JACQUELINE CHOOLJIAN, Magistrate Judge.
On November 4, 2010, plaintiff James K. Ceballos ("plaintiff") filed a Complaint seeking review of the Commissioner of Social Security's denial of plaintiff's application for benefits. The parties have consented to proceed before a United States Magistrate Judge.
This matter is before the Court on the parties' cross motions for summary judgment, respectively ("Plaintiff's Motion") and ("Defendant's Motion"). The Court has taken both motions under submission without oral argument.
Based on the record as a whole and the applicable law, the decision of the Commissioner is REVERSED AND REMANDED for further proceedings consistent with this Memorandum Opinion and Order of Remand.
On October 10, 2007, plaintiff filed an application for Disability Insurance Benefits. (Administrative Record ("AR") 20, 119-21). Plaintiff asserted that he became disabled on January 20, 2005, due to a heart condition. (AR 140). The Administrative Law Judge ("ALJ") examined the medical record and heard testimony from plaintiff (who appeared with a non-attorney representative) and a vocational expert on October 13, 2009. (AR 29-68).
On October 19, 2009, the ALJ determined that plaintiff was not disabled through June 30, 2008, the date plaintiff was last insured. (AR 20). Specifically, the ALJ found: (1) plaintiff suffered from the following severe impairments: syncope and ventricular tachycardia, dilated cardiomyopathy (alcohol related), status post internal cardiac defibrillator/pacemaker generator placement and subsequent change, hepatitis C, and history of tobacco and polysubstance abuse (AR 22); (2) plaintiff's impairments, considered singly or in combination, did not meet or medically equal a listed impairment (AR 24); (3) plaintiff retained the residual functional capacity to perform light work (20 C.F.R. § 404.1567(b)) with certain additional limitations
The Appeals Council denied plaintiff's application for review. (AR 1-3).
To qualify for disability benefits, a claimant must show that he is unable to engage in any substantial gainful activity by reason of a medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of at least twelve months.
In assessing whether a claimant is disabled, an ALJ is to follow a five-step sequential evaluation process:
The claimant has the burden of proof at steps one through four, and the Commissioner has the burden of proof at step five.
Pursuant to 42 U.S.C. section 405(g), a court may set aside a denial of benefits only if it is not supported by substantial evidence or if it is based on legal error.
To determine whether substantial evidence supports a finding, a court must "`consider the record as a whole, weighing both evidence that supports and evidence that detracts from the [Commissioner's] conclusion.'"
Plaintiff contends that the ALJ failed properly to consider the opinions of Dr. Ahn Duong, plaintiff's treating cardiologist. (Plaintiff's Motion at 12-13) (citing AR 360). As discussed in detail below, this Court agrees. As this Court cannot find that the ALJ's error was harmless, a remand is warranted.
In Social Security cases, courts employ a hierarchy of deference to medical opinions depending on the nature of the services provided. Courts distinguish among the opinions of three types of physicians: those who treat the claimant ("treating physicians") and two categories of "nontreating physicians," namely those who examine but do not treat the claimant ("examining physicians") and those who neither examine nor treat the claimant ("nonexamining physicians").
The treating physician's opinion is not, however, necessarily conclusive as to either a physical condition or the ultimate issue of disability.
In a Cardiac Impairment Questionnaire dated December 5, 2008, Dr. Duong opined that: (i) plaintiff could stand/walk for two hours and sit for eight hours in an eight-hour work day; (ii) plaintiff could occasionally lift/carry only 10 pounds; (iii) plaintiff could not push, pull, kneel, bend or stoop; (iv) plaintiff is likely to be absent from work as a result of his impairments or related treatment about once a month; (v) depression contributed to the severity of plaintiff's symptoms and functional limitations; (vi) plaintiff's subjective symptoms would periodically interfere with his attention and concentration; (vii) plaintiff could tolerate only low stress work; and (viii) other limitations that would affect plaintiff's ability to work at a regular job on a sustained basis include: psychological limitations, and plaintiff's need to avoid fumes, gasses, temperature extremes, humidity, dust, and heights (collectively "Dr. Duong's Opinions"). (AR 360).
Plaintiff's medical records reflect that beginning in December of 2007 plaintiff was prescribed Fluoxetine
At the administrative hearing, plaintiff testified that as early as February 2008, he had experienced panic attacks and anxiety, in part due to the stress from his prior job. (AR 51-52). Plaintiff testified that, as a result, he would not be able to perform the duties of his past relevant work. (AR 51-52). In light of such testimony, the ALJ asked plaintiff what treatment he had received for panic attacks:
(AR 59-60).
