Distefano v. Berryhill
This text of 363 F. Supp. 3d 453 (Distefano v. Berryhill) is published on Counsel Stack Legal Research, covering District Court, S.D. Illinois primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.
Opinion
GABRIEL W. GORENSTEIN, United States Magistrate Judge
Plaintiff Gregory Distefano brings this action pursuant to
I. BACKGROUND
A. Procedural History
Distefano filed applications for a period of disability and disability insurance benefits ("DIB") and Supplemental Security Income ("SSI") on August 12, 2014, alleging a disability onset date of October 2, 2008. See Certified Administrative Record, filed May 9, 2018 (Docket # 11) ("R."), at 198-99, 260-72. The Social Security Administration ("SSA") denied Distefano's applications on November 4, 2014. R. 201-07. Distefano then requested a hearing before an administrative law judge ("ALJ") to review the denial. R. 210-11. Distefano was represented by his attorney at a hearing before an ALJ, which occurred on December 2, 2016. R. 49-134. In a decision dated January 11, 2017, the ALJ found that Distefano was not disabled within the meaning of the Act. R. 24-42. Distefano requested that the Appeals Council review the ALJ's decision, R. 15-16, and on November 24, 2017, the Appeals Council denied Distefano's request for review of the ALJ's decision, R. 1-4. That made the ALJ's decision the final decision of the Commissioner. This action followed. See Complaint, filed Jan. 26, 2018 (Docket # 1).
B. The Hearing Before the ALJ
Distefano's hearing before ALJ Robert Gonzalez occurred on December 2, 2016, in White Plains, New York. R. 49. At the hearing, Distefano gave testimony and was represented by his attorney, William Chellis. R. 49, 200. Also present and testifying were Distefano's mother, and a vocational expert, Esperanza DiStefano, who was not related to the claimant. R. 49, 120, 417-18. Before testimony was taken, the ALJ granted Distefano's application to amend the disability onset date to January 26, 2012. R. 54-55.
*4571. Distefano
Distefano testified that he was 41 years old and had received a bachelor's degree from Middle Tennessee State University ("MTSU"), where he majored in "recording industry," which means "music production, sound engineering, and music business." R. 56-57. He is 5 feet 7.5 inches tall and weighs around 350 pounds. R. 61. While a student at MTSU, Distefano did not have any accommodations "for testing, or for schooling, or for note taking." R. 68. He graduated with a GPA of 2.9998. R. 68. Distefano was living with his mother at the time of the hearing. R. 68-69.
Distefano testified regarding his then-current part-time employment. He had been working as a union stagehand at an outdoor performing arts center in Bethel, New York ("Bethel Woods"). R. 57-58, 59. The work is seasonal, as the venue is only open from May/June to September. R. 58. He had worked that past summer. R. 62. As a stagehand at Bethel Woods, Distefano works as part of a crew assisting in setting up microphone stands, plugging in microphone cables, assisting with parts of concert production, putting up speakers, assembling video walls, hooking up cables to amplifier racks, and helping run cables. R. 59. He does not, however, "do any rigging," and he is never "on any ladders." R. 59, 60. The work generally consists of five hours of setting up and four hours of dismantling and packing up the equipment. R. 60. There are certain, more senior, union positions that Distefano cannot perform because of problems with his feet due to diabetes, which causes nerve pain. R. 61. This pain is caused "primarily" from Distefano "being on [his] feet," but he can generally carry items, with the help of others, weighing "between 30 to 80" pounds, though Distefano noted this was a "wild estimation." R. 61. Additionally, Distefano stated that, during Summer 2016, he only worked "14 out of 27" shows because of his foot pain, diabetes, and the side effects of his blood pressure medication Cinapro, which causes dizziness. R. 62-63. He cannot work an event with a "three or four-day run," R. 62, because he cannot work the consecutive days without taking a day off in between, R. 63.
Distefano testified further to his medications and their side effects: he takes "about 14 pills a day." R. 63. Besides taking Cinapro for high blood pressure, he also takes Metformin for diabetes, which sometimes causes nausea, and other diabetes medications. R. 63-64. Distefano also takes medication for cholesterol, atrial fibrillation, anxiety, and depression. R. 64. Dr. Schild, Distefano's physician, had been prescribing psychotropic medications including Lexapro and Buspar. R. 76. Distefano has anxiety, sometimes resulting in panic attacks. R. 76-77. In addition to taking medication, Distefano deals with his anxiety by trying to calm himself down. R. 77. The only "minute" side effect from these drugs was some weight gain. R. 76. Distefano stated that although his anxiety medication does the "best that it can," he still cannot drive on highways and at night. R. 80. He was hospitalized for pneumonia in San Diego, where he was visiting his brother, and for atrial fibrillation complications in approximately 2011. R. 74-75. The atrial fibrillation complications usually occur after Distefano experiences a head cold or a "bad sinus infection," or allergy complications. R. 75-76.
Distefano has had other part-time jobs. He worked at a ShopRite for a number of weeks in June 2013, but left due to his conflicting work schedule at Bethel Woods, and because the union job at Bethel Woods paid more. R. 73-74, 82-83; see R. 538. Duties at ShopRite consisted of restocking shelves and checking shelves for expired items. R. 74. The shift was "basically midnight to 7:00 a.m." R. 74. Distefano has *458looked for other work as well. For example, he applied to work at Best Buy and GameStop in the past, and since 2012, Distefano stated that he had applied to "[q]uite a bit" of employers in his search for work - "at least 20." R. 78-79. He had one interview at RadioShack, but believed the interviewer questioned why an individual with a college degree would want to work at RadioShack. R. 79. In other words: "they look at me, and, you know, like I have two heads, like why are you going to take this $ 8.50 minimum wage job, you know, at your age when you have a Bachelor's Degree." R. 79. Distefano previously worked as a stage manager for a country club around 2007. R. 91-92.
