T LANE WILSON, Magistrate Judge.
This matter is before the undersigned United States Magistrate Judge for a report and recommendation. Plaintiff Kelly Rosado, on behalf of J.R.A., a minor child, seeks judicial review of the Commissioner of the Social Security Administration's decision finding that her son is not disabled. As set forth below, the undersigned recommends that the Commissioner's decision denying benefits be
A claimant for disability benefits bears the burden of proving a disability. 42 U.S.C. § 423 (d)(5); 20 C.F.R. §§ 404.1512(a), 416.912(a). "Disabled" is defined under the Act as an "inability 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." 42 U.S.C. § 423(d)(1)(A). To meet this burden, plaintiff must provide medical evidence of an impairment and the severity of that impairment during the time of his alleged disability. 20 C.F.R. §§ 404.1512(b), 416.912(b). A disability is a physical or mental impairment "that results from anatomical, physiological, or psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques." 42 U.S.C. § 423 (d)(3). "A physical impairment must be established by medical evidence consisting of signs, symptoms, and laboratory findings, not only by [an individual's] statement of symptoms." 20 C.F.R. §§ 404.1508, 416.908. The evidence must come from "acceptable medical sources," such as licensed and certified psychologists and licensed physicians. 20 C.F.R. §§ 404.1513(a), 416.913(a). A plaintiff is disabled under the Act only if his "physical or mental impairment or impairments are of such severity that he is not only unable to do his previous work but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work in the national economy." 42 U.S.C. § 423(d)(2)(A).
The procedures for evaluating disability for children are set out at 20 C.F.R. § 416.924(a). The first step is to determine whether the child is performing substantial gainful activity. If not, the next consideration is whether the child has a "severe" mental or physical impairment. A "severe" impairment is one that causes more than minimal functional limitations. If a "severe" impairment is identified, the claim is reviewed to determine whether the child has impairment that: (1) meets, medically equals, or functionally equals the listings of impairments for children;
If the child does not have impairments of a severity to meet a listing, the severity of the limitations imposed by impairments are analyzed to determine whether they functionally equal a listing. Six broad areas of functioning, called domains, are considered to assess what a child can and cannot do. Impairments functionally equal a listing when the impairments result in "marked" limitations in two domains or an "extreme" limitation in one domain. 20 C.F.R. § 416.926a. The six domains are: (1) acquiring and using information; (2) attending and completing tasks; (3) interacting and relating with others; (4) moving about and manipulating objects; (5) caring for yourself; and (6) health and physical well-being. 20 C.F.R. § 416.926a(b)(1). A limitation is "marked" when it interferes seriously with the ability to independently initiate, sustain, or complete activities. 20 C.F.R. § 416.926a(e)(2)(i). An "extreme" limitation interferes very seriously with the ability to independently initiate, sustain, or complete activities. 20 C.F.R. § 416.926a(e)(3)(i).
Plaintiff, then a one-year-old male, applied (through his mother) for Title XVI benefits on December 11, 2008, alleging a disability onset date of April 27, 2007, his date of birth. (R. 81-83). Plaintiff's mother claimed that the child was disabled due to bilateral club foot. (R. 104). Plaintiff's claim for benefits was denied initially on March 3, 2009, and on reconsideration on July 27, 2009. (R. 43-49). Plaintiff then requested a hearing before an administrative law judge ("ALJ"), and the ALJ held the hearing on April 19, 2010. (R. 31-42). The ALJ issued a decision on May 17, 2010, denying benefits and finding plaintiff not disabled because he did not meet a listing or have the requisite limitations in the domains of functioning. (R. 11-27). For a child to qualify as disabled, he must have a marked limitation in two domains of functioning or one extreme limitation. (R. 27). The ALJ found that plaintiff had a marked limitation in only one domain — health and physical well-being — due to the treatment required to attempt to correct his club feet. (R. 22-27). The Appeals Council denied review, and plaintiff appealed to the District Court. (R. 1-4).
In that appeal, plaintiff argued that the ALJ had failed to consider the proper Listing criteria. (R. 329). The ALJ considered whether plaintiff's functional abilities were comparable to children not yet able to walk, rather than to "older children who would be expected to be able to walk."
On remand, the Appeals Council ordered the ALJ to offer plaintiff the opportunity for a new hearing, take any new evidence necessary to complete the record, and issue a new decision. (R. 335).
The ALJ
At the second hearing, plaintiff's mother recounted plaintiff's history of treatment to correct his club feet, from birth in 2007 to his most recent surgery in October 2012. (R. 282-83). She stated that plaintiff never crawled due to the foot-to-hip casting from the treatment and did not learn to walk until July 2008. (R. 284). She also testified that plaintiff's most difficult times occurred in 2010 and 2011.
