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Slotcavage v. Berryhill

United States District Court, M.D. Pennsylvania

June 3, 2019

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.


          Martin C. Carlson United States Magistrate Judge

         I. Introduction

         For Administrative Law Judges (ALJs), Social Security disability determinations frequently entail an informed assessment of medical opinions coupled with an evaluation of the severity of a claimant's impairments. The ALJ performs this task against the backdrop of a well-defined analytical paradigm. As part of this analysis, ALJ's are cautioned that great weight should be given to medical treating source opinions, and ALJ's should refrain from rejecting all medical opinions in favor of their own lay interpretation of medical evidence. ALJs are also instructed that the threshold severity inquiry regarding a claimant's impairments is a “de minimus screening device to dispose of groundless claims.” McCrea v. Comm'r of Soc. Sec., 370 F.3d 357, 360 (3d Cir. 2004); Newell v. Comm'r of Soc. Sec., 347 F.3d 541, 546 (3d Cir. 2003). “Any doubt as to whether this showing has been made is to be resolved in favor of the applicant.” Velazquez v. Astrue, No. 07- 5343, 2008 WL 4589831, *3 (E.D. Pa. Oct. 15, 2008) (quoting McCrea, 370 F.3d at 360) (internal quotations omitted)). Thus, “[t]he claimant's burden at step two is ‘not an exacting one.'” McCrea, 370 F.3d at 360 (internal citations omitted).

         Once the ALJ completes this task, on appeal it is the duty and responsibility of the district court to review these ALJ findings. In this case we are called upon to determine whether substantial evidence supported an ALJ's determination that Raymond Slotcavage could perform a range of light work, and accordingly, was not disabled. The ALJ made this determination after discounting the two medical opinions in the record-opinions from treating and consulting sources, both of whom placed greater limitations on Slotcavage than those found by the ALJ. Further, the ALJ reached this decision after concluding that Slotcavage's diagnosis of herniated discs was not a severe impairment, even though Slotcavage's treating physician deemed this impairment to be disabling.

         After a review of the administrative record, we find that the ALJ's decision to exceed all of the medical source opinions in this case, coupled with the decision to treat Slotcavage's herniated discs as a non-severe impairment, are not adequately explained and supported. Thus, we recommend that the case be remanded for further consideration of this claim.

         II. Statement and Facts of the Case

         On October 30, 2014, Raymond Slotcavage applied for disability benefits under Title II of the Social Security Act. (Tr. 52.) At the time of this disability application, Slotcavage was 50 years old. (Id.) He had a high school education and a past employment history as a construction laborer, heavy-duty semiskilled work. (Tr. 68.)

         Slotcavage alleged that he had become disabled due to a cascading array of physical and emotional impairments, including arthritis, bursitis, Crohn's disease, carpel tunnel syndrome, depression, and herniated discs. (Tr. 54-55.) With respect to this last impairment-Slotcavage's herniated disc-medical records provided by Dr. Raymond Kraynak, Slotcavage's treating physician, indicate that on March 27, 2012, Slotcavage was seen by the doctor for this back injury. At that time, Dr. Kraynak noted that “diagnostic studies showed a herniated disc at L-4/5 and L-5/S-1.” (Tr. 1012.) Over the next two years, from March 2012 through March 2014, Dr. Kraynak consistently diagnosed Slotcavage as suffering from herniated discs.[1] Dr. Kraynak's treatment notes also repeatedly observed that Slotcavage was “unable to work” and was “totally disabled” due to these injuries. (Tr. 1002-05, 1010-11.)

