Garcia v. Nancy A. Berryhill
Filing
19
OPINION AND ORDER re: 14 MOTION for Judgment on the Pleadings . filed by Enrique Garcia, 16 MOTION for Judgment on the Pleadings . filed by Nancy A. Berryhill. For the foregoing reasons, plaintiff's motion is GRAN TED, the Commissioner's motion is DENIED, and this action is REMANDED for further proceedings consistent with this Order. (As further set forth in this Order.) (Signed by Magistrate Judge Barbara C. Moses on 11/14/2018) (cf) Transmission to Orders and Judgments Clerk for processing.
UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF NEW YORK
11.14.18
ENRIQUE GARCIA,
Plaintiff,
-against-
17-CV-10064 (BCM)
OPINION AND ORDER
NANCY A. BERRYHILL, Acting
Commissioner of Social Security,
Defendant.
BARBARA MOSES, United States Magistrate Judge.
Plaintiff Enrique Garcia brings this action pursuant to § 205(g) of the Social Security Act
(the Act), 42 U.S.C. § 405(g), seeking judicial review of a final determination of the Commissioner
of Social Security (Commissioner) denying his application for Disability Insurance Benefits
(DIB). Both parties have moved for judgment on the pleadings. As discussed in more detail below,
the Administrative Law Judge (ALJ) gave “great weight” to the opinion of a non-examining
medical expert but failed to incorporate significant limitations found by that expert into his residual
functional capacity (RFC) determination. In addition, the ALJ wholly failed to consider the opinion
of the consultative examiner who evaluated plaintiff in connection with his DIB application.
Because the ALJ erred in formulating plaintiff’s RFC, there is no record evidence showing that
plaintiff could perform jobs that exist in significant number in the national economy.
Consequently, plaintiff’s motion will be granted, the Commissioner’s motion will be denied, and
the case will be remanded.
I.
BACKGROUND
A.
Procedural Background
Plaintiff filed his DIB application on December 6, 2013, alleging disability as of August
13, 2013, when he fell off a ladder at work and injured his right shoulder. See Certified
Administrative Record (Dkt. No. 12) at 136, 140 (hereinafter “R. __.”) His application was denied
on April 1, 2014. (R. 147.) Plaintiff timely requested a hearing before an ALJ (R. 159), and on
December 10, 2015, he appeared with counsel before ALJ Seth Grossman. (R. 77-88.) No other
witnesses testified. On August 19, 2016, Plaintiff appeared again, with counsel, for a second
hearing before ALJ Grossman. (R. 89-130.) At the second hearing, the ALJ also took testimony
from orthopedic surgeon Allan Levine, M.D. and vocational expert Joseph Atkinson. (R. 98-114,
121-29.)
In a written decision dated October 13, 2016 (Decision), the ALJ found that plaintiff was
not disabled within the meaning of the Act. (R. 39-47.) Plaintiff timely requested review of the
ALJ’s Decision, but on October 26, 2017, the Appeals Council denied his request. (R. 5-10.) This
was the final act of the Commissioner.
B.
Personal Background
Plaintiff was born on February 11, 1968, in Peru. (R. 82, 131.) He completed high school
in Peru. (R. 82.) He moved to the United States in 1989, when he was 21, and is now a U.S. citizen.
(R. 80-81, 118-19.) Once in the United States, plaintiff worked first as a taxi driver and later in
asbestos removal. (R. 350.) On August 13, 2013, he fell off a ladder while working, sustaining an
injury to his right shoulder. (R. 94-95, 136.) Plaintiff is right handed. (R. 136.)
Plaintiff has not engaged in any gainful activity since the date of his injury. (R. 41.) He has
undergone two shoulder surgeries (R. 438, 700), and continues to complain of pain in his upper
right extremity. In a function report completed in connection with his application for DIB, plaintiff
reported that he did not do chores or prepare meals, and had difficulty with personal care, because
he was limited to his (non-dominant) left hand. (R. 319-21.)
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II.
PLAINTIFF’S MEDICAL HISTORY
A.
Treatment Records
On August 14, 2013, the day after his accident, plaintiff was seen for an initial evaluation
by orthopedic surgeon Darren J. Friedman, M.D. (R. 435-37.) A CT scan of his right shoulder
showed a proximal humerus fracture. (R. 436.) On August 15, 2013, plaintiff underwent a
“subacromial decompression with partial acromioplasty,” “ORIF proximal humerus,” and “open
rotator cuff repair.” (R. 438.) In an August 19, 2013 post-operative note, Dr. Friedman prescribed
physical therapy and Vicodin. (R. 441.) On September 11, 2013, Dr. Friedman noted that plaintiff
was “doing well” and could “continue with work light duty.” (R. 442.) On October 9, 2018,
however, Dr. Friedman noted that plaintiff continued to complain of pain “which radiates from the
shoulder down to the hand and wrist.” (R. 542.)
On November 5, 2013, an x-ray of plaintiff’s wrist and elbow showed mild degenerative
changes without acute bony abnormalities. (R. 460-61.) On November 19, 2013, plaintiff was
diagnosed with right elbow medial epicondylitis and given an injection in his elbow. (R. 428-29.)
On December 4, 2013, an MRI showed tendinosis of the right elbow. (R. 515-16.)
On December 9, 2013, Dr. Friedman saw plaintiff and noted improved “motion,” but the
patient continued to complain of pain in the right shoulder. (R. 444.)
On February 7, 2014, Dr. Friedman certified that plaintiff was “totally disabled” for the
two-month period between February 7, 2014 and April 7, 2014. (R. 506.) On April 7, 2014, Dr.
Friedman again saw plaintiff, who reported that his pain had returned after a February 12, 2014
corticosteroid injection which had offered him mild transient benefits. (R. 686.) On May 19, 2014,
Dr. Friedman noted that plaintiff wished to proceed with a second surgery once it was approved
by his workers’ compensation provider. (R. 690-91.)
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On July 18 and September 5, 2014, plaintiff saw neurologist Aric Hausknecht, M.D. Dr.
Hausknecht prescribed a trial of Lyrica. (R. 761, 764.)
On September 18, 2014, plaintiff underwent surgery on his right shoulder for “removal of
hardware” and “total shoulder arthroplasty.” (R. 700.) During post-operative visits with Dr.
Friedman on September 26, 2014, October 24, 2014, and January 2, 2015, plaintiff was generally
observed to be doing well. (R. 706, 710, 714.) He also continued to visit Dr. Hausknacht for pain
management during this time. (R. 767, 770.)
On January 29, 2015, plaintiff was seen by neurologist and pain management physician
Douglas Schottenstein, M.D. (R. 795-99.) Dr. Schottenstein’s notes reflect a “plan” for plaintiff to
continue to undergo physical therapy, to continue taking pain medication per Dr. Hausknecht, and
to continue to see Dr. Friedman for shoulder, elbow, and hand pain. (R. 798.)
Throughout 2015, plaintiff continued to report varying amounts of pain. On March 6, 2015,
when he visited Dr. Hausknacht, his prognosis was “guarded.” (R. 777.) On April 6, 2015, Dr.
