ERIN L. SETSER, Magistrate Judge.
Plaintiff, Carolyn Phillips, brings this action pursuant to 42 U.S.C. § 405(g), seeking judicial review of a decision of the Commissioner of the Social Security Administration (Commissioner) denying her claims for a period of disability and disability insurance benefits (DIB) and supplemental security income (SSI) benefits under the provisions of Titles II and XVI of the Social Security Act (Act). In this judicial review, the Court must determine whether there is substantial evidence in the administrative record to support the Commissioner's decision.
Plaintiff protectively filed her current applications for DIB and SSI on October 23, 2008, alleging an inability to work since August 15, 2008, due to arthritis, residuals from rotator cuff surgery, a right wrist deformity, osteoarthritis in the left arm, thinning of the bones in the left arm from the elbow down, back pain, and knee pain. (Tr. 112, 116). An administrative hearing was held on October 16, 2009, at which Plaintiff appeared with counsel and testified. (Tr. 28-56).
By written decision dated April 7, 2010, the ALJ found that during the relevant time period, Plaintiff had an impairment or combination of impairments that were severe. (Tr. 15). Specifically, the ALJ found Plaintiff had the following severe impairments: left hand and wrist pain secondary to degenerative changes, and right hand and wrist pain secondary to a wrist deformity. However, after reviewing all of the evidence presented, she determined that Plaintiff's impairments did not meet or equal the level of severity of any impairment listed in the Listing of Impairments found in Appendix I, Subpart P, Regulation No. 4. (Tr. 16). The ALJ found Plaintiff retained the residual functional capacity (RFC) to perform a full range of light work. (Tr. 16). With the help of a vocational expert, the ALJ determined Plaintiff could perform her past relevant work as a cashier-checker. (Tr. 19).
Plaintiff then requested a review of the hearing decision by the Appeals Council, which after reviewing additional evidence denied that request on October 25, 2010. (Tr. 2-5). Subsequently, Plaintiff filed this action. (Doc. 1). This case is before the undersigned pursuant to the consent of the parties. (Doc. 5). Both parties have filed appeal briefs, and the case is now ready for decision. (Docs. 7,8).
This Court's role is to determine whether the Commissioner's findings are supported by substantial evidence on the record as a whole.
It is well-established that a claimant for Social Security disability benefits has the burden of proving her disability by establishing a physical or mental disability that has lasted at least one year and that prevents her from engaging in any substantial gainful activity.
The Commissioner's regulations require him to apply a five-step sequential evaluation process to each claim for disability benefits: (1) whether the claimant has engaged in substantial gainful activity since filing her claim; (2) whether the claimant has a severe physical and/or mental impairment or combination of impairments; (3) whether the impairment(s) meet or equal an impairment in the listings; (4) whether the impairment(s) prevent the claimant from doing past relevant work; and, (5) whether the claimant is able to perform other work in the national economy given her age, education, and experience.
Of particular concern to the undersigned is the ALJ's RFC determination. RFC is the most a person can do despite that person's limitations. 20 C.F.R. § 404.1545(a)(1). A disability claimant has the burden of establishing his or her RFC.
In making the RFC determination that Plaintiff could perform a full range of light work, the ALJ stated as follows:
(Tr. 19). A review of the record reveals that on January 5, 2009, after examining the medical records, Dr. Ronald Crow opined that Plaintiff's impairments were non-severe. (Tr. 237). On February 27, 2009, after reviewing additional medical records, Dr. Lucy Sauer affirmed Dr. Crow's assessment. (Tr. 242). The record is void of any other opinion from a medical professional regarding Plaintiff's capabilities.
A review of the medical evidence reveals that Plaintiff was diagnosed with a left knee sprain in June of 2009, four months after the most recent medical assessment of Plaintiff's impairments. (Tr. 247). After continued complaints of left knee pain, Plaintiff was referred to an orthopedic doctor, who in turn ordered an MRI of the knee in August of 2009, which revealed Plaintiff had a lateral femoral condyle contusion. (Tr. 266). The ALJ referred to this MRI in her decision and stated as follows:
(Tr. 18). The record reveals that Plaintiff continued to complain of left knee pain that was exacerbated by standing, climbing stairs, and squatting.
The Court questions the ALJ's finding regarding Plaintiff's knee impairment, as there is no medical evidence indicating a time frame for the healing process of Plaintiff's knee. It appears in this instance that the ALJ looked at the diagnosis and determined on her own, without the benefit of a medical professional's opinion, that Plaintiff's left knee injury would heal within months.
On remand, the ALJ is directed to address interrogatories to the physicians who have evaluated and/or treated Plaintiff asking the physicians to review Plaintiff's medical records; to complete a RFC assessment regarding Plaintiff's capabilities during the time period in question, and to give the objective basis for their opinions so that an informed decision can be made regarding Plaintiff's ability to perform basic work activities on a sustained basis during the relevant time period in question. The ALJ may also order a consultative orthopedic examination, in which, the consultative examiner should be asked to review the medical evidence of record, perform examinations and appropriate testing needed to properly diagnosis Plaintiff's condition(s), and complete a medical assessment of Plaintiff's abilities to perform work related activities.
With this evidence, the ALJ should then re-evaluate Plaintiff's RFC and specifically list in a hypothetical to a vocational expert any limitations that are indicated in the RFC assessments and supported by the evidence.
Accordingly, the Court concludes that the ALJ's decision is not supported by substantial evidence, and therefore, the denial of benefits to the Plaintiff should be reversed and this matter should be remanded to the Commissioner for further consideration pursuant to sentence four of 42 U.S.C. § 405(g).