Ecklund v. Comm'r of Soc. Sec.
This text of 349 F. Supp. 3d 235 (Ecklund v. Comm'r of Soc. Sec.) is published on Counsel Stack Legal Research, covering District Court, W.D. New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.
Opinion
ELIZABETH A. WOLFORD, United States District Judge
INTRODUCTION
Represented by counsel, Plaintiff Randall Ecklund ("Plaintiff") brings this action pursuant to Title II of the Social Security Act (the "Act"), seeking review of the final decision of the Commissioner of Social Security (the "Commissioner," or "Defendant") denying his application for disability insurance benefits ("DIB"). (Dkt. 1). This Court has jurisdiction over the matter pursuant to
BACKGROUND
Plaintiff protectively filed his application for DIB on March 6, 2014. (Dkt. 4 at 26, 89).1 In his application, Plaintiff alleged disability beginning March 1, 2013, due to a bilateral shoulder injury and lumbar spine injury. (Id. at 26, 78-88). Plaintiff's application was initially denied on May 14, 2013. (Id. at 92-103). At Plaintiff's request, a hearing was held before administrative law judge ("ALJ") Lisa Martin in Alexandria, Virginia, on July 1, 2016. (Id. at 26, 47-77). Plaintiff appeared with his attorney in Jamestown, New York. (Id. ). On August 11, 2016, the ALJ issued a partially favorable decision, awarding Plaintiff benefits as of February 1, 2016, but finding that Plaintiff was not disabled between his alleged onset date of March 1, 2013, and January 31, 2016. (Id. at 22-35). Plaintiff requested Appeals Council review; his request was denied on December 6, 2017, making the ALJ's determination the Commissioner's final decision. (Id. at 6-8). This action followed.
LEGAL STANDARD
I. District Court Review
"In reviewing a final decision of the [Social Security Administration ("SSA") ], this Court is limited to determining whether the SSA's conclusions were supported by substantial evidence in the record and were based on a correct legal standard." Talavera v. Astrue ,
II. Disability Determination
An ALJ follows a five-step sequential evaluation to determine whether a claimant is disabled within the meaning of the Act. See Bowen v. City of New York ,
At step three, the ALJ examines whether a claimant's impairment meets or medically equals the criteria of a listed impairment in Appendix 1 of Subpart P of Regulation No. 4 (the "Listings").
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ELIZABETH A. WOLFORD, United States District Judge
INTRODUCTION
Represented by counsel, Plaintiff Randall Ecklund ("Plaintiff") brings this action pursuant to Title II of the Social Security Act (the "Act"), seeking review of the final decision of the Commissioner of Social Security (the "Commissioner," or "Defendant") denying his application for disability insurance benefits ("DIB"). (Dkt. 1). This Court has jurisdiction over the matter pursuant to
BACKGROUND
Plaintiff protectively filed his application for DIB on March 6, 2014. (Dkt. 4 at 26, 89).1 In his application, Plaintiff alleged disability beginning March 1, 2013, due to a bilateral shoulder injury and lumbar spine injury. (Id. at 26, 78-88). Plaintiff's application was initially denied on May 14, 2013. (Id. at 92-103). At Plaintiff's request, a hearing was held before administrative law judge ("ALJ") Lisa Martin in Alexandria, Virginia, on July 1, 2016. (Id. at 26, 47-77). Plaintiff appeared with his attorney in Jamestown, New York. (Id. ). On August 11, 2016, the ALJ issued a partially favorable decision, awarding Plaintiff benefits as of February 1, 2016, but finding that Plaintiff was not disabled between his alleged onset date of March 1, 2013, and January 31, 2016. (Id. at 22-35). Plaintiff requested Appeals Council review; his request was denied on December 6, 2017, making the ALJ's determination the Commissioner's final decision. (Id. at 6-8). This action followed.
LEGAL STANDARD
I. District Court Review
"In reviewing a final decision of the [Social Security Administration ("SSA") ], this Court is limited to determining whether the SSA's conclusions were supported by substantial evidence in the record and were based on a correct legal standard." Talavera v. Astrue ,
II. Disability Determination
An ALJ follows a five-step sequential evaluation to determine whether a claimant is disabled within the meaning of the Act. See Bowen v. City of New York ,
At step three, the ALJ examines whether a claimant's impairment meets or medically equals the criteria of a listed impairment in Appendix 1 of Subpart P of Regulation No. 4 (the "Listings").
The ALJ then proceeds to step four and determines whether the claimant's RFC permits the claimant to perform the requirements of his or her past relevant work.
