Greene v. Berryhill

          RULING RE: MOTION FOR JUDGMENT ON THE PLEADINGS (DOC. NO. 16) & MOTION TO AFFIRM THE DECISION OF THE COMMISSIONER (DOC. NO. 20)

          Janet C. Hall, United States District Judge

         I. INTRODUCTION

         Plaintiff Jennifer Lee Greene (“Greene”) brings this appeal under section 405(g) of title 42 of the United States Code from the final decision of the Commissioner of the Social Security Administration (“SSA”), which denied her application for Title II disability insurance benefits and Title XVI supplemental security income. See Complaint (“Compl.”) (Doc. No. 1). Greene seeks either reversal or remand of the Decision rendered by Administrative Law Judge (“ALJ”) Ronald J. Thomas, which affirmed the Commissioner's denial. See Mot. for Judgment on the Pleadings (“Mot. to Reverse”) (Doc. No. 16). The Commissioner cross-moves for an order affirming that Decision. See Mot. to Affirm the Decision of the Comm'r (“Mot. to Affirm”) (Doc. No. 20).

         For the reasons set forth below, the Motion for Judgment on the Pleadings is GRANTED. The Motion to Affirm the Decision of the Commissioner is DENIED.

         II. PROCEDURAL HISTORY

         Greene applied for disability insurance benefits on January 5, 2015, and supplemental security income benefits on July 22, 2015, alleging a disability onset date of November 17, 2013, in both applications. See R. at 18. The Commissioner denied Greene's application initially on May 13, 2015, and again upon reconsideration on October 29, 2015. See id. Greene requested a hearing with an ALJ, which was held before ALJ Thomas on October 26, 2016. See id.

         On February 22, 2017, ALJ Thomas issued an unfavorable decision for Greene, affirming the Commissioner's denial and finding that Greene was not disabled. See Id. at 35-36. Specifically, ALJ Thomas found that Greene's impairments did not meet or equal any listing, see id. at 22-25, and that, with her level of residual functional capacity (“RFC”), there were jobs in the national economy that she could perform, see id. at 34- 35. Greene requested review by the Appeals Council, which denied the request on May 23, 2017. See Compl. at 2 ¶ 11. Following that denial, ALJ Thomas's February 22, 2017 Decision became a final decision reviewable by this court. See R. at 1 (Notice of Appeals Council Action). Greene then filed this appeal on July 24, 2017. See Compl.

         III. FACTS

         The court adopts the facts as stated in the parties' Joint Stipulation of Facts (“Stipulation”) (Doc. No. 18), and it will therefore only briefly describe the facts relevant to this opinion.

         Greene was 38 at the time of her hearing in February 2017. See R. at 400. She was last employed as a childcare worker in 2013, when she began experiencing pain that prevented her from lifting and tending to children. See id. at 49. The record in this case begins in September 2013, when Greene saw Dr. Katherine Kedziersky due to pain in her head, neck, arms, hands, thighs, calves, and back that she could not trace to a particular cause and was not responding to physical therapy or medication. See Stipulation at 2. Beginning in January 2014, Greene saw several physician assistants at My Health 1st Urgent Care. See id. at 9-16. On November 10, 2014, Greene began being treated by Dr. John McDougall, a rheumatologist at Yale New Haven Medical Center, for her chronic pain. See id. After Dr. McDougall moved to another hospital in June 2015, Greene established care with Dr. Kofi Mensah, another rheumatologist at Yale New Haven Medical Center, beginning on February 8, 2016. See id. at 6. Drs. McDougall and Mensah both diagnosed Greene with fibromyalgia. See id. at 4, 8.

