Connolly v. Berryhill

District Court, D. Connecticut·Decided February 18, 2020·No. 3:18-cv-00185·Unknown

Opinion

UNITED STATES DISTRICT COURT DISTRICT OF CONNECTICUT

JAMES P. CONNOLLY, Plaintiff, No. 3:18-cv-00185 (MPS) v. NANCY A. BERRYHILL, Acting Commissioner of Social Security,

Defendant.

RULING ON THE PLAINTIFF’S MOTION FOR JUDGMENT ON THE PLEADINGS AND THE DEFENDANT’S MOTION TO AFFIRM THE DECISION OF THE COMMISSIONER In this appeal from the Social Security Commission’s denial of benefits, plaintiff James Connolly argues that the Administrative Law Judge (ALJ) (1) violated the treating physician rule; (2) failed to develop the record adequately; (3) relied on opinions by an agency medical consultant that referred to documents not in the Record; and (4) erred in evaluating Mr. Connolly’s credibility. I agree with Mr. Connolly’s first argument and remand the case to the Commissioner. I assume familiarity with Mr. Connolly’s medical history, as summarized in Plaintiff’s Summary of Facts, ECF No. 21-1 at 1-18, which the Commissioner “generally adopts,” ECF No. 37-1 at 2, and which I adopt and incorporate herein by reference.1 I also assume familiarity with the ALJ’s opinion, the record, and the five sequential steps used in the analysis of disability

1 The Commissioner sets forth several objections to Plaintiff’s Summary of Facts, such as the inclusion of facts pertaining to the period prior to July 2013 and the inclusion of a summary of the ALJ’s decision. Mr. Connolly, for his part, objects to the inclusion of the supplement to the record filed by the Commissioner. To the extent that any of these disputes are relevant to the Court’s analysis, they are addressed in the discussion below. claims. I cite only those portions of the record and the legal standards necessary to explain this ruling. I. Standard of Review “A district court reviewing a final . . . decision pursuant to . . . 42 U.S.C. § 405(g), is performing an appellate function.” Zambrana v. Califano, 651 F.2d 842, 844 (2d Cir. 1981).

“The findings of the Commissioner of Social Security as to any fact, if supported by substantial evidence, shall be conclusive.” 42 U.S.C. § 405(g). Accordingly, a district court may not make a de novo determination of whether a plaintiff is disabled in reviewing a denial of disability benefits. Wagner v. Sec'y of Health & Human Servs., 906 F.2d 856, 860 (2d Cir. 1990). Rather, the Court’s function is to ascertain whether the correct legal principles were applied in reaching the decision, and whether the decision is supported by substantial evidence. Johnson v. Bowen, 817 F.2d 983, 985 (2d Cir. 1987). If the Commissioner’s decision is supported by substantial evidence, that decision will be sustained, even where there may also be substantial evidence to support the plaintiff’s contrary position. Schauer v. Schweiker, 675 F.2d 55, 57 (2d Cir. 1982). The Second Circuit has defined substantial evidence as “such relevant evidence as a reasonable

mind might accept as adequate to support a conclusion.” Williams v. Bowen, 859 F.2d 255, 258 (2d Cir. 1988) (citation and quotation marks omitted). Substantial evidence must be “more than a mere scintilla or a touch of proof here and there in the record.” Id. II. Discussion Ms. Connolly argues that the ALJ failed to comply with the treating physician rule in his analysis of the November 2014 Opinion of Dr. Shetty and Nurse Gustafson. I agree.2

2 Because this claim was filed before March 27, 2017, the treating physician rule applies here. See Claudio v. Berryhill, No. 3:17CV1228(MPS), 2018 WL 3455409, at *3 n.2 (D. Conn. July 18, 2018) ("Since [the plaintiff] filed her claim before March 27, 2017, I apply the treating physician rule under the earlier regulations."). The analysis under the treating physician rule follows a two-step process. First, “the ALJ must decide whether the opinion is entitled to controlling weight. Estrella v. Berryhill, 925 F.3d 90, 95 (2d Cir. 2019). “[T]he opinion of a claimant’s treating physician as to the nature and severity of the impairment is given controlling weight so long as it is well-supported by

medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in [the] case record.” Burgess v. Astrue, 537 F.3d 117, 128 (2d Cir. 2008) (internal citation and quotation marks omitted). Second, “if the ALJ decides the opinion is not entitled to controlling weight, [he] must determine how much weight, if any, to give it.” Estrella, 925 F.3d at 95. In doing so, “[the ALJ] must explicitly consider the following, non-exclusive ‘Burgess factors’: ‘(1) the frequen[cy], length, nature, and extent of treatment; (2) the amount of medical evidence supporting the opinion; (3) the consistency of the opinion with the remaining medical evidence; and (4) whether the physician is a specialist.’” Id. at 95-96 (citations omitted). After considering these factors, the ALJ must “comprehensively set forth his reasons for the weight assigned to a treating physician’s opinion.” Greek v. Colvin, 802 F.3d

370, 375 (2d Cir. 2015) (internal citations, quotation marks, and alterations omitted). At both steps, “the ALJ must ‘give good reasons in [his] notice of determination or decision for the weight [he gives the] treating source's [medical] opinion.” Estrella, 925 F.3d at 96 (citation and internal quotation marks omitted). An ALJ’s failure to “explicitly” apply the Burgess factors is a “procedural error.” Id. If the “Commissioner has not [otherwise] provided ‘good reasons’ for [the] weight assignment,” the appropriate remedy is remand for the ALJ to “comprehensively set forth [his] reasons.” Id.; see also Guerra v. Saul, 778 Fed. Appx. 75, 77 (2d Cir. 2019) (“To put it simply, a reviewing Court should remand for failure to explicitly consider the Burgess factors unless a searching review of the record shows that the ALJ has provided ‘good reasons’ for its weight assessment.”); Meyer v. Commissioner of Social Security, 2019 WL 6271721, at *2 (2d Cir. Nov. 25, 2019) (“A reviewing court should remand for failure to consider explicitly the Burgess factors unless a searching review of the record shows that the ALJ has provided ‘good reasons’

for its weight assessment.”). 1. The November 2014 Opinion of Nurse Gustafson and Dr. Shetty Mr. Connolly challenges the ALJ’s analysis of the November 2014 opinion of Nurse Gustafson and Dr. Shetty (“the November 2014 Opinion”), Record (“R.”) 385-89. As an initial matter, the November 2014 Opinion is from an “acceptable medical source,” as the ALJ himself concluded. See, e.g., Griffin v. Colvin, 2016 WL 912164, at *14 (D. Conn. Mar. 7, 2016) (analyzing questionnaire completed by therapist and co-signed by psychiatrist under the treating physician rule). As in Griffin, this is “not a case in which there is no evidence that the co-signing psychiatrist ever personally examined the plaintiff or had an ongoing treatment or a physician-patient relationship.” Id.; see, e.g., R. at 375-76, 382-84 (treatment

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