WALLACE CAPEL, Jr., Magistrate Judge.
Plaintiff, Sherry Dale Saunders, applied for supplemental security income benefits under Title XVI of the Social Security Act ("the Act"), 42 U.S.C. §§ 1381 et seq. Her application was denied at the initial administrative level. Tr. 82-86. Plaintiff then requested and received a hearing before an Administrative Law Judge ("ALJ"). Following the hearing, the ALJ issued a decision in which he found Plaintiff not disabled since June 10, 2008, the date the application was filed. Tr. 23. The Appeals Council rejected Plaintiff's request for review of the ALJ's decision. Tr. 1-5. The ALJ's decision consequently became the final decision of the Commissioner of Social Security ("Commissioner").
Under 42 U.S.C. § 423(d)(1)(A), a person is entitled to disability benefits when the person is unable to
42 U.S.C. § 423(d)(1)(A).
To make this determination, the Commissioner employs a five-step, sequential evaluation process. See 20 C.F.R. §§ 404.1520, 416.920 (2006).
McDaniel v. Bowen, 800 F.2d 1026, 1030 (11th Cir. 1986).
The burden of proof rests on a claimant through Step 4. See Phillips v. Barnhart, 357 F.3d 1232, 1237-39 (11th Cir. 2004). A claimant establishes a prima facie case of qualifying disability once they have carried the burden of proof from Step 1 through Step 4. At Step 5, the burden shifts to the Commissioner, who must then show there are a significant number of jobs in the national economy the claimant can perform. Id.
To perform the fourth and fifth steps, the ALJ must determine the claimant's Residual Functional Capacity (RFC). Id. at 1238-39. RFC is what the claimant is still able to do despite his impairments and is based on all relevant medical and other evidence. Id. It also can contain both exertional and nonexertional limitations. Id. at 1242-43. At the fifth step, the ALJ considers the claimant's RFC, age, education, and work experience to determine if there are jobs available in the national economy the claimant can perform. Id. at 1239. To do this, the ALJ can either use the Medical Vocational Guidelines
The grids allow the ALJ to consider factors such as age, confinement to sedentary or light work, inability to speak English, educational deficiencies, and lack of job experience. Each factor can independently limit the number of jobs realistically available to an individual. Phillips, 357 F.3d at 1240. Combinations of these factors yield a statutorily-required finding of "Disabled" or "Not Disabled." Id.
The Court's review of the Commissioner's decision is a limited one. This Court must find the Commissioner's decision conclusive if it is supported by substantial evidence. 42 U.S.C. § 405(g); Graham v. Apfel, 129 F.3d 1420, 1422 (11th Cir. 1997). "Substantial evidence is more than a scintilla, but less than a preponderance. It is such relevant evidence as a reasonable person would accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 401 (1971). See also Crawford v. Comm'r of Soc. Sec., 363 F.3d 1155, 1158 (11th Cir. 2004) ("Even if the evidence preponderates against the Commissioner's findings, [a reviewing court] must affirm if the decision reached is supported by substantial evidence."). A reviewing court may not look only to those parts of the record which support the decision of the ALJ, but instead must view the record in its entirety and take account of evidence which detracts from the evidence relied on by the ALJ. Hillsman v. Bowen, 804 F.2d 1179 (11th Cir. 1986).
Walker v. Bowen, 826 F.2d 996, 999 (11th Cir. 1987).
Plaintiff was fifty-seven years old at the time of the hearing before the ALJ. Tr. 23, 33. Plaintiff completed high school and almost two years of college. Tr. 23, 34, & 62. Plaintiff attempted to start her own sewing business doing custom orders, but indicated business was slow. Tr. 18, 35. Following the administrative hearing, and employing the five-step process, the ALJ found Plaintiff had "not engaged in substantial gainful activity since June 10, 2008, the application date." (Step 1) Tr. 18. At Step 2, the ALJ found that Plaintiff suffers from the following severe impairments: "degenerative disc disease of the lumbar spine and cervical disorder." Id. The ALJ then found that "[Plaintiff] does not have an impairment or combination of impairments that meets or medically equals one of the listed impairments." (Step 3) Id. Next, the ALJ found that Plaintiff "has the residual functional capacity to perform the full range of medium work as defined in 20 C.F.R. 416.967(c)." Tr. 19. The ALJ then found that Plaintiff "has no past relevant work." (Step 4) Tr. 23. Considering Plaintiff's "age, education, work experience, and [RFC]," and after applying the Medical Vocational Grids, the ALJ determined "there are jobs that exist in significant numbers in the national economy that [Plaintiff] can perform." Id. Accordingly, the ALJ determined that Plaintiff "has not been under a disability . . . since June 10, 2008, the date the application was filed." Id.
