Farrar v. Kijakazi

596 F.Supp.3d 255

Jamie FARRAR, Plaintiff,

v.Kilolo KIJAKAZI, Acting Commissioner of Social Security, Defendant.

CIVIL ACTION NO. 4:20-11750-TSH

United States District Court, D. Massachusetts.

Filed March 31, 2022

Patrick K.B. Tracy, Law Office of Patrick Tracy, Esq., Milton, MA, for Plaintiff.

Hugh Dun Rappaport, Louis J. George, Social Security Administration-Office of the General Counsel, Boston, MA, for Defendant Andrew Saul.

ORDER AND MEMORANDUM ON PLAINTIFF'S MOTION TO REVERSE THE COMMISSIONER'S DECISION AND THE COMMISSIONER'S MOTION TO AFFIRM THE COMMISSIONER'S DECISION (Docket Nos. 18 & 19)

HILLMAN, D.J.

This is an action for judicial review of a final decision by the Commissioner of the Social Security Administration (the "Commissioner") denying the application of Jamie Farrar (the "Plaintiff") for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI").¹ The Plaintiff filed a motion for an order reversing the decision. (Docket No. 18). The Commissioner filed a cross-motion seeking affirmance. (Docket No. 19). Because the medical opinions on which the ALJ relied were based on a significantly incomplete record, the Court vacates the decision and remands the case for further consideration. The Plaintiff's motion is granted. The Commissioner's motion is denied.

Background

The parties are familiar with the factual history of this case and the applicable five-step sequential analysis. Accordingly, the Court will recite the procedural and substantive history of the case only as it relates to the Plaintiff's arguments.

The Plaintiff filed applications for DIB and SSI on April 12, 2017, alleging a disability due to heart disease, chest pain, back pain, and peripheral neuropathy. (AR 251). The Social Security Administration denied his applications, initially on September 13, 2017, and upon reconsideration on February 22, 2018. (AR 147, 151, 157, 160).

At the initial determination stage, a non-examining state agency medical consultant, Dr. Ludmila Perel, assessed the Plaintiff's residual functional capacity ("RFC"). (AR 97-99). Dr. Perel opined that the Plaintiff could occasionally lift and/or carry twenty pounds, frequently lift and/or carry ten pounds, stand and/or walk (with normal breaks) for a total of four hours, and sit (with normal breaks) for a total of six hours in an eight-hour workday. (AR 97-98). Dr. Perel explained that the Plaintiff has normal motor strength and tone, no tenderness, normal gait, and no focal neuro deficits. (AR 98). She also noted, inter alia , that the Plaintiff alleges back pain, neuropathy, and heart disease ; has had multiple surgeries and five stents implanted; has stable angina; has chronic back pain; and walks with a cane. (AR 98).

At the reconsideration stage, a different non-examining state agency medical consultant, Dr. Ilonna Rimm, affirmed Dr. Perel's RFC assessment. (AR 124-126). Dr. Rimm explained that although the Plaintiff has many obesity-related issues, sleep apnea, and heart disease (including an additional stent placed in June of 2017), his "exam is unremarkable," and he can cook, clean, and shop. (AR 126). Dr. Rimm also found it noteworthy that the Plaintiff reports that he uses a cane, but that his physicians report that he exhibits a normal gait without a cane. (AR 126).

The Plaintiff requested a hearing before an Administrative Law Judge ("ALJ"). (AR 163). In a pre-hearing memorandum, the Plaintiff clarified that his alleged disability onset date is March 31, 2016. (AR 318). The hearing was held on November 19, 2019. (AR 36).

The Plaintiff has a ninth-grade education and was in his mid-forties at the time of the alleged disability onset date. (AR 22, 252). At the hearing, the Plaintiff testified that he had previously worked as a cook, a maintenance worker, a machinist, and a nighttime security guard. (AR 43-47). The Plaintiff testified that he stopped working in 2013. (AR 43). He testified that he is "slow" at taking care of himself; cannot do household chores without falling; cannot stand for more than five minutes at a time; cannot walk more than twenty-five or thirty feet without a cane; cannot walk across uneven surfaces; cannot lift and carry more than about seven pounds; has difficulty bending and kneeling; constantly drops things due to difficulty with his hands; has difficulty going up and down stairs; and has blurred vision, dizziness, and fatigue due to medication he takes. (AR 53-57). The Plaintiff also testified that he cannot sit for six hours a day. (AR 54-55, 58).²

A vocational expert ("VE") also testified. The ALJ asked the VE about a hypothetical person with the Plaintiff's age, education, and work experience, with limitations in line with Dr. Perel's RFC assessment. The VE testified that a person with such limitations could not perform any of the Plaintiff's past jobs, but could perform other jobs in the national economy, such as that of a ticket seller taker, a toll collector, or a school bus monitor. (AR 66).³

