Mecklenberg v. Commissioner Social Security

Filing 22

DECISION AND ORDER denying 11 Plaintiff's Motion for Judgment on the Pleadings and granting 19 Defendant's Motion for Judgment on the Pleadings. The complaint is DISMISSED WITH PREJUDICE, and the Clerk of Court is directed to enter judgment and close this case. SO ORDERED. Signed by Hon. Frank P. Geraci, Jr. on 7/15/2019. (MFM)-CLERK TO FOLLOW UP-

UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF NEW YORK
ELAINA MECKLENBURG,
Plaintiff,
v.

Case # 18-CV-55-FPG
DECISION AND ORDER

COMMISSIONER OF SOCIAL SECURITY,
Defendant.

INTRODUCTION
Plaintiff Elaina Mecklenburg brings this action pursuant to the Social Security Act seeking
review of the final decision of the Commissioner of Social Security that denied her applications
for Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”) under Titles
II and XVI of the Act. ECF No. 1. The Court has jurisdiction over this action under 42 U.S.C. §§
405(g), 1383(c)(3).
Both parties moved for judgment on the pleadings pursuant to Federal Rule of Civil
Procedure 12(c). ECF Nos. 11, 19. For the reasons that follow, the Commissioner’s motion is
GRANTED, Mecklenburg’s motion is DENIED, and the complaint is DISMISSED WITH
PREJUDICE.
BACKGROUND
Mecklenburg filed for DIB in March 2014 and for SSI in April 2014. Tr. 1 73, 83. She
alleged disability since March 2013 due to back injury, knee injury, brain damage, and vertigo.
Tr. 73-74, 78-79. Administrative Law Judge Christine A. Cooke (the “ALJ”) held hearings in June
2016 and August 2016 on the applications, at which Mecklenburg and two vocational experts

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“Tr.” refers to the administrative record in this matter. ECF No. 17.
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(“VE”) testified. Tr. 27, 51. On September 7, 2016, the ALJ issued a decision finding that
Mecklenburg was not disabled. Tr. 10-21. On November 17, 2017, the Appeals Council denied
Mecklenburg’s request for review. Tr. 1-3. This action seeks review of the Commissioner’s final
decision. ECF No. 1.
LEGAL STANDARD
I.

District Court Review
“In reviewing a final decision of the SSA, this Court is limited to determining whether the

SSA’s conclusions were supported by substantial evidence in the record and were based on a
correct legal standard.” Talavera v. Astrue, 697 F.3d 145, 151 (2d Cir. 2012) (quotation marks
omitted); see also 42 U.S.C. § 405(g). The Act holds that a decision by the Commissioner is
“conclusive” if it is supported by substantial evidence. 42 U.S.C. § 405(g). “Substantial evidence
means more than a mere scintilla. It means 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)
(quotation marks omitted). It is not the Court’s function to “determine de novo whether [the
claimant] is disabled.” Schaal v. Apfel, 134 F.3d 496, 501 (2d Cir. 1998) (quotation marks
omitted); see also Wagner v. Sec’y of Health & Human Servs., 906 F.2d 856, 860 (2d Cir. 1990)
(holding that review of the Secretary’s decision is not de novo and that the Secretary’s findings are
conclusive if supported by substantial evidence).
II.

Disability Determination
An ALJ must follow a five-step sequential evaluation to determine whether a claimant is

disabled within the meaning of the Act. See Parker v. City of New York, 476 U.S. 467, 470-71
(1986). At step one, the ALJ must determine whether the claimant is engaged in substantial gainful
work activity. See 20 C.F.R. § 404.1520(b). If so, the claimant is not disabled. If not, the ALJ

