Conetta v. Berryhill
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Opinion
GABRIEL W. GORENSTEIN, United States Magistrate Judge
Plaintiff Ralph Louis Conetta brings this action pursuant to
*387I. BACKGROUND
A. Procedural History
Conetta filed an application for a period of disability and disability insurance benefits ("DIB") on June 3, 2011, alleging a disability onset date of September 20, 2010. See R. 81, 138.2 The Social Security Administration ("SSA") denied Conetta's application on August 26, 2011. R. 84. Conetta then requested a hearing before an administrative law judge ("ALJ") to review the denial. R. 96-97. Conetta was represented by his attorney at a hearing before an ALJ, which occurred on June 28, 2012, in Jericho, New York. R. 39-77, 78-79. In a written decision dated September 10, 2012, the ALJ found that Conetta was not disabled within the meaning of the Act. R. 26-32. Conetta requested that the Appeals Council review the ALJ's decision, R. 17-20, and on October 22, 2013, the Appeals Council denied Conetta's request for review of the ALJ's decision, R. 1-3.
Conetta filed an action in federal district court appealing the Appeals Council's denial. See Complaint, filed Dec. 4, 2013 (Docket # 1), Conetta v. Comm'r of Soc. Sec., 13 Civ. 8629 (WHP) (GWG) (S.D.N.Y.). In November 2014, the court ordered - as stipulated to by the parties - that the action be remanded to the Commissioner pursuant to sentence four of
B. Testimony at the 2012 and 2016 Hearings
1. The June 2012 Hearing
At the June 2012 hearing, Conetta testified and was represented by his attorney, James King. R. 41. Conetta testified that he was 47 years old and had a high school diploma and an associate's degree. R. 42. Conetta lives in a private home with his wife, children, and stepmother, R. 43, and his source of income at the time consisted of a workers compensation lump sum award, R. 44. Conetta had been volunteering for the United States Coast Guard Auxiliary since at least 2006. R. 45. After a September 2010 workplace accident that caused Conetta to stop working, his volunteer work consisted of attending business meetings, which totaled around 30 hours a year. R. 45-47. Conetta also volunteered by teaching boating courses. R. 50-51. Conetta had previously would assisted in nautical patrols for the Coast Guard, but he had not done so in around a year and a half due to pain in his back, knees, and shoulder. R. 47-50.
Conetta testified regarding his employment as a licenced electrician and union sub-foreman. R. 43-44, 52-53. Conetta hurt his left shoulder at work in March 2010 but returned to work on "light duty." R. 53. While on "light duty," Conetta worked as a sub-foreman tasked with managing up to 10 employees. R. 54-55. He stopped working entirely in September 2010 due to a back injury sustained at work. R. 52-54. If it were not for his September 2010 back *388injury, he could still be doing his "light-duty" job as sub-foreman. R. 56. This was true even though he has shoulder and knee pain. R. 58.
As to his injuries and pain, Conetta testified that he had a herniated disk, low back pain, and sciatica, which alternates between both of his legs and affects his knees. R. 57-58. He has difficulty bending at the waist, and tries to do exercises to stretch his back out. R. 58. He does not use a cane. See R. 59-60. He uses a "TENS unit" every night before bed. R. 59-60. Walking up stairs exacerbates his back pain, as does the weather at times. R. 60-61. At the time of the hearing, Conetta could not "really reach over [his] head too good with [his] left hand," R. 61, or push open a swinging door, R. 62. However, he could do these things with his right hand. R. 62. As to lifting, Conetta could manage to lift up to 10 pounds with his right hand, and up to five pounds with his left. R. 63. The pain forces Conetta to alternate every 15 to 20 minutes between sitting, standing, and walking. R. 64.
The ALJ posed a series of hypotheticals in order to further pinpoint Conetta's pain in relation to performing everyday activities, including work activities. The ALJ asked whether Conetta, given his impairments, could perform work at public library checking out books behind a counter. R. 64-65. Conetta could not answer, because it would depend on whether he woke up on any given morning "in agony pain." R. 65. Thus, although there would be days when Conetta could do the work as described by the ALJ, there would also be times when he could not. See R. 65-66. And while Conetta had difficulty assigning a percentage figure to the number of hours in a week that he could perform the job described by the ALJ, R. 66-67, a figure of 30 to 40 percent was eventually agreed upon, with the statement that even the 30 percent figure was "unpredictable." R. 68. Conetta said that the pain in his back would affect his ability to concentrate, and that this happened "maybe" "once a day." R. 62. Overall, on a scale of zero to 10, "where zero is no pain and 10 is excruciating pain," Conetta stated that he is generally between a five and seven when taking over-the-counter pain medication. R. 59.
As to daily activities, Conetta has a "hard time tying [his] shoes" and putting his socks on, though he attempts to do these things on his own. R. 69. He bathes himself, does "some cooking," and drives to go food shopping and do other errands. R. 69-70. He also "tr[ies]" to do housework including dusting, mopping, vacuuming, doing laundry, and doing the dishes. R. 70. One hobby Conetta engages in is going to a shooting range, where he shoots for about 15 minutes at time using a .22 caliber handgun. R. 70-71. He shoots the gun, which weighs three pounds, exclusively with his right hand. R. 71.
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GABRIEL W. GORENSTEIN, United States Magistrate Judge
Plaintiff Ralph Louis Conetta brings this action pursuant to
*387I. BACKGROUND
A. Procedural History
Conetta filed an application for a period of disability and disability insurance benefits ("DIB") on June 3, 2011, alleging a disability onset date of September 20, 2010. See R. 81, 138.2 The Social Security Administration ("SSA") denied Conetta's application on August 26, 2011. R. 84. Conetta then requested a hearing before an administrative law judge ("ALJ") to review the denial. R. 96-97. Conetta was represented by his attorney at a hearing before an ALJ, which occurred on June 28, 2012, in Jericho, New York. R. 39-77, 78-79. In a written decision dated September 10, 2012, the ALJ found that Conetta was not disabled within the meaning of the Act. R. 26-32. Conetta requested that the Appeals Council review the ALJ's decision, R. 17-20, and on October 22, 2013, the Appeals Council denied Conetta's request for review of the ALJ's decision, R. 1-3.
