REAVES v. SAUL

• Court: District Court, M.D. North Carolina
• Decided: February 26, 2021
• Docket: 1:19-cv-01120
• Status: Unknown

Opinion

IN THE UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF NORTH CAROLINA

STEPHEN DOUGLAS REAVES, ) Plaintiff, v. 1:19CV1120 ANDREW SAUL, Commissioner of Social Secutity, ) Defendant.

MEMORANDUM OPINION AND RECOMMENDATION OF UNITED STATES MAGISTRATE JUDGE Plaintiff Stephen Douglas Reaves (“Plaintiff”) brought this action pursuant to Section 205(g) of the Social Security Act (the “Act”), as amended (42 U.S.C. § 405(g)), to obtain judicial teview of a final decision of the Commissioner of Social Security denying his claim for Disability Insurance Benefits (“DIB”) under Title I] of the Act. The parties have filed cross- motions for judgment, and the administrative record has been certified to the Court for review. PROCEDURAL HISTORY Plaintiff protectively filed his application for DIB on June 12, 2015, alleging a disability onset date of September 25, 2014. (Tr. at 13, 286-89.)! His claim was denied initially (I'r. at 67-84, 102-05), and that determination was upheld on reconsideration (Tr. at 85-101, 109-16). Thereafter, Plaintiff requested an administrative heating de novo before an Administrative Law Judge (“ALJ”). (Tr. at 118-19.) A hearing scheduled for May 7, 2018 was postponed

Transcript citations refer to the Administrative Record [Doc. #7].

when Plaintiff did not appear. (Tr. at 13, 60-66.) However, Plaintiff showed good cause for his failure to appear and, along with his attorney and an impattial vocational expert, attended

a subsequent heating on August 1, 2018. (Ir. at 13.) Following the hearing, the ALJ concluded that Plaintiff was not disabled within the meaning of the Act (Ir. at 25), and, on September 10, 2019, the Appeals Council denied Plaintiffs request for review of that decision, thereby making the AL]’s conclusion the Commissioner’s final decision for purposes of judicial review (Tr. at 1-5). Il. LEGAL STANDARD Federal law “authorizes judicial review of the Social Security Commissionet’s denial of social security benefits.” Hines v. Barnhart, 453 F.3d 559, 561 (4th Cir. 2006). However, “the scope of [the] review of [such an administrative] decision . . . is extremely limited.” Frady □□ □

Hartis, 646 F.2d 143, 144 (4th Cir. 1981). “The courts are not to try the case de novo.” Oppenheim v. Finch, 495 F.2d 396, 397 (4th Cir. 1974). Instead, “a reviewing coutt must uphold the factual findings of the ALJ [underlying the denial of benefits] if they are supported by substantial evidence and were reached through application of the correct legal standard.” Hancock v. Asttue, 667 F.3d 470, 472 (4th Cir. 2012) (internal brackets omitted). “Substantial evidence means ‘such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.”’ Hunter v. Sullivan, 993 F.2d 31, 34 (4th Cir. 1992) (quoting Richardson v. Perales, 402 U.S. 389, 390 (1971)). “It consists of more than a mere scintilla of evidence but may be somewhat less than a preponderance.” Mastro v. Apfel, 270 F.3d 171, 176 (4th Cir. 2001) (internal citations and quotation matks omitted). “If there is

evidence to justify a tefusal to direct a verdict were the case before a jury, then there is substantial evidence.” Hunter, 993 F.2d at 34 (internal quotation marks omitted). “In reviewing for substantial evidence, the court should not undertake to te-weigh conflicting evidence, make credibility determinations, or substitute its judgment for that of the [AL]].” Mastro, 270 F.3d at 176 (internal brackets and quotation marks omitted). “Where conflicting evidence allows reasonable minds to differ as to whether a claimant is disabled, the responsibility for that decision falls on the ALJ.” Hancock, 667 F.3d at 472. “The issue before [the reviewing court], therefore, is not whether [the claimant] is disabled, but whether the ALJ’s finding that [the claimant] is not disabled is supported by substantial evidence and was reached based upon a correct application of the relevant law.” Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996). In undertaking this limited review, the Court notes that in administrative proceedings, claimant for disability benefits bears the burden of proving a disability.” Hall v. Harris, 658 F.2d 260, 264 (4th Cir. 1981). In this context, “disability” means the “inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impaitment 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.”’ Id. (quoting 42 U.S.C. § 423(¢)(1)(A))?

