Price v. Berryhill
This text of 298 F. Supp. 3d 517 (Price v. Berryhill) is published on Counsel Stack Legal Research, covering District Court, E.D. New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.
Opinion
WILLIAM F. KUNTZ, II, United States District Judge
Sharen R. Price ("Plaintiff) brings this action pursuant to
BACKGROUND AND PROCEDURAL HISTORY
Plaintiff was born in 1950, and has a college education. Administrative Transcript pp. ("T.") 145, 150, ECF No. 7. She worked for the New York City Housing Authority from 1976 to 2007, as a housing assistant, and later in managerial positions. T. 31-33, 145, 163. As an assistant manager, a major function of her job was collecting rent and conducting inspections, and she spent about seventy-five percent of her time in the field collecting and doing inspections. T. 33. After retiring from the Housing Authority, she worked from May 2008 through February 2009, part-time, at a social services office providing childcare services for clients who dropped off their children. T. 33-34, 145. She reported working there four or five hours per day, three days per week. T. 34, 145, 165.
The relevant period of the Court's review is from February 1, 2009, Plaintiff's alleged onset date of disability, through March 31, 2014, the date Plaintiff was last insured for disability insurance benefits. See
On February 9, 2009, shortly after the beginning of the relevant period, Plaintiff visited Queens Long Island Medical Group, P.C., for an oncology consultation, at which she denied lower back pain.1 T. 402, 404. Plaintiff had normal musculoskeletal and neurological exam findings. T. 404. In the records of the examination, her primary care physician is listed as Chanchal Sabharwal, M.D. T. 402.
*520On March 5, 2009, Plaintiff was examined by Lucille Lee, M.D., a radiation oncologist, and Plaintiff reported no physical complaints relevant to her spine, and the musculoskeletal exam revealed a normal gait, and no vertebral or costovertebral tenderness. T. 400.
On January 21, 2010, Plaintiff was treated by Charlene Andrews, M.D., for lower back pain for the first time, which Plaintiff reported had lasted for a few weeks. T. 364-66. Plaintiff described the severity of the pain as moderate. T. 365. The pain was relieved by rest.
An x-ray collected on January 29, 2010, showed "severe disc degenerative changes are present at L2-L3 and L5-S1 including disc narrowing, increased sclerosis and large spur production." T. 360. The overall impression was "severe disc degenerative changes are present."
Plaintiff presented the following month, on February 11, 2010, for a routine follow-up appointment with no complaints. T. 358. Dr. Andrews noted a plan to continue Plaintiff's medication. T. 359.
In a radiation medical follow-up note for a visit on May 14, 2010, Dr. Lee noted that "patient reports feeling generally well. She has no new medical problems. She has no pain or discomfort." T. 352.
Plaintiff next sought treatment for back pain on November 3, 2011, with Dr. Andrews. T. 298. Dr. Andrews noted Plaintiff's musculoskeletal system was normal upon exam and ordered additional x-rays of the lumbosacral spine.
On February 2, 2012, Plaintiff presented to Dr. Andrews complaining of neck pain and stiffness, without any other complaints. T. 557. The doctor assessed cervicalgia, for which she prescribed Flexeril and a heating pad. T. 558.
On June 8, 2012, Plaintiff treated with Dr. Sabharwal who, upon conducting a "health maintenance exam," found tenderness on palpation of the lumbosacral spine. T. 551, 553. Plaintiff's gait and stance were normal. T. 553. Dr. Sabharwal diagnosed backache possibly due to degenerative joint disease.
On July 7, 2012, Plaintiff treated with Dr. Sabharwal for earache and reported that she was getting adequate exercise. T. 539.
On November 19, 2012, Plaintiff treated with Dr. Sabharwal for her hypertension. T. 519. Plaintiff reported getting adequate exercise. T. 520.
On June 26, 2013, an x-ray ordered by Dr. Sabharwal showed the following:
There is marginal vertebral endplate sclerosis with significant disc space narrowing at L1-L2, L2-L3 and L5-S1. Tiny endplate anterior osteophytes are noted at L2 and L3, L5 and S1. There is a straightening to reversal of the normal lordotic curvature, presumably related to muscle spasm and/or muscle contracture. There is no fracture or dislocation seen. There is no evidence of blastic or lytic lesions.
T. 508. The overall impression was "moderately severe degenerative disc disease from the level of L1 through L5-S1." T. 508-09. Dr. Sabharwal diagnosed backache possibly due to degenerative joint disease. T. 512.
