Court: District Court, S.D. Illinois; March 4, 2018; Federal District Court
Frank Perozzi, Jr. filed a case under 42 U.S.C. § 405(g) seeking judicial review of the Social Security Commissioner's final decision denying his claim for disability benefits. Both Perozzi and the Commissioner moved for judgment on the pleadings, with the Commissioner’s motion denied and Perozzi’s motion granted, resulting in a remand. Perozzi applied for disability insurance benefits and supplemental security income on June 25, 2013, claiming disability since June 13, 2009. The Social Security Administration denied his claims on November 26, 2013. He subsequently requested a hearing, held on June 16, 2015, where he was represented by attorney Gideon Miller.
During the hearing, Perozzi described his work history, stating his last job was as a maintenance helper for the Rockland County Sewer Department in 2009. He reported ongoing issues such as constant back pain, fatigue, and concentration difficulties due to pain medication, limiting his ability to sit, stand, and perform daily activities. Perozzi can walk short distances using a cane occasionally and has not worked since 2009. He has a history of a heart attack in 2013 but noted his heart condition is stable, and he also manages gout. Perozzi struggles with reading comprehension due to a lifelong learning disability.
His daily routine includes minimal personal care, occasional light chores, and limited social interactions. He drives infrequently and locally. He has tried epidural shots and physical therapy for his back pain without success and does not seek treatment for mental health issues. The ALJ also consulted a vocational expert regarding Perozzi's past work capacity. Perozzi's previous job involved significant physical demands, including heavy lifting and maintenance tasks.
VE Burk classified Perozzi's previous roles as "municipal maintenance worker" and "highway maintenance worker," both requiring heavy exertion. Perozzi also worked as a "surveyor helper," which Burk deemed to require medium exertion. The ALJ assessed Perozzi’s capabilities based on his age, education, and experience, concluding he could perform sedentary work with specific limitations: occasional climbing of stairs and ramps, no climbing of ladders, and limited balancing, stooping, crouching, kneeling, and crawling. He must avoid unprotected heights and hazardous machinery, receive a sit/stand option every two hours, and avoid extreme weather conditions. The VE indicated such a person could not return to past work but could undertake roles like small products assembler, telephone solicitor, printed circuit board assembly touch-up screener, and cashier II, all allowing flexible sitting and standing. However, if limited to sitting less than six hours, standing and walking for only two hours, lifting under ten pounds occasionally, and being off task 15% of the day with frequent absences, the VE stated no jobs would be available in the national economy.
Medical evidence summaries from both Perozzi and the Commissioner were found to be consistent, leading the Court to accept them as accurate. The ALJ denied Perozzi’s benefits application on August 28, 2015, confirming he met the insured status through December 31, 2015, and had not engaged in substantial gainful activity since June 13, 2009. The ALJ identified several severe impairments including degenerative disc disease, lumbar spine issues, coronary artery disease, and hypertension, while recognizing Perozzi's obesity. Gout and renal insufficiency were managed with medication. The ALJ noted Perozzi's learning disability minimally affected his work capabilities, supported by evidence of no cognitive deficits during hearings and evaluations, a low average IQ of 82, and his ability to read at a 12th-grade level. Independent assessments indicated only mild functional limitations, and he had successfully worked despite his learning disability for many years.
The Administrative Law Judge (ALJ) concluded that Perozzi's severe impairments did not meet or medically equal the criteria for any listed impairments under 20 C.F.R. part 404, subpart P, appendix 1. The ALJ specifically evaluated Listing 1.04 (Disorders of the Back) and Listing 4.04 (Ischemic Heart Disease). For Listing 1.04, the ALJ determined that Perozzi's degenerative disc disease lacked evidence of nerve root compromise, as required by the listing. The necessary conditions for nerve root compression, spinal arachnoiditis, or lumbar spinal stenosis were not met.
Regarding Listing 4.04, the ALJ found that Perozzi failed to demonstrate the required exercise tolerance test results or evidence of ischemic episodes necessitating revascularization. Additionally, there was no proof of coronary artery disease through acceptable imaging, and a medical consultant indicated significant risks associated with exercise tolerance testing.
