Opinion
1:22-CV-00267 EAW
2023-07-31
JANINE H., Plaintiff, v. COMMISSIONER OF SOCIAL SECURITY, Defendant.
Christopher E. Pashler, Pashler & Devereaux, LLP, Amherst, NY, for Plaintiff. Sergei Aden, Victoria Shiah Treanor, Social Security Administration Office of the General Counsel, Baltimore, MD, Elizabeth Rothstein, Social Security Administration Office of the General Counsel, New York, NY, for Defendant.
Christopher E. Pashler, Pashler & Devereaux, LLP, Amherst, NY, for Plaintiff. Sergei Aden, Victoria Shiah Treanor, Social Security Administration Office of the General Counsel, Baltimore, MD, Elizabeth Rothstein, Social Security Administration Office of the General Counsel, New York, NY, for Defendant.
DECISION AND ORDER
ELIZABETH A. WOLFORD, Chief Judge
INTRODUCTION
Represented by counsel, plaintiff Janine H. ("Plaintiff") brings this action pursuant to Title II of the Social Security Act (the "Act"), seeking review of the final decision of the Commissioner of Social Security (the "Commissioner," or "Defendant") denying her application for disability insurance benefits ("DIB"). (Dkt. 1). This Court has jurisdiction over the matter pursuant to 42 U.S.C. § 405(g). Presently before the Court are the parties' cross-motions for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure (Dkt. 11; Dkt. 13), and Plaintiff's reply (Dkt. 14). For the reasons discussed below, Plaintiff's motion (Dkt. 11) is granted to the extent that the case is remanded for further administrative proceedings, and the Commissioner's motion (Dkt. 13) is denied.
BACKGROUND
Plaintiff protectively filed her application for DIB on December 28, 2015. (Dkt. 6 at 83). In her application, Plaintiff alleged disability beginning May 1, 2006, due to back injury, lupus, fibromyalgia, osteoarthritis, sciatica, and depression. (Id. at 77). Plaintiff's application was initially denied on March 10, 2016. (Id. at 84-88). A hearing was held before administrative law judge ("ALJ") Melissa Lin Jones in Buffalo, New York, on September 6, 2018. (Id. at 37-76). On October 16, 2018, the ALJ issued an unfavorable decision. (Id. at 17-31). Plaintiff requested Appeals Council review; her request was denied on August 30, 2019. (Id. at 6-11).
When referencing the page number(s) of docket citations in this Decision and Order, the Court will cite to the CM/ECF-generated page numbers that appear in the upper right-hand corner of each document.
Plaintiff appealed the Commissioner's decision to the United States District Court for the Western District of New York, and on March 30, 2021, the Honorable Frank P. Geraci, United States District Judge, remanded the case for further administrative proceedings. (Dkt. 7 at 311-19). The Appeals Council remanded the case to the ALJ on June 2, 2021. (Id. at 321-25). On December 14, 2021, ALJ Paul Georger held an online video hearing. (Id. at 257-84). On February 1, 2022, the ALJ issued an unfavorable decision. (Id. at 234-50). This action followed.
LEGAL STANDARD
I. District Court Review
"In reviewing a final decision of the [Social Security Administration ("SSA")], this Court is limited to determining whether the SSA's conclusions were supported by substantial evidence in the record and were based on a correct legal standard." Talavera v. Astrue, 697 F.3d 145, 151 (2d Cir. 2012) (quotation omitted); see also 42 U.S.C. § 405(g). The Act holds that a decision by the Commissioner is "conclusive" if it is supported by substantial evidence. 42 U.S.C. § 405(g). "Substantial evidence means more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Moran v. Astrue, 569 F.3d 108, 112 (2d Cir. 2009) (quotation omitted). It is not the Court's function to "determine de novo whether [the claimant] is disabled." Schaal v. Apfel, 134 F.3d 496, 501 (2d Cir. 1998) (quotation omitted); see also Wagner v. Sec'y of Health & Human Servs., 906 F.2d 856, 860 (2d Cir. 1990) (holding that review of the Secretary's decision is not de novo and that the Secretary's findings are conclusive if supported by substantial evidence). However, "[t]he deferential standard of review for substantial evidence does not apply to the Commissioner's conclusions of law." Byam v. Barnhart, 336 F.3d 172, 179 (2d Cir. 2003) (citing Townley v. Heckler, 748 F.2d 109, 112 (2d Cir. 1984)).
