Dr. Thomas Argyros, M.D., a Clinical Professor of Medicine at New York
University School of Medicine, Medical Director at Lenox Hill Hospital in
Manhattan, Chief of Rheumatology at Lenox Hill Hospital, and formerly the
Chief of Lupus Erythematosus and Related Diseases at Bellevue Hospital in
In his January 1995 report, Dr. Argyros stated, "Minsky notes that she
looks as if she has a clear cut case of lupus." His report further states
that during the previous year, in April 1994, when she sat for a time she
had aching in her knees and it was hard to get up. At that time, her
joints were swollen, and she had to be taken off Prednisone because "she
could not function." Dr. Argyros observed that Minsky was "emotional and
cried a lot." Minsky was experiencing "chest pain and shortness of
breath." Testing revealed that the plaintiff's ANA (anti-nuclear
antibody), rheumatoid factor and complement levels all were normal. Her
C3 level was above normal. Dr. Argyros diagnosed undifferentiated
connective tissue disorder. The doctor noted that she was feeling better
and did not need systemic treatment.
On February 15, 1995, Minsky reported to Dr. Argyros that she was "ok"
except that she was very stiff in the morning. Later that year, in August
1995, Dr. Argyros reported that Minsky had been weaned off the adrenal
cortex injections Dr. Stoff prescribed. He noted that Minsky was on no
medication and was in remission.
The doctor's March 13, 1996 notes indicate that Minsky is "doing 16
hour days," which the ALJ interpreted to mean that Minsky was working for
16 hours a day. In Dr. Argyros' records dated between February 1996 and
June 1996, he notes that the plaintiff was experiencing great stress due
to litigation surrounding her former business and her business partner
buying her out. At various times, Minsky was suffering from butterfly
lesions on her face, abdomen and thigh.
In June 1996, following the hearing, Dr. Argyros prepared a
questionnaire, where he stated that Minsky had mixed connective tissue
disease with moderate joint and muscle involvement. He noted moderately
severe mental involvement, with depression; moderately severe facial skin
involvement; severe fatigue; and malaise. Dr. Argyros stated that
although Minsky could sit for 3 hours in an 8 hour day, she could not do
any standing or walking. She could occasionally bend, and occasionally
lift and carry up to 10 pounds; she could never squat, crawl or climb. In
his opinion, she was unable to tolerate customary work pressures.
D. The Non-Examining Social Security Reviewing Physicians
1. Dr. Grace Hughes
In March 1995, Dr. Grace Hughes, a rheumatologist, reviewed Minsky's
medical records on behalf of Social Security, without conducting a
physical examination. Dr. Hughes concluded that Minsky had the residual
functional capacity to occasionally lift and carry 20 pounds, frequently
lift and carry ten pounds, stand and walk 6 hours in an 8 hour workday,
and sit 6 hours in an 8 hour work day.
2. Dr. P.C. Pellegrino
In July 1995, Dr. P.C. Pellegrino, M.D., another non-examining Social
Security review physician, agreed with the assessment of Dr. Hughes.
E. The Expert Testimony at the Hearing
1. Dr. Charles Plotz
Dr. Charles Plotz, a rheumatologist, testified at the hearing as a
medical advisor on behalf of the Commissioner. Dr. Plotz did not examine
Minsky; he merely reviewed her medical records and the reports of her
treating doctors. He stated that Minsky's records showed intermittent
complaints of joint achiness, rash, and other symptoms, which, in Dr.
Plotz's view, the treating physicians correlated to her business problems
and related stress. In
Dr. Plots's opinion, Dr. Stoff's notes indicate virtually nothing, except
for complaints of occasional achiness and some swelling and, in fact,
often describe the plaintiff as doing or feeling well. Dr. Plotz
testified that doctors do not ordinarily use the terms "doing well" or
"feels well" to describe a patient's progress; instead, physicians
generally would use the term "improved."
Dr. Plots noted that in December 1995, all of the tests Dr. Argyros
performed were completely within normal limits. In Dr. Plots's view, the
plaintiff's lack of a response to the large doses of Prednisone indicated
that her disease was not severe. Also, Dr. Plots noted that the record
did not support Dr. Stoff's claim that the plaintiff experienced kidney
failure. Rather, Dr. Plotz stated, the plaintiff experienced urinary
retention and diarrhesis associated with Prednisone.
According to Dr. Plots, the adrenal cortex injections
Dr. Stoff recommended were outdated treatments given 40
to 50 years ago without much benefit, and now are
considered not medically appropriate treatment.
Similarly, Dr. Plots testified that the intravenous
drips were not appropriate priate medical treatment for
a person with apparent symptoms of mixed connective
tissue disease. Also, Dr. Plotz told the ALJ that Dr.
Stoff's finding of elevated virus titers simply meant
that at some time in Minsky's life she was exposed to
the viruses; they did not explain her condition. Dr.
