Anauo v. Colvin
Filing
17
DECISION AND ORDER that Defendants Motion for Judgment on the Pleadings is denied, and Plaintiffs Motion for Judgment on the Pleadings is granted to the extent that the Commissioners decision is reversed, and the matter is remanded for further admini strative proceedings consistent with this Decision and Order. Specifically, the ALJ is directed to develop the record fully by having all of Dr. Scozzaros handwritten treatment notes, reports, and questionnaires transcribed. The ALJ is then directed to evaluate Dr. Scozzaros treating source reports and opinions in light of the appropriate regulatory factors and in accordance with the case law discussed above, re-assess the weight to be given Dr. Scozzaros opinions, and, if necessary, re-formulate Plaintiffs RFC.(The Clerk of the Court is directed to close this case.) Signed by Hon. Michael A. Telesca on 12/16/16. (JMC)-CLERK TO FOLLOW UP-
UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF NEW YORK
RACHEL ANAUO,
No. 1:15-cv-00933(MAT)
DECISION AND ORDER
Plaintiff,
-vsCAROLYN W. COLVIN, Acting
Commissioner of Social Security,
Defendant.
INTRODUCTION
Represented by counsel, Rachel Anauo (“Plaintiff”) brings this
action pursuant to Title II of the Social Security Act (“the Act”),
seeking review of the final decision of the Commissioner of Social
Security
(“the
Commissioner”)
denying
her
application
for
Disability Insurance Benefits (“DIB”). The Court has jurisdiction
over this matter pursuant to 42 U.S.C. § 405(g).
PROCEDURAL STATUS
On
September
13,
2012,
Plaintiff
protectively
filed
an
application for DIB, alleging disability since June 6, 2012, due to
major depression, anxiety, panic attacks, chronic bilateral plantar
fasciitis, and high blood pressure. After her application was
denied
on
November
29,
2012,
a
hearing
was
held
before
administrative law judge David S. Lewandowski (“the ALJ”) on
January 15, 2014, at which Plaintiff and her attorney appeared.
(T.34-64). Josiah
L.
Pearson, an
impartial
vocational
expert
(“the VE”), also appeared and testified at the hearing.
On
June 23, 2014, the ALJ issued a decision finding Plaintiff not
disabled. (T.16-33). That decision became the Commissioner’s final
decision on September 3, 2015, when the Appeals Council denied
Plaintiff’s request for review. This timely action followed.
The parties have filed cross-motions for judgment on the
pleadings pursuant to Rule 12(c) of the Federal Rules of Civil
Procedure. The Court adopts and incorporates by reference herein
the undisputed and comprehensive factual summaries contained in the
parties’ briefs. Plaintiff does not challenge the physical aspect
of the ALJ’s RFC assessment, so the Court will limit its recitation
of the medical evidence to the opinions issued by Plaintiff’s
treating
psychiatrist,
her
therapist,
and
the
consultative
psychologist who examined Plaintiff at the Commissioner’s request.
For the reasons discussed below, the Commissioner’s decision
is reversed, and the matter is remanded for development of the
record with regard to Plaintiff’s treating psychiatrist and for reapplication of the treating physician rule.
SUMMARY OF RELEVANT OPINION EVIDENCE
I.
Treating Psychiatrist Phillip Scozzaro, M.D.
A.
The Letter Reports
On September 17, 2012 (T.346); October 4, 2012 (T.352);
November
12,
2012
(T.350);
February
20,
2013
(T.353);
and
August 12, 2013 (T.354), Dr. Scozzaro issued letter reports, at the
request of an individual or entity who is not identified in the
-2-
record, regarding her disability status. Dr. Scozzaro explained
that Plaintiff had stopped working as a drug abuse counselor in
April
2012.
After
having
a
total
hysterectomy,
she
began
experiencing severe menopausal symptoms that rendered incapable of
accomplishing her work, and she was terminated from her job.
