EDWARS v. COLVIN

Filing 24

ORDER THAT PLFF'S REQUEST FOR REVIEW IS GRANTED IN PART AS FOLLOWS: THIS MATTER IS REMANDED TO THE COMMISSIONER FOR FURTHER FINDINGS OF FACT REGARDING THE WEIGHT GIVEN TO THE EXPERT OPINIONS. SIGNED BY CHIEF JUDGE PETRESE B. TUCKER ON 7/28/15. 7/28/15 ENTERED AND COPIES E-MAILED.(kw, )

IN THE UNITED STATES DISTRICT COURT
FOR THE EASTERN DISTRICT OF PENNSYLVANIA

MARTA EDWARDS,

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Plaintiff,
v.

CAROLYN W. COLVIN,
Commissioner of Social Security
Defendant.

CIVIL ACTION
NO. 14-4235

MEMORANDUM OPINION
Tucker, C.J.

July 28, 2015

Plaintiff Marta Edwards seeks review of the Commissioner of Social Security’s
(“Commissioner”) denial of her application for Supplemental Security Income (“SSI”). On April
23, 2015, United States Magistrate Judge Linda K. Caracappa issued a Report and
Recommendation (“Report”) recommending that Plaintiff’s request for review be denied.
Plaintiff objected to the Report, asserting that the findings of the Administrative Law Judge
(“ALJ”) are not supported by substantial evidence. For the reasons set forth below, the Court will
grant in part Plaintiff’s request for review and remand this case to the Commissioner for further
findings of fact.
FACTUAL BACKGROUND
On May 31, 2011, Plaintiff Marta Edwards filed an application for SSI under Title XVI
of the Social Security Act, alleging disability since September 1, 2008. (Tr. 122). This
application was denied on February 1, 2012. (Tr. 61-65). Plaintiff then requested a hearing
before an ALJ on February 15, 2012. (Tr. 66). ALJ Nancy Lisewski held a hearing on February
5, 2013, in which Plaintiff, as well as an impartial vocational expert, testified. (Tr. 20-40). On

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February 27, 2013, the ALJ denied Plaintiff’s claim for SSI, finding that Plaintiff was not
disabled as defined by the Social Security Act at any time from Plaintiff’s application date
through the date of the ALJ’s decision. (Tr. 19). Plaintiff filed a request for review, and on June
18, 2014, the Appeals Council denied Plaintiff’s request, thus making the ALJ’s decision the
final decision of the Commissioner. (Tr. 1-5). Plaintiff then filed an appeal with this Court for
judicial review pursuant to 42 U.S.C. § 405(g).
The ALJ followed the five-step sequential evaluation process to determine that Plaintiff
had not been under a disability. At the first step, the ALJ found that Plaintiff has not engaged in
substantial gainful activity since May 31, 2011, the application date. (Tr. 13). At the second step,
the ALJ found that Plaintiff’s obesity, depression, disc herniation with spinal and foraminal
stenosis with thecal impingement and root compression, and degenerative joint disease were
“severe” impairments within the meaning of the regulation. (Tr. 13). At the third step, the ALJ
found that Plaintiff does not have an impairment, or combination of impairments that meets or
medically equals one of the listed impairments in 20 CFR §§ 416.920(d), 416.925, and 416.926.
(Tr. 13). At the fourth step, the ALJ found that Plaintiff “has the residual functional capacity to
perform light work, except: occasional postural activities; no reaching overhead; simple work
defined as unskilled specific vocational preparation; and, only occasional contact with the
public.” (Tr. 15). The ALJ considered all symptoms, the extent to which the symptoms could
reasonably be accepted as consistent with the objective medical evidence, and all other evidence
including opinion evidence. (Tr. 15-16). Finally, at the fifth step, the ALJ found that Plaintiff has
no past relevant work, but there are jobs that exist in significant numbers in the national
economy that Plaintiff can perform. (Tr. 18). Thus, the ALJ determined that Plaintiff has not
been under a “disability,” as defined in the Social Security Act, since the day Plaintiff’s

