Nowak v. Colvin
Filing
15
DECISION AND ORDER denying 8 Plaintiff's Motion for Judgment on the Pleadings; granting 12 Commissioner's Motion for Judgment on the Pleadings. (Clerk to close case.) Signed by Hon. Michael A. Telesca on 11/29/17. (JMC)-CLERK TO FOLLOW UP-
UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF NEW YORK
DARRYLL L. NOWAK,
No. 1:15-cv-00424-MAT
DECISION AND ORDER
Plaintiff,
-vsCAROLYN W. COLVIN, Acting
Commissioner of Social Security,
Defendant.
I. Introduction
Represented
by
counsel,
Darryll
L.
Nowak
(“Plaintiff”)
instituted this action pursuant to Titles II and XVI of the Social
Security Act (“the Act”), seeking review of the final decision of
the Acting Commissioner of Social Security (“the Commissioner”)1
denying his application for Disability Insurance Benefits (“DIB”)
and
Supplemental
Security
Income
(“SSI”).
The
Court
has
jurisdiction over the matter pursuant to 42 U.S.C. §§ 405(g),
1383(c).
II. Procedural Status
Plaintiff protectively filed applications for DIB and SSI on
May 3, 2012, alleging disability commencing May 1, 2012. His
applications
were
initially
denied
August
10,
2012.
On
1
Nancy A. Berryhill became the Acting Commissioner of Social Security on
January 20, 2017. Pursuant to Rule 25(d)(1) of the Federal Rules of Civil
Procedure, Nancy A. Berryhill should be substituted, therefore, for Acting
Commissioner Carolyn W. Colvin as Defendant in this suit. No further action need
be taken to continue this suit by reason of the last sentence of section 205(g)
of the Social Security Act, 42 U.S.C. § 405(g).
September 18, 2013, administrative law judge David S. Lewandowski
(“the ALJ”) conducted a hearing in Buffalo, New York, at which
Plaintiff
appeared
with
his
attorney
and
testified,
as
did
impartial vocational expert Esperanza DiStefano (“the VE”). On
December 26, 2013, the ALJ rendered an unfavorable decision.
(T.7-25).2
On
March
25,
2015,
the
Appeals
Council
denied
Plaintiff’s request for review, making the ALJ’s decision the
Commissioner’s final determination. Plaintiff then timely commenced
this action.
Plaintiff and Defendant have cross-moved for judgment on the
pleadings pursuant to Rule 12(c) of the Federal Rules of Civil
Procedure. The Court will discuss the record evidence further
below, as necessary to the resolution of the parties’ contentions.
For the reasons set forth herein, the Commissioner’s decision is
affirmed.
III. The ALJ’s Decision
The
ALJ
applied
the
five-step
sequential
evaluation
promulgated by the Commissioner for adjudicating disability claims.
At step one, the ALJ determined that Plaintiff had not engaged in
substantial gainful activity since May 1, 2012, and that he meets
the Act’s insured status requirements through September 30, 2015.
2
Citations to “T.” in
administrative transcript.
parentheses
-2-
refer
to
pages
in
the
certified
At step two, the ALJ assessed Plaintiff as having one “severe”
impairment: lumbar degenerative changes. The ALJ determined that
Plaintiff’s
major
depressive
disorder,
post-traumatic
stress
disorder (“PTSD”), and history of polysubstance abuse were not
“severe” impairments because they do not cause more than minimal
limitations in his ability to perform work related activities.
At step three, the ALJ found that Plaintiff’s impairments,
considered singly or in combination, do not meet or medically equal
a listed impairment, including Listing 1.04 (Disorders of the
Spine).
Prior to proceeding to step four, the ALJ assessed Plaintiff
as having the residual functional capacity (“RFC”) to perform a
range of light work as defined in 20 C.F.R. §§ 404.1567(b) and
416.967(b), except that he is limited to occasional climbing,
balancing,
stooping,
kneeling,
crouching,
or
crawling;
can
frequently perform overhead activities; and requires a sit/stand
option that can be exercised every 15 minutes.
