United States District Court, D. Massachusetts
MEMORANDUM AND ORDER REGARDING PLAINTIFF'S MOTION
FOR ORDER REVERSING THE COMMISSIONER'S DECISION AND
DEFENDANT'S MOTION TO AFFIRM THE DECISION OF THE
COMMISSIONER (DOCKET NOS. 22 & 29)
KATHERINE A. ROBERTSON, U.S. MAGISTRATE JUDGE
Myers ("Plaintiff") brings this action pursuant to
42 U.S.C. §§ 405(g) and 1383(c)(3) seeking review
of a final decision of the Acting Commissioner of Social
Security ("Commissioner") denying his application
for Supplemental Security Income ("SSI"). Plaintiff
applied for SSI on March 18, 2014, alleging an October 1,
2013 onset of disability due to degenerative disc disease
("DDD") and learning difficulties (A.R. at 87,
153). On April 14, 2017, the Administrative Law
Judge ("ALJ") found that Plaintiff was not disabled
and denied his application for SSI (A.R. at 70-86). The
Appeals Council denied review (A.R. at 6-9) and, thus,
Plaintiff is entitled to judicial review. See Smith v.
Berryhill, 139 S.Ct. 1765, 1772 (2019).
appeals the Commissioner's denial of his claim on the
ground that the decision is not supported by
"substantial evidence" under 42 U.S.C. §
405(g). Pending before this court are Plaintiff's motion
requesting that the Commissioner's decision be reversed
or remanded for further proceedings (Dkt. No. 22), and the
Commissioner's motion for an order affirming the decision
of the ALJ (Dkt. No. 29). The parties have consented to this
court's jurisdiction (Dkt. No. 10). See 28
U.S.C. § 636(c); Fed.R.Civ.P. 73. For the reasons stated
below, the court will grant the Commissioner's motion for
an order affirming the decision and deny Plaintiff's
presents multiple grounds supporting his contention that the
Commissioner's decision should be reversed or remanded
(Dkt. No. 22-1). Because Plaintiff's arguments mostly
concern Plaintiff's back condition and mental health, the
background information will be limited to the facts that are
relevant to those issues.
Plaintiff's Educational Background and Work
was forty-seven years old on the date of the July 14, 2016
hearing (A.R. at 626, 633). He was married and lived with his
wife and five of his seven children whose ages ranged from
nineteen to ten (A.R. at 154, 633, 666). Plaintiff left
school in the tenth grade and had worked delivering
newspapers, driving a taxi, and washing dishes (A.R. at 186).
In July 2013, he began stocking shelves, doing maintenance
work, and operating the cash register at an Ocean State Job
Lot store where he frequently lifted fifteen to twenty pounds
and occasionally lifted fifty pounds while performing his
duties (A.R. at 186, 634, 635, 636-37, 639). Plaintiff
stopped working at Ocean State Job Lot in March or April 2014
because he failed to adhere to his work schedule and had too
many "infractions" (A.R. at 634, 642-43, 644).
Plaintiff's Physical Condition
October 20, 2013, about two months after Plaintiff started
the new job that involved lifting heavy objects, he presented
at the emergency department of the North Adams Regional
Hospital complaining of left flank pain associated with
"lifting, motion or positioning" (A.R. at 325). The
condition was diagnosed as "likely musculoskeletal in
nature" (A.R. at 326). Plaintiff was advised to take
ibuprofen and to rest and avoid heavy lifting (A.R. at 326).
was seen in the North Adams Regional Hospital emergency
department seven days later for anxiety (A.R. at 319, 320).
