LESLIE A. BOWMAN, Magistrate Judge.
The plaintiff filed this action for review of the final decision of the Commissioner for Social Security pursuant to 42 U.S.C. § 405(g).
The Magistrate Judge presides over this case pursuant to 28 U.S.C. § 636(c) having received the written consent of both parties. See FED.R.CIV.P. 73; (Doc. 11)
The court finds the final decision of the Commissioner must be reversed. The ALJ erred by failing to find that Johnson's carpal tunnel syndrome is a severe impairment. The case will be remanded for further proceedings.
Johnson filed her application for disability insurance benefits in March of 2011. (Tr. 23) She alleged disability beginning March 1, 2011 due to back, knee, and ankle impairment; attention deficit hyperactivity disorder; headaches; diabetes; bipolar disorder; memory impairment; and depression. (Tr. 308)
Her claim was denied initially (Tr. 180-183) and upon reconsideration (Tr. 185-188). Johnson requested review and appeared with counsel at a hearing before Administrative Law Judge (ALJ) Laura Speck Havens on April 25, 2013. (Tr. 55) In her decision, dated May 10, 2013, the ALJ found Johnson was not disabled. (Tr. 34) Johnson appealed, but the Appeals Council denied review making the decision of the ALJ the final decision of the Commissioner. (Tr. 1-6) Johnson subsequently filed this action appealing the Commissioner's final decision. (Doc. 1); (Tr. 1)
Johnson was born in July of 1971. (Tr. 56) She has a high school diploma and two years of college. (Tr. 56) She worked as a clerk in a tax office, and she worked in a deli. (Tr. 59)
In January of 2011, Thompson Prout, Ph.D., reviewed the medical record for the state disability determination service. (Tr. 131) He found evidence of an affective disorder, an anxiety disorder, and a personality disorder. (Tr. 131) Prout found Johnson's activities of daily living mildly restricted. Id. He opined she was moderately limited in maintaining social functioning and maintaining concentration, persistence, or pace. (Tr. 131)
In July of 2011, Raymond Novak, M.D., reviewed the medical record for the state disability determination service. (Tr. 147) He found evidence of an affective disorder and an anxiety disorder. Id. He opined Johnson was moderately limited in her ability to understand, remember, and carry out detailed instructions. (Tr. 150) Also, she was moderately limited in her ability to work with others, complete a normal workday and work week, maintain concentration, perform at a consistent pace, interact with the general public, accept instructions, interact with supervisors, and get along with coworkers. (Tr. 150-151)
In June of 2012, Randall J. Garland, Ph.D., reviewed the medical record for the state disability determination service. (Tr. 166) He found evidence of an affective disorder and an anxiety disorder. Id. Garland opined that Johnson's activities of daily living were mildly restricted. Id. Also, she was moderately limited in maintaining social functioning and maintaining concentration, persistence, or pace. (Tr. 166)
In July of 2011, Jerry Dodson, M.D., reviewed the medical record and completed a Physical Residual Functional Capacity Assessment for the state disability determination service. (Tr. 148-149) He concluded Johnson could lift and/or carry 20 pounds occasionally and 10 pounds frequently. (Tr. 148) She could stand or walk for about four hours and sit for about six hours in an 8-hour work day. (Tr. 148) She was limited in her lower extremities due to left knee and right ankle surgery. Id. She should never crouch, crawl, or climb ladders, ropes, or scaffolds. And she should only occasionally balance, kneel, or climb ramps or stairs. Id. She should avoid concentrated exposure to extreme cold, vibration, and hazards such as machinery or heights. (Tr. 149)
In July of 2012, Linda A. Woodard, D.O., reviewed the medical record and completed a Physical Residual Functional Capacity Assessment for the state disability determination service. (Tr. 154, 167) She concluded Johnson could lift and/or carry 20 pounds occasionally and 10 pounds frequently. (Tr. 168) She could stand or walk for about three hours and sit for about six hours in an 8-hour work day. (Tr. 168) She was limited in her lower extremities due to left knee and right ankle surgery. Id. She should never crouch or crawl and should only occasionally kneel or climb ramps or stairs. Id. She should avoid even moderate exposure to hazards such as machinery or heights. (Tr. 169)
On April 25, 2013, Johnson appeared with counsel at a hearing before ALJ Laura Speck Havens. (Tr. 55)
Johnson testified that she has not worked since March 1, 2011, her alleged onset date. (Tr. 57-58) She suffers from degenerative disc disease, headaches, diabetes, COPD, bipolar disorder, depression, and ADHD. (Tr. 58)
In the past, Johnson worked in a tax office doing clerical work. (Tr. 59) She received unemployment benefits, but she was required to return some of the money because she could not work and was not eligible. (Tr. 58)
On a typical day, Johnson rises at 11:00 a.m. (Tr. 59) She can dress and bathe herself without help. (Tr. 59-60) She watches television five or six hours per day. (Tr. 60) She does not exercise. (Tr. 60) She attends church once a month. (Tr. 61)
Johnson explained she has trouble sleeping, and she hears voices. (Tr. 63) She can walk for one half hour and stand for one hour. (Tr. 63) She can sit for about 15 minutes before she has to get up due to lower back pain. (Tr. 64) She has pain in her lower back, ankle, and left knee. (Tr. 64) She also has headaches nine or 10 times per month. (Tr. 64)
People make Johnson anxious. (Tr. 65) She thinks they are out to get her, and she hears voices. (Tr. 65) Her depression, the voices, and her pain keep her from staying focused. (Tr. 68)
Ruth Van Fleet testified as a vocational expert. (Tr. 69) She explained that Johnson's previous job as a deli worker was medium unskilled work. (Tr. 70) Her tax preparation work was sedentary and semi-skilled. Id.