Although the ALJ acknowledged that hypertension should be evaluated against specific body systems, no such evidence was found in Perozzi's medical records. The ALJ noted that no treating or examining physician reported findings that equaled the severity criteria of any listed impairment.
In assessing Perozzi's residual functional capacity (RFC), the ALJ determined he could perform a full range of sedentary work, with certain limitations on climbing, balancing, stooping, crouching, kneeling, and crawling. Perozzi would also need the option to alternate between sitting and standing every two hours and avoid extreme temperatures and humidity.
The ALJ considered various medical opinions in determining the RFC. Dr. Julia Kaci, a consultative examiner, received "great weight" for her assessment of moderate limitations across several physical activities, except for hand use, which she deemed unrestricted. The opinions of three treating sources were given "some weight," noting that they had previously assessed Perozzi as not being a surgical candidate and capable of returning to work following conservative treatment methods.
The Administrative Law Judge (ALJ) evaluated multiple medical opinions regarding Perozzi's ability to work under the New York State Workers' Compensation Act. The ALJ assigned "some weight" to opinions from various independent medical examiners, including Dr. Robert Hendler, who indicated Perozzi could work with specific lifting and standing restrictions, and Dr. Charles Sallahian, who suggested sedentary work with limits on heavy lifting and bending. However, these opinions were given less weight due to their context within Perozzi's workers' compensation case and the status of Dr. Sallahian as a chiropractor.
Dr. Gerald Gaughan, Perozzi's treating physician, received "little weight" for his opinions on total disability and specific functional limitations, as the ALJ noted that treating physicians often advocate for claimants in workers' compensation cases, potentially overstating limitations. The ALJ highlighted differences between the definition of disability in workers' compensation and the Act, favoring the opinions of other doctors whose assessments aligned better with Perozzi's medical records and daily activities.
Regarding Perozzi's heart condition, the ALJ noted positive reports from Drs. John Fitzpatrick and Michael Innerfield, who indicated Perozzi was in good health and actively exercising. The ALJ assigned "great weight" to Dr. Auerbach's opinion, which confirmed Perozzi's capability to lift and perform tasks, although this assessment was limited to cardiovascular issues.
The ALJ found Perozzi's subjective complaints of pain to be not wholly credible, citing his ability to perform daily activities, including cooking, cleaning, and exercising, as inconsistent with his claims of debilitating pain. Additionally, the ALJ pointed out that Perozzi had only received routine medical treatments and often reported feeling well during visits, further undermining the credibility of his complaints.
The Administrative Law Judge (ALJ) found no evidence of debilitating symptoms from Perozzi during the hearing, which diminished the credibility of his subjective complaints. After assessing Perozzi's Residual Functional Capacity (RFC), the ALJ determined that he could not return to his past work based on vocational expert (VE) Burk's testimony, indicating that Perozzi's age, education, experience, and RFC precluded him from performing his previous roles as a municipal maintenance worker and surveyor helper. The ALJ then examined whether Perozzi could transition to other work in the national economy and, relying on the VE's testimony and additional record materials, concluded that he could. Consequently, the ALJ ruled that Perozzi was "not disabled" under the relevant statute and denied his benefits application.
The document also outlines the scope of judicial review under 42 U.S.C. § 405(g), which states that courts are limited to determining whether the Commissioner's conclusions are backed by substantial evidence and adhere to correct legal standards. Substantial evidence is defined as relevant evidence that a reasonable mind might accept as adequate to support a conclusion. The findings of the Commissioner are conclusive if supported by substantial evidence, even if alternative findings could also be supported by the record. The Second Circuit emphasizes that the substantial evidence standard is highly deferential, requiring courts to uphold the Commissioner's decision unless no reasonable factfinder could arrive at the same conclusion. It is clarified that courts do not have the authority to decide de novo whether a claimant is disabled.
The Social Security Act defines "disability" as the inability to engage in substantial gainful activity due to medically determinable physical or mental impairments expected to last at least 12 months. A person is considered disabled if their impairments prevent them from performing previous work and any other substantial gainful work available in the national economy, taking into account age, education, and work experience. The Commissioner evaluates disability claims by examining: 1) objective medical facts, 2) medical diagnoses or opinions, 3) subjective evidence of pain or disability, and 4) the claimant's educational background, age, and work experience.