Plaintiff reported that ibuprofen had relieved his back pain
and he was attempting to change the way he lifted heavy
objects (A.R. at 319). A physician's palpation of
Plaintiff's paralumbar muscles produced minimal
discomfort (A.R. at 320). Plaintiff was discharged after
receiving Ativan (A.R. at 320).
days later, on October 29, 2013, Plaintiff visited his PCP,
Shaohua Tang, M.D. of Integrative Medicine in North Adams,
complaining of low back pain and discomfort in his left groin
area (A.R. at 394). He reported that his job entailed "a
lot of lifting" (A.R. at 394). There was mild tenderness
in his lumbar area and his lumbar flexion was "slightly
limited" by pain (A.R. at 395). There was no muscle
atrophy or costovertebral angle ("CVA") tenderness
(A.R. at 395). Dr. Tang advised Plaintiff to avoid lifting or
carrying heavy objects and doing "strenuous physical
work" (A.R. at 395).
visited the emergency department the next day, October 30,
2013, again complaining of pain in his left flank, hip, and
back (A.R. at 309). Plaintiff's sensory and motor
functions were intact (A.R. at 309). An x-ray of
Plaintiff's lumbar spine revealed disc space narrowing at
¶ 5-S1 with degenerative changes (A.R. at 311). Minor
spondylolisthesis and spondylolysis were also observed (A.R.
at 311, 392). The diagnosis was back pain with left lumbar
radiculopathy (A.R. at 310).
record of Plaintiff's visit to Dr. Tang on November 5,
2013 indicates that Plaintiff's low back pain was mainly
on the left side and moved down his left leg (A.R. at 392).
The physical examination of his back revealed mild tenderness
in the lumbar area (A.R. at 393). Lumbar flexion was
"slightly limited" due to pain (A.R. at 393). The
straight leg elevation test showed "65 degrees [on the]
left side" and "80 degrees [on the] right
side" (A.R. at 393). There was no muscle atrophy or CVA
tenderness (A.R. at 393). Dr. Tang discussed treatments for
DDD and repeated his instructions to avoid lifting or
carrying heavy objects and performing "strenuous
physical work" (A.R. at 393). Plaintiff indicated that
he wanted to try an injection treatment (A.R. at 393).
Plaintiff's January 15, 2014 visit to Dr. Tang, he
reported low back pain and leg numbness "from time to
time" (A.R. at 390). Plaintiff stated that he was
performing "physical work with lots of bending and
lifting" (A.R. at 390). Dr. Tang's examination of
Plaintiff's lumbar area revealed mild tenderness, normal
range of motion, no muscle atrophy, no CVA tenderness, and no
peripheral edema (A.R. at 391). Dr. Tang advised Plaintiff to
avoid "prolonged" walking and standing, heavy
lifting or carrying, and "strenuous physical work"
(A.R. at 391). Dr. Tang reviewed Plaintiff's October 2013
x-ray and characterized Plaintiff's DDD as
"mild" (A.R. at 39). He ordered an MRI study (A.R.
returned to the emergency department on January 17, 2014 with
complaints of left lower quadrant discomfort and back pain
without radicular symptoms down either leg (A.R. at 301). The
physical examination revealed that Plaintiff's gait and
motor and sensory reflexes were within normal limits (A.R. at
301). He was instructed to take ibuprofen (A.R. at 303).
underwent an MRI of his lumbar spine on January 27, 2014
(A.R. at 299). The impression was that Plaintiff had mild,
grade 1 anterolisthesis of L5 on S1 due to bilateral pars
defects (A.R. at 299). "This [was] associated with a
diffuse annular bulge and vertebral body spurring, all of
which combine[d] to result in severe left and moderate right
foraminal narrowing. The left L5 nerve root appear[ed]
compressed" (A.R. at 299-300).
returned to Dr. Tang on January 31, 2014 and reported that he
had reduced his physical activities and his back pain was
"somewhat better" (A.R. at 388). However, he had
mild numbness in his left leg and "some pain" in
his right leg (A.R. at 388). Dr. Tang's physical
examination of Plaintiff's back revealed mild tenderness
in the lumbar area (A.R. at 389). The lumbar range of motion
and straight leg elevation on both sides were normal (A.R. at
389). There was no muscle atrophy, CVA tenderness, or
peripheral edema (A.R. at 389). Dr. Tang instructed Plaintiff
to "avoid heavy lifting and carrying," perform
lumbar stretching exercises and local massage, and use a
heating pad (A.R. at 389).
