CHARLES F. EICK, Magistrate Judge.
Pursuant to sentence four of 42 U.S.C. section 405(g), IT IS HEREBY ORDERED that Plaintiff's and Defendant's motions for summary judgment are denied and this matter is remanded for further administrative action consistent with this Opinion.
Plaintiff filed a complaint on April 9, 2018, seeking review of the Commissioner's denial of benefits. The parties filed a consent to proceed before a United States Magistrate Judge on May 22, 2018. Plaintiff filed a motion for summary judgment on August 27, 2018. Defendant filed a motion for summary judgment on September 26, 2018. The Court has taken both motions under submission without oral argument.
Plaintiff, a former reservation clerk and retail manager, claims disability since January 5, 2014, based on a host of alleged impairments (Administrative Record ("A.R.") 12-760). In evaluating Plaintiff's claim, the Administrative Law Judge ("ALJ") did not have the benefit of opinions from any state agency review physician. The ALJ did not order that any consultative physicians examine Plaintiff. The ALJ also did not retain any medical expert. The ALJ did examine Plaintiff's treatment records, however, and found that Plaintiff suffers from numerous severe impairments: "diabetes mellitus with peripheral neuropathy; cervical spine spondylosis and stenosis; status post cervical discectomy and interbody fusion of C3-C5 in September 2015; cervical spine radiculopathy; cubital syndrome left ulnar nerve elbow; cervical myelopathy; left bundle branch block; hypertension; left hip osteopenia; right shoulder tendinosis; rheumatoid arthritis; obesity; fibromyalgia; lumbago with lumbar degenerative changes; and chronic fatigue syndrome" (A.R. 12).
At the December 7, 2016 hearing before the ALJ, Plaintiff testified to allegedly disabling functional limitations from her severe impairments, including an asserted inability to stand more than "a minute or two" and an asserted inability to walk without a walker (A.R. 36-37). More than two years earlier, on October 7, 2014, Plaintiff had reported greater functionality, including an ability to walk approximately half a mile (A.R. 186).
Over the period of alleged disability, Plaintiff's treatment records have been inconsistent and ambiguous regarding her capacity to ambulate. For example, records sometimes indicated an ataxic or abnormal gait and sometimes indicated a normal gait (A.R. 301, 306, 435, 436). The very same page of one treatment record indicated both that Plaintiff's gait was ataxic and that Plaintiff's gait was normal (A.R. 436). Records sometimes reflected an alleged need for a walker or even a wheelchair (A.R. 310, 466, 494). Other records (from the same provider who recommended a wheelchair) reflected recommendations that Plaintiff walk up to 30 minutes each day (A.R. 463, 477, 485).
The ALJ concluded that, despite Plaintiff's constellation of severe impairments, Plaintiff retains the residual functional capacity to perform light work, including the capacity to "stand/walk for about 6 hours out of 8" (A.R. 15). Based on this conclusion, the ALJ deemed Plaintiff not disabled (A.R. 18-19). The Appeals Council denied review (A.R. 1-3).
Under 42 U.S.C. section 405(g), this Court reviews the Administration's decision to determine if: (1) the Administration's findings are supported by substantial evidence; and (2) the Administration used correct legal standards.
On the present record, substantial evidence does not support the ALJ's conclusion regarding Plaintiff's residual functional capacity. No medical opinion of record addresses Plaintiff's work-related functional capacity. The ALJ could not properly rely on the ALJ's own lay understanding to interpret the medical records and the medical examination results so as to gauge the functional seriousness of Plaintiff's severe impairments.
For example, the ALJ appears to have inferred from Plaintiff's "conservative" treatment that Plaintiff's severe fibromyalgia does not reduce her functionality below the capacity to perform light work (A.R. 17). The ALJ apparently reasoned that, if Plaintiff's fibromyalgia had been so profound as to limit Plaintiff's capacity further, her physicians would have done something other than prescribe medications and physical therapy (A.R. 17). The ALJ lacks the medical expertise to draw this speculative inference. The ALJ is not competent to opine regarding the relationship, if any, between particular fibromyalgia treatments and the particular limiting effects of fibromyalgia symptoms.
For further example, the record contains scans and x-rays pertaining to Plaintiff's severe orthopedic impairments (A.R. 269-70, 335, 361, 390). Inferring functional capacity from the radiologists' readings of these scans and x-rays would also appear to be beyond the medical expertise of the ALJ.
The ALJ should have more fully and fairly developed the inconsistent and ambiguous record in the present case.
The Court is unable to deem the errors in the present case to have been harmless.
Remand is appropriate because the circumstances of this case suggest that an expansion of the record and further administrative review could remedy the error discussed herein.
For all of the foregoing reasons,
LET JUDGMENT BE ENTERED ACCORDINGLY.