(T.352). She was unable to take estrogen, the usual treatment for
severe
menopausal
symptoms,
because
she
had
a
genetic
predisposition to breast cancer; her sister had had breast cancer
at age 40. Dr. Scozzaro noted that Plaintiff also suffered from
binge or stress eating at night after working, that she had trouble
losing weight, and had thought of suicide but not seriously. In the
September 2012 report, Dr. Scozzaro opined Plaintiff’s prognosis
was “fair to poor for returning to work in the next year.” (T.352).
He planned to adjust her depression medications and continue to see
her in counseling.
On November 12, 2012, Dr. Scozzaro stated that Plaintiff had
cyclothymic disorder and ongoing post-menopausal symptoms which
seemed better with gynecological treatment (though she still was
unable
to
take
estrogen).
(T.350-51).
Dr.
Scozzaro
opined
Plaintiff’s prognosis was “very poor for returning to work in the
next
Dr.
year
or
Scozzaro
two
.
.
completed
.”
(T.351).
another
report
On
February
regarding
20,
2013,
Plaintiff’s
disability, and opined that her prognosis “very poor for returning
to work in the next year or two . . .” (T.353).
-3-
On August 12,
2013, Dr. Scozzaro submitted another letter report, noting her
continued diagnoses of cyclothymic disorder and post-menopausal
symptoms. (T.354). She had started taking lithium in November 2012
for her fluctuating moods, with some improvement noted by her and
her husband. She was also taking Zoloft, and had discontinued
Buspar and Klonopin.
He opined that her prognosis was still “very
poor for returning to work in the next year or two.” (T.354). He
considered her disabled at that time from “any employment, mental
or physical [sic].” (T.354).
B.
Mental Residual Functional Capacity Questionnaire
On January 6, 2014, Dr. Scozzaro completed a Mental Residual
Functional Capacity Questionnaire at the Commissioner’s request.
(T.378-82). He noted that he treated Plaintiff for about a year and
a half on a monthly basis. She had been without health insurance
since June 30, 2012, to January 1, 2014 and had to pay for her
visits. Her diagnoses were cyclothymia with severe panic attacks,
depression, and personality disorder. She was taking lithium and
had no major side effects. Dr. Scozzaro noted that bipolar disorder
should be ruled out when she obtains insurance coverage. Her
diagnoses were chronic but stable, though she had only made modest
gains during treatment. Dr. Scozzaro assessed a GAF score of 40.
Dr. Scozzaro’s clinical findings included depression, not
being socially rounded, withdrawing into herself and not contacting
friends and hardly reacting to her husband. He opined that her
-4-
prognosis was poor to fair. Her total hysterectomy on February 22,
2012, caused a sudden estrogen-level drop, leading to stress and
panic attacks, which Dr. Scozzaro characterized as “the big reason
[she] had to stop working.” (T.378).
Dr. Scozzaro indicated Plaintiff had the following signs and
symptoms:
appetite
disturbance
with
weight
change;
decreased
energy; passive thoughts of suicide; blunt, flat or inappropriate
affect; hyperactivity with anxiety; motor tension; overeating as an
impairment in impulse control; poverty of content of speech;
generalized
thinking;
persistent
psychomotor
anxiety;
mood
disturbance;
difficulty
agitation
or
retardation;
persistent
disturbances of mood or affect; change in personality; apprehensive
expectation; emotional withdrawal or isolation; psychological or
behavioral abnormalities associated with a dysfunction of the brain
with a specific organic factor judged to be etiologically related
to the abnormal mental state and loss of previously acquired
functional abilities since her operation in February 22, 2012;
bipolar syndrome with a history of episodic periods of both manic
and depressive syndromes; emotional lability; flight of ideas;
manic syndrome, but sometimes depression lasted longer; overeating
as a deeply ingrained, maladaptive pattern of behavior; easy
distractibility; short-term memory impairment; sleep disturbance by
increased or decreased hot flashes; decreased need for sleep at
times; loss of intellectual ability; and recurrent severe panic
-5-
attacks manifested by a sudden unpredictable onset of intense
apprehension, fear, terror and sense of impending doom occurring on
the average of at least once a week. (T.378-79).