Plaintiff saw Dr. Tang on March 20, 2014 with complaints of
neck pain, he indicated that his back pain was "not so
bad lately" (A.R. at 385). Dr. Tang examined
Plaintiff's lower back (A.R. at 386). His observations
were consistent with those of the prior visit; that is, mild
tenderness, normal range of motion of the cervical spine, and
no muscle atrophy, CVA tenderness, or peripheral edema (A.R.
at 386). Dr. Tang indicated that Plaintiff's low back
pain appeared "relatively stable" and was "not
. . . bothering [him] now" (A.R. at 386). The physician
"encouraged [Plaintiff] to do suitable physical work,
but [to] avoid heavy physical work" (A.R. at 386).
completed a Social Security Administration ("SSA")
Work Activity Report on March 26, 2014 indicating that he
could lift twenty pounds (A.R. at 192, 198). On
Plaintiff's March 30, 2014 Questionnaire on Pain, he
indicated that medication relieved his pain for about six
hours, although he could still feel it (A.R. at 202-03).
notes of Plaintiff's May 1, 2014 visit to Dr. Tang
indicated that Plaintiff was generally "feeling
fine" (A.R. at 383). Again, Dr. Tang observed mild
tenderness in Plaintiff's lower cervical spine, normal
cervical spine range of motion, no muscle atrophy, and no
peripheral edema (A.R. at 384).
6, 2014, Plaintiff reported that his back pain was five on a
ten point scale and was "relatively stable" (A.R.
at 381). Dr. Tang noted that Plaintiff's back condition
was the same as the previous month (A.R. at 382). Plaintiff
received lidocaine injections into eight trigger points in
his low back (A.R. at 382).
Plaintiff's September 10, 2014 visit to Dr. Tang, he
reported that he still experienced low back pain, but the
trigger point injections enabled him to function (A.R. at
378). The results of Dr. Tang's physical examination of
Plaintiff's lumbar area remained the same: mild
tenderness; normal range of motion; no muscle atrophy; no CVA
tenderness; and no peripheral edema (A.R. at 378). Dr. Tang
administered trigger point injections (A.R. at 378).
record of Plaintiff's October 10, 2014 visit to Dr. Tang
indicates that Plaintiff experienced intermittent low back
pain (A.R. at 375, 376). Upon examination, the condition of
Plaintiff's back remained the same (A.R. at 376). Dr.
Tang administered trigger point injections and referred
Plaintiff for physical therapy ("PT") (A.R. at 376,
October 13, 2014, Plaintiff visited the Berkshire Medical
Center Satellite Emergency Facility because he was
experiencing chest pain (A.R. at 274). He did not have back
pain (A.R. at 275). The examination of Plaintiff's back
showed there was no CVA or midline point tenderness and his
range of motion was normal (A.R. at 276).
October 28, 2014 evaluation at Williamstown Physical Therapy
indicated that his lumbar flexion range of motion was 25%
limited and his lumbar extension range of motion was 50%
limited (A.R. at 462). His symptoms were consistent with
thoracic and lower back pain that was exacerbated by
"poor lifting mechanics, poor postural control,
decreased muscle tissue extensibility, and poor
strength" (A.R. at 462). The therapist recommended that
Plaintiff attend PT twice a week for four weeks (A.R. at
463). Plaintiff attended a therapy session on October 28
(A.R. at 450).
October 31, 2014, Plaintiff saw Dr. Tang with complaints of
chest pain (A.R. at 373). The results of the physical
examination of his lumbar area were consistent with the
results of Dr. Tang's prior examinations (A.R. at 374).
Plaintiff reported that PT relieved his back pain, but he
wished to continue the trigger point injections, which Dr.