Towards the end of the administrative hearing, plaintiff's representative argued that, in light of plaintiff's residual functional capacity and testimony from the vocational expert, sections 201.06 and 202.06 of the Medical-Vocational Guidelines, 20 C.F.R. Part 404, Subpart P, Appendix 2 (commonly known as "the Grids") required a finding of "disabled" in plaintiff's case. (AR 65-66). In response, the ALJ acknowledged that plaintiff's was a close case, and that plaintiff's ability to perform his past relevant work was, therefore, "the key issue" to be resolved. (AR 66). Nonetheless, the ALJ declined plaintiff's representative's request that plaintiff receive a psychological consultative examination:
(AR 66).
In his decision, the ALJ concluded that plaintiff did not have a severe mental impairment:
(AR 22-23).
Plaintiff contends that a reversal or remand is appropriate because the ALJ failed adequately to consider Dr. Duong's opinion that plaintiff had functional limitations due to depression. Defendant argues that a reversal or remand would not be appropriate essentially because (i) substantial evidence supports the ALJ's conclusion that plaintiff suffered from nothing more than a nonsevere anxiety disorder; (ii) the ALJ properly rejected Dr. Duong's Opinions "in [their] entirety" as based on plaintiff's subjective complaints and not supported by objective medical evidence; and (iii) the record before the ALJ lacked a sufficient basis for ordering a psychiatric consultative examination. (Defendant's Motion at 4-5).
This Court concludes that the ALJ erred in his assessment of Dr. Duong's Opinions. First, although the ALJ did expressly reject Dr. Duong's opinions regarding plaintiff's exertional limitations (i.e., "that [plaintiff was] capable of less than sedentary work") (AR 25-26) (citing Exhibit 9F [AR 357-62]), the administrative decision does not reflect that the ALJ addressed, much less rejected, Dr. Duong's opinion that plaintiff had functional limitations related to any mental impairment (e.g., depression). Nor does it appear that the ALJ accounted for any such asserted mental limitations in plaintiff's residual functional capacity assessment.
Second, although the ALJ determined that plaintiff's panic/anxiety attacks were not severe, contrary to defendant's suggestion, it does not appear that the ALJ's analysis at step two addressed whether plaintiff had a severe mental impairment stemming from depression (e.g., whether Dr. Duong found functional limitations related to depression which caused more than a minimal limitation in plaintiff's ability to perform basic mental work activities). Even assuming, as defendant suggests, that the ALJ included depression as one of plaintiff's non-severe mental impairments, the ALJ's analysis and findings relative to the severity/non-severity of such mental impairments is not supported by substantial evidence because it is based on a flawed premise. At the hearing the ALJ stated that "[neither] a therapist or even [plaintiff's] primary care physician" had recommended that plaintiff take "even a mild antidepressant or anti-anxiety medicine." (AR 66). Nonetheless, as noted above, plaintiff's medical records reflect that plaintiff was prescribed Fluoxetine, a medication used to treat major depressive disorder and panic disorder (AR 160, 230, 233, 244, 283, 303, 307, 312, 324, 326, 328, 329, 330, 335, 337, 340, 343, 344, 350, 352, 375, 393, 420, 450). In addition, in the decision the ALJ stated that plaintiff testified that he "was never given any psychiatric medication." (AR 22, 66) (emphasis added). At the hearing, however, plaintiff stated only that he was not given "special medication" for his anxiety attacks. (AR 59-60) (emphasis added). Such inaccuracies in the ALJ's interpretation of the record cannot support the ALJ's step two findings.
Although, as defendant suggests, the ALJ may ultimately reject Dr. Duong's opinion that plaintiff had functional limitations due to depression because such opinion was based solely on plaintiff's subjective complaints,
Third, as noted below, the record suggests that additional limitations in plaintiff's mental abilities could have a material impact on the ALJ's decision. Therefore, to the extent the evidence regarding plaintiff's alleged depression was ambiguous, or the record was inadequate to allow for proper evaluation of any limitations related to depression, the ALJ should have developed the record on that issue.
Finally, the Court cannot find the ALJ's error harmless. At the hearing, the vocational expert suggested that if plaintiff, or a hypothetical person with plaintiff's characteristics, had additional limitations in mental functioning, such individual could not perform plaintiff's past relevant work. (AR 60-61). The vocational expert also testified that, based on plaintiff's testimony regarding how he actually performed his past relevant work, such hypothetical individual would not have skills which could transfer to any other position. (AR 61-62). The Court therefore cannot conclude that the vocational expert would have opined (or that the ALJ relying upon such opinion would have determined) that plaintiff could perform his past relevant job, or other work which exists in significant numbers in the national economy, if the ALJ had included in the hypothetical question posed to the vocational expert plaintiff's asserted additional mental limitations related to depression. Accordingly, the Court cannot find the ALJ's error to be harmless.
For the foregoing reasons, the decision of the Commissioner of Social Security is reversed in part, and this matter is remanded for further administrative action consistent with this Opinion.
LET JUDGMENT BE ENTERED ACCORDINGLY.