At step four, the ALJ determined that Plaintiff cannot perform
his past relevant work as a maintenance mechanic, production
laborer, assembler, and assembler supervisor.3
3
Plaintiff stopped working as a mechanic for a chocolate manufacturer on
March 17, 2010, due to corporate downsizing and his decision not to take a
20 percent pay-cut.
-3-
At step five the ALJ relied on the VE’s testimony to conclude
that, given his age, education, work experience, and RFC, he can
the following representative occupations:
(1)
File
Clerk
206.387-034,
(Dictionary
light
of
Occupational
exertion,
semi-skilled
Titles
(SVP
(“DOT”)
3),
with
680 positions regionally, 11,730 positions in New York State, and
158,580 positions nationally); Hotel Desk Clerk (DOT 238.367-038,
light exertion, semiskilled (SVP 4), 730 positions regionally,
8,490
positions
nationally);
and
in
New
York
Companion
State,
(DOT
and
229,000
309.677-010,
light
positions
exertion,
semi-skilled (SVP 3), with 6,340 positions regionally, 127,860
positions in New York State, and 985,230 positions nationally).4
Accordingly, the ALJ found that Plaintiff had not been under a
disability as defined by the Act during the relevant period.
IV.
Scope of Review
A
district
court
may
set
aside
the
Commissioner’s
determination that a claimant is not disabled only if the factual
findings are not supported by “substantial evidence” or if the
4
The Commissioner points out that in his step five finding, the ALJ cited
the VE’s testimony that there were 3 semi-skilled jobs that Plaintiff could
perform, but mistakenly stated that transferability of skills was not material
to that finding. (T.18-19). The Commissioner notes that Plaintiff has not raised
this issue on appeal. In any event, as the Commissioner argues, any error was
harmless, because the VE also identified 3 representative unskilled jobs that he
could perform. (T.54-55). See 20 C.F.R. §§ 404.1568(d), 416.968(d); SSR 82-41,
1982 WL 31389 (S.S.A. 1982); SSR 83-10, 1983 WL 31251 (S.S.A. 1983); Bavaro v.
Astrue, 413 F. App’x 382, 385 (2d Cir. 2011) (unpublished opn.) (recognizing that
an unskilled job is viable at step five regardless of any transferability of
skills from previous job) (citation omitted).
-4-
decision is based on legal error.
42 U.S.C. § 405(g); see also
Green-Younger v. Barnhart, 335 F.3d 99, 105-06 (2d Cir. 2003). The
district court must accept the Commissioner’s findings of fact,
provided that such findings are supported by “substantial evidence”
in the record. See 42 U.S.C. § 405(g) (the Commissioner’s findings
“as to any fact, if supported by substantial evidence, shall be
conclusive”). “Substantial evidence means ‘such relevant evidence
as
a
reasonable
mind
might
accept
as
adequate
to
support
a
conclusion.’” Shaw v. Chater, 221 F.3d 126, 131 (2d Cir. 2000)
(quotation
omitted).
The
reviewing
court
nevertheless
must
scrutinize the whole record and examine evidence that supports or
detracts from both sides. Tejada v. Apfel, 167 F.3d 770, 774
(2d Cir. 1998) (citation omitted). “The deferential standard of
review
for
substantial
evidence
does
Commissioner’s conclusions of law.”
not
apply
to
the
Byam v. Barnhart, 336 F.3d
172, 179 (2d Cir. 2003) (citing Townley v. Heckler, 748 F.2d 109,
112 (2d Cir. 1984)).
V.
Discussion
A.
Failure to Develop the Record in Connection with the Step
Two Severity Determination and Erroneous Weighing of
Treating Source Opinions (Plaintiff’s Point III)
Plaintiff
contends
that
the
ALJ
erred
at
step
two
in
determining that his mental impairments (major depressive disorder,
PTSD,
and
history
of
polysubstance
abuse)
are
not
“severe”
impairments. Plaintiff faults the ALJ for not recontacting his
-5-
treating social worker or obtaining an additional consultative
psychiatric examination. For the reasons discussed below, the Court
finds that the ALJ did not fail to develop the record, and that the
ALJ’s step two finding was supported by substantial evidence.