*

“The Commissioner uses a five-step process to evaluate disability claims.” Hancock, 667 F.3d at 472 (citing 20 C.F.R. §§ 404.1520(a)(4); 416.920(a)(4)). “Under this process, the Commissioner asks, in sequence, whether the claimant: (1) worked during the alleged petiod of disability; (2) had a severe impairment; (3) had an impairment that met or equaled □□□□ requirements of a listed impairment; (4) could return to her past relevant work; and (5) if not, could perform any other work in the national economy.” Id. A finding adverse to the claimant at any of several points in this five-step sequence forecloses a disability designation and ends the inquiry. For example, “[t]he first step determines whether the claimant is engaged in ‘substantial gainful activity.’ If the claimant is working, benefits are denied. The second step determines if the claimant is ‘severely’ disabled. If not, benefits are denied.” Bennett v. Sullivan, 917 F.2d 157, 159 (4th Cir. 1990). On the other hand, if a claimant carries his or her burden at each of the first two steps, and establishes at step three that the impairment “equals or exceeds in severity one or more of the impaitments listed in Appendix I of the regulations,” then “the claimant is disabled.” Mastto, 270 F.3d at 177. Alternatively, if a claimant clears steps one and two, but falters at step three, ie., “[i]f a claimant’s impairment is not sufficiently severe to equal or exceed a listed impairment, the AL] must assess the claimant’s residual function|[al] capacity (RFC’).” Id. at 179.3 Step four then requires the ALJ to assess whether, based on that REC, the claimant can

is a measurement of the most a claimant can do despite [the claimant’s] limitations.” Hines, 453 F.3d at 562 (noting that pursuant to the administrative regulations, the “RFC is an assessment of an individual’s ability to do sustained work-telated physical and mental activities in a work setting on a regular and continuing basis .. . [which] means 8 houts a day, for 5 days a week, or an equivalent work schedule” (internal emphasis and quotation marks omitted)). The RFC includes both a “physical exertional or strength limitation” that assesses the claimant’s “ability to do sedentary, light, medium, heavy, or very heavy work,” as well as “nonexertional limitations (mental, sensory, or skin impairments).” Hall, 658 F.2d at 265. “RFC is to be

“perform past televant work”; if so, the claimant does not qualify as disabled. Id. at 179-80. However, if the claimant establishes an inability to return to prior work, the analysis proceeds to the fifth step, which “requires the Commissioner to prove that a significant number of jobs exist which the claimant could perform, despite [the claimant’s] impairments.” Hines, 453 F.3d at 563. In making this determination, the AL] must decide “whether the claimant is able to perform other work considering both [the claimant’s RFC] and [the claimant’s] vocational capabilities (age, education, and past work expetience) to adjust to a new job.” Hall, 658 F.2d at 264-65. If, at this step, the Government cannot catty its “evidentiary burden of proving that [the claimant] remains able to work other jobs available in the community,” the claimant qualifies as disabled. Hines, 453 F.3d at 567. I. DISCUSSION In the present case, the ALJ found that Plaintiff had not engaged in “substantial gainful activity” since September 25, 2014, his alleged onset date. Plaintiff therefore met his burden at step one of the sequential evaluation process. At step two, the ALJ further determined that Plaintiff suffered from the following severe impaitments: chronic liver disease, peripheral neuropathy, obesity, and alcohol use disorder[.] (Tr. at 16.) The AL} found at step three that none of these impairments, individually or in combination, met or equaled a disability listing. (Tr. at 16-18.) Therefore, the ALJ assessed Plaintiffs RFC and determined that,

determined by the AL] only after [the ALJ] considers all relevant evidence of a claimant’s impairments and any related symptoms (2g, pain).” Hines, 453 F.3d at 562-63.