Plaintiff presents three issues for this Court's consideration in review of the ALJ's decision: (1) whether the decision should be reversed because "there is absolutely no support for the ALJ's Residual Functional capacity (RFC) assessment as the record is devoid of any RFC assessments provided by a physician[;]" (2) whether "the ALJ erred in mechanically applying the medical vocational guidelines in determining there were significant jobs existing in the national economy that [Plaintiff] could perform based on her capacity to perform a full range of medium work[;]" and (3) whether "the ALJ improperly rejected [Plaintiff's] testimony concerning the effects and resulting limitations imposed by the combination of her medically determinable impairments." Pl.'s Brief (Doc. #12) at 5. The Court finds that the ALJ's RFC determination warrants remand. Because the Court finds reversal is warranted on the first issue, the Court declines consideration of the other issues raised by Plaintiff.
Plaintiff contends that the ALJ's RFC determination is not supported by substantial evidence because the "the record is completely devoid of a medical assessment that supports the ALJ's RFC." Pl.'s Brief (Doc. #12) at 6. Plaintiff argues that because "the record does not contain an RFC assessment completed by a physician . . . the ALJ simply formulated his own opinion regarding [Plaintiff's] limitations." Id. at 7. Accordingly, Plaintiff "requests that the Court reverse or remand her case so that a proper RFC assessment can be established." Id. Defendant contends that
Def.'s Brief (Doc. #13) at 9.
At the administrative law judge hearing level, the ALJ is responsible for assessing a claimant's RFC. 20 C.F.R. § 404.1546(c). The ALJ must assess a claimant's RFC "based on all of the relevant medical and other evidence[,]" and, in general, the claimant will be responsible for providing the evidence used to make a finding about the RFC. 20 C.F.R. § 404.1545(a)(3). While the ALJ has the responsibility to make a determination on Plaintiff's RFC, it is Plaintiff who bears the burden of proving her RFC. See 20 C.F.R. § 404.1512(a) & (c) (instructing claimant that ALJ will consider "only impairment(s) you say you have or about which we receive evidence" and "[y]ou must provide medical evidence showing that you have an impairment(s) and how severe it is during the time you say that you are disabled").
The Court agrees with the Commissioner that the ALJ is responsible for determining Plaintiff's RFC. The Court also agrees that the Eleventh Circuit has not set out a rule indicating that an RFC must be based on the assessment of a treating or examining physician in every case.
The Court is concerned that there is not sufficient evidence on the record to support the ALJ's finding that Plaintiff has an RFC to "perform the full range of medium work." Tr. 19. The ALJ has an affirmative duty to develop a full and fair record. Ellison v. Barnhart, 355 F.3d 1272, 1276 (11th Cir. 2003). Moreover, the ALJ must ensure that a sufficient record exists to evaluate the claimant's exertional and nonexertional limitations.
Tr. 22. The Court agrees that Dr. Childs' restriction is not "a specific evaluation of the claimant's abilities [and limitations]" and because there is no such evaluation of Plaintiff's abilities, the Court is unable to reconcile how the ALJ was able to conclude Plaintiff can perform a "full range of medium work."
The Court also notes that an error in the ALJ's RFC determination will impact the subsequent determinations at Steps Four and Five of whether or not Plaintiff can perform her previous work and whether she can perform other work in the national economy. Indeed, the ALJ's RFC determination is closely tied to another issue Plaintiff presents for this Court's consideration: the ALJ's application of the Medical Vocational Guidelines (grids).
Phillips v. Barnhart, 357 F.3d 1232, 1242 (11th Cir. 2004). Before the ALJ may use the grids to determine whether Plaintiff can perform other jobs in the national economy, the ALJ must first determine Plaintiff's RFC and determine whether, based on the evidence on the record, Plaintiff can perform all exertional demands at a given level of exertion. Accordingly, an incorrect RFC determination will lead to an incorrect application of the grids.
This case is devoid of any medical opinions regarding Plaintiff's exertional and nonexertional limitations. Because the Court finds the ALJ's RFC determination is not supported by substantial evidence, this case must be remanded. Upon remand, a medical source should be consulted to assist the ALJ in determining Plaintiff's RFC. The Court does not make a finding that Plaintiff is disabled, but notes that the ultimate determination of disability must be made with an appropriate RFC assessment to allow for the Commissioner's examination of the totality of the evidence.
The Court has carefully and independently reviewed the record and concludes that, for the reasons given above, the decision of the Commissioner is REVERSED and this case is REMANDED to the Commissioner for proceedings consistent with this decision. A separate judgment will issue.