Clough v. Berryhill

Filing 18

DECISION AND ORDER granting 9 Motion for Judgment on the Pleadings; denying 13 Motion for Judgment on the Pleadings. The Court denies Commissioners cross-motion for judgment on the pleadings, ECF No. 13, and grants Plaintiff's motion, ECF No. 9. The Court reverses the Commissioner's decision denying benefits and remands this matter for a rehearing pursuant to sentence four of 42 U.S.C. § 405(g). The Court directs the Commissioner to expedite the rehearing in this case. Signed by Hon. Charles J. Siragusa on 5/7/18. (KAP)-CLERK TO FOLLOW UP-

UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF NEW YORK

BONNIE MAY CLOUGH,
Plaintiff,
DECISION AND ORDER

-vsNANCY A. BERRYHILL, Acting Commissioner of Social Security,

17-CV-6375-CJS

Defendant.

APPEARANCES
For Plaintiff:

Howard D. Olinsky, Esq.
Olinsky Law Group
300 South State Street Suite 420
Syracuse, NY 13202
[phone]

For the Commissioner:

Catharine Louise Zurbrugg, Esq.
Social Security Administration
Office of General Counsel
26 Federal Plaza Room 3904
New York, NY 10278
[phone]
Kathryn L. Smith, A.U.S.A.
United States Attorney's Office
100 State Street, Fifth Floor
Rochester, NY 14614
[phone]
INTRODUCTION

Siragusa, J. Bonnie May Clough (“Plaintiff”) brings this action pursuant to Title II
of the Social Security Act seeking review of the final decision of the Commissioner of
Social Security (“Commissioner”) denying her application for supplemental security in-

come benefits. Presently before the Court are the parties’ competing motions for judgment on the pleadings pursuant to Federal Rule of Civil Procedure 12(c). For the reasons set forth below, the Court denies Commissioner’s cross-motion for judgment on
the pleadings, ECF No. 13, and grants Plaintiff’s motion, ECF No. 9. The Court reverses
the Commissioner’s decision denying benefits and remands this matter for a rehearing
pursuant to sentence four of 42 U.S.C. § 405(g). The Court directs the Commissioner to
expedite the rehearing in this case.
PROCEDURAL HISTORY
On December 11, 2014, Plaintiff filed a claim for Supplemental Security Income,
alleging disability beginning on October 16, 2014. R. 143. The Social Security Administration denied her claims on February 12, 2015, and she appeared by video conference
before an Administrative Law Judge (“ALJ”) for a hearing on September 7, 2016, at which
a vocational expert also testified. An attorney represented Plaintiff at the hearing. The
ALJ issued a decision on November 9, 2016, which Plaintiff appealed. The Appeals Council affirmed the ALJ’s decision on April 11, 2017, and Plaintiff commenced this action
pursuant to 42 U.S.C. § 405(g) on June 14, 2017. The Court heard oral argument on April
19, 2018.
THE ALJ’S DECISION
The ALJ applied the Commissioner’s five-step sequential evaluation for adjudicating disability claims, 20 C.F.R. §§ 404.1520, 416.920. At step one, the ALJ found Plaintiff
had not engaged in any substantial gainful employment since October 16, 2014. R. 25.
At step two, the ALJ determined that Plaintiff had the following severe impairments: Degenerative Disc Disease—Cervical Spine, Generalized Anxiety Disorder, Social Phobia,