Conetta filed an action in federal district court appealing the Appeals Council's denial. See Complaint, filed Dec. 4, 2013 (Docket # 1), Conetta v. Comm'r of Soc. Sec., 13 Civ. 8629 (WHP) (GWG) (S.D.N.Y.). In November 2014, the court ordered - as stipulated to by the parties - that the action be remanded to the Commissioner pursuant to sentence four of
B. Testimony at the 2012 and 2016 Hearings
1. The June 2012 Hearing
At the June 2012 hearing, Conetta testified and was represented by his attorney, James King. R. 41. Conetta testified that he was 47 years old and had a high school diploma and an associate's degree. R. 42. Conetta lives in a private home with his wife, children, and stepmother, R. 43, and his source of income at the time consisted of a workers compensation lump sum award, R. 44. Conetta had been volunteering for the United States Coast Guard Auxiliary since at least 2006. R. 45. After a September 2010 workplace accident that caused Conetta to stop working, his volunteer work consisted of attending business meetings, which totaled around 30 hours a year. R. 45-47. Conetta also volunteered by teaching boating courses. R. 50-51. Conetta had previously would assisted in nautical patrols for the Coast Guard, but he had not done so in around a year and a half due to pain in his back, knees, and shoulder. R. 47-50.
Conetta testified regarding his employment as a licenced electrician and union sub-foreman. R. 43-44, 52-53. Conetta hurt his left shoulder at work in March 2010 but returned to work on "light duty." R. 53. While on "light duty," Conetta worked as a sub-foreman tasked with managing up to 10 employees. R. 54-55. He stopped working entirely in September 2010 due to a back injury sustained at work. R. 52-54. If it were not for his September 2010 back *388injury, he could still be doing his "light-duty" job as sub-foreman. R. 56. This was true even though he has shoulder and knee pain. R. 58.
As to his injuries and pain, Conetta testified that he had a herniated disk, low back pain, and sciatica, which alternates between both of his legs and affects his knees. R. 57-58. He has difficulty bending at the waist, and tries to do exercises to stretch his back out. R. 58. He does not use a cane. See R. 59-60. He uses a "TENS unit" every night before bed. R. 59-60. Walking up stairs exacerbates his back pain, as does the weather at times. R. 60-61. At the time of the hearing, Conetta could not "really reach over [his] head too good with [his] left hand," R. 61, or push open a swinging door, R. 62. However, he could do these things with his right hand. R. 62. As to lifting, Conetta could manage to lift up to 10 pounds with his right hand, and up to five pounds with his left. R. 63. The pain forces Conetta to alternate every 15 to 20 minutes between sitting, standing, and walking. R. 64.
The ALJ posed a series of hypotheticals in order to further pinpoint Conetta's pain in relation to performing everyday activities, including work activities. The ALJ asked whether Conetta, given his impairments, could perform work at public library checking out books behind a counter. R. 64-65. Conetta could not answer, because it would depend on whether he woke up on any given morning "in agony pain." R. 65. Thus, although there would be days when Conetta could do the work as described by the ALJ, there would also be times when he could not. See R. 65-66. And while Conetta had difficulty assigning a percentage figure to the number of hours in a week that he could perform the job described by the ALJ, R. 66-67, a figure of 30 to 40 percent was eventually agreed upon, with the statement that even the 30 percent figure was "unpredictable." R. 68. Conetta said that the pain in his back would affect his ability to concentrate, and that this happened "maybe" "once a day." R. 62. Overall, on a scale of zero to 10, "where zero is no pain and 10 is excruciating pain," Conetta stated that he is generally between a five and seven when taking over-the-counter pain medication. R. 59.
As to daily activities, Conetta has a "hard time tying [his] shoes" and putting his socks on, though he attempts to do these things on his own. R. 69. He bathes himself, does "some cooking," and drives to go food shopping and do other errands. R. 69-70. He also "tr[ies]" to do housework including dusting, mopping, vacuuming, doing laundry, and doing the dishes. R. 70. One hobby Conetta engages in is going to a shooting range, where he shoots for about 15 minutes at time using a .22 caliber handgun. R. 70-71. He shoots the gun, which weighs three pounds, exclusively with his right hand. R. 71. Conetta also tries to attend all of his children's baseball and softball games, and either stands to watch the games, or sits in a folding chair. R. 74-75.
2. The March and April 2016 Post-Remand Hearings
A different ALJ presided over hearings in March and April 2016, at which Conetta was represented by his attorney. The March 2016 hearing was brief and consisted solely of the ALJ informing Conetta of the hearing process, R. 429-32, questioning him briefly about his volunteer work for the Coast Guard, R. 432-34, obtaining new records, and setting a new date for a supplemental hearing, R. 435-37.
The supplemental hearing took place on April 5, 2016, in White Plains, New York. Testimony was given by Conetta and Robert Baker, a vocational expert, R. 765, who appeared by telephone, R. 400.
The ALJ asked Conetta about his daily activities and hobbies. Conetta testified *389that he does some housework consisting of vacuuming, making the bed in the morning, and doing laundry. R. 404. He also attends the athletic events of his children. R. 404. Although he drives short distances (for example, to doctors' appointments and to his children's games), he does not engage in any extended travel, R. 405, and sometimes has to stop driving and "walk around the car to try to get the muscles moving to stretch out because [his] sciatic goes right down to [his] feet and crunches [his] toes." R. 418. He does do some yard-work in the form of raking leaves for 15 minutes before he goes back inside to "relax" and ice his back. R. 405. Conetta exercises by doing leg raises, leg extensions, stretching his arms, and using a one-pound dumbbell to do lateral raises. R. 409-10. He can only sit for 15 to 30 minutes at a time before needing to stand up again. R. 418. He also goes for walks every other day around his block at home, which he estimated to be about a half a mile. R. 410. Conetta goes grocery shopping, and sometimes clothes shopping. R. 406; see R. 419. As to his hobbies, Conetta goes to a shooting range, where he will "shoot 15 rounds" about "once a month." R. 406. Although he used to hunt, he has not done so since 2011. R. 406-07. Conetta stated that since September 2010 (when he injured his back), he had gone hunting "maybe twice." R. 407.