DISCUSSION
I. The ALJ's Decision
In determining whether Plaintiff was disabled, the ALJ applied the five-step *241sequential evaluation set forth in
At step two, the ALJ found that Plaintiff suffered from the following severe impairments: "bilateral shoulder disorders status post two left surgical repairs and two right surgical repairs (remote and 2016); cervical and lumbar spine disorders ; hypertension ; right knee disorder ; and right wrist arthritis." (Id. ).
At step three, the ALJ found that Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of any Listing. (Id. at 29). The ALJ particularly considered the criteria of Listings 1.00 and 4.00. (Id. ).
Before proceeding to step four, the ALJ determined that prior to February 1, 2016, Plaintiff retained the RFC to perform light work as defined in
The claimant needs a change of position opportunity as often as every 30 minutes for one to two minutes. The claimant must avoid climbing all ladders, ropes, and scaffolding, avoid all crawling tasks, and is limited to occasional climbing of ramps and stairs, balancing, stooping, kneeling, and crouching. The claimant is precluded from all overhead reaching tasks with the upper extremities, and he is limited to frequent, but not constant, upper extremity forward reaching, handling, and fingering tasks. The non-dominant upper extremity is limited to 10 pounds of lifting/carrying on an occasional basis. The claimant must avoid all dangerous work hazards (including unprotected heights and exposed moving machinery), and all exposure to extreme heat, humidity, and cold conditions.
(Id. ). The ALJ further found that beginning February 1, 2016, Plaintiff had the RFC to perform sedentary work as defined in
The claimant needs a change of position opportunity as often as every 30 minutes for one to two minutes. The claimant must avoid climbing all ladders, ropes, and scaffolding, avoid all crawling tasks, and is limited to occasional climbing of ramps and stairs, balancing, stooping, kneeling, and crouching. The claimant is precluded from all overhead reaching tasks with the upper extremities, and he is limited to frequent, but not constant, upper extremity forward reaching, handling, and fingering tasks. The non-dominant left upper extremity is limited to 10 pounds of lifting/carrying on an occasional basis and the dominant upper right extremity is limited to no lifting/carrying. The claimant must avoid all dangerous work hazards (including unprotected heights and exposed moving machinery), and [exposure] to extreme heat, humidity, and cold conditions.
(Id. at 32). At step four, the ALJ found that since March 1, 2013. Plaintiff was unable to perform any past relevant work. (Id. at 33).
At step five, the ALJ relied on the testimony of a vocational expert ("VE") to conclude that, prior to February 1, 2016, considering Plaintiff's age, education, work *242experience, and RFC, there were jobs that exist in significant numbers in the national economy that Plaintiff could perform, including the representative occupations of information clerk and furniture rental clerk. (Id. at 33-34). The ALJ further concluded that beginning on February 1, 2016, considering Plaintiff's age, education, work experience, and functional capacity, there were no jobs existing in significant numbers in the national economy that Plaintiff could perform. (Id. at 34). Accordingly, the ALJ found that Plaintiff was not disabled prior to February 1, 2016, but became disabled on that date and had continued to be disabled through the date of the ALJ's determination. (Id. at 34).
II. The Commissioner's Determination is Supported by Substantial Evidence and Free from Legal Error
Plaintiff asks the Court to reverse or, in the alternative, remand this matter to the Commissioner, arguing that (1) the ALJ failed to properly evaluate the opinion of Plaintiff's treating physician Kevin Ouweleen, M.D., that Plaintiff is totally disabled; (2) the ALJ failed to properly evaluate the opinion of Gerald Coniglio, M.D., an independent medical examiner, and the opinion of Dr. Ouweleen, relating to Plaintiff's loss of use of his left arm; and (3) the ALJ's credibility determination is flawed, because she relied on "boilerplate" analysis of Plaintiff's credibility, and she failed to credit Plaintiff's consistent employment as a welder. (Dkt. 6-1 at 12-19). The Court has considered each of these arguments and, for the reasons discussed below, finds them to be without merit.
A. Assessment of Dr. Ouweleen's Opinion
Because Plaintiff's claim was filed before March 27, 2017, the ALJ was required to apply the treating physician rule, under which a treating physician's opinion is entitled to "controlling weight" when 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[.]"
(i) the frequency of examination and the length, nature and extent of the treatment relationship; (ii) the evidence in support of the treating physician's opinion; (iii) the consistency of the opinion with the record as a whole; (iv) whether the opinion is from a specialist; and (v) other factors brought to the Social Security Administration's attention that tend to support or contradict the opinion.
