Ward v. Commissioner of Social Security

Filing 16

DECISION AND ORDER granting in part and denying in part Ward's 9 motion for judgment on the pleadings and denying the Commissioner's 13 motion for judgment on the pleadings. The decision of the Commissioner is VACATED and the matter is REMANDED for further administrative proceedings consistent with this decision. SO ORDERED. Signed by Hon. Lawrence J. Vilardo on 5/14/2019. (LCH)-CLERK TO FOLLOW UP-

UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF NEW YORK

MICHAEL JAMES WARD,
Plaintiff,
v.

17-CV-1008
DECISION AND ORDER

COMMISSIONER OF SOCIAL
SECURITY,
Defendant.

On October 6, 2017, the plaintiff, Michael James Ward, brought this action under
the Social Security Act ("the Act"). He seeks review of the determination by the
Commissioner of Social Security ("Commissioner") that he was not disabled. Docket
Item 1. On July 30, 2018, Ward moved for judgment on the pleadings, Docket Item 9,
and on October 1, 2018, the Commissioner responded and cross-moved for judgment
on the pleadings, Docket Item 13. On October 22, 2018, Ward replied. Docket Item 14.
For the reasons stated below, this Court grants Ward’s motion and denies the
Commissioner’s cross-motion.

BACKGROUND
I.

PROCEDURAL HISTORY
On August 22, 2013, Ward protectively filed a Title II application for disability and

disability insurance benefits. Tr. 18. He claimed that he had been disabled since July
31, 2013, Tr. 145, due to “[h]eart problems,” “[s]upraventricular tachycardia,”

“[d]iabetes,” “[t]ransposition of the great vessels,” “[c]ardiomyopathy,” “defective lungs
due to diaphragm muscle,” “no lower right lobe of lung due to paralyzed diaphragm,”
“[l]ow ejection fraction,” and “[h]eart [f]ailure.” Tr. 162.
On May 17, 2013, Ward’s application was denied because he was not disabled
under the Act. Tr. 82. He requested a hearing before an administrative law judge
("ALJ"), Tr. 143, which was held on April 14, 2016, Tr. 33. The ALJ then issued a
decision on May 17, 2016, confirming the finding that Ward was not disabled. Tr. 28.
Ward appealed the ALJ’s decision, but his appeal was denied, and the decision then
became final. Tr. 1-3.
II.

RELEVANT MEDICAL EVIDENCE
The following summarizes the medical evidence most relevant to Ward’s

objection. Ward was examined by several different providers but one—Marie Iacona,
M.D., a cardiologist—is of most significance to this Court’s review.
Marie Iacona, M.D., a Cardiologist
On March 19, 2014, Ward was examined by Dr. Iacona, a cardiologist. Tr. 263.
Dr. Iacona diagnosed Ward with “corrected congenital heart disease-transposition of the
great vessels in addition to paroxysmal supraventricular tachycardia, nonischemic
cardiomyopathy with an ejection fraction of 45%.” Tr. 265. She also determined that
Ward “has significant dyspnea when walking from room to room” and that he has
“atypical chest pain.” Id. And she indicated that Ward has other cardiovascular issues
that include morbid obesity, non-insulin-dependent diabetes mellitus, and dyslipidemia.
Id. Dr. Iacona found that Ward also had “second degree AV block . . . due to agents
being utilized to treat his” paroxysmal supraventricular tachycardia. Id. Dr. Iacona
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referred Ward to an electrophysiologist to opine on whether a pacemaker would be
appropriate. Id.
As a result of all that, Dr. Iacona indicated that insurers should “consider [Ward] a
candidate for longterm medical disability.” Id.
III.

