Opinion
C/A No. 2:19-cv-01709-MBS-MGB
06-17-2020
ALBERT RECCHIA, Plaintiff, v. ANDREW M. SAUL, Acting Commissioner of the Social Security Administration, Defendant.
REPORT AND RECOMMENDATION
This case is before the Court for a Report and Recommendation pursuant to Local Rule 73.02(B)(2)(a), D.S.C., concerning the disposition of Social Security cases in this District, and Title 28, United States Code, Section 636(b)(1)(B). Plaintiff Albert Recchia ("Plaintiff") brought this action pursuant to Section 205(g) of the Social Security Act, as amended, (42 U.S.C. § 405(g)), to obtain judicial review of a final decision of the Commissioner of Social Security Administration (the "Administration") regarding his claim for Disability Insurance Benefits ("DIB") under Title II of the Social Security Act (the "Act"). For the reasons set forth below, the undersigned recommends that this matter be remanded for further consideration and analysis by the Commissioner.
RELEVANT FACTS AND ADMINISTRATIVE PROCEEDINGS
Plaintiff was 50 years old on his alleged disability onset date of August 26, 2015. (R. at 15, 180-81.) Plaintiff alleged disability due to, inter alia, issues with his left knee, both shoulders, right hand, and both feet. (Id. at 182-89.) Plaintiff has past relevant work as a carpenter and drywall installer. (Id. at 25, 182-89.)
Plaintiff filed an application for DIB on March 30, 2016. (Id. at 15, 166-72.) His application was denied initially on May 31, 2016. (Id. at 15, 73-83.) Thereafter, a video hearing was held on June 1, 2018, before an Administrative Law Judge (the "ALJ"). (Id. at 15, 32-56.) On July 20, 2018, the ALJ issued a decision and found that Plaintiff was not disabled. (Id. at 15-27.) The Appeals Council denied Plaintiff's request for review on April 12, 2019, making the ALJ's decision the Commissioner's final decision for purposes of judicial review. (Id. at 1-3.)
In making the determination that Plaintiff is not entitled to benefits, the Commissioner has adopted the following findings of the ALJ's decision:
(1) The claimant meets the insured status requirements of the Social Security Act through December 31, 2020.
(2) The claimant has not engaged in substantial gainful activity since August 26, 2015, the alleged onset date (20 CFR 404.1571 et seq.).
(3) The claimant has the following severe impairments: posttraumatic osteoarthritis of the left knee; medial meniscus tear of the right knee; posttraumatic osteoarthritis left shoulder; arthritis and carpal tunnel syndrome of the right wrist; degenerative disc disease cervical spine; chronic obstructive pulmonary disease (COPD); and obesity (20 CFR 404.1520(c)).
(4) The claimant does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 404.1520(d), 404.1525, 404.1526).
(5) After careful consideration of the entire record, the undersigned finds that the claimant has the residual functional capacity to perform light work, as defined in 20 CFR 404.1567(b), except he can never reach, lift, push or pull overhead with both upper extremities. He can frequently operate hand controls, push or pull, reach, handle, finger, and feel with both upper extremities. He can occasionally push, pull, or operate foot controls with both lower extremities. He can occasionally kneel, crouch, stoop, balance, and crawl, and can occasionally climb stairs and ramps. He should never climb ladders, ropes and scaffolds, and can never be exposed to unprotected heights and moving mechanical parts. He can have occasional exposure to dust, mists, gases, noxious odors, fumes, pulmonary irritants, and poor ventilation. He can tolerate occasional exposure to vibration. He is able to
understand, carry-out, and remember simple instructions, and make simple work related decisions. He can occasionally deal with changes in a routine work setting.(Id. at 18-26.)
(6) The claimant is unable to perform any past relevant work (20 CFR 404.1565).
(7) The claimant was born on August 13, 1965 and was 50 years old, which is defined as an individual closely approaching advanced age, on the alleged disability onset date (20 CFR 404.1563).
(8) The claimant has a limited education and is able to communicate in English (20 CFR 404.1564).
(9) Transferability of job skills is not material to the determination of disability because using the Medical-Vocational Rules as a framework supports a finding that the claimant is "not disabled," whether or not the claimant has transferable job skills (See SSR 82-41 and 20 CFR Part 404, Subpart P, Appendix 2).
(10) Considering the claimant's age, education, work experience, and residual functional capacity, there are jobs that exist in significant numbers in the national economy that the claimant can perform (20 CFR 404.1569, 404.1569(a)).
(11) The claimant has not been under a disability, as defined in the Social Security Act, from August 26, 2015, through the date of this decision (20 CFR 404.1520(g)).
