United States District Court, Eastern District of New York
December 23, 2014
WADIYA BLAYLOCK, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.
For the Plaintiff: CHARLES E. BINDER, ESQ.
For the Defendant: LORETTA E. LYNCH, ESQ. United States Attorney
MEMORANDUM AND ORDER
FREDERIC BLOCK, Senior United States District Judge
Wadiya Blaylock (“Blaylock”) seeks review of the final decision of the Commissioner of Social Security (“Commissioner”) denying her application for disability benefits under the Social Security Act (the “Act”). Both parties move for judgment on the pleadings. For the reasons stated below, the Commissioner’s motion is denied and Blaylock’s motion is granted insofar as the case is remanded for further proceedings.
In November 2011, Blaylock filed applications for Supplemental Security Income and Disability Insurance Benefits. In both applications, she alleged disability, as of October 1, 2006, from left hip and lower back pain. After the Social Security Administration (“SSA”) denied her applications, Blaylock had a hearing before an Administrative Law Judge (“ALJ”) on March 11, 2013.
In a decision dated March 25, 2013, the ALJ determined that Blaylock was not disabled. Applying the familiar five-step evaluation process,  the ALJ found that: (1) Blaylock had not engaged in substantial gainful activity since December 1, 2010; (2) her left hip disorder and lumbar spine disorder qualified as severe impairments; and (3) her impairments did not meet or medically equal the criteria of an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. The ALJ then determined that Blaylock had the residual functional capacity (“RFC”) to perform a full range of sedentary work. Applying that RFC to the remaining steps, the ALJ found (4) that Blaylock was unable to perform her past relevant work as a clerical worker, but (5) that she was able to perform other work existing in significant numbers in the national economy.
The Appeals Council denied her request for review, rendering final the Commissioner’s decision to deny benefits. Blaylock timely sought judicial review.
“In reviewing the final decision of the Commissioner, a district court must determine whether the correct legal standards were applied and whether substantial evidence supports the decision.” Butts v. Barnhart, 388 F.3d 377, 384 (2d Cir. 2004); see also 42 U.S.C. § 405(g). “[S]ubstantial evidence . . . means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971); see also Selian v. Astrue, 708 F.3d 409, 417 (2d Cir. 2013). Blaylock contends that the ALJ’s RFC determination is flawed because it (1) failed to accord appropriate weight to the opinion of her treating physician, and (2) is not based on substantial evidence. Blaylock also argues that the ALJ improperly evaluated her credibility. The Court will address each argument in turn.
A. Evaluation of Blaylock’s Residual Functional Capacity
Blaylock maintains that the ALJ violated the treating physician rule by discounting the opinion of her treating physiatrist, Dr. Ledon, in determining her RFC. This argument is unavailing. A treating source’s opinion regarding a claimant’s RFC – as opposed to the nature and severity of a claimant’s impairment – is not entitled to controlling weight. See 20 C.F.R. § 416.927(d)(2) (“Although we consider opinions from medical sources on issues such as . . . your residual functional capacity . . . the final responsibility for deciding these issues is reserved to the Commissioner.”); see also Snell v. Apfel, 177 F.3d 128, 133 (2d Cir. 1999) (“A treating physician’s statement that a claimant is disabled cannot itself be determinative.”). Accordingly, the ALJ did not violate the treating physician rule by dismissing Dr. Ledon’s opinion because the ALJ retained final authority over the RFC determination.
However, the Court agrees that the ALJ’s RFC determination is not supported by substantial evidence. The ALJ found that Blaylock has the RFC to perform a full range of sedentary work. In making this finding, the ALJ relied on the medical reports of two doctors – Dr. Ledon and Dr. Wolf, the SSA’s consultative examiner.
Dr. Ledon began treating Blaylock in December 2010. On March 8, 2013, he completed a Spinal Impairment Questionnaire in which he diagnosed Blaylock with lumbar spine discogenic pain and lumbar radiculopathy. He opined that Blaylock is limited to lifting 20 pounds, sitting for 3 hours in an 8-hour period, and standing/walking for 2 hours in an 8-hour period. He further maintained that Blaylock requires unscheduled hourly breaks and would be absent from work 2 to 3 times a month as a result of her condition.
Dr. Wolf conducted a consultative examination of Blaylock on January 16, 2012. She diagnosed Blaylock with “low back pain” and a “history of misalignment of the left hip.” AR 258. In contrast to Dr. Ledon, Dr. Wolf surmised that Blaylock is “not limited for lifting, ” has “[n]o limitation in sitting provided she can stretch from time to time” and is “minimally limited in walking, standing, and climbing.” Id.
The ALJ ambiguously stated that he gave “significant weight” to Dr. Ledon’s opinion because it was “supported by and consistent with diagnostic testing and treatment notes.” AR 27. However, he then immediately contradicted himself by asserting that he “gave little weight” to Dr. Ledon’s opinion that Blaylock is limited to sitting for 3 hours in an 8-hour period, requires unscheduled hourly breaks, and will miss work 2 to 3 times a month. Id. The ALJ found these conclusions to be inconsistent with March 15, 2012 treatment notes from Dr. Ledon’s office, as well as Blaylock’s “conservative treatment history” and daily activities. Id.
The ALJ provided insufficient reasons for discounting Dr. Ledon’s opinion. In the March 15, 2012 treatment notes, Blaylock reported that her “medications [were] working well” and was “instructed to conduct all activities of daily living as normally as possible and perform stretching exercises.” AR 279. However, the ALJ failed to consider subsequent treatment notes from Dr. Ledon and other doctors in his office which demonstrate that Blaylock’s condition deteriorated and contemplate more serious treatment options. For example, on June 22, 2012, Dr. Ledon opined that Blaylock could receive a lumber epidural injection if her symptoms persisted. Similarly, August 16, 2012 treatment notes proposed a series of lumbar epidural injections because Blaylock’s “problematic discomfort . . . ha[d] persisted despite conservative treatment” and there was “evidence of a radiculopathy on her physical examination.” AR 290. Furthermore, on September 28, 2012, Dr. Ledon noted that Blaylock’s “level of functionality . . . ha[d] decreased” and that she may require a shoulder injection if her symptoms persisted. AR 291.