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and Depression. However, at step three, the ALJ found that the impairments, either singularly or together, did not meet or medically exceed the severity of one of the Commissioner’s listed impairments. R. 25–26.
Before proceeding to step four, the ALJ determined that Plaintiff retained the residual functional capacity (“RFC”) to perform light work as defined in 20 C.F.R.
404.1567(b) and 416.967(b). He added the following restrictions:
This individual cannot crawl and cannot climb ladders, ropes or scaffolds.
The individual is limited to perform simple, routine tasks, and to making simple work-related decisions. This individual requires a work environment
where change is minimal. The individual cannot perform work that involves
conveyor belts or assembly lines. And this individual cannot tolerate any
contact with the general public, and that would be in-person contact. She is
limited to work settings without excessive background noise; she can have
no public interaction and only superficial contact with coworkers and supervisors; and she can do no assembly line or fast paced work.
R. 59. Plaintiff had no past relevant work. R. 32. At step five, considering her age, education, work experience, and RFC, the ALJ determined that a significant number of jobs
existed in the national economy that Plaintiff could perform, specifically: stock clerk,
housekeeping/cleaner, and mail clerk. R. 32. Accordingly, the ALJ found Plaintiff not disabled. R. 33.
SCOPE OF REVIEW
A district court may set aside the Commissioner’s disability determination only if
the Commissioner’s “substantial evidence” is not present to support it, or if the Commissioner committed 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). “The deferential standard of review for substantial evidence does not apply to the Commissioner’s conclusions of law.” Byam v.

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Barnhart, 336 F.3d 172, 179 (2d Cir. 2003) (citing Townley v. Heckler, 748 F.2d 109, 112
(2d Cir. 1984)).
DISCUSSION
Plaintiff argues that the ALJ committed reversible error when he failed to accord
controlling weight to the opinion of Plaintiff’s treating psychiatrist, Ronald D. Spurling,
M.D., and failed to reconcile the opinion of consultative examiner Yu-Ying Lin, Ph.D., with
medical source statements. The Commissioner counters that the ALJ properly found the
Dr. Spurling’s conclusions were contradicted by his own examination findings, that Plaintiff’s reported activities were inconsistent with her allegations of disability, and that the
ALJ’s residual functional capacity finding is supported by substantial evidence in the record.
Dr. Spurling
For claims filed before March 27, 2017, the Commissioner applies this rule to the
evaluation of treating physician opinions:
(2) Treatment relationship. Generally, we give more weight to medical opinions from your treating sources, since these sources are likely to be the
medical professionals most able to provide a detailed, longitudinal picture
of your medical impairment(s) and may bring a unique perspective to the
medical evidence that cannot be obtained from the objective medical findings alone or from reports of individual examinations, such as consultative
examinations or brief hospitalizations. If we find that a treating source’s
medical opinion on the issue(s) of the nature and severity of your impairment(s) is well-supported by medically acceptable clinical and laboratory
diagnostic techniques and is not inconsistent with the other substantial evidence in your case record, we will give it controlling weight. When we do
not give the treating source’s medical opinion controlling weight, we apply
the factors listed in paragraphs (c)(2)(i) and (c)(2)(ii) of this section, as well
as the factors in paragraphs (c)(3) through (c)(6) of this section in determining the weight to give the medical opinion. We will always give good reasons
in our notice of determination or decision for the weight we give your treating
source’s medical opinion.
20 C.F.R. § 416.927(c)(2) (2017).

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Dr. Spurling is a psychiatrist at FLH Medical, P.C., in Geneva, New York, certified
by the American Board of Psychiatry & Neurology-Psychiatry.1 He has been treating
Plaintiff since September 8, 2014, for anxiety and saw her frequently. At that first examination in September of 2014, Dr. Spurling prepared a report. R. 344–50. With regard to
Plaintiff’s employment history, Dr. Spurling noted that she,
has worked at various jobs over the years, mostly doing custodial work. She
says she would not work anywhere more than a year, because she always
had difficulty with transportation and would have to give up her job because
her husband needed the car since he made more money. She does report
a history of one previous inpatient psychiatric hospitalization in 2008 related
to homicidal ideation towards her husband because she felt he was thinking
[sic] around with the wrong people. She says she was throwing knives at
him. More recently, she has been becoming stressed at home because her
husband was laid off and may have financial stressors.
R. 344. Plaintiff reported, “her primary problem is her anxiety and stress.” Id. She also
reported that her father was an alcoholic, her older brother has schizophrenia, and her
oldest son “has some type of psychiatric process, but he has not been diagnosed or
treated.” R. 345. The list of medications Plaintiff was prescribed took two paragraphs to
describe. R. 346. Dr. Spurling concluded his report with the following:
I do agree with her assessment her primary issue is anxiety. I think she has
had a long-standing generalized anxiety disorder and she is also describing
a social phobia. She is very preoccupied around her young adult sons and
concerns from them. She also has multiple other stressors with her primary
relationship and financial stressors. There Is no evidence of psychosis.
There is no clear evidence of a bipolar process. She denies any significant
use of alcohol or substances, but a urine drug test was positive for marijuana in March of this year. She seems to have cluster B., dependent and
avoidant maladaptive personality traits.