The evaluation process follows a five-step framework:
1. Determine if the claimant is engaged in substantial gainful activity.
2. If not, assess if there is a severe medically determinable impairment that significantly limits basic work activities.
3. If the impairment is severe and listed, the claimant is deemed disabled regardless of other factors.
4. If the impairment is not listed, evaluate the claimant's Residual Functional Capacity (RFC) to determine if they can perform past relevant work.
5. If unable to do past work, assess if the RFC allows for other work; if not, the claimant is considered disabled.
The burden of proof lies with the claimant for all steps except the last, which requires proof that other work exists that the claimant can perform. Additionally, an Administrative Law Judge (ALJ) must generally give more weight to the medical opinions of treating sources, as they provide unique insights that may not be captured by objective findings or individual examinations alone.
An Administrative Law Judge (ALJ) is required to give "controlling weight" to a treating physician's medical opinion regarding a claimant's impairments if it is well-supported by clinical and diagnostic evidence and not contradicted by substantial evidence in the case record. If the ALJ chooses not to give controlling weight to such an opinion, they must provide "good reasons" for this decision, or risk a remand. The ALJ should consider various factors when determining the weight of a treating source's opinion, including the duration and frequency of the treatment relationship, the opinion's supportability, its consistency with the overall record, whether the opinion comes from a specialist, and other relevant factors. The Second Circuit emphasizes the necessity for ALJs to provide thorough justifications for the weight assigned to treating physicians' opinions.
In the case discussed, Perozzi argues that the ALJ improperly evaluated his claim by failing to find that he met Listing 1.04, misapplying the treating source rule regarding Dr. Gaughan's opinions, and assessing a Residual Functional Capacity (RFC) that lacked substantial evidence. Specifically, Perozzi contends that the ALJ's reasoning was insufficient, suggesting a lack of genuine consideration of whether he met the listing requirements. He asserts that his medical records provide undeniable evidence for all necessary medical findings to qualify under the listing. To meet Listing 1.04, a claimant must demonstrate a spinal disorder that compromises a nerve root, supported by specific medical findings and diagnostic techniques.
A claimant must provide evidence of nerve root compression, including pain distribution, spinal motion limitations, motor loss (including atrophy and weakness), sensory or reflex loss, and, for lower back issues, a positive straight-leg raising test. In this case, the ALJ did not analyze these listing elements but merely stated that Perozzi did not meet them, failing to specify which elements were not satisfied. Despite this omission, case law allows courts to uphold an ALJ's conclusion at step three of the analysis if substantial evidence supports the conclusion, even without an explicit rationale. For example, in Berry v. Schweiker, the Second Circuit upheld an ALJ’s determination despite a lack of explanation. However, cases may arise where an ALJ's rationale is unclear, potentially warranting remand for further findings. While the ALJ's lack of specificity regarding Listing 11.14 was noted, the overall conclusion was supported by substantial evidence, including the claimant's testimony and the absence of compelling contradictory evidence. Consequently, the argument that remand is required solely due to the absence of an express rationale is rejected.
Perozzi cites Torres v. Colvin to support his argument regarding the ALJ's decision-making process. In Torres, the court remanded an ALJ's ruling that merely restated Listing criteria without adequately evaluating the claimant's symptoms against those criteria, preventing the court from determining if the ALJ's decision was backed by substantial evidence. The court acknowledged potential alignment with Listing requirements based on the record but criticized the lack of sufficient reasoning from the ALJ.
The Berry standard reinforces that remand is necessary if the court is unable to understand the ALJ's rationale concerning the evidence. Specifically, if credibility assessments and inferences are required at step three, the ALJ must clarify their reasoning. Other cases, such as Ryan v. Astrue and Gonzalez, similarly support remand when evidence is insufficient to substantiate the ALJ's conclusions.