The ALJ questioned Conetta about his volunteer work with the Coast Guard. Conetta explained that he still attends meetings - which last around a half an hour - "once or twice a year." R. 407. Although he has not gone on patrol for the Coast Guard since 2010, Conetta testified that he thinks he went out on a boat with the Coast Guard "once in 2011," although it was not an official patrol. R. 407-08.
Conetta testified to his physical impairments involving his shoulder, back, and knees. His previous shoulder surgery helped "a little bit," but he still experiences pain in the shoulder, and cannot, for instance, do any home repairs on his own. R. 411. Any "[o]verhead activity" - where Conetta needs to reach his hands out in front of him - results in pain: for instance, when he folds laundry. R. 411. As to his back, Conetta ices his lower back and also puts heat on it, either by using his friend's hot-tub, or by taking "hour showers." R. 412. He also tries to do "certain exercises." R. 412.
Conetta received an injection for the back pain, which he says helped, but otherwise takes over-the-counter pain medications because he wants to "stay away from the high drugs" for fear of addiction. R. 412. He does take Ultram and Aleve, which help with the pain. R. 412. He also explained that while some days are "good" (he can take Advil and "the rest of the day could be good"), some days, the pain is so intense that "I've stayed in bed and my wife came home from work and she's like, you didn't get up, and I said, no. And, I'm starving." R. 413, see R. 417. In order to manage the pain he experienced from driving 30 minutes in the car to his hearing that day, he took "four Motrin" before he left home, and "just took two Advil when [he] got out of the car." R. 413.
Regarding his knees, Conetta testified that he has had three surgeries on his right ACL, but that the orthopedist has not looked at the knee since 2010. R. 414-15. Conetta's attorney interjected at that point by explaining to the ALJ that at least one doctor in the record noted that the knee pain might be due to the L4 nerve root impingement in Conetta's back. R. 415. Conetta continued by explaining the sciatic that shoots "down [the] right knee," and sometimes to the left foot as well. R. 415. Also regarding the knee impairment, the ALJ questioned Conetta about his weight. At 5 feet, 7 inches tall *390and 230 pounds, Conetta stated that he thinks his "weight does have to reflect" on his knee "symptoms" "a little bit." R. 413-14. Indeed, he has "tried to lose some weight ... by eating right," but since he does not do "much activity," he puts the weight back on. R. 414. Conetta testified that he had no side-effects from his medications. R. 420.
The vocational expert ("VE") testified next, answering multiple questions from the ALJ regarding what work certain hypothetical individuals could perform in the national economy. First, the ALJ asked the VE
to assume a person of the claimant's age, education and work experience able to do the full range of light work as defined by the Rules and Regulations. His lift, carry limitations will be the same as his push, pull limitations. He would be limited up to occasional climbing ramps and stairs, but without climbing ladders, ropes or scaffolds and occasional balancing, stooping, kneeling, crouching and crawling. He would be limited up to frequent reaching, but with occasional overhead reaching.
He added that the individual should avoid extreme cold, extreme heat, humidity and vibration. R. 421-22 ("Hypothetical One"). As to whether there was work that such a person could perform in the national economy, the VE responded with three examples of jobs that could be performed: "photocopy machine operator," "router," and "marker." R. 422. The VE noted that these jobs provide for "regularly scheduled breaks" of "15 minutes in the morning, 15 minutes in the afternoon and a half hour to an hour midday." R. 422. As to the next hypothetical, the ALJ asked the VE to assume the same as Hypothetical One, except that the claimant is
further limited in that he's going to be able to still lift, carry, push and pull 20 pounds occasionally and ten pounds frequently. And, he could still sit for up to six hours. He can stand for four hours and he can walk for four hours. In addition, after -- at one-hour intervals, if he's in a standing position, he should be [able] to shift position permitting him to be off task for five percent of the work period in addition to those regularly scheduled breaks.
R. 422-23. Additionally, the individual, "[a]fter sitting for two hours, [should] also be able to shift position," which is a requirement that "can be accommodated for by the regularly scheduled breaks." R. 423 ("Hypothetical Two"). With these limitations, the VE stated that such an individual could still perform the jobs of "photocopy machine operator" and "router," but that the "marker" job "would be more questionable." R. 423. The VE also added that the individual in Hypothetical Two could also perform the job of "ticket taker." R. 423. The ALJ then asked the VE to assume a new hypothetical individual who has the same limitations as in Hypothetical Two, except that now the individual "would be limited to the exertional limitations for sedentary work and lift and carrying up to ten pounds occasionally and five pounds frequently, same with push, pull." R. 424. In other words: Hypothetical Two, "but now for sedentary work." R. 424 ("Hypothetical Three"). As to the individual in Hypothetical Three, the VE stated that work could be performed as an "account clerk," an "addresser," and a "document prepare[r,] microfilming." R. 424.
The VE testified that if the individuals posed in the hypotheticals were to "be off task for 20 percent of the work period," or if they were "limited to only four hours of sitting and one hour of standing in an eight-hour day," then "that would preclude all work." R. 424. The VE acknowledged that although his testimony was consistent with the Dictionary of Occupational Titles ("DOT"), the DOT "is silent" - but "not *391necessarily inconsistent" - on the issues of "shifting positions, [and] overhead reaching." R. 424-25. Finally, the VE confirmed that if Conetta would "need to be absent more than three times per month, ... that [would] affect his ability to work in any of [the] hypotheticals." R. 425.
C. The Medical Evidence
The Commissioner and Conetta have both provided summaries of the medical evidence in the record. See Pl. Mem. at 5-17; Def. Mem. at 5-19. The summaries are substantially consistent with each other. The Court had directed the parties to specify any objections they had to the opposing party's summary of the record, see Scheduling Order, filed Apr. 20, 2018 (Docket # 12), ¶ 5, and neither party has done so. Accordingly, the Court adopts both parties' summaries of the medical evidence as accurate and complete for purposes of the issues raised in this suit. We discuss the medical evidence pertinent to the adjudication of this case in Section III below.