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application was filed.
In her request for review, Plaintiff argues that the ALJ’s decision is not supported by
substantial evidence because the ALJ erred in (1) giving little weight to the opinions of
Plaintiff’s treating physician, Dr. Gupta, and great weight to the opinion of the state agency’s
doctor who did not examine Plaintiff, Dr. Huitt; (2) failing to consider Plaintiff’s chiropractic
records; and (3) disregarding Plaintiff’s hearing loss in the assessment of Plaintiff’s residual
functional capacity. In the Report, Magistrate Judge Caracappa addressed each of these
objections and found that the ALJ’s decision was supported by substantial evidence.
Consequently, Magistrate Judge Caracappa recommended that this Court deny Plaintiff’s request
for review. In her objections to the Report, Plaintiff raises the same objections as those in her
initial request for review.
This Court agrees with Magistrate Judge Caracappa’s findings as to the chiropractic
evidence and Plaintiff’s hearing loss. However, the Court will sustain Plaintiff’s objection that
the ALJ’s decision to give significant weight to Dr. Huitt’s opinion and little weight to Dr.
Gupta’s opinion is not supported by substantial evidence, and remand the case to the
Commissioner for further findings of fact.
STANDARD OF REVIEW
This court reviews those portions of Magistrate Judge Caracappa’s Report to which
objection is made de novo. 28 U.S.C. § 636(b)(1)(C). The role of the Court on judicial review of
a final decision of the Commissioner is to determine whether the Commissioner’s findings of
fact are supported by “substantial evidence” in the record. Brown v. Bowen, 845 F.2d 1211, 1213
(3d Cir. 1988); Mason v. Shalala, 994 F.2d 1058, 1064 (3d Cir. 1993). If the factual findings of
the Commissioner are supported by substantial evidence, they must be accepted as conclusive.

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Richardson v. Perales, 402 U.S. 389, 390 (1971) (citing 42 U.S.C. § 405(g)). Substantial
evidence is “such relevant evidence as a reasonable mind might accept as adequate to support a
conclusion.” Richardson, 402 U.S. at 401 (quoting Consol. Edison Co. v. NLRB, 305 U.S. 197,
229 (1938)). Substantial evidence is “more than a mere scintilla of evidence but may be less than
a preponderance.” Brown, 845 F.2d at 1213 (citing Stunkard v. Secr’y of Health and Human
Servs., 841 F.2d 57, 59 (3d Cir.1988)). When the conclusion of the ALJ is supported by
substantial evidence, this Court is bound by those findings even if it would have decided the
factual inquiry differently. Fargnoli v. Massanari, 247 F.3d 34, 38 (3d Cir. 2001) (citing
Hartranft v. Apfel, 181 F.3d 358, 360 (3d Cir. 1999)).
Substantial evidence “must take into account whatever in the record fairly detracts from
its weight.” Universal Camera Corp. v. N.L.R.B., 340 U.S. 474, 488 (1971). A single piece of
evidence is not substantial evidence if the Commissioner ignores countervailing evidence or fails
to resolve a conflict created by the evidence. Mason, 994 F.2d at 1064. The Commissioner must
provide an explanation for rejecting pertinent or probative evidence. Johnson v. Comm’r of Soc.
Sec., 529 F.3d 198, 203 (3d Cir. 2008). While the court may not reweigh the evidence, it may
evaluate the basis of the ALJ’s decision. Horst v. Comm’r of Soc. Sec., 551 F.App’x 41, 45 (3d
Cir. 2014) (quoting Cotter v. Harris, 642 F.2d 700, 706-07 (3d Cir. 1981)) (“[A]n explanation
from the ALJ of the reason why probative evidence has been rejected is required so that a
reviewing court can determine whether the reasons for rejection were improper.”).
DISCUSSION
Plaintiff argues that the ALJ’s decision is not supported by substantial evidence because
the ALJ did not justify the little weight given to the opinions of Plaintiff’s treating physician, Dr.
Gupta. Dr. Gupta, who is board certified in pain management and anesthesia, has been seeing

