Weiland v. Colvin
Filing
15
DECISION AND ORDER granting 10 Plaintiff's Motion for Judgment on the Pleadings to the extent that this matter is remanded to the Commissioner for further administrative proceedings consistent with this Decision and Order; and denying 11 Commissioner's Motion for Judgment on the Pleadings. (Clerk to close case.) Signed by Hon. Michael A. Telesca on 2/3/17. (JMC)-CLERK TO FOLLOW UP-
UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF NEW YORK
AMANDA WEILAND,
Plaintiff,
-vs-
No. 6:16-CV-06100 (MAT)
DECISION AND ORDER
CAROLYN W. COLVIN, ACTING
COMMISSIONER OF SOCIAL SECURITY,
Defendant.
I.
Introduction
Represented by counsel, Amanda Weiland (“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). Presently before
the Court are the parties’ cross-motions for judgment on the
pleadings pursuant to Rule 12(c) of the Federal Rules of Civil
Procedure. For the reasons discussed below, plaintiff’s motion is
granted
to
the
extent
that
this
matter
is
remanded
to
the
Commissioner for further administrative proceedings consistent with
this Decision and Order.
II.
Procedural History
The record reveals that in July 2012, plaintiff (d/o/b January
26, 1979) applied for DIB, alleging disability as of March 15,
2012. After her application was denied, plaintiff requested a
hearing, which was held via videoconference before administrative
law judge David J. Begley (“the ALJ”) on September 11, 2013. The
ALJ issued an unfavorable decision on December 12, 2013. The
Appeals Council denied review of that decision and this timely
action followed.
III. Summary of the Evidence
Throughout the relevant time period, plaintiff was treated for
back pain and migraines by physician’s assistant (“PA”) Laura Moore
at Arcadia Family Practice in Marion, New York. On February 2,
2012, plaintiff’s physical examination was normal and PA Moore
noted that her back pain, which was not associated with a known
injury, “[was] markedly improved.” T. 215. PA Moore also noted that
plaintiff’s headaches continued and she was prescribed Imitrex up
to three times per week. That same day, PA Moore wrote a note
stating that plaintiff could return to work “without restrictions”
on February 6, 2012. On March 15, 2012, however, plaintiff returned
to PA Moore complaining that her back pain had been resolved until
the day before “when [it] began bothering [her] at work and [she]
needed to come home.” T. 218. On physical examination, lumbosacral
range of motion (“ROM”) was decreased and straight leg raise
(“SLR”) test was positive on the right. Plaintiff was prescribed
hydrocodone for pain and Zofran for nausea. An MRI of plaintiff’s
lumbar spine dated March 23, 2012 revealed mild spondylosis of the
lumbosacral spine with mild bilateral neural foraminal narrowing at
L4-5 and L5-S1.
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Plaintiff
continued
to
demonstrate
decreased
ROM
and
tenderness of the lumbosacral spine in treatment with PA Moore
through August 2012. In a note dated April 30, 2012, PA Moore
stated that plaintiff could not work for two weeks due to low back
pain. In a treatment note dated August 31, 2012, Dr. David Moorthi,
a specialist in spine and pain care, noted that plaintiff’s MRI
“show[ed]
arthritis
and
disc
bulge
but
[did]
not
explain
[plaintiff’s] pain.” T. 245. Dr. Moorthi noted that plaintiff’s ROM
was within normal ranges and she had full strength of the lower
extremities. The record reflects that plaintiff attended physical
therapy for approximately four weeks. On September 27, 2012,
plaintiff received a bilateral sacroiliac joint injection for pain
management.
In April 2013, plaintiff saw PA Moore who noted that plaintiff
complained of gastroenteritis symptoms and a depressive episode
spanning the previous month. Plaintiff was prescribed venlafaxine,
an
antidepressant,
and
Abilify,
an
antipsychotic.
Subsequent
treatment notes indicate that plaintiff was discontinued from
Abilify and prescribed Risperdal, another antipsychotic, instead.
