United States District Court, D. Connecticut
RULING AND ORDER
Robert
N. Chatigny United States District Judge
Plaintiff
brings this action against the Commissioner of Social
Security pursuant to 42 U.S.C. §§ 405(g) and
1383(c)(3), challenging the denial of his applications for
Title II disability insurance benefits (“DIB”)
and Title XVI supplemental security income
(“SSI”) benefits.[1] Plaintiff moves for an order
reversing the decision and remanding for payment of benefits.
The
Commissioner moves for an order affirming the denial of
benefits. Because the ALJ did not provide an adequate
statement of reasons for the weight he gave to the opinions
of the plaintiff's treating physicians, as he was obliged
to do by the treating physician rule, the case must be
remanded. On the remand, the ALJ will have an opportunity to
reconsider the weight to be given the medical opinions and
provide a detailed statement of reasons. In addition, it will
be necessary for the ALJ to revisit the issue of the
plaintiff's credibility in light of the ALJ's
reassessment of the weight to be given the medical opinions
under the treating physician rule.
I.
Background
Plaintiff
first applied to the Social Security Administration
(“SSA”) for DIB on June 8, 2009, and for SSI on
April 22, 2010. The SSA determined that plaintiff was
disabled under both programs for a closed period from May 20,
2008 to December 6, 2010, but that he had medical improvement
as of December 7, 2010, which ended his disability. Plaintiff
reapplied for SSI on December 11, 2012 and for DIB the next
day, alleging a disability onset date of September 16, 2011.
Plaintiff met the insured status requirements of the Social
Security Act through March 31, 2016.[2] A disability adjudicator
denied plaintiff's applications on February 5, 2013, and
upon reconsideration on May 16, 2013.
On May
12, 2015, plaintiff appeared with counsel and a
Spanish-language interpreter for a hearing before an ALJ. On
June 11, 2015, the ALJ issued a decision denying benefits.
The Appeals Council denied plaintiff's request for review
on October 18, 2016. This appeal followed.
Plaintiff
was 38 years old on the alleged disability onset date. He has
a ninth or tenth grade education and speaks Spanish; he is
not able to communicate in English. Plaintiff previously
worked as a janitor and car mechanic.
Before
the alleged disability onset date of September 16, 2011,
plaintiff had a history of medical impairments. He
experienced problems with both wrists in 2008, leading to
surgical procedures on his right wrist that year and on his
left wrist in 2010. He had a history of some disc
degeneration at ¶ 5-S1, lower back pain with radiation
into his lower extremities, and Achilles bursitis or
tendinitis. Additionally, he had diagnoses of asthma,
obesity, a shoulder impairment, high cholesterol, and
diabetes mellitus.
A
December 2011 examination showed that plaintiff had acquired
cavovarus feet. In 2012, he underwent surgery for his right
elbow, and in 2013 he underwent a shortening osteotomy of the
right forearm. He received prescriptions for a back brace and
cane in 2013 at his request, though he eventually stopped
using the cane due to wrist pain. That same year, he was
diagnosed with insertional Achilles tendinitis and
post-trauamatic arthritis of the right wrist. X-rays of his
left elbow in 2013 were negative, but X-rays of his feet and
ankles in 2013 and 2014 showed calcaneal enthesophytes. In
2014, he underwent a tendon sheath release surgery for
stenosing tenosynovitis of his left index finger. Later that
year, a cyst was excised from his right little finger. Also
in 2014, he visited the emergency room complaining of lumbar
pain and was diagnosed with lumbar strain. Physical
examinations throughout the period in question showed ongoing
back pain, including posterior spinal tenderness and
paravertebral muscle spasm. Plaintiff's primary care
doctor noted a diagnosis of depression in 2013, 2014, and
2015.
II.
Legal Standard
“A
district court reviewing a final . . . decision [of the
Commissioner] pursuant to . . . 42 U.S.C. § 405(g), is
performing an appellate function.” Zambrana v.
Califano, 651 F.2d 842, 844 (2d Cir. 1981). Accordingly,
the court may not make a de novo determination of whether a
plaintiff is disabled in reviewing a denial of disability
benefits. See id.; Wagner v. Sec'y of Health
& Human Servs., 906 F.2d 856, 860 (2d Cir. 1990).
Rather, the court's function is to ascertain (1) whether
the Commissioner applied the correct legal principles in
reaching her conclusion and (2) whether the decision is
supported by substantial evidence. Johnson v. Bowen,
817 F.2d 983, 985 (2d Cir. 1987). The
“deferential” “substantial evidence”
standard of review does not apply to conclusions of law.
Townley v. Heckler, 748 F.2d 109, 112 (2d Cir.
1984). Absent legal error, however, this court may not set
aside the decision of the Commissioner if it is supported by
substantial evidence. Berry v. Schweiker, 675 F.2d
464, 467 (2d Cir. 1982). “The findings of the
Commissioner of Social Security as to any fact, if supported
by substantial evidence, [are] conclusive . . . .” 42
U.S.C. § 405(g). If the Commissioner's decision is
supported by substantial evidence, it will be sustained, even
if there may also be substantial evidence to support the
plaintiff's position. Schauer v. Schweiker, 675
F.2d 55, 57 (2d Cir. 1982). Substantial evidence is
“such relevant evidence as a reasonable mind might
accept as adequate to support a conclusion.”
