Evans v. Comm'r of Soc. Sec.

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KIM A. EVANS, Plaintiff, v. COMMISSIONER OF SOCIAL SECURITY, Defendant.

No. 21-CV-4876 (AMD)

United States District Court, E.D. New York

March 28, 2023

MEMORANDUM DECISION AND ORDER

ANN M DONNELLY, UNITED STATES DISTRICT JUDGE:

The plaintiff challenges the Social Security Commissioner's decision that she was not disabled for the purpose of receiving Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act. (ECF No. 10-1 at 6.) For the reasons set forth below, I grant the plaintiff's motion for judgment on the pleadings, deny the Commissioner's cross-motion and remand the case for further proceedings.

BACKGROUND

The plaintiff applied for DIB on October 16, 2019, alleging disability since March 27, 2019, caused by major depressive disorder, generalized anxiety disorder, and lumbar degenerative disc disease. (Tr. 10, 13.) The Social Security Administration (“SSA”) denied her claim after initial review on January 10, 2020, and upon reconsideration on May 12, 2020. (Tr. 10.) The plaintiff filed a written request for a hearing on July 10, 2020. (Tr. 10.) ALJ Patrick Kilgannon held a telephonic hearing on October 22, 2020, at which a vocational expert (“VE”) appeared, and the plaintiff-who was represented by counsel-testified. (Tr 10.) In a February 17, 2021, decision, ALJ Kilgannon determined that the plaintiff was not disabled and denied her claim. (Tr. 7-23.)

The ALJ concluded that: (1) the plaintiff had not engaged in substantial gainful activity since March 27, 2019, the alleged onset date, (2) the plaintiff's severe impairments included major depressive disorder, generalized anxiety disorder and lumbar degenerative disc disease, and that (3) those impairments, whether considered individually or in combination, did not meet or equal any of those listed in Appendix 1 of the regulations. (Tr. 13.) The ALJ determined that the plaintiff retained the residual functional capacity (“RFC”) to perform “light work” with a series of additional limitations:

the [plaintiff] is limited to a light level of physical exertion with an ability to lift and carry up to 20 pounds occasionally and 10 pounds frequently, and could sit for about 6 hours and stand/walk for 6 hours in an 8 hour workday with normal breaks, and should avoid climbing ladders, ropes and scaffolds, but could occasionally climb ramps and stairs could occasionally balance, stoop, kneel, crouch and crawl and should avoid hazards such as moving machinery and unprotected heights. The claimant would also only be capable of performing simple routine tasks, could sustain concentration for simple routine tasks, can maintain a schedule, can make simple work-related decisions, could occasionally interact with supervisors, coworkers and the general public, and could occasionally adapt to changes in the work setting.

(Tr. 15.)

Finally, citing the VE's testimony, the ALJ ruled that the plaintiff could not do her past relevant work as an administrative assistant or as a personnel recruiter (Tr. 21-22), but could do other jobs, including routing clerk, photocopy machine operator, and “price marker.” (Tr. 22.)

The Appeals Counsel denied plaintiff's request for review of the hearing decision on August 19, 2021, rendering the ALJ's denial the “final decision” of the Commissioner and subject to judicial review. (Tr. 1-3.) The plaintiff filed this action on August 30, 2021 (ECF No. 1), and both parties moved for judgment on the pleadings. (ECF Nos. 10, 14.)

I. The ALJ's Review of Medical Opinion Evidence

There are six relevant sources of medical opinions regarding the plaintiff's mental health, from four treating providers, two consultative examiners, and one non-examining medical expert.

a. Treating Physician Opinions^[1]

i. Dr. David Belser, Ph.D - Treating Psychologist

Dr. David Belser, a psychologist, began treating the plaintiff in November 2017. (Tr. 584.) In a July 25, 2019 narrative report, Dr. Belser concluded that the plaintiff had a severe depressive and anxiety disorder, which caused her to be “mostly in bed on a daily basis,” and that she had “to be urged to get up and conduct activities.” (Tr. 658.) She had “severe anxiety and panic throughout each day,” and her conditions caused her financial problems, housing problems, and family problems. (Tr. 658.) As a result, Dr. Belser found the plaintiff to be “unable to work in any capacity.” (Tr. 658.)