RochesterHealth.com. (2018, March 3). Ronald D. Spurling. Retrieved April 16, 2018, from
http://www.rochesterhealth.com/healthcaredirectory/profile/3754263022/ronald-d-spurling-mdpsychiatry-neurology-psychiatry.
1

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She is clearly very anxious around taking medications and repeatedly states
that she feels she is on too many medications. I strongly suspect that she
is noncompliant or intermittently compliant with many of her prescribed
medications. She is prescribed 2 different benzodiazepines, but seems to
essentially only take the Klonopin 0.5 mg b.i.d. on a regular basis, and very
real he takes [sic] the lorazepam but she has also been prescribed. She
may continue to take benzodiazepines. I have decided to add Depakote ER
500 mg tablets, one tablet by mouth at bedtime to attempt to help with her
anxiety, ruminations and insomnia. She is to call difficulties. She is to followup in 6–8 weeks.
Axis l: Anxiety Disorder Generalized, Pain Chest Other, Social Phobia, Palpitations, Depression NOS, Hyperlipidemia Mixed, Cannabis Abuse Episodic, Hypertension Unspec, Tobacco Use Disorder
Axis II: Dependent and avoidant traits
Axis Ill: Chronic Obstructive Pulmonary Disease (COPD), Hypercholestremla and Hypertension
Axis IV: Moderate: Financial stressors, poor social supports, poor family
support, poor coping mechanisms
Axis V: Current GAF Score: 46, Highest GAF Score: 50
R. 347–48.
Plaintiff saw Dr. Spurling on October 20, 2014, for a follow-up appointment. R. 415.
He noted in his report of the visit that Plaintiff:
Today, she says she’s “pretty good.” She says she is still taking her anxiety
pills. She says she is not taking the Depakote that I prescribed because she
felt it made her too sleepy in combination with the pain medication that she
takes at night she says she is sleeping well. She feels she is doing better
overall because her significant other now is working again and she has less
worries with finances and paying the bills. She says she really doesn’t eat
during the day, and is overly hungry at night. She denies any change in her
weight. She denies any depression and says that her mood is better than
at the last visit. She says she continues to be anxious and easily distracted.
R. 415. Dr. Spurling’s examination revealed the following:

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Mood/Affect: Displays anxiety periodically during encounter. Patient reports improvement in mood since last visit. Patient’s affect is anxious and
brighter. Language/Thought: Speech is clear and appropriate for age. Language processing is intact. Thought processes demonstrate circumstantial
thinking, but do not demonstrate delusional ideation or flight of ideas. Associative thinking is intact. Patient demonstrates preoccupations. Cognition:
Alert and oriented x3. Memory is grossly intact. Attention span and concentration are grossly intact. Judgment is fair. Insight is fair. Impulse control is
grossly intact.
R. 418. He concluded his report with the following plan:
Intervention/Plan:
She is returning today for followup of her generalized anxiety and social
phobia with associated mood symptoms. She is denying any symptoms of
depression and her anxiety is slightly better related to view her financial
stressors since her husband now has a job. She continues to be quite anxious overall with exaggerated fears around her health and the safety of her
children. She is describing difficulty with focusing and concentration secondary to her severe anxiety. She only took Depakote a few times, saying
that she did not like taking it in addition to her pain medications at bedtime
which made her overly tired. She does indicate that she feels her anxiety is
still elevated and says that she would be willing to try something else for her
anxiety and her difficulties with focusing and concentration. Therefore I have
decided to try lamotrigine 25 mg tablets, 1 tablet daily at bedtime. increasing
by one tablet every 2 weeks to a goal of 3 tablets daily. She is to continue
her other medications unchanged. She is to call with difficulties. She is to
followup in 6-8 weeks.
R. 418.
Dr. Spurling saw Plaintiff for a follow-up visit on December 2, 2014. R. 368–71. He
reported that Plaintiff formerly worked in a park during the summer at Seneca Lake, and
that she was then watching her niece to earn money. R. 369. Dr. Spurling noted, “[t]oday,
she says she’s ‘feeling older,’ noting that today is her birthday. She says that her mood
is okay and overall she feels happy.” R. 411. However, she also reported feeling tired and
without motivation during the day, and attributed those moods to her medications. Id. He
reported his examination results as follows:

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Const: Appears appropriately groomed and appropriately dressed. No
signs of apparent distress present. Breath has no abnormal odor. Height Is
within normal range. No involuntary movement. Facial expression appears
pleasant.
Psych: Motor: Motor activity Is WNL. Mood/Affect: Displays anxiety periodically during encounter. Patient describes mood as anxious and good.
Patient’s affect is anxious and variable.
Language/Thought: Speech is overproductive, rapid and repetitive. Language processing Is intact. Thought processes demonstrate circumstantial
thinking, but do not demonstrate delusional ideation or flight of Ideas. Associative thinking is intact. Patient demonstrates preoccupations. Cognition: Alert and oriented x3. Memory is grossly intact. Attention span and
concentration are grossly intact. Judgment is fair. Insight is fair. Impulse
control ls grossly intact. Risk Assessment: Suicidality: none. Homicidality:
none. Dangerousness: none.
R. 370. Dr. Spurling noted that Plaintiff initially appeared “calmer, but as she speaks about
her multiple stressors and physical concerns she becomes progressively more anxious
and pressured.” R. 370. He continued her on medications, added Wellbutrin to the list,
and directed her to return in two months. R. 370.
On January 7, 2015, Dr. Spurling answered questions posed by the New York
State Office of Temporary and Disability Assistance. R. 372. He reported that Plaintiff was
anxious around medications and frequently non-compliant. R. 374. He described her ability to function in a work setting as “very limited because of anxiety,” and her ability to do
work related mental activities as “limited ability to work because of anxiety.” R. 377. He
did not offer an opinion on Plaintiff’s understanding and memory, or her sustained concentration and persistence. R. 378. He described her social interaction and adaption as
limited and wrote “anxiety,” under the social interaction question. R. 378.
On January 15, 2015, Yu-Ying Lin, Ph.D., performed a consultative examination
of Plaintiff. R. 385. Dr. Lin made the following observations of Plaintiff:

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APPEARANCE: General appearance was about the same as stated age.
She was dressed casually and was well groomed. Posture and motor behavior normal. Eye contact appropriate.
SPEECH: Fluent. Quality of voice clear. Expressive and receptive languages were adequate.
THOUGHT PROCESSES: Coherent and goal directed with no evidence of
hallucinations, delusions, or paranoia in the evaluation setting. Her thought
content often focused on stress in the household where people do not help
with the house chores or picking up after themselves.
AFFECT: Dysphoric.
MOOD: Dysthymic.
SENSORIUM: Clear.
ORIENTATION: x3.
ATTENTION AND CONCENTRATION: Appeared to be mildly impaired due
to anxiety in the evaluation. Even though she was able to perform simple
counting calculations and serial 3s, she appeared to have difficulty concentrating during recitation.
RECENT AND REMOTE MEMORY SKILLS: Appeared impaired due to
anxiety in the evaluation. She recalled objects immediately, and 1 at a delay. She recalled 6 digits forward and 3 digits backwards.
COGNITIVE FUNCTIONING: Intellectual functioning appeared to be below
average. General fund of information appropriate to experience.
INSIGHT: Fair.
JUDGMENT: Poor.
R. 386–87. The portion of Dr. Lin’s report titled “mode of living,” included this language:
“She spends her days laying [sic] in bed and watching TV. She reports she does not feel
like doing anything because it is not her responsibility to do the housework since the
people in the household are grown.” R. 387. In her medical source statement, Dr. Lin
concluded the following:

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The claimant can understand simple directions and instructions. She can
perform simple tasks independently. She is mildly limited in maintaining attention and concentration. She is able to maintain a regular schedule. She
can learn new tasks. She can perform complex tasks with supervision. She
is mildly limited in making appropriate decisions. She can relate adequately
with others. She is markedly limited in appropriately dealing with stress. Difficulties are caused by distractibility and stress-related problems.
R. 387–88.
On January 16, 2015, Plaintiff saw Dr. Mane at FLH Medical. In the Objective portion of his report, Dr. Mane wrote, “[d]enies anxiety, depression and stress. Sleep: reports
no sleep problems.” R. 310.
On February 4, 2015, Dr. Spurling saw Plaintiff for a follow-up visit. R. 407–10. He
described Plaintiff’s mood and affect as: “Displays anxiety periodically during encounter.
Patient describes mood as anxious and good. Patient’s affect is anxious, depressed and
more variable.” R. 409. Under “Cognition,” Dr. Spurling wrote: “Alert and oriented x3.
Memory is grossly intact. Attention span and concentration are grossly intact. Judgment
is fair. Insight is fair. Impulse control is grossly intact.” R. 409. Under the section titled
“Intervention/Plan,” Dr. Spurling concluded:
She continues to be extremely anxious and somatically preoccupied. She
reports that she has discontinued the Abilify because of complaints of dizziness, nausea and other somatic complaints. But, she has ongoing similar
complaints which she now associates with her antihypertensive medications. She is tearful and labile in her mood today and is focused on her belief
that her significant other has only stayed with her because of the children
that they had together and that he does not really love her. I have decided
to try adding olanzapine 5 mg at bedtime to try to help her rumination, insomnia and the GI manifestations of her anxiety. I will have her continue the
lamotrigine although I suspect that she is not really compliant with that medication. I have also increased the Klonopin to 0.5 mg 3 times daily as needed
for anxiety or panic. She is to call with difficulties. She is to followup in 2
months.
R. 409.

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On March 9, 2015, Plaintiff saw Dr. Spurling for a follow-up visit. R. 403. In his
report, the doctor noted that Plaintiff “tells me she was denied again for disability. She
asked if I will fill out paperwork for repetition for disability.” R. 403. He noted that she
reported sleeping better with the medication Zyprexa at bedtime. He also noted,
She also asked me to write to read [sic] a letter for her to get DSS so that
she can continue to get food stamps without having to look for work. She
says that she does not feel that she is capable of working right now and
needs more time to get better. She says perhaps in 3 or 4 months she would
be able to work.
R. 403. Dr. Spurling noted that Plaintiff had an “[i]mprovement in mood since last visit”
and that her “affect is less anxious, brighter and less depressed.” R. 405. He also noted
that her “[m]emory is grossly intact. Attention span and concentration are grossly intact.
Judgment is fair. Insight is fair. Impulse control is grossly intact.” Id. Under the heading of
“Intervention/Plan,” Dr. Spurling wrote in his Intervention/Plan section:
Objectively, she appears much calmer today. She says she is taking the
Zyprexa and that it is helping her with her sleep. I feel it is also helping with
her mood. But, she is complaining of ongoing issues with anxiety, saying
she has been under a lot of stress recently. She describes a chaotic environment in her home which exacerbates her stress. She complains of racing
thoughts and mood swings with periods of irritability. I will have her continue
the lamotrigine and Zyprexa at the current doses and I have decided to add
clonidine 0.1 mg in the morning and 0.1 mg at 5 PM to help with her irritability and anxiety. I also gave her a new prescription for the as needed
Xanax. I have noted that her primary care provider has placed a message
in the electronic medical record that he will no longer prescribe pain medications because of her having a recent urine drug screen which was positive
for cannabis. She had informed me whenever I initially evaluated her that
she had used cannabis in the past but denied recent use, which is clearly
not true as of the labs obtained in late January of this year. In regard to her
application for disability. I told her I would be willing to do paperwork describing her issues with anxiety and her mood. I also agreed to give her a
letter stating that she is unable to work at this time.

