United States District Court, M.D. Pennsylvania
C. CARLSON UNITED STATES MAGISTRATE JUDGE
Introduction and Litigation History
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.
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.
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.)
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.
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.)
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.)
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.)
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.)
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.)
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
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.
Substantial Evidence Review - the Role of the
Administrative Law Judge and the Court
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