based on all of [his] impairments, including the substance use disorder, [Plaintiff] has the residual functional capacity to perform a full range of work at all exettional levels but with the following non-exertional limitation: [Plaintiff] would not be able to meet the attendance requirements of competitive employment. (Tr. at 18.) Because the “vocational expert testified to a required level of attendance at work that [Plaintiff] cannot meet while he is drinking,” the AL] determined at steps four and five of the sequential analysis that a finding of “disabled” was appropriate. (I't. at 19-20.) However, in accordance with the Act, the ALJ then considered the impact of Plaintiffs remaining impairments absent his substance use. Specifically, the ALJ found that, if Plaintiff stopped drinking alcohol, his remaining impairments would limit him to light work as defined in 20 CFR 404.1567(b) as he is limited to lifting and cattying 20 pounds occasionally and 10 pounds frequently; stand and walk six houts in an eight-hour workday; sit six hours in an eight-hour workday; and no additional limitations on the ability to push and pull. [Plaintiffs] mental limitations would be non-severe in the absence of alcohol abuse. (Tr. at 20.) At step four of the analysis, the ALJ determined that the exertional requirements of Plaintiffs past relevant work exceeded his RFC. (Ir. at 23.) Nevertheless, the AL] determined at step five that, given Plaintiff's age, education, work experience, RFC, and the testimony of the vocational expert as to these factors, he could perform other jobs available in the national economy if he stopped his substance use. (Ir. at 24.) Therefore, the ALJ concluded that Plaintiffs substance use disorder is a contributing factor material to the determination of disability because [Plaintiff] would not be disabled if he stopped the substance use (20 CFR 404.1520(g) and 404.1535). Because the substance use disorder is a contributing factor material to the determination of disability, [Plaintiff] has not been disabled within the meaning of the Social Security Act at any time from the alleged onset date through the date of this decision. (Tr. at 24.)

Plaintiff now raises four challenges to AL]’s decision. First, he argues that the ALJ failed to account for Plaintiff's moderate limitation in concentration, persistence, or pace in accotdance with the Fourth Circuit’s decision Mascio v. Colvin, 780 F.3d 632, 638 (4th Cit. 2015). Second, Plaintiff contends that the ALJ erred by failing include Plaintiffs oseteoatthtitis among his severe impairments at step two of the sequential analysis and by failing to develop the record regarding his osteoarthritis. Third, Plaintiff asserts that the RFC assessment is not supported by substantial evidence or the ALJ’s narrative discussion. Fourth and finally, Plaintiff contends that the ALJ failed to properly evaluate the medical opinion of Plaintiff's treating physician, Dr. Nathan Sison. After a thorough review of the record, the Coutt finds that remand is tequired in light of the inadequacies in the AL]’s RFC assessment and particularly in the weighing of the opinion evidence. For claims, like Plaintiffs, that ate filed before Match 27, 2017, ALJs evaluate the medical opinion evidence in accordance with 20 C.F.R. § 404.1527(c). Brown v. Comm’r Soc. Sec., 873 F.3d 251, 255 (4th Cir. 2017). “Medical opinions” ate “statements from acceptable medical sources that reflect judgments about the nature and severity of your impairment(s), including your symptoms, diagnosis and prognosis, what you can still do despite impaitment(s), and your physical ot mental restrictions.” Id. (citing 20 CFR. § 404.1527(a)(1)). While the regulations mandate that the AL] evaluate each medical opinion presented to her, generally “more weight is given ‘to the medical opinion of a source who has examined you than to the medical opinion of a medical source who has not examined you.” Brown, 873 F.3d at 255 (quoting 20 C.F.R. § 404.1527(c)(1)). And, undet what is commonly tefetted to as the “treating physician rule,” the ALJ generally accords the greatest weight—

