United States District Court, D. Connecticut
BRUCE E. MATTEO
v.
NANCY A. BERRYHILL, ACTING COMMISSIONER OF SOCIAL SECURITY[1]
RULING ON THE PLAINTIFF'S MOTION TO REVERSE THE
DECISION OF THE COMMISSIONER AND ON THE DEFENDANT'S
MOTION TO AFFIRM
ROBERT
M. SPECTOR, UNITED STATES MAGISTRATE JUDGE
This
action, filed under Section 205(g) of the Social Security
Act, 42 U.S.C. §§ 405(g) and 1383(c)(3), as
amended, seeks review of a final decision by the Commissioner
of Social Security [“SSA”] denying the plaintiff
Disability Insurance Benefits
[“DIB”].[2]
I.
ADMINISTRATIVE PROCEEDINGS
On
April 19, 2012, the plaintiff, Bruce Matteo filed an
application for DIB, in which he alleged that he has been
disabled since September 1, 2007 due to a back injury.
(Certified Transcript of Administrative Proceedings, dated
December 29, 2017 [“Tr.”] 188-91).[3] After exhausting
his administrative remedies, he commenced an action in this
court which resulted in judgment entering in favor of the
plaintiff, and a remand of his case to the Office of
Disability Adjudication and Review's New Haven Hearings
Office. (Tr. 540-43, 545-73; see Matteo v. Colvin,
3:15 CV 440(WWE)(JGM), Doc. No. 19 [“August 2016
Recommended Ruling”], approved and adopted by Senior
United States District Judge Warren W. Eginton, Doc. No. 22;
see generally Tr. 1-282, 574-668, 692-751). Upon
remand, a hearing was held on April 21, 2017, before
Administrative Law Judge [“ALJ”] Deirdre R.
Horton. (Tr. 1471-1522; see generally Tr. 674-81,
767-82, 794-97). On August 2, 2017, the ALJ issued her
decision denying the plaintiff benefits. (Tr. 511-30). No
written exceptions were filed, and the Appeals Council did
not take “own motion” review, thus, the ALJ's
decision became the final, appealable decision of the
Commissioner. See 20 C.F.R. § 404.984(a)
(“[W]hen a case is remanded by a Federal court for
further consideration, the decision of the [ALJ] will become
the final decision of the Commissioner after remand . . .
unless the Appeals Council assumes jurisdiction of the
case.”); 20 C.F.R. § 404.984(d) (“If no
exceptions are filed and the Appeals Council does not assume
jurisdiction of [the] case, the decision of the
administrative law judge becomes the final decision of the
Commissioner after remand.”).
On
December 21, 2017, the plaintiff filed his complaint in this
pending action. (Doc. No. 1), [4] and on February 26, 2018, the
defendant filed her answer and administrative transcript,
dated December 29, 2017 (Doc. No. 16), followed by a
supplemental transcript, dated January 3, 2018. (Doc. No.
20). On June 6, 2018, the plaintiff filed his Motion to
Reverse the Decision of the Commissioner, with Statement of
Material Facts and brief in support. (Doc. No. 25;
see Doc. No. 26 (Amended Statement of Material
Facts)).[5] On July 13, 2018, the parties consented to
the jurisdiction of a United States Magistrate Judge, and the
case was transferred to this Magistrate Judge. (Doc. No. 29).
On July 19, 2018, the defendant filed her Motion to Affirm,
with brief in support. (Doc. No. 30).
For the
reasons stated below, the plaintiff's Motion to Reverse
the Decision of the Commissioner (Doc. No. 25) is
denied, and the defendant's Motion to Affirm the
Decision of the Commissioner (Doc. No. 30) is
granted.
II.
REMAND ORDER
In the
August 2016 Recommended Ruling, Judge Margolis concluded that
remand for the “proper consideration and
treatment” of the opinion of Dr. Gary Linke, the
plaintiff's chiropractor, was appropriate given the long
treatment history “specifically for the back
impairments for which [the plaintiff] claims
disability.” (Tr. 568). Additionally, as stated in the
August 2016 Recommended Ruling:
A remand is particularly important in this case in light of
the balance of the ALJ's treatment of the other opinions
of record. The ALJ concluded that [the] plaintiff is capable
of a more restrictive RFC than the RFC assessment made by
both State medical consultants, . . . but the ALJ did not
discuss their opinions other than to state that they
“do deserve come weight, particularly in a case like
this in which there exist a number of other reasons to reach
similar conclusions.” Similarly, the ALJ assigned
limited weight to Dr. Mongillo's opinion because it
“was based upon a one-time consultative examination[,
]” Dr. Mongillo “did not have diagnostic testing
to review[, ] and the evidence reflects that the claimant
treated with only physical therapy and over-the-counter pain
medication.” However, when an ALJ does not assign
controlling weight to the opinion of the treating provider,
the ALJ must explain the weight given to the opinions of the
State agency consultants by considering the relevant factors
set forth in the Regulations. 20 C.F.R. § 404.1527. The
ALJ failed to do so in this case; upon remand, she shall
properly explain the weight assigned to the opinions of
record.