On June 10, 2013, Plaintiff filed an application for Title II disability benefits alleging *521disability beginning February 1, 2009, due to degenerative disc disease and osteoarthritis of the spine. PL's Mot at 1; T. 132, 144.
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WILLIAM F. KUNTZ, II, United States District Judge
Sharen R. Price ("Plaintiff) brings this action pursuant to
BACKGROUND AND PROCEDURAL HISTORY
Plaintiff was born in 1950, and has a college education. Administrative Transcript pp. ("T.") 145, 150, ECF No. 7. She worked for the New York City Housing Authority from 1976 to 2007, as a housing assistant, and later in managerial positions. T. 31-33, 145, 163. As an assistant manager, a major function of her job was collecting rent and conducting inspections, and she spent about seventy-five percent of her time in the field collecting and doing inspections. T. 33. After retiring from the Housing Authority, she worked from May 2008 through February 2009, part-time, at a social services office providing childcare services for clients who dropped off their children. T. 33-34, 145. She reported working there four or five hours per day, three days per week. T. 34, 145, 165.
The relevant period of the Court's review is from February 1, 2009, Plaintiff's alleged onset date of disability, through March 31, 2014, the date Plaintiff was last insured for disability insurance benefits. See
On February 9, 2009, shortly after the beginning of the relevant period, Plaintiff visited Queens Long Island Medical Group, P.C., for an oncology consultation, at which she denied lower back pain.1 T. 402, 404. Plaintiff had normal musculoskeletal and neurological exam findings. T. 404. In the records of the examination, her primary care physician is listed as Chanchal Sabharwal, M.D. T. 402.
*520On March 5, 2009, Plaintiff was examined by Lucille Lee, M.D., a radiation oncologist, and Plaintiff reported no physical complaints relevant to her spine, and the musculoskeletal exam revealed a normal gait, and no vertebral or costovertebral tenderness. T. 400.
On January 21, 2010, Plaintiff was treated by Charlene Andrews, M.D., for lower back pain for the first time, which Plaintiff reported had lasted for a few weeks. T. 364-66. Plaintiff described the severity of the pain as moderate. T. 365. The pain was relieved by rest.
An x-ray collected on January 29, 2010, showed "severe disc degenerative changes are present at L2-L3 and L5-S1 including disc narrowing, increased sclerosis and large spur production." T. 360. The overall impression was "severe disc degenerative changes are present."
Plaintiff presented the following month, on February 11, 2010, for a routine follow-up appointment with no complaints. T. 358. Dr. Andrews noted a plan to continue Plaintiff's medication. T. 359.
In a radiation medical follow-up note for a visit on May 14, 2010, Dr. Lee noted that "patient reports feeling generally well. She has no new medical problems. She has no pain or discomfort." T. 352.
Plaintiff next sought treatment for back pain on November 3, 2011, with Dr. Andrews. T. 298. Dr. Andrews noted Plaintiff's musculoskeletal system was normal upon exam and ordered additional x-rays of the lumbosacral spine.
On February 2, 2012, Plaintiff presented to Dr. Andrews complaining of neck pain and stiffness, without any other complaints. T. 557. The doctor assessed cervicalgia, for which she prescribed Flexeril and a heating pad. T. 558.
On June 8, 2012, Plaintiff treated with Dr. Sabharwal who, upon conducting a "health maintenance exam," found tenderness on palpation of the lumbosacral spine. T. 551, 553. Plaintiff's gait and stance were normal. T. 553. Dr. Sabharwal diagnosed backache possibly due to degenerative joint disease.
On July 7, 2012, Plaintiff treated with Dr. Sabharwal for earache and reported that she was getting adequate exercise. T. 539.
On November 19, 2012, Plaintiff treated with Dr. Sabharwal for her hypertension. T. 519. Plaintiff reported getting adequate exercise. T. 520.
On June 26, 2013, an x-ray ordered by Dr. Sabharwal showed the following:
There is marginal vertebral endplate sclerosis with significant disc space narrowing at L1-L2, L2-L3 and L5-S1. Tiny endplate anterior osteophytes are noted at L2 and L3, L5 and S1. There is a straightening to reversal of the normal lordotic curvature, presumably related to muscle spasm and/or muscle contracture. There is no fracture or dislocation seen. There is no evidence of blastic or lytic lesions.
T. 508. The overall impression was "moderately severe degenerative disc disease from the level of L1 through L5-S1." T. 508-09. Dr. Sabharwal diagnosed backache possibly due to degenerative joint disease. T. 512.