At step two, the ALJ must determine whether the claimant has
“a severe medically determinable physical or mental impairment that
meets the duration requirement in [20 C.F.R.] § 404.1509, or a
combination of impairments that is severe and meets the duration
requirement.” Cichocki v. Astrue, 534 F. App’x 71, 73–74 (2d Cir.
2013)
(unpublished
opn.).
The
Regulations
provide
that
“[a]n
impairment or combination of impairments is not severe if it does
not significantly limit [a claimant’s] physical or mental ability
to do basic work activities.” 20 C.F.R. § 404.1521 (eff. until
Mar. 27, 2017). “Basic work activities . . . mean the abilities and
aptitudes necessary to do most jobs[.]” Id. As relevant to mental
impairments,
“(3)
“[b]asic
[u]nderstanding,
work
carrying
activities”
out,
and
remembering
include
simple
instructions; (4) [u]se of judgment; (5) [r]esponding appropriately
to
supervision,
co-workers
and
usual
work
situations;
and
(6) [d]ealing with changes in a routine work setting.” 20 C.F.R.
§ 404.1521(b) (eff. until Mar. 27, 2017).
As
discussed
further
below,
the
ALJ
correctly
weighed
consultative psychologist Dr. Renee Baskin’s report, which provides
substantial evidence to support the ALJ’s step two finding. In
-6-
addition,
the
ALJ
correctly
weighed
the
report
of
treating
therapist Rachel C. Lauria, LMSW (“LMSW Lauria”)which was vague,
incomplete,
and,
in
any
event,
fails
to
support
Plaintiff’s
argument that the ALJ’s step two finding was erroneous.
1.
Erroneous Weighing of Consultative Psychologist’s
Report and Failure to Request Second Consultative
Examination
Plaintiff argues that the ALJ erroneously gave significant
weight to the opinion (T.280-83) of Dr. Baskin, who conducted a
consultative psychiatric examination of Plaintiff on July 6, 2012.
Plaintiff reported some apprehension and worry, and dysphoric
moods, but he denied nightmares, flashbacks, or any other PTSD
symptoms. (T.280-81). He also denied manic symptomatology, thought
disorder
symptomatology,
(T.281).
Dr.
Baskin
or
noted
cognitive
that
symptomatology/deficits.
Plaintiff
was
cooperative,
responsive to questions; his manner of relating, social skills, and
overall presentation all were adequate. (Id.). Plaintiff’s affect
“was
of
full
range
and
appropriate
in
speech
and
thought
content[;]: his mood was “pleasant, polite, personable, and easily
engaged.” (T.281-82). Plaintiff’s attention and concentration were
intact, as were his recent and remote memory skills. (T.282).
Dr. Baskin estimated that Plaintiff’s intellectual function was in
the low average range, and his general fund of information was
appropriate to his experience level. (Id.). For her medical source
statement, Dr. Baskin opined that with
-7-
regard to his vocational
functional capacities, Plaintiff has “minimal to no limitations
being
able
to
instructions,
follow
perform
and
understand
simple
tasks
simple
directions
independently,
and
maintain
attention and concentration, maintain a regular schedule, learn new
tasks,
perform
complex
tasks
independently,
make
appropriate
decisions, relate adequately with others and appropriately deal
with
stress.”
(Id.).
According
to
Dr.
Baskin,
Plaintiff’s
“psychiatric problems” were “not significant enough to interfere
with [his] ability to function on a daily basis.” (T.283).
Dr. Baskin’s report finding “minimal to no limitations” in his
ability to perform the types of basic work activities typically
affected by mental impairments is consistent with Plaintiff’s own
statements in the record about his symptomatology. In a function
report submitted with his disability applications, Plaintiff stated
that he had trouble remembering where he put things, such as minor
misplacements of objects, but he had no problems paying attention.