conttolling weight—to the well-supported opinion of a treating source as to the nature and sevetity of a claimant’s impairment, based on the ability of treating sources to ptovide a detailed, longitudinal picture of [the claimant’s] medical impaitment(s) [which] may bring a unique perspective to the medical evidence that cannot be obtained from the objective medical findings alone or from reports of individual examinations, such as consultative examinations or brief hospitalizations. 20 C.F.R. § 404.1527(c)(2). However, if a treating soutce’s opinion is not “well-supported by medically acceptable clinical and laboratory diagnostic techniques” or is “inconsistent with other substantial evidence in [the] case record,” it is not entitled to controlling weight. 20 C.F.R. § 404.1527(c)(2); see also Social Security Ruling (“SSR”) 96-2p, 1996 WL 374188, at *4; Brown, 873 F.3d at 256; Craig, 76 F.3d at 590; Mastro, 270 F.3d at 178.4 Instead, the opinion must be evaluated and weighed using all of the factors provided in 20 C.F.R. § 404.1527(c)(2)- (c)(6), including (1) the length of the treatment relationship, (2) the frequency of examination, (3) the nature and extent of the treatment relationship, (4) the supportability of the opinion, (5) the consistency of the opinion with the record, (6) whether the source is a specialist, and (7) any other factors that may support or contradict the opinion. Even if an opinion by a treating physician is given controlling weight with respect to the nature and severity of a claimant’s impaitments, opinions by physicians regarding the ultimate issue of whether a plaintiff is disabled within the meaning of the Act ate never accorded controlling weight

* For claims filed after March 27, 2017, the regulations have been amended and several of the prior Social Security Rulings, including SSR 96-2p, have been rescinded. ‘The new regulations provide that the Social Security Administration “will not defer or give any specific evidentiary weight, including controlling weight, to any medical opinion(s) or prior administrative medical finding(s), including those from your medical sources.” 20 C.F.R. § 404.1520c. However, the claim in the present case was filed before March 27, 2017, and the Court has therefore analyzed Plaintiffs claims pursuant to the treating physician rule set out above.

because the decision on that issue is teserved for the Commissioner alone. 20 C.F.R. § 404.1527(d). Where an ALJ declines to give controlling weight to a treating source opinion, he must “sive good teasons in [his] . . . decision for the weight” assigned, taking the above factors into account. 20 C.F.R. § 404.1527(c)(2). This requires the AL] to provide “sufficient explanation fot ‘meaningful teview’ by the courts.” Thompson v. Colvin, No. 1:09CV278, 2014 WL 185218, at *5 (M.D.N.C. Jan. 15, 2014) (quotations omitted). Notably, “[w]hile an ALJ may choose to give less weight to the testimony of a treating physician if there is persuasive contrary evidence, the ALJ may not cherty-pick trivial inconsistencies between a treating physician’s opinion and the record or take evidence out of context to discount the physician’s opinion.” Meyet-Williams v. Colvin, 87 F. Supp. 3d 769, 772 (M.D.N.C. 2015) (internal citations and quotation omitted); see also Lewis v. Berryhill, 858 F.3d 858, 869 (4th Cit. 2017) (quoting Denton v. Asttue, 596 F.3d 419, 425 (7th Cir. 2010) (“An ALJ has the obligation to consider all relevant medical evidence and cannot simply chertypick facts that support a finding of nondisability while ignoring evidence that points to a disability finding.”)). The Fourth Circuit has recently confirmed the application of the treating physician rule in Atakas v. Commissioner, 983 F.3d 83 (4th Cir. 2020) and Dowling v. Commissioner, 986 F.3d 377 (4th Cir. 2021). In Arakas, the Fourth Circuit “emphasized that the treating physician tule is a robust one: ‘[T]he opinion of a claimant’s treating physician [must] be given great weight and may be disregarded only if thete is persuasive contradictory evidence.” Arakas, 983 F.3d at 107 (quoting Coffman v. Bowen, 829 F.2d 514, 517 Ath Cir. 1987)). Thus, “the opinion must be given controlling weight wa/ess it is based on medically unacceptable clinical or

laboratory diagnostic techniques ot is contradicted by the other substantial evidence in the record.” Id. (emphasis in original). Similarly, in Dowling, the Fourth Circuit emphasized that