Plaintiff's mother testified that plaintiff's left leg "still turns in." (R. 284). She said that the doctors were not sure why treatment was less effective on plaintiff's left foot and had told her that it could be an issue with his hip. (R. 285). At the time of the hearing, plaintiff attended physical therapy twice a week, where he worked on being able to "stand, sit, squat, play . . . and do the normal things a kid would do." (R. 284). He "waddl[ed] like a duck" when walking in an attempt to keep his weight of his left foot. (R. 285). He drags his left foot, causing him to trip and fall.
After receiving plaintiff's mother's testimony and adding some exhibits to the record, the ALJ closed the hearing. (R. 280-81, 289-90).
The ALJ issued a new decision on June 28, 2013. (R. 252-70). The ALJ found that plaintiff was an older infant on the date of his application for benefits and a preschooler at the time of the decision. (R. 258). Plaintiff had the severe impairment of bilateral club foot.
b. What we mean by inability to ambulate effectively.
(R. 259). Applying these definitions, the ALJ stated that "[t]he claimant's limitations do not appear to meet these requirements, as the claimant is able to ambulate without a handheld assistive device."
The ALJ then recited the mother's testimony in great detail, including her recitation of plaintiff's treatment history and her perceptions of his current functional ability. (R. 260-61). After restating the mother's testimony, the ALJ found that it was "not entirely credible for the reasons explained below." (R. 261).
Following that statement, the ALJ reviewed the medical evidence. The ALJ discussed the initial evaluation and casting performed when plaintiff was twenty-four days old; the first Achilles tendon lengthening surgeries in July 2007; and the subsequent casting, bracing, and splinting. (R. 261). In September 2007, Dr. Alan W. Holderness, plaintiff's orthopedist, noted that plaintiff's "left heel cord `has resumed some tightness,'" but the right foot was able to "move to `past neutral.'"
In October 2007, plaintiff began treatment at Shriner's Hospital. (R. 262). Casts did not improve plaintiff's condition, so surgeons at Shriner's performed a second surgery on both Achilles tendons in January 2008.
Plaintiff continued outpatient treatment at Shriner's in 2009. During a January 2009 examination, the doctor noted that generally, plaintiff's heels were in a neutral position while walking and that plaintiff quickly corrected walking on the lateral aspect of his foot.
Plaintiff underwent a physical consultative examination in February 2009.
With respect to plaintiff's physical therapy, on May 10, 2013, the physical therapist found that plaintiff's balance was improving.
Plaintiff's primary care records showed treatment for a number of general childhood issues. (R. 263). Early on, plaintiff did have an allergic reaction to his leg braces, resulting in a "`weeping' rash."
The ALJ also reviewed a questionnaire from plaintiff's kindergarten teacher, dated May 2013.
The ALJ concluded that, based on the medical evidence, plaintiff's clubfoot was resolved on the right side. (R. 263). The ALJ found that plaintiff's prognosis on the left foot was unknown but that, with physical therapy and continued treatment, plaintiff had the opportunity to improve.
The only medical opinion evidence in the record came from the agency physicians. (R. 264). The two physicians who reviewed plaintiff's case opined that plaintiff has a marked limitation in the area of Health and Physical Well-Being based on plaintiff's bilateral clubfoot.
In assessing plaintiff's limitations in the six domains of functioning, the ALJ found that plaintiff had a marked limitation in the domain of Moving About and Manipulating Objects and less than marked limitations in the domains of Health and Physical Well-Being and Caring for Yourself. (R. 264, 267-70). In the area of Moving About and Manipulating Objects, the ALJ based his finding on the fact that "[t]he claimant has considerable difficulty walking, but he is able to walk without a handheld device." (R. 268). In the area of Caring for Yourself, plaintiff's less than marked limitation was "associated with his difficulty with walking." (R. 269). In the area of Health and Physical Well-Being, plaintiff's less than marked limitation acknowledged the lengthy treatment process that plaintiff has undergone to correct bilateral club foot. (R. 270). That treatment necessarily required significant recovery time that "has caused the claimant marked limitation in his ability to ambulate over the three year period."
Because the ALJ did not find marked limitations in at least two domains of functioning or an extreme limitation in one domain of functioning, the ALJ concluded that plaintiff was not disabled.
The Appeals Council denied review, and plaintiff appealed. (R. 239-42; dkt. 2).
Plaintiff's allegations of error do not challenge the ALJ's interpretation of the medical evidence. Any necessary discussion of the evidence itself, then, will be addressed in the analysis section of this Report and Recommendation.