D. The ALJ's 2016 Decision
The ALJ denied Conetta's DIB application on May 16, 2016. R. 390. First, the ALJ found that Conetta met the insured status requirements of the SSA on December 31, 2015. R. 369. Then, following the five-step test set forth in the SSA regulations, the ALJ found at step one that Conetta had not engaged in "substantial gainful activity" during the time between his alleged disability onset date - September 20, 2010 - and his date last insured of December 31, 2015 (the "relevant period"). R. 369. At step two, the ALJ found that during the relevant period, Conetta suffered from "severe impairments" of "Degenerative Disc Disease of the Lumbar Spine; Left Shoulder Labral Tear/Tendinitis ; Impingement of Right Shoulder; Right Knee Meniscus and Cruciate Ligament Tear, Status-Post Arthroscopic Repair; [and] Obesity." R. 369. At step three, the ALJ found that none of Conetta's severe impairments singly or in combination met or medically equaled an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1 (the "Listings"). R. 369. In reaching this conclusion, the ALJ gave particular attention to listings 1.02 (Major dysfunction of a joint) and 1.04 (Disorders of the spine ), and to Social Security Ruling ("SSR") 02-1p (Policy Interpretation Ruling Titles II and XVI: Evaluation of Obesity ). R. 369.
Before moving to step four, the ALJ addressed Conetta's residual functional capacity ("RFC"). R. 370-88. The ALJ found that Conetta had the RFC to perform "light work,"3 except that Conetta
can sit for up to 6 hours in an 8 hour workday, stand or walk for up to 4 hours in an 8 hour workday, and at one hour intervals, if in the standing position, should be able to shift positions permitting him to be off task for 5% of the work period in addition to regularly scheduled breaks. After sitting for 2 hours, he can also shift positions, but his need to do so would be accommodated *392by regularly scheduled breaks. The claimant can lift/carry/push/pull 20 pounds occasionally and 10 pounds frequently. He is limited to up to occasional climbing of ramps and stairs, without climbing of ladders, ropes or scaffolds, and occasional balancing, stooping, kneeling, crouching and crawling. He is limited to up to frequent reaching, but with occasional overhead reaching, and should avoid extreme cold, extreme heat, humidity and vibration.
R. 370. In making the RFC determination, the ALJ reviewed the objective medical evidence and other evidence including Conetta's testimony and symptoms under
For these reasons, the ALJ concluded that Conetta "was not under a disability, as defined in the Social Security Act, at any time from September 20, 2010, the alleged onset date, through December 31, 2015, the date last insured." R. 390. Accordingly, Conetta was found "not disabled" under sections 216(I) and 223(d) of the Social Security Act. R. 390.
II. GOVERNING STANDARDS OF LAW
A. Scope of Judicial Review Under 42 U.S.C. § 405 (g)
A court reviewing a final decision by the Commissioner "is limited to determining whether the [Commissioner's] conclusions were supported by substantial evidence in the record and were based on a correct legal standard." Selian v. Astrue,
*393Matthews v. Leavitt,
"Even where the administrative record may also adequately support contrary findings on particular issues, the ALJ's factual findings must be given conclusive effect so long as they are supported by substantial evidence." Genier v. Astrue,
B. Standard Governing Evaluation of Disability Claims by the Agency
The Social Security Act defines the term "disability" as the "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."
To evaluate a Social Security claim, the Commissioner is required to examine: "(1) the objective medical facts; (2) diagnoses or medical opinions based on such facts; (3) subjective evidence of pain or disability testified to by the claimant or others; and (4) the claimant's educational background, age, and work experience." Mongeur v. Heckler,
Regulations issued pursuant to the Act set forth a five-step process that the Commissioner must use in evaluating a disability claim. See
C. The "Treating Physician" Rule
Under the so-called "treating physician" rule, in general, the ALJ must give "more weight to medical opinions" from a claimant's "treating source" - as defined in the regulations - when determining if the claimant is disabled. See
If the ALJ does not give controlling weight to a treating source's opinion, the ALJ must provide "good reasons" for the weight given to that opinion or face remand. See Greek,
III. DISCUSSION
Conetta raises three grounds for reversing the ALJ's decision: (1) that the ALJ failed to properly evaluate the effects of Conetta's impairments at step three of the sequential evaluation process, Pl. Mem. at 18-20; Pl. Reply at 2-4; (2) that the ALJ failed to properly evaluate the medical evidence from Conetta's treating physicians and to March 19, 2019make a proper RFC determination, Pl. Mem. at 20-28; Pl. Reply at 4-7; and (3) that the ALJ failed to properly assess Conetta's allegations with respect to his level of pain, Pl. Mem. at 28-31; Pl. Reply at 7-8. We discuss each of Conetta's arguments next.
A. The ALJ's Step Three Analysis
Conetta first argues that the ALJ erred at step three in determining that Conetta's impairments did not meet or equal listing 1.04(a), "Disorders of the spine." Pl. Reply at 2. Conetta argues that the determination was incorrect because there was objective medical evidence showing Conetta's "deficits in range of motion, diminished strength, muscle weakness and positive straight leg raising results." Pl. Mem. at 19. Conetta points to the fact that diagnostic testing confirmed the presence of nerve root impingement in the lumbar spine, and that an April 2011 MRI revealed diffuse disc bulging and "annular tear with moderate central canal stenosis and bilateral neuroforaminal narrowing, right worse than left, at the L3-L4 level; and annular tear with right neuroforaminal narrowing at the L4-L5 level." Id. at 18. Conetta argues that because "the ALJ does not make mention of these significant findings at all in his Step-3 analysis," that analysis is flawed. Id. at 20.
*396As stated above, at step three in the sequential analysis, the ALJ determines if the claimant suffers from a listed impairment.
Here, the ALJ addressed the 1.04 listing by noting Conetta's obesity and stating that "[b]ecause the record does not establish that the claimant's impairments, alone or in combination, reach the level of severity contemplated in any relevant listings, disability cannot be established on this basis." R. 369. In other words, the ALJ referred to his discussion of Conetta's impairments in addressing the 1.04 listing. Conetta argues that because the ALJ did not conduct the "thorough analysis required at Step 3 of the sequential evaluation process as stated above, which ultimately impacts the Plaintiff's assessed residual functional capacity," it follows that "the ALJ's assessment of Plaintiff's residual functional capacity is flawed." Pl. Mem. at 20.