(T.159-60). Although he was not always able to finish what he
started because pain caused him to take breaks from physical
activity, he was able to follow spoken and written instructions,
and he had no problems getting along with people in authority.
(T.159-60). He admitted that, at the time, he was not receiving any
treatment for his pain apart from taking Meloxicam, a non-steroidal
anti-inflammatory medication. (T.161-62). Plaintiff went outside,
usually on a daily basis, and he was able to go outside by himself.
-8-
(T.155). He traveled by walking and using public transportation,
and shopped in stores for groceries and other items twice a month.
(T.156). He attended class at Erie County Community College (“ECC”)
3 to 6 days per week during the summer, and 6 days per week while
school was in session. (T.157). He spent time weekly with family
members. Plaintiff stated that his anxiety symptoms were now
controlled
by
medication
that
he
received
from
his
general
practitioner and mindfulness/relaxation techniques that he had
previously learned in treatment. (T.162-63). His panic attacks now
occurred “very seldom.” (T.163). His anxiety did not result in any
difficulties
in
socializing
with
others.
(T.164).
Indeed,
as
compared to this function report, Plaintiff reported fewer symptoms
related to his depression, anxiety, and PTSD during his subsequent
examination with Dr. Baskin.
Plaintiff notes that Dr. Baskin’s assessment was conducted
only 2 months after he filed his disability applications, and
argues
period.
that
This
his
condition
contention
is
worsened
belied
throughout
by
the
the
record,
disability
including
Plaintiff’s testimony at the September 18, 2013 administrative
hearing. Plaintiff testified that he had started working at a
bowling alley as a pin-setter mechanic and general handyman on
September 13, 2013, for 8 to 9 hours per week. Plaintiff stated
that he could “only concentrate for short periods of time, half
hour, 45 minutes max before the pain and the anxiety begin to set
-9-
in,” and he has to take a break. (T.44). When asked about his
anxiety specifically, Plaintiff did not describe any particular
symptoms, but responded that he thought that his anxiety came “from
the years of drug and alcohol abuse and it just set in at that
point where [he’s] still learning how to cope with life.” (T.44).
As far as his PTSD, he said he has “[s]light flashbacks now.”
(T.45).
Plaintiff further testified that he was attending school at
Buffalo
State
mechanical
College
engineering,
(“BSC”)
and
for
electrical
computer
engineering,
information
systems.
(T.47-49). He attended classes Monday through Friday, and had 1 to
3 classes per day, with breaks in between. R47-48. Prior to that,
he had attended ECC for 2 years, and he was on the Dean’s List for
3 of 4 semesters. (T.48-49). At the time of the hearing, he had not
received grades yet for the current semester, but he thought he was
doing “fairly well.” (T.49).
Dr. Baskin’s report is also consistent with other evidence
cited by the ALJ. The treatment records from primary care physician
Dr. Antonia Redhead between May 2012, and June 2013, document that
Plaintiff had a normal mood and affect. When he complained of
depressive symptoms, he rated them as only mild in severity.
(T.361). The mental health treatment records from Lake Shore
Behavioral Health Franklin Counseling Clinic (“Lake Shore Clinic”)
show improvement in Plaintiff’s symptoms by July 2013, when he was
-10-
noted to be working part-time and attending school. Plaintiff
reported increased self-esteem as the result of his increased
social and vocational activity, along with a marked reduction in
symptoms of trauma and depression. (T.388-90). Since Plaintiff
appeared stable, the frequency of his visits to the Lake Shore
Clinic was reduced from weekly to every 2 weeks. (T.388, 392). A
treatment
plan
prepared
at
Lake
Shore
Clinic
indicated
that
Plaintiff’s strengths included his abilities to work part-time and
attend school. (T.392).