Plaintiff raises multiple issues on appeal: (1) that the ALJ erred in finding that plaintiff did not meet the listing under 20 C.F.R. Pt. 404, Subpt. P, App. 1, Listing 101.00B2(b) or its functional equivalent; (2) that the ALJ did not conduct a proper credibility analysis; and (3) that the ALJ should have found that plaintiff was entitled to benefits for a closed period. (Dkt. 13). Because the analysis of the credibility findings impacts the resolution of the listing issue, the undersigned will address the credibility findings first.
Plaintiff argues that the ALJ found plaintiff's mother's testimony not entirely credible without consideration of any of the credibility factors. (Dkt. 13). Plaintiff also argues that the ALJ's credibility analysis is limited to a conclusory statement that the mother was not credible, followed by a recitation of the medical evidence.
The Commissioner contends that the ALJ considered the mother's credibility in light of all the medical evidence and that the analysis was proper. (Dkt. 16). The Commissioner argues that the review of the medical evidence includes the ALJ's findings on the efficacy of treatment and plaintiff's activities, both proper factors in assessing credibility.
This Court is not to disturb an ALJ's credibility findings if they are supported by substantial evidence because "[c]redibility determinations are peculiarly the province of the finder of fact."
In child disability cases, the testimony of a parent or other adult most familiar with the child is often used in lieu of the claimant's testimony regarding symptoms.
The Tenth Circuit reiterated this position in
In this case, the ALJ gave a narrative of the mother's testimony and a narrative of the medical evidence, but he did not link the two. Although the Commissioner contends that the ALJ rejected the mother's testimony regarding plaintiff's pain and fatigue, the ALJ's decision does not state what portions of the mother's testimony he found not credible. The mother accurately testified to plaintiff's treatment history, which would tend to bolster her credibility. Additionally, the ALJ made several statements that praised the mother's diligent pursuit of treatment options, which would also tend to bolster her credibility. In light of these facts and the ALJ's failure to link his findings to substantial evidence in the record, the ALJ's reasons for finding the mother not credible are unclear. Therefore, the undersigned finds that they are not supported by substantial evidence, and the undersigned recommends remanding the case for proper credibility findings.
Plaintiff argues that the ALJ did not consider all of the portions of Listing 101.00. (Dkt. 13). Plaintiff contends that the ALJ was required to consider the criteria for age-appropriate activities in determining whether plaintiff was unable to ambulate effectively under 101.00B2b(3).
The Commissioner raises two counter-arguments. (Dkt. 16). First, the Commissioner argues that plaintiff cannot establish that his diagnosis of bilateral clubfoot falls under one of the categories of impairments in Listing 101.00 and that plaintiff argues, improperly, that proof of an inability to ambulate effectively is its own listing.
With respect to the Commissioner's first argument, the Commissioner ignores the ALJ's own findings. (R. 258). At step two, the ALJ found that plaintiff has the severe impairment of "bilateral clubfoot."
The undersigned also rejects the Commissioner's second argument. To meet the listing, plaintiff must establish that he satisfies the criteria for one of the categorical musculoskeletal impairments. The ALJ found that plaintiff has "Major dysfunction of a joint(s) (due to any cause)," one of the impairments included in the listing.
As an initial matter, the Commissioner's argument ignores the fact that, on remand, the Court ordered the ALJ to consider the criteria set forth in 101.00B2b(3). (R. 329). In the context of Social Security disability cases, the Supreme Court has held that "[d]eviation from the court's remand order in the subsequent administrative proceedings is itself legal error, subject to reversal on further judicial review."
In this case, however, the sole issue is the degree to which plaintiff's clubfoot impacts his ability to function, including his ability to ambulate. The ALJ simply did not use the proper criteria to assess plaintiff's ability to ambulate effectively at step three. Contrary to the Commissioner's claim, the ALJ's statement that his discussion of the medical evidence at step four supported his step three finding does not demonstrate that the ALJ even understood that evaluating plaintiff's ability to effectively ambulate required him to consider age-appropriate activities. Accordingly, the undersigned finds that the ALJ failed to comply with the Court's remand order, which required the ALJ to analyze plaintiff's ability to ambulate effectively under 101.00B2b(3), requires remand because the ALJ's decision cannot be upheld on other grounds.
Turning to the merits of the Commissioner's argument, the regulation provides that the inability to ambulate effectively "is defined generally as having insufficient lower extremity functioning (see 101.00J) to permit independent ambulation without the use of a hand-held assistive device(s) that limits the functioning of both upper extremities." 20 C.F.R. Pt. 404, Subpt. P, App. 1, 101.00B2b(1). The reference to 101.00J includes instructions for examiners to follow in cases where the child does use hand-held assistive devices.
Additionally, the regulations provide that, in assessing an older child's ability to ambulate effectively, the ALJ must consider whether the child is "capable of sustaining a reasonable walking pace over a sufficient distance to be able to carry out age-appropriate activities."