The Second Circuit, however, has stated that although it has
cautioned that an ALJ "should set forth a sufficient rationale in support of his decision to find or not to find a listed impairment," the absence of an express rationale for an ALJ's conclusions does not prevent us from upholding them so long as we are "able to look to other portions of the ALJ's decision and to clearly credible evidence in finding that his determination was supported by substantial evidence."
Salmini v. Comm'r of Soc. Sec.,
Thus, the ALJ's reference here to the "record" in assessing Conetta's impairments is permissible as long as the ALJ supported his determination elsewhere in his decision. See De Gonzalez v. Berryhill,
*397Roche v. Berryhill,
In this case, the ALJ's determination at step three that Conetta did not meet or equal listing 1.04(A) (disorders of the spine ) was supported by substantial evidence in the record and is explained in the rest of the ALJ's decision. Listing 1.04(A) is entitled "Disorders of the spine (e.g., herniated nucleus pulposus, spinal arachnoiditis, spinal stenosis, osteoarthritis, degenerative disc disease, facet arthritis, vertebral fracture ), resulting in compromise of a nerve root (including the cauda equina ) or the spinal cord." It requires that the claimant show each of the following:
[1] Evidence of nerve root compression characterized by neuro-anatomic distribution of pain, [2] limitation of motion of the spine, [3] motor loss (atrophy with associated muscle weakness or muscle weakness) accompanied by sensory or reflex loss and, [4] if there is involvement of the lower back, positive straight-leg raising test (sitting and supine).
20 C.F.R. Part 404, Subpart P, Appendix 1, § 1.04(A) (bracketing added). We agree with the Commissioner that it is not enough to show that one of these criteria existed on a single occasion or for a brief period. See Def. Mem. at 24. Rather, given that the definition of disability requires that the inability to work last for consecutive period of twelve months, see
As to the medical evidence, the ALJ cited evidence supporting Conetta's claim of spinal deficits. R. 373-74. But, as the ALJ recounted, there was ample evidence to the contrary. Independent medical examiner and orthopedist Dr. Marc Berezin's notes from 2012, 2013, and 2014, revealed a "non-antalgic gait, with intact reflexes, negative straight leg raises, and no motor or sensory deficits." R. 374 (citing R. 951-52, 960-61, 970-71). The ALJ also cited treating physician and orthopedic surgeon, R. 343, Dr. David Benatar as "repeatedly" noting that Conetta "exhibit[ed] near normal lumbar flexion" in 2012 and 2013. R. 374 (citing R. 326-27, 833-35). Furthermore, the ALJ found that "while an MRI of the claimant's lumbar spine taken in April 2011 revealed contact with the L4 foraminal nerve root from a disc protrusion at L2-3, and moderate canal stenosis and bilateral neuroforaminal narrowing at L3-4," a subsequent January 2014 "MRI of his lumbar spine... showed only 'borderline' canal stenosis at L3-4, only 'borderline' neural foraminal narrowing at L2-3, L3-4, and L4-5, and no evidence of any compression deformity, and with the conus, nerve roots and remaining neural foraminal and apophyseal facts all appearing to be normal." R. 374 (citing R. 821); see R. 821 (January 2014 MRI showed "no evidence of a compression deformity ... [or] disc space narrowing"). There is other medical evidence suggesting that Conetta's deficiencies with respect to his range of motion were not as severe as Conetta and other physicians indicated. See, e.g., R. 850-51 (September 2015 follow-up physical indicating "[n]ormal" gait, "5/5" motor, and unrestricted range of motion), 815 (August 2014 notes indicating no swelling or deformity of the thoracic spine and pelvis, good strength, and "intact" sensory), 825-26 (June 2014 physical exam showing normal *398gait, and range of motion "without restriction"); 833-34 (February 2013 and April 2013 examinations noting no sensory loss or deficit); 960 (October 2011 physical therapy progress notes indicating "non-antalgic gait," "[n]o tenderness or spasm" in back, and "[n]o motor or sensory deficits, [r]eflexes intact and equal," and negative straight leg raise tests). Also, as the ALJ noted, Conetta's "treatment records do not document any observed use of a cane or other handheld assistive device to aid his ambulation or station." R. 375.
In light of this evidence, the ALJ could properly conclude that Conetta did not meet the criteria of listing 1.04(A). See, e.g., Beall v. Colvin,
B. The ALJ's Failure to Evaluate Treating Sources
Conetta's next argument is that the ALJ failed to properly evaluate the medical and opinion evidence necessary to make a proper RFC determination. Pl. Mem. at 20-28; Pl. Reply at 4-7. This is because, according to Conetta, the opinions of his treating physicians, orthopedic surgeons Dr. Peter L. Varriale and Dr. David Benatar, should have been accorded "greater weight or at minimum greater deference" because substantial evidence exists in the record to support their opinions. Pl. Mem. at 21, 23. Conetta further argues that it was erroneous to give greater weight to the opinions of consultative examiner Dr. John Axline and the "IMEs" - that is, the independent medical examiners who examined Conetta in connection with his workers' compensation case. Pl. Mem. at 23-26.
A claimant's RFC is "the most [a claimant] can still do despite [their] limitations."
Here, the ALJ did not err in according "little weight" to the opinions of Drs. Varriale and Benatar. See R. 378-83. Conetta has been treated by Dr. Varriale since 1997, who opined that Conetta has been unable to perform work at various points, mostly due to prior shoulder and knee injuries. See R. 299. In 2007, based on injuries Conetta sustained in an automobile accident in 2006, Dr. Varriale opined that Conetta was "permanently disabled from performing the duties of" construction work, and that he would be limited to "light duty" jobs. R. 304. And Dr. Varriale opined in May 2011 that Conetta could only sit for 20 minutes at a time, stand for 10 minutes at a time, and sit/stand for less than two hours total in an eight hour work day. R. 193; see R. 231-33 (noting that Conetta could not lift or perform overhead work, and that Conetta would need periods of rest). Dr. Varriale consistently made note of Conetta's symptoms and physical deficiencies throughout 2010, 2011, and 2012. See, e.g., R. 238, 246, 260, 262, 266, 274, 280, 294, 330 (Dr. Varriale's notations showing either that Conetta could not return to work at all because of his shoulder injury, or that he could return with limitations on bending/twisting, climbing stairs/ladders, and lifting); see also R. 334 (noting that Conetta "is totally disabled from work").