APPLICABLE LAW
The Act provides that disability benefits shall be available to those persons insured for benefits, who are not of retirement age, who properly apply, and who are under a "disability." 42 U.S.C. § 423(a). "Disability" is defined in the Act as the inability to "engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than" twelve months. See 42 U.S.C. § 423(d)(1)(A) (DIB context).
To facilitate a uniform and efficient processing of disability claims, the Act has by regulation reduced the statutory definition of "disability" to a series of five sequential questions. An examiner must consider whether the claimant (1) is engaged in substantial gainful activity, (2) has a severe impairment, (3) has an impairment which equals an illness contained in the Administration's official Listing of Impairments found at 20 C.F.R. Part 404, Subpart P, Appendix 1, (4) has an impairment which prevents past relevant work, and (5) has an impairment which prevents him from doing substantial gainful employment. See 20 C.F.R. § 404.1520 (DIB context). If an individual is found not disabled at any step, further inquiry is unnecessary. See 20 C.F.R. § 404.1520(a)(4) (DIB context); see also Hall v. Harris, 658 F.2d 260 (4th Cir. 1981).
The claimant bears the burden of proof with respect to the first four steps of the analysis. Pass v. Chater, 65 F.3d 1200, 1203 (4th Cir. 1995). Once the claimant has established an inability to return to his past relevant work, the burden shifts to the Commissioner to show that the claimant—considering his age, education, work experience, and residual functional capacity—can perform alternative jobs and that such jobs exist in the national economy. See SSR 82-62, 1982 WL 31386, at *3; Grant v. Schweiker, 699 F.2d 189, 191 (4th Cir. 1983); see also Monroe v. Colvin, 826 F.3d 176, 180 (4th Cir. 2016). The Commissioner may satisfy this burden by obtaining testimony from a vocational expert. See Grant, 699 F.2d at 191-92.
The scope of judicial review by the federal courts in disability cases is narrowly tailored to determine whether the findings of the Commissioner "are supported by substantial evidence and whether the correct law was applied." Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990); see also Woods v. Berryhill, 888 F.3d 686, 691 (4th Cir. 2018); Mascio v. Colvin, 780 F.3d 632, 634 (4th Cir. 2015); 42 U.S.C. § 405(g); 42 U.S.C. § 1383(c)(3). Consequently, the Act precludes a de novo review of the evidence and requires that the court uphold the Commissioner's decision as long as it is supported by substantial evidence. Pyles v. Bowen, 849 F.2d 846, 848 (4th Cir. 1988) (citing 42 U.S.C. § 405(g) and Smith v. Schweiker, 795 F.2d 343, 345 (4th Cir. 1986)); see also Mascio, 780 F.3d at 640; Bird v. Comm'r of Soc. Sec. Admin., 699 F.3d 337, 340 (4th Cir. 2012).
Substantial evidence is "more than a mere scintilla of evidence but may be less than a preponderance." Pearson v. Colvin, 810 F.3d 204, 207 (4th Cir. 2015) (citing Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir. 2012)). "In reviewing for substantial evidence, [the court does] not undertake to reweigh conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the [ALJ]." Hancock, 667 F.3d at 472. "Where conflicting evidence allows reasonable minds to differ as to whether a claimant is disabled, the responsibility for that decision falls on the [ALJ]," not on the reviewing court. Id. However, "[a] factual finding by the ALJ is not binding if it was reached by means of an improper standard or misapplication of the law." Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987).
DISCUSSION
On appeal, Plaintiff contends that the ALJ erred in failing to properly evaluate several aspects of his disability claim. First, Plaintiff argues that the ALJ committed reversible error by failing to properly consider and account for the medical opinions of Plaintiff's treating physicians, Dr. James Penna, M.D. (orthopedist) and Dr. Samantha Muhlrad, M.D. (orthopedic hand surgeon), and Plaintiff's consultative examiner, Dr. Saadia Wasty, M.D. (Dkt. No. 18 at 12-23.) Along those same lines, Plaintiff contends that the ALJ also erred in failing to properly evaluate his subjective complaints. (Id. at 23-27.) Finally, Plaintiff claims that the ALJ erred at Step 5 of the sequential evaluation by failing to demonstrate that there were sufficient alternative jobs in the national economy that Plaintiff could perform. (Id. at 27-29.)
