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Bethea v. Saul

United States District Court, M.D. Pennsylvania

December 20, 2019

ANDREW M. SAUL, Commissioner of Social Security, [1] Defendant

          Carlson Magistrate Judge



         Presently before the court is the Report and Recommendation (“R&R”) of Magistrate Judge Martin C. Carlson, wherein Judge Carlson recommends that this action be remanded to the Commissioner of Social Security (“Commissioner”) for a new administrative hearing. (Doc. 17). The government objects to the R&R arguing that the Administrative Law Judge (“ALJ”) properly discounted the medical opinion of Dr. Raymond Dahl, the plaintiff's treating physician. This matter is now ripe for the court's disposition.


         On January 22, 2016, the plaintiff, Curtis Bethea, applied for benefits under Title II and Title XVI of the Social Security Act, alleging an onset of disability beginning on July 24, 2014 due to the combined effects of joint disease in his hips and knees along with degenerative disc disease in his spine. (Doc. 9-3, Administrative Record at (hereinafter “R. at”) 125, 127). At the time of this disability application, Bethea, who was born in November of 1968, was approximately 45 years old. (R. at 133). Bethea had a limited education, having attended school through the 11th grade, and had a vocational history in heavy-to-medium work, having been employed as a laborer and warehouse worker. (R. at 133).

         Bethea also suffered from a cascading array of orthopedic impairments, including conditions which had spanned nearly a decade and had required significant treatment beginning as early as 2008. (R. at 350-90). In the course of this past ten years, Bethea had been diagnosed with bilateral osteoarthritis in both knees, severe lumbar spinal stenosis with disc extrusion, and bilateral necrosis of both hips. (R. at 127). As a result of his hip conditions, Bethea had undergone a left hip replacement in 2013, (R. at 130), and reported at his August 2017 disability hearing that he was scheduled to undergo a right hip replacement procedure in the near future. (R. at 35).

         Bethea reported that the combined effects of these conditions caused him significant, disabling pain. In particular, Bethea reported as early as January of 2015 that he could not sit for more than an hour at a time without experiencing significant discomfort. (R. at 683-84). Bethea repeated these allegations at the August 23, 2017 disability hearing conducted in this case, where he stated that he would experience pain after sitting for less than one hour. (R. at 27). Indeed, the ALJ noted that Bethea sought to stand up during his hearing testimony due to his discomfort. (R. at 130).

         Bethea's treatment records, and particularly those records from 2016 through 2017, documented Bethea's reported pain and discomfort. Records from January through August of 2015, reported that Bethea was experiencing severe back pain. (R. at 312, 314, 330-32, 338). Moreover, clinical notes from six different treatment sessions spanning from February of 2016 through June of 2017 indicated that Bethea walked with a mild limp, (R. at 747); had pain moving from a sitting to standing position, (R. at 756); ambulated with difficulty, (R. at 740, 750); experienced pain and an antalgic gait, (R. at 707); had difficulty walking, (R. at 710); had a significant antalgic gait, (R. at 758-59); and was fairly limited and debilitated by his pain. (R. at 758-59).

         These clinical notes and Bethea's subjective complaints, in turn, were consistent with the report of Bethea's treating orthopedic specialist, Dr. Raymond Dahl. On December 15, 2016, Dr. Dahl submitted a medical source statement which opined that Bethea could sit for no more than two hours and stand or walk for no more than one hour per workday due to the joint disease in his hips and knees as well as his severe lumbar stenosis. (R. at 508).

         Dr. Dahl's opinion was significant in several respects. First, it was the opinion of a treating source, and as such was entitled under the Commissioner's regulations to careful consideration and significant weight. Second, Dr. Dahl was an orthopedic specialist, a factor which gave his judgment regarding these essentially orthopedic limitations greater credence. Third, Dr. Dahl's opinion was the only opinion from an acceptable medical source detailing the functional limitations Bethea was experiencing due to his medical impairments from 2015 through 2017. Notably, there was no state agency medical opinion in this case, which had been assessed by an agency Single Decision Maker (SDM), rather than a doctor. This SDM decision had no weight in these proceedings since it is well established that “RFC determinations by SDM's should not be afforded any evidentiary weight at the administrative hearing level.” Rhyder v. Colvin, No. 16-884, 2017 WL 81273, at *6 (M.D. Pa. Jan. 9, 2017). Moreover, the only other medical opinion cited by the ALJ was a temporally remote June 20, 2014, notation recorded by a physician assistant on a check block form indicating that Bethea could return to work at that time. The summary notation both pre-dated the alleged onset of Bethea's disability and came from a source that was not deemed an acceptable medical source under the Commissioner's regulations. Genier v. Astrue, 298 Fed.Appx. 105, 108 (2d Cir. 2008); Long v. Colvin, No. 14-2192, 2016 WL 1320921, at *7 (M.D. Pa. Apr. 5, 2016).

         It was against this medical backdrop that a hearing was conducted regarding Bethea's disability claim on August 23, 2017. (R. at 16-45). At this hearing, both Bethea and a Vocational Expert appeared and testified. (R. at 16-45). In the course of her testimony, the Vocational Expert acknowledged that if Bethea was limited to two hours sitting, and one hour each standing or walking during an 8-hour workday, he would be unemployable. (R. at 44). Thus, the Vocational Expert concluded that the physical postural limitations found by Dr. Dahl-the sole acceptable medical source to opine in this case and an orthopedic specialist who had actually treated Bethea- would render the plaintiff disabled.

         Notwithstanding this evidence, following this hearing testimony, on November 1, 2017, the ALJ entered a decision denying Bethea's disability claim. (R. at 122-35). In this decision, the ALJ first found that Bethea met the insured status requirements of the Social Security Act. (R. at 127). At Step 2 of this sequential analysis, the ALJ determined that Bethea's bilateral hip and knee impairments, along with his severe degenerative disc disease of the lumbar spine were severe impairments. (R. at 127-28). The ALJ found at Step 3 of this sequential analysis, however, that none of Bethea's impairments met a listing requirement. (R. at 128-29).

         The ALJ then fashioned a limited, light work residual functional capacity (RFC) assessment for Bethea. (R. at 129). In doing so, the ALJ considered, but rejected, the only treating source and acceptable medical source opinion in the record, Dr. Dahl's opinion, which stated that Bethea could only sit for two hours per day and stand or walk for one hour per day. (R. at 133). While acknowledging that Dr. Dahl was both a treating source and an orthopedic expert whose opinion was entitled to significant weight, the ALJ rejected the work preclusive aspects of Dr. Dahl's expert opinion because the ALJ found that it was not consistent with the longitudinal record which the ALJ insisted showed that Bethea ambulated effectively with little or no impairment in his gait. Notably, the ALJ's decision relied primarily upon medical records from 2014 and 2015 to reach this conclusion, rather than the body of contemporaneous treatment records in 2016 and 2017 which described symptoms that were consistent with the limitations prescribed by Dr. Dahl. (R. at 133, citing R. at 312-39).

         Having made these determinations, the ALJ concluded at Step 4 that Bethea's RFC would not permit him to perform his past work but found at Step 5 of this sequential analysis that there were significant jobs in the national economy that he ...

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