even if a “medical opinion was not entitled to controlling weight, it does not follow that the AL] had free teign to attach whatever weight to that opinion that he deemed fit. The ALJ was requited to consider each of the six 20 C.F.R. § 404.1527(c) factors before casting [treating physician] opinion aside. Dowling, 986 F.3d at 385. “While an AL] is not required to set forth

a detailed factot-by-factot analysis in order to discount a medical opinion from a treating physician, it must nonetheless be apparent from the ALJ's decision that he meaningfully considered each of the factors before deciding how much weight to give the opinion.” Id. In the present case, Plaintiffs treating primary cate physician, Dr. Nathan Sison, provided an opinion in a treatment record in February 2018 (Tr. at 1142) and in a six-page Medical Source Statement and separate letter in April 2018 (Tr. at 1255-61, 1262.) Dr. Sison had been treating Plaintiff approximately once a month since October 2017. At a visit in November 2017, Dr. Sison noted that Plaintiff had “severe peripheral neuropathy” due to alcohol use that “significantly limits his mobility.” (Ir. at 1226.) In a February 2018 treatment record, Dr. Sison included a letter providing: [Plaintiff] is under my care as his primary care physician. He is unable to work consistently due to debilitating pain in his feet, legs, and hands. Please afford all due accommodations and exceptions to him as we work together to improve his quality of life and pain control. (Tr. at 1142.) Two months later, in April 2018, Dr. Sison prepared another letter, which read: My name is Nathan Sison, MD and I am Stephen Douglas Reaves’ primaty cate physician (DOB .../1970). I have been his physician since October 2017 and have seen him neatly monthly since then. In my medical opinion, Mr. Reaves has a painful and significant peripheral neuropathy in his feet and legs and

sevet[ely] decreases the time and distance he can ambulate without severe pain. This has limited his ability to travel and work on a regulat and meaningful basis. (Tr. at 1262). Dr. Sison’s medical records reflect monthly treatment visits for alcoholic petipheral neuropathy, with repeated increasing of Plaintiffs medications in an effort to control his pain without narcotic medications in light of his history of substance abuse. □□□□ at 1226-29, 1154-57, 1149-52, 1144-47, 1138-42, 1131-35, 1435-38, 1398-1400, 1456-58.) In his Medical Source Statement, Dr. Sison explained that he had been Plaintiffs primary care physician since October 2017, and that Plaintiff was diagnosed with “peripheral neuropathy, citthosis, anxiety disorder, panic disorder, and low back pain.” (Tr. at 1255.) Dr. Sison described Plaintiffs symptoms as “bilateral leg pain, numbness, tingling, lower and middle back pain, unsteady gait, shoulder pain.” (I't. at 1255.) With respect to Plaintiffs pain, Dr. Sison explained that Plaintiff had “|b]utning, stinging pain in both feet. Numbness present in both legs from knees down. The symptoms ate continuous but worsened with exertion. Stiff back in morning with pain, continuous shoulder pain bilaterally.” (Tr. at 1255.) Dr. Sison noted that Plaintiff had sensory changes, tenderness, muscle spasm, and abnormal gait. (Tt. at 1255.) He then answered questions on the form reflecting that Plaintiffs pain was “frequently” severe enough to interfere with attention and concentration, that Plaintiff suffered from a “marked limitation” in his ability to deal with work stress, that the longest he he could sit in a work position at a desk was 3 hours and the total he could sit during an 8 hout work day was 3 hours, that the longest he could stand or walk was 15 minutes at a time, that the total cumulate standing or walking was 3 hours in an 8-hour work day, and that he would tequite 4 hours of resting or lying down/reclining in an 8 hour work day. (I't. at 1256-