Distefano also testified as to his daily activities and hobbies. He sometimes helps a musician friend out with setting the friend's equipment up, whether it be to record music, or to play at a local tavern, bar, or "open mike" night. R. 64-66. However, this only happens "once or twice every couple months." R. 65. Distefano himself "dabble[s] with guitar," but is "not very good." R.
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GABRIEL W. GORENSTEIN, United States Magistrate Judge
Plaintiff Gregory Distefano brings this action pursuant to
I. BACKGROUND
A. Procedural History
Distefano filed applications for a period of disability and disability insurance benefits ("DIB") and Supplemental Security Income ("SSI") on August 12, 2014, alleging a disability onset date of October 2, 2008. See Certified Administrative Record, filed May 9, 2018 (Docket # 11) ("R."), at 198-99, 260-72. The Social Security Administration ("SSA") denied Distefano's applications on November 4, 2014. R. 201-07. Distefano then requested a hearing before an administrative law judge ("ALJ") to review the denial. R. 210-11. Distefano was represented by his attorney at a hearing before an ALJ, which occurred on December 2, 2016. R. 49-134. In a decision dated January 11, 2017, the ALJ found that Distefano was not disabled within the meaning of the Act. R. 24-42. Distefano requested that the Appeals Council review the ALJ's decision, R. 15-16, and on November 24, 2017, the Appeals Council denied Distefano's request for review of the ALJ's decision, R. 1-4. That made the ALJ's decision the final decision of the Commissioner. This action followed. See Complaint, filed Jan. 26, 2018 (Docket # 1).
B. The Hearing Before the ALJ
Distefano's hearing before ALJ Robert Gonzalez occurred on December 2, 2016, in White Plains, New York. R. 49. At the hearing, Distefano gave testimony and was represented by his attorney, William Chellis. R. 49, 200. Also present and testifying were Distefano's mother, and a vocational expert, Esperanza DiStefano, who was not related to the claimant. R. 49, 120, 417-18. Before testimony was taken, the ALJ granted Distefano's application to amend the disability onset date to January 26, 2012. R. 54-55.
*4571. Distefano
Distefano testified that he was 41 years old and had received a bachelor's degree from Middle Tennessee State University ("MTSU"), where he majored in "recording industry," which means "music production, sound engineering, and music business." R. 56-57. He is 5 feet 7.5 inches tall and weighs around 350 pounds. R. 61. While a student at MTSU, Distefano did not have any accommodations "for testing, or for schooling, or for note taking." R. 68. He graduated with a GPA of 2.9998. R. 68. Distefano was living with his mother at the time of the hearing. R. 68-69.
Distefano testified regarding his then-current part-time employment. He had been working as a union stagehand at an outdoor performing arts center in Bethel, New York ("Bethel Woods"). R. 57-58, 59. The work is seasonal, as the venue is only open from May/June to September. R. 58. He had worked that past summer. R. 62. As a stagehand at Bethel Woods, Distefano works as part of a crew assisting in setting up microphone stands, plugging in microphone cables, assisting with parts of concert production, putting up speakers, assembling video walls, hooking up cables to amplifier racks, and helping run cables. R. 59. He does not, however, "do any rigging," and he is never "on any ladders." R. 59, 60. The work generally consists of five hours of setting up and four hours of dismantling and packing up the equipment. R. 60. There are certain, more senior, union positions that Distefano cannot perform because of problems with his feet due to diabetes, which causes nerve pain. R. 61. This pain is caused "primarily" from Distefano "being on [his] feet," but he can generally carry items, with the help of others, weighing "between 30 to 80" pounds, though Distefano noted this was a "wild estimation." R. 61. Additionally, Distefano stated that, during Summer 2016, he only worked "14 out of 27" shows because of his foot pain, diabetes, and the side effects of his blood pressure medication Cinapro, which causes dizziness. R. 62-63. He cannot work an event with a "three or four-day run," R. 62, because he cannot work the consecutive days without taking a day off in between, R. 63.
Distefano testified further to his medications and their side effects: he takes "about 14 pills a day." R. 63. Besides taking Cinapro for high blood pressure, he also takes Metformin for diabetes, which sometimes causes nausea, and other diabetes medications. R. 63-64. Distefano also takes medication for cholesterol, atrial fibrillation, anxiety, and depression. R. 64. Dr. Schild, Distefano's physician, had been prescribing psychotropic medications including Lexapro and Buspar. R. 76. Distefano has anxiety, sometimes resulting in panic attacks. R. 76-77. In addition to taking medication, Distefano deals with his anxiety by trying to calm himself down. R. 77. The only "minute" side effect from these drugs was some weight gain. R. 76. Distefano stated that although his anxiety medication does the "best that it can," he still cannot drive on highways and at night. R. 80. He was hospitalized for pneumonia in San Diego, where he was visiting his brother, and for atrial fibrillation complications in approximately 2011. R. 74-75. The atrial fibrillation complications usually occur after Distefano experiences a head cold or a "bad sinus infection," or allergy complications. R. 75-76.
Distefano has had other part-time jobs. He worked at a ShopRite for a number of weeks in June 2013, but left due to his conflicting work schedule at Bethel Woods, and because the union job at Bethel Woods paid more. R. 73-74, 82-83; see R. 538. Duties at ShopRite consisted of restocking shelves and checking shelves for expired items. R. 74. The shift was "basically midnight to 7:00 a.m." R. 74. Distefano has *458looked for other work as well. For example, he applied to work at Best Buy and GameStop in the past, and since 2012, Distefano stated that he had applied to "[q]uite a bit" of employers in his search for work - "at least 20." R. 78-79. He had one interview at RadioShack, but believed the interviewer questioned why an individual with a college degree would want to work at RadioShack. R. 79. In other words: "they look at me, and, you know, like I have two heads, like why are you going to take this $ 8.50 minimum wage job, you know, at your age when you have a Bachelor's Degree." R. 79. Distefano previously worked as a stage manager for a country club around 2007. R. 91-92.
