Opinion
1:20-CV-00446 EAW
2021-07-30
MY-LEIN L., Plaintiff, v. COMMISSIONER OF SOCIAL SECURITY, Defendant.
Justin David Jones, Kenneth R. Hiller, Law Offices of Kenneth Hiller, PPLC, Amherst, NY, for Plaintiff. Judith Cohen, Social Security Administration Office of General Counsel, New York, NY, for Defendant.
Justin David Jones, Kenneth R. Hiller, Law Offices of Kenneth Hiller, PPLC, Amherst, NY, for Plaintiff.
Judith Cohen, Social Security Administration Office of General Counsel, New York, NY, for Defendant.
DECISION AND ORDER
ELIZABETH A. WOLFORD, Chief Judge INTRODUCTION
Represented by counsel, Plaintiff My-Lein L. ("Plaintiff") brings this action pursuant to Titles II and XVI 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 applications for disability insurance benefits ("DIB") and supplemental security income ("SSI"). (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. 15; Dkt. 19), and Plaintiff's reply (Dkt. 20). For the reasons discussed below, the Commissioner's motion (Dkt. 19) is granted and Plaintiff's motion (Dkt. 15) is denied.
BACKGROUND
Plaintiff protectively filed her applications for DIB and SSI on December 8, 2016. (Dkt. 12 at 19, 65, 75). In her applications, Plaintiff alleged disability beginning April 1, 2013, due to migraines, a chipped tailbone, and degenerative disc disease. (Id. at 19, 56-57, 66-67). Plaintiff's applications were initially denied on March 31, 2017. (Id. at 19, 76-83). A video hearing was held before administrative law judge ("ALJ") Robert Wright on January 2, 2019. (Id. at 19, 30-55). Plaintiff appeared in Buffalo, New York and the ALJ presided over the hearing from Albany, New York. (Id. ). On February 21, 2019, the ALJ issued an unfavorable decision. (Id. at 16-25). Plaintiff requested Appeals Council review; her request was denied on February 14, 2020, making the ALJ's determination the Commissioner's final decision. (Id. at 5-7). This action followed.
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 righthand corner of each document.
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 Parker 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), 416.920(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), 416.920(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), 416.920(d). If the impairment meets or medically equals the criteria of a Listing and meets the durational requirement (id. §§ 404.1509, 416.909), 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), 416.920(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), 416.920(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), 416.920(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 and 416.920. Initially, the ALJ determined that Plaintiff last met the insured status requirements of the Act on June 30, 2018. (Dkt. 12 at 22). At step one, the ALJ determined that Plaintiff had not engaged in substantial gainful work activity since April 1, 2013, the alleged onset date. (Id. ).
At step two, the ALJ found that Plaintiff suffered from the severe impairments of: "anemia, metro menorrhagia, obesity and headaches." (Id. ).
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. ). The ALJ particularly considered the criteria of Listing 7.02 in reaching his conclusion, as well as considering the effect of Plaintiff's obesity as required by Social Security Ruling ("SSR") 02-1p. (Id. ).
Before proceeding to step four, the ALJ determined that Plaintiff retained the RFC to perform the full range of sedentary work as defined in 20 C.F.R. §§ 404.1567(a) and 416.967(a). (Id. ).
At step four, the ALJ found that Plaintiff had no past relevant work. (Id. at 24).
At step five, the ALJ found 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. (Id. ). Accordingly, the ALJ found that Plaintiff was not disabled as defined in the Act. (Id. at 24-25).
II. The Commissioner's Determination is Supported by Substantial Evidence and Free from Legal Error
Plaintiff asks the Court to reverse or, in the alternative, to remand this matter to the Commissioner, arguing that the RFC is not supported by substantial evidence because the ALJ did not rely on opinion evidence in assessing the RFC, as he assigned only partial weight to every medical opinion in the record. (Dkt. 15-1 at 1, 10-15). Plaintiff contends that, as a result, the ALJ "relied on raw medical data" to make the RFC finding, and "by failing to assign controlling weight to any opinion, it is unclear how the ALJ determined Plaintiff could perform sedentary work." (Id. at 11). The Court has considered this argument and, for the reasons discussed below, finds it without merit.
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). An ALJ's conclusion need not "perfectly correspond with any of the opinions of medical sources cited in his decision." Id. However, an ALJ is not a medical professional, and "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 omitted). In other words:
An ALJ is prohibited from ‘playing doctor’ in the sense that ‘an ALJ may not substitute his own judgment for competent medical opinion.... This rule is most often employed in the context of the RFC determination when the claimant argues either that the RFC is not supported by substantial evidence or that the ALJ has erred by failing to develop the record with a medical opinion on the RFC.
