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Nieves-Rivas v. Berryhill

United States District Court, M.D. Pennsylvania

June 18, 2018

NANCY A. BERRYHILL[1] Deputy Commissioner for Operations of Social Security Defendant.



         I. Introduction and Litigation History

         This case calls upon us to examine a recurring issue in Social Security litigation-the sufficiency of an ALJ's assessment of a treating source medical opinion. Under the longstanding legal guidance which was in effect at the time of this case, we were instructed that:

A cardinal principle guiding disability eligibility determinations is that the ALJ accord treating physicians' reports great weight, especially "when their opinions reflect expert judgment based on a continuing observation of the patient's condition over a prolonged period of time." Plummer [v. Apfel, 186 F.3d 422, 429 (3d Cir.1999)] (quoting Rocco v. Heckler, 826 F.2d 1348, 1350 (3d Cir.1987)); see also Adorno v. Shalala, 40 F.3d 43, 47 (3d Cir.1994); Jones, 954 F.2d at 128; Allen v. Bowen, 881 F.2d 37, 40-41 (3d Cir.1989); Frankenfield v. Bowen, 861 F.2d 405, 408 (3d Cir.1988); Brewster, 786 F.2d at 585. Where, as here, the opinion of a treating physician conflicts with that of a non-treating, non-examining physician, the ALJ may choose whom to credit but "cannot reject evidence for no reason or for the wrong reason." Plummer, 186 F.3d at 429 (citing Mason v. Shalala, 994 F.2d 1058, 1066 (3d Cir.1993)). The ALJ must consider the medical findings that support a treating physician's opinion that the claimant is disabled. See Adorno, 40 F.3d at 48. In choosing to reject the treating physician's assessment, an ALJ may not make "speculative inferences from medical reports" and may reject "a treating physician's opinion outright only on the basis of contradictory medical evidence" and not due to his or her own credibility judgments, speculation or lay opinion. Plummer, 186 F.3d at 429; Frankenfield v. Bowen, 861 F.2d 405, 408 (3d Cir.1988); Kent, 710 F.2d at 115.

Morales v. Apfel, 225 F.3d 310, 317-18 (3d Cir. 2000).

         In this case Marta Nieves-Rivas (“Nieves-Rivas”) presents a claim for disability due to various physical limitations relating to diabetes, hypertension, and osteoarthritis. This Court has been called upon to review the sufficiency of the Administrative Law Judge's (“ALJ”) evaluation of a treating physician's Medical Source Statement which opines on some of Nieves-Rivas's physical capabilities in a fashion which would likely render her disabled.

         On August 6, 2015, Ms. Nieves-Rivas protectively filed claims under Titles II and XVI of the Social Security Act for disability and disability insurance benefits, and supplemental security income. (Tr. 17.) In both applications, she alleged the onset date of disability as July 7, 2015. (Id.) Her claims were initially denied on November 9, 2015, and subsequently, she filed a written request for an administrative law hearing on December 11, 2015. (Id.) Represented by counsel, Nieves-Rivas appeared and testified at a hearing held on November 9, 2016. (Id.) On December 22, 2016, the ALJ issued a written decision finding that Nieves-Rivas was not disabled within the meaning of the Social Security Act. In turn, Nieves-Rivas filed a request for review with the Appeals Council, which was denied on March 14, 2017. (Id. at 1.) Following this rejection, Nieves-Rivas filed the instant appeal with the District Court on May 17, 2017. (Doc. 1.)

         Both parties have briefed this case, and it is ripe for resolution. For the reasons set forth below, we conclude that the ALJ's findings are not supported by substantial evidence, in that the opinion of Nieves-Rivas' treating source was not sufficiently considered and addressed. Accordingly, we find that a remand is in order for further consideration of this opinion evidence.

         II. Factual Background

         Ms. Nieves-Rivas is a 47 year old woman with a ninth-grade education who has previously worked as a clothes presser. (Doc. 12 p. 3.) When Nieves-Rivas applied for disability benefits, she listed high blood pressure, asthma, hepatitis C, diabetes, lupus, and heart murmur as severe conditions that limit her ability to work. (Tr. 210.) Though Ms. Nieves-Rivas did not list osteoarthritis on her disability report, the record indicates that she was experiencing issues with her knees at the time of her disability report. On August 17, 2015, Nieves-Rivas had a consultation with rheumatologist Dr. Praveen Jajoria (“Dr. Jajoria”) due to knee pain associated with polyarthralgia. (Id. at 313), and on December 2, 2015, she saw Dr. Adam M. Buerk (“Dr. Buerk”) for complaints of right knee pain. (Id. at 534.) At her appointment with Dr. Buerk, Dr. Buerk evaluated an MRI of Nieves-Rivas's right knee and x-rays of both Nieves-Rivas's knees. The MRI revealed that Nieves-Rivas had an ACL tear, and the x-rays revealed that she had “fairly significant primary osteoarthritis with bone-on-bone arthritis” in both knees. (Id.)