Dr. Scozzaro indicated that Plaintiff had no useful ability to
function
with
regard
to
maintaining
attention
for
two-hour
segments; maintaining regular attendance and being punctual within
customary,
usually
strict
tolerances;
sustaining
an
ordinary
routine without special supervision; completing a normal workday
and workweek
without
interruptions
from
psychologically
based
symptoms; performing at a consistent pace without an unreasonable
number and length of rest periods; accepting instructions and
responding appropriately to criticism from supervisors; dealing
with normal work stress; understanding and remembering detailed
instructions; carrying out detailed instructions; and dealing with
stress associated with semiskilled and skilled work. (T.380). He
also indicated that Plaintiff was “seriously limited”1 in her
ability to remember work-like procedures; understand and remember
very short and simple instructions; carry out very short and simple
instructions; work in coordination with or proximity to others
without
being
unduly
distracted;
make
simple
work-related
decisions; respond appropriately to changes in a routine work
1
The questionnaire defined “seriously limited” to mean that the
individual’s ability to function in that area was seriously limited
and would frequently be less than satisfactory in any work setting.
(T.379).
-6-
setting; set realistic goals and make plans independently of
others; interact appropriately with the general public; maintain
socially appropriate behavior; and travel in an unfamiliar place.
(T.380-81).
Dr. Scozzaro explained that Plaintiff’s limitations were due to her
depression since February 22, 2012. (Tr. 381). He noted that her IQ
had not been tested but that her thinking ability decreased as a
result of her depression. He indicated that Plaintiff’s psychiatric
condition exacerbated her experience of pain and any other physical
symptoms, making her more sensitive to pain. In Dr. Scozzaro’s
opinion, if Plaintiff attempted to return to even low stress
employment in which she would only have to occasionally interact
with co-workers and supervisors, it would lead to an exacerbation
of her symptoms that would prevent her from performing full-time,
competitive employment. (T.381). He further opined that Plaintiff’s
symptoms would lead to an inability to stay on task for even simple
task work tasks for more than 20% of an 8-hour workday. (T.381).
Dr. Scozzaro opined that Plaintiff would be unable to complete a
normal
workday
and
workweek
without
interruptions
from
psychologically based symptoms, or to perform at a consistent pace
without an unreasonable number and length of rest periods. He
anticipated that Plaintiff’s impairments or treatment would cause
her to be absent from work more than 4 days per month. Plaintiff’s
impairment lasted or was expected to last at least 12 months. He
-7-
stated that Plaintiff was not a malingerer. The unpredictability of
when Plaintiff’s symptoms appeared would also cause her difficulty
in working at a regular job on a sustained basis. Dr. Scozzaro
opined
that
Plaintiff
has
been
limited
as
stated
in
the
questionnaire since at least April 13, 2012. He further opined that
Plaintiff had been
unable to engage in full-time competitive
employment on a sustained basis at any time since April 13, 2012.
As a post-script, Dr. Scozzaro noted that the usual treatment for
Plaintiff’s surgically-induced menopause was hormone replacement
therapy which was not possible for Plaintiff because of her genetic
predisposition to breast cancer.
II.
Treating Therapist Lucia Wronski, LCSW-R
Registered licensed master social worker (“LCSW-R”) Lucia
Wronski of Counseling and Enrichment Resource Center (“CERC”), at
the
Commissioner’s
“Information
request,
Request”
on
completed
an
a
unspecified
brief
date.
form
titled
(T.276).
She
indicated that she had treated Plaintiff on May 16, 2012; May 21,
2012; June 4, 2012; June 13, 2012; July 23, 2012; August 3, 2012;
August 23,
2012;
September 6,
2012;
and
September
25,
2012.
(T.276). Although the form did not ask for any commentary, LCSW-R
Wronski noted that Plaintiff was diagnosed with moderate depression
which impeded her ability to function efficiently in a job and in
certain tasks of daily living. (T.276).
