Estrella v. Berryhill
925 F.3d 90
| 2d Cir. | 2019Background
- Brenda Estrella applied for Social Security Disability Insurance and SSI in June 2012, alleging disability from August 27, 2008, due in part to major depressive disorder, bipolar disorder, and ADHD.
- Treated intermittently by psychiatrist Dr. Felix Dron (2003–2006; 2010–2013); Dr. Dron submitted an October 2013 Medical Source Statement finding marked limitations in concentration, decision‑making, and handling detailed instructions.
- Administrative Law Judge (ALJ) found severe impairments but concluded Estrella retained an RFC for light work with limitations and could perform past administrative clerk work; ALJ assigned Dr. Dron’s opinion "little weight."
- ALJ relied in part on two treatment notes showing improvement and on a single consultative exam by Dr. Christopher Flach, which suggested only mild attention problems; ALJ treated GAF scores as indicating mild depression.
- District court affirmed the Commissioner; Estrella appealed to the Second Circuit challenging the ALJ’s treatment of her treating psychiatrist’s opinion under the treating‑physician rule and the ALJ’s failure to explain minimal weight given that opinion.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether ALJ erred in declining to give controlling weight to treating psychiatrist’s opinion | Estrella: ALJ failed to give controlling weight and ignored treating relationship and longitudinal evidence supporting marked limitations | Commissioner: ALJ permissibly found the opinion inconsistent with contemporaneous treatment notes, GAF scores, and a consultative exam | ALJ correctly rejected controlling weight because the opinion was inconsistent with some evidence, but further analysis required at step two |
| Whether ALJ provided required "good reasons" and explicitly applied Burgess factors when assigning little weight | Estrella: ALJ failed to explicitly consider Burgess factors (frequency, length, nature, extent of treatment) and thus committed procedural error | Commissioner: Record and ALJ’s citations to treatment notes and consultative exam supplied adequate reasons | Court: ALJ procedurally erred by not explicitly addressing Burgess factors and did not provide other "good reasons"—remand required |
| Reliance on single consultative exam to discount treating opinion | Estrella: Single exam is a snapshot and cannot reliably rebut longitudinal treating evidence | Commissioner: Consultative examiner’s findings were consistent with some treatment notes and supported weight reduction | Court: Cautioned against heavy reliance on single exam for mental impairments; consultative opinion did not supply adequate basis to discount treating opinion |
| Use of GAF scores as justification for discounting treating opinion | Estrella: GAF scores were unexplained and inconsistent with treating notes; therefore entitled to little weight | Commissioner: ALJ relied on GAF scores indicating only mild impairment | Court: GAF scores without explanation/consistency are unreliable and not a "good reason" to minimize treating opinion |
Key Cases Cited
- McIntyre v. Colvin, 758 F.3d 146 (2d Cir. 2014) (standard of review and five‑step sequential evaluation)
- Burgess v. Astrue, 537 F.3d 117 (2d Cir. 2008) (treating‑physician rule; controlling weight standard)
- Selian v. Astrue, 708 F.3d 409 (2d Cir. 2013) (ALJ must explicitly consider Burgess factors when not giving controlling weight)
- Halloran v. Barnhart, 362 F.3d 28 (2d Cir. 2004) (requirement to give good reasons for weight assigned to treating source)
- Ferraris v. Heckler, 728 F.2d 582 (2d Cir. 1984) (ALJ must set forth crucial factors with specificity)
- Cichocki v. Astrue, 729 F.3d 172 (2d Cir. 2013) (plenary review of administrative record)
- Garrison v. Colvin, 759 F.3d 995 (9th Cir. 2014) (mental illness can fluctuate; error to rely on isolated improvements)