Upon review of the parties' arguments, the ALJ's decision, and the record as a whole, the undersigned finds that the ALJ's analysis of the aforementioned medical opinions falls short of the clearly established standards under the Treating Physician Rule. At the very least, the ALJ failed to adequately explain the weight assigned to the opinions of Plaintiff's treating physicians, Dr. Penna and Dr. Muhlrad, thereby precluding meaningful review of the ALJ's ultimate conclusions. Accordingly, for the reasons set forth below, this matter should be remanded for further consideration and analysis by the Commissioner.
I. Medical Opinion Evidence
A claimant's residual functional capacity ("RFC") represents the most he can still do despite his limitations. Ladda v. Berryhill, 749 F. App'x 166, 172 (4th Cir. 2018). In reaching a determination regarding a claimant's RFC, the ALJ is obligated to consider "all of the relevant evidence in the case record," including any medical source statements submitted by the claimant's treating source(s) and/or other acceptable medical sources. SSR 96-8P, 1996 WL 374184 (July 2, 1996); 20 C.F.R. § 404.1545; see also 20 C.F.R. § 404.1527. Indeed, the regulation, known as the "Treating Physician Rule," imposes a duty on the Commissioner to "evaluate every medical opinion we receive." 20 C.F.R. § 404.1527(c). Special consideration is to be given to the opinions of treating physicians of the claimant, based on the view that "these sources are likely to be the medical professionals most able to provide a detailed, longitudinal picture of [the claimant's] medical impairment(s) and may bring a unique perspective to the medical evidence that cannot be obtained from objective medical findings alone or from reports of individual examinations, such as consultative examinations or brief hospitalizations." 20 C.F.R. § 404.1527(c)(2).
The "Treating Physician Rule" applies only to claims filed before March 27, 2017. See 20 C.F.R. § 404.1527(c); see also Collins v. Berryhill, No. 1:17-cv-03422-DCC-SVH, 2018 WL 7137848, at *8 (D.S.C. Nov. 14, 2018), adopted, 2019 WL 341717 (D.S.C. Jan. 28, 2019).
Under some circumstances, the opinions of treating physicians are to be accorded controlling weight. See id. (stating that the opinion of a treating physician is given controlling weight if it is "well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in [the] case record"). However, even where the opinions of the claimant's treating physicians are not accorded controlling weight, the Commissioner is still obligated to weigh those opinions in light of a broad range of factors, including the examining relationship; the length, nature and extent of the treatment relationship; supportability of the opinions in the medical record; consistency; medical specialization by physician; and any other factors that tend to support or contradict the opinion. 20 C.F.R. § 404.1527(c)(1)-(5). "A treating physician is entitled to great weight because it reflects a judgment based on continuing observation over a number of years." Campbell v. Bowen, 800 F.2d 1247, 1250 (4th Cir. 1986). Accordingly, the Commissioner is obligated to weigh the findings and opinions of treating physicians and to give "good reasons" in the written decision for the weight given to a treating source's opinions. SSR 96-2P, 1996 WL 374188, at *5; see also 20 C.F.R. § 404.1527(c)(2); Hendrix v. Astrue, No. 1:09-cv-1283-HFF, 2010 WL 3448624, at *3 (D.S.C. Sept. 1, 2010) (noting that although "an express discussion of each factor is not required," the ALJ must demonstrate that he applied the relevant factors in evaluating the opinion and provide good reasons for his decision).
A. Dr. Wasty's Opinion
On May 9, 2016, Plaintiff presented to Dr. Saadia Wasty, M.D. for a consultative examination in relation to his application for disability benefits. Dr. Wasty diagnosed Plaintiff with right wrist pain, status post surgery; left shoulder pain, status post surgery; left knee pain, status post surgeries; obstructive sleep apnea; bilateral foot pain; and chronic obstructive pulmonary disease. (R. at 328.) In reaching these determinations, Dr. Wasty noted that while Plaintiff's gait and stance appeared normal, he exhibited difficulty walking on his heels and toes and could squat only one-half of the way. Dr. Wasty further noted surgical scars on Plaintiff's left knee, left shoulder, and right wrist. (Id. at 327.) Dr. Wasty also observed that Plaintiff's cervical spine and lumbar spine showed full flexion, extension, lateral flexion bilaterally, and rotary movement bilaterally, but noted that his shoulders exhibited limited forward elevation, adduction, and rotation. (Id. at 327-28.) Based on the above, Dr. Wasty opined that,
[Plaintiff] should avoid heavy exertion due to chronic obstruction sleep apnea and fatigue. He should avoid environments with smoke, dust, and known respiratory irritants. He has moderate to marked limitation to pushing, pulling, carrying, lifting, and overhead reaching using the left arm. He has moderate limitation to squatting, kneeling, long periods of sitting, standing, and walking.(Id. at 328-29.)
