Newman v. Berryhill
Filing
26
MEMORANDUM (Order to follow as separate docket entry) re 1 Complaint filed by Tina Newman. Signed by Magistrate Judge Karoline Mehalchick on 3/21/2018. (cw)
UNITED STATES DISTRICT COURT
MIDDLE DISTRICT OF PENNSYLVANIA
TINA NEWMAN,
Plaintiff,
CIVIL ACTION NO. 3:17-CV-00177
v.
(MEHALCHICK, M.J.)
NANCY A. BERRYHILL, Acting
Commissioner of Social Security,
Defendant.
MEMORANDUM OPINION
This is an action brought under Section § 1383(c)(3) of the Social Security Act and 42
U.S.C. § 405(g), seeking judicial review of the final decision of the Commissioner of Social
Security (“Commissioner”) denying Plaintiff Tina Newman’s (“Ms. Newman”) claims for a
period of disability and disability insurance benefits (“DIB”) under Title II of the Social
Security Act. This matter has been referred to the undersigned United States Magistrate Judge
on consent of the parties, pursuant to the provisions of 28 U.S.C. § 636(c) and Rule 73 of the
Federal Rules of Civil Procedure. For the reasons expressed herein, and upon detailed
consideration of the arguments raised by the parties in their respective briefs, it is ordered that
the Commissioner's decision be VACATED and this case REMANDED to conduct a new
administrative hearing.
I.
BACKGROUND & PROCEDURAL HISTORY
On December 17, 2015, Ms. Newman protectively filed applications for benefits under
Title II and Part A of Title XVIII of the Social Security Act, 1 asserting an onset date of March
6, 2014 at which time Ms. Newman was forty-five (45) years old. (Doc. 12-5, at 3). Ms.
Newman alleged that she became disabled due to a combination of vertigo, high blood pressure,
asthma, bronchitis, allergies, depression, and anemia. (Doc. 12-6, at 5).
On March 10, 2016, Ms. Newman’s claims were denied at the initial level of
administrative review. (Doc. 12-4, at 4). Ms. Newman filed a timely request for a hearing before
an administrative law judge (“ALJ”) on March 22, 2016 (Doc. 12-4, at 9), and appeared with
her attorney and testified at an administrative hearing before ALJ Frank Barletta on September
26, 2016. (Doc. 12-2, at 59-90). Impartial vocational expert (“VE”) Gerald Keating also
appeared and testified at the hearing. (Doc. 12-2, at 81-89). The ALJ denied Ms. Newman’s
claims in a written decision dated October 3, 2016, in which the ALJ concluded that while Ms.
Newman was unable to perform any past relevant work, she was capable of performing light
exertional work. (Doc. 12-2, at 24-28). On November 21, 2016, Ms. Newman requested review
of the ALJ’s decision by the Appeals Council of the Office of Disability Adjudication and
Review. (Doc. 12-2, at 11-13). The Appeals Council denied her request for review on December
1
The Court recognizes that Ms. Newman’s complaint asserts she is entitled to
Supplemental Security Income (“SSI”) benefits under Title XII of the Act, instead of DIB under
Title II of the Act. (Doc. 1, at 1). However, as the initial application filed with the Social
Security Administration relates to DIB, and indicates that Ms. Newman did not want to file for
SSI, the Court will focus its analysis under Title II accordingly. (Doc. 12-5, at 2).
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2, 2016 thus affirming the ALJ’s October of 2016 decision as the final decision of the
Commissioner subject to judicial review by this Court. (Doc. 12-2, at 2-5).
Ms. Newman initiated this action by filing a complaint through her counsel of record,
received and filed by the Court on January 1, 2017. (Doc. 1). In her complaint, Ms. Newman
alleges that the ALJ’s decision was not supported by substantial evidence in the record and was
contrary to law and regulation. (Doc. 1, at 2). Ms. Newman requests that this Court remand the
case for a further administrative hearing and award attorney’s fees. (Doc. 1, at 2). After service
of the complaint, the Commissioner filed an answer together with a certified transcript of the
entire record of the administrative proceedings on April 4, 2017. (Doc. 11; Doc. 12). In her
answer, the Commissioner asserts that the ALJ’s decision was made in accordance with the law
and regulations and that the findings of fact are supported by substantial evidence. (Doc. 11, at
3, ¶8). This matter has been fully briefed by the parties and is now ripe for decision. (Doc. 16;
Doc. 20; Doc. 21).
II. STANDARD OF REVIEW
In order to receive benefits under Title II of the Social Security Act, a claimant must
demonstrate an “inability to engage in any substantial gainful activity by reason of any
medically determinable physical or mental impairment which can be expected to result in death
or which has lasted or can be expected to last for a continuous period of not less than 12
months.” 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A). To satisfy this requirement, a claimant
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must have a severe physical or mental impairment 2 that makes it impossible to do his or her
previous work or any other substantial gainful activity 3 that exists in significant numbers in the
national economy. 42 U.S.C. § 423(d)(2)(A); 20 C.F.R. § 404.1505(a). Additionally, to be
eligible to receive benefits under Title II of the Social Security Act, a claimant must be insured
for disability insurance benefits. 42 U.S.C. § 423(a); 20 C.F.R. § 404.131.