In Perozzi's case, the record presents substantial evidence indicating he may meet the criteria for Listing 1.04A, which concerns spinal disorders leading to nerve root compromise. An MRI from August 2009 indicated a disc protrusion causing moderate compression of the right L2 nerve root, and subsequent imaging in 2013 revealed additional degenerative conditions and disc issues. The ALJ's failure to thoroughly address the medical evidence raises doubts about whether a reasoned evaluation would have led to a conclusion that Perozzi did not meet the listing.
In 2014, a third MRI revealed advanced disc degeneration at L2-3, with caudal migration affecting the right L4 nerve root, mild stenosis at L2-3 and L3-4, and right facet osteoarthritis. The Commissioner argued that earlier MRI findings from 2009 were not referenced in later imaging; however, the ALJ acknowledged the 2009 MRI and did not dismiss it based on subsequent MRIs, indicating that Perozzi might satisfy the first listing requirement. To meet the second requirement, Perozzi needed to demonstrate "neuro-anatomic distribution of pain." Evidence of radicular pain linked to compression of the right L2 nerve root was present, supported by EMG results suggesting left L2-L3 radiculopathy and a diagnosis from Dr. Gaughan. Although left-sided radiculopathy is not entirely consistent with right L2 nerve root compression, it may still align with L2-L3 nerve compression.
The remaining criteria include limitations in spine motion, motor loss with sensory or reflex loss, and positive straight-leg raising. Medical assessments indicated muscle atrophy and weakness, with Dr. Gaughan noting limited spine motion due to lumbar dysfunction and decreased vibration sensitivity. Other doctors corroborated findings of limited spine movement and slow, guarded gait, with some stating Perozzi could not walk on his heels and toes due to pain. Positive straight-leg raising was documented in multiple assessments by Dr. Gaughan. Overall, the evidence supports that Perozzi may meet the criteria for disability based on the combination of findings related to motor loss, pain distribution, and spinal limitations.
Dr. Kaci’s November 2013 assessment indicated positive straight-leg raising at 30 degrees bilaterally, and Dr. Sallahian observed supine straight-leg raising to 45 degrees on the right with pain and 60 degrees on the left without complaint. This evidence potentially meets the Listing 1.04A criteria. Although the ALJ assigned varying weights to the opinions of different doctors, he did not clarify how he considered the specific medical evidence and what conclusions he drew from it. Contradictory findings exist in the record, including observations by Drs. Hendler and Semble of normal range of motion and strength, and Dr. Fitzpatrick’s consistent findings of normal muscle strength in Perozzi. Dr. Bottiglieri also noted normal muscle strength and negative straight-leg raising tests. The court emphasizes that while the ALJ may have ultimately determined that Perozzi's impairments did not meet Listing 1.04A, he is required to discuss its potential applicability and provide a rationale for his conclusions. Unlike in Kretovic, where the ALJ provided detailed reasoning for not meeting the listing, the current ALJ failed to adequately explain his rationale. As such, on remand, the ALJ must reassess whether Perozzi meets Listing 1.04A and offer a clearer explanation if he reaffirms his earlier conclusion. Additionally, Perozzi challenges the ALJ’s evaluation of his residual functional capacity (RFC), which determined he is capable of performing sedentary work with specific limitations on climbing and balancing activities.
The individual is required to avoid unprotected heights and hazardous machinery, and must have a sit/stand option every two hours. Conditions to avoid include wetness, humidity, and extreme temperatures. Sedentary work is defined as involving the lifting of no more than 10 pounds and typically requires sitting for about six hours in an eight-hour workday. Perozzi disputes the ALJ's reliance on Dr. Hendler's opinions, alleging bias stemming from Dr. Hendler's involvement in his workers' compensation case and claiming Dr. Hendler misdiagnosed him. The ALJ acknowledged Dr. Hendler's role and noted that other doctors, including Drs. Bottiglieri and Semble, also reported negative straight leg raise tests. Additionally, Dr. Fitzpatrick consistently observed normal muscle strength and range of motion.
Perozzi also argues that the ALJ erred by not addressing a social security employee's observation of his discomfort while sitting, but the ALJ is not obligated to cite all evidence, especially non-medical sources. Furthermore, Perozzi contests the ALJ's finding that he could sit for six hours in a workday, challenging the interpretation of Dr. Kaci's opinion, which indicated a "moderate limitation" on sitting. The ALJ gave great weight to Dr. Kaci's opinion, while giving little weight to Dr. Gaughan, who suggested Perozzi could sit for only limited periods. The ambiguity of "moderate" limitations and similar vague terms has previously been deemed insufficient for determining a claimant's RFC without additional clarification, as established in case law.