Where
record,”
there
and
the
are
“no
ALJ
obvious
already
gaps
possesses
in
a
the
administrative
“complete
medical
history,” the Second Circuit has consistently held that the ALJ is
under
no
obligation
to
seek
additional
information
prior
to
rejecting a disability benefits claim. E.g., Rosa v. Callahan, 168
F.3d 72, 79 n.5 (2d Cir. 1999). The administrative transcript here
contains all of Plaintiff’s treatment records. As discussed above,
they do not demonstrate a worsening of Plaintiff’s mental health
condition over time. There is thus no indication that the opinion
offered by consultative psychologist Dr. Baskin had become stale in
the intervening period. Under these circumstances, the Court finds
the ALJ did not fail in his duty to ensure there was a complete
record on which to base his decision.
-11-
2.
Erroneous
Report
Weighing
of
Treating
Social Worker’s
On April 15, 2013, Plaintiff’s treating therapist, Rachel C.
Lauria, LMSW (“LMSW Lauria”), submitted a letter indicating that
Plaintiff had received treatment at the Lake Shore Clinic since
March 11, 2013, but he was not prescribed medication through that
provider. (T.398). She stated that Plaintiff had “difficulties
related to his mental health diagnosis that interfere with his
daily functioning.” However, she noted that the clinic “cannot
provide adequate information related to questions posed on this
form [Mental Medical Source Statement] and do not observe or have
any opportunity to determine how a person responds in a work
environment.” (T.398). Accordingly, LMSW Lauria only partially
completed the attached Mental Medical Source Statement. (T.399404). She only answered the questions on 1 page, and struck through
the portions of the form requesting that she provide ratings
regarding Plaintiff’s mental abilities and attitudes needed to do
unskilled
work,
semi-skilled,
and
skilled
work,
his
stress
tolerance, and his likely rate of absenteeism due to his mental
impairments. Thus, LMSW Lauria’s report substantively is of very
little utility. The only “opinion” she provided—that Plaintiff has
“difficulties related to his mental health diagnosis that interfere
with his daily functioning”—is too vague to be of any use in
assessing
Plaintiff’s
RFC.
Finally,
LMSW
Lauria
is
not
an
acceptable medical source under the Regulations, and her opinion is
-12-
not a “medical opinion” entitled to controlling weight even when it
concerns an impairment within the realm of her expertise. See Diaz
v. Shalala, 59 F.3d 307, 314 & n.8 (2d Cir. 1995).
B.
Erroneous
Weighing
of
Treating
Physician’s
and
Consultative Physician’s Opinions (Plaintiff’s Points I
and IV)
A treating physician’s opinion on the issues of the nature and
severity of a claimant’s impairments is accorded controlling weight
when it is well-supported by medically acceptable clinical and
laboratory diagnostic techniques, and is not inconsistent with the
other
substantial
evidence
in
the
record.
See
20
C.F.R.
§§ 404.1527(c)(2), 416.927(c)(2); Halloran v. Barnhart, 362 F.3d
28, 32 (2d Cir. 2004). When an ALJ declines to accord a treating
physician’s opinion controlling weight, he must consider several
factors, including the length, nature and extent of the treatment
relationship; the frequency of examination; the supportability of
the opinion; the consistency of the opinion; and whether the
treating source is a specialist. See 20 C.F.R. § 404.1527(c)(1)(6); § 416.927(c)(1)-(6). These factors are also to be considered
with regard to non-treating acceptable medical sources, such as
consultative
physicians
and
psychiatrists.
See
20
C.F.R.
§ 404.1527(a)(1), (c), (e); 20 C.F.R. § 404.1513(a)(1), (2) (eff.
until
Mar.
26,
2017);
20
C.F.R.