In evaluating whether a claimant is disabled as defined in the Social Security Act, the
Commissioner follows a five-step sequential evaluation process. 20 C.F.R. § 404.1520(a). Under
this process, the Commissioner must determine, in sequence: (1) whether the claimant is
engaged in substantial gainful activity; (2) whether the claimant has a severe impairment; (3)
whether the claimant’s impairment meets or equals a listed impairment; 4 (4) whether the
claimant is able to do past relevant work, considering his or her residual functional capacity
(“RFC”); 5 and (5) whether the claimant is able to do any other work that exists in significant
2
A “physical or mental impairment” is defined as an impairment resulting from
“anatomical, physiological, or psychological abnormalities which are demonstrable by
medically acceptable clinical and laboratory diagnostic techniques.” 42 U.S.C. § 423(d)(3).
3
“Substantial gainful activity” is defined as “work that—(a) involves doing significant
and productive physical or mental duties; and (b) is done (or intended) for pay or profit.” 20
C.F.R. § 404.1510.
4
An extensive list of impairments that warrant a finding of disability based solely on
medical criteria, without considering vocational criteria, is set forth at 20 C.F.R. Part 404,
Subpart P, Appendix 1.
5
A claimant's RFC is the most a claimant can still do despite the physical and mental
limitations of his or her impairment(s) and any related symptoms (e.g., pain). 20 C.F.R.
§ 404.1545(a)(1). This assessment encompasses all of the claimant’s medically-determinable
impairments, including those that are not severe. 20 C.F.R. § 404.1545(a)(2). The ALJ assesses
(footnote continued on next page)
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numbers in the national economy, considering his or her RFC, age, education, and work
experience. 20 C.F.R. § 404.1520(a). The claimant bears the initial burden of demonstrating a
medically determinable impairment that prevents him or her from doing past relevant work. 20
C.F.R. § 404.1512(a) (effective Apr. 20, 2015, through Mar. 26, 2017). Once the claimant has
established at step four that he or she cannot do past relevant work, the burden then shifts to the
Commissioner at step five to show that jobs exist in significant numbers in the national
economy that the claimant could perform that are consistent with his or her RFC, age,
education, and past work experience. 20 C.F.R. § 404.1512(f) (effective Apr. 20, 2015, through
Mar. 26, 2017).
In reviewing the Commissioner’s final decision denying a claimant’s application for
benefits, the Court is limited to determining whether the findings of the final decision-maker are
supported by substantial evidence in the record. See 42 U.S.C. § 1383(c)(3) (incorporating 42
U.S.C. § 405(g) by reference); Johnson v. Comm'r of Soc. Sec., 529 F.3d 198, 200 (3d Cir.
2008); Ficca v. Astrue, 901 F. Supp. 2d 533, 536 (M.D. Pa. 2012). Substantial evidence “does not
mean a large or considerable amount of evidence, but rather such relevant evidence as a
reasonable mind might accept as adequate to support a conclusion.” Pierce v. Underwood, 487
U.S. 552, 565 (1988) (internal quotations omitted). Substantial evidence is less than a
preponderance of the evidence but more than a mere scintilla. Richardson v. Perales, 402 U.S.
389, 401 (1971). A single piece of evidence is not substantial evidence if the ALJ ignores
the claimant’s RFC before proceeding from step three to step four in the sequential evaluation
process. 20 C.F.R. § 404.1520(a)(4). The RFC is then used at steps four and five to evaluate the
claimant’s case. 20 C.F.R. § 404.1520(a)(4).
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countervailing evidence or fails to resolve a conflict created by the evidence. Mason v. Shalala,
994 F.2d 1058, 1064 (3d Cir. 1993). In an adequately developed factual record, however,
substantial evidence may be “something less than the weight of the evidence, and the possibility
of drawing two inconsistent conclusions from the evidence does not prevent [the ALJ’s
decision] from being supported by substantial evidence.” Consolo v. Fed. Maritime Comm’n, 383
U.S. 607, 620 (1966). “In determining if the Commissioner’s decision is supported by
substantial evidence the court must scrutinize the record as a whole.” Leslie v. Barnhart, 304
F.Supp.2d 623, 627 (M.D. Pa. 2003). The question before the Court, therefore, is not whether
Ms. Newman is disabled, but whether the Commissioner’s finding that she is not disabled was
supported by substantial evidence and was reached based upon a correct application of the
relevant law. See Arnold v. Colvin, No. 3:12-CV-02417, 2014 WL 940205, at *1 (M.D. Pa. Mar.
11, 2014) (“[I]t has been held that an ALJ’s errors of law denote a lack of substantial
evidence.”); Burton v. Schweiker, 512 F. Supp. 913, 914 (W.D. Pa. 1981) (“The
[Commissioner]’s determination as to the status of a claim requires the correct application of
the law to the facts.”); see also Wright v. Sullivan, 900 F.2d 675, 678 (3d Cir. 1990) (noting that
the scope of review on legal matters is plenary); Ficca, 901 F. Supp. 2d at 536 (“[T]he court has
plenary review of all legal issues decided by the Commissioner.”).
III. THE ALJ’S DECISION
In his May 2015 decision, the ALJ found Ms. Newman was not disabled and thus
declined her application for benefits. (Doc. 9-2, at 21). The ALJ assessed Ms. Newman’s case
through the five-step sequential evaluation required by the Social Security Act. See 20 C.F.R. §
404.1520.
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As a preliminary matter, the ALJ found that Ms. Newman met the insured status
requirement of Title II of the Social Security Act through September 30, 2020. (Doc. 12-2, at
20). Proceeding to step one of the sequential evaluation process, the ALJ next found that Ms.