58.) Dr. Sison further opined that Plaintiff could “never” lift and carry any weight, even 1-5 pounds, could never stoop, and could only occasionally rotate his neck. (T'r. at 1259.) The ALJ addressed Dr. Sison’s opinion along with the opinion of another treating provider, Dr. Shungu. Dr. Shungu provided a letter on June 1, 2017, explaining that: [Plaintiff] has lower extremity neuropathy which causes significant disability. He is unable to ambulate for any significant amount of distance without pain. This limits his ability to travel to and participate in gainful employment. (Tr. at 795.) The ALJ analyzed all of this treating physician opinion evidence as follows: [The AL}] gives little weight to the opinions of Nathan Sison, M.D., and Nicholas Shungu, M.D. Dr. Sison opined the claimant has limited ability to travel and work and has marked mental limitations. Dr. Shungu opined the claimant has limited ability to travel and engage in gainful employment. They did not provide an adequate explanation for theit opinions. In addition, their opinions ate not consistent with the medical evidence analyzed above. For example, both Dr. Forero and Dr. Burgess [the consultative examiners] opined the claimant is able to perform basic work activities. Further, the undersigned notes determination of disability is an issue reserved solely for the Commissioner. Therefore, the undersigned afforded little weight to these opinions. (Tt. at 22-23 (internal citations omitted).) With respect to this analysis, it is true that the final determination of whether an individual is disabled is for the Commissioner. However, Dr. Sison included specific functional limitations in his Medical Source Statement, including that Plaintiff could stand and/or walk for a total of 3 hours per workday, not including rest periods, could sit no more than a cumulative total of 3 houts per workday, would requite 4 houts per workday resting/reclining, and required further limitations as to balancing, stooping, and bending. (Tr. at 1257-59.) The AL] did not address these specific functions in assigning Dr. Sison’s opinion little weight. (Tr. at 22-23.) Instead, she more generally concluded that Dr. Sison’s opinion did not include “adequate explanation” and was “not consistent with the

medical evidence analyzed above.” (Tr. at 23). The ALJ considered a similar analysis at length in Dowling: The AL] explained that he afforded only negligible weight to [the treating physician’s] medical opinion because he found the opinion to be inconsistent with other evidence in the tecord, and the basis for the opinion was “not adequately explained” by [the treating physician]. This explanation by the ALJ touches on two of the Section 404.1527(c) factors -- consistency and suppottability. However, there is no indication that the ALJ actually undertook the tequited analysis of [the treating physician] opinion. Indeed, the AL] never so much as acknowledged the existence of the Section 404.1527(c) factots. Moreover, the ALJ was completely silent as to the remaining four Section 404.1527(c) factors; for instance, the AL] considered neither the “[llength of the treatment telationship and the frequency of examination,” nor the “[nJature and extent of the treatment relationship.” 20 C.F.R. § □□□□□□□□□□□□□□□□□□□□□ The AL)’s failure to consider each of the Section 404.1527(c) factors was error. While an AL] is not requited to set forth a detailed factor-by-factor analysis in otder to discount a medical opinion from a tteating physician, it must nonetheless be appatent from the AL]’s decision that he meaningfully considered each of the factors before deciding how much weight to give the opinion. See Arakas, 983 F.3d at 107 n.16 (“20 C.F.R. § 404.1527(c) requires © ALJs to consider a// of the enumerated factors in deciding what weight to give a medical opinion.” (emphasis in original)); Newton v. Apfel, 209 F.3d 448, 456 (5th Cir. 2000) (agreeing with the “[s]everal federal courts [that] have concluded that an AL] is required to consider each of the § 404.1527[c] factors” when weighing the medical opinion of a treating physician). In this case, it is far from apparent that the ALJ considered -- or was even aware of -- each of the Section 404.1527(c) factors. In addition to ignoring a majority of the specific factors, the AL]’s decision was bereft of any reference to the factors as a whole. The AL} simply declared that he possessed “the discretion to give less [than controlling] weight” to the opinion of the treating physician. J.A. 15. The ALJ nevet so much as hinted that his discretion was checked by the factors enumerated in Section 404.1527(c), which it is. In failing to acknowledge and apply each of these six factors, the AL] erted. Dowling, 986 F.3d at 385-86; see also Arakas, 983 F.3d at 106 (“The AL]’s conclusion that ‘[t]he lack of substantial support from the other objective evidence of record render[ed] [Dtr. Hatpet’s] opinion less persuasive,’ . .. was erroneous for multiple reasons. To start, it is vague and conclusoty, as the AL] did not specify what ‘objective evidence’ he was referring to. . . . 13

