MONTE C. RICHARDSON, MAGISTRATE JUDGE.
This cause is before the Court on Plaintiff's appeal of an administrative decision denying his application for Social Security benefits. The Court has reviewed the record, the briefs, and the applicable law. For the reasons set forth herein, the Commissioner's decision is
Plaintiff filed an application for disability insurance benefits ("DIB") on February 25, 2008, alleging an inability to work since November 23, 2007. (Tr. 123-27). The Social Security Administration ("SSA") denied the application initially and again upon reconsideration. (Tr. 68-69, 77-78). Plaintiff then requested and received a hearing before an Administrative Law Judge ("the ALJ") on October 7, 2008. (Tr. 10, 79). On December 16, 2009, the ALJ issued a decision finding Plaintiff was not disabled. (Tr. 7-18). Plaintiff requested review of the ALJ's decision by the Appeals Council, but the request was denied. (Tr. 1). Plaintiff timely filed his Complaint in the U.S. District Court on January 20, 2010. (Tr. 4).
Plaintiff claimed to be disabled due to back pain, neck pain, anxiety, and depression since November 23, 2007. (Tr. 41, 123).
Plaintiff was forty-eight years of age on the date of the hearing. (Tr. 31). He has a limited education, but is able to read, write, and communicate in English. (Tr. 31, 145, 150). He has past relevant work experience as a crane operator, rigger, and groundskeeper. (Tr. 36-39).
In September 2000, Plaintiff was diagnosed with "degenerative disc disease at C5-6 with mild disc narrowing and spurring anteriorly and posteriorly." (Tr. 197). He also had "mild cervical scoliosis convex right and . . . uncovertebral hypertrophy at the C5-6 level on the left side that cause[d] minimal impingement on the left C5-6 neuroforamen."
In October 2004, Plaintiff visited Dr. Fetchero. (Tr. 260). He returned to Dr. Fetchero on an "as needed" basis through 2009. (Tr. 260, 294-97). Dr. Fetchero opined Plaintiff suffered from back pain, neck pain, neuropathy, radiculopathy, and paresthesias in the feet. (Tr. 260). Dr. Fetchero's notes indicate Plaintiff required an MRI, but Plaintiff was unable to obtain the test due to a lack of insurance. (Tr. 251). In July 2008, Dr. Fetchero completed a physical residual functional capacity ("RFC") questionnaire for Plaintiff. (Tr. 260). Dr. Fetchero noted Plaintiff had not improved in more than seven months and was only able to sit for less than two hours, stand for less than two hours, and walk for less than two hours in an eight-hour workday. (Tr. 262). He further opined Plaintiff could only sit or stand for ten minutes before needing to change positions and occasionally required the assistance of a cane. (Tr. 262-63). Dr. Fetchero determined Plaintiff could rarely lift items weighing ten pounds or less and could never lift items heavier than ten pounds. (Tr. 263). Dr. Fetchero further opined Plaintiff was likely to be absent from work more than four days per month as a result of his impairments. (Tr. 265). Finally, Dr. Fetchero suggested Plaintiff's pain would frequently interfere with his attention and concentration, but Plaintiff could tolerate moderate work stress. (Tr. 261).
Dr. Choisser examined Plaintiff in May 2008. (Tr. 209). He noted Plaintiff had "good bony alignment" in his lumbar spine, but "some narrowing of disc space" and "arthritic changes" in the cervical spine. (Tr. 210). Dr. Choisser opined Plaintiff suffered moderate muscle spasms along the lumbar spine as well as traumatic disc disease and osteoarthritis of the lumbar and cervical spine with insufficient medical work-up.
In June 2008, Dr. Dianna Ahmad diagnosed Plaintiff with degenerative disc disease of the lumbar spine and osteoarthritis in the cervical spine. (Tr. 235, 242). Dr. Ahmad opined Plaintiff could occasionally lift twenty pounds, frequently lift ten pounds, and could stand, walk, or sit for six hours in an eight-hour workday. (Tr. 236).
In September 2008, Dr. Puestow diagnosed Plaintiff with lumbar spondylolisthesis and affective/mood disorder. (Tr. 66-67). Dr. Puestow indicated Plaintiff could occasionally lift twenty pounds and frequently lift ten pounds. (Tr. 282). Dr. Puestow opined Plaintiff could stand or walk for six hours and sit for six hours in an eight-hour workday. (Tr. 282).
In May 2008, Dr. Knox, a consultative psychologist, evaluated Plaintiff. (Tr. 214). Dr. Knox opined Plaintiff suffered mild depression and had a Global Assessment of Functioning of 60. (Tr. 218). Dr. Knox also noted there were no behavioral indications of anxiety, depression, or thought disorder at the time of the interview. (Tr. 217). Dr. Knox went on to opine Plaintiff had no significant issues in the areas of concentration or persistence and his memory was intact.