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Plaintiff since February 17, 2010. (Tr. 210-213). The Court agrees that the ALJ erred by failing
to explain why she relied on the opinion of the non-examining State agency consultant, Dr. Huitt,
and rejected the opinion of Dr. Gupta.
An ALJ must consider all relevant evidence from acceptable medical sources, including
licensed physicians, when evaluating a claimant’s impairment. See 20 C.F.R. § 416.913(a). The
opinions of a treating physician, if supported by the medical records, are entitled to great, or even
controlling weight in Social Security disability cases. 20 CFR § 405.1527; Adrono v. Shalala, 40
F.3d 43 (3d Cir. 1994); Mason v. Shalala, 994 F.2d 1058 (3d Cir. 1993). This is especially true
when the treating physicians’ opinions “reflect expert judgment based on a continuing
observation of the patient’s condition over a prolonged period of time.” Morales v. Apfel, 225
F.3d 310, 317 (3d Cir. 2000) (quoting Plummer v. Apfel, 186 F.3d 422, 429 (3d Cir. 1999)). The
ALJ can only reject the medical judgment of a treating physician on the basis of contradictory
medical evidence or substantial evidence otherwise, but she “may afford a treating physician’s
opinion more or less weight depending upon the extent to which supporting explanations are
provided.” Plummer, 186 F.3d at 429. (Tr. 16-17).
In rejecting a treating physician’s assessment, the ALJ may not make “speculative
inferences from medical reports” or “employ her own expertise against that of a physician.” Id.
(citing Ferguson v. Schweiker, 765 F.2d 31, 36 (3d Cir.1985)). The ALJ must also make clear
her reasons for giving a treating physician’s opinion less than controlling weight. See Horst, 551
F. App’x at 45 (3d Cir. 2014). The ALJ may not “reject evidence for no reason or for the wrong
reason.” Rutherford v. Barnhart, 399 F.3d 546, 554 (3d Cir. 2005) (quoting Mason v. Shalala,
994 F.2d 1058, 1066 (3d Cir.1993)). If the ALJ does not give a treating physician’s opinions
controlling weight, in deciding the weight to give to the opinion, the ALJ should consider factors

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such as the nature and extent of the treatment relationship, length of the treatment relationship
and frequency of examination, supportability, consistency, and specialization. See 20 C.F.R. §
416.927(c)(2). In rejecting or giving less weight to the treating physician’s opinion, the ALJ
should specify her reasons for doing so and make a clear and satisfactory record. See Kent v.
Schweiker, 710 F.2d 110, 115 (3d Cir. 1983).
Here, the ALJ fails to explain her reasoning for not giving Dr. Gupta’s opinion significant
weight over that of Dr. Huitt. As such, the Court does not have sufficient information to
determine whether the ALJ’s decision with respect to Plaintiff’s residual capacity to perform
light work is supported by substantial evidence. Firstly, to determine that Plaintiff has the
residual functional capacity to perform light work, the ALJ considered Plaintiff’s symptoms, the
extent to which those symptoms could reasonably be accepted as consistent with other evidence,
and opinion evidence. (Tr. 16). According to Plaintiff, she is unable to work due to back
problems and depression. (Id.). Plaintiff states that she can only stand for 20-30 minutes and sit
for one hour at a time because of the pain. (Id.). The ALJ found that Plaintiff’s statements as to
the intensity, persistence and limiting effects of her symptoms were not credible. The ALJ
further found that the medical evidence, along with Plaintiff’s noted activities of daily living, did
not support her allegations. (Id.). Secondly, the ALJ considered the results of medical evidence
including diagnostic evidence, a Magnetic Resonance Imaging scan (“MRI”), an
Electromyography scan (“EMG”), Plaintiff’s treatment records, and Plaintiff’s physical
examination reports from June 2011 and November 2011to evaluate Plaintiff’s residual
functional capacity. (Tr. 16-17).
Next, the ALJ considered opinion evidence because the objective medical evidence does
not determine the effects of Plaintiff’s conditions on her ability to work, and needs to be

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analyzed by a doctor. The ALJ considered the opinion of Dr. Huitt who completed a physical
residual functional capacity assessment and found Plaintiff capable of medium exertion. (Tr. 17).
The ALJ also considered Dr. Gupta’s assessment, which indicated that Plaintiff “can never lift or
carry, and can only stand/walk for less than two hours and sit for 2-3 hours total in an eight-hour
workday.” (Tr. 17). Dr. Gupta described Plaintiff’s conditions as, inter alia, cervical
radiculopathy, cervical root lesion, disc herniation, and disc degeneration. (See Tr. 198 – 216.)
Dr. Gupta concluded that Plaintiff “will need a change in her working and living life style,” is
unable to work, and is a candidate for long-term disability. (Tr. 194-95.) The ALJ gave these
findings “little weight” because she found them “inconsistent with the examination reports of
record and the claimant’s noted functional abilities, including walking into the hearing room,
hanging up her coat, and having no difficulties walking or sitting when present for hearing.” (Tr.
17). However, the ALJ is not permitted to place her non-expert observations of the claimant at
the hearing above the opinions of the treating physician. See, e.g., Frankenfield v. Bowen, 861
F.2d 405, 408 (3d Cir. 1988) (“What we are left with is a rejection of medically credited
symptomatology based solely on the administrative law judge’s observation of the claimant at
the hearing . . . That is not permissible.”).
Although the ALJ found that Plaintiff was not fully credible (Tr. 16), that credibility
determination is not an acceptable basis for rejecting a treating physician’s conclusions. See
Morales, 225 F.3d at 318 (“Although an ALJ may consider his own observations of the claimant
and this court cannot second-guess the ALJ’s credibility judgments, they alone do not carry the
day and override the medical opinion of a treating physician that is supported by the record.”).
Moreover, the ALJ’s opinion must offer some reasons as to how Dr. Gupta’s opinions are
inconsistent with the examination reports and why they were given little weight. See Cotter, 642