The AL]’s cutsoty explanation fell far short of his obligation to provide a narrative discussion [of] how the evidence support[ed] [his] conclusion, and [a]s such, the analysis is incomplete and precludes meaningful review.” (internal quotations omitted)). In the present case, as in Dowling, even if the AL]’s general explanation provided a basis for not giving Dr. Sison’s opinion conttolling weight, “it does not follow that the ALJ had free reign to attach whatever weight to that opinion that [she] deemed fit,” and there is no indication that the ALJ actually undertook the required analysis of each of the relevant factors. See Dowling, 986 F.3d at 385. Moteover, in the present case, the only specific alleged inconsistency identified by the AL] as to Plaintiffs physical limitations was the inconsistency of Dr. Sison’s opinion with that of Dr. Foreto, the consultative examiner, who the AL] said “opined the claimant is able to perform basic work activities.” (Tr. at 23.) However, even if a single examination by a consultative examiner were alone sufficient to reject a treating physician opinion, in this case Dr. Forero, the consultative examiner, found Plaintiff moderately limited in his ability to sit, stand, move about, lift, and carry. (Tr. at 22, 771-72.) Upon examination, Dr. Forero noted Plaintiffs poor balance, “decteased sensation in both lower extremities to the feet,” difficulty tising from both seated and supine positions, and inability to walk heel to toe. (Tr. at 22, 771- 72.) Dr. Foteto also found, but the AL] did not mention, that Plaintiff was unable to squat, had a significantly decreased range of motion in his knees and hips, could not walk a block at

a teasonable pace on uneven terrain, and could only walk “about '2 block” before becoming fatioued and expetiencing pain in his feet. (Tr. at 769, 772.) With respect to diagnosis and prognosis, Dr. Forero noted: “Peripheral Neuropathy — lower extremities causing permanent

pain and moderate disability.” (I'r. at 772.)5 The ALJ accorded Dr. Forero’s opinions only “some weight” because the examiner “did not provide a specific function-by-function assessment of [Plaintiffs] abilities.” (Tr. at 22.) However, even accepting this explanation, Dr. Forero’s underlying findings clearly support some degree of postural and walking restrictions, both of which were ultimately omitted from Plaintiff's RFC, and it is not cleat how Dr. Foteto’s opinion provides a basis for completing discounting the limitations found by treating physician Dr. Sison.° .

Notably, the ALJ gave great weight only to the non-examining state agency medical consultants in formulating the RFC. In doing so, the AL] explained as follows: The undersigned gives great weight to the assessments of the state agency medical consultants, which conclude the claimant is able to perform light work, with additional limitations (Ex. 1A, 13-15; Ex. 3A, 13-14). The state agency consultants ate familiar with our program. In addition, the state agency consultants had an opportunity to view the claimant’s conditions and their treatment as a whole. Further, the state agency consultants’ assessments are generally consistent with the medical evidence analyzed above. For example, both Dr. Forero and Dr. Burgess [the consultative examiners] opined the claimant is able to perform basic work activities... The [RFC] as formulated above accounts for the claimant’s problems with a limitation to light work, with additional limitations. Moreover, the current evidence does not support the inclusion of manipulative limitations. As discussed above, Dr. Forero found [the] ability to pinch, grasp, and manipulate and [a] normal range of motion of [the] bilateral wrists and hands.

° The Psychiatric Consultative Examiner, Ms. DeLarosa under supervision of Dr. Burgess, similarly noted that Plaintiff “ambulated slowly with a slight limp,” and reported neuropathy and lower extremity pain. (I'r. at 774.) ° Notably, the AL] failed to reconcile any of Dr. Forero’s findings with her conclusion that Plaintiff could stand and walk for six houts in an eight-hour day with no postural limitations. ‘The only reasons the ALJ gave for assigning Dr. Forero’s opinion “some weight” were Dr. Forero’s failure to provide a function-by-function assessment and the lack of clinical findings to support manipulative limitations. Neither of these reasons ptovide a basis to wholly discount Dr. Forero’s underlying findings relating to Plaintiff's standing, walking, and postural difficulties. 15