Tang administered (A.R. at 373, 374).
attended PT sessions on November 5, 12, 14, 21, and 25, 2014,
but missed sessions on November 7 and 19 (A.R. at 448, 449,
450). On November 12, 2014, Plaintiff indicated that he felt
better after the previous PT appointment (A.R. at 448). At
the November 25, 2014 appointment, he reported that his back
was feeling better "lately" (A.R. at 449).
visited Dr. Tang on December 3, 2014 to receive a trigger
point injection treatment for his lower back (A.R. at 372).
Plaintiff reported that the injections "really
help[ed]" for "some days" (A.R. at 372). Dr.
Tang indicated that Plaintiff's lumbar range of motion
was normal and his low back pain was "stable" (A.R.
January 13, 2015 letter from Williamstown Physical Therapy to
Dr. Tang indicated that Plaintiff had attended six PT
sessions, but had not received PT between November 25, 2014
and January 13, 2015 (A.R. at 444). Consequently, "there
was a setback in his progress" (A.R. at 444). The
therapist recommended continuing PT twice a week for six
weeks (A.R. at 444). Plaintiff indicated that he was
"feeling okay" due to the injections that Dr. Tang
administered on that date (A.R. at 445).
Plaintiff's preventive physical examination on February
4, 2015, he told Dr. Tang that the trigger point injections
relieved his lower back pain (A.R. at 368). Again, Dr. Tang
observed minimal tenderness in Plaintiff's lumbar area
and no muscle atrophy or CVA tenderness (A.R. at 370). He
assessed Plaintiff's low back pain and DDD as
"stable" (A.R. at 370).
received trigger point injections on February 10 and March 5,
2015 (A.R. at 367, 458). On those dates, Plaintiff's
condition was "relatively stable," his lumbar area
was mildly tender, and his lumbar range of motion was normal
(A.R. at 367, 458).
attended PT sessions on February 4, 11, and 13, 2015 (A.R. at
442, 445). Plaintiff indicated that he felt better for
"about two days" after receiving PT (A.R. at 442).
By a February 13, 2015 letter, Williamstown Physical Therapy
notified Dr. Tang that Plaintiff "has attended PT for 9
visits since 10/28/14 and shows poor compliance [with a] home
exercise program" (A.R. at 441). The letter further
indicated that Plaintiff reported "some improvement in
his pain to a 4/10" (A.R. at 441). According to the
letter, Plaintiff could stand and walk for five to ten
minutes (A.R. at 441). The therapist recommended continuing
PT once or twice a week for two weeks (A.R. at 441).
Plaintiff was discharged from PT on March 3, 2015 because he
was "non-compliant [with] appointments" (A.R. at
October 30, 2015, Plaintiff presented at the Berkshire
Medical Center emergency department with dental pain (A.R. at
490). He had full range of motion in his back and no CVA
tenderness (A.R. at 492).
November 19, 2015, an ambulance transported Plaintiff to the
Berkshire Medical Center emergency department with complaints
of pain on his right side (A.R. at 499). He had no CVA
tenderness in his back, had normal range of motion, and had
no tenderness or edema in his extremities (A.R. at 500).
returned to the Berkshire Medical Center emergency department
on February 11, 2016 after he experienced dizziness,
especially when he stood up quickly (A.R. at 514, 517).
Plaintiff reported that his chronic low back pain with
paresthesia in the left leg had improved with exercise (A.R.
at 514). The physical examination of his back revealed no
CVA, midline vertebra, or paraspinal tenderness (A.R. at
515). Plaintiff's range of motion was normal and his gait
was steady (A.R. at 512, 515).
visited CHP North Adams Family Medicine on March 31, 2016
complaining of pain on his right side and in his lower back,
which radiated to his right thigh and left foot, but without
numbness in his legs and feet (A.R. at 557). He indicated
that the pain was aggravated by "movement/positioning,
flexing [his] back, [and] lifting more than [twenty]
pounds" (A.R. at 557). Plaintiff reported that rest,
heat, and over-the-counter medication (Aleve) relieved the
pain (A.R. at 557). Plaintiff ambulated normally (A.R. at
559). The examination by Marguerite Vardman, N.P., revealed
tenderness of Plaintiff's left spine, positive standing
and sitting flexion tests on the right side, unequal leg
lengths, and normal movement of all his extremities (A.R. at
560). N.P. Vardman observed abnormal lordosis of
Plaintiff's back (A.R. at 560).