Friedman noted that plaintiff was “making progress” and recommended continued physical
therapy. (R. 718.) On April 23, 2015, Dr. Schottenstein noted “continued right wrist and hand
pain” but wrote that plaintiff obtained “70% relief” from stellate ganglion blocks (injections for
pain). (R. 825.) On June 26, 2015, plaintiff stopped taking Lyrica, due to dizziness, and began
taking Neurontin. (R. 783.) On June 29, 2015, Dr. Schottenstein reported that plaintiff’s motor
strength in his upper extremities was “5/5 on standard manual resistance technique” except for his
right upper extremity, “which is 5-/5.” (R. 846.)
On August 28, 2015, Dr. Hausknecht increased plaintiff’s dosage of Neutontin. (R. 786.)
On October 13, 2015, the patient reported continued pain. (R. 855.) On November 13, 2015, Dr.
4
Hausknecht again increased plaintiff’s dosage of Neutontin. (R. 959.) On December 15, 2015,
plaintiff again reported continued pain. (R. 929.)
On December 28, 2015, plaintiff saw physical therapist Mital Patik Saparia. (R. 973.) Ms.
Saparia’s diagnosis included “MS wasting on anterior deltoids” – i.e., muscle atrophy. (Id.)
Throughout the first half of 2016, plaintiff continued to see Drs. Hausknect and
Schottenstein. (R. 956, 905, 953, 950, 869, 981.) During this period, Dr. Schottenstein continued
to provide plaintiff with semi-regular injections (once every month or two), of “right stellate
ganglion blocks” to address his pain. (R. 789, 817, 821, 837, 851, 943, 921, 889.) Dr. Schottenstein
noted some temporary improvement from those injections, but he also reported, as late as May 11,
2016, that plaintiff had “worsen[ing]” pain. (R. 869.)
B.
Medical Opinion Evidence
Numerous physicians have provided written or testimonial opinion evidence concerning
plaintiff’s ability to work. Two of them – Dr. Levine and family medicine physician John Fkiaras,
M.D. – provided their opinions in connection with plaintiff’s application for DIB benefits. Six
other doctors provided their opinions in connection with plaintiff’s workers’ compensation
applications.
1.
Dr. John Fkiaras
Dr. Fkiaras performed a consultative internal medicine examination of plaintiff on March
14, 2014, in connection with his DIB application. (R. 480-83.) Plaintiff’s physical exam was
normal except for his upper right extremity, where Dr. Fkiaras found a decreased range of motion
in the shoulder, elbow, and wrist, “decreased sensation to light touch in the right hand[],” and “3/5
muscle strength in the right upper extremity.” (R. 482.) Dr. Fkiaris also noted that plaintiff could
“zip, button and tie with the right hand with difficulty.” (Id.) In a medical source statement, Dr.
Fkiaras wrote that plaintiff was “restricted from any lifting, carrying, pushing, and pulling,” that
5
he was “unable to participate in activities which require reaching with his right upper extremity,”
that he had “a moderate to severe limitation grabbing and squeezing with his right hand,” and that
he was “restricted from activities which require use of his right upper extremity.” (R. 483.)
2.
Dr. Allan Levine
Dr. Levine, who did not personally examine the plaintiff, testified as a medical expert at
the second ALJ hearing on August 19, 2015. (R. 98.) As discussed in greater detail below, Dr.
Levine concluded, based on plaintiff’s testimony and medical records, that he was limited to lifting
ten pounds occasionally and that he could not do “any pushing or pulling,” any “reaching above
shoulder level,” or any “forceful grip, grasp, or torque activities” with his upper right extremity.
(R. 110-12.)
3.
Dr. Robert D. Kramberg
Pain management specialist Robert D. Kramberg, M.D. completed a progress report on
November 6, 2013, after giving plaintiff a corticosteroid injection to his right shoulder. (R. 57374.) This was approximately three months after plaintiff’s first shoulder surgery. Dr. Kramberg
reported that plaintiff had a 25% “temporary impairment.” (R. 574.) In addition, Dr. Kramberg
checked a box indicating that plaintiff was working at the time of the report (which is not otherwise
supported in the record). (R. 574.) Dr. Kramberg also twice referenced an “attached medical
report” which appears to be missing from the record. 1 Insofar as the record reveals, plaintiff did
not visit Dr. Kramberg again.
1
The two record pages following Dr. Kramberg’s report are slip sheets indicating that the pages
were “replaced with [these pages] because [they] referenced another individual.” (R. 573-576.)
6
4.
Dr. Vincent Huang
Physical medicine and rehabilitation specialist Vincent Huang, M.D. authored a
“Certificate of Disability” concerning plaintiff on December 2, 2013. (R. 433.) Dr. Huang opined
that plaintiff was “unable to return to work.” (Id.) Insofar as the record reveals, plaintiff did not
visit Dr. Huang again.
5.
Dr. Alexios Apazidis
Orthopedic surgeon Alexios Apazidis, M.D., performed an independent orthopedic
examination of plaintiff on December 19, 2013. (R. 448-56.) Dr. Apazidis opined that plaintiff had
a “marked (75%) disability,” based on “the physical examination at this time” and the “available
medical documentation.” (R. 451.)
Dr. Apazidis performed a second examination of plaintiff on April 24, 2014 (R. 642-45),
after which he reported limitations in flexibility in plaintiff’s right shoulder but opined that plaintiff
was capable of working, so long as he did not work “at or above shoulder level with the right arm.”
(R. 644.)
6.
Dr. Howard V. Katz
Orthopedic surgeon Howard V. Katz, M.D. performed three evaluations of plaintiff
between August 2014 and August 2015, each for workers’ compensation purposes. (R. 725-49.)
On August 26, 2014, Dr. Katz opined that plaintiff and was capable of working “with restrictions
of no repetitive use of [the] right arm, no pushing, no pulling, and no heavy lifting over 40 pounds.”
(R. 728.) On April 20, 2015, Dr. Katz opined that plaintiff could perform sedentary work with “no
overhead repetitive use of the right arm” and “[n]o pushing, pulling and lifting over 15 lbs.” (R.
737.) On August 31, 2015, Dr. Katz noted that plaintiff had reached “maximal medical
improvement” and opined that he was capable of working “with restrictions.” (R. 745.) Dr. Katz
did not identify those restrictions. (Id.)
7
7.
Dr. Maury Harris
Orthopedic surgeon Maury Harris, M.D. performed an independent orthopedic evaluation
of plaintiff on February 11, 2016. (R. 960-69.) Dr. Harris reported that plaintiff could perform light
or sedentary duties, “with restrictions placed on any lifting over 20 lbs., and any overhead
repetitive movement.” (R. 966.) In an April 1, 2016 addendum, Dr. Harris reported a “schedule[d]
loss” of 50% in plaintiff’s right shoulder. (R. 961.)
8.
Dr. Douglas C. Schottenstein
Treating physician Dr. Schottenstein completed an evaluation form for workers’
compensation purposes on April 4, 2016, based on his March 23, 2016 examination of plaintiff.
(R. 901.) Dr. Schottenstein reported in relevant part that plaintiff should “avoid pushing, pulling,
lifting, carrying >10-15 lbs.” (R. 901.)