The ALJ could properly give "little weight" to Dr. Varriale's opinions because they were inconsistent with the record as a whole. To start with, the ALJ could properly conclude that Dr. Varriale's 2007 opinion that Conetta was "permanently disabled from performing ... construction work" due to shoulder and knee injuries sustained in a motor vehicle accident in 2006 was of "scant relevance" to the current claim for DIB, because Conetta had actually returned to work after that date. R. 378; see, e.g., R. 149 (showing Conetta's wage earnings from years 2008 to 2010); see also R. 292-94 (March 2010 opinion that Conetta had a 50% temporary impairment, and that he could return to work with certain physical imitations).
As to Dr. Varriale's March 2010 opinion that Conetta should avoid heavy lifting or overhead work, R. 292-94, the ALJ noted that Conetta underwent arthroscopic shoulder surgery in February 2011, but that in February 2012 he exhibited "significant gains" in his shoulder's strength and range of motion. R. 377; see R. 1059 (workers compensation consultant, or "IME," Dr. Robert Moriarty's examination notes that the "rather routine" left shoulder surgery produced a "good result," and that Conetta "demonstrate[d] excellent motion and excellent strength to his shoulder with a negative impingement sign");
As to Dr. Varriale's May 2011 opinion that Conetta could only sit for 20 minutes at a time, stand for 10 minutes at a time, and sit/stand for less than two hours total in an eight hour work day, R. 193, this opinion was also contradicted by evidence in the record. In July 2012, consultative examiner Dr. Axline opined that Conetta could sit for two hours at a time, stand for one hour at a time, walk for two hours at a time, and sit, stand, and walk for four to six hours total during an eight-hour work day. R. 350. The ALJ gave "significant weight" to Dr. Axline's assessment, which was based on a "thorough review of [Conetta]'s medical records that were submitted in connection with his claim for disability insurance by mid-2012." R. 376-77. In November 2015, treating source and chiropractor Charles Aronica provided a medical statement that Conetta could sit for 30 minutes at a time, stand for 12 minutes at a time, and walk for five minutes at a time, and could sit, stand, and walk for one to three hours total during an eight-hour work day. R. 884. The ALJ relied on other medical evidence contradicting Dr. Varriale's opinion. For example, the ALJ found that Conetta generally exhibited no motor or sensory defects. R. 379; see, e.g., R. 843 (noting "[t]here is no gross motor, strength, or sensory deficit" in March 2014), 841 (noting "[n]o motor or sensory deficits in either lower extremity" in November 2013), 837 (noting "[n]o motor or sensory deficits" in August 2013), 326 (noting "[n]o motor or sensory deficits" in May 2012). The ALJ also noted that Conetta was found to be able (despite some discomfort or difficulty) to heel and toe walk, R. 842 (February 2014), 835 (July 2013), 834 (February 2013), and to heel and toe rise, R. 833 (April 2013), 326 (May 2012), with a non-antalgic gait, R. 970 (August 2014), 951 (October 2012). In December 2011, Dr. Moriarty noted that Conetta expressed 75% improvement of his symptoms post-surgery, and that there would be "no need for any further specific medical care." R. 1054-55.
Conetta also argues the ALJ improperly assigned "little weight" to the opinions of Dr. Benatar, who had been treating Conetta *401since 2012, and who "continuously" made "findings similar to those of Dr. Varriale, including: tenderness and spasm in the paraspinals, left worse than right; limited range of motion; positive straight leg raising at 50 degrees on the left and 60 degrees on the right; absent Achilles' reflex; and an antalgic gait, left worse than right." Pl. Mem. at 22. In addition to making those medical findings, Dr. Benatar also opined that Conetta's condition limits him to sitting, standing, and walking for a total of three hours during an eight-hour workday. R. 338. He also noted that Conetta would need to "get up and move around" every 30-45 minutes for 15-20 minutes at a time. R. 338-39. Dr. Benatar indicated that Conetta's symptoms would "likely increase" if he was "placed in a competitive work environment." R. 340. Dr. Benatar opined that Conetta was disabled on multiple occasions. See, e.g., R. 833 (April 2013); see also R. 893 (March 2015 opinion that Conetta "could only consider very sedentary" work, which still "would be difficult").
However, the ALJ could reasonably choose to assign "little weight" to Dr. Benatar's opinions, see R. 382-83, because of substantial contradictory evidence in the record. For instance, with respect to Conetta's range of motion, in August 2011, Dr. Moriarty noted that an inspection revealed "excellent motion" in Conetta's left shoulder. R. 1050. And in December 2011, Dr. Moriarty noted that "testing again reveals excellent motion." R. 1055. As previously stated, the ALJ pointed to findings that Conetta exhibited no motor or sensory defects, R. 379; see, e.g., R. 843, 839, 326, and also noted that Conetta was generally found to be able to heel and toe walk, R. 842 (February 2014), 835 (July 2013), 834 (February 2013) and heel and toe rise, R. 833 (April 2013), 326 (May 2012), with a non-antalgic gait, R. 970 (August 2014), 951 (October 2012). As to whether Conetta's conditions limit him to sitting, standing, and walking for a total of three hours during an eight-hour workday, or force him to "get up and move around" every 30-45 minutes for 15-20 minutes at a time, R. 338-39, the ALJ found persuasive Dr. Axline's opinion that Conetta could sit for two hours at a time, stand for one hour at a time, walk for two hours at a time, and sit, stand, and walk for four to six hours total during an eight-hour work day, R. 350, giving "significant weight" to the assessment, R. 376. The ALJ could properly accord "little weight" to Dr. Benatar's opinions, especially considering that in April 2014, pain management physician Dr. Neil Kirschen indicated that Conetta's symptoms were "[i]improved," that his pain level was "1-2" out of ten, and that Conetta's pain was more than 70% relieved. R. 823. In June 2014, Dr. Kirschen noted Conetta reported "increased activities," "increased walking," "[l]ess back pain," and "less frequent leg pain." R. 825; see R. 1094 (February 2016 physical noting that Conetta's chronic low back pain was "[b]etter with previous L4-5 epidural injections," and that he "states pain relief: better, 50% improvement"). Dr. Neal Dunkelman, another treating source, found that although Conetta was "partially disabled," his sensory and strength testing were often normal. See, e.g., R. 820 (noting, in January 2014, "intact" sensory, "good strength" and that gait was "stable without assist[ive] device"), 821 (noting "no evidence of a compression deformity" or "disc space narrowing"), 816 (finding only "partial disability" in September 2013). In 2011, treating source and chiropractor Dr. Aronica noted similarly that Conetta was only partially disabled, and also opined that he could not lift more than 50 pounds. R. 973. In 2015, Dr. Aronica opined that Conetta could occasionally lift up to 20 pounds, carry up to 20 pounds, and climb stairs and ramps. R. 883, 886.