§
416.927(a)(1),
(c),
20 C.F.R. § 416.913(a)(1), (2) (eff. until Mar. 26, 2017).
-13-
(e);
Here, on October 15, 2013, Plaintiff’s treating primary care
physician Dr. Antonia Redhead completed a form titled, “Lumbar
Spine Medical Source Statement.” (T.406-09). She noted she had
treated Plaintiff for lower back pain every 3 months over the
course of 3 years. With regard to the clinical findings that show
Plaintiff’s
impairments,
she
listed
MRI
findings
of
“disc
degeneration at L5-S1 facet hypertrophy at L3-L4 [with]
disc
bulge, narrowing bilateral neural foramina.” (T.406). Plaintiff
argues that the results of this MRI is only consistent with a
finding of disability, but in a form submitted to the Social
Security Administration on January 11, 2013, in response to a
question regarding what his doctors had told him about his back
condition, Plaintiff stated that “no direct indication has been
given
from
the
MRI.”
(T.201).
Furthermore,
Dr.
Redhead’s
characterization of the MRI findings is misleading, since she
omitted the words qualifying the degree of abnormalities seen.
Namely, the degenerative changes were “mild;” the disc bulging was
“mild” and “diffuse;” the narrowing of the neural foramina was
“mild
to
moderate
at
L4-L5;”
and
while
there
was
“moderate
narrowing of the bilateral neural foramina” at L5-Sl, there was “no
significant spinal canal stenosis.” (T.336-38).
Asked to identify Plaintiff’s symptoms, Dr. Redhead listed
“severe back pain with limited range of motion [and] anxiety.”
(Id.). She opined that Plaintiff would be able to walk 4 city
-14-
blocks without resting or severe pain, sit for 30 minutes at a
time, stand for 30 minutes at a time, sit for about 4 hours in an
8-hour day, stand for about 2 hours in an 8-hour day, requires a
sit/stand option, needs to walk for about 10 minutes at a time
every 30 minutes, will need 2 to 3 unscheduled 10- to 15-minute
breaks a day, does not need to elevate his legs when sitting, can
occasionally lift 10 pounds, can never twist or climb ladders, can
occasionally stoop (bend) and crouch/squat, and can frequently
climb stairs. (T.407-08). The foregoing limitations assessed by
Dr. Redhead are not necessarily indicative that Plaintiff is
disabled.
In
particular,
her
opinions
that
Plaintiff
could
occasionally stoop (bend) and crouch/squat, and frequently climb
stairs, are consistent with the ALJ’s RFC finding. (T.15, 408).
Moreover, although Dr. Redhead opined that Plaintiff needed the
ability to sit and stand at will, she also stated that Plaintiff
could sit for 30 minutes before needing to get up, which is
consistent with the ALJ’s inclusion of a sit/stand option that
could be exercised every 15 minutes. (T.17, 407). In addition,
Dr. Redhead estimated that Plaintiff could stand for 2 hours total,
walk for 2 hours total, and sit for 4 hours total in an 8-hour day.
While this level of physical exertion is more restrictive than the
ALJ’s RFC finding for a range of light work with a sit/stand
option, the ALJ reasonably concluded that Dr. Redhead’s opinion was
-15-
not well-supported by her clinical findings and was inconsistent
with the medical record.
For
instance,
on
May
1,
2012,
his
alleged
onset
date,
Plaintiff presented to Dr. Redhead to follow up regarding his
psoriasis
and
PTSD;
he
had
“no
new
complaints.”
(T.275).
Dr. Redhead noted that Plaintiff had normal gait and station, was
able to rise in a single motion, and had no reports of back pain.
(T.275-76).
Although
lower
back
pain
was
listed
as
one
of
Plaintiff’s diagnoses, he was not prescribed any medication or
treatment for back pain.