Van Fleet opined that a person who is 41 years old with a high school education and two years of college, who could sit for six hours, stand for three hours, walk for three hours, who could occasionally lift and carry 20 pounds and frequently lift and carry 10 pounds, who should never climb ladders or crouch or crawl, who should only occasionally climb stairs and kneel, who must avoid concentrated exposure to heights, machinery, dust, fumes, smoke and temperature extremes, who can remember and carry out simple job instructions only, and can only occasionally deal with the public could not perform Johnson's past relevant work. (Tr. 70-71) She could, however, work as an assembler, DOT (Dictionary of Occupational Titles) 725.684-018, or electronic equipment assembler, DOT 726.687-030. (Tr. 70-71)
Social Security Administration (SSA) regulations require that disability claims be evaluated pursuant to a five-step sequential process. 20 C.F.R. § 404.1520; Baxter v. Sullivan, 923 F.2d 1391, 1395 (9
If the claimant is not engaged in substantial gainful activity, the ALJ proceeds to step two, which requires a determination of whether the claimant has a "medically severe impairment or combination of impairments." 20 C.F.R. § 404.1520(a)(4). In making a determination at step two, the ALJ uses medical evidence to consider whether the claimant's impairment more than minimally limits or restricts his or her "physical or mental ability to do basic work activities." Id. If the ALJ concludes the impairment is not severe, the claim is denied. Id.
Upon a finding of severity, the ALJ proceeds to step three, which requires a determination of whether the impairment meets or equals one of several listed impairments that the Commissioner acknowledges are so severe as to preclude substantial gainful activity. 20 C.F.R. § 404.1520(a)(4); 20 C.F.R. Pt. 404, Subpt. P, App.1. If the claimant's impairment meets or equals one of the listed impairments, then the claimant is presumed to be disabled, and no further inquiry is necessary. Ramirez v. Shalala, 8 F.3d 1449, 1452 (9
The fourth step requires the ALJ to consider whether the claimant has sufficient residual functional capacity (RFC)
At step one of the disability analysis, the ALJ found Johnson "has not engaged in substantial gainful activity since March 1, 2011, the alleged onset date." (Tr. 26) At step two, she found Johnson "has the following severe impairments: degenerative disc disease, headaches, diabetes, obesity, COPD, bipolar disorder, depression, and attention deficit hyperactivity disorder (ADHD)." (Tr. 26) At step three, the ALJ found Johnson's impairments did not meet or equal the criteria for any impairment found in the Listing of Impairments, Appendix 1, Subpart P, of 20 C.F.R., Part 404. (Tr. 26)
The ALJ then analyzed Johnson's residual functional capacity (RFC). She found Johnson "has the residual functional capacity to perform a wide range of sedentary work . . . except the claimant is limited to lifting-carrying 20 pounds occasionally and 10 pounds frequently; is limited to sitting six hours, standing three hours, and walking three hours; is limited to occasional pushing-pulling with the lower extremities; is limited to occasionally climbing stairs [and] kneeling, can never climb ladders, crouch, and crawl; must avoid concentrated exposure to heights, moving machinery, dust, fumes, smoke, and temperature extremes; is limited to understanding and carrying out simple job instructions; and is limited to occasionally dealing with the public." (Tr. 29)
At step four, the ALJ found Johnson is not able to perform her past relevant work. (Tr. 32) At step five, she found Johnson can work as an assembler, DOT 725.684-018, or electronic assembler, DOT 726.687-030. Accordingly, she found Johnson was not disabled. (Tr. 33)
An individual is entitled to disability benefits if he or she demonstrates, through medically acceptable clinical or laboratory standards, an inability to engage in substantial gainful activity due to a physical or mental impairment that can be expected to last for a continuous period of at least twelve months. 42 U.S.C. § 423(d)(1)(A). "[A] claimant will be found disabled only if the impairment is so severe that, considering age, education, and work experience, that person cannot engage in any other kind of substantial gainful work which exists in the national economy." Penny v. Sullivan, 2 F.3d 953, 956 (9
The findings of the Commissioner are meant to be conclusive. 42 U.S.C. § 405(g). The decision to deny benefits "should be upheld unless it contains legal error or is not supported by substantial evidence." Orn v. Astrue, 495 F.3d 625, 630 (9
"Where evidence is susceptible to more than one rational interpretation, the ALJ's decision should be upheld." Orn, 495 F.3d at 630. "However, a reviewing court must consider the entire record as a whole and may not affirm simply by isolating a specific quantum of supporting evidence." Id.