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F.2d at 705-06) (“While the ALJ is, of course, not bound to accept physicians’ conclusions, he
may not reject them unless he first weighs them against other relevant evidence and explains
why certain evidence has been accepted and why other evidence has been rejected.”). Instead,
the ALJ in this case, merely stated that Dr. Gupta’s opinions are inconsistent with the record
without explaining the inconsistencies or addressing the contradictory relationship between the
record and Dr. Gupta’s opinions.
Here, the ALJ relied upon the reports of Dr. Huitt who never met with Plaintiff rather
than the reports from Dr. Gupta who treated Plaintiff over an extended period of time. The ALJ
credits Dr. Huitt’s opinion, giving it “great weight” because “it is largely consistent with the
records as a whole.” (Tr. 17). Consistency with the record as a whole is one of the factors to
consider when determining how much weight to give to varying medical opinions. See 20 C.F.R.
§ 416.927(c)(4). However, the ALJ did not analyze any other factors when determining the
comparative weight that should be given to the two medical opinions from Dr. Huitt and Dr.
Gupta. As discussed above, the regulations provide that factors to consider include the nature and
length of Plaintiff’s relationship with the authors of any medical opinion, the extent of the
relationship, supportability, and consistency. 20 C.F.R. § 416.927(c). In addition, the ALJ simply
states, without any further explanation, that Dr. Huitt’s opinions are accepted because they are
consistent with the record while Dr. Gupta’s opinions are rejected because they are inconsistent
with the record. As such, this Court does not have sufficient information to determine that the
ALJ’s decision is supported by substantial evidence.
CONCLUSION
In order for this Court to determine whether the reasons for rejecting Dr. Gupta’s
opinions were proper, the ALJ is required to provide further explanation as to the weight given to

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each doctor’s opinions. Here, the ALJ’s analysis does not sufficiently justify the rejection of Dr.
Gupta’s opinion and partially relies on impermissible observations of Plaintiff from the hearing.
Thus, this Court cannot conclude that the ALJ’s findings of fact are supported by substantial
evidence. The Court will grant Plaintiff’s request for review and remand this case to the
Commissioner for further findings of fact regarding the weight given to the opinions of Dr.
Gupta and Dr. Huitt. An appropriate Order follows.

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IN THE UNITED STATES DISTRICT COURT
FOR THE EASTERN DISTRICT OF PENNSYLVANIA

MARTA EDWARDS,

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Plaintiff,
v.

CAROLYN W. COLVIN,
Commissioner of Social Security,
Defendant.

CIVIL ACTION
NO. 14-4235

ORDER
AND NOW, this 28th day of July, 2015, upon careful and independent consideration of
Plaintiff’s request for review (Doc. 3), Defendant’s Answer (Doc. 7), Plaintiff's Brief In Support
of Request for Review (Doc. 10), Defendant’s Response to Request for Review (Doc. 14),
Plaintiff’s Reply Brief (Doc. 15), the Report and Recommendation of United States Magistrate
Judge Linda K. Caracappa (Doc. 17), Plaintiff’s Objections to the Report and Recommendation
(Doc. 20), and all other responses thereto, IT IS HEREBY ORDERED AND DECREED that
Plaintiff’s Request for Review is GRANTED IN PART as follows:
1) This matter is REMANDED to the Commissioner for further findings of fact regarding
the weight given to the expert opinions.

BY THE COURT:
/s/ Petrese B. Tucker
_____________________________
Hon. Petrese B. Tucker, C.J.

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