Estrella v. Berryhill , 925 F.3d 90 ( 2019 )

17‐3247‐cv
Estrella v. Berryhill
UNITED STATES COURT OF APPEALS
FOR THE SECOND CIRCUIT
______________
August Term 2018
(Argued: April 18, 2019 Decided: May 29, 2019)
Docket No. 17‐3247
BRENDA ESTRELLA
Plaintiff‐Appellant,
–v.–
NANCY A. BERRYHILL, ACTING COMMISSIONER OF SOCIAL SECURITY,
Defendant‐Appellee.
______________
Before:
WESLEY, CHIN, Circuit Judges; KAPLAN, District 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 denial of disability benefits. Estrella contends
that the administrative law judge 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
*Judge Lewis A. Kaplan, United States District Court for the Southern District of
New York, sitting by designation.
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.
_________________
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.
_________________
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
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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
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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
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“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
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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).
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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
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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
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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 entitled to controlling weight, the ALJ
pointed to two positive treatment notes from July and August 2012. The October
2013 Medical Source Statement, it explained,
[was] inconsistent with the evidence and [Dr. Dron’s own]
examination of [Estrella]. During [Dr. Dron’s] examination of
[Estrella], . . . most of her mental status examinations were normal,
she only had at most mild depression, she denied having
hallucination [sic], and suicidal, homicidal ideations, and there was
no evidence of cognitive limitations or psychosis. Most importantly,
from September 12, 2012 through October 15, 2013, [Estrella’s] [Global
Assessment of Functioning] scores [had] been consistently at 70,
which indicate[d] mild depression, not marked depression.
Admin. R. 29. In subsequently deciding, at step two, to assign “little weight” to
Dr. Dron’s opinion, the ALJ provided no additional reasoning. It thus failed to
“explicitly consider” the first Burgess factor—“the frequen[cy], length, nature, and
extent of [Dr. Dron’s] treatment”—before weighing the value of the opinion. See
Selian, 708 F.3d at 418. Nowhere in the ALJ’s decision, for example, is the fact that
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Dr. Dron treated Estrella from 2004 to 2006, and again from 2010 to 2013. Nor did
the ALJ consider that Dr. Dron prescribed various psychotropic medications over
the course of his treatment, in addition to providing monthly psychotherapy
sessions.
Because the ALJ procedurally erred, the question becomes whether “a
searching review of the record . . . assure[s us] . . . that the substance of the . . . rule
was not traversed”—i.e., whether the record otherwise provides “good reasons”
for assigning “little weight” to Dr. Dron’s opinion. See Halloran, 362 F.3d at 32. It
does not.
First, a number of treatment notes not cited by the ALJ reflect a more serious
impairment than the ALJ acknowledged. For example, in January 2012, prior to
the only two referenced notes, Dr. Dron observed that Estrella
[was] inattentive[,] . . . ha[d] a short attention span[,] . . . often [did]
not seem to be listening when spoken to directly[,] . . . often [did] not
follow through on instructions[,] and fail[ed] to finish tasks. She [was]
disorganized . . . [and avoided t]asks that require sustained mental
effort . . . . She often los[t] things necessary for tasks or activities[,] . . .
[and was] easily distracted . . . [and] forgetful.
Admin. R. 456. In June 2013, subsequent to the two referenced notes and closer in
time to the ALJ’s decision, Dr. Dron observed that Estrella’s
anxiety symptoms continue[d] . . . . [She] continue[d] to be
inattentive[,] . . . [and did] not seem to be listening when spoken to
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directly . . . . Tasks that require[d] sustained mental effort [were] still
being avoided . . . . [Estrella] continue[d] to often lose things necessary
for tasks or activities[,] . . . [was] still as forgetful as previously[,] . . .
[and showed] signs of anxiety.
Id. at 434.
The ALJ made no attempt to “reconcile” or “grapple with” the apparent
longitudinal inconsistencies in Estrella’s mental health—one of the motivations
behind Burgess’s procedural requirement of explicit consideration of “the
frequen[cy], length, nature, and extent of [a physician’s] treatment.” See Selian, 708
F.3d at 418–19. This failure is especially relevant here because the first Burgess
factor, and therefore evidence supporting its satisfaction, is of heightened
importance in the context of Estrella’s claimed impairment: depression. “Cycles of
improvement and debilitating symptoms [of mental illness] are a common
occurrence, and in such circumstances it is error for an ALJ to pick out a few
isolated instances of improvement over a period of months or years and to treat
them as a basis for concluding a claimant is capable of working.” Garrison v. Colvin,
759 F.3d 995, 1017 (9th Cir. 2014); see also Bauer v. Astrue, 532 F.3d 606, 609 (7th Cir.
2008) (“A person who has a chronic disease, whether physical or psychiatric, and
is under continuous treatment for it with heavy drugs, is likely to have better days
and worse days . . . . Suppose that half the time she is well enough that she could
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work, and half the time she is not. Then she could not hold down a full‐time job.”).
