Crayton v. Astrue
Filing
11
-CLERK TO FOLLOW UP-ORDER denying the Commissioner's 6 Motion for Judgment on the Pleadings; granting plaintiff's 7 Motion for Judgment on the Pleadings and remanding the matter for further proceedings consistent with this opinion. Signed by Hon. David G. Larimer on 5/10/13. (EMA)
UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF NEW YORK
_______________________________________________
TANYA MARIE CRAYTON,
Plaintiff,
DECISION AND ORDER
11-CV-6617L
v.
MICHAEL J. ASTRUE,
Commissioner of Social Security,
Defendant.
________________________________________________
Plaintiff appeals from a denial of supplemental security income benefits by the Commissioner
of Social Security (“the Commissioner”). The action is one brought pursuant to 42 U.S.C. § 405(g)
to review the final determination of the Commissioner.
On July 27, 2009, plaintiff, then forty years old, filed an application for Supplemental
Security Income benefits under Title II of the Social Security Act. Plaintiff alleged an inability to
work since June 1, 2009, due to, inter alia, depression, arthritis, “back problems” (scoliosis and
pain), anxiety and asthma. (T. 186). Her application was initially denied. Plaintiff requested a
hearing, which was held via video conference on March 2, 2011 before Administrative Law Judge
(“ALJ”) MaryJoan McNamara. (T. 69). The ALJ issued a decision on April 21, 2011, concluding
that plaintiff was not disabled under the Social Security Act. (T. 69-79). That decision became the
final decision of the Commissioner when the Appeals Council denied review on October 21, 2011
(T. 1-3). Plaintiff now appeals from that decision. The Commissioner has moved (Dkt. #6), and the
plaintiff has cross moved (Dkt. #7) for summary judgment. For the reasons set forth below,
plaintiff’s cross motion is granted, the Commissioner’s motion is denied, and the matter is remanded
for further proceedings.
DISCUSSION
Determination of whether a claimant is disabled within the meaning of the Social Security
Act requires a five-step sequential evaluation. See Bowen v. City of New York, 476 U.S. 467, 470-71
(1986). See 20 CFR §§404.1509, 404.1520. If the ALJ concludes that the claimant is not engaged
in substantial gainful employment and suffers from a severe impairment, the ALJ examines whether
the claimant’s impairment meets or equals the criteria of those listed in Appendix 1 of Subpart P of
Regulation No. 4. If the impairment does so, and has continued for the required duration, the
claimant is disabled. If not, analysis proceeds and the ALJ determines the claimant’s residual
functional capacity (“RFC”), which is the ability to perform physical or metal work activities on a
sustained basis, notwithstanding limitations for the collective impairments.
See 20 CFR
§404.1520(e), (f). If the claimant’s RFC permits her to perform relevant jobs she has done in the
past, she is not disabled. If not, analysis proceeds to the final step, and the burden shifts to the
Commissioner to show that the claimant is not disabled, by presenting evidence demonstrating that
the claimant “retains a residual functional capacity to perform alternative substantial gainful work
which exists in the national economy” in light of her age, education, and work experience. See Rosa
v. Callahan, 168 F.3d 72, 77 (2d Cir.1999), quoting Bapp v. Bowen, 802 F.2d 601, 604 (2d
Cir.1986). See also 20 CFR §404.1560(c).
The Commissioner’s decision that a plaintiff is not disabled must be affirmed if it is
supported by substantial evidence, and if the ALJ applied the correct legal standards. See 42 U.S.C.
§ 405(g); Machadio v. Apfel, 276 F.3d 103, 108 (2d Cir.2002). Substantial evidence is defined as
“more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as
adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971) (quoting
Consolidated Edison Co. v. N.L.R.B., 305 U.S. 197, 229 (1938)). “The Court carefully considers the
whole record, examining evidence from both sides ‘because an analysis of the substantiality of the
evidence must also include that which detracts from its weight.’” Tejada v. Apfel, 167 F.3d 770,
774 (2d Cir. 1998) quoting Quinones v. Chater, 117 F.3d 29, 33 (2d Cir.1997). Still, “it is not the
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function of a reviewing court to decide de novo whether a claimant was disabled.” Melville v. Apfel,
198 F.3d 45, 52 (2d Cir.1999). “Where the Commissioner’s decision rests on adequate findings
supported by evidence having rational probative force, [this Court] will not substitute our judgment
for that of the Commissioner.” Veino v. Barnhart, 312 F.3d 578, 586 (2d Cir.2002).
The ALJ summarized plaintiff’s medical records, particularly with respect to her scoliosis,
which she determined constituted a severe impairment not meeting or equaling a listed impairment.
I believe the evidence supports the ALJ’s findings concerning plaintiff’s exertional limitations, but
that the ALJ failed to apply the correct legal standards in analyzing plaintiff’s non-exertional
limitations. The matter is accordingly remanded for further proceedings.
I.