Whatever weight the ALJ assigns to the treating physician's opinion, he must "give good reasons in [his] notice of determination or decision for the weight [he gives to the] treating source's medical opinion."
Plaintiff began treating with Dr. Ouweleen in 2006. (Dkt. 4 at 464). Plaintiff initially underwent two surgeries, including one *243surgery on his right shoulder on November 25. 2008, and another surgery on his left shoulder on March 1, 2013. (Id. at 435, 443, 456, 462). Plaintiff "tolerated the [March 1, 2013] procedure well." (Id. at 444). During a follow-up visit with Dr. Ouweleen on March 12, 2013, 11 days post-surgery, Plaintiff reported that he was "doing very well," was "comfortable," and was no longer taking any pain medication. (Id. at 425). During examination, Dr. Ouweleen "was able to abduct [Plaintiff] 60 degrees," and was "sure [Plaintiff] [could] go beyond that." (Id. ). Dr. Ouweleen noted that forward flexion was "about the same." (Id. ). Dr. Ouweleen also found that Plaintiff's left hand was neurovascularly intact and that Plaintiff had a "good active range of motion of his fingers and his elbow." (Id. ). Under the heading "PLAN," Dr. Ouweleen noted that Plaintiff "currently is on total disability." (Id. ).
Plaintiff treated with Dr. Ouweleen on June 13, 2013. (Id. at 421). Dr. Ouweleen noted that Plaintiff "was doing very well," and an examination revealed "very good forward flexion, abduction, internal and external rotation," and that Plaintiff had "excellent rotator cuff strength." (Id. ). Dr. Ouweleen's impression was "excellent progress." (Id. ). Under "PLAN," Dr. Ouweleen assessed that Plaintiff would be able to return to light duty on June 17, 2013, with no "explosive situations with the left shoulder," or "heavy lifting or carrying." (Id. ). Dr. Ouweleen noted that Plaintiff would be considered to have a "mild partial disability at this point." (Id. ). At a follow-up visit with Dr. Ouweleen on July 25, 2013, Plaintiff reported that "although he went back to light duty, he basically has been doing normal duty," and that he "stopped therapy a few weeks ago." (Id. at 420). An examination revealed "very good" range of motion for Plaintiff's left shoulder, and "excellent" rotator cuff strength. (Id. ). Plaintiff had "no pain with provocative testing." (Id. ). Under "PLAN," Dr. Ouweleen noted that Plaintiff was "allowed activities as tolerated at this point." (Id. ).
Plaintiff visited Dr. Ouweleen on September 5, 2013. (Id. at 419). Plaintiff reported that he was back at work lifting duct work overhead and had developed pain in his left shoulder. (Id. ). Plaintiff found it difficult to continue working. (Id. ). An examination revealed tenderness over the biceps, but good range of motion and good rotator cuff strength. (Id. ). Dr. Ouweleen assessed biceps tendonitis, and noted that Plaintiff would continue working, but reassess his pain in 10 days. (Id. ). A September 7, 2013 MRI of Plaintiff's left shoulder (ordered by Dr. Ouweleen) was unremarkable, other than a small amount of fluid in the subacromion bursa. (Id. at 432). Additional findings included a "status post successful surgical repair of a supraspinatus tendon rotator cuff tear," and "status post successful surgical repair of a SLAP tendon." (Id. ). Medical records from the months following reveal that Plaintiff was laid off from work, and that his left shoulder pain continued. (Id. at 415-18).
On January 3, 2014, Plaintiff underwent an additional surgery - a left shoulder arthroscopy with biceps tenotomy and a labral debridement with an open subpectoral biceps tenodesis. (Id. at 388, 392). Plaintiff tolerated the procedure well. (Id. at 393). Following the procedure, Plaintiff returned to physical therapy on February 10, 2014. (Id. at 485). Plaintiff followed-up with Dr. Ouweleen over the next several months, during which he reported soreness, but demonstrated good and improving ranges of motion. (Id. at 774, 776, 780, 782, 784, 786, 788). For example, on March 6, 2014, Dr. Ouweleen noted that Plaintiff "report[ed] continued improvement," and found Plaintiff's range of motion "ha[d] improved dramatically since [his] last visit." (Id. at 776). Plaintiff's forward flexion *244was full, abduction was 120 degrees, and internal and external rotation were almost equal to the right. (Id. ). Under the "Plan" section for these treatment notes, Dr. Ouweleen noted that Plaintiff was "totally disabled." On January 5, 2015, Dr. Ouweleen examined Plaintiff and found that, based on New York State Workers' Compensation Guidelines, Plaintiff had a 52 percent loss of use of his left arm. (Id. at 792).