THE ALJ’S DECISION
In denying Ward’s application, the ALJ evaluated Ward’s claim under the Social

Security Administration’s five-step evaluation process for disability determinations. See
20 C.F.R. § 404.1520. At the first step, the ALJ must determine whether the claimant is
currently engaged in substantial gainful employment. § 404.1520(a)(4)(i). If so, the
claimant is not disabled. Id. If not, the ALJ proceeds to step two. § 404.1520(a)(4).
At step two, the ALJ decides whether the claimant is suffering from any severe
impairments. § 404.1520(a)(4)(ii). If there are no severe impairments, the claimant is
not disabled. Id. If there are any severe impairments, the ALJ proceeds to step three.
§ 404.1520(a)(4).
At step three, the ALJ determines whether any severe impairment or impairments
meet or equal an impairment listed in the regulations. § 404.1520(a)(4)(iii). If the
claimant’s severe impairment or impairments meet or equal one listed in the regulations,
the claimant is disabled. Id. But if the ALJ finds that none of the severe impairments
meet any of the regulations, the ALJ proceeds to step four. § 404.1520(a)(4).
As part of step four, the ALJ first determines the claimant’s residual functional
capacity (“RFC”). See §§ 404.1520(a)(4)(iv); 404.1520(d)-(e). The RFC is a holistic
assessment of the claimant—addressing both severe and nonsevere medical

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impairments—that evaluates whether the claimant can perform past relevant work or
other work in the national economy. See 20 C.F.R. § 404.1545.
After determining the claimant's RFC, the ALJ completes step four. 20 C.F.R.
§ 404.1520(e). If a claimant can perform past relevant work, he or she is not disabled
and the analysis ends. § 404.1520(f). But if the claimant cannot, the ALJ proceeds to
step five. 20 C.F.R. §§ 404.1520(a)(4)(iv); 404.1520(f).
In the fifth and final step, the Commissioner must present evidence showing that
the claimant is not disabled because the claimant is physically and mentally capable of
adjusting to an alternative job. See Bowen v. Yuckert, 482 U.S. 137, 146 n.5 (1987);
20 C.F.R. § 404.1520(a)(v), (g). More specifically, the Commissioner bears the burden
of proving that a claimant "retains a residual functional capacity to perform alternative
substantial gainful work which exists in the national economy." Rosa v. Callahan, 168
F.3d 72, 77 (2d Cir. 1999).
In this case, the ALJ determined at step one that Ward was had “not engaged in
substantial gainful activity since July 31, 2013, the alleged onset date.” Tr. 20. At step
two, the ALJ found that Ward had the following severe impairments: chronic heart
failure and obesity. Id. The ALJ found that Ward also had several non-severe
impairments: “diabetes mellitus; hypertension (HTN); anxiety; status post, transposition
of the great vessels; and sleep apnea.” Id. At step three, the ALJ determined that Ward
did “not have an impairment or combination of impairments that meets or medically
equals the severity of one of the listed impairments in 20 CFR Part 404, Subpart P,
Appendix 1.” Tr. 22.

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In assessing Ward’s RFC, the ALJ determined that Ward could perform
sedentary work, as defined in 20 C.F.R. § 404.1567(a). 1 Tr. 22. The ALJ explicitly
found that Ward “is able to do simple tasks; can occasionally climb ramps, and stairs;
but never ladders or scaffolds; can occasionally balance, stoop, kneel, crouch or crawl;
can occasionally work at unprotected heights; and can occasionally be exposed to dust,
odors, fumes or other pulmonary irritants.” Tr. 22-23.
At step four, the ALJ determined that Ward was “unable to perform any past
relevant work.” Tr. 26. But at step five, the ALJ concluded that Ward could perform
“jobs that exist in significant numbers in the national economy.” Tr. 26. Specifically, the
ALJ determined that Ward could work as a surveillance systems monitor, a telephone
information clerk, or a file assembler. Tr. 27.
LEGAL STANDARDS
When evaluating a decision by the Commissioner, district courts have a narrow
scope of review: they are to determine whether the Commissioner's conclusions are
supported by substantial evidence in the record and whether the Commissioner applied
the appropriate legal standards. Talavera v. Astrue, 697 F.3d 145, 151 (2d Cir. 2012).
Indeed, a district court must accept the Commissioner's findings of fact if they are
supported by substantial evidence in the record. 42 U.S.C. § 405(g). Substantial

