Opinion ID: 2597
Heading Depth: 3
Heading Rank: 2

Heading: Other Evidence Before the ALJ

Text: In addition to being treated by Dr. Smith, Burgess was treated by Dr. Kim for more than a year, beginning just over a week after the accident. His initial diagnosis was that Burgess suffered traumatic internal derangement of the cervical and lumbosacral spines with sprain and strain of ligaments and muscles, traumatic lumbar radiculitis with radicular pain into the left lower extremity, traumatic myofascial pain dysfunction syndrome, and fracture of the left patella. He stated that Burgess was disabled at present with serious and substantial functional impairment associated with symptoms subject to recurrence and acute exacerbations, and that [t]he prognosis for recovery following such trauma and injuries [wa]s guarded because of the possibility of long term or lifelong symptomatology. (Report of Dr. Choong Kim dated October 16, 1997.) Subsequent diagnoses stated that Burgess had, inter alia, traumatic cervical and lumbosacral derangements. Dr. Kim prescribed physical therapy. Dr. Zaretsky examined Burgess for the Workers' Compensation Board a dozen times from April 23, 1998 through January 17, 2001. In several of his reports, Dr. Zaretsky described certain pain complaints by Burgess that he opined were not physiologically credible. ( See Reports of Dr. Robert Zaretsky dated October 1 and November 19, 1998, October 21, 1999, and November 1, 2000.) In November 1998, Dr. Zaretsky stated that he d[id] not find any evidence of disability flowing from [Burgess's] back, neck, ankle or foot (Report of Dr. Robert Zaretsky dated November 19, 1998), but thereafter he learned of the January 1999 MRI on Burgess's back and he requested and received the MRI Report. His report in May 1999 stated that at this time a mild partial disability is noted rel[e]vant to findings of the lumbar MRI. (Report of Dr. Robert Zaretsky dated May 20, 1999.) In a January 2000 report, Dr. Zaretsky again noted a mild partial disability ... relevant to findings in the lumbar MRI, but stated his opinion that Burgess was capable of gainful employment. (Report of Dr. Robert Zaretsky dated January 12, 2000.) None of his subsequent reports repeated that opinion, however, and all of them noted a continued mild partial disability, usually citing the MRI findings concerning Burgess's lower back. (Reports of Dr. Robert Zaretsky dated May 3, August 30, and November 1, 2000, and January 17, 2001.) The November 2000 and January 2001 reports stated that that disability could be considered permanent. Dr. Mancheno, who examined Burgess once in June 1999, diagnosed her as having, inter alia, a discogenic disorder of the lumbosacral spine. His report stated that Burgess said that she did her own shopping, cooking, and cleaning. Dr. Mancheno opined that Burgess had a mild impairment of her ability to sit, stand, walk, lift, carry, push, and pull. In the section of his report recounting Burgess's history, Dr. Mancheno noted that Burgess reported that she did have MRI with abnormalities reported; however, in the Laboratories section of the report he listed only X-rays of the knee and spine, with no mention of an MRI. (Report of Dr. Mario Mancheno dated June 3, 1999.) The record before the ALJ also included a report form filled out by a state agency medical consultant on July 6, 1999, and endorsed by another such consultant on October 1, 1999, both of whom had reviewed the record to provide a residual-functional-capacity opinion to the Commissioner, but neither of whom had examined Burgess. The boxes checked indicated that Burgess could frequently lift 25 pounds and occasionally lift 50; that she could sit for about six hours out of an eight-hour workday; and that she could stand or walk for about six hours out of an eight-hour workday. In the section of the form that asked for an explanation of how and why the evidence supported the consultants' conclusions, the response was that the X-rays of Burgess's spine and knee were normal. The consultants did not mention, inter alia, the MRI on Burgess's spine. The only witness other than Burgess to testify at the hearing before the ALJ was Dr. Abeles, an orthopedic surgeon who had testimony at the hearing, but had not examined her. (The Commissioner notes in his brief on appeal at 22 n. 4 that since the time of the hearing in this case, Dr. Abeles has entered into a Consent Decree that limits his practice of medicine in New York State to conducting consultative examinations for the SSA and insurance carriers.) Dr. Abeles, when asked by the ALJ what the [medical] record reveals about this young woman (Hearing Transcript, May 9, 2002 (ALJ Tr.), at 36), stated that the record showed that Burgess had suffered contusions of both knees, but that the X-rays were normal; and that she had had arthroscopic surgery on her knee, but that the only abnormal finding from that procedure was that certain tissue was less prominent than normal. When the ALJ asked what other objective evidence we have other than the fact that we have a negative x-ray[ ], contusion in both knees, and [a]n arthroscopy which revealed nothing, Dr. Abeles responded Yeah. I see nothing else that's available to me that's on the record. The x-rays of the back are also within normal limits. There is some mention of an MRI, but there is no report of an MRI of the lumbar spine. Q. [ALJ]: Of the lumbar spine  A. Lumbar spine. There's no report of it. Q. X-rays of the back were normal and no report of the lumbosacral? A. There apparently was one done, because there's a letter here of '99 which shows a protruding disc at the L2/3 level on an MRI in a letter of Dr. Smith, but there is no report incorporated in the records. Q. I see. And any other findings in a chart at all in this proceeding? A. Just that there are continued complaints of pain of the neck, back, and left knee, but no examination finding other than that. (ALJ Tr. 38 (emphases added).) When the ALJ asked about Dr. Smith's conclusion that Burgess was totally disabled, Dr. Abeles stated, I don't think there is any objective reason why she couldn't sit, stand, and walk six hours out of an eight-hour workday. ( Id. at 40.) He stated that, Burgess having had extensive physical therapy[, s]he should at this point be able to do these things. There is no objective reason why she can't. ( Id. ) Dr. Abeles attributed Burgess's weakness to atrophy of her muscles from lying in bed not doing anything, opining that  [t]here is no other reason for any of this.  ( Id. ) (emphasis added). In response to questions from counsel for Burgess, Dr. Abeles testified he believed that Burgess feels the[] things reflected in her subjective complaints and that subjectively she has [a] disability (ALJ Tr. 41). But as to Dr. Smith's conclusions, Dr. Abeles testified that he did not think Burgess was disabled objectively, and that although he th[ought] that in good faith [Dr. Smith] can write that, ... he's been seeing this patient month [in] and month out. And he is being influenced by seeing her.... ( Id. )