It was improper for the ALJ to consider only the March 15, 2012 treatment notes. See Lopez v. Sec’y of Dept. Of Health and Human Services, 728 F.2d 148, 150-51 (2d Cir. 1984) (“We have remanded cases where it appears that the ALJ has failed to consider relevant and probative evidence which is available to him.”); see also 20 C.F.R. § 404.1520 (“We will consider all evidence in your case record when we make a determination or decision whether you are disabled.”). On remand, the ALJ should consider the other treatment notes in assessing Dr. Ledon’s opinion.
The ALJ also determined that Dr. Ledon’s opinion was inconsistent with Blaylock’s daily activities – shopping, cooking, washing dishes, doing light laundry, using public transportation and driving a car. However, the ALJ did not explain how Blaylock’s ability to perform these activities undermined Dr. Ledon’s opinion that Blaylock has significant sitting limitations and requires unscheduled hourly breaks. See Balsamo v. Chater, 142 F.3d 75, 81 (2d Cir. 1998) (“We have stated on numerous occasions that a claimant need not be an invalid to be found disabled under the Social Security Act.”).
Furthermore, the ALJ failed to consider evidence that supported Dr. Ledon’s opinion. In her activities report, Blaylock stated that she cannot dress, bathe, cook or use the bathroom when her back hurts. She also maintained that she only goes outside “if [her] back, knee or hip can handle it.” AR 137. Moreover, during her hearing, Blaylock testified that she experiences “constant pain” and that her legs swell if she sits for over an hour. AR 36. The ALJ’s failure to address this evidence constitutes error. See Sutherland v. Barnhart, 322 F.Supp.2d 282, 289 (E.D.N.Y. June 23, 2004) (“It is not proper for the ALJ to simply pick and choose from the transcript only such evidence that supports his determination, without affording consideration to evidence supporting the plaintiff’s claims.”). The ALJ should consider this evidence in evaluating Dr. Ledon’s opinion on remand.
The ALJ also accorded “significant weight” to Dr. Wolf’s opinion because it was “consistent with diagnostic testing and treatment notes.” AR 27. However, record evidence belies this assertion. Dr. Wolf’s findings regarding Blaylock’s lumbar spine flexion conflict with diagnostic results that show Blaylock has a much more limited range of motion in her lower back. Moreover, Dr. Wolf’s opinion that Blaylock has “no limitation in sitting provided she can stretch from time to time” is not consistent with treatment notes from Dr. Ledon’s office detailing Blaylock’s decreased functionality and debilitating lower extremity pain. AR 290. Some treatment notes even propose spinal epidural injections because of Blaylock’s worsening condition.
On remand, the ALJ should reevaluate Blaylock’s RFC. In making this determination, the ALJ should reconsider Dr. Ledon and Dr. Wolf’s opinions in light of all materials in the record.
B. Evaluation of Blaylock’s Subjective Complaints
Blaylock next argues that the ALJ improperly evaluated her credibility. To evaluate credibility, an ALJ must first determine whether the claimant has a medically determinable impairment that could reasonably be expected to produce her symptoms, and second, evaluate the intensity, persistence and limiting effects of those symptoms. See 20 C.F.R. § 404.1529(b)-(c). The ALJ must provide “specific reasons for the finding on credibility, supported by evidence in the case record.” SSR 96-7p.
The ALJ found that although Blaylock’s “medically determinable impairments could reasonably be expected to cause the alleged symptoms, ” her statements regarding “the intensity, persistence and limiting effects of these symptoms are not entirely credible for the reasons explained in this decision.” An ALJ must consider seven factors when a claimant’s subjective complaints suggest greater severity than can be shown by objective medical evidence.
The ALJ emphasized Blaylock’s daily activities in finding her not credible. However, the ALJ failed to explain how Blaylock’s ability to complete routine daily activities demonstrates her capacity to perform sedentary work. See Murdaugh v. Sec’y. of Dep’t. Of Health & Human Servs., 837 F.2d 99, 102 (2d Cir. 1988) (noting that the fact that a claimant “waters his landlady’s garden, occasionally visits friends and is able to get on and off an examination table can scarcely be said to controvert the medical evidence” of disability).
Moreover, the evidence relied on by the ALJ is contradicted by other evidence in the activities report. For example, Blaylock drives “very very little” and sometimes uses a motorized shopping cart. AR 138. Additionally, Blaylock testified that she has “difficulty sleeping” because of pain. AR 42. These limitations undermine the ALJ’s conclusion that Blaylock’s daily activities evince an ability to work.
The ALJ also ignored evidence regarding the circumstances that precipitate and aggravate Blaylock’s condition. As mentioned, Blaylock testified that her legs swell if she sits for over an hour and that she cannot stand for more than 10 minutes at a time. Moreover, in her activities report, Blaylock maintained that she “[cannot] stand for a long time” and that “[her] legs swell drastically” if she sits “for several hours at a time.” AR 139-40. The ALJ should explore this evidence on remand.
Finally, reconsideration of Blaylock’s credibility is necessary because the ALJ improperly discounted Dr. Ledon’s opinion in determining her RFC. Once the ALJ reconsiders the medical evidence, it may support Blaylock’s subjective complaints.
For the foregoing reasons, the Commissioner’s motion is denied and Blaylock’s motion is granted to the extent that the case is remanded for further proceedings.