II. Disability Determination
An ALJ follows a five-step sequential evaluation to determine whether a claimant is disabled within the meaning of the Act. See Bowen v. City of New York, 476 U.S. 467, 470-71, 106 S.Ct. 2022, 90 L.Ed.2d 462 (1986). At step one, the ALJ determines whether the claimant is engaged in substantial gainful work activity. See 20 C.F.R. § 404.1520(b). If so, the claimant is not disabled. If not, the ALJ proceeds to step two and determines whether the claimant has an impairment, or combination of impairments, that is "severe" within the meaning of the Act, in that it imposes significant restrictions on the claimant's ability to perform basic work activities. Id. § 404.1520(c). If the claimant does not have a severe impairment or combination of impairments, the analysis concludes with a finding of "not disabled." If the claimant does have at least one severe impairment, the ALJ continues to step three.
At step three, the ALJ examines whether a claimant's impairment meets or medically equals the criteria of a listed impairment in Appendix 1 of Subpart P of Regulation No. 4 (the "Listings"). Id. § 404.1520(d). If the impairment meets or medically equals the criteria of a Listing and meets the durational requirement, id. § 404.1509, the claimant is disabled. If not, the ALJ determines the claimant's residual functional capacity ("RFC"), which is the ability to perform physical or mental work activities on a sustained basis, notwithstanding limitations for the collective impairments. See id. § 404.1520(e).
The ALJ then proceeds to step four and determines whether the claimant's RFC permits the claimant to perform the requirements of his or her past relevant work. Id. § 404.1520(f). If the claimant can perform such requirements, then he or she is not disabled. If he or she cannot, the analysis proceeds to the fifth and final step, wherein the burden shifts to the Commissioner to show that the claimant is not disabled. Id. § 404.1520(g). To do so, the Commissioner must present evidence to demonstrate that the claimant "retains a residual functional capacity to perform alternative substantial gainful work which exists in the national economy" in light of the claimant's age, education, and work experience. Rosa v. Callahan, 168 F.3d 72, 77 (2d Cir. 1999) (quotation omitted); see also 20 C.F.R. § 404.1560(c).
DISCUSSION
I. The ALJ's Decision
In determining whether Plaintiff was disabled, the ALJ applied the five-step sequential evaluation set forth in 20 C.F.R. § 404.1520. Initially, the ALJ determined that Plaintiff last met the insured status requirements of the Act on June 30, 2011. (Dkt. 7 at 240). At step one, the ALJ determined that Plaintiff had not engaged in substantial gainful work activity from her amended onset date of November 22, 2010, through her date last insured of June 30, 2011. (Id.).
At step two, the ALJ found that Plaintiff suffered from the severe impairments of: "sciatica, general osteoarthritis, fibromyalgia and obesity." (Id.). The ALJ further found that Plaintiff's medically determinable impairments of hypertension, hyperlipidemia, esophagitis, gastroesophageal reflux disease, chronic obstructive pulmonary disease (COPD) and/or any pulmonary condition such as asthma, right sided carpal tunnel syndrome, migraine headaches, depression, and anxiety, were non-severe. (Id. at 240-42).
At step three, the ALJ found that Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of any Listing. (Id. at 242-43). The ALJ particularly considered the criteria of Listings 1.15, 1.16, and 14.09 in reaching his conclusion, as well as considering the effect of Plaintiff's obesity as required by Social Security Ruling ("SSR") 19-2p, and her fibromyalgia as required by SSR 12-2p. (Id. at 243).