Quinto v. Berryhill , No. 3:17-cv-00024 (JCH), 2017 WL 6017931, at *12 (D. Conn. Dec. 1, 2017) (citations omitted). "[A]s a result[,] an ALJ's determination of RFC without a medical advisor's assessment is not supported by substantial evidence." Dennis v. Colvin , 195 F. Supp. 3d 469, 474 (W.D.N.Y. 2016) (quotation and citation omitted).
Plaintiff's argument, which is based on the ALJ's assignment of "partial weight" to the opinion evidence, is a non-starter. It is well settled that the ALJ is not required to formulate the RFC by adopting any one medical opinion in its entirety. See Matta , 508 F. App'x at 56 ; see also William M. v. Comm'r of Soc. Sec. , No. 1:19-CV-1665-DB, 2021 WL 3077885, at *4 (W.D.N.Y. July 21, 2021) (explaining that determination of the RFC is not a medical determination but an administrative finding which is reserved to the Commissioner, and "the ALJ's conclusion need not perfectly correspond with any of the opinions of medical sources cited in his decision, because the ALJ is entitled to weigh all of the evidence available to make an RFC finding that is consistent with the record as a whole" (alterations, citations, and quotations omitted)); Janet L. K. v. Saul , No. 1:20-CV-0725 (GTS), 2021 WL 2592899, at *4 (N.D.N.Y. June 24, 2021) ("The ALJ need not adopt opinions in their entirety, but may instead adopt only those portions that she finds to be consistent with the record as a whole."). Accordingly, to the extent Defendant's argument for remand rests on the fact that the ALJ did not adopt in their entirety the limitations included in any one medical opinion in the record, that argument is contrary to established law and remand is not required on that basis.
Further, contrary to Plaintiff's implication (see Dkt. 15-1 at 13), this is not a case where there were no medical opinions in the record and the ALJ formulated the RFC in a vacuum. Rather, the ALJ relied on opinion evidence offered by Nikita Dave, M.D., the consultative examiner, and J. Koenig, M.D., the state agency doctor, in assessing the RFC. The ALJ discussed those opinions and explained the weight he afforded to them:
As for the opinion evidence, partial weight is assigned to the opinion of Dr. Dave, MD (2F). Dr. Dave assessed the claimant with mild limitations for prolonged sitting, prolonged standing and prolonged walking due to lumbar spine and moderate limitations for lifting, carrying, pushing and pulling of heavy objects (2F6). The overall record, including the complaints of fatigue and recurring migraines, supports closer to moderate limitations in prolonged standing. Likewise, partial weight is assigned to the opinions of Dr. Koenig, MD (1A and 3A). The opinions of Dr. Koenig, MD are similar to those of Dr. Dave, MD. However, based on the claimant's appearance at the hearing and history of fatigue the undersigned finds that a range of sedentary work is more consistent with the overall record.
(Dkt. 12 at 23-24).
The Court has reviewed the opinion evidence offered by Dr. Dave and Dr. Koenig. Dr. Dave, an internist, examined Plaintiff on February 3, 2017. (Id. at 264-68). After reviewing Plaintiff's complaints and medical history (id. at 264-65), Dr. Dave performed a physical examination and a mental status screen of Plaintiff (id. at 265-67). Plaintiff's physical examination was largely normal, but showed some tenderness to the bilateral trapezii, cervical paraspinals, and occipitalis muscles. (Id. ). Consistent with the results of her physical examination, Dr. Dave offered the following medical source statement:
Mild limitations for prolonged sitting, prolonged standing, and prolonged walking due to lumbar spine. With regard to the abdomen hernias and repairs, the claimant would have moderate limitations for lifting, carrying, pushing, and pulling of heavy objects. No other limitations based on the physical evaluation.
(Id. at 268). Dr. Koenig assessed similar limitations, opining that Plaintiff could occasionally lift and/or carry 20 pounds, frequently lift and/or carry 10 pounds, stand and/or walk (with normal breaks) about six hours in an eight-hour workday, sit (with normal breaks) about six hours in an eight-hour workday, and push/pull (including the operation of hand and/or foot controls) for an unlimited amount, other than the restrictions for lifting and carrying. (Id. at 60-61, 70-71). Dr. Koenig also opined that Plaintiff should avoid concentrated exposure to humidity, noise, and fumes, odors, dusts, gases, and poor ventilation, based on Plaintiff's complaints of migraines. (Id. at 61-62, 71-72). The exertional limitations assessed by Drs. Dave and Koenig are fully accounted for by the RFC, which requires that Plaintiff perform sedentary work. Sedentary work "involves lifting no more than 10 pounds at a time and occasionally lifting or carrying articles like docket files, ledgers, and small tools. Although a sedentary job is defined as one which involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking and standing are required occasionally and other sedentary criteria are met." See 20 C.F.R. §§ 404.1567(a) and 416.967(a) ; see also Jessica J. L. v. Saul , No. 18-CV-399-A, 2021 WL 1405788, at *2 (W.D.N.Y. Apr. 14, 2021) ("Sedentary work generally involves six hours of sitting and two hours of standing or walking during an eight-hour workday." (alterations, quotations, and citations omitted)). As explained above, Dr. Dave found that Plaintiff had moderate limitations for lifting and carrying heavy objects, and Dr. Koenig found that Plaintiff could occasionally carry and lift up to 20 pounds and frequently carry and lift up to 10 pounds. For prolonged sitting, standing, and walking, Dr. Dave found that Plaintiff had mild limitations, and Dr. Koenig found that Plaintiff could sit, stand, and walk for up to six hours in an eight-hour workday.