On June 10, 2013, Plaintiff filed an application for Title II disability benefits alleging *521disability beginning February 1, 2009, due to degenerative disc disease and osteoarthritis of the spine. PL's Mot at 1; T. 132, 144.
Plaintiff reported in her Function Report dated July 1, 2013, that she continued to walk her dog, run errands, do household chores, and drive and travel independently. T. 152-59. She also reported she had experienced back pain for the preceding five years, with the pain getting progressively worse, yet she was not receiving any medical treatment for the pain at the time of the Function Report. T. 160. She also reported taking two Aleve pills per day for the pain on and off for the past five years, and, though it took three-four hours to relieve the pain, the Aleve was sufficient to relieve the pain for one day. T. 161. She reported also occasionally using hot and cold pads to relieve the pain. T. 162.
On July 17, 2013, Plaintiff presented to a consultative internal medicine examination per the request of the Division of Disability Determinations. T. 196. The consultative examiner was Joyce Graber, M.D.
Plaintiff did not present with any acute distress, and had a normal gait and stance. T. 197. She was able to walk on heels and toes without difficulty and could do a full squat.
On July 23, 2013, Dr. Sabharwal, Defendant's treating physician, filled out a "Lumbar Spine Residual Functional Capacity Questionnaire." T. 203, 208. Dr. Sabharwal stated Plaintiff had limitations resulting from degenerative disc disease from L1 through L5-S1. T. 203. Dr. Sabharwal indicated she had seen Plaintiff every three months for one year.
On August 28, 2013, during a follow-up visit for hypertension, Plaintiff treated with Dr. Sabharwal for, inter alia , severe back pain described as constantly throbbing with increased pain standing and walking. T. 492. Examination again showed tenderness in the lumbar spine, and Plaintiff was referred to pain management. T. 493.
On August 9, 2013, Plaintiff's claim for disability was denied. T. 62.
On September 20, 2013, Plaintiff began care with pain management specialist Reginald Rousseau, M.D. for lower back pain she reportedly experienced over the last ten years. T. 293. Plaintiff described her pain as dull and mostly non-radicular, although it did travel to the right side of the hip, and it had improved in the past with physical therapy and medication management.
Plaintiff saw Dr. Sabharwal on October 4, 2013, complaining of constant, but non-radiating, back pain with an eight out of ten intensity. T. 490. She was in no acute distress, and the doctor noted her lumbar spine was tender to palpation. T. 491. The doctor again assessed backache possibly due to degenerative joint disease and provided a physical therapy referral and referral for MRI. T.491.
In a letter from Dr. John Himmlefarb outlining the results of the MRI to Dr. Sabharwal, the MRI revealed the following impression: slight right convex lumbar scoliosis with some loss of the normal lordosis ; discogenic degenerative changes throughout the lumbar spine, but most prominent at the L2-3 through L5-S1 levels; central posterior disc herniation superimposed upon a posterior disc bulge at the L5-S1 level; posterior disc bulges at the L3-4 and L4-5 levels; far left posterolateral disc herniation at the L2-3 level superimposed upon a posterior disc bulge; posterior disc bulge at the L1-2 level; and enlarged heterogeneous uterus with an enlarged central stripe. T. 481-82.
Plaintiff returned to Dr. Rousseau on November 1, 2013, following her MRI. T. 292; see T. 213-15 (MRI findings from October 2013). Plaintiff's spine was mildly tender to palpation with limited range of motion, increased pain on flexion and extension, and positive right hip tenderness. T. 292. Plaintiff retained full motor *523strength bilaterally in the lower extremities.
On November 22, 2013, Plaintiff treated with Dr. Sabharwal for constant throbbing back pain radiating to the right leg described as seven out of ten in intensity. T. 476. The purpose of this visit was to follow up on MRI results.
On November 26, 2013, Plaintiff saw physical therapist Paul Espocia, reporting back pain and noting physical therapy had been helpful in the past. T. 473. Her recent epidural injection helped "for some days" but she continued to experience pain and stiffness, which was worse with prolonged sitting and upon getting up.
Plaintiff received another lumbar facet medial branch block injection on December 17, 2013, without complication. T. 239. Around the same time, Plaintiff reported moderate back pain to physical therapist Christine Samuels, who noted Plaintiff was managing well with pain tolerance. T. 462. The epidural injection helped her "some days," and she reported still experiencing pain and stiffness in the back pain, which was worse with prolonged sitting and upon getting up.