III.
HEARING
A.
December 10, 2015 Hearing
At the December 10, 2015 hearing, plaintiff testified, through a Spanish translator, that he
was 47 years old, that he entered the United States from Peru in 1989, that he became a U.S.
citizen, and that he understood basic English. (R. 80-81.) Plaintiff confirmed that he took his U.S.
citizenship test in English. (R. 81.)
In response to the ALJ’s questions, plaintiff testified that he could not “do any heavy
lifting” with his right hand and arm, stating “I can’t do a lot of movements because I get pain.” (R.
83.) When asked if he could lift a gallon of milk with his right hand, he testified “I can pick it up
but I cannot sustain it” for more than “one to two minutes” before he “[got] pain.” (Id.) When
asked by the ALJ if there was anything wrong with him besides his right hand and arm, plaintiff
said no. (R. 83) He testified that he could walk five miles and could drive short distances with his
left hand. (R. 83, 85.)
8
The ALJ then questioned plaintiff’s attorney about the merits of plaintiff’s disability claim,
stating “Counsel, to be blunt about it and, you know, it’s – it’s really hard to make out a case of
disability” with nothing more than “limited use of your arm.” (R. 84.) However, the ALJ concluded
that the case required “another hearing with the [vocational expert].” (R. 86.)
B.
August 19, 2015 Hearing
At the August 19, 2015 hearing, the ALJ heard live testimony from plaintiff and telephonic
testimony from Dr. Levine and VE Atkinson. (R. 89-130.) Dr. Levine was present by telephone
for all of plaintiff’s testimony (R. 93-94), but Mr. Atkinson was not. (R. 118.)
1.
Plaintiff’s Testimony
Plaintiff once again testified through a Spanish interpreter. He stated that he remained
unemployed, and described the moment of his right upper extremity injury as when his “shoulder
broke.” (R. 94-95.) He noted again that he is right handed. (Id.)
Asked by the ALJ about the state of his right arm, plaintiff testified that it was “very bad.”
(R. 95.) He could lift it only up to desk level. (Id.) He could dial on a cell phone but would not
pick up that cell phone with his right hand. (Id.) He drove “with one hand,” though he
acknowledged that he could use his right hand to hold the steering wheel momentarily while
turning with his left hand. (R. 96.) He thought he could lift 20 pounds with his left hand. (R. 97.)
Asked by his own attorney what other activities he had “problems doing” with his right shoulder,
arm, or hand, plaintiff responded “I can’t barely do anything with that arm.” (R. 98.)
Medical expert Dr. Levine also questioned plaintiff. In response, plaintiff testified that he
had pain in his right elbow, and that his shoulder had not gotten better after shoulder replacement
surgery. (R. 100-01.) Plaintiff stated that he could use his right hand to feed himself, and could
hold a cup of coffee with his right hand, but could not write “that much” with his right hand because
his hand hurt. (R. 101.)
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2.
Dr. Levine’s Testimony
After questioning plaintiff, Dr. Levine testified that plaintiff “had a medically-determinable
impairment of chronic pain in the right shoulder secondary to a fracture of the proximal right
humerus [], and a rotator cuff tear and development of degenerative joint disease of the shoulder
and that was in 8/13/2013.” (R. 102.) Dr. Levine testified that plaintiff had a second medicallydeterminable impairment of chronic pain of the right elbow and a third medically-determinable
impairment of “chronic pain in the right wrist and hand.” (R. 103-04.) He testified that “the medical
records are replete with [reports of] chronic pain of the right shoulder since his on-the-job injury
in August 2013.” (R. 102.)
However, according to Dr. Levine, the record did not show signs of “complex regional pain
syndrome” (R. 105-06), and there was “a question” as to whether plaintiff had “a medicallydeterminable impairment” based on a diagnosis of “chronic pain syndrome.” (R. 106.) Dr. Levine
noted that plaintiff had found some relief with ganglion blocks and that a recent EMG and nerve
conduction study of his right upper extremity was normal. (R. 107.)
When asked by the ALJ what use plaintiff had of his right upper extremity, Dr. Levine
stated that plaintiff had “minimal to no use really of the shoulder itself,” but retained some use of
his right hand. (R. 108, 112-13.) Dr. Levine explained that “with the upper arm at its side it
effectively takes the shoulder out of the equation and it has no effect on fine and gross
manipulation.” (R. 109.)
Based on his review of the medical record and plaintiff’s testimony, Dr. Levine opined that
plaintiff should not engage in “any lifting more than occasionally, ten pounds with the right alone,”
any “lifting above chest level with the right,” or any “pushing or pulling with the right upper
extremity,” but that he could “sit, stand or walk six out of eight hours with customary breaks,”
with “unlimited stairs or ramps, [] kneeling, crouching, or stooping.” (R. 110-11.) Dr. Levine
10
added that plaintiff should avoid “ladders, scaffolds, [] crawling, heavy vibratory machinery or
dangerous-type equipment, [] unprotected heights and extreme cold exposure,” should not “reach[]
above shoulder level with the right,” and should avoid “any forceful grip, grasp or torque activities
with the right upper extremity.” (R. 111-12.)
Other than these restrictions, Dr. Levine testified that plaintiff “had unlimited use of the
upper extremities for fine and gross manipulation.” (R. 112-13.) Dr. Levine clarified that plaintiff
should be able to use both hands for things like picking up a receiver and writing. (R. 113.) Dr.
Levine also opined that plaintiff’s “limitations are primarily in and/or around the shoulder itself.
If he can do things without involving the shoulder such as even putting his hand on a desk and
writing, that really does not affect the shoulder.” (R. 113.)
3.
VE Atkinson’s Testimony
VE Atkinson testified by telephone. (R. 118.) Before questioning the VE, the ALJ again
questioned plaintiff – with Mr. Atkinson on the line – about his English language ability. (R. 11819.) Plaintiff restated that he took his citizenship test in English and that he could carry on a
basic/simple conversation in English “a little bit.” (R. 119.) Asked about his ability to read simple
instructions in English, he responded, “It depends; sometimes there are difficult words that I don’t
understand.” (Id.)
The ALJ asked VE Atkinson to identify jobs for two hypothetical claimants. The first was:
A hypothetical person of the claimant’s educational and vocational background
who can carry on a simple conversation in English, basic English skills and this
person has – well, this is the most extreme, the person had – can stand or walk six
hours and sit six hours in an eight-hour day. The person can lift and carry 20 pounds
with their upper extremity frequently, 10 pound – or, I’m sorry 10 – 20 pounds
occasionally and 10 pounds frequently and no use of the right upper extremity.
(R. 121-22) (emphasis added). The ALJ asked whether this hypothetical claimant could perform
any light jobs. (R. 122.)