*402In addition to the medical evidence, there was another important type of evidence here: namely, evidence regarding Conetta's activities, which contradicted the opinions of Drs. Varriale and Benatar that Conetta suffered from debilitating impairments. During the relevant period, Conetta continued to engage in activities consisting of: driving independently (R. 42), taking walks of up to a half mile every other day (R. 410), exercising (R. 58, 410, 834), going to a shooting range (R. 70-72, 406), hunting (R. 406-07), engaging in volunteer work with the U.S. Coast Guard (R. 45-47, 347, 407-08), driving to and attending the athletic events of his children (R. 404), and doing chores such as shopping, cooking, and cleaning (R. 69-70, 404). In multiple instances, Conetta testified to engaging in the same activities at two hearings that took place four years apart.
Additional evidence regarding Conetta's activities came in the form of surveillance conducted as part of Conetta's workers' compensation claim. During an August 2011 surveillance, Conetta was observed leaving his home and assisting another individual with electrical work. R. 801-02. During a September 2011 investigation, investigators observed Conetta driving to the marina wearing his Coast Guard uniform, entering a boat, holding a metal rod to assist in anchoring a boat, picking up a rope to tie off the boat, and stretching his arms above his head to place a plastic cover around the boat's cabin. R. 783-84. On that date, after Conetta returned from the marina, he went grocery shopping, holding bags in his left hand as he walked to his vehicle after shopping. R. 769, 785.
On October 8, 2011, the investigator observed Conetta go to a delicatessen to make a purchase and then drive to the Coast Guard station at Jones Beach. R. 769. In the afternoon, Conetta returned home and removed fishing rods from the rear of his vehicle. Once again, he traveled to a supermarket afterwards and emerged with a shopping bag in one hand and a cell phone in the other. R. 769, 786.
These unchallenged observations as well as the testimony regarding Conetta's walks and exercising undercut the opinions of the treating physicians, who during this same time period noted that Conetta's physical ailments and resulting pain substantially impaired him from lifting, reaching, and walking. See, e.g., R. 232-33 (Dr. Varriale's July 2011 notes that Conetta's "constant, burning" pain prohibited him from "lifting" and engaging in any "overhead work"), 328-29 (Dr. Benatar's June 2012 notes stating that Conetta "remains disabled" in part due to his bilateral antalgic gait and limited range of motion), 985 (Dr. Aronica's June 2011 opinion that Conetta could return to work with the limitation of no heavy lifting); see also R. 179-80, 183-84 (July 2011 function report stating that "pain" affected Conetta's ability to bathe and groom himself, that lifting results in pain, and that Conetta can reach with his right arm only).
Conetta maintains that the ALJ erred in giving greater weight to consultative examiner Dr. Axline, Pl. Mem. at 23, and to independent medical examiners ("IMEs"), id. at 25-27. As to Dr. Axline, Conetta maintains it was erroneous to give "significant weight" to the opinion that "Plaintiff could sit for 6 hours and stand and walk for up to 4 hours in an 8 hour workday, and could lift or carry up to 20 pounds occasionally and 10 pounds frequently." Id. at 23 (citing R. 344-54). This is because, according to Conetta, Dr. Axline's opinion is now "defunct" because "[t]he Federal District Court found [the ALJ's reliance on the opinion] to be a violation of sentence four of 42 U.S.C. 405(g) and thus remanded the claim back for administrative proceedings consistent with the Social Security Act ... whereupon *403the Appeals Council remanded the claim for a de novo hearing." Id. (record citations omitted). This argument fails for two reasons. First, the district court did not find any "violation" of Section 405(g) ; rather, the parties agreed and stipulated that Conetta's case would be remanded to the SSA for further proceedings. Second, after remand, the new ALJ considered "all the evidence" in the record in making his determination. R. 367. There is no rule or legal principle requiring the ALJ to ignore evidence that was before the first ALJ in making his own disability determination.
Also with regard to Dr. Axline, Conetta argues that the ALJ erred because he "cited to various instances in the record that do not contain severe findings in order to subvert and overpower the numerous instances in the record that do contain severe findings." Pl. Mem. at 23-24. Conetta argues that the ALJ "glossed over" the fact that a 2014 MRI that the ALJ cited to showed that there was no evidence of nerve root compression also showed certain disk abnormalities that had not been present in a 2011 MRI. Id. at 24. But the ALJ is not required to discuss every piece of evidence. See, e.g., Fiorello v. Heckler,
Last, as to the opinions of the opinions of the "IMEs" who were involved in a workers' compensation investigation regarding Conetta, Conetta argues that these IME opinions "are not dispositive of disability under Social Security." Pl. Mem. at 26. According to Conetta, "numerous cases in the Federal District Courts have held that these [IME] reports cannot be considered substantial evidence for the purposes of determining entitlement to Social Security benefits."