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R. 405-406. Dr. Spurling wrote a letter for Plaintiff in which he stated that she “is unable
to work at this time related to her anxiety and mood symptoms until further notice.” R.
398.
Dr. Spurling completed a medical source statement on March 15, 2015. R. 394–
96. The copy contained in the Record is particularly difficult to read. It appears the doctor
did not respond “no” or “yes” to the first question about the claimant’s ability to understand,
remember and carry out instructions. He did mark the form to indicate she had mild limitations in understanding and remembering simple instructions, carrying out simple instructions, and the ability to make judgments (the remainder of the words are too blurred
to read). R. 394. He marked the form indicating that she had moderate limitations in understanding and remembering complex instructions, carrying out complex instructions,
and make judgments (the remainder of the words are too blurred to read). Id. Dr. Spurling
noted, “her significant anxiety and social phobia cause her difficult with focusing, retaining
information.” R. 394. Despite marking the form to show Plaintiff had moderate limitations
in understanding and remembering, he recorded in his examination report that Plaintiff’s
“[m]emory is grossly intact. Attention span and concentration are grossly intact. Judgment
is fair. Insight is fair. Impulse control is grossly intact.” R. 409.
Dr. Spurling also indicated on the form that Plaintiff had a marked limitation in interacting appropriately with the public and moderate limitations in interacting appropriately
with supervisors and co-workers. One other category is too blurred on the form to read.
R. 395.

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Additionally, on March 15, 2015, Dr. Spurling completed a form entitled “Complete
Medical Report (Mental),” and on it indicated the medications he had prescribed for Plaintiff. He also answered the question “Prognosis” as “Fair.” R. 393.
On May 11, 2015, Dr. Spurling completed a medical source statement for New
York State. R. 431. The form he used had three categories for mental functioning: No
Evidence of Limitations, Moderately Limited, and Very Limited. R. 432. He marked the
form to show that he thought Plaintiff was moderately limited in understanding and remembering instructions, carrying out instructions, maintaining attention and concentration, making simple decisions, interacting appropriately with others, maintaining personal
hygiene, and functioning in a work setting at a consistent pace. R. 432. He marked that
she was very limited in maintaining socially appropriate behavior without exhibiting behavior extremes. Id.
Dr. Spurling completed another medical source statement dated May 9, 2016. R.
439. In that report, he marked the following areas as moderately limited: understanding
and remembering instructions; maintaining attention and concentration; and making simple decisions. He marked “No Evidence of Limitations” in maintaining basic standards of
personal hygiene and grooming. And he marked as very limited the following: carrying
out instructions; interacting appropriately with others; maintaining socially appropriate behavior without exhibiting behavior extremes and appearing able to function in a work setting at a consistent pace. R. 439.
The ALJ concluded that Dr. Spurling’s March 2015 opinion and his May 2015 letter
“appear to be unsupported by the medical record.” R. 30. He noted specifically that Dr.
Spurling’s mental status examination results “revealed normal concentration, attention,