Newman had not engaged in substantial gainful activity since the March 6, 2014 onset date.
(Doc. 12-2, at 21).
At step two, the ALJ found that the medical evidence of record established the presence
of the following medically determinable severe impairments during the relevant period: asthma;
anemia; obesity; hypertension; depression; and an anxiety disorder. (Doc. 12-2, at 21). The ALJ
found that the combination of these impairments caused “more than a minimal functional
limitation” in Ms. Newman’s ability to perform basic work functions, and was thus considered
to be severe. (Doc. 12-2, at 21). The ALJ further recognized that Ms. Newman’s medical
history included hyperlipidemia, bronchitis, and vertigo, however determined these
impairments were non-severe. (Doc. 12-2, at 21).
At step three, the ALJ found that during the relevant period, Ms. Newman did not have
an impairment or combination of impairments that met or medically equaled the severity of a
listed impairment in the version of 20 C.F.R. Part 404, Subpart P, Appendix 1 that was in effect
when the ALJ issued his decision. (Doc. 12-2, at 21). First, the ALJ determined that Ms.
Newman’s impairments did not meet the listings in Section 3.03 for asthma, because the record
did not show that she suffered from asthma with chronic asthmatic bronchitis as outlined under
Section 3.02A, or from asthma with attacks, as defined in Section 3.00C, that occurred at least
once every two (2) months. (Doc. 12-2, at 21). The ALJ also considered the hematological
listings in Section 7.00, but found that the record did not reveal Ms. Newman’s anemia
achieved the necessary level of severity. (Doc. 12-2, at 21). Next the ALJ considered listing 4.00
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for Ms. Newman’s hypertension, and evaluated her condition in the context of the other body
systems it affected (namely her heart, brain, kidneys or eyes). (Doc. 12-2, at 22). Although the
ALJ noted Ms. Newman’s hypertension was severe, he concluded that it did not meet the
requirements for severity under the listing. (Doc. 12-2, at 22). The ALJ additionally evaluated
Ms. Newman’s obesity under several listings, and in conjunction with any related
musculoskeletal, respiratory, or cardiovascular conditions she had. (Doc. 12-2, at 22). However,
after considering both the singular or cumulative effects of Ms. Newman’s obesity, the ALJ
determined that she did not meet the criteria of a listing. (Doc. 12-2, at 22). Finally, the ALJ
considered section 12.00 of the listings for Ms. Newman’s mental health impairments, however
found that she did not meet their requirements of 12.04 or 12.06 based on her medical records.
(Doc. 12-2, at 22-24).
Between steps three and four, the ALJ assessed Ms. Newman’s RFC. (Doc. 12-2, at 24).
Ms. Newman alleged that her impairments caused the following symptoms: fatigue, high blood
pressure, dizziness, shortness of breath, depression, difficulty with lifting, difficulty with
interacting with others, a preference for isolation, and neglect of household responsibilities.
(Doc. 12-2, at 25). After examining her statements and the medical evidence, the ALJ found
that Ms. Newman’s impairments could reasonably be expected to cause the alleged symptoms,
but that her statements about the intensity, persistence, and the limiting effects of the symptoms
were not entirely credible. (Doc. 12-2, at 25). The ALJ then went on to detail Ms. Newman’s
medical records and treatment history. (Doc. 12-2, at 25-27). In doing so, the ALJ considered
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and weighed medical opinions by the following sources: non-treating physician 6 Jay Willner,
M.D. (“Dr. Willner”) (Doc. 12-2, at 26); treating psychiatrist 7 Sharon Cline, M.D. (“Dr.
Cline”) (Doc. 12-2, at 26); and non-examining 8 state agency psychological consultant Anthony
Galdieri, Ph.D. (“Dr. Galdieri”) (Doc. 12-2, at 26-27). The ALJ also considered Ms. Newman’s
Global Assessment of Functioning (“GAF”) scores that were rendered over the course of her
treatment, and gave them little weight. (Doc. 12-2, at 26).
Dr. Willner completed a consultative examination of Ms. Newman on March 3, 2016.
(Doc. 12-7, at 50-59). In his report, Dr. Willner noted that Ms. Newman had a fair prognosis,
and could continuously lift and carry up to 10, 20, 50, and 100 pounds (Doc. 12-7, at 53-54).
Dr. Willner further noted that Ms. Newman did not require the use of a cane to ambulate, and
could sit, stand, and walk for 8 hours without interruption, and for 8 hours total in a work day.
6
A non-treating source is defined by the Social Security Regulations as any physician,
psychologist, or other acceptable medical source that examined the claimant, but does not have any
ongoing or past treatment relationship with him or her. 20 C.F.R. § 404.1502. This term includes an
acceptable medical source who is a consultative examiner for the Social Security Administration,
when that consultative examiner is not a claimant’s treating source. 20 C.F.R. § 404.1502.
7
A treating source is defined by the Social Security Regulations as a claimant’s “own
physician, psychologist, or other acceptable medical source who provides . . . medical treatment or
evaluation and who has, or has had, an ongoing treatment relationship with [the claimant].” 20
C.F.R. § 404.1502. An “ongoing treatment relationship” exists or existed if the claimant “see[s], or
ha[s] seen, the source with a frequency consistent with accepted medical practice for the type of
treatment and/or evaluation required for [the claimant’s] medical condition(s).” 20 C.F.R. §
404.1502.