Distefano also testified as to his daily activities and hobbies. He sometimes helps a musician friend out with setting the friend's equipment up, whether it be to record music, or to play at a local tavern, bar, or "open mike" night. R. 64-66. However, this only happens "once or twice every couple months." R. 65. Distefano himself "dabble[s] with guitar," but is "not very good." R. 67. Distefano drives a car, but only on local roads because of his "very huge anxiety of driving on the highway." R. 67. He testified to driving recently to get breakfast at Dunkin' Donuts, go to the post office, and run errands for his mother. R. 67. Typically, while his mother is away at work, Distefano makes himself breakfast, takes his medication, and does household chores including vacuuming, doing the dishes, taking out the garbage, and doing the laundry. R. 69. He also sometimes shops for his mother. R. 69. During the months when he is not working at Bethel Woods, Distefano plays video games on his Xbox console, uses his computer and laptop, watches videos on YouTube, listens to music, and watches television. R. 77. He has "tried" looking for work, and had been working with the New York State Office for People With Developmental Disabilities ("OPWDD"), an agency which was helping him look for work. R. 77, 87. Distefano does "some" yoga so he is not "housebound so much." R. 77.
As for social relationships, Distefano stated that he has "a couple" friends he socializes with, but it is difficult to see them in part because his mother uses the car to drive to work. R. 69. However, he stated: "there are times ... when I'm feeling comfortable, and the anxiety isn't at an all-time high, I'm feeling kind of okay, I will go out with my friends and go to a concert, or go out to a movie, or something like that." R. 69-70. In 2014 or 2015, he drove with a friend to Massachusetts to attend a concert, and he sometimes attends the concerts that he helps set up as a stagehand. R. 70-71. He has visited his brother in San Diego by airplane, usually "during the holidays," around six to eight times since 2012. R. 71-72.
Distefano then gave testimony in response to his attorney's questioning. R. 80-91. As to his work at Bethel Woods, Distefano confirmed that he would not be able to "work [a] full shift continuously for nine hours, or eight hours, or even seven hours." R. 82. As to the panic attacks, he stated that they "come and go whenever," and that the attacks result in "a feeling that comes on that's very overwhelming, and then I start to sweat, my hand sometimes shakes ...." R. 83. Vested, a rehabilitation agency, helped Distefano apply for jobs, and although he went on interviews and achieved "excellent" assessment tests, he was "the only one out of all the people they had who wasn't able to get a job." R. 86-87. Distefano expressed that although he "push[ed] through" in college, his anxiety and panic attacks prevent him from working a regular job. R. 87-89. It takes "about an hour at least" for Distefano to "come back to" himself after a *459panic attack. R. 89. He has some "good days," and some "bad days," which can sometimes last for an entire week. R. 90.
2. Ms. Distefano
Ms. Distefano testified that her son has been searching for work, including at WalMart, Staples, Best Buy, and Home Depot. R. 95. She stated that Distefano, as part of his daily activities, washes dishes and towels, and does some laundry. R. 96. His medication side effects, which include dizziness and nausea, have been discussed with his doctors. R. 97. Distefano has "one very good friend that lives close by," R. 98, and enjoys going to concerts, R. 99. She testified that he visits family in California but never alone. R. 100. The ALJ acknowledged that Distefano has "really tried hard by going to [various agencies and] programs in order to try to get placed at a job." R. 103. Despite this, "no one will hire him." R. 103. Ms. Distefano expressed concern that "he keeps coming up as do not hire" due to the amount of times he has applied or how he has answered certain questions on applications or at interviews. R. 103. Ms. Distefano agreed that "he's never gotten a fair shake to get a job to determine what he can or can't do," and that "[h]e just needs an opportunity." R. 104. Ms. Distefano agreed that Distefano "requires a fairly secure and structured environment to be able to flourish." R. 106. She also discussed how Distefano's grandfather's death affected his life negatively. R. 109-110. Finally, she noted that Distefano has been diagnosed with Asperger's, R. 111, though he never received special accommodations in college, R. 111-12, and expressed sadness that he would be unable to function without her, R. 112-116.
The ALJ reminded Ms. Distefano that his job "is to determine whether or not Gregory can work at any capacity," and that although he sympathized with her and her son, the only question he would be answering was "whether or not he's disabled under Social Security rules and regulations." R. 116-17.
3. The Vocational Expert
The VE first testified that Distefano's prior work as a stagehand and stage manager are the same job, "just alternate titles." R. 120. The Dictionary of Occupational Titles ("DOT") categorized the job as a skilled position with heavy exertion. R. 120.
The ALJ then posed a number of hypothetical scenarios to the VE. First, the ALJ asked the VE
to assume a hypothetical person of the claimant's age, education, and work history. I want you to further assume that the person has the residual functional capacity to engage in a full range of light exertional work as it's defined in *460the Dictionary of Occupational Titles, except that the person has the following additional limitations. The person cannot work at unprotected heights. The person cannot work on ladders, ropes, or scaffolds. The person must avoid concentrated exposure to dust, fumes, and noxious gases, and the person can occasionally interact with the supervisors, coworkers, and the general public.
R. 120-21. The VE confirmed that such a hypothetical individual could not perform Distefano's past work as a stagehand/stage manager. R. 121. The individual could, however, perform work in the national economy as a "marker," a "router," a "photocopying machine operator," and an "electrical equipment assembler." R. 122. For a second hypothetical, the ALJ asked the VE to again:
assume a hypothetical person of the claimant's age, education, and work history. I want you to further assume that the person has a residual functional capacity to engage in a full range of sedentary exertional work as it's defined in the Dictionary of Occupational Titles, except that the person has the following additional limitations. The person cannot work at unprotected heights. The person cannot work on ladders, ropes, or scaffolds. The person must avoid concentrated exposure to dust, fumes, and noxious gases. The person can occasionally interact with supervisors, coworkers, and the general public.
R. 123. The VE again confirmed that such a hypothetical individual could not perform Distefano's past work as a stagehand/stage manager. R. 123. However, the individual could perform work in the national economy as a "document preparer," a "toy stuffer," an "addresser," and a "cutter/paster[,] press clippings." R. 123-24. The ALJ then asked: "If I were to add to both hypotheticals that a person could understand, remember, and carry out simple work, and adapt to routine workplace changes. Would the jobs you returned in hypotheticals one and two still stay?" R. 124. The VE responded that they would. R. 124.
