United States District Court, M.D. Pennsylvania
Carlson Magistrate Judge
M. MUNLEY JUDGE UNITED STATES DISTRICT COURT
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.
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).
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).
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
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).
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).
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).
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.
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).
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).
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