Williams v. Bowen, 859 F.2d 255, 258 (2d Cir. 1988)
(quoting Richardson v. Perales, 402 U.S. 389, 401
(1971)). Substantial evidence must be “more than a mere
scintilla or a touch of proof here and there in the
record.” Id.
III.
Discussion
The
Social Security Act establishes that benefits are payable to
individuals who have a disability. 42 U.S.C. §§
423(a)(1), 1381a. A “disability” is an
“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.” Id. §
423(d)(1)(A); see also id. § 1382c(a)(3)(A).
There are five steps in a disability determination: (1) the
Commissioner considers whether the claimant is currently
engaged in substantial gainful activity; (2) if not, the
Commissioner considers whether the claimant has a
“severe medically determinable physical or mental
impairment” which limits his mental or physical ability
to do basic work activities; (3) if so, the Commissioner asks
whether, based solely on the medical evidence, the claimant
has an impairment which “meets or equals” an
impairment listed in Appendix 1 of the regulations. If so,
and the impairment meets the duration requirements, the
Commissioner will consider the claimant disabled, without
considering other factors; (4) if not, the Commissioner then
asks whether, despite the claimant's severe impairment,
he has the “residual functional capacity”
(“RFC”) to perform his past work; and (5) if the
claimant cannot perform his past work, the Commissioner then
determines whether there is other work in the national
economy which the claimant can perform.[3] 20 C.F.R.
§§ 404.1520(a)(4)(i)-(v), 416.920(a)(4)(i)-(v). The
claimant bears the burden of proof at the first four steps,
while the burden shifts to the Commissioner at the last step.
McIntyre v. Colvin, 758 F.3d 146, 150 (2d Cir. 2014)
(citing Brault v. Soc. Sec. Admin., Comm'r, 683
F.3d 443, 445 (2d Cir. 2012); Burgess v. Astrue, 537
F.3d 117, 128 (2d Cir. 2008)).
In this
case, the issues presented by the parties are (1) whether the
ALJ correctly determined that plaintiff's depressive
disorder was non-severe and did not meet or equal the
severity of a listed impairment under 20 C.F.R. Part 404,
Subpart P, Appendix 1; and (2) whether substantial evidence
supports the ALJ's determination that plaintiff's RFC
was for a limited range of unskilled sedentary work.
Regarding plaintiff's RFC, plaintiff challenges (a)
whether the ALJ properly found that reports from a treating
physician, Syed Naqvi, M.D., and treating surgeon, Duffield
Ashmead, M.D., were “not entitled to significant
probative weight”; and (b) whether the ALJ properly
found that plaintiff's statements concerning the
intensity, persistence, and limiting effects of his symptoms
were “not entirely credible.” After careful
review of the record, I agree with the Commissioner that the
ALJ relied on substantial evidence in determining that
plaintiff's depressive disorder was non-severe.
However,
because the ALJ did not comply with the requirements of the
treating physician rule, the case must be remanded. Because
the weight to be given the medical opinions bears on the
plaintiff's credibility, the ALJ must also revisit the
credibility issue.
A.
Depressive Disorder
At step
two of his analysis, the ALJ found that plaintiff had a
medically determinable depressive disorder that was
non-severe because it did not “cause more than minimal
limitation in [plaintiff's] ability to perform basic
mental work activities.” R. at 15. At step three, the
ALJ also found that none of plaintiff's impairments,
including his depressive disorder, met or medically equaled
the severity of one of the listed impairments in 20 C.F.R.
Part 404, Subpart P, Appendix 1. Plaintiff contends that the
ALJ's determinations were not supported by substantial
evidence. The Commissioner responds that the ALJ's
reasoning was supported by substantial
evidence.[4]
Once
the ALJ found that plaintiff had a medically determinable
mental impairment in the form of a depressive disorder, he
next had to consider “four broad functional areas in
which [the ALJ would] rate the degree of [plaintiff's]
functional limitation: Activities of daily living; social
functioning; concentration, persistence, or pace; and
episodes of decompensation.” 20 C.F.R. §
404.1520a(c)(3) (2015).[5] If the plaintiff's degree of
limitation in the first three areas was “none or mild,
” and in the fourth area was “none, ” it
would be proper to find that his impairment was not severe,
“unless the evidence otherwise indicate[d]
that there [was] more than a minimal limitation in
[plaintiff's] ability to do basic work activities.”
Id. § 404.1520a(d)(1) (emphasis added).
In this
case, the ALJ considered the “four broad functional
areas” and concluded that plaintiff's degree of
limitation was “none” in all four. Accordingly,
20 C.F.R. § 404.1520a(d)(1) would direct a finding that
the impairment was not severe unless additional
evidence indicated that there was more than a minimal
limitation in his ability to ...