In giving Dr. Wasty's opinion "great weight," the ALJ provided the following explanation:
Dr. Wasty had the opportunity to examine the claimant, and, overall, her opinion is consistent with her examination of the claimant. For example, the claimant was observed to have a normal gait and was able to walk on his heels and toes without difficulty (6F-3). However, the claimant was only able to partially squat (6F-3). The claimant also did not need any help changing for the examination, was able to get on and off the exam table, and was able to rise from a chair without difficulty (6F-3). Additionally, the examination of the claimant's shoulders showed reduced range of motion (6F-3/4). An x-ray of the claimant's let [sic] shoulder showed mild widening of the acromioclavicular (AC) joint (6F-6).(Id. at 23.) For the reasons set forth below, the undersigned finds this explanation insufficient to allow for meaningful review of the weight assigned to Dr. Wasty's opinion and, therefore, cannot conclude that the ALJ's decision is supported by substantial evidence.
First, the undersigned agrees with Plaintiff that the ALJ's heavy reliance on Dr. Wasty's opinion is internally inconsistent with several of the limitations prescribed in the ALJ's RFC assessment. And while the undersigned appreciates that the Commissioner is not obligated to adopt Dr. Wasty's opinion "wholesale" when formulating Plaintiff's RFC, "'a necessary predicate to engaging in a substantial evidence review is a record of the basis for the ALJ's ruling,' including 'a discussion of which evidence the ALJ found credible and why. . . .'" See Monroe, 826 F.3d at 189 (quoting Radford v. Colvin, 734 F.3d 288, 295 (4th Cir. 2013)). In other words, the ALJ must "build an accurate and logical bridge from the evidence to his conclusion." Id. In the instant case, however, it is unclear why the ALJ apparently disregarded certain physical limitations noted in Dr. Wasty's assessment when determining Plaintiff's RFC.
For example, although Dr. Wasty opined that Plaintiff demonstrated "moderate to marked" limitations in "pushing, pulling, carrying, lifting, and overhead reaching using the left arm," the ALJ nevertheless concluded that Plaintiff could "frequently operate hand controls, push or pull, reach, handle, finder, and feel with both upper extremities." (R. at 19 (emphasis added).) Moreover, despite Dr. Wasty's finding that Plaintiff had moderate limitations in "long periods of sitting, standing, and walking," the ALJ included no such limitations in Plaintiff's RFC. To the contrary, the ALJ limited Plaintiff to "light work," which generally "requires a good deal of walking or standing"—up to six (6) hours in an eight (8) hour workday. See 20 C.F.R. § 404.1567(b); see also Cohen v. Berryhill, No. 2:16-cv-01238-RMG-MGB, 2017 WL 3638229, at *7 (D.S.C. July 31, 2017), adopted, 2017 WL 3476738 (D.S.C. Aug. 14, 2017) and 272 F. Supp. 3d 779 (D.S.C. 2017).
Additionally, the ALJ misstated Dr. Wasty's examination findings regarding Plaintiff's ability to walk, asserting that Plaintiff was able to ambulate on his heels and toes without difficulty. (R. at 23.) As noted above, however, Dr. Wasty observed that Plaintiff was able to walk on his heels and toes with difficulty. (Id. at 327.)
Thus, despite affording Dr. Wasty's opinion "great weight," it appears the ALJ relied on only some of Dr. Wasty's examination findings in forming Plaintiff's RFC. When the ALJ's analysis contains inadequacies or gaps that frustrate meaningful review, such as here, the court may remand the claim back to the Commissioner for further explanation. See Radford, 734 F.3d at 296; see also Moreland v. Astrue, No. 4:08-cv-3902-CMC, 2010 WL 2851119, at *3 (D.S.C. July 16, 2010) (explaining that Commissioner's position was not supported by substantial evidence where ALJ limited plaintiff to light work despite findings that plaintiff had limited ability to walk and stand for long periods of time); Holmes v. Berryhill, No. 5:17-cv-1531-RBH-KDW, 2018 WL 6926611, at *8 (D.S.C. Sept. 18, 2018), adopted sub nom., 2018 WL 6829116 (D.S.C. Dec. 28, 2018) (agreeing that remand may be appropriate where an ALJ fails to assess a claimant's capacity to perform relevant functions, despite contradictory evidence in the record).