Bruce Navom of Living Well Chiropractic, LLC evaluated
Plaintiff on April 2, 2016 and noted "[s]egmental and
somatic dysfunction of [the] sacral region" and
"low back pain" (A.R. at 585). Dr. Navom performed
spinal adjustments (A.R. at 585).
April 7, 2016 x-rays of Plaintiff's lumbar spine revealed
the previously viewed pars defect at ¶ 5 with
spondylolisthesis of L5 over S1 (A.R. at 524).
"Vertebral body height [was] maintained.
Flexion-extension views demonstrate marked movement of 9 mm
indicating presence of instability" (A.R. at 524).
treatment record of Plaintiff's visit to N.P. Vardman on
April 18, 2016 states that he was walking for exercise and
his lumbar radiculopathy was "improving" (A.R. at
570, 573). Plaintiff reported that his back felt "much
better" after Dr. Novom's chiropractic treatment
(A.R. at 570). His gait was normal on that date (A.R. at
April 19, 2016, Plaintiff presented at the emergency
department complaining of pain in his lower abdomen (A.R. at
536). He stated "that he had been golfing the past
couple days" and indicated that "he probably
strained his abdominal muscles" (A.R. at 530, 532, 536).
His ability to walk was not impaired (A.R. at 536). He had
full range of motion and no CVA tenderness in his back (A.R.
at 537). He was diagnosed with diverticulitis (A.R. at 533,
was ambulating normally during his May 4, 2016 visit to
Anping Han, M.D. at CHP (A.R. at 576, 578). Based on
Plaintiff's chronic back pain, Dr. Han referred Plaintiff
to Joshua Yurfest, M.D. (A.R. at 33).
visited Dr. Yurfest on July 5, 2016 with complaints of lower
back pain that radiated into both of his legs and sometimes
produced numbness and weakness (A.R. at 586). Plaintiff
reported that his pain was five on ten point scale (A.R. at
586). Plaintiff told Dr. Yurfest that physical therapy and
chiropractic manipulation did not relieve the pain, but
trigger point injections provided relief (A.R. at 586). Upon
examination, Dr. Yurfest noted that trigger points were
present in the piriformis muscle, gluteus maximus, gluteus
medius, and lumbar paraspinals (A.R. at 587). Assessment of
Plaintiff's back revealed that straight leg raises
("SLR") were negative, the PSIS level was equal,
and kyphosis and scoliosis were absent (A.R. at 587). Dr.
Yurfest reviewed the April 4, 2016 x-rays of Plaintiff's
lumbar spine and indicated that Plaintiff's "pain
syndrome [was] secondary" to the increased movement at
the L5-S1 level (A.R. at 587). Dr. Yurfest further indicated
that the electrodiagnostic studies were normal thereby
excluding a lumbar radiculopathy (A.R. at 587). Plaintiff
rejected surgical intervention (A.R. at 587). The physician
recommended PT and core strengthening exercises (A.R. at
was evaluated by Adams Physical Therapy, LLC on July 18, 2016
(A.R. at 595-98, 600-01). Plaintiff reported that he
experienced pain when lifting and bending (A.R. at 595). He
could walk about 100 yards, sit for about thirty minutes, and
stand for about ten minutes without pain (A.R. at 595, 600,
601). Plaintiff indicated that he was unable to carry
anything (A.R. at 600). Upon examination, Plaintiff's
lumbar flexion range of motion/strength were 4/5 and his hip
range of motion/strength ranged from 4/5 to 5/5 (A.R. at
596). Plaintiff attended a PT session on July 20, 2016 (A.R.
at 593). The therapist told Plaintiff that PT would not
"fix" his condition and that surgery usually was
indicated (A.R. at 593).