(T.276-77). Two months later, on July 6,
2012, Plaintiff presented for a consultative internal examination
with Hongbiao Liu, M.D. (T.284-88), and reported “constant” “sharp”
neck and back pain rated at a 7 to 8, without radiation to the
legs, which was “secondary to the [sic] sports activity when he was
15 years old.” (T.284). On examination, Dr. Liu observed lumbar
spine flexion and extension to 75 degrees, lumbar lateral flexion
to 15 degrees on the right and left, and lumbar rotary movement to
15 degrees on the right
and left.5 Straight leg raising was
positive bilaterally (supine and sitting). (T.286). Plaintiff had
5
Basic ranges of motion for the lumbar spine are as follows: flexion
(80 to 90 degrees), extension (30 degrees), lateral flexion (20 degrees), and
rotation (45 degrees). See
http://www.ssas.com/disability-medical-tests/musculoskeletal/range-of-motion-t
est/ (last accessed Nov. 28, 2017). Thus, Plaintiff’s flexion and lateral
flexion ROMs are only 5 degrees below the “normal” range. His extension ROM
appears to be greater than normal, but that is perhaps a typographical error
by Dr. Liu and should instead read 15 degrees. His rotary movement ROM is
30 degrees less than “normal” but, overall, his lumbar spine ROMs are not far
from “normal.”
-16-
full range of motion in his hips, knees, and ankles bilaterally,
and full range of motion in his shoulders, elbows, forearms, and
wrists bilaterally. He had full strength in his upper and lower
extremities
bilaterally,
intact
hand
and
finger
dexterity
bilaterally, and full grip strength bilaterally. (T.286). An x-ray
of the lumbar spine on July 16, 2012 was negative. (T.286).
Plaintiff had no difficulty getting on and off the examination
table, needed no assistance changing, used no assistive devices,
and was able to rise from the chair without difficulty. For his
medical source statement, Dr. Liu opined that Plaintiff has “mild
to moderate limitation for his routine activities” and “should try
to
avoid
lifting,
carrying,
bending,
and
overhead
reaching.”
(T.287) (emphasis supplied). Dr. Liu did not specify what was meant
by “routine activities.”
The ALJ assigned “some weight” to Dr. Liu’s report, which
Plaintiff contends supports an RFC for less than sedentary work.
According to Plaintiff, Dr. Liu opined that Plaintiff should “avoid
lifting, carrying, bending, and overhead reaching[,]” (Plaintiff’s
Brief
at
16
(citing
T.287)).
Plaintiff
argues
that
“these
restrictions on lifting, carrying, and bending clearly prevent
[him] from performing even a sedentary job.” (Id.). However,
Plaintiff
misquotes
Dr.
Liu’s
report,
which
was
much
more
equivocal; Dr. Liu actually stated that Plaintiff “should try to
avoid lifting, carrying, bending, and overhead reaching.” (T.287)
-17-
(emphasis supplied). Moreover, a limitation totally precluding
Plaintiff from lifting, carrying, bending, and overhead reaching
would not be consistent with Dr. Liu’s essentially normal clinical
findings and observations, discussed above. And, such a restrictive
limitation would not be consistent with Dr. Redhead’s opinion or
Plaintiff’s own statements about his daily activities.
C.
Failure to Consider Social Security Ruling Regarding Use
of Handheld Assistive Device (Plaintiff’s Point II)
Plaintiff contends that the ALJ erred by not specifically
considering Dr. Redhead’s opinion that Plaintiff required a cane
for
occasional
considering
standing
TITLES
II
&
or
walking,
XVI:
and
DETERMINING
by
not
specifically
CAPABILITY
TO
DO
OTHER
WORK–IMPLICATIONS OF A RESIDUAL FUNCTIONAL CAPACITY FOR LESS THAN A FULL RANGE
OF SEDENTARY WORK, SSR 96-9p, 1996 WL 374185 (S.S.A. July 2, 1996).