Notwithstanding the aforementioned inconsistencies, the undersigned finds that the ALJ's decision also fails to explain why recent medical records showing further worsening of Plaintiff's various conditions did not support greater limitations than those noted during Dr. Wasty's examination and/or those imposed in the RFC. Indeed, Dr. Wasty's opinion was completed in May 2016, which means that she did not review any of the subsequent medical records from 2017-2018. Notably,
Subsequent treatment records show the claimant continued to report experiencing pain in his left knee (7F-31, 7F-41). In October 2016, the claimant's doctor noted that another arthroscopy was not appropriate to treat the claimant's left knee pain (7F-22). Subsequent treatment records show that the claimant continued to report experiencing left knee pain and swelling (7F-13). Examination of the claimant's left knee showed patellofemoral crepitus, and reduced extension and flexion (7F-13). Treatment records, during 2017, show that the claimant continued to report left knee pain with popping (7F-1, 7F-9, and 9F-1). The claimant was also participating in physical therapy (7F-10). In December 2017, the claimant reported experiencing right knee pain and that he was unable to kneel (12F-1, 13F-1). An MRI of the claimant's right knee showed a right medial meniscus tear (12F-2). Surgical options were discussed with the claimant to repair the meniscus tear (12F-2, 13F-2).(R. at 21.) Additionally, the record shows that Plaintiff underwent a "right carpal tunnel release" in May 2017, and that he "continued to experience ulnar sided wrist pain with ulnar deviation and gripping" thereafter. (Id. at 22.)
Despite acknowledging that Plaintiff's knee and wrist pain had continued, if not worsened, following the completion of Dr. Wasty's consultative examination, the ALJ failed to explain why the evidence of greater deterioration did not require limitations beyond those initially opined in mid-2016. See Rogers v. Colvin, No. 0:12-cv-2210-MGL, 2014 WL 1330088, at *4 (D.S.C. Mar. 31, 2014) (remanding where medical sources did not have the benefit of all medical evidence prior to issuing their opinions, such that the court was unable to discern whether the ALJ's decision was supported by substantial evidence); Brewer v. Colvin, No. 6:14-cv-3980-RBH-KFM, 2015 WL 6549696, at *12 (D.S.C. Oct. 8, 2015), adopted, 2015 WL 6549257 (D.S.C. Oct. 28, 2015) (remanding for further review where ALJ gave great weight to medical opinions that were based on partial record). Thus, without further explanation, the ALJ's failure to reconcile the evidence of Plaintiff's worsening impairments with his reliance on Dr. Wasty's opinion leaves a critical gap in the RFC assessment and, ultimately, precludes meaningful review by this Court.
B. Dr. Penna's and Dr. Muhlrad's Opinions
Although the undersigned finds the ALJ's treatment of Dr. Wasty's opinion sufficient to warrant remand, the undersigned agrees that the ALJ's failure to properly consider the opinions of Plaintiff's treating physicians, Dr. James Penna, M.D. and Dr. Samantha Muhlrad, M.D., also demonstrates reversible error. Specifically, both Dr. Penna and Dr. Muhlrad completed a series of "Doctor's Narrative Reports" for the State of New York Workers' Compensation Board in relation to certain work-related injuries Plaintiff sustained in February 2015. Specifically, Dr. Penna opined that Plaintiff was 47%-100% "disabled" from approximately May 2015 through December 2016, based on Plaintiff's severe knee pain. (See, e.g., R. at 291-311, 332-81, 411-22, 427-36, 452-91.) Dr. Penna's corresponding treatment records show, among other things, that Plaintiff suffered a tear in his left meniscus and required several subsequent surgical procedures, including a partial medial menisectomy. (Id. at 246-47, 242-43.) Similarly, Dr. Muhlrad's reports opined that Plaintiff was 100% disabled from approximately October 2016 through April 2018, due to primary osteoarthritis of the right wrist. (See, e.g., id. at 384-410, 423-26, 437-40.) More specifically, Dr. Muhlrad's accompanying treatment records show that Plaintiff suffered continuous pain in his right wrist, which eventually required an endoscopic carpal tunnel release, arthroscopy, synovectomy, and arthroscopic debridement. (Id. at 386-87.)
As Plaintiff correctly notes, most of Dr. Penna's Doctor's Narrative Reports rate Plaintiff as 100% disabled, absent a few outlying examinations that report a lower rating. (Dkt. No. 18 at 18.)