In
December
2013,
plaintiff
reported
to
PA
Moore
that
her
sacroiliac joint injection was helpful and she was trying to obtain
insurance coverage for another. On physical examination, plaintiff
demonstrated decreased ROM of the lumbosacral spine and right-side
positive SLR. Plaintiff had another sacroiliac injection in early
3
January 2014, but complained to PA Moore that her pain remained the
same. SLR was negative but plaintiff reported tenderness in the
lumbosacral spine. In a treatment note dated August 13, 2013, PA
Moore indicated that plaintiff could stand for approximately two
hours in an eight-hour workday; could walk for a total of three
hours in an eight-hour workday but would need to rest after walking
for 30 minutes; could sit for two hours in an eight-hour workday
but only continuously for one hour at a time; and could not lift
more than 10 pounds.
Plaintiff received mental health treatment at Wayne Behavioral
Health Network from approximately May through October 2013. Upon
diagnostic review in May 2013, plaintiff reported “sadness starting
about 3 years ago when life felt out of control, then leveled off
and since being pulled out of work due to back problems a year ago
she report[ed] mood lability; easily irritated by others; decreased
appetite; decrease in hygiene . . .; little motivation and energy
to take care of herself and her home.” T. 298. She was currently
prescribed Effexor and Wellbutrin (both antidepressants). She was
diagnosed
(“NOS”).
with
depressive
Plaintiff’s
disorder,
treating
social
not
otherwise
worker,
specified
Rachel
Prince,
assigned plaintiff a global assessment of functioning (“GAF”) score
of
50,
indicating
Psychiatric
serious
Association,
symptoms.
See
generally
Diagnostic and Statistical
American
Manual
of
Mental Disorders (“DSM–IV”), at 34 (4th ed. rev. 2000) (describing
4
global assessment of functioning (“GAF”) scoring). On mental status
examination
(“MSE”)
upon
initial
consultation,
plaintiff
demonstrated depressed mood, poor hygiene, and limited judgment,
but otherwise the MSE was generally unremarkable. On August 27,
2013, plaintiff’s MSE was unremarkable except for depressed mood.
IV. The ALJ’s Decision
Initially, the ALJ determined that plaintiff met the insured
status requirements of the Act through June 30, 2017. At step one
of the five-step sequential analysis, see 20 C.F.R. § 404.1520, the
ALJ determined that plaintiff had not engaged in substantial
gainful activity since March 15, 2012, the alleged onset date. At
step two, the ALJ found that plaintiff suffered from the following
severe impairments: lumbosacral neuritis, migraines, obesity, and
depression. At step three, the ALJ found that plaintiff did not
have an impairment or combination of impairments that met or
medically equaled a listed impairment. In considering plaintiff’s
mental
impairments,
the
ALJ
found
that
plaintiff
had
mild
restrictions in activities of daily living (“ADLs”) and social
functioning; moderate restrictions in maintaining concentration,
persistence, or pace; and no prior episodes of decompensation.
Before proceeding to step four, the ALJ determined that
plaintiff retained the RFC to perform light work as defined in 20
C.F.R. § 404.1567(b) except that she could not climb ladders,
ropes, or scaffolds; she was limited to occasional climbing of
5
ramps and stairs, balancing, stooping, kneeling, crouching, and
crawling; she must avoid slippery or uneven surfaces, hazardous
machinery, and unprotected heights; and she was limited to simple,
routine, and repetitive tasks. At step four, the ALJ concluded that
plaintiff could perform past relevant work as a filler operator and
assembler. Accordingly, the ALJ found that plaintiff was not
disabled at step four and did not proceed to step five.
V.
Discussion
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
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).
“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).
A.
Failure to Develop the Record
Plaintiff contends that the ALJ failed to fully develop the
record and therefore his RFC finding was unsupported by substantial
evidence. Specifically, plaintiff contends that the ALJ formulated
an
RFC
without
the
benefit
of
any
medical
opinion
regarding
plaintiff’s functional abilities. For the reasons that follow, the
Court agrees.
6
Initially, the Court notes that the ALJ did not order a
consulting examination regarding either plaintiff’s physical or
mental limitations. In his decision, the ALJ gave “limited weight”
to the only functional assessment in the record, which was given by
PA Moore and related to plaintiff’s physical limitations. As noted
above, PA Moore opined that plaintiff could stand for approximately
two hours in an eight-hour workday; could walk for a total of three
hours in an eight-hour workday but would need to rest after walking
for 30 minutes; could sit for two hours in an eight-hour workday
but only continuously for one hour at a time; and could not lift
more than 10 pounds. The ALJ rejected this opinion as inconsistent
with the medical evidence of record.