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After a period of silence from Mr. Atkinson, the ALJ prompted him, asking whether the
hypothetical claimant could perform the job of usher (DOT code 344.677-014, light work, SVP of
2). (R. 122-23.) Mr. Atkinson testified that “[i]t would be difficult,” given that ushers “have to
hand out pamphlets and things like that and hold pamphlets.” (R. 122.) He continued, “I would say
the individual could perform the occupation of usher, but we would have a significant erosion.” 2
(R. 122.) VE Atkinson estimated the erosion to the national employment figure of usher (4,823) at
50 percent. (R. 123.) 3
Mr. Atkinson then opined that the first hypothetical claimant could also perform the job of
school bus monitor (DOT code 372.667-042, light work, SVP of 2), though the national
employment for that job (1,081) would be eroded by 60 percent. (R. 124.) VE Atkinson further
opinioned that the first hypothetical claimant could perform the job of monitor (DOT code
379.367-010, sedentary work, SVP of 2), though the national employment for that job (4,558)
would also be eroded 50 to 60 percent. (R. 125.)
The ALJ then provided VE Atkinson a second hypothetical, involving the same limitations
as the first, except that the claimant had some additional use of the upper right extremity:
[W]ith the right arm this person is limited in the following manner. This person has
no over-shoulder lifting and is limited – just a second, the person can lift ten pounds
2
Social Security Administration regulations provide that ALJs must consider “the extent of any
erosion of the occupational base” when a claimant has limitations preventing him or her from
performing the full range of light or sedentary work. SSR 83-12, 1983 WL 31253 (S.S.A. 1983);
see also Carolyn A. Kubitschek & Jon C. Dubin, Social Security Disability Law and Procedure in
Federal Court § 3:94 (2018) (noting that vocational expert testimony is required where the “extent
of the erosion of the occupational base is not clear.”). Thus, vocational experts often testify, as VE
Atkinson did here, concerning the extent to which the number of jobs otherwise available in a
particular occupation should be “eroded” (reduced) due to a claimant’s specific limitations. See,
e.g., Glast v. Astrue, 2013 WL 5532696, at *6 (E.D.N.Y. Sept. 30, 2013); Crossman v. Comm’r of
Soc. Sec., 2015 WL 5943506, at *19 (N.D.N.Y. Oct. 13, 2015).
3
The ALJ and VE Atkinson then agreed that the resulting figure, after erosion, was “about 1,500
jobs.” (R. 123.) It is not clear from the record why this figure differed from 50 percent of 4,823
(i.e., 2,411).
12
to the chest level, in other words no more than that, with no overhead lifting but the
person can finger, handle, you know, fine manipulation frequently.”
(R. 125-26.) The ALJ elaborated: “So that the main problems are no overhead lifting with the right
and no lifting more than ten pounds at chest level.” (R. 126.)
In response, Mr. Atkinson opined that this second hypothetical claimant could perform the
jobs of electronics worker (DOT code 726.687-010, light work, SVP of 2, national employment
figure of 3,437), office helper (DOT code 239.567-010, light work, SVP of 2, national employment
figure of 3,728), information clerk (DOT code 237.367-018, light work, SVP of 2, national
employment figure of 1,609), or ticket taker (DOT code 344.667-010, SVP of 2, national
employment figure of 6,785). (R. 126-28.) Mr. Atkinson added that the second hypothetical
claimant – like the first – could perform the job of usher, but without any erosion. (R. 127-28.)
IV.
ALJ DECISION
A.
Standards
A five-step sequential evaluation process is used pursuant to 20 C.F.R. § 404.1520(a) to
determine whether a claimant over the age of 18 is disabled within the meaning of the Act. The
Second Circuit has described the sequence as follows:
First, the Commissioner considers whether the claimant is currently engaged in
substantial gainful activity. Where the claimant is not, the Commissioner next
considers whether the claimant has a “severe impairment” that significantly limits
her physical or mental ability to do basic work activities. If the claimant suffers
such an impairment, the third inquiry is whether, based solely on medical evidence,
the claimant has an impairment that is listed in 20 C.F.R. pt. 404, subpt. P, app.
1 . . . Assuming the claimant does not have a listed impairment, the fourth inquiry
is whether, despite the claimant’s severe impairment, she has the residual functional
capacity [RFC] to perform her past work. Finally, if the claimant is unable to
perform her past work, the burden then shifts to the Commissioner to determine
whether there is other work which the claimant could perform.
Jasinski v. Barnhart, 341 F.3d 182, 183-84 (2d Cir. 2003) (citation omitted).
13
If it is determined that the claimant is or is not disabled at any step of the evaluation process,
the evaluation will not progress to the next step. 20 C.F.R. § 404.1520(a)(4). A claimant bears the
burden of proof as to the first four steps, while the Commissioner bears the burden at the fifth step.
See Melville v. Apfel, 198 F.3d 45, 51 (2d Cir. 1999); Schaal v. Apfel, 134 F.3d 496, 501 (2d Cir.
1998). To support a finding that the claimant is not disabled at step five, the Commissioner must
offer evidence demonstrating that other work exists in significant numbers in the national and local
economies that the claimant can perform, given the claimant’s RFC, age, education, and past
relevant work experience. See 20 C.F.R. §§ 404.1512(f) (2015), 404.1560(c). “Under the law of
this Circuit and the SSA Guidelines, the ALJ must call a vocational expert to evaluate a claimant’s
significant non-exertional impairments in order to meet the step five burden.” Lacava v. Astrue,
2012 WL 6621731, at *18 (S.D.N.Y. Nov. 27, 2012) (citations omitted), report and
recommendation adopted, 2012 WL 6621722 (S.D.N.Y. Dec. 19, 2012).
For steps four and five, the ALJ must also determine the claimant’s RFC. The ALJ must
make this determination based on all of the relevant medical and other evidence in the record,
including the claimant’s credible testimony, the objective medical evidence, and medical opinions
from treating and consulting sources. 20 C.F.R. §§ 404.1520(e), 404.1545(a)(3). An ALJ must
consider all medical evidence on the record. 20 C.F.R. § 404.1527(c)(1) (“Regardless of its source,
we will evaluate every medical opinion we receive.”).
B.
Application of Standards
At step one, the ALJ found that plaintiff has not engaged in substantial gainful activity
since August 13, 2013, the alleged onset date. (R. 41.)
At step two, the ALJ determined that plaintiff has the following severe impairments: “right
shoulder impairment, status-post to right shoulder surgeries, and right elbow impairment.” (Id.)
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The ALJ explained that these impairments “cause more than a minimal effect on the claimant’s
ability to perform his physical or work activities.” (Id.)
At step three, the ALJ concluded that plaintiff does not have an impairment or combination
of impairments that meets or medically equals the severity of one of the listed impairments set
forth at 20 C.F.R. pt. 404, subpt. P, app. 1. (Id.)
Before considering step four, the ALJ determined plaintiff’s RFC. The ALJ found that
plaintiff has “the residual functional capacity to perform light work as defined in 20 CFR
404.1567(b) except that the claimant has limited use of his upper right extremity as follows: he is
unable to lift overhead, cannot lift and carry more than 10 pounds, and can only lift up to chest
level.” (R. 41-42.)
In determining plaintiff’s RFC, the ALJ (a) found plaintiff’s testimony not entirely credible
(R. 42); (b) accorded Dr. Levine’s opinion testimony “great weight” (R. 45); (c) failed to give any
weight to (or even consider) the opinion testimony of consultative examiner Dr. Fkiaras; and (d)
accorded all other medical opinions in the record “little weight.” (R. 44.)
