to and as a cause of her depression and anxiety.
However, as the ALJ pointed out, “there is no indication that this condition causes her any workrelated limitations” on its own. See AR at 21. Plaintiff has failed to point to any evidence
suggesting how her Muenke/Crouzon syndrome is independently severe, or how it limits her
ability to work. Accordingly, the Court finds that there was substantial evidence in the record to
support the ALJ’s finding that Plaintiff’s Muenke/Crouzon syndrome had “no more than a
minimal effect” on her ability to work. 1 SSR 85-28, 1985 WL 56856, at *3.
Plaintiff also states that the ALJ erred in failing to list her CTS as a severe impairment.
See Dkt. No. 15 at 19. Plaintiff argues that the ALJ inappropriately discounted her CTS because
it was merely a clinical diagnosis without a referral. See id. at 19 n.12. Contrary to Plaintiff’s
position, the ALJ considered her complaints regarding her CTS but noted that the record
indicated that, after she initially complained of tingling in her hands in June 2013, she was
In any event, any error is harmless because the ALJ considered Plaintiff’s Muenke/Crouzon
syndrome and the psychological impact it had on her ability to function throughout the remainder
of her analysis and included commensurate limitations in Plaintiff’s RFC. See AR at 23; Snyder,
2014 WL 3107962, at *5.
prescribed medical braces and her symptoms were controlled with treatment. 2 See AR at 20. Dr.
Gooldy’s records show that the braces “help ‘very much,’” see id. at 663; and, by September 26,
2013, Plaintiff stated that she no longer felt numbness or tingling and only had pain “‘once in a
while,’” see id. at 672.
Additional records indicated that Plaintiff started to experience CTS symptoms again in
January 2014 and was referred for an EMG with Dr. Kim, see id. at 727, and that the results of
the EMG were negative, see id. at 730 (treatment date on February 4, 2014). This evidence,
which the Appeals Council considered, did “not alter the weight of the evidence so dramatically
as to require the Appeals Council to take the case.” Bushey v. Colvin, 552 F. App’x 97, 98 (2d
Cir. 2014) (summary order). Accordingly, the Court finds that there was substantial evidence in
the record to support the ALJ’s finding that Plaintiff’s CTS had “no more than a minimal effect”
on her ability to work. SSR 85-28, 1985 WL 56856, at *3.
Finally, with respect to migraine headaches, Plaintiff relies solely on her hearing
testimony to support her contention that her migraines are a severe impairment. 3 In her analysis,
The ALJ incorrectly stated that Plaintiff had failed to pick-up the prescribed braces. See AR at
20, 25. The record indicates that, on July 1, 2013, Plaintiff had yet to pick-up the braces, see id.
at 657; however, subsequent records clearly show that Plaintiff experienced symptom relief
because she obtained and started to use the braces, see id. at 663, 667, 672.
When assessing Plaintiff’s testimony, the ALJ weighed Plaintiff’s credibility, which was her
responsibility to do. Furthermore, the ALJ properly applied the Social Security Administration’s
two-step standard for assessing a claimant’s credibility. See SSR 16-3p, 2016 WL 1119029,
(Mar. 16, 2016) (although SSR 16-3p superseded SSR 96-7p, 1996 WL 374186 (July 2, 1996);
both SSR 16-3p and SSR 96-7p require that the ALJ perform a two-step analysis to assess a
claimant’s credibility in reporting her symptoms); Meadors v. Astrue, 370 F. App’x 179, 183 (2d
Cir. 2010) (summary order).
First, the ALJ must determine whether the claimant suffers from a “medically
determinable impairment[ ] that could reasonably be expected to produce” the pain
alleged. 20 C.F.R. § 404.1529(c)(1); . . . Second, the ALJ must evaluate the
intensity and persistence of those symptoms considering all of the available
evidence; and, to the extent that the claimant's pain contentions are not
the ALJ acknowledged that Plaintiff had been diagnosed with migraine headaches but noted that
an MRI of Plaintiff’s brain was normal. See AR at 21. Furthermore, the ALJ stated that Plaintiff
had had “very little medical treatment over the years” for her chronic headaches, and her doctors
had indicated that medication helped. See id. at 20-21. Moreover, no treating or examining
physician identified any functional limitations arising out of Plaintiff’s migraine headaches. For
these reasons, the Court finds that the ALJ was justified in “relying on what [the record did] not
say” in this instance. Dumas v. Schweiker, 712 F.2d 1545, 1553 (2d Cir. 1983) (citation
omitted). Accordingly, the Court finds that there was substantial evidence in the record to
support the ALJ’s finding that Plaintiff’s migraine headaches had “no more than a minimal
effect” on her ability to work. SSR 85-28, 1985 WL 56856, at *3.