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proceeds to step two and determines whether the claimant has an impairment, or combination of
impairments, that is “severe” within the meaning of the Act, meaning that it imposes significant
restrictions on the claimant’s ability to perform basic work activities. Id. § 404.1520(c). If the
claimant does not have a severe impairment or combination of impairments, the analysis concludes
with a finding of “not disabled.” If the claimant does, the ALJ continues to step three.
At step three, the ALJ examines whether a claimant’s impairment meets or medically
equals the criteria of a listed impairment in Appendix 1 of Subpart P of Regulation No. 4 (the
“Listings”). Id. § 404.1520(d). If the impairment meets or medically equals the criteria of a Listing
and meets the durational requirement, the claimant is disabled. If not, the ALJ determines the
claimant’s residual functional capacity (“RFC”), which is the ability to perform physical or mental
work activities on a sustained basis, notwithstanding limitations for the collective impairments.
See id. § 404.1520(e)-(f).
The ALJ then proceeds to step four and determines whether the claimant’s RFC permits
him or her to perform the requirements of his or her past relevant work. 20 C.F.R. § 404.1520(f).
If the claimant can perform such requirements, then he or she is not disabled. Id. If he or she
cannot, the analysis proceeds to the fifth and final step, wherein the burden shifts to the
Commissioner to show that the claimant is not disabled. Id. § 404.1520(g). To do so, the
Commissioner must present evidence to demonstrate that the claimant “retains a residual
functional capacity to perform alternative substantial gainful work which exists in the national
economy” in light of his or her age, education, and work experience. See Rosa v. Callahan, 168
F.3d 72, 77 (2d Cir. 1999) (quotation marks omitted); see also 20 C.F.R. § 404.1560(c).

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DISCUSSION
I.

The ALJ’s Decision
The ALJ analyzed Mecklenburg’s claim for benefits under the process described above.

At step one, the ALJ found that Mecklenburg had not engaged in substantial gainful activity since
the alleged onset date. Tr. 13. At step two, the ALJ found that Mecklenburg had severe
impairments of degenerative disc disease, history of psoriasis, history of alcohol abuse, cognitive
dysfunction, and pelvic fracture. Id. At step three, the ALJ found that these impairments, alone
or in combination, did not meet or medically equal any Listings impairment. Id.
Next, the ALJ determined that Mecklenburg retains the RFC to perform light work 2 with
additional limitations. Tr. 14. As is relevant here, the ALJ found that Mecklenburg can sit for 6
hours and stand and walk in combination for 4 hours during a normal workday; can never be
exposed to vibration or hazards; and must be able to shift positions without leaving her duty station
on an hourly basis. Tr. 14-15.
At step four, the ALJ indicated that Mecklenburg has no past relevant work. Tr. 19. At
step five, the ALJ found that Mecklenburg can adjust to other work that exists in significant
numbers in the national economy given her RFC, age, education, and work experience. Tr. 19-21.
Accordingly, the ALJ concluded that Mecklenburg was not disabled. Tr. 21.

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“Light work involves lifting no more than 20 pounds at a time with frequent lifting or carrying of objects
weighing up to 10 pounds. Even though the weight lifted may be very little, a job is in this category 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, [the claimant] must have the ability to do substantially all of these activities. If someone can do light
work, [the SSA] determine[s] that he or she can also do sedentary work, unless there are additional limiting
factors such as loss of fine dexterity or inability to sit for long periods of time.” 20 C.F.R. §§ 404.1567(b),
416.967(b).
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II.

Analysis
Mecklenburg argues that the ALJ erroneously evaluated the evidence and medical opinions

related to her severe gait dysfunction and balance issues. ECF No. 11-1 at 11-13. After reviewing
the record and the parties’ briefing, the Court disagrees.
a. Facts
In early April 2013, Mecklenburg met with her treating physician, Juliane Maciejewski,
M.D., complaining of balance issues. Tr. 491. She noted that if she stopped “looking where she
[was] going, she [felt] like she [was] going to fall.” Id. To cope with this, Mecklenburg brought
someone with her everywhere she went. Id. She stated that she had had these symptoms for “more
than a year” and was “frightened by this.” Id. Dr. Maciejewski noted that Mecklenburg had
ataxia—i.e., impaired muscle coordination and balance—and an intention tremor. Tr. 493. She
referred Mecklenburg to a neurology specialist and ordered an MRI. Id. The MRI revealed a
“very subtle” signal associated with Wernicke’s encephalopathy, a neurological condition
associated with chronic alcohol abuse and characterized by, among other things, gait and balance
dysfunction. Tr. 519; see Estrada v. Barnhart, No. SA01CA0679OG, 2002 WL 31422431, at *3
n.28 (W.D. Tex. Aug. 13, 2002).
On May 2, 2013, Mecklenburg met with Xiuli Li, M.D., for a neurologic consultation.
Mecklenburg reported that her balance issues had “developed over the last couple of years.” Tr.
278. When she walked, “she [had] to put her hands and arms at a stretched position and she [had]
to use a wide based gait” to prevent falls. Id. Standing up or moving increased balance difficulty.
Id. On examination, Dr. Li found that Mecklenburg walked with a wide based gait with her arms
outstretched and could not walk with one eye closed. Tr. 279. Dr. Li concluded that Mecklenburg
had a gait disturbance with “wide based gait.” Tr. 280. Dr. Li suggested that those symptoms may