In addition to the workers' compensation reports, Dr. Penna and Dr. Muhlrad also completed separate "Medical Source Statements" in relation to Plaintiff's DIB application. Dr. Penna completed a statement dated March 20, 2018, in which he opined that Plaintiff's severe knee pain rendered him entirely unable to work. In support of this opinion, Dr. Penna noted that Plaintiff's knee pain, which was corroborated by positive McMurray tests in relation to Plaintiff's meniscus damage, resulted in various physical limitations, including walking no more than one (1) block, standing for no more than fifteen (15) minutes at once, sitting for no more than thirty (30) minutes at once, and never stooping, bending or balancing. (Id. at 447-51.) Dr. Penna further opined that Plaintiff's knee pain would likely cause him to miss five (5) or more days of work each month. (Id. at 448.) Dr. Muhlrad completed a similar statement, dated February 26, 2018, in which she too opined that Plaintiff was unable to work. More specifically, Dr. Muhlrad stated that the arthritis in Plaintiff's right wrist caused severe pain and weakness that interfered with his ability to lift, twist, grasp, push and pull. (Id. at 441-46.) Like Dr. Penna, she also agreed that Plaintiff's physical impairments would cause him to miss five (5) or more days of work each month. (Id. at 442.)
In rejecting these medical source opinions, the ALJ provided the following explanation:
The undersigned gives limited weight to these opinions. These opinions were all rendered within the purview of the Worker's Compensation law, and are not binding on the Agency pursuant to 20 C.F.R. 404.1504. Moreover, any opinions regarding the ability to work is reserved for to [sic] the Commissioner (20 CFR 404.1527(d)(1), (2)). For these reasons, the undersigned gives limited to weight to the opinions of [Dr. Penna and Dr. Muhlrad].(Id. at 24.) The undersigned finds that this cursory discussion of the treating physicians' opinions precludes meaningful review for several reasons.
At the outset, the undersigned acknowledges that Dr. Penna's and Dr. Muhlrad's workers' compensation reports are not binding on this Court, as government agencies employ different administrative and legal standards to determine disability. See Greco v. Colvin, No. 9:13-cv-1414-RMG, 2014 WL 3571523, at *3 (D.S.C. July 17, 2014) (referencing DeLoatche v. Heckler, 715 F.2d 148, 150 n.1 (4th Cir. 1983)). However, it is well-established that an ALJ is nonetheless "required to evaluate all the evidence in the case record that may have a bearing on [his] determination or decision of disability, including decisions by other governmental and nongovernmental agencies." Lewis v. Saul, No. 1:18-cv-2451-CMC-SVH, 2019 WL 7882149, at *13 (D.S.C. Dec. 3, 2019), adopted, 2020 WL 58282 (D.S.C. Jan. 6, 2020). Accordingly, the ALJ must, at the very least, consider and explain his evaluation of a treating physician's workers' compensation report(s) as potential evidence of disability, rather than summarily reject the statement(s) as the ALJ did here.
In fact, the current regulations now state that the ALJ must "consider all of the supporting evidence underlying [any] other governmental agency or nongovernmental entity's decision," that is received as part of the record evidence in support of the present disability claim "in accordance with § 404.1513(a)(1) through (4)." 20 C.F.R. § 404.1504 (2017).
Second, the ALJ also seemed to discount, with little explanation, the Medical Source Statements of record, which were created independent of Plaintiff's workers' compensation claim. Indeed, the ALJ's only apparent reason for affording these statements "limited weight" was that they addressed the ultimate issue of disability. See 20 C.F.R. § 404.1527(d) (explaining that determinations of disability are findings reserved to the Commissioner); see also Patterson v. Colvin, No. 4:14-cv-0041 DCN, 2015 WL 450477, at *9 (D.S.C. Feb. 3, 2015) (noting that the questions of whether a claimant is unable able to work, is disabled, or can perform at a certain residual functional capacity level are issues reserved to the Commissioner). However, while treating source opinions on issues reserved to the Commissioner are not entitled to special significance, the adjudicator is still obligated to "evaluate all the evidence in the case record to determine the extent to which the opinion is supported by the record." Patterson, 2015 WL 450477, at *9; see also SSR 96-5P, 1996 WL 374183, at *1 ("[O]pinions from any medical source about issues reserved to the Commissioner must never be ignored, and . . . the notice of the determination or decision must explain the consideration given to the treating source's opinion(s).") Accordingly, even if a physician's opinion addresses an issue reserved to the Commissioner, the ALJ must nonetheless consider that opinion in light of the record and adequately explain the weight assigned to the opinion in accordance with the applicable regulations. See McGraw v. Colvin, No. 8:14-cv-03208-RMG-JDA, 2015 WL 13215548, at *14 (D.S.C. Nov. 13, 2015), adopted, 2015 WL 7306429 (D.S.C. Nov. 19, 2015) (remanding matter for further consideration because, while the ALJ was not required to give special significance to the doctor's opinion regarding whether plaintiff could only perform sedentary work, the ALJ was still required to adequately explain his consideration of and the weight assigned to said opinion).