The consulting physician's vague use of "moderate" limitations fails to provide adequate support for the Administrative Law Judge's (ALJ) conclusion that the plaintiff could engage in activities for six hours within an eight-hour workday. Previous cases, such as Young v. Comm'r of Soc. Sec. and Richardson v. Astrue, highlight that vague medical opinions regarding limitations are insufficient for determining a claimant's ability to perform sedentary work. The opinion of Dr. Kaci specifically does not substantiate the ALJ's findings. The Commissioner referenced several cases to defend the ALJ's determination, but these cases are not applicable. For instance, Martin v. Astrue did not address functional limitations, while Burdick v. Astrue involved detailed medical opinions that provided a clearer basis for the ALJ's RFC determination. Additionally, other cited cases, including Mitchell ex rel. Mitchell and Williams v. Colvin, similarly featured vague opinions but were distinguished due to stronger corroborating evidence in the records that supported the RFC decisions. In Mitchell, multiple medical opinions limited the claimant to light or sedentary work, while Williams acknowledged the limited utility of vague functional limitations in determining RFC.
The ALJ did not fully rely on the consulting physician's opinion, assigning it only partial weight, which distinguishes this case from prior cases where vague opinions were partly considered. In contrast, the ALJ gave "great weight" to Dr. Kaci's opinion without addressing its vagueness. The Funk case involved an underdeveloped medical record and was remanded for further development, specifically regarding the RFC, without requiring the ALJ to contact a consultative examiner. The court in Funk assessed the consistency of the consultative examiner's opinion with the plaintiff's ability to perform sedentary work, not the opinion's vagueness. The ALJ's conclusion that "moderate" limitations on sitting permit sedentary work lacks substantial evidence, raising doubts about whether Perozzi could sit for six hours as determined. The ALJ’s assertion regarding the absence of observable muscle wasting or atrophy indicating non-severe pain is unsupported by medical evidence, reflecting a layperson's judgment not appropriate for the ALJ. This error also impacts the credibility of the ALJ's findings regarding Perozzi's sitting limitations. On remand, the ALJ is required to reassess Perozzi's ability to sit for the necessary duration and may further develop the record. Additionally, the ALJ's reasoning suggested a reliance on treating sources because their opinions aligned with the ALJ’s view of the RFC, particularly in giving "great weight" to Dr. Kaci’s opinion based on its support for sedentary work.
Dr. Hendler's opinion, suggesting a light exertional level, does not contradict the sedentary exertional level assigned in this case. Though a chiropractor's opinion is generally not considered acceptable, Sallahian's assessment was given some weight as it aligned with the determination of Perozzi's residual functional capacity (RFC) for sedentary work. This situation reflects similar reasoning found in Campbell v. Comm'r of Soc. Sec., where the ALJ first determined the RFC and then asserted that medical evidence supported this determination, a method criticized for being circular and prejudicial. ALJs are mandated to base RFC determinations on comprehensive evidence, including medical opinions, rather than forming an RFC and then evaluating credibility against it.
On remand, the ALJ is instructed to avoid this flawed reasoning. Regarding the treating source rule, Perozzi argued that the ALJ should have given controlling weight to Dr. Gaughan's opinions, which the ALJ dismissed as unreliable due to Dr. Gaughan's adversarial role in Perozzi's workers' compensation case and inconsistencies with other medical records and Perozzi's daily activities. The ALJ favored the opinions of Drs. Kaci, Hendler, Bottiglieri, and Sallahian, deeming them more persuasive and consistent with the overall medical evidence. This rationale supports giving less than controlling weight to Dr. Gaughan's views, as they did not align with substantial evidence. The ALJ's explanations constituted "good reasons" for this weight assignment, conforming to regulatory standards without necessitating an exhaustive list of factors, provided the reasoning is clear and adheres to established regulations.