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be the irreversible result of Mecklenburg’s chronic alcohol abuse. Id. Dr. Li recommended
physical therapy, vitamins, and the use of a cane for “gait protection.” Tr. 280.
On May 8, 2013, Mecklenburg followed up with Dr. Maciejewski. Dr. Maciejewski
concluded that Mecklenburg’s chronic alcohol abuse had caused permanent damage, resulting in
poor balance and frequent falls. Tr. 499. She opined that “[t]his condition will not get better and
likely will deteriorate” and that Mecklenburg “is for all purposes totally and permanently
disabled.” Id. Dr. Maciejewski recommended that Mecklenburg use a cane to walk. Id.
In August 2013, Mecklenburg met with Rebecca Beardsley, a nurse practitioner.
Mecklenburg reported that she had received a cane and had been undergoing physical therapy until
her recent breast infection. Tr. 440. She stated that physical therapy “helped her walk with a
cane.” Id. Beardsley provided Mecklenburg with another neurology referral to assess her
disability status. Tr. 442.
Mecklenburg had subsequent appointments with Dr. Maciejewski where balance issues
were noted. In October 2013, Dr. Maciejewski indicated that Mecklenburg had a “wide based gait
with arms held out at sides,” could not tandem walk, and had an intention tremor. Tr. 469. Dr.
Maciejewski referred Mecklenburg to physical therapy for evaluation and treatment. Id. At a
March 2014 appointment, Mecklenburg did not complain about gait dysfunction or balance issues,
and Dr. Maciejewski did not describe any observations beyond noting that Mecklenburg had been
diagnosed with a gait abnormality and prescribed a cane. Tr. 604. In January 2015, Mecklenburg
reported to Dr. Maciejewski that she had no change in her tremors and falling. She stated that she
did not “travel further than [the] corner store by herself” and had “difficulty looking up.” Tr. 632.
She still used a cane. Id.

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At the August 2016 hearing, Mecklenburg testified that her balance issues significantly
curtail her ability to walk and engage in daily activities. She stated that she gets dizzy and loses
balance if she does not focus on the ground as she walks, making it difficult to cross streets or ride
the bus. Tr. 35. To walk, even around her home, she either needs to use a cane or hold onto
something or someone. Tr. 36, 40. Mecklenburg estimated that she could stand unassisted—
without a cane or something to lean on—for about sixty seconds. Tr. 42. With assistance, she can
walk for at most an hour, though it exhausts her for the remainder of the day. Tr. 43. Mecklenburg
also testified that she falls three to four times per year. Tr. 36.
The ALJ concluded that Mecklenburg’s balance and gait problems were not as persistent
or severe as she alleged. Tr. 15-16. The ALJ noted that the brain MRI showed only a “very subtle”
finding associated with Wernicke’s encephalopathy. Tr. 15. The ALJ rejected Dr. Li’s opinion
that Mecklenburg needed a cane because Dr. Li met with her once and therefore did not personally
observe persistent gait or balance problems. Tr. 16, 18. Furthermore, Dr. Li’s opinion was
inconsistent with the observations of other physicians who, between June 2013 and March 2016,
noted that Mecklenburg displayed normal gait and coordination at appointments. See, e.g., Tr.
299, 317, 325-26, 761. Finally, the ALJ noted that “the need for a cane did not align with”
Mecklenburg’s sparing use of pain medication and her reported daily activities like shopping. Tr.
18; see also Tr. 632 (reporting, in January 2015, that she used pain medication sparingly); Tr. 494
(reporting, in March 2014, that she has back pain after “she has a full day out and about, shopping
etc”).
The ALJ also rejected Dr. Maciejewski’s opinion that Mecklenburg was “totally and
permanently disabled” and would need a cane to walk. Tr. 18. As with Dr. Li, the ALJ noted that
other providers observed that Mecklenburg had normal gait and coordination from mid-2013 to