-8-
III. Consultative Psychologist Susan Santarpia, Ph.D.
On , Upon mental status examination, Dr. Santarpia found that
Plaintiff’s demeanor and responsiveness to Manner of relating and
overall; she was dressed neatly and well-groomed; motor behavior
was normal and eye contact was appropriate; and thought processes
were coherent and goal directed with no evidence of hallucinations,
delusions , or paranoia in the evaluation setting. Plaintiff’s
affect was of full range and appropriate in speech and thought
content; her mood was neutral. Her attention and concentration were
“[g]rossly intact” insofar as Plaintiff could do simple one-step,
but not two-step, mathematical calculations, and correctly did
serial subtraction. Plaintiff’s recent and remote memory skills
were
“[i]ntact”
insofar
as
she
could
recall
3-of-3
objects
immediately, and 3-of-3 objects after a delay; and she could recite
5 digits forward and 3 digits in reverse order. Dr. Santarpia
“[e]stimated”
Plaintiff’s
cognitive
functioning
to
be
in
the
“average range of ability,” with a general fund of information that
was “appropriate to experience.” Plaintiff’s insight and judgment
were both “[f]air.” Dr. Santarpia indicated diagnoses of depressive
disorder, not otherwise specified (“NOS”) and anxiety disorder,
NOS.
For her medical source statement, Dr. Santarpia stated that
Plaintiff
“presents
as
able
to
follow
and
understand
simple
directions and instructions, perform simple tasks independently,
-9-
maintain attention and concentration, maintain a regular schedule,
learn new tasks, make appropriate decisions, relate adequately with
others, and appropriately deal with stress within normal limits[,]”
although
she
demonstrates
complex
tasks
“[m]ild
independently.”
impairment”
“performing
Santarpia
Dr.
in
commented,
“Difficulties are caused by lack of motivation.” Dr. Santarpia
concluded
that
the
results
of
the
evaluation
appear
to
be
consistent with psychiatric problems which, in and of themselves,
do
“not
appear
to
be
significant
enough
to
interfere
with”
Plaintiff’s “ability to function on a daily basis.”
THE ALJ’S DECISION
At step one of the sequential evaluation, the ALJ found that
Plaintiffs meets the insured status requirements of the Act through
December 31, 2016, and had not engaged in substantial gainful
activity since June 6, 2012, the alleged onset date.
At
step
two,
the
ALJ
determined
that
Plaintiff
has
the
following severe impairments, meaning that they significantly limit
her ability to perform basic work activities: neuropathy in feet,
obesity,
right
knee
degenerative
changes,
cyclothymia,2
panic
attacks and personality disorder. The ALJ found that Plaintiff’s
2
“Cyclothymia, also called cyclothymic disorder, is a rare mood
disorder. . . that causes emotional ups and downs, but . . . not as
extreme
as
those
in
bipolar
I
or
II
disorder.”
http://www.mayoclinic.org/diseases-conditions/cyclothymia/basics/
definition/con-20028763 (last accessed Dec. 14, 2016).
-10-
plantar fasciitis and hypertension are not severe impairments, a
finding that Plaintiff does not challenge on appeal.
At step three, the ALJ considered whether any of Plaintiff’s
impairments, singly or in combination, meet or medically equal the
severity of one of the impairments in the Listing of Impairments,
20
C.F.R.
Part
404,
Subpart
P,
Appendix
1
(20
C.F.R.
§§ 404.1520(d), 404.1525 & 404.1526). In particular, Plaintiff’s
right knee pain has not resulted in the inability to ambulate
effectively as defined by Listing 1.00(B)(2)(b), and thus the
severity criteria of Listing 1.02(A) (Major Dysfunction of a Major
Peripheral Weight-Bearing Joint) have not been met. Plaintiff’s
diabetic neuropathic pain does not meet the criteria set forth in
Listing 11.14 (Peripheral Neuropathies) because she has retained
the ability to walk effectively. Additionally, although Plaintiff
experiences peripheral neuropathy, it has improved with Sombra and,
in
mid-2013,
successfully
Plaintiff
addressed
received
her
residual
modified
pain.
orthotics
With
which
regard
to
Plaintiff’s mental impairments, the ALJ found that they do not,
either singly or in combination, meet or medically equal the
criteria of Listing 12.04 (Affective Disorders), because she has
“mild
restriction”
in
activities
of
daily
living
and
social
functioning; “moderate difficulties” in maintaining concentration,
persistence or pace; and had not experienced any episodes of
decompensation, which have been of extended duration.