In summary, for the above-stated reasons, the Court finds that there was substantial
evidence in the record to support the ALJ’s finding, at Step 2 of her analysis, that Plaintiff’s
Muenke/Crouzon syndrome, CTS, and migraine headaches did not amount to severe
impairments, or a combination thereof, as defined in the regulations. See Richardson, 402 U.S.
C. ALJ’s RFC analysis
Between steps three and four of the disability analysis, the ALJ must determine the
claimant’s residual functional capacity (“RFC”), which is defined as “the most you can still do
substantiated by the objective medical evidence, the ALJ must engage in a
credibility inquiry. . . .
Meadors, 370 F. App’x at 183 (internal citations and footnote omitted). In this case, the ALJ
found that Plaintiff’s medically determinable impairments could reasonably be expected to cause
the alleged symptoms. She then found that Plaintiff’s statements concerning the intensity,
persistence, and limiting effects of those symptoms were not fully credible. See AR at 24.
[in a work setting] despite your limitations.” See 20 C.F.R. § 416.945(a)(1); 20 C.F.R.
§ 416.920(e). The RFC analysis considers “all of your medically determinable impairments of
which we are aware” even if they are not severe. 20 C.F.R. § 416.945(a)(2). The ALJ is to
consider “all of the relevant medical and other evidence” in assessing RFC. 20 C.F.R.
§ 416.945(a)(3). As stated above, the ALJ found that Plaintiff could perform unskilled light
work with “no overhead lifting[.]” See AR at 23.
In this case, Plaintiff argues that substantial evidence does not support the ALJ’s
determination that she can perform light work and that the ALJ should have found that she is
unable to reach/lift in any direction. See Dkt. No. 15 at 17-18. According to Plaintiff, the
uncontroverted testimony of the vocational expert establishes that Plaintiff could not perform
light work had the ALJ added this additional limitation. See id. at 17 (asserting that the
vocational expert testified that limiting Plaintiff to occasional reaching in other directions would
eliminate work as a Shipping and Receiving Weigher and Cleaner).
Plaintiff argues that the ALJ ignored record evidence regarding her shoulder deformity.
See id. at 18. In that regard, the record indicates that Plaintiff has “marked restrictions for
overhead lifting” due to a recurring dislocated shoulder. See AR at 411. Furthermore Plaintiff
relies on record citations that acknowledge her shoulder instability. See AR at 327, 332, 337,
347, 350, 561, 566, 660, 667, 675. Each of these records reflects treatment notes from Dr.
Gooldy. Dr. Gooldy also completed a “Musculoskeletal Questionnaire” on June 20, 2013,
indicating that Plaintiff could occasionally reach, occasionally lift/carry over 20lbs, frequently
bend or twist at the waist, occasionally use her hands, and could stand/walk for less than two
hours per work-day. See AR at 594.
The ALJ discredited Dr. Gooldy’s opinion, as demonstrated in the questionnaire, because
it was not adequately supported by Dr. Gooldy’s clinical reporting, and it was inconsistent with
the remainder of the medical evidence. See id. at 25 (citing Social Security Ruling 96-2p).
Specifically, the ALJ found that Plaintiff’s “testimony and the activities of daily living reported
to examining sources and treating sources support a higher level of functioning.” See id.
Notably lacking from the record is any evidence that specifically limits Plaintiff’s ability
to reach from side to side. “The [ALJ] is entitled to rely not only on what the record says, but
also on what it does not say.” Dumas, 712 F.2d at 1553 (citations omitted). Thus, the ALJ did
not err in concluding that Plaintiff is able to reach in other directions, nor did the ALJ err in
limiting her hypothetical questioning to the vocational expert to only include a limitation of
overhead lifting. See Dumas, 712 F.2d at 1554 n.4 (stating that “[t]he ALJ is responsible for
determining, based on all the evidence, the claimant’s physical capabilities”).
In sum, to the extent that Plaintiff points to evidence in the Administrative Record that
reasonably might support a different conclusion in her favor, “whether there is substantial
evidence supporting the appellant’s view is not the question” on appeal. Bonet v. Colvin, 523 F.
App’x 58, 59 (2d Cir. 2013) (summary order). Moreover, to the extent that the ALJ’s RFC
analysis failed to make express findings with respect to Plaintiff’s medically determinable
impairments, such lack of explanation does not constitute legal error where, as here, the ALJ
clearly considered much of the evidence that Plaintiff argues she ignored. See id. For these
reasons, the Court finds that substantial evidence supports the ALJ’s findings in her RFC
analysis and that she applied the appropriate legal standards. See Richardson, 402 U.S. at 401.
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D. ALJ’s treatment of medical source opinions
During the disability analysis, the ALJ “will always consider the medical opinions” in the
record together with other relevant evidence. 20 C.F.R. § 404.1527(b). “Medical opinions are
statements from physicians and psychologists or other acceptable medical sources that reflect
judgments” about a claimant’s impairments and their effects. 20 C.F.R. § 404.1527(a)(2).