Plaintiff complained of throbbing, non-radiating back pain to Dr. Sabharwal on February 5,2014. T. 455. Her lumbar spine was tender to palpation. T. 456. The doctor continued to assess a backache possibly due to degenerative joint disease.
On May 9, 2014, about a month after her insured status expired, Plaintiff presented to Dr. Sabharwal. T. 442. A tender right index finger was the sole musculoskeletal finding. T. 443. No abnormal findings or diagnoses were noted regarding Plaintiff's spine. T. 442-43.
On July 15, 2014, Plaintiff saw Dr. Sabharwal for an "annual risk assessment exam," during which the doctor noted normal neurological findings and advised Plaintiff on diet, exercise, and weight reduction. T. 439, 441. No abnormal findings or diagnoses were noted regarding Plaintiff's spine. T. 439-41. Plaintiff reported getting adequate exercise. T. 439.
*524Following the denial of her claim, Plaintiff requested a hearing, which was held on August 11, 2014. T. 26-50. At the hearing, Plaintiff testified she can stand for about 10 minutes before she needs to lean against something, and she needs to constantly change positions. T. 40-41. A vocational expert, Marianne Marracco, testified someone with Plaintiff's age, education, work experience, who is limited to light work activity but must take a five-minute break every hour to move about, could have performed work as a housing manager and office manager/assistant manager. T. 43-44.
On November 6, 2014, Administrative Law Judge ("ALJ") Margaret L. Pecoraro denied Plaintiff's application via written decision on November 6, 2014. See T. 10-22. The ALJ found
[T]he claimant's allegations are not substantiated by the record and are therefore, not wholly credible. The claimant's longitudinal medical history is not consistent with the allegation that she is restricted from all work activity. The medical records simply fail to confirm the accuracy of the claimant's assertions and hearing testimony. Although the claimant alleged functional limitations, those subjective complaints were not adequately supported by objective medical evidence. There is no evidence that the claimant's impairments resulted in limitations so severe that she could not engage in any work activity.
T.20.
The Appeals Council denied Plaintiff's request for review on August 17, 2016, rendering the ALJ's decision the final decision of the Commissioner. T. 1-3. Plaintiff commenced the present action on October 7, 2016. ECF No. 1.
DISCUSSION
I. Standard of Review
When a claimant challenges the Social Security Administration's ("SSA") denial of disability benefits, the Court's function is not to evaluate de novo whether the claimant is disabled, but rather to determine "whether the correct legal standards were applied and whether substantial evidence supports the decision." Butts v. Barnhart ,
It is the function of the SSA, not the federal district court, "to resolve evidentiary conflicts and to appraise the credibility of witnesses, including the claimant."
*525Carroll v. Sec'y of Health & Human Servs. ,
To fulfill this burden, the ALJ must "adequately explain his reasoning in making the findings on which his ultimate decision rests" and must "address all pertinent evidence." Kane v. Astrue ,
II. Determination of Disability
A. Applicable Law
For purposes of disability benefits, disability is defined 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 determine whether a claimant is disabled, the Commissioner must apply the five-step sequential process set forth in
B. The ALJ's Decision
The ALJ followed the five-step procedure, determined Plaintiff's residual functional capacity ("RFC") under
Plaintiff moves for judgment on the pleadings, arguing: (1) the ALJ's RFC finding is unsupported by substantial evidence; and (2) the ALJ's finding that the claimant's RFC allows the claimant to perform past relevant work is unsupported by substantial evidence (Step Four). Pl's Mot. at 1. Defendant cross-moves for summary judgment on pleadings, arguing: (1) the ALJ's decision that Plaintiff was not disabled was supported by substantial evidence; and (2) the ALJ properly denied Plaintiff's claim at Step Four. Def.'s Mot. at 14-24.
C. Analysis
RFC is "what an individual can still do despite his or her limitations." Pardee v. Astrue ,
In reviewing the ALJ's determination, the Court considers whether it "affords an adequate basis for meaningful *527judicial review, applies the proper legal standards, and is supported by substantial evidence such that additional analysis would be unnecessary or superfluous." Cichocki v. Astrue ,
Plaintiff first argues the RFC is unsupported by substantial evidence as the ALJ improperly evaluated the opinion evidence and "did not provide an accurate and logical bridge tying the evidence to the RFC determination." PL's Mot. at 8. In particular, Plaintiff takes issue with the weight the ALJ assigned the consultative examiner, Dr. Graber, who found Plaintiff had no physical limitations, T. 198, versus Plaintiff's treating physician, Dr. Sabharwal, who found Plaintiff could sit, stand and walk for less than two hours in an eight-hour workday, T. 206. Plaintiff argues the treating physician's opinion should have been entitled to significantly more weight, and the RFC should have reflected this greater deference. Pl.'s Mot. at 8.