-11-
Before
proceeding
to
the
next
step,
the
ALJ
assessed
Plaintiff’s residual functional capacity (“RFC”), and determined
that she can
perform sedentary work as defined in 20 CFR 404.1567(a)
except she can stand and walk for one hour during an
eight hour workday; she can stand and walk for ten
minutes at one time; . . . can occasionally climb stairs
and balance; . . . can frequently engage in kneeling,
crouching and crawling; . . . cannot climb ladders, ropes
and scaffolds; and . . . can only engage in simple and
semi-skilled tasks.
(T.23).
At step four, the ALJ noted that Plaintiff had past relevant
work
(“PRW”)
Occupational
as
a
Titles
substance
(“DOT”)
abuse
counselor
045.107-058,
(Dictionary
skilled
(svp
8)
of
and
sedentary); a central supply worker (DOT 381.687-010, semi-skilled
(svp 4) and light exertion); a surgical assistant (DOT 079-364-022,
skilled (svp 6) and light exertion); and an assistant program
administrator
(alcohol/drug
abuse
treatment
program)
(DOT
155.167-042, skilled (svp 7) and light exertion). In light of her
RFC, the ALJ found Plaintiff is unable to perform any PRW. As of
the onset date, Plaintiff was 38 years-old, making her a “younger
individual” under the Act.
At step five, the ALJ relied on the VE’s testimony that a
person of Plaintiff’s age, and with her education, work experience,
and
RFC,
could
perform
the
requirements
of
representative
occupations such as addresser (DOT 029.587-010, unskilled (svp 2)
-12-
and sedentary), of which there are 21,344 jobs available in the
national economy and 294 jobs in the Western New York economy;
information
clerk
(DOT
237.367-022,
semi-skilled
(svp
4)
and
sedentary job), of which there are 42,337 jobs available in the
national economy and 210 jobs in the Western New York economy); and
appointment
clerk
(DOT
237.367-010,
semi-skilled
(svp
3)
and
sedentary job), of which there are 199,085 jobs available in the
national economy and 987 jobs in the Western New York economy.
Accordingly, the ALJ found that Plaintiff has not been under a
disability, as defined in the Act, from June 6, 2012, through the
date of the decision.
SCOPE OF REVIEW
When considering a claimant’s challenge to the Commissioner’s
decision denying benefits under the Act, a 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”).
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),
but
“defer[s]
to
the
Commissioner’s
resolution
of
conflicting evidence.” Cage v. Comm’r of Soc. Sec., 692 F.3d 118,
122 (2d Cir. 2012) (citation omitted)). “The deferential standard
-13-
of
review
for
substantial
evidence
Commissioner’s conclusions of law.”
does
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)).
DISCUSSION
Plaintiff’s
sole
contention
on
appeal
is
that
the
ALJ
misapplied the treating physician rule and erroneously discounted
the
reports
and
Questionnaires
the
Mental
completed
Residual
by
her
Functional
treating
Capacity
psychiatrist,
Dr. Scozzaro.
The Second Circuit has explained that “[a]lthough the treating
physician rule generally requires deference to the medical opinion
of a claimant’s treating physician, the opinion of the treating
physician is not afforded controlling weight where . . . the
treating physician issued opinions that are not consistent with
other substantial evidence in the record. . . .” Halloran v.
Barnhart, 362 F.3d 28, 32 (2d Cir. 2004) (per curiam) (internal and
other
citations
omitted).
When
an
ALJ
declines
to
accord
controlling weight to a treating physician’s opinion, the ALJ “must
consider various ‘factors’ to determine how much weight to give to
the opinion[,]” id. (quoting 20 C.F.R. § 404.1527(d)(2)), such as
“(i) the frequency of examination and the length, nature and extent
of the treatment relationship; (ii) the evidence in support of the
treating physician’s opinion; (iii) the consistency of the opinion
-14-
with the record as a whole; (iv) whether the opinion is from a
specialist;
and (v) other factors brought to the Social Security
Administration’s attention that tend to support or contradict the
opinion.’” Id. (quoting 20 C.F.R. § 404.1527(d)(2)).