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“Sedentary work involves lifting no more than 10 pounds at a time and
occasionally lifting or carrying articles like docket files, ledgers, and small tools.
Although a sedentary job is defined as one which involves sitting, a certain amount of
walking and standing is often necessary in carrying out job duties. Jobs are sedentary if
walking and standing are required occasionally and other sedentary criteria are met.”
20 C.F.R. § 404.1567(a).
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evidence is more than a scintilla and includes "such relevant evidence as a reasonable
mind might accept as adequate to support a conclusion." Moran v. Astrue, 569 F.3d
108, 112 (2d Cir. 2009). In other words, a district court does not review a disability
determination de novo. See Schaal v. Apfel, 134 F.3d 496, 501 (2d Cir. 1998).
DISCUSSION
Ward raises two objections to the ALJ’s formulation of his RFC. First, Ward
argues that the ALJ erred in failing to address the opinion of Dr. Iacona. Docket Item 91 at 10-11. Second, Ward contends that his RFC is not supported by substantial
evidence, especially because it conflicts with the opinion of a consulting examiner. Id.
at 11-13.
When determining a plaintiff’s RFC, the ALJ must evaluate every medical opinion
received. 20 C.F.R. § 404.1527(c). “Among the ALJ’s legal obligations is the duty to
adequately explain [her] reasoning in making the findings on which [her] ultimate
decision rests, and in doing so [s]he must address all pertinent evidence.” Klemens v.
Berryhill, 703 F. App’x 35, 36 (2d Cir. 2017). “Although the ALJ was not required to
mention every piece of evidence, [she was required] to confront the evidence in
[Ward’s] favor and explain why it was rejected before concluding that [his] impairments
did not impose more than a minimal limitation on [his] ability to perform basic work
tasks.” Thomas v. Colvin, 826 F.3d 953, 961 (7th Cir. 2016) (quoting Roddy v. Astrue,
705 F.3d 631, 636 (7th Cir. 2013)).
Here, the ALJ failed to address Dr. Iacona’s opinions in her assessment of what
the objective medical evidence said about Ward’s limitations. Dr. Iacona diagnosed
Ward with several severe conditions and indicated that those conditions undermined
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Ward’s ability to work. Tr. 265. For example, Dr. Iacona found that Ward has
significant shortness of breath when simply moving from room to room. Id. Yet the ALJ
did not “acknowledge [Dr. Iacona’s opinion] or . . . explain its implicit rejection.” Kuleszo
v. Barnhart, 232 F. Supp. 2d 44, 57 (W.D.N.Y. 2002) (quoting Maisch v. Heckler, 606 F.
Supp. 982, 991 (S.D.N.Y. 1985)). In fact, without addressing Dr. Iacona’s opinion, the
ALJ determined that Ward is able to climb ramps and stairs. Tr. 23.
The Commissioner argues that Dr. Iacona’s opinions were not “medical opinions”
as that term is used in 20 C.F.R. § 404.1527(c). Docket Item 13-1 at 14. Therefore,
she argues, the ALJ was not required to consider them in formulating Ward’s RFC. Id.
For example, the Commissioner states that Dr. Iacona’s finding that Ward “‘experienced
significant dyspnea when walking from room to room’ is not a ‘medical opinion’ because
it is not a statement about what [Ward] can still do.” Docket Item 13-1 at 15.
But the definition of “medical opinion” that the Commissioner uses here conflicts
with the agency’s definition in its regulations. The regulations define medical opinions
as “statements from acceptable medical sources that reflect judgments about the nature
and severity of [a claimant’s] impairment(s), including [the claimant’s] symptoms,
diagnosis and prognosis, what [the claimant] can still do despite impairment(s), and [the
claimant’s] physical or mental restrictions.” 20 C.F.R. § 404.1527(a)(1). Here, Dr.
Iacona’s findings are indeed statements from a medical source—specifically, a
cardiologist and therefore a particularly important medical source given Ward’s
impairments—reflecting a judgment about the nature and severity of Ward’s
impairments. Her findings reflect Ward’s symptoms and his physical restrictions.
Therefore, Dr. Iacona rendered a medical opinion as defined in § 404.1527(a)(1).

