Estrella v. Berryhill

• Citation: 925 F.3d 90
• Decision Date: 29 May 2019
• Docket Number: August Term 2018,Docket No. 17-3247
• Parties: Brenda ESTRELLA, Plaintiff-Appellant, v. Nancy A. BERRYHILL, Acting Commissioner of Social Security, Defendant-Appellee.
• Court: United States Courts of Appeals. United States Court of Appeals (2nd Circuit)

925 F.3d 90

Brenda ESTRELLA, Plaintiff-Appellant,

v.Nancy A. BERRYHILL, Acting Commissioner of Social Security, Defendant-Appellee.

Docket No. 17-3247

August Term 2018

United States Court of Appeals, Second Circuit.

Argued: April 18, 2019

Decided: May 29, 2019

CAROLYN A. KUBITSCHEK, Lansner & Kubitschek, New York, NY, for Plaintiff-Appellant.

CANDACE SCOTT APPLETON, Assistant United States Attorney (Varuni Nelson and Arthur Swerdloff, Assistant United States Attorneys, on the brief), for Richard P. Donoghue, United States Attorney for the Eastern District of New York, New York, NY, for Defendant-Appellee.

Before: WESLEY, CHIN, Circuit Judges; KAPLAN, District Judge.^*

WESLEY, Circuit Judge:

Plaintiff-Appellant Brenda Estrella appeals from a judgment of the United States District Court for the Eastern District of New York (Kuntz, J. ), affirming the Commissioner of Social Security's ("Commissioner") denial of disability benefits under Titles II and XVI of the Social Security Act ("SSA" or "the Act"), 42 U.S.C. §§ 401 – 434 and 1381 – 1383. Estrella contends that the administrative law judge ("ALJ") who reviewed her claim, and whose decision the Commissioner adopted, erred by (A) failing to give controlling weight to the opinion of her treating physician and (B) failing to explain the reasons for giving that opinion minimal weight. For the reasons that follow, we vacate the judgment of the district court and remand the case to the Commissioner for further proceedings consistent with this opinion.

BACKGROUND

Estrella worked as an administrative clerk from 1994 until 2008. Beginning in 2002 and continuing through at least 2013, Estrella suffered from, as relevant to this appeal, major depressive disorder

, bipolar disorder, and Attention Deficit Hyperactive Disorder. From 2003 to 2006, and again from 2010 to 2013, Estrella took various medications to treat her mental illness and attended monthly psychotherapy sessions. Estrella testified that she did not seek treatment between 2006 and 2010 because she "was in an abusive relationship[,] ... was suffering from severe depression," and had consequently "withdr[awn] [her]self." Admin. R. 108.

In June 2012, Estrella applied for Social Security Disability Insurance and Supplemental Security Income benefits. She claimed that she had been unable to work since August 27, 2008 because of depression, herniated discs

, knee pain, diabetes, nerve damage, sleep apnea, and "spasms." Id. at 236.

A claimant is disabled for purposes of the SSA if she is unable to "engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment

[that] can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." 42 U.S.C. § 423(d)(1)(A). The Social Security Administration has outlined a "five-step, sequential evaluation process" to determine whether a claimant is disabled:

(1) whether the claimant is currently engaged in substantial gainful activity; (2) whether the claimant has a severe impairment or combination of impairments; (3) whether the impairment meets or equals the severity of the specified impairments in the Listing of Impairments; (4) based on a "residual functional capacity" assessment, whether the claimant can perform any of his or her past relevant work despite the impairment; and (5) whether there are significant numbers of jobs in the national economy that the claimant can perform given the claimant's residual functional capacity, age, education, and work experience.

McIntyre v. Colvin , 758 F.3d 146, 150 (2d Cir. 2014) (citing Burgess v. Astrue , 537 F.3d 117, 120 (2d Cir. 2008) ; 20 C.F.R. §§ 404.1520(a)(4)(i)–(v), 416.920(a)(4)(i)–(v) ). The claimant bears the burden of proving her case at steps one through four. Id. The burden shifts to the Commissioner at step five. Id.

On October 22, 2012, the Commissioner denied Estrella's application. The Social Security Administration's Office of Disability Adjudication and Review subsequently granted Estrella's request for a hearing before an ALJ. Following a hearing in October 2013, and a second hearing in January 2014, the ALJ determined, in accordance with the five-step process, the following: (1) Estrella "ha[d] not engaged in substantial gainful activity since August 27, 2008," Admin. R. 25; (2) her mild lumbar and median nerve radiculopathy

, mild to moderate bilateral carpal tunnel syndrome, diabetes, and depression were severe impairments because the conditions "impose[d] more than minimal limitations" on her ability to perform basic work activities, id. ; (3) she did not have an impairment or combination of impairments that met or equaled the severity of the specified impairments in the Listing of Impairments, id. ; (4) she had the residual functional capacity ("RFC") to perform light work, with certain limitations, and she could perform past relevant work as an administrative clerk, which would not be precluded by her RFC, id. at 27, 30; and (5) she could otherwise perform a "wide range of light level ... work," id. at 30.