In June 2008, Dr. Zelenka diagnosed Plaintiff's mental impairments as not severe. (Tr. 221). Dr. Zelenka opined Plaintiff had mild limitations in the activities of daily living and maintaining social functioning. (Tr. 231). Plaintiff was also mildly limited in maintaining concentration, persistence, or pace and suffered no episodes of extended decompensation.
Plaintiff's hearing before the ALJ was conducted on November 3, 2009. (Tr. 10, 25). During the hearing, Plaintiff testified that during the day, he spent most of the time in a recliner watching television and napping. (Tr. 47, 56). Plaintiff also testified he was able to cook, clean, dress himself, wash dishes, pay bills, make change, and read. (Tr. 32, 42-45). Plaintiff admitted he could lift items such as a twelve pack of beer or two gallons of milk, but lifting the items caused neck and back pressure. (Tr. 45-46).
A plaintiff is entitled to disability benefits when he is unable to engage in a substantial gainful activity by reason of any medically-determinable physical or mental impairment which can be expected to either result in death or last for a continuous period of not less than twelve (12) months. 42 U.S.C. §§ 416(i)(1), 423(d)(1)(A); 20 C.F.R. § 404.1505(a). The ALJ must follow five steps in evaluating a claim of disability.
In the instant case, the ALJ determined Plaintiff met the insured status requirements of the Social Security Act through December 31, 2007. (Tr. 12). At step one, the ALJ found Plaintiff had not engaged in substantial gainful activity since his alleged onset date, November 23, 2007.
At step three, the ALJ found "the claimant did not have an impairment or combination of impairments that met or medically equaled one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1." (Tr. 13). With respect to Plaintiff's RFC, the ALJ found Plaintiff was able to perform "less than the full range of sedentary work as defined by 20 C.F.R. § 404.1567(a)" and was able to "lift and/or carry up to 10 pounds; stand or walk for 2 hours in an 8-hour workday; and sit for 6 hours in an 8-hour workday." (Tr. 13). But, "for every hour of sitting he [would] need to stand for 5 or 10 minutes," and Plaintiff needed the use of a cane.
At step four, the ALJ determined Plaintiff was unable to perform his past relevant work as a groundskeeper, rigger, or crane operator. (Tr. 17). However, at step five, the ALJ stated, "considering [Plaintiff's] age, education, work experience, and residual functional capacity, there were jobs that existed in significant numbers in the national economy that [Plaintiff] could have performed."
The scope of this Court's review is limited to determining whether the ALJ applied the correct legal standards,
Where the Commissioner's decision is supported by substantial evidence, the district court will affirm, even if the reviewer would have reached a contrary result as finder of fact, and even if the reviewer finds that the evidence preponderates against the Commissioner's decision.
Plaintiff raises three issues in this appeal. Specifically, Plaintiff claims the ALJ erred by failing to give the opinion of Plaintiff's treating physician, Dr. Fetchero, controlling weight. (Doc. 16, p. 7). Second, Plaintiff argues the ALJ failed to properly classify Plaintiff's depression as a severe impairment. (Doc. 16, p. 9). Lastly, Plaintiff argues the ALJ erred by finding Plaintiff was not disabled even though Plaintiff could only perform less than the full range of sedentary work. (Doc. 16, p. 11).
Plaintiff first argues the ALJ improperly discredited Dr. Fetchero's opinion. The opinion of a treating physician "must be given substantial or considerable weight unless `good cause' is shown to the contrary."
In this case, the ALJ provided three reasons for according "little weight" to Dr. Fetchero's opinion. (Tr. 15). Specifically, the ALJ stated:
(Tr. 15). With respect to the first reason cited by the ALJ, that the doctor relied too heavily on Plaintiff's subjective complaints, it is true that a treating physician's opinion may be discredited when the opinion is based primarily on the plaintiff's subjective reports of pain.
In the instant case, the ALJ found Plaintiff's subjective complaints were not credible, however, the undersigned does not believe substantial evidence supports the ALJ's reasons for questioning Plaintiff's credibility. To support his findings regarding Plaintiff's credibility, the ALJ pointed to Plaintiff's allegations that he experienced chronic neck and back pain with numbing in his hands and that he could not sit, stand, or walk without pain even with pain medications. (Tr. 16). The ALJ then noted that despite these claims, Plaintiff was able to lift a twelve-pack of beer and two gallons of milk. The ALJ acknowledged that Plaintiff stated doing these activities made him feel pressure or pain. The Court does not see how Plaintiff's ability to lift beer and milk is somehow inconsistent with Plaintiff's allegations of constant pain and inability to sit, stand, or walk without pain. Had Plaintiff testified he could not lift more than a few pounds and then stated he could lift a twelve-pack and two gallons, the Court would agree that his credibility was lacking. However, the ability to lift does not necessarily affect the ability to sit, stand, or walk.