A corollary to the treating physician rule is the so-called
“good reasons rule,” which is based on the regulations specifying
that “the Commissioner ‘will always give good reasons’” for the
weight given to a treating source opinion. Halloran, 362 F.3d at 32
(quoting
20
C.F.R.
§
404.1527(d)(2);
citing
20
C.F.R.
§ 416.927(d)(2); Schaal v. Apfel, 134 F.3d 496, 503-04 (2d Cir.
1998)). “Those good reasons must be ‘supported by the evidence in
the case record, and must be sufficiently specific . . . .’”
Blakely v. Commissioner of Social Sec., 581 F.3d 399, 406 (6th Cir.
2009) (quoting Social Security Ruling (“SSR”) 96–2p, 1996 WL
374188, at *5 (S.S.A. July 2, 1996)). Because the “good reasons”
rule exists to “ensur[e] that each denied claimant receives fair
process,” Rogers v. Commissioner of Social Sec., 486 F.3d 234, 243
(6th Cir. 2007), an ALJ’s “‘failure to follow the procedural
requirement of identifying the reasons for discounting the opinions
and for explaining precisely how those reasons affected the weight’
given ‘denotes a lack of substantial evidence, even where the
conclusion of the ALJ may be justified based upon the record.’”
Blakely, 581 F.3d at 407 (quoting Rogers, 486 F.3d at 243; emphasis
in Blakely).
-15-
Here, the regulatory factors regarding the length of the
treatment relationship and the nature of Dr. Scozzaro’s practice
support a finding that he is a treating source: Dr. Scozzaro is a
specialist in the field of psychiatry, and he treated Plaintiff on
a consistent basis (approximately once a month) from May 27, 2011,
through
at
least
December
9,
2013.
(T.343).
Indeed,
the
Commissioner does not dispute that Dr. Scozzaro qualifies as a
treating source.
First, the ALJ considered Dr. Scozzaro’s letter reports from
October 2012, November 2012, February 2013, and August 2013, and
decided to give them “no weight[.]” The ALJ provided three reasons
for entirely discounting the letter reports. First, the ALJ noted,
“a
statement
that
a
claimant
is
disabled
or
unable
to
work
addresses a question which is reserved to the Commissioner[.].
Second, the ALJ stated, Dr. Scozzaro’s “conclusions clearly
[we]re based largely on the claimant’s subjective complaints and
allegations[,]” and the “absence of significant objective findings
during Dr. Scozzaro’s examinations is given much greater weight
than these conclusions.” Both of these reasons are contrary to the
prevailing law in the Second Circuit. As courts in this Circuit
have observed, that “[i]t is axiomatic” that in diagnosing a mental
disorder,
“a
treating
psychiatrist
must
consider
a
patient’s
subjective complaints[.]” Santana v. Astrue, No. 12 CIV. 0815 BMC,
2013 WL 1232461, at *14 (E.D.N.Y. Mar. 26, 2013) (citing Hernandez
-16-
v.
Astrue,
814
F.
Supp.2d
168,
182
(E.D.N.Y.
2011)
(citing
Green–Younger v. Barnhart, 335 F.3d 99, 108 (2d Cir. 2003)).
Indeed, whether a medical provider is dealing with mental or
physical impairments, “consideration of a “patient’s report of
complaints, or history, [a]s an essential diagnostic tool,’ is a
medically acceptable clinical and laboratory diagnostic technique.”
Id.
(quoting
Hernandez,
814
F.
Supp.2d
at
182)
(citing
Green–Younger, 335 F.3d at 107); see also, e.g., Lopez-Tiru v.