(Tr. at 23.) The ALJ’s discussion clearly implies that the State agency consultants included the same “additional limitations” in their assessments. Howevet, upon review, striking differences appeat between the two. The consultant on reconsideration, Dr. Evelyn Jimenez-Medina, opined restrictions identical to those ultimately included in the RFC, including the abilities to stand, walk, and sit for a total of 6 hours each in an eight-hour workday. (Tr. at 97-98.) Notably, Dr. Jiminez-Medina posited no additional postural or environmental limitations. (Tr. at 97.) In contrast, Dr. Quinlan, the initial consultant, opined that Plaintiff was limited to standing and/or walking for a total of 2 hours in an eight-hour workday. (Tr. at 79.) Dr. Quinlan further opined that, chiefly due to Plaintiffs poor balance, he was limited to only occasional stooping, kneeling, crouching, crawling, balancing, and climbing of ramps and and he should never climb ladders, ropes, or scaffolds. (Tr. at 79-80.) In terms of environmental limitations, Dr. Quinlan found that Plaintiffs balance issues would also pteclude all work involving hazards such as machinery and unprotected heights, and that Plaintiff should avoid concentrated exposute to extreme temperatures and humidity due to his “chronic systemic disease.” (Tr. at 80.) Despite assigning “great weight” to the State agency opinions, the AL] failed to acknowledge the inconsistencies between the two assessments, let alone explain why she favored the findings of Dr. Jiminez-Medina over those of Dr. Quinlan. The ALJ’s failure to address the standing, walking, and postural limitations opined by Dr. Quinlan is particularly problematic given Plaintiffs documented difficulties in these areas, as described in his treatment notes, testimony, and the medical opinions of Drs. Forero and Sison, all of which the ALJ discounted in favor of the State agency assessments. See also Arakas, 983 F.3d at 110

(“Moreovet, under the factors listed in 20 C.F.R. § 404.1527(c), the ALJ’s decision to assign gteater weight to the non-examining, non-treating consultants’ opinions than to [the treating physician’s opinion] makes little sense. Under the regulation, greater weight is generally accotded to the medical opinion of a soutce who has examined the claimant; a source who has tteated the claimant; and a specialist in the relevant area of medicine. 20 C.F.R. § 404.1527(c)(1), (2), (5).”). In sum, the ALJ’s failure to adequately address the inconsistencies in the State agency consultants’ opinions, coupled with her more general failure to fairly and adequately address the medical opinion evidence, particularly the treating physician opinions of Dr. Sison, resulted in a decision that is not fairly susceptible to judicial review, and a resulting RFC assessment that is unsupported by substantial evidence.’ In light of the recommended remand, the Court need not address Plaintiffs additional contentions at this time.® IT IS THEREFORE RECOMMENDED that the Commissionet’s decision finding no disability be REVERSED, and that the matter be REMANDED to the Commissioner under sentence four of 42 U.S.C. § 405(g). Defendant’s Motion for Judgment on the Pleadings

7 The Coutt notes that it may well be that the limitations noted by Dr. Sison resulting from Plaintiffs alcoholic peripheral neuropathy, even if adopted in full, would not persist if Plaintiff stopped the substance use, and would therefore result in the same RFC adopted by the ALJ (with a similar conclusion that Plaintiff is not disabled for purposes of the Act). However, the ALJ did not undertake this analysis and the Court cannot do so in the first instance. This analysis must be undertaken by the ALJ, with further development of the record if necessary. 8 The Court does note that the record includes some evidence of osteoarthritis not addressed by the ALJ. Gee, eg. Tr. at 1398, 1408, 1173, 1175.) On remand, the ALJ can fully consider all of the issues raised by Plaintiff on a complete record. 17

[Doc. #13] should be DENIED, and Plaintiff's Motion for Judgment on the Pleadings [Doc. #11] should be GRANTED to the extent set out herein. This, the 26 day of February, 2021.

/s/ Joi Elizabeth Peake United States Magistrate Judge