Additionally, the ALJ noted that Plaintiff testified his depression and anxiety occasionally caused him to not want to get out of bed.
Finally, the ALJ pointed to Plaintiff's claim that he was laid off in December 2003 because he would miss one to two days of work per week. To contradict that statement, the ALJ pointed to Plaintiff's report during a consultative examination in 2008 where Plaintiff reported he had a lawn service company and stated he had to stop that business two years earlier because he never had enough customers and he started to hurt and his hands went numb. Based on Plaintiff's statement during the consultative exam, the ALJ determined there was "a question as to whether the claimant's unemployment [was] actually due to a medical impairment or an inability to secure work."
The Court also has concerns regarding the ALJ's remaining reasons for discrediting Dr. Fetchero's opinions. The ALJ discredited Dr. Fetchero's opinions because he found Plaintiff's activities of daily living were inconsistent "with his allegations of disability." (Tr. 15). Although it is not clear, the undersigned assumes this means the ALJ believed Plaintiff's activities of daily living were not consistent with the limitations imposed by Dr. Fetchero. In any event, the ALJ did not provide any further detail regarding which of Plaintiff's daily activities were inconsistent with the limitations and how. Without any such discussion, this reason is not supported by substantial evidence.
Finally, the ALJ discredited Dr. Fetchero's opinion because there was insufficient medical evidence in the record. However, as Plaintiff observed, part of the reason for the lack of medical evidence was Plaintiff's inability to pay for an MRI. While the Commissioner is correct the plaintiff has the burden of proving his disability, it is similarly true that the ALJ has a duty to develop a full and fair record, even when the plaintiff is represented by counsel.
Here, two physicians, Dr. Fetchero and Dr. Choisser, both indicated an MRI was necessary for further diagnosis (Tr. 209, 251) and the ALJ noted this in his decision (Tr. 15). The responsibility of ordering the MRI fell on the ALJ due to the ALJ's duty to develop a full and fair record unless the record contained sufficient evidence for the ALJ to make an informed decision.
Although the Court is remanding the matter based on Plaintiff's first argument, the Court will consider the remaining two issues raised in Plaintiff's memorandum.
Plaintiff next argues the ALJ erred in classifying Plaintiff's mental health condition as non-severe. (Doc. 16, p. 9). At step two, the ALJ must determine whether a claimant's impairments are severe, both individually and in combination.
In this case, Plaintiff's date last insured was December 31, 2007. (Tr. 12). As a result, Plaintiff has the burden to prove that his depression was severe on or before that date.
Further, three physician's opinions support the ALJ's finding. Dr. Michael Zelenka stated in his report that Plaintiff's limitations due to his mental health condition were mild. (Tr. 231). Dr. Zelenka opined Plaintiff's mental limitations at his date last insured were also mild. (Tr. 233). Dr. Angeles Alvarex-Mullin's report also noted Plaintiff's mental impairment was mild. (Tr. 277). In addition, Dr. Knox observed Plaintiff exhibited no behavioral indications of anxiety, depression, or thought disorder at the time of his examination, and diagnosed Plaintiff with mild dysthymic depression. (Tr. 217-218). Therefore, there is substantial evidence in the record to support the ALJ's determination that Plaintiff's mental impairment was not severe.
Finally, Plaintiff argues the ALJ erred in finding Plaintiff was not disabled even though he found Plaintiff was only able to perform less than the full range of sedentary work. According to Plaintiff, the definition of sedentary work requires one to be able to "sit for extended periods of time and if the person is unable to perform that function, he or she is disabled." (Doc. 16, p. 11) (citing
Sedentary work is defined in the regulations to include work where "sitting, [and] a certain amount of walking and standing is often necessary." 20 C.F.R. § 404.1567(a). However, a plaintiff may be limited to less than a full range of sedentary work and nonetheless, have a vocational expert ("VE") find he can perform a significant number of jobs in the economy.
In this case, the ALJ determined Plaintiff could perform less than the full range of sedentary work. (Tr. 13). Plaintiff does not contest this finding. Instead, Plaintiff argues that because the ALJ found Plaintiff could perform less than the full range of sedentary work, Plaintiff is necessarily disabled. (Doc. 16, p. 11). The Court finds no merit in this argument. To support this position, Plaintiff cites to the
For the foregoing reasons, the Commissioner's decision is hereby
Should this remand result in the award of benefits, Plaintiff's attorney is hereby granted, pursuant to Rule 54(d)(2)(B), an extension of time in which to file a petition for authorization of attorney's fees under 42 U.S.C. § 406(b), until thirty (30) days after the receipt of a notice of award of benefits from the Social Security Administration.