The ALJ did not conduct a complete analysis at step three. Instead, he simply concluded that plaintiff did not meet the general definition of ineffective ambulation because plaintiff did not require the use of hand-held assistive devices. (R. 259). Notably, although the ALJ quoted portions of 101.00B2b(3), he did not include the specific examples of ineffective ambulation in that quote.
The Commissioner argues that the ALJ's failure to do so is harmless error because the ALJ's step four findings properly address plaintiff's functional abilities. (Dkt. 16). The undersigned disagrees and finds that the harmless error analysis would not apply to the ALJ's step three analysis in this case. In
Here, plaintiff's mother testified that plaintiff's activities are limited, that his gait is unstable, and that he experiences pain and fatigue easily. (R. 283-88). The ALJ found the mother's testimony not entirely credible, but as discussed supra, the ALJ failed to conduct a proper credibility analysis. Therefore, the undersigned cannot rely on the credibility findings to confirm the ALJ's factual findings. Moreover, after reviewing the record, the undersigned finds that the ALJ's factual findings at step three discount the issues with plaintiff's gait and contain inconsistencies that cannot meet the requirement for harmless error.
For example, the ALJ found that plaintiff's "surgeries, bracing and casting has caused the claimant marked limitations in his ability to ambulate over the three year period."
Because the ALJ failed to consider all of the criteria in Listing 101.00 and because the ALJ's failure to do so was not harmless error, the undersigned recommends that the decision be remanded to the ALJ for further proceedings.
Plaintiff argues that the Court's previous order mandates a finding of marked limitation in the area of Health and Physical Well-Being. (Dkt. 13). Plaintiff contends that the Court's holding, combined with the ALJ's current finding of a marked limitation in the area of Moving About and Manipulating Objects, constitutes a finding of marked limitations in two domains of functioning and requires a finding that plaintiff is disabled.
The Commissioner argues that plaintiff misinterprets the Court's remand order. (Dkt. 16). The Commissioner contends that the order simply found no error in the ALJ's findings and that the ALJ was free, on remand, to re-assess the evidence as long as the ALJ's actions did not conflict with the remand order.
The Court's order remanding the case addressed two issues with respect to the impact of plaintiff's impairment on the domains of functioning. (R. 324-32). In the first decision, the ALJ found that plaintiff had a marked limitation in the domain of Health and Physical Well-Being, based on plaintiff's bilateral clubfoot. (R. 296-97, 330-31). Plaintiff challenged the finding of a marked limitation, arguing that the ALJ should have found an extreme limitation. (R. 330). The Court held that it would not re-weigh the evidence, found substantial evidence to support the marked limitation, and stated that "[t]he marked limitation in the `Health and Physical Well-Being' domain is, therefore, affirmed."
Although that statement appears to be an affirmance of the marked limitation in that domain, it is not the end of the court's analysis. Plaintiff also challenged the ALJ's finding that plaintiff had no limitation in the domain of Moving About and Manipulating Objects.
The ALJ's decision on remand complied with these instructions. The question of the proper domain to address plaintiff's bilateral club foot arose in this case because the agency physicians opined that plaintiff's impairment caused a marked limitation in the domain for Health and Physical Well-Being. (R. 264). As the ALJ explained in reciting the proper standard for evaluating each domain, the domain for Moving About and Manipulating Objects "considers how well a child is able to move his body from one place to another and how a child moves and manipulates objects." (R. 267, citing 20 C.F.R. § 416.926a(j)). The domain for Health and Physical Well-Being, however, "considers the cumulative physical effects of physical and mental impairments and any associated treatments or therapies on a child's health and functioning that were not considered in the evaluation of the child's ability to move about and manipulate objects." (R. 269, citing 20 C.F.R. § 416.926a(l)). The ALJ determined that the agency physicians conducted an analysis of plaintiff's clubfoot in the wrong domain. (R. 264). Having reviewed the applicable regulations, the undersigned agrees with the ALJ's analysis and finds that it resolves the conflict in the original ALJ decision.
Accordingly, the undersigned recommends a finding of no error on this issue. The ALJ was not bound, under the law of the case doctrine, to maintain a finding of a marked limitation in the area of Health and Physical Well-Being.
Because the undersigned has recommended remanding the case for further proceedings on issues impacting the ultimate question of disability, the undersigned finds that an analysis of plaintiff's request for a finding of a closed period of disability is not warranted.
For the reasons set forth above, the undersigned
In accordance with 28 U.S.C. §636(b) and Fed. R. Civ. P. 72(b)(2), a party may file specific written objections to this report and recommendation. Such specific written objections must be filed with the Clerk of the District Court for the Northern District of Oklahoma by March 1, 2016.
If specific written objections are timely filed, Fed. R. Civ. P. 72(b)(3) directs the district judge to