Plots dismissed Dr. Stoff's other findings regarding
fatty acid, aminoacid metabolism and neurotransmitters,
and ACTH levels, because mainstream medical opinion
would be that elevated levels are only associated if
there is independent evidence of the disease. In Dr.
Plots's opinion, there was no basis for significantly
restricting Minsky residual functional capacity.
2. Expert Vocational Test
Lynn Jones, a vocational exert, testified at the
hearing on behalf of the Commissioner regarding the jobs
an individual of Minsky's age, education and work
experience would be able to perform, involving light
exertion and low stress, and not requiring intense
concentration. Jones identified that an individual could
perform such jobs as office mail clerk, hand assembler
and parking lot attendant. If Minsky were restricted to
sedentary work, Jones identified possible jobs such as
assembler, ticket-taker, and sedentary cashier.
3. The ALJ's Findings
The ALJ determined that Minsky was not disabled due to
connective tissue disorder prior to December 31, 1994.
In the ALJ's decision, he found that while the plaintiff
had a severe impairment, it did not meet or equal the
criteria of Section 14.06 of the Listing of
Impairments. The ALJ also found that while Minsky was
not able to perform her past relevant work as a business
manager, kennel worker or credit sales representative,
she retained the residual functional capacity for the
full range of light work, except for lifting more than
20 pounds occasionally or 10 pounds frequently.
The ALJ found that the plaintiff's condition did not
meet the diagnostic criteria of Section 14.06 of the
Listing of Impairments for "undifferentiated connective
tissue disorder." Section 14.06 of the Listing of
Undifferentiated connective tissue disorder (14.06)
— This listing includes syndromes with clinical
and immunologic features of several connective tissue
disorders, but that do not satisfy the criteria for
any of the disorders described; for instance, the
individual may have clinical features of systemic
lupus erythematosus and systemic vasculitis and the
serologic findings of rheumatoid arthritis. It also
includes overlap syndromes with clinical features of
more than one established connective tissue disorder.
For example, the individual may have features of both
rheumatoid arthritis and scleroderma. The correct
designation of this disorder is important for
assessment of prognosis.
20 C.F.R. Pt. 404, Subpt. P, App. 1. The ALJ found that she did not
suffer from any of these diagnostic criteria, and that none of the
laboratory tests indicated she had any of the conditions necessary to
meet the "connective tissue disorder" criteria. Further, the ALJ
determined that even if she met the diagnostic criteria, her impairment,
including her symptoms, did not otherwise meet or equal the criteria of
In addition, the ALJ determined that assuming the diagnostic criteria
of Section 14.06 were met, Minsky's impairment should be assessed under
Section 14.00B. However, the ALJ found that Minsky's impairment did not
meet or equal Section 14.00B. That section requires "significant,
documented, constitutional symptoms and signs of severe fatigue, fever,
malaise, and weight loss. At least one of the organ/body systems must be
involved to at least a moderate level of severity." Section 14.00B of the
Listing of Impairments provides as follows:
14.00 Immune System
(B) Dysregulation of the immune system may result in
the development of a connective tissue disorder.
Connective tissue disorders include several chronic
multisystem disorders that differ in their clinical
manifestation, course, and outcome. They generally
evolve and persist for months or years, may result in
loss of functional abilities, and may require
long-term, repeated evaluation and management.
The documentation needed to establish the existence
of a connective tissue disorder is medical history,
physical examination, selected laboratory studies,
medically acceptable imaging techniques and, in some
instances, tissue biopsy. However, the Social Security
Administration will not purchase diagnostic tests or
procedures that may involve significant risk, such as
biopsies or angiograms. Generally, the existing
medical evidence will contain this information.
A longitudinal clinical record of at least 3 months
demonstrating active disease despite prescribed
treatment during this period with the expectation that
the disease will remain active for 12 months is
necessary for assessment of severity and duration of
To permit appropriate application of a listing, the
specific diagnostic features that should be documented
in the clinical record for each of the disorders are
summarized for systemic lupus erythematosus (SLE),
systemic vasculitis, systemic sclerosis and
scleroderma, polymyositis or dermatomyositis, and
undifferentiated connective, tissue disorders.
In addition to the limitations caused by the
connective tissue disorder per se, the chronic adverse
effects of treatment (e.g., corticosteroid-related
ischemic necrosis of bone) may result in functional
These disorders may preclude performance of any
gainful activity by reason of severe loss of function
in a single organ or body system, or lesser degrees of
functional loss in two or more organs/body systems
associated with significant constitutional symptoms
and signs of severe fatigue, fever, malaise, and
weight loss. We use the term "severe" in these
listings to describe medical severity; the term does
not have the same meaning as it does when we use it in
connection with a finding at the second step of the
sequential evaluation processes in §§ 404.1520,
416.920, and 416.924.
20 C.F.R. Pt. 404, Subpt. P, App. 1