Defendant argues the ALJ's RFC finding is supported by substantial evidence. Def.'s Mot. at 14. In response to Plaintiff's arguments, Defendant argues that Dr. Sabharwal's opinion was not entitled to controlling weight because the "ALJ's decision demonstrates that she properly considered its deficient supportability, and its inconsistency with the record as a whole." Def.'s Mot. at 16.
It is the task of the ALJ to resolve conflicts in the medical evidence. Cage v. Comm'r of Soc. Sec. ,
It is indisputable that Dr. Sabharwal's assessment conflicts with that of Dr. Graber, and the ALJ identifies areas in Plaintiff's *528medical records that she believes are inconsistent with Dr. Sabharwal's ultimate assessment. Therefore, it was reasonable that the ALJ did not give controlling weight to Dr. Sabharwal's opinion. T. 21. However, while the ALJ states she gave "some" weight to Dr. Sabharwal's opinion,
Given that the ALJ did not give Dr. Sabharwal's opinion controlling weight, the ALJ was required to address the six factors outlined above in determining how much weight to give to Dr. Sabharwal's opinion under
The ALJ focuses primarily on the fourth factor, consistency with other medical evidence, when evaluating the weight to give Dr. Sabharwal's opinion and notes areas where she finds Dr. Sabharwal's opinion inconsistent with medical evidence. First, the ALJ notes, "[a]lthough the record indicates positive findings on MRI studies and indication of pain and tenderness, the record indicates that the claimant's pain started progressing in the latter part of 2013 and the claimant's treatment has been conservative." T. 20. However, "[n]either the trial judge nor the ALJ is permitted to substitute his own expertise or view of the medical proof for the treating physician's opinion," and the use of conservative medical interventions and over-the-counter, rather than prescription, medications is not "substantial evidence that plaintiff was not physically disabled during the relevant period." Shaw ,
Second, the ALJ states the "[t]he record is replete with physical examinations where the claimant's gait and stance are normal, there is no motor dysfunction, nor muscle atrophy, or sensory or reflect abnormalities." T. 21. However, Dr. Sabharwal's report is not inconsistent with these records. See T. 205 (indicating no muscle atrophy or normal gait).
Third, the ALJ's decision also points to Plaintiff's daily activities as inconsistent with Dr. Sabharwal's findings, noting that "claimant indicated her daily activities include taking care of [her] mother including errands with and for her, driving, and shopping. Additionally, treating *529notes indicate Plaintiff should exercise." T. 21. Without more explanation, it is not clear from the ALJ's decision how these activities are inconsistent with Dr. Sabharwal's findings. "Exercise" means drastically different things to different people, based on age, ability, and medical conditions. The same could be said of "errands." "Driving" could span from a length of a few minutes over the course of a few blocks to virtually any length of time or distance. The citations to these activities, without more, do not necessarily render Dr. Sabharwal's findings inconsistent, nor, for that matter, do they necessarily support an RFC finding that Plaintiff "could sit, stand, and walk for a maximum of 6 hours each." T. 13. To the extent the ALJ was unsure about the nature and extent of Plaintiff's activities and whether they were inconsistent with Dr. Sabharwal's findings, the "ALJ may not reject a treating physician's conclusions for lack of clear findings without first attempting to fill in the gaps in the administrative record." Kane v. Astrue ,
The fifth factor to consider is whether Dr. Sabharwal offered a medical opinion about medical issues related to her specialty. The ALJ's decision does not discuss Dr. Sabharwal's specialty, if any.
The sixth factor requires consideration of any other relevant factors, "[f]or example, the amount of understanding of our disability programs and their evidentiary requirements that a medical source has ... and the extent to which a medical source is familiar with the other information in [the] case record...."
While the ALJ's decision reports that both Dr. Graber's and Dr. Sabharwal's reports were accorded "some weight," because the ALJ's opinion did not "comprehensively set forth reasons for the weight assigned to a treating physician's opinion," this Court finds remand is appropriate. Halloran ,
CONCLUSION
For the reasons stated herein, the Commissioner's motion for judgment on the pleadings, ECF No. 19, is hereby DENIED, and Plaintiff's cross-motion for judgment on the pleadings, ECF No. 17, is hereby GRANTED. The Court hereby REMANDS this action to the Social Security Administration for further administrative proceedings consistent with this opinion.
SO ORDERED.
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