Based on questioning by Distefano's attorney, the VE also testified that if the hypothetical individuals previously described "were to miss more than two days per month" of work, they "would be unable to maintain employment." R. 124-25. If the individuals were "only able to stand for four hours in a day," the VE confirmed that the individuals still "would be able to do those positions." R. 125. The VE confirmed that his testimony was consistent with the DOT except as to his answer regarding days absent from work, which was based on his experience and knowledge. R. 126.
After the VE testified, the ALJ followed up with Distefano regarding a few additional points. As to Distefano's engagement with the organization helping him try to find work, Distefano testified that an individual comes to his house once a week, picks him up, and gets him out of the house, whether it is to have breakfast, or to go exercise at the gym. R. 127-28. At the time of the hearing, Distefano had been working with the organization for about three weeks. R. 128.
C. The Medical Evidence
The Commissioner and Distefano have both provided summaries of the medical evidence in the record. See Pl. Mem. at 7-13; Def. Mem. at 3-15. The summaries are substantially consistent with each other, although the Commissioner's summary is more comprehensive. In any event, 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 June 27, 2018 (Docket # 14), ¶ 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 Decision
The ALJ denied Distefano's applications on January 11, 2017. R. 42. First, the ALJ found that Distefano met the insured status requirements of the SSA through September 30, 2017. R. 26. Then, following the five-step test set forth in the SSA regulations, the ALJ found at step one that Distefano had not engaged in "substantial gainful activity" since January 26, 2012, the alleged onset date. R. 26; see R. 54. At step two, the ALJ found that during the relevant period, Distefano suffered from "severe impairments" of "obesity ; Asperger's syndrome ; autism spectrum disorder; atrial fibrillation ; hypertension ; sleep apnea ; depression; anxiety; asthma ; and plantar fasciitis." R. 27. At step three, the ALJ found that none of Distefano's severe impairments *461singly or in combination met or medically equaled the severity of an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1 (the "Listings"). R. 27. In reaching this conclusion, the ALJ gave particular attention to listings 1.02 (major dysfunction of a joint), 3.03 (asthma ), 4.05 (recurrent arrhythmias ), 12.04 (affective disorders), 12.06 (anxiety-related disorders), and 12.08 (personality disorders). R. 27-29. As to mental impairments, the ALJ specifically considered whether the "paragraph B" and "paragraph C" criteria were satisfied, and found that they were not.2 R. 28-29. Before moving to step four, the ALJ addressed Distefano's residual functional capacity ("RFC"). R. 29-40. After consideration of the record, the ALJ found that Distefano had the RFC to perform "light work,"3 except that Distefano "is restricted from working at unprotected heights or climbing ladders/ropes/scaffolds. He must avoid concentrated exposure to dust, fumes and noxious gases and can only occasionally interact with supervisors, coworkers and the general public." R. 29. In making the RFC determination, the ALJ considered Distefano's "symptoms and the extent to which these symptoms can reasonably be accepted as consistent with the objective medical evidence and other evidence," R. 29-31, the objective medical evidence of record, R. 31-34, and opinion evidence in accordance with SSA regulations, R. 34-38. In determining Distefano's RFC, the ALJ accorded varying weights to the opinions of treating and non-treating sources who examined Distefano and/or his medical records, to other medical reports in the record, and to the testimony of Distefano and his mother. R. 34-40. Having determined Distefano's RFC, the ALJ evaluated at step four whether Distefano could continue his past work and concluded that based on Distefano's RFC, he could not. R. 40. At step five, the ALJ concluded - based on Distefano's age, education, work experience, and RFC - that there were jobs that exist in significant numbers in the national economy that Distefano could perform pursuant to
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,
"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."
*463To 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
Distefano raises essentially two grounds for reversing the ALJ's decision. First, he argues that the ALJ erred at step three in concluding that Distefano did not meet or medically equal a listing. Pl. Mem. at 13-14. Second, he argues that the ALJ failed to accord proper weight to the opinions of his treating physicians, and for that reason incorrectly determined his RFC. Id. at 14-16. We discuss these arguments next.
A. The ALJ's Step Three Analysis
Distefano first argues that the ALJ erred at step three in determining that Distefano's impairments did not meet or equal listings 12.04 (affective disorders), 12.06 (anxiety-related disorders), and 12.08 (personality disorders). Pl. Mem. at 13. He argues that the ALJ's analysis was incomplete *465because the ALJ primarily based his decision on "the opinion of [state agency consultant] Dr. [J.] Dambrocia," a physician "who did not have the opportunity to examine the plaintiff[,]" and who "did not have all of the medical evidence in the record when his evaluation was performed." Id. at 14. "If proper weight was given to Dr. Schild or Dr. Meland Lewis," Distefano argues, "at least marked limitations would have been found." Id.
As stated above, at step three in the sequential analysis, the ALJ determines if the claimant suffers from a listed impairment.
Here, the ALJ addressed listings 12.04, 12.06, and 12.08 and considered whether the "paragraph B" criteria were met. R. 27-29. In evaluating the listings, an ALJ must, for each listing, determine whether the "paragraph B" or "paragraph C" are met. For paragraph B, an applicant must meet two of the following criteria:
1. Marked restriction of activities of daily living; or
2. Marked difficulties in maintaining social functioning; or
3. Marked difficulties in maintaining concentration, persistence, or pace; or
4. Repeated episodes of decompensation, each of extended duration.
20 C.F.R. Pt. 404, Subpt. P, App. 1 §§ 12.04(B), 12.06(B) 12.08(B).5 Marked "means more than moderate but less than extreme," or "such as to interfere seriously with [a claimant's] ability to function independently, appropriately, effectively, and on a sustained basis."