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memory, and judgment.” Id. For those reasons, the ALJ accorded “little weight” to Dr.
Spurling’s opinions. Id. The Commissioner expanded on the reasons for declining to give
Dr. Spurling’s opinion controlling, or great weight by pointing out that in a “Function Report
– Adult,” R. 184–92, dated December 23, 2014, Plaintiff noted that she went to doctors’
appointments, church, and the food store every week. R. 193. She also responded that
she did not have “any problems getting along with family, friends, neighbors, or others,”
and hand wrote, “I love everyone[.] I have a big heart.” R. 189. She further indicated she
finishes what she starts, but that “I start it, and go do something else, while it[’]s not finish[ed] and before I know it the whole house is a mess.” R. 191. She responded that she
can follow spoken instructions if they are not too long and can follow written instructions.
Id. In response to the question, “[h]ave you ever lost a job because of problems getting
along with people?” she responded “No.” Id. She also wrote that stress or changes in a
schedule affect her “very, very, very bad. It acts up my COPD, my heart starts to get high
blood pressure. Stress[,] I’m around it all day—every day!” R. 192.
The Commissioner also points out that Dr. Spurling frequently mentioned Plaintiff
was either non-compliant, or only intermittently compliant with many of her prescribed
medications. R. 347 (“I strongly suspect that she is noncompliant or intermittently compliant with many of her prescribed medications.”); R. 409 (“I will have her continue the
lamotrigine although I suspect that she is not really compliant with that medication.”); R.
424 (“I strongly suspect that she is noncompliant or intermittently compliant with many of
her prescribed medications.”). Despite suspecting she was not entirely compliant with the
medications he prescribed, Dr. Spurling noted during his October examination that she

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had an improved mood possibly due to her husband’s new job, which relieved some financial stress. Dr. Spurling also noted in his October examination that Plaintiff’s memory,
attention span, and concentration were intact and that her insight and judgment were fair.
R. 418. David Mane, M.D., who, like Dr. Spurling, worked at FLH Medical, saw plaintiff on
October 13, 2014. In a report signed just a few days before she saw Dr. Spurling for a
second visit, Plaintiff reported “she is having less amount of anxiety,” and Dr. Mane observed that she “[d]enies anxiety, depression and stress.” R. 252–53. Plaintiff returned to
FLH Medical on November 13, 2014, and saw Dr. Mane. R. 257. Dr. Mane noted that
Plaintiff “has a lot of anxiety and neck tension… [and] constant daily pain.” R. 258. However, when asked by the doctor, she “denie[d] anxiety, depression and stress… [and]
reports no sleep problems.” R. 258. Upon examination, Dr. Mane observed that Plaintiff
“[a]ppears well. No signs of apparent distress present. Speech is clear and appropriate.”
R. 259.
Other medical evidence in the record in part contradicts Dr. Spurling’s conclusions.
The ALJ’s reason for affording Dr. Spurling’s opinions only little weight was that “mental
status examination revealed normal concentration, attention, memory, and judgment.” R.
30. However, the Commissioner’s rule requires that the ALJ give the treating physician
controlling weight, and if not, then “[w]e will always give good reasons in our notice of
determination or decision for the weight we give your treating source’s medical opinion.”
20 C.F.R. § 416.927(c)(2). The ALJ failed to provide a good reason for not giving Dr.
Spurling’s opinion controlling weight. It is possible that after reviewing the factors in
§ 416.927(c), the ALJ can sustain his decision not to give Dr. Spurling’s opinion controlling, or even substantial weight, but considering the length of treatment relationship and

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frequency of examination, and the nature and extent of the treatment relationship, the
explanation in this record is lacking.
CONCLUSION
For the foregoing reasons, the Court denies Commissioner’s cross-motion for judgment on the pleadings, ECF No. 13, and grants Plaintiff’s motion, ECF No. 9. The Court
reverses the Commissioner’s decision denying benefits and remands this matter for a
rehearing pursuant to sentence four of 42 U.S.C. § 405(g). The Court directs the Commissioner to expedite the rehearing in this case.

IT IS SO ORDERED.
DATED: May 7, 2018
Rochester, New York
/s/ Charles J. Siragusa
CHARLES J. SIRAGUSA
United States District Judge

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