8
A non-examining source is defined by the Social Security Regulations as a physician,
psychologist, or other acceptable medical source that has not examined the claimant, but provides a
medical or other opinion in the case. At the ALJ hearing and Appeals Council levels of the
administrative review process, it includes State agency medical and psychological consultants, other
program physicians and psychologists, and medical experts or psychological experts consulted by
the Social Security Administration. 20 C.F.R. § 404.1502.
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(Doc. 12-7, at 55). Dr. Willner did not note any limitations with Ms. Newman’s use of her
hands or feet (Doc. 12-7, at 56), however found that, due to her vertigo, she could never climb
ladders or scaffolds or balance, and could occasionally climb stairs and ramps, stoop, kneel,
crouch and crawl. (Doc. 12-7, at 57). Dr. Willner further opined that due to Ms. Newman’s
vertigo and asthma, she experienced the following environmental limitations: that she could
never be exposed to unprotected heights, humidity and wetness, dust, odors, fumes, and
pulmonary irritants, extreme cold, or extreme heat; that she could occasionally be exposed to
moving mechanical parts; that she could frequently be exposed to operating a motor vehicle and
vibrations; and that she could tolerate loud noises. (Doc. 12-7, at 58). The ALJ afforded this
evaluation little weight, as it was inconsistent with the medical evidence in the record and
examination findings. (Doc. 12-2, at 26). The ALJ additionally noted that Dr. Willner was not
Ms. Newman’s treating physician, and that he generally underestimated Ms. Newman’s
ongoing limitations. (Doc. 12-2, at 26).
The ALJ also considered the opinion of treating physician Dr. Cline, who evaluated Ms.
Newman and completed a medical source statement on July 25, 2016. In her report, Dr. Cline
found that Ms. Newman had lifting and carrying limitations, and could occasionally lift 0-5
pounds and 10-20 pounds, but could never lift 10-20 pounds or 20-50 pounds. (Doc. 12-8, at
41). Dr. Cline also noted that Ms. Newman could stand and walk for a total of 1 hour in an 8
hour work day, and could sit for a total of 5 hours in an 8 hour work day. (Doc. 12-8, at 41).
Further, Dr. Cline indicated that Ms. Newman had limitations with postural activities such that
she could never climb, bend, balance, stoop, crouch, or crawl, but could occasionally kneel. Ms.
Newman also had manipulative limitations such that she could never reach, but could
frequently feel and handle and occasionally push and pull. (Doc. 12-8, at 42). Dr. Cline
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additionally opined that Ms. Newman experienced environmental limitations when exposed to
extreme temperatures, chemicals, dust, fumes and humidity. (Doc. 12-8, at 42). However, the
ALJ concluded that Ms. Newman’s limited treatment history did not support the extreme
limitations found by Dr. Cline. (Doc. 12-2, at 26). Specifically, the ALJ noted that Ms.
Newman’s physical examination findings were relatively normal throughout her period of
treatment, and did not corroborate a finding of disability. (Doc. 12-2, at 26). Finally, the ALJ
indicated that any finding of “disabled” not was persuasive, as this was an opinion reserved to
the Commissioner (SSR 96-5p). As such, the ALJ afforded Dr. Cline’s medical source
statement little weight. (Doc. 12-2, at 26).
Finally, the ALJ considered the stage agency mental assessment of Dr. Galdieri,
completed on February 23, 2016. (Doc. 12-3, at 2-12). Therein, Dr. Galdieri noted that Ms.
Newman’s affective disorder, considered under listing 12.04, resulted in mild restrictions in
activities of daily living, moderate difficulties in maintaining social functioning, moderate
difficulties in maintaining concentration, persistence, or pace, and no repeated episodes of
decompensation. (Doc. 12-3, at 7). The ALJ gave this opinion great weight, as the record and
mental status examination findings supported Dr. Galdieri’s conclusion that Ms. Newman’s
limitations were moderate at worst. The ALJ further noted that Ms. Newman had primarily
received mental health counseling on an intermittent basis, and that she had not required any
intensive care as a result of her symptoms. (Doc. 12-2, at 27).
Based on his consideration of the above referenced medical opinions and of the other
relevant evidence of record, the ALJ assessed that, during the relevant period, Ms. Newman
had the RFC to perform light work, but with the following limitations:
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“[Ms. Newman] could lift and carry up to 20 pounds occasionally and up to 10
pounds frequently; could push/pull for as much as she could lift/carry; could sit,
stand, and walk for up to 6 hours, each, in an 8-hour workday; could
occasionally climb ramps/stairs, but never ladders, ropes, and scaffolds; could
never balance; could occasionally stoop, kneel, crouch, and crawl; must avoid
exposure to dusts, odors, fumes, pulmonary irritants, humidity, and wetness;
could perform only unskilled work, involving only simple tasks, not performed in
a fast-paced production environment; would be limited to low-stress occupations
with only occasional, simple decision-making; would be limited to occasional
changes in work duties or the work setting; and could have occasional
interaction with the public, coworkers, and supervisors.”
(Doc. 12-2, at 24).
At step four of the sequential evaluation process, the ALJ found that Ms. Newman was
not able to perform her past relevant work as a field supervisor. (Doc. 12-2, at 27). In reaching
this conclusion, the ALJ relied on the testimony of VE Keating, who stated that work as a field
supervisor was classified at the light exertional level and is skilled in nature. (Doc. 12-2, at 27).