Before proceeding to step four, the ALJ determined that Plaintiff retained the RFC to perform light work as defined in 20 C.F.R. § 404.1567(b), except that Plaintiff:
can climb ramps and stairs occasionally, never climb ladders, ropes, or scaffolds, balance occasionally, stoop occasionally, kneel occasionally, crouch occasionally, crawl occasionally; the claimant can in humidity and wetness occasionally, in dust, odors, fumes and pulmonary irritants occasionally, in extreme cold occasionally,
in extreme heat occasionally; and sit/stand option, changing positions every 30-minutes.(Id.). At step four, the ALJ found that Plaintiff had no past relevant work. (Id. at 248).
As written, the portion of the RFC stating that "the claimant can in humidity and wetness occasionally, in dust, odors, fumes and pulmonary irritants occasionally, in extreme cold occasionally, in extreme heat occasionally; and sit/stand option, changing positions every 30-minutes," does not make sense. The Court presumes that language should state that Plaintiff could "work" in humidity and wetness occasionally, in dust, odors, fumes and pulmonary irritants occasionally, in extreme cold occasionally, and in extreme heat occasionally, and that she "requires" a sit-stand option.
At step five, the ALJ relied on the testimony of a vocational expert ("VE") to conclude that, considering Plaintiff's age, education, work experience, and RFC, there were jobs that exist in significant numbers in the national economy that Plaintiff could perform, including the representative occupations of photocopy machine operator, ticket seller, and router. (Id. at 249-50). Accordingly, the ALJ found that Plaintiff was not disabled as defined in the Act. (Id. at 250).
II. Remand of this Matter for Further Proceedings is Necessary
Plaintiff asks the Court to remand this matter to the Commissioner, arguing: (1) the RFC determination does not include limitations for reaching, handling, or fingering; (2) the RFC is an impermissible expression of the ALJ's lay opinion; and (3) the ALJ improperly evaluated the treating source opinions. (Dkt. 11-1 at 2). For the reasons explained below, the Court finds that the RFC is not supported by substantial evidence, and therefore remand for further administrative proceedings is required.
A. Evaluation of the RFC and Limitations for Reaching , Handling, and Fingering
Plaintiff's first two arguments challenge the ALJ's assessment of the RFC. First, Plaintiff contends that the ALJ, despite acknowledging that Plaintiff experienced symptoms of hand pain relating to her fibromyalgia and osteoarthritis, did not assess an RFC with manipulative limitations, such as for reaching, fingering, and handling. (Dkt. 11-1 at 15-18). Second, Plaintiff argues that the ALJ assessed the RFC using his own lay medical opinion, including because the record does not include any opinion evidence assessing Plaintiff's work-related functional limitations. (Id. at 18-26).
In response to Plaintiff's contention regarding the lack of manipulative limitations, the Commissioner argues that the ALJ assessed an RFC for light work, which already includes a 20-pound lifting restriction, and allows for frequent lifting or carrying of objects weighing up to 10 pounds. (Dkt. 13-1 at 13). In response to Plaintiff's argument with respect to the lack of medical opinion evidence in the record, the Commissioner contends that an RFC is not required to be supported by any one medical opinion, including because the RFC is an administrative finding within the province of the ALJ. (Id. at 14-16).