Acceptable medical sources include licensed physicians, licensed or certified psychologists,
licensed optometrists, licensed podiatrists, and qualified speech-language pathologists. See 20
C.F.R. § 404.1513(a).
Generally, the ALJ will consider the following factors in deciding what weight to afford
the opinion of an acceptable medical source: whether the source examined the claimant; how
well the source explains his or her opinion with relevant evidence; how consistent the opinion is
with the record as a whole; whether the source is a specialist in the area of his or her opinion; and
other factors tending to support or contradict the opinion. See 20 C.F.R. § 404.1527(c)(1)-(6).
Additionally, the Commissioner’s regulations instruct that,
[g]enerally, we give more weight to opinions from your treating sources, since these
sources are likely to be the medical professionals most able to provide a detailed,
longitudinal picture of your medical impairment(s) . . . . If we find that a treating
source’s opinion on the issue(s) of the nature and severity of your impairment(s) is
well-supported by medically acceptable clinical and laboratory diagnostic
techniques and is not inconsistent with the other substantial evidence in your case
record, we will give it controlling weight.
20 C.F.R. § 404.1527(c)(2).
However, treating physician opinions are “‘not afforded controlling weight where . . . the treating
physician issued opinions that are not consistent with other substantial evidence in the record . . .
.’” Petrie v. Astrue, 412 F. App’x 401, 405 (2d Cir. 2011) (summary order) (quoting Halloran v.
Barnhart, 362 F.3d 28, 32 (2d Cir. 2004) (per curium)). An ALJ may also properly afford less
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than controlling weight to a treating physician’s medical source statement where the “medical
source statement conflict[s] with his own treatment notes[.]” Cichocki v. Astrue, 534 F. App’x
71, 75 (2d Cir. 2013) (summary order).
When affording a treating physician’s opinion less than controlling weight, the ALJ
“‘will always give good reasons’” for doing so. Halloran v. Barnhart, 362 F.3d 28, 32 (2d Cir.
2004) (quoting 20 C.F.R. § 404.1527(d)(2)); see also 20 C.F.R. § 416.927(c)(2). To that end,
“[t]he factors that must be considered when the treating physician's opinion is not
given controlling weight include: ‘(i) the frequency of examination and the length,
nature, and extent of the treatment relationship; (ii) the evidence in support of the
opinion; (iii) the opinion’s consistency with the record as a whole; and (iv) whether
the opinion is from a specialist.’”
Brickhouse v. Astrue, 331 F. App’x 875, 877 (2d Cir. 2009) (summary order) (quoting Clark v.
Comm’r of Soc. Sec., 143 F.3d 115, 118 (2d Cir. 1998)); see also 20 C.F.R. § 416.927(c)(1)-(6).
In this case, Plaintiff argues that the ALJ erred in failing to give Dr. Gooldy’s opinion
controlling weight. See Dkt. No. 15 at 22-23. In her decision, the ALJ discounted Dr. Gooldy’s
opinion because Dr. Gooldy’s treating notes did not adequately support the conclusions she gave
in her questionnaire with respect to Plaintiff’s ability to sit, stand, and walk. See AR at 25.
Furthermore, the ALJ found that Dr. Gooldy’s opinion was inconsistent with the remainder of
the medical evidence. See id. (citing Social Security Ruling 96-2p). Specifically, the ALJ found
that Plaintiff’s “testimony and the activities of daily living reported to examining sources and
treating sources support a higher level of functioning.” See id.
With respect to Dr. Hansen’s psychological consultative examination, the ALJ provided
sufficient reason to discount part of that opinion. For example, the ALJ disregarded some of the
“marked” restrictions due to Plaintiff’s testimony that indicated she socialized outside of the
house with family and with a friend rather frequently, attended her children’s school events, and
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was struck by a car while she was outside of the house. See id. Thus, there was no error in the
ALJ rejecting Dr. Hansen’s analyses as far as they conflicted with Plaintiff’s own testimony. See
Wright v. Barnhart, 473 F. Supp. 2d 488, 493 (S.D.N.Y. 2007). For these reasons, the Court
finds that substantial evidence supports the weight that the ALJ afforded to Dr. Gooldy’s and Dr.
Hansen’s opinions. See Richardson, 402 U.S. at 401.
Having reviewed the entire record in this matter, the parties’ submissions, and the
applicable law, and for the above-stated reasons, the Court hereby
ORDERS that Plaintiff’s motion for judgment on the pleadings, see Dkt. No 15, is
DENIED; and the Court further
ORDERS that Defendant’s motion for judgment on the pleadings, see Dkt. No. 21, is
GRANTED; and the Court further
ORDERS that the Commissioner’s decision is AFFIRMED and Plaintiff’s complaint is
DISMISSED; and the Court further
ORDERS that the Clerk of the Court shall enter judgment in favor of Defendant and
close this case.
IT IS SO ORDERED.
Dated: February 10, 2017
Syracuse, New York
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