The ALJ therefore found that Ms. Newman was unable to perform the requirements of her past
relevant work, given her assessed RFC. (Doc. 12-2, at 28).
At step five of the sequential analysis process, the ALJ considered Ms. Newman’s age,
education, work experience and residual functioning capacity to see if she could make the
adjustment to other work. 20 C.F.R. § 404.1569. The ALJ determined that Ms. Newman was a
younger individual under 20 C.F.R. § 404.1563, as she was 45 years old on the alleged disability
onset date. (Doc. 12-2, at 28). The ALJ also found that Ms. Newman had at least a high school
education and was able to communicate in English as described under 20 C.F.R. § 404.1564.
(Doc. 12-2, at 28). While the ALJ recognized that Ms. Newman’s RFC to perform a range of
light work had been impeded by additional limitations, it did not entirely eliminate the work
base in which she could participate. (Doc. 12-2, at 28). Thus, the ALJ found that Ms. Newman
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retained the ability to perform occupations such as an assembler of small products, apparel
stock checker, and housekeeper. (Doc. 12-2, at 28-29).
As a result of these findings, the ALJ determined that Ms. Newman had “not been
under a disability, as defined in the Social Security Act, from March 6, 2014, through [October
3, 2016].” (Doc. 12-2, at 29).
IV. DISCUSSION
Ms. Newman advances two arguments on appeal. First, Ms. Newman asserts that the
RFC determination is unsupported by substantial evidence, as the ALJ failed to accord proper
weight to the opinion of Ms. Newman’s treating physician, or rely on any medical opinion
evidence in support of the ultimate RFC determination. (Doc. 16, at 7). Second, Ms. Newman
argues that the ALJ’s determination at step five is unsupported by substantial evidence, as it
improperly relied on his own interpretation of medical evidence and thus rendered the
hypothetical question posed to the VE incomplete. (Doc. 16, at 7, 13).
A. THE ALJ ERRED IN HIS EVALUATION OF OPINION EVIDENCE
Ms. Newman contends that the ALJ improperly weighed the opinions of her treating
physician, Dr. Cline, and examining physician, Dr. Willner. (Doc. 16, at 8). Specifically, Ms.
Newman asserts that the ALJ failed to fully credit any medical evidence that contradicted the
treating source’s opinion, and did not rely on any opinion that was consistent with the ultimate
RFC determination. (Doc. 16, at 9). As a result, Ms. Newman alleges that the RFC is not
supported by substantial evidence, but rather based upon the ALJ’s impermissible lay
interpretation of the medical record. (Doc. 16, at 9). The Commissioner argues that the ALJ’s
evaluation of the medical opinion evidence, and subsequent RFC determination, is supported
by substantial evidence. (Doc. 20, at 17). Further, the Commissioner argues that the ALJ is not
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bound by the opinions of treating physicians, as the RFC is ultimately an assessment reserved to
the ALJ. (Doc. 20, at 18, 22).
In making the RFC determination, “the ALJ must consider all evidence before him” and
“evaluate every medical opinion…receive[d].” Burnett v. Comm'r of Soc. Sec. Admin., 220 F.3d
112, 121 (3d Cir. 2000) (citations omitted); 20 C.F.R. § 404.1527(c); see also Adorno v. Shalala, 40
F.3d 43, 48 (3d Cir. 1994) (“The Secretary must ‘explicitly’ weigh all relevant, probative and
available evidence. . . . The Secretary may properly accept some parts of the medical evidence
and reject other parts, but she must consider all the evidence and give some reason for
discounting the evidence she rejects.”). The Social Security Regulations define “medical
opinions” as “statements from physicians and psychologists or other acceptable medical sources
that reflect judgments about the nature and severity of [the claimant’s] impairment(s), including
… symptoms, diagnosis and prognosis, what [the claimant] can still do despite [his or her]
impairment(s), and … physical or mental restrictions.” 20 C.F.R. §404.1527(a)(2). Social
Security Ruling (“SSR”) 96-5p further clarifies that “opinions from any medical source on
issues reserved to the Commissioner must never be ignored,” and specifically states that the
ALJ’s “decision must explain the consideration given to the treating source's opinion(s).” 9 SSR
96-5p, 1996 WL 374183, at *3, *6 (July 2, 1996).
9
SSRs are agency rulings published under the authority of the Commissioner and are
binding on all components of the Social Security Administration. 20 C.F.R. § 402.35(b)(1).
SSRs do not have the force and effect of the law or regulations but are to be “relied upon as
precedents in determining other cases where the facts are basically the same.” Heckler v.
Edwards, 465 U.S. 870, 873, n.3 (1984).
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SSR 96-6p addresses the weight afforded to treating medical sources, such as Dr. Cline.
SSR 96-6p, 1996 WL 374180 (July 2, 1996). 10 Because treating sources often have the closest
ties to a claimant, their opinions are generally entitled to more weight. 20 C.F.R. §
404.1527(c)(2). Under certain circumstances, the medical opinion of a treating source may even
be entitled to controlling weight. See 20 C.F.R. § 404.1527(c)(2); see also SSR 96-2p, 1996 WL
374188 at *1. A treating physician’s opinion warrants controlling weight where the opinion is
“well-supported by medically acceptable clinical and laboratory diagnostic techniques and is
not inconsistent with the other substantial evidence in [the] case record.” 20 C.F.R. §
404.1527(c)(2). On the other hand, a treating source’s opinion may be rejected “only on the
basis of contradictory medical evidence . . . .” Plummer v. Apfel, 186 F.3d 422, 429 (3d Cir.