On January 15, 2020, the ALJ issued his decision. (AR 12). Undertaking the familiar five-step sequential analysis, the ALJ concluded that the Plaintiff was not disabled from his alleged onset date through the date of the decision. (AR 16). At step one, the ALJ found that the Plaintiff had not engaged in substantial gainful activity since before the alleged onset date. (AR 17). At step two, the ALJ found that the Plaintiff had the following severe impairments: coronary artery disease status-post stents, peripheral neuropathy, obesity, degenerative disc disease, sleep apnea, and left shoulder dysfunction. (AR 18). The ALJ further found that the Plaintiff had the following non-severe impairments: hip issues, prior hernia surgeries, diabetes, chronic pain, alcohol dependence (in sustained remission), and depression. (AR 18-19).⁴ At step three, the ALJ found that the Plaintiff did not have an impairment or combination of impairments that met or were medically equivalent to any of the impairments listed in the Social Security regulations. (AR 19).

The ALJ then found that the plaintiff had the RFC to perform light work as defined in 20 C.F.R. 404.1567(b) and 416.967(b), with the limitations largely as described by Dr. Perel.⁵ (AR 22). The ALJ reasoned that while the Plaintiff's impairments could reasonably be expected to cause his alleged symptoms, the Plaintiff's "statements concerning the intensity, persistence and limiting effects of these symptoms are not entirely consistent with the medical evidence and other evidence in the record." (AR 22-23). The ALJ acknowledged that the Plaintiff testified to more extreme limitations but pointed to the Plaintiff's medical examinations from 2016 through 2019 in which the Plaintiff exhibited normal heart rate and rhythm, a normal gait and station,⁶ normal motor strength and tone, generally normal movement in his extremities,⁷ normal breath sounds, grossly intact sensation, and the ability to ambulate normally or with a cane.⁸ (AR 23-25). The ALJ further pointed to reports that the Plaintiff was spending time on activities outside of the home, such as fishing, barbequing, and working on cars.⁹ (AR 25-26).

The ALJ found "highly persuasive" the RFC opinions of Dr. Perel and Dr. Rimm, noting that their opinions were "generally consistent with the medical record and the claimant's reported activities and hobbies." (AR 27). The ALJ did not expressly rely on or credit any other medical opinions on the Plaintiff's physical impairments.

Finally, accepting the testimony of the VE, the ALJ found, at step four, that the Plaintiff was unable to perform any past relevant work, and, at step five, that there were jobs in the national economy that the Plaintiff could perform. (AR 27-29). Accordingly, the ALJ found that the Plaintiff was not disabled. (AR 29). The Appeals Council denied the Plaintiff's request for review, making the ALJ's decision final and subject to judicial review. (AR 1).

Standard of Review

The Court may affirm, modify, or reverse the final decision of the Commissioner, with or without remanding the case for a rehearing. 42 U.S.C. § 405(g). The Commissioner's factual findings, "if supported by substantial evidence, shall be conclusive," id. , because "the responsibility for weighing conflicting evidence, where reasonable minds could differ as to the outcome, falls on the Commissioner and his designee, the ALJ." Seavey v. Barnhart , 276 F.3d 1, 9 (1st Cir. 2001) (citation omitted); see also Evangelista v. Sec'y of Health & Human Servs. , 826 F.2d 136, 143-44 (1st Cir. 1987). "Judicial review of a Social Security Claim is limited to determining whether the ALJ used the proper legal standards, and found facts based on the proper quantum of evidence." Ward v. Commissioner of Soc. Sec. , 211 F.3d 652, 655 (1st Cir. 2000).

Discussion

The Plaintiff contends that the ALJ's RFC determination is not supported by substantial evidence. Substantial evidence is that which "a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales , 402 U.S. 389, 401, 91 S.Ct. 1420, 28 L.Ed.2d 842 (1971) (quoting Consolidated Edison Co. v. NLRB , 305 U.S. 197, 229, 59 S.Ct. 206, 83 L.Ed. 126 (1938) ). An ALJ's RFC determination must be supported by a "medical opinion" to be supported by substantial evidence. See Nguyen v. Chater , 172 F.3d 31, 35 (1st Cir. 1999) ; Berrios Lopez v. Sec'y of Health & Human Servs. , 951 F.2d 427, 430 (1st Cir. 1991). A "medical opinion" is a statement from a medical source about what a person can do, despite the person's impairments. See 20 C.F.R. § 404.1513(a)(2). A medical opinion cannot serve as substantial evidence if it is based on a significantly incomplete record. See Alcantara v. Astrue , 257 Fed. Appx. 333, 335 (1st Cir. 2007) (unpublished); Valle v. Berryhill , 444 F. Supp. 3d 299, 313 (D. Mass. 2020) ; Arrington v. Colvin , 216 F. Supp. 3d 217, 239 (D. Mass. 2016).

The Plaintiff argues that the medical opinions on which the ALJ...