The ALJ afforded "great weight" to Dr. Ouweleen's opinion that Plaintiff could return to light duty work after his first left shoulder surgery, and "some weight" to Dr. Ouweleen's January 2015 opinion that Plaintiff had a problem with his left shoulder following his second left shoulder surgery without specific limitations. (Id. at 32). Plaintiff argues that the ALJ did not address any of the factors articulated in
Likewise, the ALJ discussed assessments following Plaintiff's 2014 left shoulder surgery which resulted in opinions similar to Dr. Ouweleen's 2015 opinion, including the May 9, 2014 opinion of Gilbert Jenouri, M.D., that Plaintiff had minimal restrictions walking, standing, sitting long periods, bending, stair climbing, lifting, and carrying. (Id. at 31, 715-718). The ALJ also discussed the assessments of Louis Nunez, M.D., who performed an IME in May 2014, and Dr. Coniglio's February 2015 IME. (Id. at 31). At the May 2014 IME, Dr. Nunez noted some reduced range in Plaintiff's left shoulder. (Id. at 31, 732). At the February 2015 IME, Dr. Coniglio found reduced range of motion and tenderness over the left joint, but assessed no sitting, lifting, bending, or standing restrictions. (Id. at 31, 741, 744). In other words, although the ALJ did not engage in a step-by-step written analysis of each of the
Plaintiff further argues that the ALJ did not properly address Dr. Ouweleen's opinion that Plaintiff was "totally disabled." (Dkt. 6-1 at 12). Plaintiff points to seven visits during which Dr. Ouweleen opined that Plaintiff was "totally disabled" following Plaintiff's January 2014 surgery. (Id. ).
*245These "opinions" are not accompanied by any meaningful functional assessment and are listed under a heading entitled "Plan" at the end of the treatment notes for Plaintiff's left shoulder injury; they appear to be status updates for planning and treatment purposes, rather than a formal opinion on Plaintiff's ability to work. (See
Indeed, it is well-established that a treating physician's opinion that an individual is disabled is not entitled to controlling weight, because the ultimate issue of disability is reserved to the Commissioner. Taylor v. Barnhart ,
Plaintiff further makes a cursory statement that the ALJ should have contacted Dr. Ouweleen to obtain clarification of his opinion relating to Plaintiff's ability to work. (Dkt. 6-1 at 15). "[T]here is no duty to re-contact a treating physician to obtain a function-by-function analysis of [p]laintiff's impairments where consultative physicians assess a plaintiff's functional limitations and provide an opinion on them."Sink v. Colvin , No. 12-CV-00239(T)(M),
B. Assessment of the Loss of Use Evidence
Plaintiff next argues that the ALJ improperly evaluated the opinion of Dr. Coniglio that Plaintiff had a 42.5 percent loss of use of his left arm for his workers' compensation case, as well as Dr. Ouweleen's opinion that Plaintiff had a 52 percent scheduled loss of use of the left arm. (Dkt. 6-1 at 15). Specifically, Plaintiff contends that the ALJ relied on these opinions to justify that Plaintiff could frequently reach with his bilateral upper extremities and therefore had a duty to develop the record, because Dr. Ouweleen's opinion relating to Plaintiff's left arm loss of use did not specify any further limitations. (Id. at 16). Plaintiff does not make any specific argument as to Dr. Coniglio's opinion.
As discussed above, an ALJ has a duty to develop the record, particularly where there are "gaps in the record," or "when the record serves as an inadequate basis on which to render a decision." Grey v. Colvin , No. 14-CV-127S,
This case does not present the situation where there is a complete lack of medical opinion evidence relating to Plaintiff's ability to reach. To the contrary, aside from Dr. Ouweleen's January 2015 opinion relating to Plaintiff's loss of use of his left arm, the ALJ also discussed and relied on (1) treatment records from Dr. Ouweleen, from between 2013 and 2015, including that Plaintiff was permitted to return to light duty work following his 2013 left shoulder surgery; (2) a May 2014 consultative examination with Dr. Jenouri, which revealed some improvement in Plaintiff's shoulder, as well as his examination findings of Plaintiff's shoulder, which included shoulder forward elevation right 150 degrees and left 100 degrees, abduction right 150 degrees and left 100 degrees, full range of motion adduction, internal rotation, and external rotation bilaterally; (3) a *247May 2014 IME with Dr. Nunez, which revealed some reduced range of motion in Plaintiff's left shoulder; and (4) a February 2015 IME with Dr. Coniglio, which revealed reduced range of motion, flexion, and adduction, and a 42.4 percent loss of use of Plaintiff's left arm (an opinion to which the ALJ afforded "some weight"). (See Dkt. 4 at 30-31).