1999). Thus, even if a treating source’s medical opinion is not entitled to controlling weight, it
still may be entitled to significant deference. SSR 96-2p, 1996 WL 374188 at *4.
Upon establishing that a treating source’s opinion is not entitled to controlling weight,
an ALJ must weigh the opinion “using all of the factors provided in 20 CFR 404.1527,” which
are also used for evaluating opinions by non-treating and non-examining medical sources. SSR
96-2p, 1996 WL 374188 at *4. These factors include: (1) the examining relationship; (2) the
treatment relationship, including its length and nature; (3) the supportability of the medical
source’s opinions; (4) consistency; (5) specialization; and (6) other relevant factors. 20 C.F.R. §
404.1527(c); see also SSR 96-6p, 1996 WL 374180 at *2 (“The regulations provide progressively
10
SSR 96-6p was published and became effective on July 2, 1996. Although since
rescinded and replaced by SSR 17-2p, SSR 96-6p was in effect at the time the ALJ rendered his
decision that is now before this Court.
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more rigorous tests for weighing opinions as the ties between the source of the opinion and the
individual become weaker.”). Further, 20 C.F.R. § 404.1527(c)(2) requires that the
Commissioner “will always give good reasons in [his] notice of determination or decision for
the weight [he] gives to [a claimant’s] treating source’s opinion.” See also Cotter v. Harris, 642
F.2d 700, 704 (3d Cir. 1981) (Finding the ALJ’s articulation of the weight accorded to each
medical opinion must be accompanied by "a clear and satisfactory explication of the basis on
which it rests."). “Where a conflict in the evidence exists, the ALJ may choose whom to credit
but ‘cannot reject evidence for no reason or the wrong reason.’” Plummer, 186 F.3d at 429
(quoting Mason v. Shalala, 994 F.2d 1058, 1066 (3d Cir. 1993)); see also Morales v. Apfel, 225 F.3d
310, 317 (3d Cir. 2000).
Here, the ALJ afforded “little weight” to the medical source statements of Dr. Willner
and Dr. Cline, which were the only two physicians that authored opinions regarding Ms.
Newman’s physical impairments. (Doc. 12-2, at 26-27). However, Ms. Newman particularly
contests the weight afforded to Dr. Cline’s medical source statement of July 25, 2016. 11 (Doc.
12-2, at 26; Doc. 12-8, at 41). In the report, Dr. Cline opined that Ms. Newman’s impairments
affected her ability to sit, stand, and walk over the course of a work day. (Doc. 12-8, at 41-42).
Notably, Dr. Cline found that, as a result of Ms. Newman’s asthma and anemia, she was
11
Indeed, that Ms. Newman does not appear to ultimately disagree with the weight
afforded to Dr. Willner’s evaluation, as it “is clearly contradicted by the record.” (Doc. 16, at
12). As such, the Court will focus its analysis on the weight afforded to Dr. Cline’s opinion.
However, the Court recognizes that Ms. Newman also seems to argue that affording both the
treating and examining physician’s opinions little weight, and formulating an RFC that was not
consistent with either opinion, was improper. (Doc. 16, at 12).
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unable to walk or stand more than 1 hour, or sit more than 5 hours, over the course of an 8
hour work day, and experienced several postural and environmental limitations. (Doc. 12-8, at
41-42). In support of his decision to discount this opinion, however, the ALJ explained:
“…[Ms. Newman’s] limited treatment history does not support the extreme
limitations noted [by Dr. Cline]. More specifically, [Ms. Newman’s] physical
examination findings, findings that are largely normal throughout her period of
care, are not corroborative of this finding of disability. Finally, all opinions
rendered as to a claimant’s status as ‘disabled,’ are clearly reserved to the
Commissioner. (SSR 96-5p). 12”
(Doc. 12-2, at 26).
Ms. Newman asserts that the treatment of Dr. Cline’s opinion is erroneous, as it fails to
properly consider the limitations that stem from her anemia, vertigo, and asthma. (Doc. 16, at
9). Specifically, Ms. Newman contends that these impairments are triggered by exertion and
thus not generally observable during routine examinations. (Doc. 16, at 9). For instance, Ms.
Newman notes that she experiences difficulty with dizziness and fatigue, in addition to
shortness of breath, upon walking and standing for extended periods of time. (Doc. 16, at 9).
Upon review of the record, Ms. Newman also testified that her shortness of breath and vertigo
primarily occurred when she exerted herself. (Doc. 12-2, at 78). This resulted in dizziness and
fatigue, which purportedly caused her to often feel like she might lose consciousness. (Doc. 122, at 69, 78-79). Ms. Newman further argues that Dr. Cline’s treatment notes consistently
documented her anemia, vertigo, asthma and hypertension. (Doc. 21, at 2-3). Indeed, Dr.
12
“Under 20 CFR 404.1527(e)…some issues are not medical issues regarding the nature
and severity of an individual's impairment(s) but are administrative findings that are dispositive
of a case; i.e., that would direct the determination or decision of disability.” SSR 96-5p, 1996
WL 374183 at *2.