Plaintiff’s Exertional Limitations
In determining plaintiff’s RFC, the ALJ considered the medical record, which included
treatment notes for diagnoses of, inter alia, scoliosis, asthma (controlled with medication), posttraumatic stress disorder (“PTSD”), bipolar disorder with depression, and anxiety. Based on this
evidence, the ALJ determined that plaintiff retained the residual functional capacity to perform light
work, with limitations to occasional overhead reaching, handling and fingering, occasional climbing,
occasional balancing, stooping, kneeling and crawling, and avoidance of concentrated exposure to
respiratory irritants. (T. 72). (The ALJ also listed several as non-exertional limitations, discussed
below.) I find the ALJ’s determination of plaintiff’s exertional limitations is supported by the
substantial evidence cited by the ALJ.
Plaintiff challenges the ALJ’s assessment of her exertional limitations, arguing that the ALJ
failed to evaluate the effect of plaintiff’s alleged arthritis on her functional limitations, and that the
ALJ should have given controlling weight to the opinion of plaintiff’s treating physician, Dr. Walter
Stewart Beecher.
Withe respect to plaintiff’s claimed arthritis, I note that there is little evidence concerning
diagnosis and treatment of arthritis in the record, and that to the extent that arthritis symptoms are
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documented, they were included in the exertional limitations found by the ALJ. Although there are
indications that plaintiff has pain in her wrists and has utilized knee and left wrist braces in the past,
the ALJ discussed these symptoms in her opinion in connection with plaintiff’s claims of carpal
tunnel syndrome and generalized back, knee and wrist pain, and, with the exception of the opinion
of Dr. Beecher, incorporated them into plaintiff’s RFC. (T. 76, 77)
The report of plaintiff’s treating physician, Dr. Beecher, was rejected by the ALJ. It is wellsettled that “the medical opinion of a claimant’s treating physician is given controlling weight if it
is well supported by medical findings and not inconsistent with other substantial record evidence.”
Shaw v. Chater, 221 F.3d 126, 134 (2d Cir. 2000). See 20 C.F.R. § 404.1527(d)(2). In determining
the weight to which a treating physician’s opinion is entitled, the Commissioner must consider: (1)
the length, nature and extent of the treatment relationship; (2) the frequency of examination; (3) the
evidence supporting the treating physician’s opinion; (4) whether the opinion is consistent with the
record as whole; and (5) whether the opinion is rendered by a specialist in a relevant field(s). 20
C.F.R. § 404.1527(d). Further, the ALJ must have clearly articulated her reasons for assigning the
level of weight she assigns to a treating physician’s opinion. Shaw, 221 F.3d at 134; see also Snell
v. Apfel, 177 F.3d 128, 133 (2d Cir. 1999).
The ALJ rejected Dr. Beecher’s opinion on the grounds that it was unsupported by medical
evidence in the record, and was inconsistent with the opinions of other treating and examining
physicians, and plaintiff’s own reports of her physical activities. (T. 77). For example, Dr. Beecher
opined that plaintiff could “never” twist, stoop, crouch, squat, climb ladders, grasp, turn or twist
objects with her hands – but simultaneously opined that plaintiff could perform fine manipulation
with her fingers for 50% of a full workday. (T. 369). A report by examining physician Karl
Eurenius on August 26, 2009 noted that plaintiff had normal gait, normal stance, could perform a
full squat, has full spinal flexion, extension and rotary movement, full lateral flexion and rotation
in the low back, full range of movement in her hips, knees, ankles, strength of 5/5 in her upper and
lower extremities, and intact hand and finger dexterity and 5/5 grip strength, despite tenderness in
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both wrists. (T. 273). Plaintiff’s self-reported activities of daily living, including reading books,
dressing herself and attending to personal hygiene, loading and unloading laundry from the washer
and dryer, grocery shopping and performing light housework, also conflict with Dr. Beecher’s
opinion that plaintiff can “never” stoop, crouch, squat, or handle items with her hands. (T. 49-52).
Finally, there are no objective medical tests or reports supporting the level of postural and manual
disability contained in Dr. Beecher’s report, and Dr. Beecher did not adjust or increase plaintiff’s
prescribed back pain medication, or even deem it appropriate to order any testing, imaging studies
or x-rays of her back, knees or wrists. (T. 29, 74).
Balancing these factors, I find that the ALJ’s rejection of Dr. Beecher’s opinion concerning
plaintiff’s exertional limitations was proper.
Plaintiff also challenges the ALJ’s finding that plaintiff’s complaints of disabling pain were
not wholly credible. “When rejecting subjective complaints, an ALJ must do so explicitly and with
sufficient specificity to enable the Court to decide whether there are legitimate reasons for the ALJ’s
disbelief.” Cornell v. Astrue, 2013 U.S. Dist. LEXIS 9513 at *20-*21 (N.D.N.Y. 2013).