[m]edically documented history of a chronic affective disorder of at least 2 years' duration that has caused more than a minimal limitation of ability to do basic work activities, with symptoms or signs currently attenuated by medication or psychosocial support, and one of the following:
1. Repeated episodes of decompensation, each of extended duration; or
2. A residual disease process that has resulted in such marginal adjustment that even a minimal increase in mental *466demands or change in the environment would be predicted to cause the individual to decompensate; or
3. Current history of 1 or more years' inability to function outside a highly supportive living arrangement, with an indication of continued need for such an arrangement.
The Second Circuit 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.,
The ALJ's determination at step three that Distefano did not meet or equal listings 12.04 (affective disorders), 12.06 (anxiety-related disorders), and 12.08 (personality disorders) because neither the paragraph B nor paragraph C criteria were satisfied is supported by substantial evidence in the record and is explained in the ALJ's decision. See R. 28-29, 32-40.
First, as to activities of daily living, the ALJ found that Distefano had only "mild restriction." R. 28. This was in large part because he "works on a part-time basis during the summer months, can drive short distances, prepares simple meals, performs household chores, produces music and attends concerts/conventions." R. 28. To be sure, the notes of treating and non-treating sources have indicated that Distefano has some restrictions in his activities of daily living. For example, treating physician and psychiatrist Dr. Linden Schild noted in May 2015 that Distefano's overall medical problems "appear to be exacerbated by his inability to get out of the house and inability to stay active." R. 860. Dr. Schild continued by noting that Distefano "drives but only to a very limited degree, and he is essentially unable to take public transit." R. 860. In March and April 2015, treating physician Dr. Kelli Meland-Lewis diagnosed Distefano as being on the Autistic Spectrum and indicated that he would be "[s]eriously limited," in "[i]nteract[ing] appropriately with the general public" and "[t]ravel[ing] in unfamiliar place[s]." R. 689, 685. A February 2016 form completed by OPWDD indicated that Distefano "needs assistance or training to perform tasks to be a contributing member of a household." R. 1409. However, other evidence reflects that activities of daily living were not so restricted as the above statements would indicate. In June 2013, treating physician Dr. Schild noted that Distefano had started working part time at ShopRite, while also maintaining *467employment at Bethel Woods. R. 538. Also, Ms. Distefano reportedly noticed improvement in activities of daily living, for example "showering and getting ready for work." R. 538. In August 2013, Dr. Schild noted that Distefano had been "helpful around the house," and was neatly dressed and groomed and "in fair spirits." R. 536. Similar findings were made by Dr. Schild in November 2013. R. 534-35. In March 2014 evaluation notes, Dr. Meland-Lewis indicated that Distefano was dressed appropriately, and that hygiene "was within normal limits." R. 560. Dr. Meland-Lewis made similar notations after a March 2015 evaluation. R. 680-81. Both treating and non-treating sources indicated Distefano's ability to work on a part-time basis. See, e.g., R. 875 (Dr. Schild, June 2016), 688 (Dr. Meland-Lewis, March 2015), 659 (consultative examiner Dr. Greg Grabon, October 2014), 534 (Dr. Schild, November 2013). In September 2014, consultative examiner Dr. Leslie Helprin indicated that Distefano had the ability to prepare food, do the laundry, go food shopping, manage his own finances, and drive on local roads. R. 649. Notably, Distefano's December 2016 hearing testimony also supports the ALJ's conclusion. Distefano testified to being able to drive on local roads, go out for breakfast, go to the post office, and run errands for his mother. R. 67. While his mother is at work, Distefano makes himself breakfast, takes his medication, does household chores including vacuuming, washing the dishes, taking out the garbage, and doing laundry. R. 69. He indicated minimal side effects from his medications. R. 76. Based on this evidence, the ALJ did not err in concluding that Distefano had only "mild restrictions" in terms of activities of daily living.
Second, in terms of social functioning, the ALJ found that Distefano has "moderate difficulties," as he "suffers from depressive and anxiety symptomatology that would likely worsen with frequent (or more) interaction with others." R. 28. The ALJ also found that Distefano "has demonstrated difficulty interpreting social cues and has some history of irritability," and has "isolative or reclusive tendencies." R. 28. However, as the ALJ noted, Distefano "admitted he enjoyed socializing with others and noted no particular interpersonal difficulties when attending concerts or conventions or working part time." R. 28.
Again, the record contains some evidence of limitations in social functioning. See, e.g., R. 560-61 (Dr. Meland-Lewis's March 2014 observation that Distefano "initially presented as hostile" during an evaluation, and notes of "poor eye contact, looking down or away"), 683 ("Seclusiveness or autistic thinking" in April 2015 notes); see also R. 693 (Dr. Schild opining that Distefano had "[n]o useful ability to function" in regards to "[m]aintain[ing] socially appropriate behavior"), 684 (Dr. Schild opining that Distefano was "[u]nable to meet competitive standards" in regards to "[getting] along with co-workers or peers without unduly distracting them or exhibiting behavioral extremes"). But the ALJ's conclusion that only moderate difficulties existed is supported by other record evidence. For example, treating physician Dr. Meland-Lewis's April 2015 evaluation indicated "[l]imited but satisfactory" ability to "[m]aintain socially appropriate behavior." R. 685. In October 2014, Dr. Grabon reported that Distefano enjoys going to concerts and socializing with friends. R. 660. More significantly, the record reveals numerous examples from 2013 to 2016, by treating and non-treating sources, indicating Distefano's ability to work with others in a part-time employment setting, see, e.g., R. 875, 688, 659, 534, and attend social events with others, see, e.g., R. 864 (going to concerts), 660 (going to concerts and movies), 649 (going to concerts and traveling to visit his sibling in other states), 562 ("hanging out with his *468friends and going to concerts"). Distefano's own testimony tends to support the physicians' notes. See, e.g., R. 61 (discussing his job at Bethel Woods in terms of working with others: "but, you know, anything heavy that we carry is always more than a one-man job"), 70 (When "I'm feeling kind of okay, I will go out with my friends and go to a concert, or go out to a movie, or something like that."). Distefano even testified that he sometimes helps his musician friend set up the friend's equipment, whether it be to record music, or to play at a local tavern, bar, or "open mike" night. R. 64-66. The ALJ could rely on this substantial evidence to conclude that Distefano's ability to function socially is only "moderately" restricted.