When viewed alongside the evidence of the apparently cyclical nature of Estrella’s
depression, the ALJ’s two cherry‐picked treatment notes do not provide “good
reasons” for minimalizing Dr. Dron’s opinion.
Second, Estrella’s Global Assessment of Functioning (“GAF”) scores, which
the ALJ concluded “indicated mild depression, not marked depression,” Admin.
R. 29, do not provide good reasons for assigning little weight to Dr. Dron’s
opinion.1 The Social Security Administration has explained that “[u]nless [a]
clinician clearly explains the reasons behind his or her GAF rating, and the period
to which the rating applies, it does not provide a reliable longitudinal picture of
the claimant’s mental functioning for a disability analysis.” U.S. Soc. Sec. Admin.,
Office of Disability Programs, AM‐13066, Global Assessment of Functioning
(GAF) Evidence in Disability Adjudication (Oct. 14, 2014). Furthermore, “[u]nless
the GAF rating is well supported and consistent with other evidence in the file, it
1The Government contends Estrella waived any argument regarding the ALJ’s treatment
of the GAF scores. However, as we have explained, claimants in Social Security cases
must preserve legal arguments—not necessarily factual ones. See Poupore v. Astrue, 566
F.3d 303, 306 (2d Cir. 2009) (per curiam). Estrella preserved the legal argument that the
ALJ erroneously assigned little weight to the opinion of her treating physician.
Accordingly, we will review her factual GAF argument in support of that claim of legal
error.
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is entitled to little weight under our rules.” Id. Because Estrella’s GAF scores were
bereft of any explanation of Dr. Dron’s reasoning, and because they are
unsupported by Dr. Dron’s other conclusions as to the severity of Estrella’s
depression, they do not provide “good reasons” for assigning little weight to Dr.
Dron’s opinion.
Finally, the opinion of Dr. Christopher Flach, a one‐time consultative
psychologist, similarly does not provide a good reason for diminishing Dr. Dron’s
opinion. After examining Estrella once in September 2012, Dr. Flach opined that
Estrella had mild problems maintaining attention and concentration but could
follow and understand simple directions and instructions, maintain a regular
schedule, learn new tasks, perform complex tasks independently, and make
appropriate decisions. The ALJ assigned “substantial weight” to Dr. Flach’s
opinion because it “[was] consistent with [Dr. Dron’s] mental treatment notes,
which [did] not show marked limitations.” Admin. R. 29.
We have frequently “cautioned that ALJs should not rely heavily on the
findings of consultative physicians after a single examination.” Selian, 708 F.3d at
419. This concern is even more pronounced in the context of mental illness where,
as discussed above, a one‐time snapshot of a claimant’s status may not be
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indicative of her longitudinal mental health. Because the ALJ made the same error
with respect to Dr. Flach as it did with respect to Dr. Dron—namely, relying on his
opinion without “reconcil[ing]” or “grappl[ing] with” Estrella’s fluctuating state
of mental health—we are not assured that, had the ALJ complied with the
procedural mandates of the treating physician rule, it would still have assigned
significant weight to Dr. Flach’s opinion. The opinion of Dr. Flach, in other words,
similarly does not provide a “good reason” for minimizing that of Dr. Dron.
In light of the ALJ’s failure to “explicitly consider” the first Burgess factor
before assigning “little weight” to the opinion of Estrella’s treating psychiatrist,
and the lack of other “good reasons” to support that decision, we conclude that
the ALJ traversed the substance of the treating physician rule.2 Accordingly, we
remand to the ALJ for reconsideration of Estrella’s claim for disability benefits
consistent with the procedural mandates of the SSA and this Court.3 On remand,
2 Estrella also challenges the ALJ’s hypothetical question to the vocational expert.
However, because she “does not challenge the ALJ’s determination that she has the
physical [RFC] to perform light work,” Appellant Br. 19 n.23, we do not consider this
argument, which concerns her physical limitations resulting from her mild to moderate
bilateral carpal tunnel syndrome.
3Although we have the “power to enter, upon the pleadings and transcript of the record,
a judgment affirming, modifying, or reversing the decision of the Commissioner of Social
Security, with or without remanding the cause for a rehearing,” 42 U.S.C. § 405(g), the
record here does not “provide[] persuasive evidence of total disability that [would]
14
the ALJ should apply all four Burgess factors in determining the appropriate
weight to accord to Dr. Dron’s opinion.
CONCLUSION
For the foregoing reasons, the judgment of the district court is VACATED,
and the case is REMANDED to the Commissioner for further proceedings
consistent with this opinion.
render[] any further proceedings pointless,” Williams v. Apfel, 204 F.3d 48, 50 (2d Cir.
1999).
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