In evaluating evidence to determine whether a claimant is disabled, the opinion of a treating physician is entitled to great weight. Ramirez v. Shalala, 8 F.3d 1449, 1453-54 (9
"The opinion of an examining physician is, in turn, entitled to greater weight than the opinion of a non[-]examining physician." Lester v. Chater, 81 F.3d 821, 830 (9
"Where medical reports are inconclusive, questions of credibility and resolution of conflicts in the testimony are functions solely of the [Commissioner]." Magallanes, 881 F.2d 747, 751 (9
The ALJ need not accept the claimant's subjective testimony of disability, but if she decides to reject it, "she must provide specific, cogent reasons for the disbelief." Lester, 81 F.3d at 834. "Unless there is affirmative evidence showing that the claimant is malingering, the Commissioner's reasons for rejecting the claimant's testimony must be clear and convincing." Id. "General findings are insufficient; rather, the ALJ must identify what testimony is not credible and what evidence undermines the claimant's complaints." Id.
Johnson argues in her opening brief, among other things, that the ALJ erred at step two of the disability analysis by failing to find her carpal tunnel syndrome a severe impairment. The court agrees and will remand for further proceedings. The court does not reach Johnson's alternate allegations of error.
"[T]he step-two inquiry is a de minimis screening device to dispose of groundless claims." Smolen v. Chater, 80 F.3d 1273, 1290 (9
The regulations explain that a severe impairment "significantly limits your physical or mental ability to do basic work activities." 20 C.F.R. § 404.1520(c). Basic work activities include, among other things, "[p]hysical functions such as walking, standing, sitting, lifting, pushing, pulling, reaching, carrying, or handling. 20 C.F.R. § 404.1521(b)(1) (emphasis added).
The medical record in this case contains treatment records from Stephen A. Shapiro, M.D., documenting examination and treatment for right wrist pain. (Tr. 1619-1625, 1628-1629) In July of 2012, Johnson complained of "numbness and tingling in a stocking and glove distribution from her mid forearm to her fingertips." (Tr. 1628) She had a positive Tinel's sign indicating nerve damage. (Tr. 1625); The Merck Manual of Diagnosis and Therapy 1491 (17th ed. 1999). Shapiro ordered nerve conduction studies and an MRI. (Tr. 1619-1625, 1628-1629) Johnson has received cortisone injection, physical therapy, and bracing, but she reports her pain was not helped by these treatments. (Tr. 1620) In August of 2012, Eugene Y. Mar, M.D., diagnosed "mild bilateral carpal tunnel syndrome" based on nerve conduction studies. (Tr. 1621)
Based on the medical record, it appears that Johnson's carpal tunnel syndrome has more than a minimal effect on her ability to do basic work activities such as handling. Or to use Webb's formulation of the rule, the ALJ's implicit conclusion that Johnson's carpal tunnel syndrome is not severe is not "clearly established by medical evidence." Webb v. Barnhart, 433 F.3d 683, 687 (9
The Commissioner correctly points out that this error would be harmless if the ALJ considered the effect of Johnson's carpal tunnel later in the disability analysis when analyzing her residual functional capacity (RFC). (Doc. 18, p. 5); see, e.g., Lewis v. Astrue, 498 F.3d 909, 911 (9
This error is particularly important because at step five of the disability analysis, the ALJ found that Johnson could perform the job of assembler or electronic assembler. (Tr. 33) It seems likely that those jobs would ordinarily require "a high level of finger dexterity and frequently handling and fingering." Betsey v. Astrue, 2008 WL 5231839, 4 (M.D.Fla. 2008). It is therefore possible that Johnson's carpal tunnel syndrome could affect her ability to perform those jobs. At the very least, her condition could limit the number of those jobs available to her.
The Commissioner further argues that Johnson failed to affirmatively establish that her impairment results in specific functional limitations affecting her ability to work. At step-five of the disability analysis, however, the Commissioner has the burden of proving that Johnson can perform work that exists in significant numbers in the national economy. Bruton v. Massanari, 268 F.3d 824, 828 n. 1 (9
Johnson argues that if the decision of the Commissioner is reversed, then the case should be remanded for computation of benefits. Here, however, it is not clear from the record that Johnson is indeed disabled. The case therefore will be remanded for further proceedings. See Garrison v. Colvin, 759 F.3d 995, 1019 (9
IT IS ORDERED that the final decision of the Commissioner is reversed. The case is remanded for further proceedings.
The Clerk of the Court is directed to prepare a judgment and close this case.