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Cline’s progress notes frequently assessed Ms. Newman with asthma (Doc. 12-7, at 5, 6-7, 9,
20), hypertension (Doc. 12-7, at 6-7, 9, 12, 18), and indicated that she had a history of shortness
of breath and bronchitis. (Doc. 12-7, at 4, 6, 8, 11, 15, 17). Dr. Cline also assessed Ms. Newman
with anemia (Doc. 12-7, at 16, 19) and vertigo (Doc. 12-7, at 5), and, in her most recent
treatment notes, found that Ms. Newman’s asthma was poorly controlled and characterized as
moderate persistent asthma without complication. (Doc. 12-7, at 19-20). Thus, Ms. Newman
contends that the ALJ’s reasons for discounting Dr. Cline’s medical opinions are vague, do not
consider the well documented nature of her impairments, and are not supported by any
reference to the evidence. (Doc. 16, at 10; Doc. 21, at 2).
It is well established in the Third Circuit that the ALJ must “set forth the reasons for his
decision” to allow for meaningful judicial review. Burnett, 220 F.3d at 119 (citing Cotter, 642
F.2d at 704–05). Most significantly, the ALJ’s decision must be paired with “a clear and
satisfactory explication of the basis on which it rests.” Cotter, 642 F.2d at 704. Such discussion
helps to facilitate the Court’s review of an ALJ’s conclusions under the substantial evidence
standard. See Pope ex re. T.L.D. v. Astrue, No. 1:11-CV-1820, 2013 WL 4804725, at *3 (M.D. Pa.
Sept. 6, 2013) (citing Cotter, 642 F.2d at 704). However, the Court also recognizes that an ALJ
is not required “to use particular language or adhere to a particular format in conducting his [or
her] analysis.” Jones v. Barnhart, 364 F.3d 501, 505 (3d Cir. 2004). Rather, there must be
“sufficient development of the record and explanation of findings to permit meaningful
review.” Jones, 364 F.3d at 505; see e.g. Rivera v. Comm’r of Soc. Sec., 164 F.App’x 260, 262 (3d
Cir. 2006) (“The only requirement is that, reading the ALJ’s decision as a whole, there must be
sufficient development of the record and explanation of findings.”). Nonetheless, the doctrine in
Cotter is not implicated when the reviewing Court can determine that substantial evidence
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supports the Commissioner’s decision. Hernandez v. Comm’r of Soc. Sec., 89 F.App’x 771, 774 (3d
Cir. 2004).
Here, the Commissioner alleges that the ALJ’s rationale for discounting Dr. Cline’s
opinion was supported by substantial evidence. (Doc. 20, at 19). Specifically, the Commissioner
contends that Dr. Cline failed to provide any supporting evidence for the limitations found in
her opinion, thereby rendering it “weak evidence at best.” (Doc. 20, at 20). Additionally, the
Commissioner posits that an ALJ’s reliance on a medical opinion is not required in light of the
regulations and Third Circuit case law. See Cummings v. Colvin, 129 F.Supp.3d 209, 214-15
(W.D. Pa. 2015) (Noting that a claimant’s “reliance on Doak v. Heckler, 790 F.2d 26 (3d Cir.
1986) and the other cases cited in his brief for the proposition that an ALJ must always base his
RFC on a medical opinion from a physician is misguided.”); 20 C.F.R. §404.1527(d)(2); SSR
96-5p, 1996 WL 374183, at *2. The Commissioner further provides examples of alleged
inconsistencies which appeared in Dr. Cline’s own findings, and argues that Ms. Newman’s
anemia was reasonably controlled with medication. (Doc. 20, at 19-20). However, the evidence
cited to by the Commissioner in support of the ALJ’s assessment of Dr. Cline’s opinion cannot
be considered upon substantial evidence review—indeed, the Court may only review the
decision based upon the ALJ’s own rationale and findings. See SEC v. Chenery, 318 U.S. 80, 87
(1943) (“The grounds upon which an administrative order must be judged are those upon which
the record discloses that its action was based.”); Fargnoli v. Massanari, 247 F.3d 34, 44 n.7; Sykes
v. Apfel, 228 F.3d 259, 271 (3d Cir. 2000). Further, “the [ALJ's] decision must contain specific
reasons for the weight given to the treating source's medical opinion, supported by the evidence
in the case record, and must be sufficiently specific to make clear to any subsequent reviewers
the weight the adjudicator gave to the treating source's medical opinion and the reasons for that
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weight.” SSR 96–2p, 1996 WL 374188 at *5. “[W]hen an ALJ fails to adequately explain why a
treating physician's medical assessment has been discounted, a remand for further development
of the factual record is proper. Reader v. Colvin, No. 1:12-CV-1623, 2014 WL 1653090, at *8
(M.D. Pa. Apr. 24, 2014). In this case, the ALJ provided a general explanation that Ms.
Newman’s limited treatment history did not corroborate Dr. Cline’s extreme findings, but did
not cite to any specific part of the record in support of this contention. (Doc. 12-2, at 26).
Further, the ALJ did not describe which findings were purportedly normal, reference any
particular evidence in support of his conclusion, or consider the fact that exertion generally
triggered Ms. Newman’s impairments. Moreover, upon determining that Dr. Cline’s treating
physician opinion was not entitled to controlling weight, it is unclear whether the ALJ
subsequently weighed the opinion “using all of the factors provided in 20 CFR 404.1527.” SSR
96-2p, 1996 WL 374188 at *4. Thus, the vague basis for the ALJ’s finding does not constitute a
“clear and satisfactory explication of the basis on which it rests.” Cotter, 642 F.2d at 704-05.