Here, the ALJ rejected plaintiff’s testimony based on several inconsistencies. Not only did
plaintiff’s complaints of disabling pain appear to conflict with her medical treatment records, which
reflect few complaints and no aggressive or additional treatment for back, knee and wrist pain, as
discussed above, but they also contained a number of internal inconsistencies. For example, plaintiff
listed, among her activities of daily living, dressing and caring for herself, performing light
housework and grocery shopping, and stated that she could lift ten pounds, but later plaintiff testified
that the pain in her hands rendered her unable to “even stir food.” (T. 33, 52). Plaintiff initially
testified that “I try to clean the house the best I can, but what I can’t do, my fiancé does for me,” but
afterwards, in answer to the question of whether she was able to clean the house, replied, “[n]o, my
fiancé does all that . .. I can’t, like, clean my house . . .” (T. 32, 36). Later, she appeared to reverse
course, testifying that when she is wearing her knee braces she can “stand up and vacuum my floors
and stuff.” (T. 48). Given the inconsistencies between plaintiff’s reports of disabling pain, other
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testimony by plaintiff and the rest of the record, I find no basis to disturb the ALJ’s findings as to
plaintiff’s credibility.
II.
Plaintiff’s Non-exertional Limitations
Plaintiff also alleges that the ALJ failed to apply the Psychiatric Review Technique (“PRT”)
to her claims of mental disability.
In addition to the usual five-step analysis, the regulations “require application of a ‘special
technique’ at the second and third steps of the five-step framework.’” Kohler v. Astrue, 546 F.3d
260, 265 (2d Cir. 2008). If the claimant is found to have a medically determinable mental
impairment, the ALJ must assess the claimant’s degree of resulting limitations in four broad
functional areas: (1) activities of daily living; (2) social functioning; (3) concentration, persistence
or pace; and (4) episodes of decompensation. 20 CFR § 404.1520a(c)(3). If and how the analysis
proceeds from that point depends upon the degree of impairment found. However, the ALJ must
document her application of the PRT, and her written decision must “reflect application of the
technique, and . . . ‘include a specific finding as to the degree of limitation in each of the [four]
functional areas.’” Kohler, 546 F.3d 260 at 266, quoting 20 CFR §404.1520a(e)(2).
Plaintiff’s medical records consistently indicate the presence of one or more medically
determinable mental impairments, in the form of a history of anxiety, depression and PTSD.
Psychiatric assessments by certified social worker Elizabeth Driscoll list diagnoses of anxiety,
depression, and PTSD, and recommend treatment with medication, individual therapy and group
therapy. (T. 299-307). A Psychiatric Review Technique form completed by non-examining state
agency review physician T. Harding notes the existence of affective disorders and anxiety-related
disorders, and finds moderate limitations in a number of functional areas. (T. 256). Consultative
psychologist Kavitha Finnity examined plaintiff and diagnosed her with bipolar disorder, posttraumatic stress disorder, and generalized anxiety disorder, and recommended psychological and
psychiatric treatment. (T. 278). Plaintiff’s treating physician, Dr. Beecher, also noted plaintiff’s
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history of symptoms of a depressive disorder, and prescribed her Prozac and Trazodone,
antidepressant medications. (T. 340). As the ALJ noted, plaintiff has commenced – and
discontinued – mental health treatment multiple times. (T. 38-41, 72).
Although the ALJ incorporated a number of non-exertional limitations into plaintiff’s RFC
in deference to the opinions of plaintiff’s treating, examining and consulting physicians concerning
her alleged mental impairments, (T. 72), the ALJ did not explicitly apply the PRT and her opinion
contains no analysis or discussion of the four functional areas.
Thus, while I concur that the ALJ’s findings as to plaintiff’s exertional limitations are wellsupported by substantial evidence of record, the ALJ’s failure to apply the PRT in determining the
effect, if any, of plaintiff’s mental impairments on her RFC necessitates remand of the matter. See
generally Kohler, 546 F.3d 260 at 266-269; Moore v. Astrue, 2013 U.S. Dist. LEXIS 52183 at *21
(N.D.N.Y. 2013). While it may be that application of the PRT yields the same or similar results to
those previously reached by the ALJ, the effort is necessary in order to ensure that the agency’s
ultimate conclusion is grounded by a proper application of the required analytical framework. As
such, the matter is remanded for the limited purpose of reviewing the evidence of record with regard
to plaintiff’s mental functioning in the four areas prescribed by the PRT and making specific findings
of fact, incorporating those findings into the plaintiff’s RFC, and conducting such other and further
proceedings as may be necessary and appropriate.
CONCLUSION
The Commissioner’s motion for summary judgment (Dkt. #6) is denied, the plaintiff’s cross
motion for summary judgment (Dkt. #7) is granted, and the matter is remanded for further
proceedings consistent with this opinion.
IT IS SO ORDERED.
_______________________________________
DAVID G. LARIMER
United States District Judge
Dated: Rochester, New York
May 10, 2013.
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