         IV. STANDARD OF REVIEW

         Under section 405(g) of title 42 of the United States Code, it is not a function of the district court to review de novo the ALJ's decision as to whether the claimant was disabled. See Schaal v. Apfel, 134 F.3d 496, 501 (2d Cir. 1998). Instead, the court may only set aside an ALJ's determination as to social security disability if the decision “is based upon legal error or is not supported by substantial evidence.” Balsamo v. Chater, 142 F.3d 75, 79 (2d Cir. 1998). Substantial evidence requires “more than a mere scintilla, ” but is a “very deferential standard of review.” Brault v. Soc. Sec. Admin., Comm'r, 683 F.3d 443, 447-48 (2d Cir. 2012). It requires “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Id. at 448. If the Commissioner's findings of fact are supported by substantial evidence, those findings are conclusive, and the court will not substitute its judgment for the Commissioner's. 42 U.S.C. § 405(g) (2016); see also Yancey v. Apfel, 145 F.3d 106, 111 (2d Cir. 1998).

         V. DISCUSSION

         Greene argues that ALJ Thomas's decision should be reversed or remanded for three reasons. First, she argues that the ALJ failed to properly apply the treating physician rule to Dr. McDougall's July 2015 opinion and Dr. Mensah's September 2016 opinion. See Mem. of Law in Supp. of Pl.'s Mot. for J. on the Pleadings (“Pl.'s Mem.”) at 1-5. Second, she argues that the ALJ committed legal error when evaluating her symptoms. See id. at 7-12. Third, Greene argues that the ALJ's assessment of her Residual Functional Capacity (“RFC”) was not supported by substantial evidence. See id. at 5-6.

         A. Treating Physician Rule

         SSA regulations give the opinions of treating physicians “controlling weight, ” so long as those opinions are “well-supported by medically acceptable clinical and laboratory diagnostic techniques and [are] not inconsistent with the other substantial evidence in . . . [the] record.” 20 C.F.R. § 416.927(c)(2);^[1] see also Lesterhuis v. Colvin, 805 F.3d 83, 88 (2d Cir. 2015). In other words, “the SSA recognizes a ‘treating physician' rule of deference to the views of the physician who has engaged in the primary treatment of the claimant.” Burgess v. Astrue, 537 F.3d 117, 128 (2d Cir. 2008) (quoting Green-Younger v. Barnhart, 335 F.3d 99, 106 (2d Cir. 2003)). “Even if the treating physician's opinion is contradicted by other substantial evidence, and so is not controlling, it may still be entitled to significant weight ‘because the treating source is inherently more familiar with a claimant's medical condition than are other sources.'” Tankisi v. Comm'r of Social Sec., 521 Fed.Appx. 29, 33 (2d Cir. 2013) (Summary Order) (quoting Schisler v. Bowen, 851 F.2d 43, 47 (2d Cir. 1988)).

         The ALJ declined to give controlling weight to either Dr. McDougall or Dr. Mensah's medical source statements. See R. at 32-33. Greene argues that the ALJ erred by rejecting specific physical limitations described by Greene's treating rheumatologists and instead relying on a letter Dr. McDougall wrote to Greene's counsel several months after his first opinion in which he made the vague statement that Greene could perform light duty work. See Pl.'s Mem. at 2. She also argues that the ALJ failed to assess the factors he was obligated to consider when assigning value to the medical opinions short of controlling weight. See id. at 4. The Commissioner argues that, after reviewing the medical record to reconcile the inconsistency between Dr. McDougall's two medical opinions, the ALJ properly found that, apart from Dr. McDougall's letter, the medical opinions were not supported by the record. See Def.'s Mem. in Supp. of Her Mot. for an Order Affirming the Feb. 22, 2017 Final Decision Pursuant to 42 U.S.C. § 405(g) (“Def.'s Mem.”) (Doc. No. 20) at 3-6.

         1. Dr. McDougall's Opinions

         On July 28, 2015, Dr. McDougall completed a fibromyalgia questionnaire regarding Greene's condition. See R. at 641-45. Dr. McDougall indicated that Greene had “widespread pain or a history of widespread pain in all quadrants of the body that has persisted for at least 3 months” and had tender points in her shoulders, elbows, hips, knees, and chest. R. at 642. He noted that Greene experiences chronic pain in her chest, lower back, shoulder girdles, upper and lower arms, upper legs, and hips. See id. He also observed that Greene had several symptoms, signs, or co-occurring conditions of ...