Dr. Gaughan's involvement in Perozzi's workers' compensation case and his medical evaluations were extensively detailed by the ALJ, who noted the consistency of Dr. Gaughan's opinions with other medical evidence. The ALJ referenced the supporting medical evidence from multiple tests conducted by Dr. Gaughan, including MRIs and neurological assessments. Although the ALJ did not explicitly state Dr. Gaughan's specialization, he acknowledged the specializations of other doctors involved in Perozzi's care. The ALJ's application of the treating physician rule was deemed adequate as he provided sufficient reasons for discounting Dr. Gaughan's opinion, aligning with regulatory factors without directly citing them.
Perozzi argues that the ALJ's decision is flawed because Dr. Gaughan's findings align with those of Drs. Kaci and Sallahian. However, notable disagreements exist among their assessments. Dr. Gaughan uniquely identified left leg muscle atrophy, consistent weakness in the lower extremities, imposed specific limitations on Perozzi’s hand use, and deemed Perozzi "totally disabled." In contrast, Dr. Kaci observed no muscle atrophy, noted full grip strength, and assessed a moderate limitation in various physical activities, while Dr. Sallahian's findings also conflicted with Dr. Gaughan’s conclusions. Overall, Dr. Gaughan's opinions diverged significantly from those of other treating physicians, particularly regarding Perozzi's disabilities and physical limitations.
Dr. Gaughan indicated that Perozzi tested positive for a straight leg test at 45 degrees on his left leg, alongside muscle weakness and atrophy. In contrast, Dr. Sallahian found no such abnormalities, reported no motor or sensory deficits in Perozzi's lower extremities, and noted that his spine showed no muscle spasms or trigger points. Dr. Sallahian concluded that Perozzi had a "moderate, partial disability" and could perform sedentary work with limitations on heavy lifting and repetitive bending. This assessment conflicts with Dr. Gaughan's consistent conclusion of total disability. Dr. Bottiglieri's observations also diverged from Dr. Gaughan's; although he noted paraspinal spasms and moderate limitations in flexion, he found no neurological deficits and confirmed intact sensation and strength. Dr. Bottiglieri later referred Perozzi to Dr. Jack Stern for a surgical evaluation, who recommended against surgery and suggested continued conservative care. Following further assessments, Dr. Bottiglieri certified Perozzi as able to return to work as of June 22, 2010.
The Administrative Law Judge (ALJ) found Dr. Gaughan’s findings inconsistent with those of Dr. Bottiglieri, Sallahian, and Kaci, and exercised discretion in resolving these conflicts. Perozzi contested the ALJ's reliance on his reported daily activities to diminish Dr. Gaughan's opinion, arguing that such activities should not be considered unless they indicate the ability to perform substantial gainful activity. However, no legal precedent was cited to support this assertion, and the ALJ was found to have the authority to weigh conflicting evidence, including daily activities, regardless of their severity. The ALJ referenced substantial evidence to justify giving limited weight to the treating physician's restrictive assessment, highlighting inconsistencies with Perozzi's testimony regarding daily functioning and his participation in a range of light activities.
Perozzi contends that the ALJ incorrectly dismissed Dr. Gaughan's opinion solely because it was provided in connection with Perozzi's workers' compensation claim. The court agrees that an ALJ cannot reject a treating physician's opinion for this reason alone, citing precedents such as Mercado v. Colvin and Snell v. Apfel. However, the ALJ referenced Dr. Gaughan’s role in the workers' compensation case as one factor among others for assigning low weight to his opinions. The ALJ also pointed out that the definition of disability in workers' compensation differs from that under the Act and found opinions from Drs. Kaci, Hendler, Bottiglieri, and Sallahian to be more persuasive and consistent. Consequently, the ALJ did not err in considering Dr. Gaughan’s role.
The court concludes by granting Perozzi's motion for judgment on the pleadings and denying the Commissioner's motion, remanding the case for further proceedings. It clarifies that Perozzi applied for benefits on June 25, 2013, as supported by multiple documents, despite discrepancies regarding the filing date. Additionally, there are assumptions made regarding the ALJ's possible typographical errors in medical terminology and uncertainty about the findings of certain doctors concerning straight-leg raise tests.