As for [the] plaintiff's treating providers'
opinions, the ALJ's treatment of such records is
inconsistent in that she assigned them limited weight because
of the timing of such opinions, but yet went on to weigh such
opinions against the record. . . .
(Tr. 568-69) (internal citations omitted). Additionally, as
stated in the August 2016 Recommended Ruling,
“[a]lthough the ALJ did conflate Dr. Parillo's
opinion and his underlying treatment notes, the ALJ was
correct that Dr. Parillo noted improvement in [the]
plaintiff's condition under his case, and noted the
record of improvement in [the] decision.” (Tr. 570)
(internal citations omitted). Judge Margolis concluded that,
on remand, the ALJ must weigh [the] plaintiff's
credibility after, and in light of, proper consideration of
the opinions and the objective evidence of the record. Once
the ALJ revisits the opinions of record consistent with this
remand order, the ALJ shall consider what effect, if any,
such consideration has on [the] plaintiff's RFC and the
corresponding vocational analysis.
(Tr. 571).
Following
Judge Eginton's ruling approving and adopting the August
2016 Recommended Ruling over objection, judgment entered, and
the case was remanded to the Appeals Council. (Tr. 573). The
Appeals Council remand order “vacate[d] the final
decision of the Commissioner of Social Security and
remand[ed] th[e] case to an Administrative Law Judge for
further proceedings consistent with the order of the
court.” (Tr. 542). Additionally, the Appeals Council
directed the ALJ “to offer the claimant the opportunity
for a new hearing, take any further action needed to complete
the administrative record and issue a new decision.”
(Tr. 542).
In her
decision, ALJ Horton stated: “To implement the
Court's remand order, the Appeals Council ordered a new
hearing, without additional instructions. The remand requires
the undersigned to assess pain-related and residual
functional capacity issues described in the “August
2016 Recommended Ruling which was approved and adopted in
September 2016.” (Tr. 514).
III.
FACTUAL BACKGROUND
As
noted above, the plaintiff's alleged onset date was
September 1, 2007, and his date last insured was December 31,
2012. Familiarity with the extensive factual background as it
existed up to October 2013, including the plaintiff's
activities of daily living, his medical records, the
assessments of the State agency consultants, and the medical
opinions, is presumed and is detailed in the August 2016
Recommended Ruling. See Matteo v. Colvin, 3:15 CV
440 (WWE)(JGM), Doc. No. 19 at 2-14.
Following
remand to the ALJ, a hearing was held on April 21, 2017, at
which the plaintiff, APRN Linda Grisgraber, and a vocational
expert testified. (Tr. 1471-1522). Their testimony is
detailed below. See Section IV.B. & IV.E.
infra. At that point, the plaintiff was 47 years old
(Tr. 1477). He testified that he has worn a back brace when
walking since it was prescribed to him in the middle of 2012.
(Tr. 1481-82). The plaintiff recounted that he had performed
food service work until May 2005, following which he
collected unemployment for 26 weeks, and began seeing Dr.
Gary Linke, a chiropractor, and then Dr. Lucien Parillo who
treated the plaintiff with epidural shots in his spine. (Tr.
1483-86). The plaintiff testified that he has been treated by
APRN Grisgraber for the past four years to get him
“mentally balanced[.]” (Tr. 1486). The plaintiff
also testified that, in addition to his back issues, his
hands “clinch up” and he “drops
stuff” but that he declined surgery because he is
“scared” of it. (Tr. 1491-92).
He
testified that his partner performs most of the house and
yard work, and his partner's mother, who lives with them,
“cooks a lot of meals[.]” (Tr. 1494). The
plaintiff also testified that he fell in the previous two
years after losing his balance in his kitchen; CT scans
revealed that he suffered a concussion. (Tr. 1495).
IV.
THE ALJ'S DECISION
Following
the five-step evaluation process, [6] the ALJ found that the
plaintiff did not engage in substantial gainful activity
during the period from his alleged onset date of September 1,
2007 through his date last insured of December 31, 2012. (Tr.
517, citing 20 C.F.R. § 404.1571 et seq.). The
ALJ concluded that through his date last insured of December
31, 2012, the plaintiff had the following severe impairments:
degenerative disc disease of his lumbar spine and minimal
cervical stenosis at ¶ 3-4. (Tr. 517-23, citing 20
C.F.R. § 404.1520(c)). The ALJ explained that APRN
Grisgraber's hearing testimony that the plaintiff's
mental impairments are disabling was not supported by the
chronological treatment history; the record revealed a
history of “favorable mental/cognitive
relationships” with the plaintiff's longtime
employer; and, the record did not support a history of mental
limitations before the plaintiff's date last insured.