Notably, none of these medical examinations resulted in an opinion that Plaintiff had no ability whatsoever, or even a very limited ability, to use and/or reach with his left arm. Rather, these medical opinions, which all reveal some loss of use in Plaintiff's left arm due to his shoulder impairment, are consistent with the RFC assessment that Plaintiff "is precluded from all overhead reaching tasks with the upper extremities, and he is limited to frequent, but not constant, upper extremity forward reaching, handling, and fingering tasks." The fact that the ALJ did not adopt a specific RFC proposed by any one medical opinion is of no consequence and is not required. Matta v. Astrue ,
C. Evaluation of Plaintiff's Credibility
Plaintiff's third and final argument is that the ALJ erred in assessing Plaintiff's credibility. (Dkt. 6-1 at 17). For the reasons set forth below, the Court finds no error in the ALJ's credibility assessment.
The ALJ, who has the "opportunity to observe witnesses' demeanor, candor, fairness, intelligence and manner of testifying," is "best-positioned to make accurate credibility determinations." Whiting v. Astrue , No. CIV.A. 1:12-274,
In assessing the credibility of a claimant's subjective complaints, the Commissioner's regulations require ALJs to employ a two-step inquiry. Meadors v. Astrue ,
*248In this case, the ALJ applied the two-step inquiry. At the first step, she found that Plaintiff's "medically determinable impairments could reasonably be expected to cause the alleged symptoms" but that "[Plaintiff's] statements concerning the intensity, persistence and limiting effects of these symptoms are not fully supported prior to February 1, 2016." (Dkt. 4 at 30). Accordingly, the ALJ assessed Plaintiff's credibility, and pointed to several pieces of evidence that contradict Plaintiff's subjective complaints. First, the ALJ recognized Plaintiff's difficulties using his upper extremities and his multiple surgeries, but noted that, until recently, Plaintiff's medical care providers released him to light duty work.3 (Id. ). Further, the objective medical evidence showed that, following his 2013 and 2014 left shoulder surgeries, Plaintiff's condition was improving. (Id. at 30-31). Additionally, IMEs performed by Drs. Jenouri, Nunez, and Coniglio showed some reduced range of motion in Plaintiff's left shoulder, and minimal to no restrictions for walking, standing, sitting long periods, bending, stair climbing, lifting, and carrying. (Id. at 31).
Plaintiff argues that the ALJ relied on "boilerplate" language in making the credibility assessment. (Dkt. 6-1 at 18). Plaintiff specifically points to the ALJ's statement that Plaintiff's subjective statements:
could reasonably be expected to cause the alleged symptoms; however, the claimant's statements concerning the intensity, persistence, and limiting effects of these symptoms are not fully supported prior to February 1, 2016 for the reasons explained in this decision. However, until recently, the claimant's medical providers released him to light duty work consistent with the residual functional capacity.
(Id. ; Dkt. 4 at 30). The written determination includes a discussion of Plaintiff's application for disability and his testimony at the administrative hearing, including his alleged impairments. (See
Accordingly, the Court finds that the ALJ's credibility analysis was not "boilerplate." Rather, the ALJ wrote over two full pages containing information relevant to her credibility analysis, including specific testimony by Plaintiff refuted by specific objective medical evidence. See Trifiletti v. Comm'r of Soc. Sec. , No. 1:14-CV-1427 (GTS/WBC),
Plaintiff also contends that the ALJ failed to consider his work history as part of her credibility determination. (Dkt. 6-1 at 19). While "a good work history may be deemed probative of credibility," it is "just one of many factors considered in assessing credibility." Motyka v. Colvin , No. 15-CV-54S,
Here, the ALJ did not specifically discuss Plaintiff's entire work history, but he did acknowledge that Plaintiff worked as a welder since at least 2008, when he sustained his initial right shoulder injury. (Dkt. 4 at 30). The ALJ also acknowledged that Plaintiff returned to work on multiple occasions after surgeries. (Id. at 30-31). It is clear from the record that the ALJ was aware of Plaintiff's history working as a welder and, based on the information included in the written determination, this history was considered by the ALJ in arriving at a decision. See Motyka ,
CONCLUSION
For the foregoing reasons, the Commissioner's motion for judgment on the pleadings (Dkt. 10) is granted and Plaintiff's motion for judgment on the pleadings (Dkt. 6) is denied. The Clerk of Court is directed to enter judgment and close this case.
SO ORDERED.
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