Third, the ALJ determined that Distefano had only "mild difficulties" in terms of concentration, persistence, or pace. R. 28. This was because "[c]ognitive testing in the record revealed, at most, mild memory problems/forgetfulness with no significant attention/concentration issues," which was "consistent with the claimant's daily activities, such as his ability to drive a car, play video games (which require considerable concentration and attention to detail) and play a guitar." R. 28. While there is some evidence in the record indicating some limitations in Distefano's cognitive abilities, see, e.g., R. 1020 (treating physician Dr. Syed Jafri's March 2015 note of "memory impairment"), there was significant evidence that Distefano's ability in terms of concentration, persistence, and pace was largely intact. Normal cognitive functioning was found in May 2013. R. 540-41 (Dr. Schild's evaluation notes indicating "normal" psychomotor activity and speech, as well as "goal directed" and "logical" thought process, and "fair to good" judgment and insight). Indeed, treating and non-treating physician notes ranging from 2011 to 2014 indicate either "normal" intelligence, R. 1157 ("Grossly normal intellect," in April 2011), or "average" intelligence, R. 649 ("Intellectual skills estimated in the average range," in September 2014); see R. 659 ("[Distefano] is very intelligent," though "he occasionally freezes if he is in certain wrong environments," in October 2014). Treating physician Dr. Meland-Lewis indicated that there was no "low IQ or reduced intellectual functioning" in April and May 2015. R. 685, 693. Treating physician Dr. Schild made similar findings in April 2015 and October 2016. R. 160, 167. In terms of memory, physician notes dating from 2007 reveal either "normal" memory, R. 515 (August 2012), 914 (September 2012), 1275 (June 2015), 1263 (February 2016), or "intact" memory, R. 574 (November 2007), 588 (September 2009), 900 (September 2012), 1194 (November 2013). On one occasion in March 2015, Dr. Jafri noted normal memory and that a psychiatric examination revealed that Distefano was "[o]riented to time, place, person [and] situation," with "[a]ppropriate mood and affect." R. 1020. Memory impairment was not noted as one of Distefano's "signs and symptoms" in medical source statements from Dr. Meland-Lewis in April 2015 and October 2016. R. 165, 158. In September 2014, consultative examiner Dr. Helprin noted that recent and remote memory skills were only mildly impaired. R. 649. Critically, Distefano's acknowledged ability to engage in activities such as driving on local roads, R. 67, playing video games and watching videos on YouTube, R. 77, and playing guitar, R. 67, suggests that he has the ability to maintain concentration, persistence, and pace. For these reasons, we find that the ALJ did not err in his determination.
Finally, the ALJ could properly find that Distefano had not experienced any episodes of decompensation of extended duration. R. 28. As stated above, SSA regulations define episodes of decompensation as "exacerbations or temporary increases in symptoms or signs accompanied by a *469loss of adaptive functioning, as manifested by difficulties in performing activities of daily living, maintaining social relationships, or maintaining concentration, persistence, or pace." 20 C.F.R. § Pt. 404, Subpt. P, App. 1 § 12.00(C)(4). These episodes "may be demonstrated by an exacerbation in symptoms or signs that would ordinarily require increased treatment or a less stressful situation (or a combination of the two)," and "may be inferred from medical records showing significant alteration in medication; or documentation of the need for a more structured psychological support system (e.g., hospitalizations ...); or other relevant information in the record about the existence, severity, and duration of the episode."
As to Distefano's claim that "at least marked limitations would have been found" had "proper weight [been] given to Dr. Schild or Dr. Meland Lewis," Pl. Mem. at 14, we disagree. Distefano does not point to specific opinions or observations of Drs. Schild and Meland-Lewis that he believes should have been accorded more weight. But even considering Dr. Schild's opinion that Distefano had "[n]o useful ability to function" in regards to "[m]aintain[ing] socially appropriate behavior," R. 693, or Dr. Meland-Lewis's view that Distefano was "[s]eriously limited" with respect to interacting appropriately with the public, maintaining regular attendance, and working in coordination with or proximity to others without being unduly distracted, R. 684-85, the ALJ was entitled to weigh their opinions against the entire record and accord their opinions little weight. See Veino,
Distefano argues that the ALJ improperly relied "primarily" on state agency examiner Dr. Dambrocia's opinion in determining that Distefano's symptoms did not establish the presence of the paragraph B or C criteria. Pl. Mem. at 13-14; see R. 191. But the ALJ specifically stated that the latter section of his decision regarding Distefano's RFC "reflects the degree of limitation the undersigned has found in the 'paragraph B' mental function analysis." R. 29. In other words, the remainder of the ALJ's decision explicates his findings as to the lack of showing as to the paragraph B criteria.
In any event, the ALJ could properly assign great weight to the opinion of Dr. Dambrocia for the reasons already stated and that are discussed further in the next section discussing Distefano's RFC. See, e.g., Bryant v. Berryhill,
Distefano argues that the ALJ erred because he did not consider listing 12.10 for Autism Spectrum Disorder. Pl. Mem. at 13. Thus, he claims, the ALJ's conclusion of whether Distefano met a listing is incomplete, as "the ALJ did not even evaluate the appropriate listings."