Astrue, No. 09-CV-1638 ARR, 2011 WL 1748515, at *4 (E.D.N.Y. May 5,
2011) (ALJ rejected treating source’s opinion because it “was based
on subjective complaints,” “not supported by clinical findings,”
and “not confirmed to the extent claimed by the other treating
physicians”;
statements
district
are
not
court
‘good
found
reasons’
that
to
“[t]hese
reject
[the
conclusory
doctor’s]
opinion”). Furthermore, it was improper for the ALJ to assign “much
greater weight” to the “absence of significant objective findings
during Dr. Scozzaro’s examinations. . . .” “The ALJ cannot rely on
the absence of evidence, and is thus under an affirmative duty to
fill any gaps in the record.” Rosado v. Barnhart, 290 F. Supp. 2d
431, 440 (S.D.N.Y. 2003) (citing Schaal v. Apfel, 134 F.3d 496, 505
(2d Cir. 1998) (“Even if the clinical findings were inadequate, it
was the ALJ’s duty to seek additional information from . . . [the
treating source] sua sponte.”) (internal quotations and citations
omitted). Thus, to the extent the ALJ believed that Dr. Scozzaro’s
-17-
opinion was not supported by clinical findings, the ALJ had an
obligation to develop the record by re-contacting the doctor. E.g.,
Lopez-Tiru, 2011 WL 1748515, at *4; see also Thompson v. Colvin,
No. 14-CV-3843 JFB, 2015 WL 5330373, at *12 (E.D.N.Y. Sept. 14,
2015)
(“[T]he
ALJ
failed
to
apply
the
proper
standard
for
evaluating the opinion of Dr. Richstone, the treating physician. .
. solely on the basis of statements in the April 2012 Report that
the ALJ viewed as internally inconsistent and inconsistent with
earlier treatment notes—without evaluating his opinion pursuant to
the
factors
detailed
in
Halloran
or
recontacting
him
for
clarification, and instead simply assigned more weight to [a review
analyst’s and non-treating source’s] opinions.”).
Third, the ALJ rejected Dr. Scozzaro’s letter reports because
his “opinion that the claimant’s physical impairments render her
disabled appears to rest, at least in part, on an assessment of
physical
impairments
outside
his
area
of
expertise.”
This
mischaracterizes the record as only one of Dr. Scozzaro’s four
letter reports s stated that Plaintiff was disabled due to her
mental impairments and her physical impairments. (T.354). In any
event, this reason is misleading, because the ultimate issue of
disability obviously is reserved to the Commissioner. However, the
narratives of Dr. Scozzaro’s four letter reports contained details
about
Plaintiff’s
functioning
was
mental
affected
impairments,
by
them;
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symptoms,
these
were
and
how
entitled
her
to
consideration by the ALJ. See Snell v. Apfel, 177 F.3d at 133
(“[T]he Social Security Administration considers the data that
physicians provide but draws its own conclusions as to whether
those data indicate disability.”).
Turning
to
Dr.
Scozzaro’s
January
2014
Mental
Residual
Functional Capacity Questionnaire, the ALJ gave “no weight to this
opinion because Dr. Scozzaro's treatment records do not provide
objective
mental
status
examination
findings
to
support”
it.
(T.26). This reason does not constitute a good reason. To the
extent she was concerned that Dr. Scozzaro’s psychiatric medical
opinion lacked a proper clinical foundation, the ALJ was again
obligated to follow-up with the doctor before discounting his
opinion. See Lopez-Tiru, 2011 WL 1748515, at *4 (“When a treating
physician’s
opinion
‘is
not
adequately
supported
by
clinical
findings, the ALJ must attempt, sua sponte, to develop the record
further by contacting the treating physician to determine whether
the required information is available.’”) (quoting Cleveland v.
Apfel, 99 F. Supp.2d 374, 380 (S.D.N.Y. 2000) (citing 20 C.F.R.
§ 404.1512(e))).