As to the plaintiff’s testimony, the ALJ found that his “medically determinable
impairments could reasonably be expected to cause the alleged symptoms,” but that “the
claimant’s statements concerning the intensity, persistence and limiting effects of these symptoms
are not entirely consistent with the medical evidence and other evidence in the record” and that
“his overall condition is not of disabling character.” (R. 42.) The ALJ noted that Dr. Friedman had
observed some improvement after plaintiff’s initial surgery (R. 43); that in May 2014 plaintiff was
experiencing “moderate” relief through twice-weekly physical therapy sessions (id.); that Dr.
Hausknecht found “four out of five grip strength in the right hand” in April 2014; and that, other
than some muscle atrophy in the shoulder, and pain in the right shoulder and elbow, plaintiff
15
“otherwise showed full muscle strength in the upper and lower extremities, normal muscle tone
throughout the body.” (Id.) The ALJ also noted that Dr. Schottenstein reported in June 2015 that a
ganglion block procedure had resulted in 70% pain relief, and that as recently as January 2016, on
examination by Dr. Schottenstein, plaintiff continued to show “a normal gait, full muscle strength
throughout the body . . . and apart from some diminished sensation in the upper right extremity,
no sensory defects.” (R. 44.) The ALJ also considered a May 2016 x-ray report which revealed
significant “translation” of the humoral head but “no evidence of AC joint arthrosis soft tissue
abnormalities, and stated that [plaintiff’s] bone mineral density appeared normal.” (Id.)
The ALJ gave Dr. Levine’s opinion great weight because it was “based on a thorough
review of the medical record, detailed questioning of the claimant during the hearing, [and] a
knowledge of Social Security’s adjudicative process, and is consistent with the medical record as
a whole.” (R. 45.) The ALJ noted Dr. Levine’s opinion that plaintiff was “limited to lifting and
carrying 10 pounds, should not lift above chest level or reach above shoulder level, and that he is
unable to push and pull” with his upper right extremity. (Id.) Notwithstanding the “great weight”
he gave to Dr. Levine’s testimony, however, in formulating plaintiff’s RFC the ALJ did not place
any limitation on plaintiff’s ability to push or pull. Nor did he incorporate the other limitations that
Dr. Levine described: that plaintiff was unable to “reach above shoulder level” or to engage in
“any forceful grip, grasp, or torque activities” with his right upper extremity. (R. 110-12.)
The ALJ did not mention or address Dr. Fkiaras’s opinion anywhere in the Decision. As to
the remaining medical opinion evidence in the record, the ALJ expressly gave it little weight. (R.
44.) ALJ Grossman acknowledged that the record was “replete” with opinion evidence from
plaintiff’s treating physicians and/or worker’s compensation doctors, but found all of them “either
vague or conclusory in nature.” (Id.) The ALJ noted that several physicians had opined on
16
plaintiff’s “disability,” including Dr. Friedman (“totally disabled”), Dr. Huang (“unable to return
to work”), Dr. Kramberg (“25% ‘temporary impairment’”), Dr. Katz (“‘moderate partial
disability”), Dr. Harris (echoing Dr. Katz), and Dr. Hausknecht (“100% temporary impairment”).
(Id.) However, the ALJ reasoned, these physicians “either opined on a matter reserved for the
Commissioner to determine, or are vague and fail to provide a specific function-by-function
assessment of the claimant’s limitations.” (Id.)
At step four, the ALJ concluded that, given his RFC, plaintiff was unable to perform his
past relevant work as an asbestos removal worker. (R. 45.)
At step five, the ALJ found that, considering plaintiff’s age, education, work experience,
and RFC, there are jobs that exist in significant numbers in the national economy that plaintiff can
perform. (R. 45.) Citing VE Atkinson’s testimony that plaintiff “would be able to perform the
requirements of representative occupations such as an electronics worker [], office helper [], and
information clerk” (R. 46) (DOT codes omitted), the ALJ noted that these jobs “exist in the national
economy in the following numbers: 3,437 jobs (electronics worker), 3,728 jobs (office helper),
and 1,609 jobs (information clerk)” – for a total of 8,774 jobs (Id.) The ALJ then concluded that
the plaintiff was “capable of making a successful adjustment to other work that exits in significant
numbers in the national economy” and therefore was “not disabled” within the meaning of the Act
from August 13, 2013 through the date of the Decision. (R. 46.)
V.
ANALYSIS
A.
Standard of Review
Both parties have moved for judgment on the pleadings pursuant to Fed. R. Civ. P. 12(c).
To prevail on such a motion, a party must establish that no material facts are in dispute and that
judgment must be granted to that party as a matter of law. Sellers v. M.C. Floor Crafters, Inc., 842
17
F.2d 639, 642 (2d Cir. 1988); Claudio v. Comm’r of Soc. Sec., 2017 WL 111741, at *1 (S.D.N.Y.
Jan. 11, 2017).
The Act provides that the Commissioner’s findings “as to any fact, if supported by
substantial evidence, shall be conclusive.” 42 U.S.C. § 405(g). The reviewing court may set aside
a decision of the Commissioner only if it is “based on legal error or if it is not supported by
substantial evidence.” Geertgens v. Colvin, 2014 WL 4809944, at *1 (S.D.N.Y. Sept. 24, 2014)
(quoting Hahn v. Astrue, 2009 WL 1490775, at *6 (S.D.N.Y. May 27, 2009)); accord Longbardi
v. Astrue, 2009 WL 50140, at *21 (S.D.N.Y. Jan. 7, 2009). Thus, where an applicant challenges
the agency’s decision, the district court must first decide whether the Commissioner applied the
correct legal standards. Tejada v. Apfel, 167 F.3d 770, 773 (2d Cir. 1999); Calvello v. Barnhart,
2008 WL 4452359, at *8 (S.D.N.Y. Apr. 29, 2008). If there was no legal error, the court must
determine whether the ALJ’s decision was supported by substantial evidence. Tejada, 167 F.3d at
773; Calvello, 2008 WL 4452359, at *8.
“Substantial evidence is ‘more than a mere scintilla. It means such relevant evidence as a
reasonable mind might accept as adequate to support a conclusion.’” Halloran v. Barnhart, 362
F.3d 28, 31 (2d Cir. 2004) (quoting Richardson v. Perales, 402 U.S. 389, 401 (1970)). “In
determining whether substantial evidence exists, a reviewing court must consider the whole record,
examining the evidence from both sides, because an analysis of the substantiality of the evidence
must also include that which detracts from its weight.” Longbardi, 2009 WL 50140, at *21 (citing
Brown v. Apfel, 174 F.3d 59, 62 (2d Cir. 1999) and Williams v. Bowen, 859 F.2d 255, 256 (2d Cir.