In this case, it was improper for the ALJ to arrive at an RFC
without the benefit of expert medical opinion. “Although residual
functional
capacity
determinations
are
reserved
for
the
Commissioner, administrative law judges are unqualified to assess
residual functional capacity on the basis of bare medical findings
in instances when there is a relatively high degree of impairment.”
Palascak v. Colvin, 2014 WL 1920510, *8 (W.D.N.Y. May 14, 2014);
see also Staggers v. Colvin, 2015 WL 4751123, *2 (D. Conn. Aug. 11,
2015) (“[A]n ALJ who makes an RFC determination in the absence of
supporting expert medical opinion has improperly substituted his
own opinion for that of a physician, and has committed legal
error.”) (quoting Hilsdorf v. Comm’r of Soc. Sec., 724 F. Supp. 2d
7
330, 347 (E.D.N.Y. 2010)). Here, the only treating assessment1 in
the record opined that plaintiff had significant work-related
restrictions, yet the ALJ gave this opinion little weight, thus
rendering his RFC finding unsupported by substantial evidence. See
Lowe v. Colvin, 2016 WL 624922, at *7 (W.D.N.Y. Feb. 17, 2016)
(“Because Dr. Sheehan is the only medical opinion in the record to
assess Plaintiff’s ability to lift and carry with specificity, and
because the ALJ ultimately gave little evidentiary weight to that
opinion, the Court is left with the circumstance of the ALJ
interpreting raw medical data to arrive at a residual functional
capacity determination, without the benefit of an expert medical
opinion.”) (internal quotation marks omitted).
As to plaintiff’s mental limitations, the record does not
contain a medical or other source opinion. Although plaintiff was
treated for depression throughout much of the relevant time period,
the ALJ failed to obtain a functional assessment from a treating
mental health provider and did not order a consulting examination
or even a reviewing psychologist’s psychiatric review technique or
mental
RFC.
Considering
the
record
evidence
of
plaintiff’s
diagnosis and treatment for depression, the ALJ erred in failing to
obtain a medical source opinion regarding her mental limitations.
1
The Court notes that PA Moore was not formally an
“acceptable medical source” under the applicable regulations. As an
“other source,” PA Moore’s opinion is relevant to determining “the
severity of [plaintiff’s] impairment(s) and how it affects [her]
ability to do work.” 20 C.F.R. § 404.1513(d).
8
See, e.g., Cyman v. Colvin, 2015 WL 5254275, *6 (W.D.N.Y. Sept. 9,
2015) (reversing and remanding where record contained evidence of
mental
impairments
and
therefore
“the
ALJ’s
determination
of
plaintiff’s mental RFC without reference to any treating source or
consulting opinions was reversible error.”);
2012
WL
695856,
*11
(N.D.N.Y.
Mar.
1,
Stokes v. Astrue,
2012)
(reversing
and
remanding where ALJ determined mental RFC without reference to any
medical assessment of functional limitations, and where record
contained evidence of mental impairments).
This
case
plaintiff’s
is
RFC.
On
therefore
remand,
remanded
the
ALJ
for
is
reconsideration
directed
to
of
contact
plaintiff’s treating medical sources for opinions as to plaintiff’s
physical
and
mental
functional
limitations.
If
opinions
from
treating sources cannot be obtained, the ALJ is directed to order
consulting examinations. Having found remand necessary, the Court
declines to address plaintiff's argument regarding credibility.
Plaintiff's
thorough
credibility
consideration
must
of
be
the
reconsidered
fully
developed
on
remand
upon
administrative
record.
VI. Conclusion
For the foregoing reasons, the Commissioner’s motion for
judgment on the pleadings (Doc. 11) is denied and plaintiff’s
motion (Doc. 10) is granted to the extent that this matter is
remanded to the Commissioner for further administrative proceedings
9
consistent with this Decision and Order. The Clerk of the Court is
directed to close this case.
ALL OF THE ABOVE IS SO ORDERED.
S/Michael A. Telesca
HON. MICHAEL A. TELESCA
United States District Judge
Dated:
February 3, 2017
Rochester, New York.
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