The ALJ accordingly denied Estrella's application. Id.

The Office of Disability Adjudication and Review denied Estrella's request for review on May 14, 2015, at which point the ALJ's decision became the final decision of the Commissioner. On July 8, 2015, Estrella filed a complaint in the United States District Court for the Eastern District of New York, effectively appealing the Commissioner's decision. On September 6, 2017, the district court denied Estrella's motion for judgment on the pleadings and granted the Commissioner's cross-motion for the same. This appeal followed.

DISCUSSION

I. Standard of Review

On an appeal from the denial of disability benefits, "we focus on the administrative ruling rather than the district court's opinion." McIntyre , 758 F.3d at 149 (citation omitted). "We conduct a plenary review of the administrative record to determine if there is substantial evidence, considering the record as a whole, to support the Commissioner's decision and if the correct legal standards have been applied." Cichocki v. Astrue , 729 F.3d 172, 175–76 (2d Cir. 2013) (per curiam) (quotation marks and citation omitted). Substantial evidence is evidence that "a reasonable mind might accept as adequate to support a conclusion." McIntyre , 758 F.3d at 149 (citation omitted). Although we do not require that "every conflict in a record be reconciled by the ALJ or the Secretary, ... we do [require] that the crucial factors in any determination ... be set forth with sufficient specificity to enable us to decide whether the determination is supported by substantial evidence." Ferraris v. Heckler , 728 F.2d 582, 587 (2d Cir. 1984).

II. Treating Physician Rule

Estrella principally challenges the ALJ's handling of her treating psychiatrist's opinion. In October 2013, Dr. Felix Dron submitted a Medical Source Statement to the Office of Disability Adjudication and Review in which he opined that Estrella's "poor concentration, forgetful[ness], low stress tolerance, rage outbursts[,] ... depression[,] and anxiety" resulted in "marked" limitations in the areas of making work-related decisions and understanding, remembering, and carrying out detailed instructions. Admin. R. 507–08. Although Dr. Dron had treated Estrella for roughly five years, the ALJ assigned "little weight" to his opinion. Id. at 29. Estrella argues that, in doing so, the ALJ failed to comply with the procedural mandates of the so-called treating physician rule. We agree.

Social Security Administration regulations, as well as our precedent, mandate specific procedures that an ALJ must follow in determining the appropriate weight to assign a treating physician's opinion. First, the ALJ must decide whether the opinion is entitled to controlling weight. "[T]he opinion of a claimant's treating physician as to the nature and severity of [an] impairment is given ‘controlling weight’ so long as it ‘is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in [the] case record.’ " Burgess , 537 F.3d at 128 (third brackets in original) (quoting 20 C.F.R. § 404.1527(c)(2) ). Second, if the ALJ decides the opinion is not entitled to controlling weight, it must determine how much weight, if any, to give it. In doing so, it must "explicitly consider" the following, nonexclusive " Burgess factors": "(1) the frequen[cy], length, nature, and extent of treatment; (2) the amount of medical evidence supporting the opinion; (3) the consistency of the opinion with the remaining medical evidence; and (4) whether the physician is a specialist." Selian v. Astrue , 708 F.3d 409, 418 (2d Cir. 2013) (per curiam) (citing Burgess , 537 F.3d at 129 (citing 20 C.F.R. § 404.1527(c)(2) )). At both steps, the ALJ must "give good reasons in [its] notice of determination or decision for the weight [it gives the] treating source's [medical] opinion." Halloran v. Barnhart , 362 F.3d 28, 32 (2d Cir. 2004) (per curiam) (quoting 20 C.F.R. § 404.1527(c)(2) ).

An ALJ's failure to "explicitly" apply the Burgess factors when assigning weight at step two is a procedural error. Selian , 708 F.3d at 419–20. If "the Commissioner has not [otherwise] provided ‘good reasons’ [for its weight assignment]," we are unable to conclude that the error was harmless and consequently remand for the ALJ to "comprehensively set forth [its] reasons." See Halloran , 362 F.3d at 33. If, however, "a searching review of the record" assures us "that the substance of the treating physician rule was not traversed," we will affirm. See id. at 32.

To begin, although substantial evidence supports the ALJ's decision at step one to assign less-than-controlling weight to Dr. Dron's opinion, the same is not true of its decision at step two to assign "little weight" thereto. In deciding, at step one, that Dr. Dron's opinion was not...