1988)). However, the reviewing court’s task is limited to determining whether substantial evidence
exists to support the ALJ’s fact-finding; it may not reweigh that evidence or substitute its judgment
for that of the ALJ where the evidence is susceptible of more than interpretation. “[O]nce an ALJ
18
finds facts, [the court] can 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) (emphasis in
original) (quotation marks and citation omitted). Thus, the substantial evidence standard is “a very
deferential standard of review – even more so than the ‘clearly erroneous’ standard.” Id. (citation
omitted); see also Brown v. Colvin, 73 F. Supp. 3d 193, 198 (S.D.N.Y. 2014).
“[T]he crucial factors in any determination must be set forth with sufficient specificity to
enable [the reviewing court] to decide whether the determination is supported by substantial
evidence.” Ferraris v. Heckler, 728 F.2d 582, 587 (2d Cir. 1984). Thus, remand may be
appropriate if the ALJ fails to provide an adequate roadmap for his reasoning. Id. But if the ALJ
adequately explains his reasoning, and if his conclusion is supported by substantial evidence, the
district court may not reverse or remand simply because it would have come to a different decision
on a de novo review. Genier v. Astrue, 606 F.3d 46, 49 (2d Cir. 2010) (“Even where the
administrative record may also adequately support contrary findings on particular issues, the ALJ’s
factual findings must be given conclusive effect so long as they are supported by substantial
evidence.”) (citation and internal quotation marks omitted); see also Yancey v. Apfel, 145 F.3d
106, 111 (2d Cir. 1998) (“the court should not substitute its judgment for that of the
Commissioner”); Ryan v. Astrue, 5 F. Supp. 3d 493, 502 (S.D.N.Y. 2014) (“[T]his Court may not
substitute its own judgment as to the facts, even if a different result could have been justifiably
reached upon de novo review.”) (quoting Beres v. Chater, 1996 WL 1088924, at *5 (E.D.N.Y.
May 22, 1996)).
B.
The Parties’ Positions
In this case, plaintiff argues that the ALJ failed “to meet his burden at step 5 to show that
there are a ‘significant number’ of jobs that Plaintiff could perform” given his RFC, and that the
ALJ’s hypotheticals to the vocational expert “were not accurate,” meaning that they did not
19
incorporate the limitations specified by Dr. Levine, thus invalidating VE Atkinson’s testimony
concerning the jobs that plaintiff could perform. See Pl. Mem. (Dkt. No. 15) at 25-26 (relying on
Podedworny v. Harris, 745 F.2d 210, 218 (3d Cir. 1984) (“In our view, the fact that these
conditions were not included in the hypothetical question rendered that question defective, and
thus the expert’s answer cannot be considered substantial evidence.”)). In his reply brief, plaintiff
further argues that the ALJ erred by failing even to consider the opinion of Dr. Fkiaras, which also
included limitations not incorporated into the ALJ’s RFC. Pl. Reply Mem. (Dkt. No. 18) at 2.
The Commissioner counters that substantial evidence supports the ALJ’s RFC
determination, as well as the step five finding concerning available jobs. See Def. Mem. (Dkt. No.
17) at 15-24. Alternatively, defendant argues that even if it was error for the ALJ not to include all
of plaintiff’s limitations in his RFC determination, the error was harmless because it would not
have changed the ALJ’s ultimate determination. Id. at 22-23.
The Court largely agrees with plaintiff. It may well be, as the ALJ suggested during the
first hearing, that “it’s really hard to make out a case of disability” with nothing more than “limited
use of [one] arm.” (R. 84.) And it is true, as the ALJ noted in his Decision, that “apart from the
impairment to his right upper extremity, the claimant denied having any other medical conditions
that prevent him from working.” (R. 42.) However, the reviewing court must set aside the agency
decision if the ALJ committed legal error, see Tejada v. Apfel, 167 F.3d at 773, unless “application
of the correct legal principles to the record could lead only to the same conclusion,” Zabala v.
Astrue, 595 F.3d 402, 409 (2d Cir. 2010), rendering the errors harmless. In this case, the ALJ erred
by failing – without explanation – to incorporate the limitations described by Dr. Levine into his
RFC determination and by wholly ignoring the opinion of Dr. Fkiaris. Moreover, the omitted
20
limitations would have disqualified plaintiff from some of the jobs cited by the vocational expert
(and relied on by the ALJ). The Court therefore cannot conclude that the errors were harmless.
C.
The ALJ’s RFC Determination
1.
Dr. Levine’s Opinion
As noted above, the ALJ determined that plaintiff had the “residual functional capacity to
perform light work as defined in 20 CFR 404.1567(b) except that the claimant has limited use of
his upper right extremity as follows: he is unable to lift overhead, cannot lift and carry more than
10 pounds, and can only lift up to chest level.” (R. 41-42.) In formulating plaintiff’s RFC, the ALJ
relied primarily on the opinion of Dr. Levine, to which he assigned “great weight,” with no
reservations, in part because it was “consistent with the medical record as a whole.” (R. 45.)
However, the ALJ disregarded Dr. Levine’s view that plaintiff could not push or pull, reach above
shoulder level, or engage in “any forceful grip, grasp, or torque activities” with his right upper
extremity. (Compare R. 41-42 with R. 110-12.) These additional limitations – referred to herein
as the “push/pull, reach, and torque limitations” – were simply left out of the RFC, without
explanation. (R. 45.)
This was error. As the Commissioner correctly notes, see Def. Mem. at 18-19, an ALJ is
not required to “accept or reject a medical expert’s opinion in toto. Some portions may be entitled
to greater weight than other portions.” Annabi v. Berryhill, 2018 WL 1609271, at *16 (S.D.N.Y.
Mar. 30, 2018). “However, when the ALJ uses a portion of a given opinion to support a finding,
while rejecting another portion of that opinion, the ALJ must have a sound reason for the
discrepancy.” Id. (quoting Artinian v. Berryhill, 2018 WL 401186, at *8 (E.D.N.Y. Jan. 12, 2018)).
Here, the ALJ offered no reason at all for the discrepancy between Dr. Levine’s opinion – which
he appeared to accept in toto – and his determination of the plaintiff’s RFC. He did not even
acknowledge the variance. See Soc. Sec. Ruling 96-8p, 1996 WL 374184, at *7 (1996) (“If the
21
RFC assessment conflicts with an opinion from a medical source, the adjudicator must explain
why the opinion was not adopted.”); Kuleszo v. Barnhart, 232 F. Supp. 2d 44, 57 (W.D.N.Y. 2002)
(“The ALJ’s failure to acknowledge relevant evidence or to explain its implicit rejection is plain
error.”).
Moreover, the Commissioner does not point to any conflicting evidence in the record upon
which the ALJ could have relied to reject the push/pull, reach and torque limitations articulated by
Dr. Levine. Cf. Veino v. Barnhart, 312 F.3d 578, 588 (2d Cir. 2002) (“Genuine conflicts in the
medical evidence are for the Commissioner to resolve.”). In this case, all of the physicians who
addressed the issue agreed that plaintiff could not push or pull with his upper right extremity: Dr.
Schottenstein (R. 901); Dr. Katz (R. 728, 737); and Dr. Fkiaras, who also opined that plaintiff had
“a moderate to severe limitation grabbing and squeezing with his right hand” and concluded that
he should be restricted from all activities “which require use of his right upper extremity.” (R.