Here, the undersigned finds that the ALJ's explanation falls short of this obligation. As noted above, the ALJ provided no substantive explanation or support from the record regarding his decision to give Dr. Penna's and Dr. Muhlrad's medical conclusions limited weight. His cursory discussion of their medical opinions is particularly puzzling because his overall decision appears to rely largely on their treatment notes. Indeed, the ALJ seemed to credit the treatment notes as valid evidence in his review of Plaintiff's medical history, and yet gave little weight to the opinions that Dr. Penna and Dr. Muhlrad derived from that very same treatment of Plaintiff. The ALJ's failure to bridge the gap between his acceptance of Dr. Penna's and Dr. Muhlrad's treatment notes and his simultaneous rejection of their Medical Source Statements leaves the Court guessing as to how the ALJ arrived at his ultimate RFC determinations. See Williams v. Berryhill, No. 0:17-cv-1203-DCC-PJG, 2018 WL 4560530, at *4 (D.S.C. May 15, 2018), adopted, 2018 WL 3569076 (D.S.C. July 25, 2018) (remanding where ALJ offered no explanation as to how physician's opined limitations were unsupported by the record and, as a result, the court was "left to guess" at how the ALJ arrived at his conclusions regarding the opinion evidence).
The undersigned cautions that an ALJ may not substitute his own opinion for that of an expert. See Sheppard v. Colvin, No. 5:13-cv-1027-RMG, 2014 WL 3110063, at *3 (D.S.C. July 7, 2014) (noting that while an ALJ may resolve issues of credibility as to lay testimony or choose between properly submitted medical opinions, he may not set his own expertise against that of a physician). Thus, it is especially important that the ALJ in the instant case explain his reasoning for discounting these physicians' statements given that their treatment notes make up a significant portion of the medical record.
Next, as discussed in greater detail above, the two aforementioned Medical Source Statements are the most recent medical opinions in the record. To reiterate, following his consultative examination with Dr. Wasty in May 2016, Plaintiff experienced continued knee pain and suffered another medial meniscus tear. Dr. Penna determined that another arthroscopy would be ineffective and that the next step would be an entire knee replacement. (R. at 352-53.) The pain in Plaintiff's wrist also continued, such that Dr. Muhlrad had to perform an endoscopic carpal tunnel release, along with several other related procedures. (Id. at 386-88.) However, the ALJ's cursory consideration of the treating physicians' medical opinions brushes past the significance of this more recent medical evidence and makes no attempt to reconcile the longitudinal worsening of Plaintiff's knee and wrist impairments with an RFC of light work. See Watson v. Astrue, No. 2:09-cv-00039, 2010 WL 3244499, at *5-6 (W.D. Va. Aug. 17, 2010) (remanding where ALJ failed to adequately explain consideration of MRI results showing that plaintiff's condition had worsened due to increased disc protrusion with left lateral recess narrowing and nerve root impingement); see also Gilchrist v. Colvin, No. 1:14-cv-02196-DCN, 2016 WL 1178204, at *3 (D.S.C. Mar. 28, 2016) ("Unless the [ALJ] has analyzed all evidence and has sufficiently explained the weight he has given to obviously probative exhibits, to say that his decision is supported by substantial evidence approaches an abdication of the court's duty to scrutinize the record.") (internal citations omitted).