As his second reason for discounting the Questionnaire, the
ALJ stated that the functional limitations assigned by Dr. Scozzaro
“contradicted the record” because Dr. Scozzaro’s notes indicated
that Plaintiff was active in church, attended a church picnic, and
attended Bible study, all of which require “good social, attention
-19-
and
concentration
Plaintiff
Dr.
skills,”
the
argues,
Scozzaro
guesswork
on
socialized
according
is
meant
his
with
ALJ
by
being
to
merely
to
conclude
people
at
the
ALJ.
(T.26).
As
speculating
as
to
what
in
“active
part
the
it
is
pure
that
church
church”;
Plaintiff,
picnic,
and
in
fact,
maintained
attention and concentration while at bible study. Moreover, even
assuming that attending church picnics and bible study are reliable
measures of an individual’s ability to interact appropriately with
employers and supervisors in a normal workplace environment and to
maintain attention and concentration at the level required to
perform even unskilled competitive full-time employment, there is
no suggestion in the record that Plaintiff was attending church
picnics and bible study on a “‘regular and continuing basis’
[which] means 8 hours a day, for 5 days a week, or an equivalent
work schedule.” Melville v. Apfel, 198 F.3d 45, 52 (2d Cir. 1999).
As
his
third
reason
for
rejecting
Dr.
Scozzaro’s
Questionnaire, the ALJ asserted that Plaintiff’s GAF scores of 51
to 60 (as assessed by her therapist, LCSW-R Wronski) contradicted
Dr. Scozzaro’s opinion. (T.26). This was inappropriate. Courts in
the Second Circuit consistently have refused to find that GAF
scores constitute “good reasons” to discount a treating source
opinion. See, e.g., Carton v. Colvin, No. 3:13-C-379 CSH, 2014 WL
108597, *14-15 (D. Conn. Jan. 9, 2014) (ALJ improperly discounted
treating source’s opinion on the grounds that “the finding of
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extreme difficulties is patently inconsistent with [the doctor’s]
own assessment of a GAF of 55”; “the ALJ erred in relying on the
GAF score as an indicat[ion] of the severity of the plaintiff’s
mental impairment”) (internal quotation omitted); see also id. at
*15 (“A GAF score ‘does not have a direct correlation to the
severity requirements in [the SSA’s] disorders listing.’”) (quoting
Revised
Medical
Criteria
for
Evaluating
Mental
Disorders
and
Traumatic Brain Injuries, 65 Fed. Reg. 50746, 50764–5 (Aug. 21,
2000)). Moreover, the GAF scores upon which the ALJ relied were
assessed by LCSW-R Wronski, who does not qualify as an “acceptable
medical source” under the Commissioner’s regulations.
The ALJ did consider any of the appropriate factors relevant
to the assessment of a treating physician’s opinion, and instead
relied on only inappropriate reasons, speculation, and his own lay
opinion to dismiss Dr. Scozzaro’s various reports. Furthermore,
despite identifying gaps in the record based on his belief that
Dr. Scozzaro failed to substantiate some of his reports with
clinical findings, the ALJ abdicated his duty to develop the record
and did not request clarification from Dr. Scozzaro. In short, the
ALJ’s determination that Dr. Scozzaro’s opinions were entitled to
no weight at all is marred by legal error and unsupported by
substantial evidence in the record.
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CONCLUSION
For the foregoing reasons, Defendant’s Motion for Judgment on
the Pleadings is denied, and Plaintiff’s Motion for Judgment on the
Pleadings is granted to the extent that the Commissioner’s decision
is reversed, and the matter is remanded for further administrative
proceedings consistent with this Decision and Order. Specifically,
the ALJ is directed to develop the record fully by having all of
Dr.
Scozzaro’s
handwritten
treatment
notes,
reports,
and
questionnaires transcribed. The ALJ is then directed to evaluate
Dr. Scozzaro’s treating source reports and opinions in light of the
appropriate regulatory factors and in accordance with the case law
discussed above, re-assess the weight to be given Dr. Scozzaro’s
opinions, and, if necessary, re-formulate Plaintiff’s RFC.
The Clerk of the Court is directed to close this case.
SO ORDERED.
S/Michael A. Telesca
HON. MICHAEL A. TELESCA
United States District Judge
Dated:
December 15, 2016
Rochester, New York.
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