         Given this diagnosis and treatment history, Dr. Kraynak twice opined that Slotcavage was disabled due to these herniated discs. Initially, on February 10, 2015, Dr. Kraynak reported that Slotcavage had been under his care for a herniated lumbar disc “for some time, ” and stated that these lumbar impairments, coupled with Slotcavage's Crohn's disease, hypertension, and depression, “render him totally disabled from any and all employment.” (Tr. 341.) Two years later, in March of 2017, Dr. Kraynak issued a second medical opinion, which concluded that Slotcavage could lift and carry less than 10 pounds, and sit or stand for less than 2 hours a day. (Tr. 1042-44.) According to Dr. Kraynak, due to his impairments, Slotcavage could never twist, stoop, crouch, or climb stairs and ladder. (Id.) Dr. Kraynak also indicated that Slotcavage could be expected to be absent from work more than 3 days each month due to his impairments. (Id.)

         A second medical source, Dr. Jay Willner, examined Slotcavage in April of 2015. (Tr. 343-57.) While this consultative examination report found that Slotcavage was capable of performing lifting and carrying consistent with light work, it also concluded that he was significantly restricted in performing a range of activities, such as traveling without assistance, walking distances, or shopping. (Id.) In addition, Dr. Willner found that Slotcavage could never climb ladders, kneel, crouch or crawl and could only occasionally stoop or climb stairs. (Tr. 350.)

         Slotcavage's initial claim for benefits was denied on May 6, 2015. (Tr. 52.) He then requested a hearing, which was held on March 31, 2017. At this hearing, the plaintiff amended his onset date to June 19, 2013, his 50th birthday, and Slotcavage and a vocational expert (“VE”) both testified, describing his impairments and employment prospects. (Tr. 104-163.)

         On April 24, 2017, the ALJ issued a decision denying Slotcavage's application for benefits. (Tr. 49-70.) In this decision, the ALJ initially found that the plaintiff met the insured status requirements through December 31, 2016. (Tr. 54.) At Step 2 of the sequential analysis that governs Social Security cases, the ALJ found that Slotcavage's severe impairment included arthritis, bursitis, Crohn's disease, and carpel tunnel syndrome. (Tr. 54-55.) However, the ALJ found that Slotcavage's herniated discs were not a severe impairment at Step 2, concluding that these impairments were not “expected to cause any significant ongoing functional limitations for a continuous period of at least 12-consecutive months since the amended onset date.” (Tr. 55.) Thus, the ALJ's Step 2 analysis completely discounted the diagnosis, treatment records, and opinion of Dr. Kraynak, who stated on March 27, 2012, that “diagnostic studies showed a herniated disc at L-4/5 and L-5/S-1” (Tr. 1012), and over the next two years consistently diagnosed Slotcavage as suffering from herniated discs, [2] while also frequently observing that Slotcavage was “unable to work” and was “totally disabled” due to these injuries. (Tr. 1002-1005, 1010-11.) Notably, this Step 2 determination seemed to be based upon the ALJ's subjective evaluation of the doctor's credibility. Thus, while Dr. Kraynak stated in his treatment notes that “diagnostic studies showed a herniated disc at L-4/5 and L-5/S-1, ” (Tr. 1012), the ALJ appeared to openly doubt this assertion, stating that the doctor's diagnosis “is not supported by ANY diagnostic radiological study.” (Tr. 55.) Simply put, given that Dr. Kraynak had stated that “diagnostic studies showed a herniated disc at L-4/5 and L-5/S-1, ” (Tr. 1012), the ALJ's finding was tantamount to a declaration that the doctor's statements were unsupported and untrue.

         Having discounted this disc herniation as a severe impairment at Step 2, the ALJ went on to conclude at Step 3 that Slotcavage did not have an impairment that met or medically equaled a listed impairment. (Tr. 57-58.)

         Between Steps 3 and 4, the ALJ fashioned a residual functional capacity (“RFC”), for Slotcavage, concluding that he could perform light work and occasionally climb stairs and ladders, balance, stoop, kneel, crouch, and crawl. (Tr. 58.)

