ANDREW P. RODOVICH, Magistrate Judge.
This matter is before the court on petition for judicial review of the decision of the Commissioner filed by the plaintiff, Torie B., on October 11, 2018. For the following reasons, the decision of the Commissioner is
The plaintiff, Torie B., filed an application for Disability Insurance Benefits on July 2, 2015, alleging a disability onset date of August 17, 2013. (Tr. 16). The Disability Determination Bureau denied Torie B.'s application initially on August 11, 2015, and again upon reconsideration on December 21, 2015. (Tr. 16). Torie B. subsequently filed a timely request for a hearing on February 9, 2016. (Tr. 16). A hearing was held on July 14, 2017, before Administrative Law Judge (ALJ) Trina Moore, and the ALJ issued an unfavorable decision on November 21, 2017. (Tr. 16-25). Vocational Expert (VE) Stephanie Archer appeared at the hearing. (Tr. 16). The Appeals Council denied review making the ALJ's decision the final decision of the Commissioner. (Tr. 1-3).
Torie B. last met the insured status requirements of the Social Security Act on June 30, 2016. (Tr. 18). At step one of the five-step sequential analysis for determining whether an individual is disabled, the ALJ found that Torie B. had not engaged in substantial gainful activity during the period from her alleged onset date of August 17, 2013 through her date last insured of June 30, 2016. (Tr. 18).
At step two, the ALJ determined that Torie B. had the following severe impairments: chronic hypertension, cardiac arrhythmia, breast cancer/ductal carcinoma in situ (DCIS), fibrocystic breast disease/breast fibroadenoma, asthma, degenerative disc disease of the lumbar spine, and obesity. (Tr. 18). The ALJ found that the above medically determinable impairments significantly limited Torie B.'s ability to perform basic work activities. (Tr. 18).
Torie B. also alleged disability due to her chronic migraines and insomnia with observed sleep apnea. (Tr. 18). However, the ALJ indicated that Torie B.'s migraines and insomnia were well-controlled and caused no more than a minimal limitation on her ability to engage in basic work activities. (Tr. 19). Furthermore, the ALJ determined that Torie B.'s anxiety did not cause more than a minimal limitation on her ability to engage in basic work activities. (Tr. 19). The ALJ found that Torie B. experienced mild limitations in understanding, remembering, or applying information; a mild limitation interacting with others; mild limitations concentrating, persisting, or maintaining pace; and no limitations adapting or managing herself. (Tr. 19). The ALJ concluded that because Torie B.'s anxiety caused no more than a mild limitation in any of the functional areas it was non-severe. (Tr. 19).
At step three, the ALJ concluded that Torie B. did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1. (Tr. 20). The ALJ indicated that no treating physician or examining physician indicated diagnostic findings that satisfied any listed impairment. (Tr. 20). The ALJ also considered Torie B.'s obesity in conjunction with her severe impairments. (Tr. 20). However, the ALJ determined that none of the listings were met. (Tr. 20).
After consideration of the entire record, the ALJ then assessed Torie B.'s residual functional capacity (RFC) as follows:
(Tr. 20). The ALJ explained that in considering Torie B.'s symptoms she followed a two-step process. (Tr. 21). First, she determined whether there was an underlying medically determinable physical or mental impairment that was shown by a medically acceptable clinical or laboratory diagnostic technique that reasonably could be expected to produce Torie B.'s pain or other symptoms. (Tr. 21). Then she evaluated the intensity, persistence, and limiting effects of the symptoms to determine the extent to which they limited Torie B.'s functioning. (Tr. 21).
After considering the evidence, the ALJ found that Torie B.'s medically determinable impairments reasonably could be expected to produce her alleged symptoms. (Tr. 21). However, her statements concerning the intensity, persistence, and limiting effects of her symptoms were not entirely consistent with the medical evidence and other evidence in the record. (Tr. 21). The ALJ assigned little weight to the opinions of the State agency medical consultants, treating physician Dr. Okechi Nwabara, M.D., and the third-party function report submitted by Torie B.'s brother. (Tr. 23).
At step four, the ALJ found that Torie B. was unable to perform any past relevant work. (Tr. 23). Considering Torie B.'s age, education, work experience, and RFC, the ALJ determined that there were jobs in the national economy that she could perform, including rental clerk (52,000 jobs nationally) and sandwich board carrier (1,300 jobs nationally). (Tr. 24). The ALJ found that Torie B. had not been under a disability, as defined in the Social Security Act, from August 17, 2013 through June 30, 2016. (Tr. 24).
The standard for judicial review of an ALJ's finding that a claimant is not disabled within the meaning of the Social Security Act is limited to a determination of whether those findings are supported by substantial evidence.
Disability insurance benefits are available only to those individuals who can establish "disability" under the terms of the Social Security Act. The claimant must show that she is unable "to engage in any substantial gainful activity by reason of any 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 not less than 12 months."
Torie B. has requested that the court reverse the ALJ's decision and award benefits, or in the alternative, remand this matter for additional proceedings. In her appeal, Torie B. has argued that the ALJ's RFC was not based upon substantial evidence.
Torie B. contends that the ALJ's RFC finding was not supported by substantial evidence because the ALJ improperly weighed the medical opinion evidence, did not consider the combined effects of her impairments, and did not properly consider her subjective allegations pursuant to SSR 16-3p. "The RFC is an assessment of what work-related activities the claimant can perform despite his limitations."
SSR 96-8p explains how an ALJ should assess a claimant's RFC at steps four and five of the sequential evaluation. In a section entitled, "Narrative Discussion Requirements," SSR 96-8p specifically spells out what is needed in the ALJ's RFC analysis. This section of the Ruling provides:
SSR 96-8p (footnote omitted). Thus, as explained in this section of the Ruling, there is a difference between what the ALJ must contemplate and what she must articulate in her written decision. "The ALJ is not required to address every piece of evidence or testimony presented, but he must provide a `logical bridge' between the evidence and his conclusions."