In deciding a disability claim, an ALJ is tasked with "weigh[ing] all of the evidence available to make an RFC finding that [is] consistent with the record as a whole." Matta v. Astrue, 508 F. App'x 53, 56 (2d Cir. 2013). While an ALJ's conclusion need not "perfectly correspond with any of the opinions of medical sources cited in his decision," id., an ALJ is not a medical professional, and therefore he "is not qualified to assess a claimant's RFC on the basis of bare medical findings," Ortiz v. Colvin, 298 F. Supp. 3d 581, 586 (W.D.N.Y. 2018) (quotation and citation omitted). At bottom, "[a]n RFC finding is administrative in nature, not medical, and its determination is within the province of the ALJ, as the Commissioner's regulations make clear." Curry v. Comm'r of Soc. Sec., 855 F. App'x 46, 48 n.3 (2d Cir. 2021) (finding it was proper for the ALJ "pursuant to his statutory authority . . . [to] consider[ ] the medical and other evidence in the record in its totality to reach an RFC determination"); see also Monroe v. Comm'r of Soc. Sec., 676 F. App'x 5, 8 (2d Cir. 2017) ("Where . . . the record contains sufficient evidence from which an ALJ can assess the claimant's residual functional capacity, a medical source statement or formal medical opinion is not necessarily required." (quotations, citations, and alteration omitted)).
Despite that the RFC is an administrative finding, it is well-settled that an ALJ must explain how he arrived at the RFC, including by explaining "the link between [the] RFC assessment and the record evidence," so that the Court can undertake a meaningful review of the RFC. See Cherise J. v. Comm'r of Soc. Sec., No. 20-CV-1924MWP, 2023 WL 2472476, at *4 (W.D.N.Y. Mar. 13, 2023) (alteration and citation omitted); see also Cichocki v. Astrue, 729 F.3d 172, 177 (2d Cir. 2013) ("Remand may be appropriate . . . where an ALJ fails to assess a claimant's capacity to perform relevant functions, despite contradictory evidence in the record, or where other inadequacies in the ALJ's analysis frustrate meaningful review.").
Plaintiff testified at her administrative hearing that her pain is mostly focused in her back and her hands due to both carpal tunnel and osteoarthritis. (Dkt. 7 at 267-68). Plaintiff stated that using her hands "too much" or for "too long" makes her pain worse. (Id. at 268). She stated that she can lift five pounds. (Id. at 270). She has braces for her wrists and hands, which she wears when she sleeps. (Id. at 271). She testified that her arms hurt when she washes her hair, and as a result she does not shower as often. (Id. at 273). She cannot keep up with household chores. (Id. at 273-74). As a result of her lupus, Plaintiff's arms burn when she lifts them, they are weak, and sometimes she has trouble holding up her coffee cup or opening baggies. (Id. at 276).
Contrary to the Commissioner's implication that the record does not support that Plaintiff had limitations for the use of her hands (see Dkt. 13-1 at 12-13), Plaintiff's complaints of pain in her upper extremities are substantiated by medical records, including records prior to her date last insured of June 30, 2011. Dr. Swetz began noting Plaintiff's discomfort in her upper extremities in 2009. (See Dkt. 6 at 545 (at January 5, 2009 visit for discomfort due to fibromyalgia, during exam noting discomfort with movement in the bilateral upper extremities)). Although 2009 was prior to the relevant period of disability, Dr. Swetz continued noting Plaintiff's upper arm discomfort, including up through the relevant period of disability. (See, e.g., id. at 565-66, 567-68, 569-70 (on April 12, 2011, April 26, 2011, and May 24, 2011, noting "crepitation, discomfort, limitation and pain with movement of the upper extremities bilaterally")). Dr. Gosy, Plaintiff's pain management specialist, also noted tender points in her upper extremities. (See, e.g., Dkt. 7 at 174-77 (on January 14, 2011, noting that Plaintiff had upper body strength, but also noting tenderness in the upper inferior chest wall region, as well as tenderness over the medial epicondyles bilaterally, i.e., over the wrist and elbow)).