         By prescribing this RFC for Slotcavage, the ALJ was setting exertional standards that exceeded those found by every doctor who had examined or treated the plaintiff. This RFC far exceeded the limitations prescribed twice by Dr. Kraynak, Slotcavage's treating physician, who concluded that Slotcavage was totally disabled due to his back problems and related ailments. (Tr. 241, 1042-44.) Moreover, notably this RFC also exceeded the physical limitations described by the consulting examining physician, Dr. Willner, who found that Slotcavage could never climb ladders, kneel, crouch, or crawl and could only occasionally stoop or climb stairs. (Tr. 350.) In rejecting portions of Dr. Willner's opinion, the ALJ stated that, in his opinion “many of Dr. Willner's noted limitations are actually too restrictive . . . .” (Tr. 62.)

         Having completely discounted Slotcavage's herniated discs as a severe impairment at Step 2, then having completely discounted the treating source opinion of Dr. Kraynak, and having further prescribed an RFC which exceeded the physical limitations found by the only other medical source to have examined Slotcavage, Dr. Willner, the ALJ found that, while Slotcavage could not return to his past work, there were substantial jobs in the regional and national economy he could perform. The ALJ therefore denied this claim at Step 5 of the sequential analysis which applies to disability cases. (Tr. 69-70.)

         This appeal followed. (Doc. 1). On appeal, Slotcavage challenges the ALJ's determination in several respects. First, Slotcavage presents an Appointments Clause challenge, arguing that the ALJ was not constitutionally appointed at the time of his hearing, and thus he is entitled to a new hearing in front of a properly appointed ALJ. Slotcavage also contends that the ALJ erred at Step 2 when he discounted the plaintiff's herniated discs as a severe impairment, and erred in his assessment of the medical opinion evidence by crafting an RFC which exceeded all exertional limitations found by the medical professionals who treated and examined Slotcavage.

         For the reasons set forth below, we recommend that this case be remanded for further considerations of the medical treatment and opinion evidence.

         III. Discussion

         A. Substantial Evidence Review - The Role of this Court

          When reviewing the Commissioner's final decision denying a claimant's application for benefits, this Court's review is limited to the question of whether the findings of the final decision-maker are supported by substantial evidence in the record. See 42 U.S.C. § 405(g); Johnson v. Comm'r of Soc. Sec., 529 F.3d 198, 200 (3d Cir. 2008); Ficca v. Astrue, 901 F.Supp.2d 533, 536 (M.D. Pa. 2012). Substantial evidence “does not mean a large or considerable amount of evidence, but rather such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Pierce v. Underwood, 487 U.S. 552, 565 (1988). Substantial evidence is less than a preponderance of the evidence but more than a mere scintilla. Richardson v. Perales, 402 U.S. 389, 401 (1971). A single piece of evidence is not substantial evidence if the ALJ ignores countervailing evidence or fails to resolve a conflict created by the evidence. Mason v. Shalala, 994 F.2d 1058, 1064 (3d Cir. 1993). But in an adequately developed factual record, substantial evidence may be “something less than the weight of the evidence, and the possibility of drawing two inconsistent conclusions from the evidence does not prevent [the ALJ's decision] from being supported by substantial evidence.” Consolo v. Fed. Maritime Comm'n, 383 U.S. 607, 620 (1966). “In determining if the Commissioner's decision is supported by substantial evidence the court must scrutinize the record as a whole.” Leslie v. Barnhart, 304 F.Supp.2d 623, 627 (M.D. Pa. 2003).

         The question before this Court, therefore, is not whether the claimant is disabled, but rather whether the Commissioner's finding that he is not disabled is supported by substantial evidence and was reached based upon a correct application of the relevant law. See Arnold v. Colvin, No. 3:12-CV-02417, 2014 WL 940205, at *1 (M.D. Pa. Mar. 11, 2014) (“[I]t has been held that an ALJ's errors of law denote a lack of substantial evidence”) (alterations omitted); Burton v. Schweiker, 512 F.Supp. 913, 914 (W.D. Pa. 1981) (“The Secretary's determination as to the status of a claim requires the correct application of the law to the facts”); see also Wright v. Sullivan, 900 F.2d ...

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