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That is especially true of Dr. Iacona’s opinion that Ward should be considered for
“longterm medical disability.” Tr. 265. The Commissioner argues that this statement
“was not a ‘medical opinion,’” Docket Item 13-1 at 17; instead, she says “[i]t was a
request, not a judgment about the nature and severity of [Ward’s] impairments.” Id. But
the Commissioner’s position again conflicts with the agency’s own regulations. Medical
opinions are not only judgments from acceptable medical sources about the nature and
severity of a claimant’s impairments; they also may be “statements from acceptable
medical sources that reflect judgments about the nature and severity of [a claimant’s]
impairment[s].” § 404.1527(a)(1) (emphasis added).
Surely, Dr. Iacona’s opinion that Ward is a candidate for longterm disability
reflects her judgment about the nature and severity of Ward’s impairments. Indeed,
there is little doubt that her statement could not have been made but for a judgment that
Ward’s impairments were severe.
This Court recognizes that the ultimate determination of whether a claimant is
disabled within the meaning of the Act is reserved to the Commissioner, and the agency
“will not give any special significance to the source of an opinion on issues reserved to
the Commissioner.” See 20 C.F.R. § 404.1527(d)(3). But the ALJ still must grapple
with the medical opinion implicit in Dr. Iacona’s statement that Ward should not be
working. See Thomas, 826 F.3d at 961; Social Security Ruling 06-03p, 2006 WL
2329939, at *6 (“the adjudicator generally should explain the weight given to opinions
from these ‘other sources,’ or otherwise ensure that the discussion of the evidence in
the determination or decision allows a claimant or subsequent reviewer to follow the
adjudicator’s reasoning, when such opinions may have an effect on the outcome of the

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case”).; Social Security Ruling 96-5p, 1996 WL 374183, at *3 (“opinions from any
medical source on issues reserved to the Commissioner must never be ignored”).
SSA regulations required the ALJ to evaluate medical opinions in the record from
all sources. 20 C.F.R. § 404.1527(c). She did not do that. This case therefore is
remanded for a full evaluation of Dr. Iacona’s opinions and so that the ALJ can then
reweigh the evidence. Without written consideration of Dr. Iacona’s opinions, this Court
cannot “be satisfied that the claimant has had a full hearing under the . . . regulations
and in accordance with the beneficent purposes of the Social Security Act.” Moran, 569
F.3d at 112 (quoting Cruz v. Sullivan, 912 F.3d 8, 11 (2d Cir. 1990)).
Ward also contends that his RFC is not supported by substantial evidence,
especially because it conflicts with an opinion from a consulting examiner—Donna
Miller, D.O., a family medicine physician. Id. at 11-13. Because this “remaining issue[] .
. . may be affected by the ALJ’s treatment of this case on remand,” this Court does not
reach it. Watkins v. Barnhart, 350 F.3d 1297, 1299 (10th Cir. 2003). Since Ward’s
“case must return to the agency either way for the reasons already given, the
Commissioner will have the opportunity on remand to obviate this dispute . . .by making
clear” how Dr. Miller’s opinion supports the ALJ’s finding that Ward can perform
sedentary work (if the ALJ adheres to that conclusion). Lockwood v. Comm’r of Soc.
Sec. Admin., 914 F.3d 87, 94 (2d Cir. 2019).
CONCLUSION
For the reasons stated above, the Commissioner's motion for judgment on the
pleadings, Docket Item 13, is DENIED, and Ward’s motion for judgment on the
pleadings, Docket Item 9, is GRANTED in part and DENIED in part. The decision of the
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Commissioner is VACATED and the matter is REMANDED for further administrative
proceedings consistent with this decision.
SO ORDERED.
Dated:

May 14, 2019
Buffalo, New York

s/ Lawrence J. Vilardo
LAWRENCE J. VILARDO
UNITED STATES DISTRICT JUDGE

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