At step two of the sequential evaluation, the ALJ assessed Plaintiff with several severe impairments, including general osteoarthritis and fibromyalgia. (Dkt. 7 at 240). Despite the ALJ's acknowledgement that Plaintiff reported discomfort in her upper extremities caused by her fibromyalgia and/or osteoarthritis, the RFC does not include limitations for Plaintiff's use of her upper extremities and, perhaps more problematic is that the written determination does not explain why the RFC lacks any such limitations. Without further explanation from the ALJ, the Court cannot undertake a meaningful review of the written determination. See Samuel N. v. Comm'r of Soc. Sec., No. 21-cv-6414-FPG, 2023 WL 3962821, at *3 (W.D.N.Y. June 13, 2023) ("Because the ALJ did not explain why he did not include a reaching limitation in the RFC, the Court cannot determine whether or how he intended for the RFC to address Plaintiff's reaching limitation and remand is required." (quotations and citation omitted)); Beers v. Comm'r of Soc. Sec., 449 F. Supp. 3d 96, 100 (W.D.N.Y. 2020) ("It is the ALJ's responsibility . . . to build an accurate and logical bridge from the evidence to his or her conclusion to enable a meaningful review," and "the Court cannot . . . conduct a review that is both limited and meaningful if the ALJ does not state with sufficient clarity the legal rules being applied and the weight accorded the evidence considered." (alterations and citation omitted)).
The Court acknowledges the Commissioner's argument that the RFC is an administrative finding, that the ALJ is not required to base the RFC on any one medical assessment, and that there is no functional assessment in the record opining that Plaintiff requires further limitations. However, this does not excuse the ALJ's duty to explain in the written determination why certain limitations finding support in the record—such as Plaintiff's upper extremity pain and limitations—are not accounted for in the RFC. Here, the ALJ has not adequately explained why he did not credit Plaintiff's consistent complaints of pain in her upper extremities, which are reflected by both her testimony at the administrative hearing and medical records from during the relevant period of disability.
As noted in the written determination, the record before the ALJ contained opinions from various medical sources opining on the ultimate issue of disability, but these opinions did not assess Plaintiff's work-related functional limitations during the period at issue. (See, e.g., Dkt. 7 at 247-48 (discussing reports from treating sources in connection with workers' compensation claims that Plaintiff is partially or totally disabled, as well as reports from other physicians that contained "no specific or appropriate function-by-function assessments of the claimant's work-related abilities")). In March 2016, a state agency medical consultant noted that the record lacked sufficient evidence enabling him to make a determination on Plaintiff's disability claim, including because there was no assessment of Plaintiff's work-related functional limitations in the record. (See Dkt. 6 at 81-82). The ALJ did not order a consultative examination to supplement the record.
Accordingly, the case is remanded for further proceedings. On remand, should the ALJ again conclude that limitations for reaching, handling, and fingering are not required, the ALJ shall specifically explain how he reached this conclusion in the written determination.
B. Plaintiff's Remaining Arguments
As set forth above, Plaintiff has identified additional reasons why she contends the ALJ's decision was not supported by substantial evidence. However, because the Court has already determined, for the reasons previously discussed, that remand of this matter for further administrative proceedings is necessary, the Court declines to reach these issues. See, e.g., Bell v. Colvin, No. 5:15-CV-01160 (LEK), 2016 WL 7017395, at *10 (N.D.N.Y. Dec. 1, 2016) (declining to reach arguments "devoted to the question whether substantial evidence supports various determinations made by [the] ALJ" where the court had already determined remand was warranted); Morales v. Colvin, No. 13cv06844 (LGS) (DF), 2015 WL 13774790, at *23 (S.D.N.Y. Feb. 10, 2015) (the court need not reach additional arguments regarding the ALJ's factual determinations "given that the ALJ's analysis may change on these points upon remand"), adopted, 2015 WL 2137776 (S.D.N.Y. May 4, 2015).
CONCLUSION
For the foregoing reasons, Plaintiff's motion for judgment on the pleadings (Dkt. 11) is granted to the extent that the matter is remanded for further administrative proceedings, and the Commissioner's motion for judgment on the pleadings (Dkt. 13) is denied.
SO ORDERED.