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2016. Id. The ALJ also found that Dr. Maciejewski’s examinations “beyond the alleged onset
date do not include associated objective findings to support the degree of limitation conveyed.”
Id. In addition, the ALJ stated that the opinion about Mecklenburg’s “disability status concerns
an administrative finding reserved to the Commissioner.”

Id.

She therefore gave Dr.

Maciejewski’s opinion little weight. Id.
More generally, the ALJ reasoned, “Although one treating source considered
[Mecklenburg] disabled and others noted a need for an assistive device, these opinions were not
supported by [Mecklenburg’s] apparent recovery from her [December 2015] pelvic fracture,
clinical presentation throughout the period at issue, or denial of pain symptoms prior to leaving
inpatient rehabilitation against medical advice [after her pelvic fracture].” Tr. 19.
b. Analysis
The Court is not persuaded that the ALJ erred on any of the grounds that Mecklenburg
raises.
First, Mecklenburg asserts that the ALJ “gave [too] much credence” to certain physicians
who observed that Mecklenburg had normal coordination and gait at appointments. ECF No. 111 at 11. This is because those physicians were treating Mecklenburg for other issues and therefore
did not need to be concerned about her “gait or back related health issues.” Id.
The Court disagrees. It would be one thing if these providers had simply omitted any
mention of Mecklenburg’s gait and coordination.

In such a scenario, it may have been less

reasonable for the ALJ to conclude that Mecklenburg had no balance or gait issues based on the
providers’ notes, as those providers were treating her for other conditions and would not have
necessarily examined her gait and coordination. By contrast, in this case several providers from
2013 to 2016 affirmatively noted that Mecklenburg had normal gait and coordination. This

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uniform observation—over several years and by different providers—is clearly relevant to
assessing Dr. Maciejewski’s and Dr. Li’s opinions.

See 20 C.F.R. §§ 404.1527(c)(4),

416.927(c)(4) (stating that one relevant factor in weighing a medical opinion is its consistency
“with the record as a whole”). Even if these other providers did not undertake complete gait or
coordination examinations, their notes remain relevant because they conflict with Mecklenburg’s
testimony that she is essentially unable to walk normally without assistance. In turn, those notes
undermine Dr. Maciejewski’s and Dr. Li’s opinions, which are based on that alleged level of gait
and balance dysfunction. See Tr. 278, 499. Therefore, the ALJ’s reliance on the observations of
other providers was not impermissible.
Second, Mecklenburg argues that, in violation of the treating physician rule, the ALJ did
not provide good reasons for affording Dr. Maciejewski’s opinion little weight. Specifically, she
claims that the ALJ incorrectly stated that (1) only “one provider documented gait and balance
problems” and (2) Dr. Maciejewski’s examinations did not include objective findings to support
the conclusion of total disability. 3 ECF No. 11-1 at 12-13.
Under the treating physician rule, the ALJ must give a treating physician’s opinion
controlling weight if it is “well-supported by medically acceptable clinical and laboratory
diagnostic techniques and is not inconsistent with the other substantial evidence in [the] record.”
20 C.F.R. § 416.927(c)(2); see also Green-Younger v. Barnhart, 335 F.3d 99, 106 (2d Cir. 2003).
An ALJ may discount a treating physician’s opinion if it does not meet this standard, but she must
“comprehensively set forth [her] reasons for the weight assigned to a treating physician’s opinion.”