Distefano also argues that the ALJ erred because "nowhere in [his] analysis did he consider Listing ... 12.11 for a neurodevelopmental disorder." Pl. Mem. at 13. This argument fails for the simple reason that listing 12.11 was not in effect when the ALJ rendered his decision. See 20 C.F.R. Pt. 404, Subpt. P, App. 1, § 12.00 (effective Sept. 29, 2016 to Jan. 16, 2017) (describing listings 12.02 through 12.10); see also Lowry v. Astrue,
Finally, Distefano argues that the Court, "[a]t a minimum," should direct the ALJ "to enlist the help of a Medical Expert, a common practice, to help determine whether the plaintiff's condition is of the severity to meet or equal any of the Listings in 12.00." Pl. Mem. at 14. This argument fails as well. To start, it is within the ALJ's discretion to obtain the opinion of a medical expert in order to determine whether a claimant's impairments meet or equal a particular listing. See
B. The ALJ's Failure to Evaluate Treating Sources
Distefano argues that the ALJ failed to properly evaluate the opinion evidence of record necessary to make a proper RFC determination. Pl. Mem. at 14-16. This is because, according to Distefano, the ALJ should have given more than "little weight to the opinion[s] of Dr. Schild" as provided in two medical sources statements from May 2015 and October 2016. Id. at 14-15. Dr. Schild's opinions, he argues, are "supported by his own office notes and other evidence in the record." Id. at 16. Distefano further argues that the "ALJ's decision improperly does not give significant weight to [the opinions of] Dr. Jafri, Dr. Barbanel, Dr. Nelson and Dr. Hulse" that Distefano "would likely be off task 20% of the work day and absent anywhere from 2 to 4 days per month." Id. at 15. We address these issues in turn.
A claimant's RFC is "the most [a claimant] can still do despite [their] limitations."
Certainly, Dr. Schild, with whom Distefano has been treating since 2013 after a four-year gap in treatment, R. 540, opined on numerous occasions that Distefano was either partially disabled, or totally disabled and not capable of gainful employment. See R. 534 (partially disabled in November 2013), 860 (unable to work due to developmental disability in May 2015), 157 ("Patient has improved over the years, but continues to be disabled from gainful employment due to chronic and persistent mental illness (depression, panic, anxiety, agoraphobia )" in October 2016). In medical source statements from May 2015 and October 2016, Dr. Schild opined that Distefano's mental abilities were either seriously limited, unable to meet competitive standards, or represented no useful ability to function. These abilities ranged from working in coordination and proximity to others without being distracted and sustaining an ordinary routine without special supervision, to setting realistic goals and maintaining socially appropriate behavior. See R. 159-60, 692-93. As to the opinions that Distefano was disabled, ALJ assigned little weight to these opinions because they were "vague, conclusory, on an issue reserved to the Commissioner, fail to set forth a function-by-function analysis of the claimant's abilities and difficulties and are inconsistent with the claimant's daily activities, the doctor's own treatment notes ..., his part-time work activity, recreational activities and the State agency expert opinion evidence." R. 34.
The ALJ could properly decide to accord "little weight" to Dr. Schild's opinions because they were inconsistent with the record as a whole. To begin, the opinions as stated in Dr. Schild's May 2015 Medical Source Statement are contradicted by notes from treating and non-treating sources, as well as Distefano's own testimony, as described in section III.A above. For example, Dr. Schild identified as symptoms: "pervasive loss of interest in almost all activities," trouble thinking or concentrating, and emotional withdrawal and isolation. R. 691. However, these purported limitations are contradicted by the record evidence. It is apparent from treating and non-treating physician notes that Distefano has continued to engage in and enjoy social activities and has not been completely emotionally withdrawn or isolated. See, e.g., R. 864 (going to concerts, in September 2015), 660 (going to concerts and movies, in October 2014), 649 (going to concerts and traveling to visit his sibling in other states, in September 2014), 562 ("hanging out with his friends and going to concerts," in March 2014). Further contradicting Dr. Schild's opinions is the fact that Distefano testified at his December 2016 hearing that he performs part-time work at Bethel Woods, R. 57-58, plays video games, watches YouTube videos, listens to music, watches television, R. 77, and plays guitar, R. 67. Moreover, in October 2016, just two months prior to the hearing before the ALJ, while opining that Distefano remained "partially disabled from gainful employment," Dr. Schild noted that Distefano tolerated his medication well, denied side effects, and also noted: "Mother confirms [patient] is doing fairly well overall." R. 879. Similar findings were made in August and March 2016. R. 877 (noting that Distefano was "considering move to S[an] Diego," and that his mother *473"confirms [he] is doing well"), 873 ("Tries to get out of the house and spend time with friends over the winter."); see also R. 862 (noting Distefano "[c]ontinues to benefit from medication" and has been "good, calm" at home, in June 2015), 864 (noting Distefano was "[h]oping to visit [his] brother in San Diego for Xmas, or preferably sooner," and that he "tries to keep busy, [and for example] has a concert to go to tomorrow," in September 2015), 866 ("[Patient's] mother confirms [patient is] doing well overall," in December 2015). Dr. Schild's comments throughout 2015 and 2016 came after an 18-month period in which Distefano sought no treatment at all. See R. 860. There is significant additional evidence in the record suggesting that Dr. Schild's opinions overstated the extent of Distefano's limitations as to his ability to work and function on a daily basis with moderate limitations, such as Distefano's own testimony that he was performing part time work, R. 57-58, engaging in social activities, R. 69-71, and actively seeking employment, R. 86-87. Thus, the ALJ could conclude that Dr. Schild's opinions regarding Distefano's abilities concerning memory, concentration, maintaining a routine work schedule, following instructions, and maintaining socially appropriate behavior, R. 692-93, were belied by the record evidence, see R. 37-38, including by the notes of treating and non-treating sources, and Distefano's own testimony regarding the scope of his activities.