It is well settled that the opinions of a treating source "need not be given controlling weight where they are contradicted by other substantial evidence in the record." Veino,
C. Credibility of Claimant's Allegations
"After careful consideration of the evidence," the ALJ found that Conetta's "medically determinable impairments could reasonably be expected to cause the alleged symptoms." R. 371. However, the ALJ also determinated that Conetta's "statements concerning the intensity, persistence and limiting effects of these symptoms are not entirely consistent with the medical evidence and other evidence in the record." R. 371. Conetta contends that the ALJ's "boilerplate statement as to [his] credibility" was insufficient under the SSA regulations. Pl. Mem. at 29-30. He argues that although his daily activities should be factored into the credibility determination, they are "but one of many factors that must be considered." Id. at 30. In other words, according to Conetta, the ALJ, in making his decision to discredit Conetta's statements, erred in relying too heavily on Conetta's ability to engage in certain activities including work with the Coast Guard, performing household chores, and exercising. Id. at 30-31.
"It is the function of the [Commissioner], not [the reviewing court], to resolve evidentiary conflicts and to appraise the credibility of witnesses, including the claimant." Carroll v. Sec'y of Health & Human Servs.,
To start, the ALJ concluded that as to Conetta's "shoulder impairments, the medical evidence of record provides only limited support for the claimant's allegations, and tends to indicate that his symptoms are not as severe, persistent or limiting as *405he has alleged." R. 371. This conclusion is supported by the notes and medical findings of treating physician Dr. Varriale, and IMEs Drs. Michael Katz, and Moriarty. For instance, though he continued to treat Conetta into 2011, shortly after Conetta injured his shoulder in March 2010, Dr. Varriale noted that an x-ray of Conetta's shoulder was "within normal limits," and that his impressions as to Conetta's symptoms was shoulder strain. R. 292. In November 2010, Dr. Katz evaluated the shoulder, and observed close to normal abduction, flexion, and external rotation, "moderate impingement," "no deformity about the clavicle or AC joint," and intact sensation. R. 1046. And even post-shoulder surgery, R. 371, Dr. Varriale's notes from July 2011 indicate that Conetta's left shoulder range of motion was greatly improved from March 2011. Compare R. 222 with R. 235-36; see also R. 333 (Dr. Varriale's December 2011 notes indicating that the range of motion in Conetta's left shoulder had improved since the July 2011 examination). That same month, Conetta indicated to Dr. Moriarty that "he feels 75% improved," R. 1054, and testing revealed "excellent" range of motion, R. 1055. Notes from a follow up examination in April 2014 by treating physician Dr. Benatar show that Conetta did not report any shoulder pain. R. 823; see R. 844 (April 2014 report from Dr. Benatar's office noting that Conetta "rarely uses pain medication"). Finally, Conetta himself stated he could still be doing his "light-duty" job as a sub-foreman if he had the shoulder pain he is experiencing. R. 58. Based on this evidence, the ALJ clearly could make the determination that Conetta's left shoulder injury was not as restrictive as he stated.
As to his knee pain, the ALJ specifically noted that Conetta had undergone three "knee surgeries, in 1997, 2000, and in 2006, to fix cruciate ligament and meniscus tears in his right knee, including tears that occurred following a motor vehicle collision that occurred in March 2006." R. 373. However, it is not disputed that Conetta returned to work after these surgeries. See, e.g., Pl. Mem. at 5-6. Furthermore, the ALJ, "[i]n accordance with SSR 02-1p, ... considered the extent to which the claimant's obesity may exacerbate his other impairments. In particular, [the ALJ] [found] that the claimant's obesity may exacerbate the claimant's knee and back impairments, resulting in greater symptoms and limitations than those impairments might cause on their own." R. 373. Indeed, at his April 2016 hearing, Conetta stated that he thinks his "weight does have to reflect" on his knee "symptoms" "a little bit," R. 413-14. At his 2012 hearing, Conetta testified that if it were not for his September 2010 back injury, he could still be doing his "light-duty" job as sub-foreman even with his knee pain. R. 56, 58. Accordingly, the ALJ could reasonably make the determination that Conetta's left shoulder pain and knee pain was not as severe as he stated.
As to his symptoms of back pain, the ALJ discussed at length why the "evidence tends to show that these symptoms are not as severe, persistent or limiting as the claimant has alleged." R. 374; see R. 374-76. The ALJ's conclusion is supported by the notes of treating physicians Drs. Varriale and Benatar, and IME Dr. Berezin, evidence that has been already detailed in Sections III.A and III.B above. For example, Dr. Berezin's notes from 2012, 2013, and 2014, reveal non-antalgic gait, intact reflexes, negative straight leg raises, and no motor or sensory deficits. See R. 951-52, 960-61, 970-71. Moreover, as early as July 2011, Dr. Varriale noted that Conetta exhibited no significant abnormality in gait. R. 232. And in April 2014, Dr. Kirschen indicated that Conetta's symptoms were "[i]improved," that his pain level was "1-2" out of ten, and that Conetta's pain was at least 70% relieved. R. 823. In June *4062014, Dr. Kirschen noted Conetta reported "increased activities," "increased walking," "[l]ess back pain," and "less frequent leg pain." R. 825. In light of these notations and others in the record, the ALJ could reasonably determine that Conetta's symptoms as to his back and back pain were "not as severe, persistent or limiting as [Conetta] ... alleged." R. 374.
Conetta again invokes the district court's 2014 remand of the case in arguing that the ALJ's reliance on Conetta's ability to engage in certain activities is erroneous because "[t]he Federal District Court found this to be a violation of sentence four of 42 U.S.C. 405(g) and thus remanded the claim back for administrative proceedings consistent with the law, ... whereupon the Appeals Council remanded the claim for a de novo hearing." Pl. Mem. at 30 (record citations omitted). But as previously stated, see Section III.B above, the district made no such finding when it remanded in 2014. See R. 457-59.
Conetta cites Marcus v. Califano,
Conetta argues that the ALJ relied too heavily on Conetta's ability to engage in certain activities in making his credibility determination. See Pl. Mem. at 28-31; Pl. Reply at 7-8. But case law holds that an ALJ " 'is not required to accept the claimant's subjective complaints without question; he may exercise discretion in weighing the credibility of the claimant's testimony in light of the other evidence in the record.' " Barry v. Colvin,
V. CONCLUSION
For the foregoing reasons, the Commissioner's motion for judgment on the pleadings (Docket # 21) is granted and Conetta's motion for judgment on the pleadings (Docket # 14) is denied. The Clerk is requested to enter judgment.
SO ORDERED.
Related
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