Moreover, although cited to by the ALJ in support of his decision to discount Dr. Cline’s
medical source statement, the Court notes that SSR 96-5p does not apply to the ALJ’s
assessment of Dr. Cline’s opinion. 20 C.F.R. §404.1527(d) addresses the assessment of medical
source opinions on issues reserved to the Commissioner. Examples of such issues, which are
not considered medical opinions entitled to any special deference, include: whether an
individual’s impairments meet the required severity of an impairment in the listings; opinions
regarding what an individual’s RFC is; whether an individual’s RFC prevents the performance
of past work; how an individual’s vocational factors apply; and determinations of whether an
individual is “disabled” under the Act. SSR 96-5p, 1996 WL 374183 at *2. Dr. Cline, however,
completed a medical source statement about Ms. Newman’s ability to perform work-related
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physical activities on a day-to-day basis, and is not an opinion on an issue reserved to the
Commissioner. See 20 C.F.R. §404.1527(d); SSR 96-5p, 1996 WL 374183. Thus, the Court is
not persuaded that this was a proper reason to discount Dr. Cline’s opinion. See Plummer, 186
F.3d at 429 (An ALJ “cannot reject evidence for no reason or the wrong reason.”). 13
Because the ALJ failed to properly consider Dr. Cline’s opinion, and adequately explain
why he discounted her report, the Court is hampered in its ability to conduct a meaningful
review of the ALJ’s decision. See, e.g., Ray v. Colvin, Civ. No. 13-CV-0073, 2014 WL 1371585,
at *21 (M.D. Pa. Apr. 8, 2014) (“The cursory manner in which the ALJ rejected Dr. Jacob's
opinions runs afoul of the regulation's requirement to ‘give good reasons’ for not crediting the
opinion of a treating source upon consideration of the factors listed above. While there may be
sufficient evidence in the record to support the ALJ's ultimate decision that Plaintiff was not
under a disability, and, thus, the same outcome may result from remand, the court cannot
13
However, even if Dr. Cline’s opinion did contain a statement on an issue reserved to
the commissioner, the ALJ was not necessarily entitled to discount the opinion on this ground.
SSR 96-5p discusses medical opinions on issues reserved to the Commissioner, and
“emphasizes to the adjudicator the importance of making ‘every reasonable effort to re-contact
such sources for clarification when they provide opinions on issues reserved to the
Commissioner and the bases for such opinions are not clear to us.’” Ferari v. Astrue, No. CIV.A.
1:07-CV-01287, 2008 WL 2682507, at *6 (M.D. Pa. July 1, 2008). Here, the Commissioner
argues that Dr. Cline’s opinion was not entitled to greater weight as it was not supported by her
medical findings in the record. (Doc. 20, at 20-21). However, there is no indication that
the ALJ made any effort to re-contact Dr. Cline for clarification, much less “every reasonable
effort.” Thus, even if Dr. Cline’s opinion’s was based on an issue reserved to the commissioner,
and had no apparent supporting basis in the medical evidence, the Commissioner’s decision to
discount the source statement was still not in accordance with the regulations. Miller v. Colvin,
No. 3:13-CV-02594-GBC, 2015 WL 1609671, at *8–9 (M.D. Pa. Apr. 10, 2015) (“Rejecting
the opinion of a treating opinion because it is on an issue reserved to the Commissioner without
attempting to re-contact the treating physician for clarification generally constitutes rejecting
evidence for the “wrong reason.”).
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excuse the denial of a mandatory procedural protection on that basis.”); Foley v. Barnhart, 432 F.
Supp. 2d 465, 479 (M.D. Pa. 2005) (“…[T]he ALJ did not properly consider the treating
physician's opinion so we cannot say that her decision is supported by substantial evidence.”).
This failure undermines the accuracy of the ALJ’s subsequent RFC assessment, and ultimately
his conclusion that Ms. Newman was not disabled at step five. Therefore, based on a review of
the ALJ’s decision and supporting medical evidence, substantial evidence does not support the
weight afforded to Dr. Cline’s medical opinion.
B. REMEDY
As a final matter, the Court addresses whether this case should be remanded to the
Commissioner for further administrative proceedings or whether reversal and an award of
benefits is appropriate. The Court has authority to affirm, modify or reverse the Commissioner's
decision “with or without remanding the case for rehearing.” 42 U.S.C. § 405(g); Melkonyan v.
Sullivan, 501 U.S. 89, 100-01 (1991). However, the Third Circuit has advised that benefits
should only be awarded where “the administrative record of the case has been fully developed
and when substantial evidence in the record as a whole indicates that the claimant is disabled
and entitled to benefits.” Morales v. Apfel, 225 F.3d 310, 320 (3d Cir. 2000); see e.g. Fla. Power &
Light Co. v. Lorion, 470 U.S. 729, 744 (1985) (“[T]he proper course, except in rare circumstances,
is to remand to the agency for additional investigation or explanation.”).
V. CONCLUSION
Because the Court concludes that the ALJ erred in his rationale for discounting the
medical opinion evidence of record, further development of the record is necessary, and the
decision of the Commissioner is VACATED and the case REMANDED. On remand, the ALJ
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shall evaluate the medical opinion evidence of record, explain his evaluation of the medical
opinion evidence of record, and cite to specific evidence that supports his conclusion.
An appropriate Order shall follow.
s/ Karoline Mehalchick
Dated: March 21, 2018
KAROLINE MEHALCHICK
United States Magistrate Judge
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