Plaintiff's Mental Condition
presented records of The Brien Center spanning the period
from September 11, 2014 to November 20, 2014 (A.R. at
410-29). During the initial evaluation on September
11, 2014, Plaintiff reported that family and friends
supported him and his activities of daily living were not
limited (A.R. at 417). The mental status exam revealed that
Plaintiff's appearance, eye contact, speech, mood,
affect, facial expression, perception, thought content,
thought process, intellectual functioning, orientation,
memory, insight, and judgment were within normal limits (A.R.
at 420). His behavior was relaxed (A.R. at 420). He was
diagnosed with anxiety disorder NOS (A.R. at 425). On
September 30, 2014, Plaintiff reported that he had increased
his activities and was spending more time with his family
(A.R. at 410-11). The counselor and Plaintiff discussed
anxiety management on October 14, 2014 (A.R. at 412-13). On
November 20, 2014, the counselor did not observe or report
any significant changes in Plaintiff's condition (A.R. at
records of Plaintiff's emergency department visits on
January 17, 2014, April 2, October 31, and November 19, 2015,
and February 11 and April 19, 2016 indicated that
Plaintiff's mood and affect were normal (A.R. at 301,
479, 480, 490, 492, 499, 500, 514, 515, 536, 537, 570, 573).
The records indicated no depression on April 2, 2015 and no
anxiety, depression, or suicidal thoughts on October 31, 2015
and April 19, 2016 (A.R. at 479, 490, 536). Treatment records
of October 29, 2013, January 15 and 31, March 20, May 1, June
6, October 10 and 31, 2014, February 4 and March 23, 2015,
and March 31 and July 5, 2016 indicated no sleep disturbances
or insomnia (A.R. at 368, 373, 375, 381, 383, 385, 388, 390,
394, 456, 557-58, 586).
March 31, 2016, N.P. Vardman noted Plaintiff's report
that his depression and anxiety had improved after he stopped
drinking alcohol and started taking vitamins (A.R. at 558).
N.P. Vardman observed that Plaintiff was active and alert and
his mood and affect were normal (A.R. at 559). Dr. Han made
the same notation on April 14, 2016 (A.R. at 573).
Consultative Examiner's Evaluation
Guenther, Ph.D., conducted a consultative examination of
Plaintiff on August 13, 2014 (A.R. at 401). Plaintiff
reported "a long history of learning difficulties"
and participation in special education, including remedial
classes at school (A.R. at 401). He expressed difficulty with
reading comprehension, spelling, concentration, and memory
(A.R. at 401, 409). His wife assisted him with paperwork
because his math skills were subpar (A.R. At 401, 404, 406).
Plaintiff described symptoms of depression and anxiety,
including "what may be panic attacks" (A.R. at
403-04). His hobbies and interests were limited to playing
video games with his children (A.R. at 406). He reported
having "limited" social contacts and difficulty
sleeping (A.R. at 403).
mental status examination, Plaintiff's gait and motor
behavior were normal, his eye contact was appropriate, his
thought processes were concrete, and his insight and judgment
were fair (A.R. at 404). "His speech [was] fluent and
intelligible but there . . . [were] some expressive language
difficulties, as he ha[d] trouble organizing or articulating
his thoughts" (A.R. at 404). He "often" asked
Dr. Guenther to repeat or clarify her questions (A.R. at 404,
Guenther administered intellectual and achievement tests
(A.R. at 404-06). On the WRAT-4 subtests, Plaintiff's
grade equivalents were as follows: reading was 11.2; spelling
was 3.9; and mathematics was 2.9 (A.R. at 405, 406).