(Tr. 517-22). She next found that, through his date last
insured, the plaintiff did not have an impairment or
combination of impairments that met or medically equal the
severity of a listed impairment in 20 C.F.R. Part 404,
Subpart P, Appendix 1. (Tr. 524, citing 20 C.F.R.
§§ 404.1520(d), 404.1525 and 404.1526). The ALJ
noted that the medical evidence did not support a finding
that the plaintiff's back impairment met Listing 1.04 as
he had “no nerve root compression[, ]” he could
walk without an assistive device, and he did not have
“major disc herniation.” (Tr. 524).
At Step
Four, the ALJ concluded that, “[a]fter careful
consideration of the entire record, ” the plaintiff had
the RFC to perform light work as defined in 20 C.F.R. §
404.1567(b) except lifting and carrying was limited to ten
pounds; standing and walking was limited to four hours per
eight-hour workday; he was unable to climb
ladders/ropes/scaffolds or stairs; he could do occasional
stooping and kneeling, and no crouching or crawling; and
could do frequent balancing, handling and reaching. (Tr.
524-28). The ALJ discussed the treatment records of Dr.
Samma, which she found inconsistent and lacking
“clinical findings”; she addressed Dr.
Parillo's treatment records in which “the claimant
described . . . improvement in his pain level and activity
level”; and she discussed Dr. Linke's records and
disability rating in connection with the plaintiff's
worker's compensation case, before concluding that
“his course of chiropractic care, if anything, would
support less work restrictions than are adopted [by the
ALJ].” (Tr. 525-26). Additionally, the ALJ found Dr.
Mongillo's report “more consistent with the State
Agency denial[, ]” and “more consistent with Dr.
Linke's ten percent disability rating than with the
claimant's testimony about alleged, disabling
pain.” (Tr. 526). Finally, the ALJ considered the
consistency of the plaintiff's testimony at the two
hearings, with the underlying medical records, as well as the
plaintiff's pain, which the ALJ noted was managed with
“conservative care.” (Tr. 527-28).
The ALJ
then concluded that, through his date last insured, the
plaintiff was unable to perform his past relevant work as a
cashier, dishwasher and cook's helper (Tr. 528, citing 20
C.F.R. § 404.1565), but that there were jobs that
existed in significant numbers in the national economy that
the plaintiff could have performed, such as the work of an
assembler of small products, an inspector/hand packager, or a
mail room clerk. (Tr. 528-29, citing 20 C.F.R. §§
404.1569 and 1569(a)). Accordingly, the ALJ concluded that
the plaintiff was not under a disability, as defined in the
Social Security Act, at any time from September 1, 2007,
through his date last insured, December 31, 2012. (Tr. 529,
citing 20 C.F.R § 404.1520(g)).
V.
STANDARD OF REVIEW
The
scope of review of a Social Security disability determination
involves two levels of inquiry. First, the court must decide
whether the Commissioner applied the correct legal principles
in making the determination. Second, the court must decide
whether the determination is supported by substantial
evidence. See Balsamo v. Chater, 142 F.3d 75, 79 (2d
Cir. 1998) (citation omitted). The court may “set aside
the Commissioner's determination that a claimant is not
disabled only if the factual findings are not supported by
substantial evidence or if the decision is based on legal
error.” Burgess v. Astrue, 537 F.3d 117, 127
(2d Cir. 2008) (internal quotation marks & citation
omitted); see also 42 U.S.C. § 405(g).
Substantial evidence is evidence that a reasonable mind would
accept as adequate to support a conclusion; it is more than a
“mere scintilla.” Richardson v. Perales,
402 U.S. 389, 401 (1971) (citation omitted); see Yancey
v. Apfel, 145 F.3d 106, 111 (2d Cir. 1998) (citation
omitted). The substantial evidence rule also applies to
inferences and conclusions that are drawn from findings of
fact. See Gonzalez v. Apfel, 23 F.Supp.2d 179, 189
(D. Conn. 1998) (citation omitted); Rodriguez v.
Califano, 431 F.Supp. 421, 423 (S.D.N.Y. 1977)
(citations omitted). However, the court may not decide facts,
reweigh evidence, or substitute its judgment for that of the
Commissioner. See Dotson v. Shalala, 1 F.3d 571, 577
(7th Cir. 1993) (citation omitted). Instead, the court must
scrutinize the entire record to determine the reasonableness
of the ALJ's factual findings. See Id.
Furthermore, the Commissioner's findings are conclusive
if supported by substantial evidence and should be upheld
even in those cases where the reviewing court might have
found otherwise. See 42 U.S.C. § 405(g);
see also Beauvoir v. Chater, 104 F.3d 1432, 1433 (2d
Cir. 1997) (citation omitted); Eastman v. Barnhart,
241 F.Supp.2d 160, 168 (D. Conn. 2003).
VI.
DISCUSSION
A.
PLAINTIF ...