At her administrative hearing, Plaintiff testified that she suffered from migraines and uterine bleeding. (Dkt. 12 at 36, 48-49). Her headaches were triggered by over exertion (id. at 42, 49), and her bleeding became worse the more standing she did (id. at 48). Plaintiff underwent cervical surgery, which she testified improved her headaches and that her bleeding "stopped completely." (Id. at 50). The RFC for sedentary work, which imposes significant exertional limitations including limited standing and walking, appears to accommodate Plaintiff's described limitations.
Despite that the ALJ did not adopt in its entirety either Dr. Dave's or Dr. Koenig's opinion, Plaintiff points to no evidence demonstrating that the RFC does not incorporate the exertional limitations assessed by both doctors. In fact, the limitations contained in the RFC are more restrictive than the limitations assessed by Drs. Dave and Koenig, which are arguably consistent with an RFC for light work. See, e.g., April B. v. Saul , No. 8:18-CV-682 (DJS), 2019 WL 4736243, at *5 (N.D.N.Y. Sept. 27, 2019) ("moderate limitations in standing and walking are consistent with light work"); Michael V. v. Comm'r of Soc. Sec. , No. 6:18-CV-0481 (GTS), 2019 WL 4276722, at *5 n.3 (N.D.N.Y. Sept. 10, 2019) ("Courts have held that ‘moderate’ lifting or carrying limitations are consistent with RFC limitations to light work."); Gurney v. Colvin , No. 14-CV-688S, 2016 WL 805405, at *3 (W.D.N.Y. Mar. 2, 2016) (finding that moderate limitations for "repetitive heavy lifting, bending, reaching, pushing, pulling or carrying" are consistent with an RFC for a full range of light work). Although Drs. Dave and Koenig indicated that Plaintiff had mild-to-moderate limitations for performing these activities, the ALJ imposed an RFC for sedentary work, which affords Plaintiff more generous limitations. The fact that the ALJ imposed more restrictive limitations is not a basis for remand. See Angelia J. v. Comm'r of Soc. Sec. , No. 19-cv-00272, 2021 WL 2715801, at *3-4 (W.D.N.Y. July 1, 2021) (rejecting the plaintiff's argument that remand was required because the ALJ did not fully adopt any particular medical opinion, and explaining that "[t]he inclusion of postural limitations represented a more restrictive RFC than assessed by the treatment providers at ECMC," which "[wa]s not cause for remand as alleged by plaintiff"); Baker o/b/o Baker v. Berryhill , 1:15-cv-00943-MAT, 2018 WL 1173782, at *2 (W.D.N.Y. Mar. 6, 2018) ("[w]here an ALJ makes an RFC assessment that is more restrictive than the medical opinions of record, it is generally not a basis for remand"); Castle v. Colvin , No. 1:15-cv-00113(MAT), 2017 WL 3939362, at *3 (W.D.N.Y. Sept. 8, 2017) ("the fact that the ALJ's RFC assessment did not perfectly match Dr. Balderman's opinion, and was in fact more restrictive than that opinion, is not grounds for remand").
In sum, despite the ALJ's affording "partial weight" to both Dr. Dave's and Dr. Koenig's opinions, the RFC is supported by substantial evidence. Graham v. Colvin , No. 13-CV-940S, 2014 WL 5465460, at *3 (W.D.N.Y. Oct. 28, 2014) ("the opinions of consultative physicians and State agency consultants can constitute substantial evidence where ... they are consistent with the other evidence in the record"). Plaintiff points to no evidence that additional limitations are warranted. See Danielle S. v. Comm'r of Soc. Sec. , No. 1:20-cv-1013-DB, 2021 WL 2227913, at *7 (W.D.N.Y. June 2, 2021) ("While Plaintiff may disagree with the ALJ's RFC finding, Plaintiff has not shown that no reasonable factfinder could have reached the ALJ's conclusions based on the evidence in the record."). Accordingly, remand is not required on this basis.
CONCLUSION
For the foregoing reasons, the Commissioner's motion for judgment on the pleadings (Dkt. 19) is granted and Plaintiff's motion for judgment on the pleadings (Dkt. 15) is denied.
SO ORDERED.