EVELYN J. FURSE, Magistrate Judge.
Plaintiff Connie B.,
Ms. B. filed an application for Title II disability benefits with a protective filing date of October 3, 2013, with an alleged onset date of disability of March 26, 2013. (See Certified Administrative Transcript (herein Tr. __) 148-49, ECF No. 18.) The Social Security Administration ("SSA") denied her claim initially (Tr. 95), and upon reconsideration. (Tr. 100.) Ms. B. timely requested a hearing (Tr. 104), and on December 1, 2015 an Administrative Law Judge ("ALJ") held a hearing on her disability determination. (Tr.141.) On January 16, 2016, the ALJ found Ms. B. not disabled. (Tr. 18-33.) In his decision, the ALJ found that Ms. B. had severe medically determinable impairments of migraine headaches and temporomandibular joint disorder (Tr. 23), and that she retained the residual functional capacity to perform a restricted form of light work consistent with the ability to perform jobs existing in significant numbers in the national economy. (Tr. 27-28.)
Ms. B. timely appealed the decision to the Appeals Council (Tr. 15), who subsequently denied her Request for Review on April 17, 2017. (Tr. 1.) She appealed the decision by filing a complaint with this Court on June 8, 2017. (ECF No. 3.) On September 1, 2017, the parties consented to the jurisdiction of the undersigned Magistrate Judge pursuant to 28 U.S.C. 636(c). (ECF No. 22.)
42 U.S.C. § 405(g) provides for judicial review of a final decision of the Commissioner. The Court reviews the Commissioner's decision to determine whether the record as a whole contains substantial evidence in support of the Commissioner's factual findings and whether the SSA applied the correct legal standards. 42 U.S.C. § 405(g);
Ms. B. presents three challenges to the ALJ's decision. She argues that: (1) the ALJ's decision to find her medically determinable mental impairments not severe was not based upon substantial evidence, (2) that the residual functional capacity the ALJ assigned was not based upon substantial evidence, and (3) that the ALJ erred in not addressing Ms. B.'s impairments at step three of the disability adjudication process. After review of the issues and arguments, the Court remands this case back to the SSA.
The ALJ concluded that Ms. B.'s medically determinable mental impairments of "depression, post-traumatic stress disorder, and generalized anxiety disorder" were non-severe. (Tr. 23.) However, the ALJ found that Ms. B's migraine headaches and temporomandibular joint disorder constitute severe impairments. (Tr. 23) "[T]he failure to find a particular impairment severe at step two is not reversible error when the ALJ finds that at least one other impairment is severe."
In determining whether a plaintiff qualifies as disabled, the ALJ must consider and weigh all acceptable medical source opinions.
The ALJ failed to evaluate the medical source opinions of Mark Chamberlain, Ph.D., (Tr. 330-333) and Lynda R. Healey, APRN, properly. (Tr. 410.) Both opinions describe limitations Ms. B. suffers due to her psychiatric impairments, but none of these limitations were considered by the ALJ. Consideration of these opinions is warranted when determining the severity and limiting effects of Ms. B.'s psychiatric impairments. 20 C.F.R. § 404.1527(c). Further, the Court declines to recognize these omissions simply as "harmless error." The ALJ's decision fails to make clear that he considered either opinion statement. Nothing else in the opinion elucidates what the ALJ thought about these opinions or whether he just missed them. Without any analysis by the ALJ, the Court cannot determine how he would have ruled had he followed the proper procedure. Therefore, this Court remands the claim back to the ALJ to further evaluate the opinion evidence in determining Ms. B.'s mental impairments in accordance with the regulations and to provide specific, detailed rationales for each of the functional areas described in 20 C.F.R. § 404.1520a(c).
This Court also remands for further proceedings in light of errors found in the ALJ's analysis of Ms. B.'s daily activities and the medical evidence when determining she had the residual functional capacity to perform light work. For a decision to be based upon substantial evidence, the ALJ must not only discuss the evidence that supports his decision but also "must discuss the uncontroverted evidence he chooses not to rely upon, as well as significantly probative evidence he rejects."
Moreover, the ALJ cited to several points in the record that simply do not show what he purports they show. (Tr. 26.) He cited records to show Ms. B.'s medical treatment has been "reasonably effective and successful in terms of pain relief and symptom suppression, including increased sleep," but the records themselves fail to discuss pain relief at all. (Tr. 26.)
Given the Court already requires remand to allow for additional proceedings, the ALJ should also address these failings. Moreover, as the decision does not contain an analysis of Dr. Chamberlain's or Ms. Healy's opinions, this Court cannot understand how the ALJ would have viewed the impact the impairments described therein would have had on Ms. B.'s residual functional capacity.
This Court declines to rule on whether the ALJ erred in his analysis at step three. However, in light of the remand and directive for the ALJ to properly analyze Ms. B.'s psychiatric impairments under 20 C.F.R. § 404.1920a and to consider all medical opinions as required under 20 C.F.R. § 404.1927, the further proceedings may provide clarity to the findings at step three. Accordingly, upon remand the ALJ must evaluate whether the Ms. B.'s medically determinable severe impairments, singly, or in combination, meet or medically equal any of the listed impairments at step three.
For the foregoing reasons and based on the standard of review, the Court concludes that the decision rendered by the Commissioner must be REVERSED and REMANDED.