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West v. Berryhill

United States District Court, D. Connecticut

January 16, 2019

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.


          Michael P. Shea, U.S.D.J.

         In this appeal from the Social Security Commissioner's denial of benefits, claimant Lisa Jean West[1] moves for judgment on the pleadings, arguing that the ALJ failed to properly weigh the medical opinion evidence and erroneously discounted Ms. West's testimony. (ECF No. 15 at 2-10; ECF No. 19.) The Commissioner filed a motion to affirm, arguing that the ALJ gave appropriate weight to the medical opinions and that substantial evidence supported the ALJ's finding that Ms. West was not disabled. (ECF No. 18 at 5-13.) For the reasons that follow, I GRANT in part and DENY in part West's motion for judgment on the pleadings (ECF No. 14), DENY the Commissioner's motion to affirm (ECF No. 18), and REMAND for further proceedings.

         I. Background and Legal Standard

         I assume the parties' familiarity with Ms. West's medical history (summarized in a joint stipulation of facts filed by the parties, ECF No. 16, which I adopt and incorporate herein by reference), the ALJ opinion, the record, the parties' briefs, and the five sequential steps used in the analysis of disability claims. I cite only those portions of the record and the legal standards necessary to explain this ruling.

         “A district court reviewing a final . . . decision pursuant to . . . 42 U.S.C. § 405(g), is performing an appellate function.” Zambrana v. Califano, 651 F.2d 842, 844 (2d Cir. 1981). As such, the Commissioner's decision “may be set aside only due to legal error or if it is not supported by substantial evidence.” Crossman v. Astrue, 783 F.Supp.2d 300, 302-03 (D. Conn. 2010). The Second Circuit has defined substantial evidence as “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) (citation and quotation marks omitted). Substantial evidence must be “more than a mere scintilla or a touch of proof here and there in the record.” Id.

         II. Discussion

         The ALJ determined here at Steps Two and Three that West had three severe impairments (degenerative disc disease, carpal tunnel syndrome, and asthma), but that West's impairments did not meet or equal a Listing. (R. 14-15.) At Step Four, the ALJ concluded that West had the residual functional capacity (“RFC”) to perform light work, with certain functional limitations.[2](R. 16.) For the RFC analysis, the ALJ accorded “great weight” to the opinion of the state's non-examining consultant, Dr. Jeanne Kuslis, which indicated that West could perform light work, and “little weight” to the opinions of Dr. Bulent Atac, West's primary treating physician, and Dr. James Marshall, the Social Security Administration's examining physician, which both supported more severe functional limitations. (R. 20-21.) The ALJ also discounted West's testimony concerning the “intensity, persistence and limiting effects” of her symptoms as “not entirely consistent with the medical evidence and other evidence in the record.” (R. 19.) West now argues that the ALJ improperly gave Dr. Kuslis' opinion more weight than those of Dr. Atac and Dr. Marshall, and that the ALJ also should not have discounted West's testimony. (ECF No. 15 at 2-13.)

         I conclude that the ALJ properly applied the “treating physician rule” to Dr. Atac's opinion, and the ALJ's decision to give both Dr. Atac and Dr. Marshall's opinion “little weight” was supported by substantial evidence. However, the ALJ improperly relied on Dr. Kuslis' opinion, which did not address subsequent evidence that undercut its conclusions, in formulating the RFC. This error warrants remand. Accordingly, I do not reach West's challenge to the ALJ's decision to discount her testimony on the “intensity, persistence and limiting effects” of her symptoms.

         A. Dr. Atac's Opinion

         West argues that the ALJ “grossly mischaracterized the record” in giving “little weight” to the medical opinion of West's primary treating physician, Dr. Bulent Atac, and failed to correctly apply the “treating physician rule” to his opinion. (ECF No. 15 at 3-6.) Because the ALJ applied the substance of the “treating physician rule, ” and the ALJ's decision to give Dr. Atac's opinion “little weight” was supported by substantial evidence, I conclude that the ALJ made no error.

         Under the “treating physician rule, ” “the opinion of a claimant's treating physician as to the nature and severity of the impairment is given controlling weight so long as 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.” Burgess v. Astrue, 537 F.3d 117, 128 (2d Cir. 2008) (internal citation and quotation marks omitted); see 20 C.F.R. § 404.1527(c)(2) (effective Aug. 24, 2012 to March 26, 2017) (same).[3] However, “the opinion of the treating physician is not afforded controlling weight where . . . the treating physician issued opinions that are not consistent with other substantial evidence . . . .” Halloran v. Barnhart, 362 F.3d 28, 32 (2d Cir. 2004). “The regulations further provide that even if controlling weight is not given to the opinions of the treating physician, the ALJ may still assign some weight to those views, and must specifically explain the weight that is actually given to the opinion.” Schrack v. Astrue, 608 F.Supp.2d 297, 301 (D. Conn. 2009); see also 20 C.F.R. § 404.1527(c)(2) (effective Aug. 24, 2012 to March 26, 2017) (“When we do not give the treating source's medical opinion controlling weight, we apply the [following] factors . . . in determining the weight to give the medical opinion. We will always give good reasons in our notice of determination or decision for the weight we give your treating source's medical opinion.”). In deciding how much weight to give a treating physician's opinion, the ALJ must explicitly consider:

(1) the frequency, length, nature, and extent of treatment; (2) the amount of medical evidence supporting the opinion; (3) the consistency of the opinion with the remaining medical evidence; and, (4) whether the physician is a specialist. After considering the above factors, the ALJ must comprehensively set forth his reasons for the weight assigned to a treating physician's opinion.

Greek v. Colvin, 802 F.3d 370, 375 (2d Cir. 2015) (internal citations, quotation marks, and alterations omitted). “The failure to provide good reasons for not crediting the opinion of a claimant's treating physician is a ground for remand.” Id. (citations omitted). Nonetheless, “slavish recitation of each and every factor [is not required] where the ALJ's reasoning and adherence to the regulation are clear.” Atwater v. Astrue, 512 Fed.Appx. 67, 70 (2d Cir. 2013).

         The ALJ first accurately summarized the relevant contents of Dr. Atac's opinion, a Disability Impairment Questionnaire. (R. 20; R. 389-93. (Feb. 8, 2016 opinion of Dr. Atac).) The ALJ then concluded that the opinion merited “little weight, as it is not supported by explanation and is not supported by the relevant medical evidence.” (R. 20.) The ALJ reasoned that the functional limitations Dr. Atac described were “inconsistent with the longitudinal medical record, ” including: “neurological examinations which documented increased tone of the lumbar paraspinals and some decrease in sensation in an L4-L5 distribution without loss of motor strength, coordination or reflexes and with normal gait”; “physical examinations by the treating ...

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