483.) In the absence of any “genuine conflicts” in the medical evidence, Veino, 312 F.3d at 588,
the Court cannot accept the Commissioner’s contention that the ALJ’s rejection of the push/pull,
reach and torque limitations was based upon his consideration and resolution of such conflicts.
2.
Dr. Fkiaras’s Opinion
While Dr. Schottenstein and Dr. Katz evaluated plaintiff for workers’ compensation
purposes, 4 Dr. Fkiaras examined him on referral from the Division of Disability Determination,
4
For this reason, the ALJ correctly disregarded their ultimate conclusions as to whether, and to
what extent, plaintiff was “disabled.” See, e.g., DeJesus v. Chater, 899 F. Supp. 1171, 1177
(S.D.N.Y. 1995) (“[F]indings of disability for workers’ compensation purposes are of limited
utility for disability purposes under the Social Security Act.”). However, an opinion as to whether
a claimant can push or pull is a functional assessment, not a general disability conclusion, and as
such should not be rejected simply because of the context in which the opinion is rendered. See
Urbanak v. Berryhill, 2018 WL 3750513, at *25 (S.D.N.Y. July 18, 2018), report and
recommendation adopted, 2018 WL 3745667 (S.D.N.Y. Aug. 7, 2018) (“The ALJ properly
afforded ‘little weight’ to Dr. Jacobs’ opinions that plaintiff was 100% disabled for purposes of
workers’ compensation and ‘great weight’ to his functional assessments and observations of
22
for purposes of his DIB application. (R. 480-83.) Nonetheless, Dr. Fkiaras’s opinion goes wholly
unmentioned in the ALJ’s Decision. This was also error, because an ALJ must at least consider
limitations identified by a consultative examiner, see 20 C.F.R. § 404.1527(c) (“we will evaluate
every medical opinion we receive”) and, if those limitations are rejected, must explain why. See,
e.g., Hall v. Colvin, 37 F. Supp. 3d 614, 627 (W.D.N.Y. 2014) (remanding where the ALJ failed
to explain what weight the ALJ gave the opinion of a physician who performed a consultative
examiner of the claimant); Harnisher v. Apfel, 40 F. Supp. 2d 121, 130 (E.D.N.Y. 1999)
(remanding in part because “the ALJ failed to even mention the medical opinions of Dr. Mark
Thomas, who performed a consultative exam on behalf of the Commissioner, and Dr. Michael
Katz, who testified at the first administrative hearing.”). ALJ Grossman may have discounted Dr.
Fkiaras’s opinion for any number of reasons. However, where the record gives no hint of those
reasons – and does not even mention the consultative examiner’s opinion – the Court cannot simply
assume that the required consideration and analysis took place.
D.
Number of Jobs in the National Economy
As noted above, the ALJ presented two different hypotheticals to VE Atkinson. The first
hypothetical asked the vocational expert to assume that the claimant could not use his right upper
extremity at all (R. 121-22), thereby incorporating all of the limitations specified by Dr. Levine
and Dr. Fkiaras. In response, however, Mr. Atkinson identified three jobs with relatively modest
national employment figures (after erosion to account for the hypothetical claimant’s limitations):
usher (after 50% erosion, 2,412 jobs in the national economy); school bus monitor (after 60%
plaintiff during numerous physical examinations.”); Garcia v. Colvin, 219 F. Supp. 3d 1063, 1075
(D. Colo. 2016) (“[W]hile it is true that workers’ compensation standards differ from the Social
Security disability standard, the limitations provided by a workers’ compensation medical provider
are relevant in determining a claimant’s RFC.”).
23
erosion, 432 jobs); and monitor (after 50-60% erosion, 1,823 to 2,279 jobs). (R. 123-25.) VE
Atkinson was not asked for, and did not provide, regional or local employment figures for any of
these three jobs. In sum, therefore, the record contains evidence of between 4,667 and 5,123 jobs
in the national economy that could be performed by the first hypothetical claimant. This is not a
“significant number.” See, e.g., Hanson v. Comm’r of Soc. Sec., 2016 WL 3960486, at *13
(N.D.N.Y. June 29, 2016) (“Courts have held that [national] numbers around between [sic] 4,000
and 5,000 did not constitute “significant.”), report and recommendation adopted, 2016 WL
3951150 (N.D.N.Y. July 20, 2016); Hamilton, 105 F. Supp. 3d at 231 (finding that three positions
regionally and a total of 5,160 nationally did not constitute significant numbers); Torres v. Colvin,
2017 WL 1734020, at *3 (D. Conn. May 3, 2017) (“[I]t is clear to me that 756 laundry laborer jobs
nationally does not constitute a significant number.”).
In response to the second hypothetical – which corresponded to the ALJ’s RFC
determination 5 – VE Atkinson identified four additional jobs: electronics worker (3,437 jobs in
the national economy); office helper (3,728 jobs); information clerk (1,609 jobs); and ticket taker
(6,785 jobs). (R. 126-29) The vocational expert also noted that the second hypothetical claimant
could “do the full . . . usher position” (4,823 jobs), thus providing evidence of a total of at least
20,382 jobs in the national economy that could be performed by an individual with the RFC that
the ALJ formulated for the plaintiff in this case.
5
The second hypothetical asked the vocational expert to assume that the claimant “can lift and
carry 20 pounds with their upper extremity frequently, 10 pound – or, I’m sorry 10 – 20 pounds
occasionally and 10 pounds frequently . . . [A]nd with the right arm can finger – this person no –
okay, with the right arm this person is limited in the following manner. This person has no overshoulder lifting and is limited – just a second, the person can lift ten pounds to the chest level, in
other words no more than that, with no overhead lifting but the person can finger, handle, you
know, fine manipulation frequently.” (R. 121-22, 125-26.)
24
That number may indeed be “significant.” See Hanson 2016 WL 3960486, at *13 (“Courts
have held that numbers varying from 9,000 upwards constituted ‘significant.’”); Gray v. Colvin,
2014 WL 4146880, at *6 (W.D.N.Y. Aug. 19, 2014) (holding that 16,000 jobs in the national
economy was “significant”); Gutierrez v. Comm’r of Soc. Sec., 740 F.3d 519, 529 (9th Cir. 2014)
(characterizing 25,000 jobs in the national economy as a “close call” but affirming the ALJ’s
finding that 25,000 was “significant”). However, because ALJ Grossman’s RFC determination
was based on legal error, evidence that a person with such an RFC could perform work that exists
in significant numbers in the national economy does not satisfy the Commissioner’s burden at step
five. See Calabrese v. Astrue, 358 F. App’x 274, 276–77 (2d Cir. 2009) (the ALJ “may rely on a
vocational expert’s testimony regarding a hypothetical as long as the facts of the hypothetical are
based on substantial evidence.”) (emphasis added).
E.
Harmless Error
The Commissioner argues in the alternative that any error committed by the ALJ in
formulating plaintiff’s RFC was harmless because it “would have no impact on the outcome of the
case.” Def. Mem. at 22-23 (citing Zabala, 595 F.3d at 409). According to the Commissioner, “light
work” generally does not require an employee to push and pull with “both hands bilaterally or with
the dominant hand.” Def. Mem. at 22. In other words, the Commissioner argues that any pushing
or pulling required by the jobs identified by VE Atkinson in response to the second hypothetical
(or by other jobs similarly classified as “light work”) could be done one-handed, with the
employee’s non-dominant hand. The Court disagrees.