         As treatment for her osteoarthritis, Nieves-Rivas received cortisone injections in both knees during her December 2015 appointment with Dr. Buerk, (tr. 534), and on February 3, 2016, Dr. Buerk administered a “Synvisc-one” injection to Nieves-Rivas for her right knee and a betamethasone injection in her left knee. (Id. at 539, 544.) Because of recurring pain in both knees, Dr. Buerk administered betamethasone injections in both of Ms. Nieves-Rivas's knees, and he ordered an MRI for her left knee. (Id. at 549.) Dr. Buerk evaluated the MRI of Nieves-Rivas's left knee on March 30, 2016, which revealed that there were significant degenerative changes in that knee. (Id. 554.) Dr. Buerk also noted that Nieves-Rivas would probably need a knee replacement in the future. (Id.) After finding no relief from a Synvisc-one injection in her left knee on April 27, 2016, (id. at 559), Nieves-Rivas underwent several surgical procedures for her left knee on June 2, 2016. (id. at 490.) At her third post-surgery appointment with Dr. Buerk on August 17, 2016, Ms. Nieves-Rivas still reported having severe pain in her left knee but was unable to get another injection because her insurance would not cover it until October 2016. (Id. at 580.)

         With regard to Ms. Nieves-Rivas's diabetes and peripheral neuropathy, her primary care physician, Dr. Clem Ciccarelli (“Dr. Ciccarelli”), diagnosed her with new-onset diabetes on August 5, 2015. (Tr. 413.) At this appointment, Nieves-Rivas denied any numbness/tingling and dropping of objects. (Id.) Ms. Nieves-Rivas was also diagnosed with hepatitis C at this appointment. (Id.) Dr. Ciccarelli reported on October 15, 2015, that Nieves-Rivas had peripheral neuropathy secondary to hepatitis C and type-two diabetes. (Id. at 505.) Dr. Ciccarelli also opined that during Nieves-Rivas's October 2015 appointment, that Nieves-Rivas was disabled due to her peripheral neuropathy, chronic fatigue, chronic neuropathic pain and arthritic knee pain as a result of her hepatitis C and diabetes. (Id. at 507.) On May 20, 2016, Dr. Ciccarelli completed a Medical Source Statement opining on the limitations caused by Nieves-Rivas's knee pain and peripheral neuropathy of the hands and feet. (Id. at 456-457.) On July 25, 2016, Dr. Ciccarelli reported in his examination notes that Nieves-Rivas had stocking paresthesia of the hands and feet, and gross sensory paresthesia of the lower extremities. (Id. at 523.)

         In addition, to these medical concerns, Nieves-Rivas faced a series of additional physical and emotional challenges and limitations. Ms. Nieves-Rivas has also been assessed as having major depressive disorder (tr. 420), systolic cardiovascular murmurs (id. at 433), asthma, essential hypertension, hyperlipidemia, dyspnea (id. at 509), lupus (id. at 323), history of tuberculosis (id. at 236), and morbid obesity. (Id. at 641.) Additionally, Nieves-Rivas has a prosthetic right eye. (Id. at 269.)

         There were three medical opinions in the record to which the ALJ accorded weight when making his decision. The ALJ assigned limited weight to two of these opinions because he determined that their findings concerning Ms. Nieves-Rivas's ability to lift/carry weight were inconsistent with other doctors' findings and were not supported by the record as a whole. (Id. at 24.) The specific medical opinion that was rejected by the ALJ and is at issue in this appeal is that of Dr. Ciccarrelli. Dr. Ciccarelli opined that Nieves-Rivas's neuropathy and osteoarthritis resulted in a cascading array of physical limitations for the plaintiff. According to the doctor, these limitations, considered in combination, were deemed disabling. However, the ALJ only discussed one limitation found by Dr. Ciccarrelli, that Nieves-Rivas should not carry more than six to ten pounds, in rejecting the Medical Source Statement. The other limitations found by this treating source relating to her ability to sit, stand, and walk; her ability to use her hands and arms for manipulations; and her level of pain and how much it causes her to be off task were not addressed by the ALJ in this decision. (Id. at 456-457.)

         In light of the medical evidence presented by Nieves-Rivas, the ALJ concluded that Nieves-Rivas was severely impaired by her diabetes, asthma, monocular vision, obesity, and osteoarthritis. (Tr. 19.) In consideration of the entire record, the ALJ found that Nieves-Rivas had the capacity to do sedentary work, however, she could only sit, stand, or walk for six of the eight hours in a workday; she was limited to occasional climbing of ramps and stairs, balancing, stooping, kneeling, crouching, and crawling; she should never climb ladders, ropes, or scaffolds; and she should have no exposure to dusts, gases, odors, fumes, or poor ventilation. (Id. at 22.) The ALJ also noted in the RFC that Nieves-Rivas has monocular vision. (Id.) Thus, even when the ALJ largely discounted Dr. Ciccarelli's treating source opinion, the resulting RFC fashioned by the ALJ permitted Nieves-Rivas to perform only a very narrow range of sedentary work.

         On appeal, Nieves-Rivas asserts one objection to the ALJ's decision. She argues that Dr. Ciccarelli's opinion was entitled to either controlling or significant weight in formulating the RFC, and that the ALJ provided an inadequate explanation for rejecting Dr. Ciccarelli's opinion. (Doc. 12 p. 12-15.) For the reasons set forth below, we find that the ALJ has not provided an adequate rationale for discounting this treating source opinion. Therefore we conclude that the ALJ's decision denying Ms. Nieves-Rivas benefits should be vacated and remanded.

         III. Discussion

         A. Substantial Evidence Review - the Role of the Administrative Law Judge and the Court

         Resolution of the instant social security appeal involves an informed consideration of the respective roles of two adjudicators-the ALJ and this court. At the outset, it is the responsibility of the ALJ in the first instance to determine whether a ...

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