Dr. Belser completed a mental capacity questionnaire on October 17, 2019, in which he diagnosed the plaintiff with Major Depression, Generalized Anxiety Disorder and Panic Disorder, which “completely incapacitate[d] her,” leaving her unable to work or perform simple, repetitive tasks. (Tr. 399-402.) Dr. Belser found that the plaintiff was “markedly limited” in her ability to understand and remember detailed instructions, as well as “markedly limited” in her ability to carry out detailed instructions, concentrate for extended periods of time, remain on a schedule, attend work consistently or be on time, maintain an ordinary routine without special supervision, work with others without being distracted by them and complete a normal workday or workweek without interruptions from psychological based symptoms. (Tr. 400-01.) Dr. Belser also found that the plaintiff was “markedly limited” in her ability to interact appropriately with the public and her ability to maintain socially appropriate behavior and maintain basic standards of neatness and cleanliness. (Tr. 401.) Finally, Dr. Belser determined that the plaintiff was “markedly limited” in her ability to respond appropriately to changes at work and her ability to set realistic goals or make independent plans. (Tr. 402.) Dr. Belser filled out a second mental capacity questionnaire on June 2, 2020, in which he again found that the plaintiff's conditions “completely incapacitate[d] her,” and that she could not work. (Tr. 738-40.) Dr. Belser found the plaintiff to be “markedly limited” in the same ways as in his prior evaluation. (Tr. 738-40, 765.)

Dr. Belser completed a third mental capacity questionnaire on September 29, 2020. (Tr. 586-91.) Dr. Belser found, once again, that the plaintiff could not work and had a “complete inability to function independently outside the area of [her] home.” (Tr. 595-96.) Dr. Belser explained that the plaintiff had “no useful ability” to remember locations and work-like procedures, to understand, remember, and carry out detailed instructions, to perform activities within a schedule, maintain regular attendance and be on time, and to work with or near others without being distracted by them. (Tr. 588-91.)

ALJ Kilgannon found Dr. Belser's opinion “less persuasive,” determining that the doctor's findings were “inconsistent with [the] mental status exams and his treatment notes,” and that they were “conclusory and lack[ed] objective support.” (Tr. 16-17.)

ii. Dr. Paris Arianas, MD - Treating Psychiatrist

Dr. Arianas, the plaintiff's treating psychiatrist, submitted the plaintiff's medical records from January 2020 to October 2020. (Tr. 19.) During an examination on January 29, 2020, Dr. Arianas diagnosed the plaintiff with severe depression and possible bipolar affective disorder. (Tr. 558-59.) Because he was concerned about the onset of a “psychiatric disturbance,” Dr. Arianas told the plaintiff to go to the emergency room for evaluation. (Tr. 558-59.) The plaintiff went to the ER but did not want to be admitted. (Tr. at 560, 785.) According to Dr. Arianas' treatment notes, he ultimately diagnosed the plaintiff with bipolar affective disorder, depression and anxiety. (Tr. 830-31.) Dr. Arianas did not provide an opinion on the plaintiff's ability to work. The ALJ did not consider the merits of Dr. Arianas' treatment notes and therefore did not afford them any specific weight.

iii. Rosemary Luke, NPP - Treating Psychiatric Nurse Practitioner

Nurse Practitioner Rosemary Luke submitted treatment records from February 2018 to December 2019. (Tr. 19.) NP Luke diagnosed the plaintiff with bipolar disorder and in an April 2018 letter, stated that the plaintiff was not medically capable of returning to work. (Tr. 19.) NP Luke also wrote that the plaintiff was “alert and oriented with clear and spontaneous speech, appropriate behavior, normal psychomotor activity, normal thought process and content, intact memory and good abstract thinking” and that her cognitive exams were intact. (Tr. 19.) The ALJ described NP Luke's conclusion as “less persuasive,” because she rendered it two months after the plaintiff started treatment. (Tr. 19.) In addition, the ALJ concluded that the findings were “not supported by the fairly benign mental status exams of Ms. Luke and by other doctors.” (Tr. 19.)

b. Consultative Opinions

i. Dr. David Schaich, Ph.D - Consultative Examining Psychologist

The consultative psychologist, Dr. Schaich, examined the plaintiff in December 2019, and issued a report in which he noted that the plaintiff “had sleep difficulty fluctuating appetite, daily depressed mood, crying spells, guilt, hopelessness, loss of interests, irritability, loss of energy, worthlessness, diminished self-esteem, concentration problems, diminished sense of pleasure, and social withdrawal.” (Tr. 18.) He also noted that the plaintiff had anxiety symptoms, including panic attacks with heart palpitations, and that she reported symptoms of “mania” and concentration problems. (Tr. 18.) Dr. Schaich found that the plaintiff had “fair” social skills, that she had “below average cognitive functioning but was otherwise normal,” that her attention, concentration and memory were all “intact,” and she had good insight and judgment. (Tr. 18.) Dr. Schaich diagnosed unspecified depressive disorder and unspecified anxiety...