First, Torie B. has argued that the ALJ improperly rejected the opinions of her treating physician, Dr. Okechi Nwabara. A treating source's opinion is entitled to controlling weight if the "opinion on the issue(s) of the nature and severity of [the claimant's] impairment(s) is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence" in the record.
"`[O]nce well-supported contradicting evidence is introduced, the treating physician's evidence is no longer entitled to controlling weight' and becomes just one more piece of evidence for the ALJ to consider."
An ALJ first must determine whether the treating source's opinion is entitled to controlling weight in consideration of supportability and consistency with the record. If the ALJ finds the opinion is lacking in either of these aspects, the ALJ must proceed to step two, where she applies the checklist of factors articulated in 20 C.F.R. § 404.1527. The ALJ must use these factors to determine exactly what weight to assign to the opinion. These factors are set forth in
The ALJ found that Dr. Nwabara's opinions were "simply not supported by the evidence of record." (Tr. 23). First, the ALJ stated that the diagnostic imaging and testing of Torie B.'s heart, lungs, and back were all relatively benign. Next, the ALJ indicated that it appeared that Torie B.'s breast cancer was treated successfully. Third, the ALJ concluded that Torie B.'s physical examinations were essentially normal. Finally, the ALJ noted that Torie B. routinely denied any symptoms related to her impairments. The ALJ also indicated that the determination of disability was reserved for the Commissioner. For those reasons, the ALJ assigned little weight to the opinions of Dr. Nwabara.
The ALJ in discussing what weight she assigned to Dr. Nwabara's opinions used rather broad descriptions like the diagnostic imaging and testing was "relatively benign", "appears [Torie B's] breast cancer was successfully treated", and her physical examination were "essentially normal". (Tr. 23). Furthermore, the ALJ cited entire exhibits containing hundreds of pages of medical evidence. (Tr. 23, citing Exhibits 4F; 5F; 7F; 12F; 14F; 45F; 31F; 2F-13F; 10F-13F; 15F; 16F; 19F-21F; 24F; 31F; 40F; 41F; 2F-5F; 7F-13F; 15F; 16F; 21F; 31F; 40F; 41F). In support of the ALJ's decision, the Commissioner has cited to specific pages of the Exhibits. However, the court is limited only to the reasons provided in the ALJ's decision. The court cannot assume that the ALJ relied on the portions of the record cited by the Commissioner.
The parties have agreed that the medical evidence in the instant matter was extensive, spanning over 1,891 pages. The court recognizes that an extensive medical record, such as this one, may produce some evidence that supports the ALJ's decision and some that does not. Therefore, the ALJ erred by failing to articulate her analysis of the evidence allowing the court to trace her path of reasoning. See
Moreover, Torie B. has argued that the ALJ impermissibly "played doctor" by giving all the medical opinions little weight and arguably leaving no medical opinion to rely upon as evidence for the RFC finding. The ALJ assigned little weight to the opinions of Dr. Nwabara, the State agency medical consultants, and the third-party function report completed by Torie B.'s brother. The ALJ indicated that the State agency consultants' opinions were entitled to little weight because evidence was submitted after their opinions were given. (Tr. 22). Thus, the agency consultants did not have the benefit of reviewing the entire record. Furthermore, the ALJ found that Torie B.'s brother was not an "acceptable medical source" and that there was "simply insufficient evidence to support his contentions." (Tr. 23).
A determination of a claimant's RFC is a matter, not for the treating or examining physicians, but for the ALJ alone.
Next, Torie B. has argued that the ALJ did not properly consider all of her impairments in formulating the RFC. The ALJ should consider all impairments, even if they are non-severe, in the RFC analysis. See
Torie B. contends that the ALJ found that her hypertension was a severe impairment but failed to explain how the limitations in the RFC accounted for that severe impairment. Moreover, Torie B. asserts that the ALJ did not consider the effects of her headaches and insomnia, in combination with all her impairments, in determining the RFC. The ALJ found that Torie B.'s chronic migraines and insomnia were not severe impairments because they were well-controlled and caused no more than a minimal limitation. (Tr. 19). The ALJ's decision stated, "the undersigned has considered all medically determinable impairments, in combination, when assessing the claimant's residual functional capacity and when determining whether her impairments met or medically equaled a listed impairment." (Tr. 19). However, other than providing a summary of the extensive medical record, the ALJ did not discuss what evidence she relied on in support of the RFC finding.
Finally, Torie B. has argued that the ALJ did not provide a coherent analysis under SSR 16-3p. An ALJ's evaluation of subjective symptoms will be upheld unless it is patently wrong.
The ALJ stated that Torie B.'s medically determinable impairments reasonably could be expected to cause the alleged symptoms, "however, the claimant's statements concerning the intensity, persistence, and limiting effects of these symptoms are not entirely consistent with the medical evidence and other evidence in the record for the reasons explained in the decision." (Tr. 21). Nowhere in the ALJ's decision does she explain the reasons for not crediting Torie B.'s allegations. Rather, the decision consists of a recitation of Torie B.'s allegations, followed by the above statement, then concludes with a recitation of the medical evidence. (Tr. 21-22). On remand, the ALJ should perform the required analysis under SSR 16-3p. Accordingly, the RFC was not supported by substantial evidence and remand is appropriate.
Torie B. has requested that the court remand for an award of benefits. An award of benefits is appropriate "only if all factual issues involved in the entitlement determination have been resolved and the resulting record supports only one conclusion—that the applicant qualifies for disability benefits."
Based on the foregoing reasons, the decision of the Commissioner is