Finally, even if Dr. Penna's and Dr. Muhlrad's opinions are not entitled to controlling weight, they are still entitled to a certain level of deference as treating physicians: "Treating source medical opinions are still entitled to deference and must be weighed using all of the factors provided in 20 C.F.R. 404.1527 and 416.927. In many cases, a treating source's opinion will be entitled to the greatest weight and should be adopted, even if it does not meet the test for controlling weight." See McGraw, 2015 WL 13215548, at *13 (referencing SSR 96-2P). It is unclear from the ALJ's decision if he considered the factors outlined in 20 C.F.R. § 404.1527 in his evaluation of Dr. Penna's and Dr. Muhlrad's opinions. Specifically, the ALJ did not explain how he considered the physicians' long-standing treatment relationship with Plaintiff, which spanned several years. The ALJ also failed to explain how he accounted for Dr. Penna's and Dr. Muhlrad's specialized knowledge in orthopedics, if at all. See, e.g., Kneece v. Colvin, No. 5:12-cv-2637-TMC, 2014 WL 368586, at *15 (D.S.C. Feb. 3, 2014) (finding that, although the ALJ discussed the physician's treatment of the plaintiff in Step Two of his evaluation, remand was necessary because he made no reference to the physician's long treatment history with the plaintiff or his specialized knowledge with regard to the plaintiff's pain symptoms in assigning weight to the medical opinion); Hodge v. Colvin, No. 8:15-cv-00440-JMC-JDA, 2016 WL 4238646, at *17 (D.S.C. July 8, 2016), adopted, 2016 WL 4196670 (D.S.C. Aug. 8, 2016) (remanding where ALJ failed to address that physician had known the plaintiff for years and was a specialist in the area of psychiatry). Additionally, the ALJ did not address the fact that Dr. Penna's Medical Source Statement was largely consistent with that of Dr. Muhlrad. See Jordan v. Colvin, No. 8:12-cv-01676-DCN, 2013 WL 5317334, at *8 (D.S.C. Sept. 20, 2013) (explaining that the court could not divine how the physician's medical opinion was inconsistent with the longitudinal record without further analysis, especially where there were examining doctors who appeared to provide consistent opinions); see also Thomas v. Colvin, No. 2:14-cv-383-RMG, 2015 WL 1909903, at *6-7 (D.S.C. Apr. 27, 2015) (finding that the rejection of treating physicians' opinions was not supported by substantial evidence where opinions were largely dismissed "without reference to the standards of the Treating Physician Rule").
Without further explanation from the ALJ, the undersigned simply cannot conclude that the ALJ's decision to afford Plaintiff's treating physicians' opinions limited weight is supported by substantial evidence. See Alexander v. Colvin, No. 9:14-cv-2194-MGL-BM, 2015 WL 2399846, at *6 (D.S.C. May 19, 2015) ("Thus, although the ALJ may have properly considered the relevant factors and may have had appropriate reasons in discounting the physicians' opinions (as the Commissioner argues in his objections), . . . the ALJ must be more specific when discounting a treating physician's opinion."). While the ALJ may still choose to reject Dr. Penna's and/or Dr. Muhlrad's medical opinions on remand, "that is not a decision that can be made by this Court in the first instance on appellate review." Alexander, 2015 WL 2399846, at *6. To rule otherwise would require the Court to weigh the evidence and substitute its own judgment for that of the ALJ, which it may not do. Accordingly, the undersigned recommends that this matter be remanded for further consideration and explanation by the ALJ so that the Court may undertake a meaningful review as to whether the ALJ's decision is supported by substantial evidence.
II. Remaining Allegations of Error
The undersigned finds the ALJ's inadequate analysis of the aforementioned medical opinions a sufficient basis on which to remand this case to the Commissioner and, thus, the undersigned declines to specifically address Plaintiff's additional allegations of error. However, upon remand, the Commissioner should take into consideration Plaintiff's remaining allegations of error.
CONCLUSION
It is therefore RECOMMENDED, for the foregoing reasons, that the Commissioner's decision be REVERSED and that the case be REMANDED for further proceedings consistent with this Report and Recommendation.
IT IS SO RECOMMENDED.
/s/_________
MARY GORDON BAKER
UNITED STATES MAGISTRATE JUDGE June 17, 2020
Charleston, South Carolina
Notice of Right to File Objections to Report and Recommendation
The parties are advised that they may file specific written objections to this Report and Recommendation with the District Judge. Objections must specifically identify the portions of the Report and Recommendation to which objections are made and the basis for such objections. "[I]n the absence of a timely filed objection, a district court need not conduct a de novo review, but instead must 'only satisfy itself that there is no clear error on the face of the record in order to accept the recommendation.'" Diamond v. Colonial Life & Acc. Ins. Co., 416 F.3d 310 (4th Cir. 2005) (quoting Fed. R. Civ. P. 72 advisory committee's note).
Specific written objections must be filed within fourteen (14) days of the date of service of this Report and Recommendation. 28 U.S.C. § 636(b)(1); Fed. R. Civ. P. 72(b); see Fed. R. Civ. P. 6(a), (d). Filing by mail pursuant to Federal Rule of Civil Procedure 5 may be accomplished by mailing objections to:
Robin L. Blume, Clerk
United States District Court
Post Office Box 835
Charleston, South Carolina 29402
Failure to timely file specific written objections to this Report and Recommendation will result in waiver of the right to appeal from a judgment of the District Court based upon such Recommendation. 28 U.S.C. § 636(b)(1); Thomas v. Arn, 474 U.S. 140 (1985); Wright v. Collins, 766 F.2d 841 (4th Cir. 1985); United States v. Schronce, 727 F.2d 91 (4th Cir. 1984).