SSR 96-9p addresses the effect of a “[m]edically required
hand-held assistive device,” such as a cane, on occupational the
base
of
sedentary
required,”
the
work.
claimant
For
a
must
cane
to
produce
be
deemed
“medical
“medically
documentation
establishing the need for a handheld assistive device to aid in
walking or standing, and describing the circumstances for which it
is needed, (i.e., whether all the time, periodically, or only in
certain situations; distance and terrain; and any other relevant
information).” SSR 96-9p, 1996 WL 374185, at *7. SSR 96-9p states
that “[t]he adjudicator must always consider the particular facts
of a case.” Id. From this sentence, Plaintiff extrapolates that “an
-18-
ALJ must make a specific finding when a claimant needs to use a
cane or
other
assistive
device
for
more
than
just
prolonged
ambulation.” (Plaintiff’s Brief at 18). The Court is doubtful that
SSR 96-9p imposes the fact-finding requirement articulated by
Plaintiff, but even if it did, there is not substantial evidence in
the record supporting a finding that Plaintiff’s use of a cane is
“medically
required,”
or
that
it
significantly
eroded
the
occupational base of sedentary work.
Dr. Redhead stated in her RFC opinion that Plaintiff required
a cane for “occasional” standing or walking. However, Dr. Redhead’s
clinical findings during her physical examinations of Plaintiff
indicate that he had a normal gait and the ability to rise from
sitting to standing in a single motion. (See, e.g., T.275-76, 317,
319, 323, 325, 334, 336, 358, 360, 361, 363, 365, 367). Moreover,
she does not mention that Plaintiff is using a cane; nor do her
treatment notes indicate that she has issued a prescription for a
cane. Likewise, Plaintiff did not use any assistive device during
Dr. Liu’s July 6, 2012 consultative examination, and Dr. Liu did
not state that Plaintiff required the use of a cane. Notably, the
one occasion on which was Plaintiff specifically was prescribed a
cane was in connection with his May 2013 diagnosis of onychomycosis
(fungal infection of the toenails) and subsequent surgical removal
of his toenails—not for his lumbar back pain. (T.366).
-19-
SSR 96-9p specifically notes that “[s]ince most unskilled
sedentary work requires only occasional lifting and carrying of
light objects such as ledgers and files and a maximum lifting
capacity for only 10 pounds, an individual who uses a medically
required hand-held assistive device in one hand may still have the
ability to perform the minimal lifting and carrying requirements of
many sedentary unskilled occupations with the other hand.” SSR 969p, 1996 WL 374185, at *7 (footnote omitted). As an example, SSR
96-9p posits “an individual who must use a hand-held assistive
device to aid in walking or standing . . . to reduce pain when
walking, who is limited to sedentary work because of the impairment
affecting the lower extremity, and who has no other functional
limitations or restrictions may still have the ability to make an
adjustment to sedentary work that exists in significant numbers.”
Id. This hypothetical individual describes Plaintiff’s situation.
He stated in his June 6, 2012 function report that he used a cane
only as necessary, specifically, “when need [sic] to assist in
getting to places.” (T.15-16, 159). Plaintiff also testified that
he was performing work as a pin setter mechanic at a bowling alley
for 8 or 9 hours one day a week; although he stated that this work
activity exacerbated his back pain, he did not that his ability to
perform this work was impeded by the use of a cane. In addition,
Plaintiff attended college throughout the relevant period, which
required him to walk to get to his classes; at the time of the
-20-
administrative hearing, he was attending classes 5 days per week.
In sum, the record does not contain substantial evidence supporting
Plaintiff’s
argument
that
his
occasional
use
of
a
cane
significantly eroded the occupational base for sedentary work. Any
error by the ALJ in not making a specific factual finding therefore
is harmless.
VI.
Conclusion
For
the
foregoing
reasons,
the
Court
finds
that
the
Commissioner’s decision was not legally erroneous and is supported
by substantial evidence. It therefore is affirmed. Accordingly,
Defendant’s motion for judgment on the pleadings is granted, and
Plaintiff’s motion for judgment on the pleadings is denied. The
Clerk of Court is directed to close this case.
SO ORDERED.
S/Michael A. Telesca
HON. MICHAEL A. TELESCA
United States District Judge
Dated:
November 29, 2017
Rochester, New York.
-21-
Disclaimer: Justia Dockets & Filings provides public litigation records from the federal appellate and district courts. These filings and docket sheets should not be considered findings of fact or liability, nor do they necessarily reflect the view of Justia.
Why Is My Information Online?