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Mecklenburg also asserts that the ALJ mischaracterized the evidence when she stated that Dr. Li “did not
ascertain the persistence of gait and balance problems from personal observation.” Tr. 18. Mecklenburg
asserts that, to the contrary, “it is clear that Dr. Li . . . personally ascertain[ed] the problems with [her] gait
[and] found that the problems could not be reversed.” ECF No. 11-1 at 12. But the Court reads the ALJ’s
decision to mean that Dr. Li only met with Mecklenburg once and so did not have a longitudinal picture of
her condition based on personal observation. That is accurate.
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Halloran v. Barnhart, 362 F.3d 28, 33 (2d Cir. 2004). Remand is appropriate if the ALJ does not
provide good reasons for rejecting a treating physician’s opinion. Newbury v. Astrue, 321 F. App’x
16, 17 (2d Cir. 2009) (summary order).
In this case, the ALJ provided good reasons for not giving controlling weight to Dr.
Maciejewski’s opinion. As already discussed, the ALJ reasonably considered that the claimed
severity and persistence of the gait and balance issues were inconsistent with the observations of
other providers. See 20 C.F.R. §§ 404.1527(c)(4), 416.927(c)(4). Moreover, while the ALJ’s
statement that “[o]nly one provider documented gait and balance problems” may be inaccurate
insofar as both Dr. Li and Dr. Maciejewski documented such problems, it is clear that the ALJ
recognized and considered both opinions despite that isolated misstatement. See Tr. 16-18; see
also Scarpino v. Colvin, No. 15-CV-6231, 2016 WL 5372493, at *15 (W.D.N.Y. Sept. 26, 2016)
(ALJ’s misstatement of fact did not compel remand where it was harmless); Cote v. Berryhill, No.
17-CV-1843, 2018 WL 4092068, at *19 (D. Conn. Aug. 28, 2018) (same).
Similarly, the ALJ reasonably relied on the absence of corresponding clinical or
examination findings to discount Dr. Maciejewski’s opinion. See Gorny v. Comm’r of Social
Security, No. 18-CV-06, 2018 WL 5489573, at *3 n.4 (W.D.N.Y. Oct. 29, 2018) (noting that an
ALJ is “entitled to discount a treating physician’s opinion that he finds unsupported by the doctor’s
treatment notes” and citing applicable regulations).

As Mecklenburg acknowledges, Dr.

Maciejewski only examined Mecklenburg’s gait and coordination on two occasions: in April 2013,
when she noted that Mecklenburg had ataxia and an intention tremor, and in October 2013, when
she observed that Mecklenburg had a wide based gait, could not tandem walk, and had an intention
tremor. See Tr. 469, 493. Although Mecklenburg continued to visit with Dr. Maciejewski over
the subsequent years, Dr. Maciejewski did not conduct any further gait examinations or note any

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clinical findings to suggest that Mecklenburg continued to have persistent, severe balance
problems beyond that short timeframe in mid-2013.
The ALJ also stated that she discounted Dr. Maciejewski’s opinion because it conflicted
with evidence of Mecklenburg’s “apparent recovery from her pelvic fracture” and her “denial of
pain symptoms prior to leaving inpatient rehabilitation against medical advice.”

Tr. 19.

Mecklenburg advances no argument challenging the ALJ’s reasoning in these respects.
Ultimately, the evidence concerning Mecklenburg’s balance and gait problems was
conflicting. There was some evidence to support Mecklenburg’s claim, but there was also
substantial evidence that undermined Mecklenburg’s claim. It was the “ALJ’s task to resolve
genuine conflicts in the medical evidence,” McGill v. Berryhill, No. 16-CV-4970, 2018 WL
1368047, at *10 (E.D.N.Y. Mar. 16, 2018), and Mecklenburg’s arguments have not persuaded the
Court that the ALJ’s decision is factually unsupported or legally erroneous.
CONCLUSION
Accordingly, the Commissioner’s Motion for Judgment on the Pleadings (ECF No. 19) is
GRANTED and Plaintiff’s Motion for Judgment on the Pleadings (ECF No. 11) is DENIED. The
complaint is DISMISSED WITH PREJUDICE, and the Clerk of Court is directed to enter
judgment and close this case.
IT IS SO ORDERED.
Dated: July 15, 2019
Rochester, New York

______________________________________
HON. FRANK P. GERACI, JR.
Chief Judge
United States District Court

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