Plaintiff's full-scale IQ, as measured by the WAIS-IV,
was 77 (A.R. at 405). His verbal comprehension score of 85
was in the 16th percentile, his perceptual reasoning score of
81 was in the 10th percentile, his working memory score of 77
was in the 6th percentile, and his processing speed score of
79 was in the 8th percentile (A.R. at 405). His verbal
comprehension index and perceptual reasoning scores
"placed him in the low average range of intellectual
functioning" and his working memory and processing speed
scores were deemed to be "borderline" (A.R. at
Guenther determined that Plaintiff's test scores
reflected "a learning disability/border intellectual
functioning" (A.R. at 406). She opined that Plaintiff
was capable of "following and understanding simple
directions and instructions" (A.R. at 407). He might
have difficulty, however, executing more complicated requests
and completing tasks efficiently or on time (A.R. at 407).
Based on Plaintiff's description of being "a bit
socially withdrawn," the examiner indicated that he
might have difficulty relating to co-workers (A.R. at 407).
Dr. Guenther diagnosed Plaintiff with anxiety disorder NOS,
depressive disorder NOS, "borderline intellectual
functioning (versus learning disorder NOS)," and a
learning disability (A.R. at 407). She assigned a GAF score
of 55 (A.R. at 407). The examiner concluded that
"considering the presence of the learning difficulties
and psychiatric symptoms, the results of the present
evaluation are consistent with the [Plaintiff's]
allegations" (A.R. at 407). She recommended formal
psychiatric intervention and vocational rehabilitation and
training and listed the prognosis as "fair" (A.R.
State Agency Consultants' Opinions
8, 2014, S. Ram Upadhyay, M.D., assessed Plaintiff's
physical residual functional capacity ("RFC") based
on a review of his records (A.R. at 92-94). Dr. Upadhyay
opined that Plaintiff could: lift twenty pounds occasionally
and ten pounds frequently; stand and/or walk and sit for
about six hours in an eight hour workday with normal breaks;
occasionally climb ramps, stairs, ladders, ropes, or
scaffolds, stoop, and crawl (A.R. at 93). Dr. Upadhyay opined
that Plaintiff was capable of performing light work and was
not disabled (A.R. at 96-97).
Perlman, Ed.D., assessed Plaintiff's mental RFC on August
26, 2014 (A.R. at 94-95). Dr. Perlman determined that
Plaintiff had mild restrictions in activities of daily
living, moderate difficulties in maintaining social
functioning and concentration, persistence, or pace, and no
repeated episodes of decompensation (A.R. at 91).
Specifically, Dr. Perlman opined that Plaintiff's ability
to understand, remember, and carry out detailed instructions
was moderately limited, but Plaintiff could understand and
remember simple instructions (A.R. at 94). Plaintiff's
ability to maintain attention and concentration for extended
periods, complete a normal workday and workweek without
interruption from psychologically based symptoms, and perform
at a consistent pace were moderately limited (A.R. at 94-95).
According to Dr. Perlman, Plaintiff could complete simple,
routine tasks and maintain concentration for at least two
hours when performing simple one and two step tasks (A.R. at
95). Finally, Dr. Perlman opined that Plaintiff's ability
to get along with coworkers was moderately limited, although
he could relate to others in a socially appropriate manner
(A.R. at 95).
Malin Weeratne, M.D., conducted a reconsideration evaluation
of Plaintiff's physical RFC on March 26, 2015 (A.R. at
454). Dr. Weeratne agreed with Dr. Upadhyay's opinion
(A.R. at 454-55).
Higgins, Ph.D., reconsidered Plaintiff's mental RFC on
February 17, 2015 (A.R. at 453). Dr. Higgins adopted Dr.
Perlman's assessment except Dr. Higgins opined that
Plaintiff was markedly limited in his ability to carry out
detailed tasks and moderately limited in his ability to
interact with the general public (A.R. at 453).