The ALJ could properly discount or accord little weight to Dr. Schlid's opinions that Distefano was "disabled." Snell,
Distefano also argues that the ALJ improperly and inconsistently weighed the opinions of Dr. Meland-Lewis, a treating physician who, like Dr. Schild, found "serious" limitations in Distefano's ability to maintain a regular schedule, work in close proximity to and with others, follow directions, and interact with the public. Pl. Mem. at 15; see R. 684-85. Dr. Meland-Lewis also found Distefano to exhibit "difficulty with social cues," and a "low tolerance" to frustration, stress, and unexpected changes in environment. R. 685. The ALJ could properly assign "very little weight" to these opinions, as they are inconsistent with the record, as already discussed above. Specifically, we agree that Dr. Meland-Lewis's "findings that [Distefano] effectively could not work with others, detect social cues, cope with stress or deal with work changes [are] inconsistent with [Distefano's] successful, steady part-time work activity and broad range of daily activities," R. 37, which include working part-time as a stagehand, going to concerts with friends, and going to movies. These activities were not only detailed by the state agency consultant and mental consultative examiner, but were confirmed by notes of Distefano's own treating physician, Dr. Schild, and by Distefano himself at his December 2016 hearing. And of course mental consultative examiner Dr. Helprin has opined that Distefano had "no limitations in his ability to ... maintain a regular schedule given something to do on a regular basis." R. 650. State agency examiner Dr. Dambrocia found similarly in October 2014. R. 193-94. Notably, the opinions of Drs. Helprin and Dambrocia are supported by at least one note from treating physician Dr. Meland-Lewis in April 2015. See R. 684 (the ability to "[c]omplete *474a normal workday and workweek without interruptions from psychologically based symptoms" was limited but "satisfactory"),
To the extent Distefano argues the ALJ erred as to Dr. Meland-Lewis simply by according more weight to a state agency consultant, see Pl. Mem. at 15, it is well-established that "[s]tate agency physicians are qualified as experts in the evaluation of medical issues in disability claims," and as such, "their opinions may constitute substantial evidence if they are consistent with the record as a whole." Leach ex rel. Murray v. Barnhart,
Distefano contends that the ALJ improperly did not accord significant weight to the opinions of "[m]ultiple doctors[, Jafri, Barbanel, Nelson, and Hulse,] [who] indicate the plaintiff would likely be off task 20% of the work day and absent anywhere from 2 to 4 days per month." Pl. Mem. at 15; see R. 667 (Dr. Hulse, absent "[a]bout two days per month"), 670-71 (Dr. Barbanel, "off task" for 20%, and absent "[m]ore than four days per month"), 679 (Dr. Jafri, "off task" for 20%, and absent "[m]ore than four days per month"), 699 (Dr. Nelson, absent "[a]bout two days per month"). These doctors primarily addressed physical, not mental, limitations - such as asthma, atrial fibrillation, and sleep apnea - and Distefano gives no indication of why these opinions on physical limitations are supported by the doctors' treatment notes, let alone other evidence in the record. The ALJ could properly assign little or very little weight to these opinions because of the absence of any indication that Distefano could not perform light work on a regular basis. See R. 35-36, 38. In fact, Distefano testified that he worked at ShopRite for seven-hour shifts for a number of weeks because the work was not as "physical" as his concert work. R. 83.
Additionally, the opinions referenced above are contradicted by the notes and opinions of non-treating physicians such as physical consultative examiner Dr. Grabon's medical source statement that Distefano need only avoid respiratory irritants and heavy exertion. R. 662. An ALJ may decide to accord more weight to the opinions of non-treating physicians if their opinions are consistent with the record, as is the case here. See Diaz v. Shalala,
*475Distefano argues that "plaintiff's past history of only working part time work supports the limitations of being absent from work 2 to 4 times a month and off task 20% of the work day." Pl. Mem. at 15. But the ALJ found that Distefano was unable to perform his past work as a stagehand, R. 40, and was instead able to perform light work with certain limitations, R. 29. Thus, the ALJ accepted that Distefano would be unable to perform full-time work as a stagehand, specifically considering the inability to work more than two days in a row due to the heavy physical exertion involved. R. 40; see R. 61, 63. It does not follow, however, that those same limitations would apply to the performance of light work.
Distefano makes several additional arguments. He argues that the ALJ "failed to analyze the opinion of Dr. Schild," and "ignored the fact that Dr. Schild has seen the plaintiff for years and is a psychiatric expert." Pl. Mem. at 15, 14. In fact, the ALJ noted that Dr. Schild is a psychiatrist, explicitly commented on the fact that Dr. Schild had been treating Distefano for years, and fully considered the opinions of Dr. Schild. See R. 32-34, 37-38. That the ALJ chose to accord little weight to those opinions does not mean that he "ignored" Dr. Schild's role as a treating source. Distefano also argues that the ALJ failed to "take in account exhibit 17F, the May 26, 2015 report," and "d[id] not indicate how much weight he is providing the opinion[s]" set forth in the report. Pl. Mem. at 14-15. But the ALJ discussed Exhibit 17F, including whether or not it is a "function by function assessment," in his opinion, see R. 37-38, and decided to accord the opinions as stated in the exhibit "very little weight," R. 38.
At one point, Distefano suggests that the Appeals Council improperly failed to consider new evidence in the form of Dr. Schild's October 2016 report. See Pl. Mem. at 8. That argument fails, however, for the simple reason that the October 2016 report is identical to the May 2015 report - it is obviously a photocopy of the earlier handwritten document - with only the date and signature page changed. Compare, R. 157-63 with, 690-95. There is no suggestion that there were any records generated between May 2015 and October 2016 that entitled the later report to more weight. Having already found that the ALJ could properly accord "little weight" to Dr. Schild's opinions in the May 2015 report, the "application of the correct legal standard could lead to only one conclusion" with respect to the duplicate report from October 2016. Schaal,
Finally, Distefano argues that the ALJ's RFC determination is flawed because the "ALJ's hypothetical presented to the Vocational Expert does not accurately represent this plaintiff." Pl. Mem. at 16. This is because, it is argued, Distefano "has greater limitations than as found based upon the findings by the plaintiff's treating physicians."
IV. CONCLUSION
For the foregoing reasons, the Commissioner's motion for judgment on the pleadings (Docket # 28) is granted and Distefano's motion for judgment on the pleadings (Docket # 15) is denied. The Clerk is requested to enter judgment and to close this case.
SO ORDERED.
Related
Cite This Page — Counsel Stack
363 F. Supp. 3d 453, Counsel Stack Legal Research, https://law.counselstack.com/opinion/distefano-v-berryhill-ilsd-2019.