1.
Exclusion of Push/Pull, Reach and Torque Limitations
The Commissioner is correct that the omission of Dr. Levine’s push/pull, reach and torque
limitations would be harmless if that omission would not have affected his ultimate disability
determination. See, e.g., Akey v. Astrue, 467 F. App’x 15, 17 (2d Cir. 2012) (“The ALJ’s failure to
25
include the limitation to unskilled and semi-skilled work is harmless because the only jobs the
vocational expert identified were unskilled or semi-skilled.”). However, the sources that the
Commissioner cites do not stand for the proposition that the pushing and pulling contemplated in
“light work” can generally be done with the non-dominant hand alone.
According to 20 C.F.R. § 404.1567(b), a job is considered “light work” when it requires “a
good deal of walking or standing, or when it involves sitting most of the time with some pushing
and pulling of arm or leg controls. To be considered capable of performing a full or wide range of
light work, you must have the ability to do substantially all of these activities.” Similarly, SSR 8310, 1983 WL 31251 (S.S.A. 1983), notes that “light work” involves “sitting most of the time but
with some pushing and pulling of arm-hand or leg-foot controls, which require greater exertion
than in sedentary work; e.g., mattress sewing machine operator, motor-grader operator, and roadroller operator (skilled and semiskilled jobs in these particular instances).” To be sure, some
individuals who have lost the use an upper extremity “have been known to perform selected
occupations at nearly all exertional levels.” SSR 83-12, 1983 WL 31253 (S.S.A. 1983). The key
phrase here, however, is “selected occupations.” Once an individual’s RFC is determined, a
vocational expert may be required “to determine the size of the remaining occupational base, cite
specific jobs within the individual’s RFC, and provide a statement of the incidence of those jobs
in the region of the individual’s residence or in several regions of the country.” Id. Nothing in these
authorities permits the Court to assume that a right-handed claimant who cannot push, pull, reach,
or engage in “any forceful grip, grasp, or torque activities” with his right upper extremity can
nonetheless engage in “light work” in general, much less the specific jobs identified by VE
Atkinson in response to the ALJ’s second hypothetical.
26
The Court has also consulted the Department of Labor’s Dictionary of Occupational Titles
(DICOT), 6 which suggests that at least two of the jobs identified by VE Atkinson in response to
the ALJ’s second hypothetical could not be performed by an individual with push/pull, reach and
torque limitations affecting his dominant upper extremity. See DICOT 726.687-010 ELECTRONICS
WORKER (“Prepares wires for assembly by measuring, cutting, stripping, twisting, tinning, and
attaching contacts, lugs, and other terminal devices, using handtools, and power tools and
equipment.”); DICOT 239.567-010 OFFICE HELPER (“May use office equipment, such as
envelope-sealing machine, letter opener, record shaver, stamping machine, and transcribing
machine.”).
It is possible that the other jobs identified by the vocational expert could be performed by
an individual with all of the limitations found by Dr. Levine. See DICOT 237.367-018
INFORMATION CLERK; DICOT 344.667-010 TICKET TAKER; DICOT 344.677-014 USHER.
However, this Court will not substitute its own speculation for the testimony of a vocational expert
on this point, particularly where the aggregate number of jobs available (nationally) in these three
occupations – assuming no erosion at all as a result of the claimant’s limitations – is only 13,217.
As in Rochek v. Colvin, 2013 WL 4648340, at *12 (W.D. Pa. Aug. 23, 2013), “the better course
here is for the Court to decline to find harmless error, and allow the appropriately evaluated . . .
limitations of the RFC to be explicitly factored into the testimony of the VE, who enjoys the
greatest expertise in this area.”
6
Courts regularly look to the description of jobs in DICOT to conduct harmless error analyses.
See, e.g., Holloman v. Comm’r of Soc. Sec., 639 F. App’x 810, 816 (3d Cir. 2016); Miller v.
Berryhill, 2018 WL 1885013, at *13 (M.D. Pa. Jan. 23, 2018), report and recommendation
adopted, 2018 WL 822662 (M.D. Pa. Feb. 12, 2018).
27
2.
Failure to Consider the Opinion of Dr. Fkiaras
The ALJ’s failure to consider the opinion of Dr. Fkiaras would also be harmless error if it
could not have changed the outcome at the agency level. Greek v. Colvin, 802 F.3d 370, 376 (2d
Cir. 2015); Gemmell v. Comm’r of Soc. Sec., 2017 WL 3328237, at *5 (N.D.N.Y. Aug. 2, 2017)
(“[F]ailure to consider or weigh an opinion may be harmless error where consideration of that
opinion would not have changed the outcome.”) (collecting cases) (citations omitted). An ALJ’s
failure to consider a medical opinion is not harmless, however, where that opinion is significantly
more favorable to the plaintiff than those that were considered, and is not otherwise covered by
other record evidence. See Sottasante v. Colvin, 209 F. Supp. 3d 578, 594 (W.D.N.Y. 2016)
(because “Dr. Tzetzo’s statement is significantly more favorable to Plaintiff than other opinions in
the record,” the ALJ’s “failure to address this opinion was not harmless”). Applying this standard,
the Court cannot conclude that it was harmless error for ALJ Grossman to overlook Dr. Fkiaras’s
opinion.
Dr. Fkiaras included push/pull limitations similar to those of Drs. Levine, Katz, and
Schottenstein, opining that plaintiff should be “restricted from any lifting, carrying, pushing, and
pulling,” and had “a moderate to severe limitation grabbing and squeezing with his right hand.”
(R. 483.) In addition, however, Dr. Fkiaras opined that plaintiff was “restricted from activities
which require use of his right upper extremity.” (Id.) This much broader restriction is not
duplicative of other evidence in the record. Had it been considered and accepted by the ALJ, it
would have resulted in a significantly more restrictive RFC. Moreover, there is no evidence in the
record demonstrating that an individual with that RFC could perform work which exists in
significant numbers in the national or local economy. To the contrary: as noted above, the ALJ’s
first hypothetical to the vocational expert, which assumed that the claimant could not use his right
upper extremity, produced testimony identifying a maximum of 5,123 jobs in the national economy
28
that could be performed by such a claimant. (R. 123-25.) The error was therefore not harmless.
See Rousey v. Comm’r of Soc. Sec., 285 F. Supp. 3d 723, 742 (S.D.N.Y. 2018) (rejecting harmless
error argument where “[t]he Commissioner [did] not explain[] how the ALJ’s RFC finding or the
hypothetical otherwise accounted for plaintiff’s mental health limitations”).
VI.
CONCLUSION
For the foregoing reasons, plaintiff’s motion is GRANTED, the Commissioner’s motion is
DENIED, and this action is REMANDED for further proceedings consistent with this Order.
Dated: New York, New York
November 14, 2018
SO ORDERED.
________________________________
BARBARA MOSES
United States Magistrate Judge
29
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