Carpenter v. Astrue, No. 5:10–cv–249 (D.Vt., Sept. 7, 2011), 169 Soc.Sec.Rep.Serv. 431, 2011 WL 3951623 (D.Vt.)

 SSA denied dual applications for SSI and SSDI benefits for a younger individual (at the time of the AOD) with HS education and PRW as a truck driver, logger, and laborer.

After a video hearing ALJ Thomas Merrill denied both applications and held that the applicant retained an RFC for light simple work and thus could perform jobs of a cleaner, small product assembler, or mail clerk (VE testimony). 

The DRB failed to review the ALJ denial within the allotted 90 days.  The applicant   sought review at the Federal District Court for the District of Vermont. 

Chief Judge Christina Reiss reversed the Commissioner’s decision and remanded the matter for a new hearing with specific instructions to evaluate the opinions of the plaintiff’s treating physicians in their entirety including their opinions regarding specific functional limitations related to the plaintiff’s thoracic outlet syndrome.   

Judge Reiss acknowledged that the ALJ properly accorded little weight to the letter written by one of the Plaintiff’s treating physicians because the letter was “brief, conclusory, and inadequately supported by clinical findings.”  However, the ALJ erred when he  “inexplicably ignored the remainder of [Dr’s] approximately one and a half year history of treating Plaintiff, including extensive referrals to specialists.” 

The court held that an ALJ cannot reject,  without further explanation, all evidence from a treating physician because one component of the treating physician's opinions is unsupported and conclusory. Instead, the ALJ “must weigh all of the evidence and make a disability determination based on the totality of that evidence.” Armstrong v. Comm'r of Soc. Sec., 2008 WL 2224943, at *4 (N.D.N . Y. May 27, 2008) (citing 20 C.F.R. § 404.1527(c)(2)).

The court further stated that the ALJ’s error was exacerbated because he misidentified two other SSA consultants as “treating physicians,” accorded their incomplete opinions “great weight,” and relied upon their incomplete assessments in order to determine Plaintiff's RFC. The court rejected the Commissioner's assertion that the omission was a simple “drafting error,” finding “no basis in the record or in the law for adopting this approach.” See Snell v. Apfel, 177 F.3d 128, 134 (2d Cir.1999) (explaining that a reviewing court “may not accept ... counsel's post hoc rationalizations for agency actions.”)

The ALJ also erroneously concluded that the Plaintiff’s thoracic outlet syndrome (TOS) was not a medically determinable impairment.  The court held that the ALJ focused on a single statement from an Agency physician (“the diagnosis of thoracic outlet syndrome in 1994 was considered dubious”) despite the TOS diagnosis from the Plaintiff’s treating physicians, the surgery to correct it, and “the many other record references to TOS-related symptoms that Plaintiff suffered.”

In its analysis the court stated that the Plaintiff’s treating physicians were “acceptable medical sources. Their diagnoses and assessments related to the anatomical/physiological abnormality of TOS and were based upon acceptable clinical and laboratory diagnostic techniques established by medical evidence consisting of signs, symptoms, and laboratory findings.”  Thus, on the facts of this case, “it was error for the ALJ to find that Plaintiff's TOS was not medically determinable. Moreover, the court cannot find that this error was harmless because SSR 96–3 provides that symptom-related limitations will only be considered if the impairment to which they are related is medically determinable. Because the ALJ found Plaintiff's TOS not medically determinable, the ALJ did not consider symptoms related to it in his RFC assessment.”