DAVID A. BAKER, Magistrate Judge.
The Plaintiff brings this action pursuant to the Social Security Act (the Act), as amended, Title 42 United States Code Section 405(g), to obtain judicial review of a final decision of the Commissioner of the Social Security Administration (the Commissioner) finding her disability had ceased as of June 10, 2010 and curtailing her Supplemental Security Income (SSI) benefits under the Act.
The record has been reviewed, including a transcript of the proceedings before the Administrative Law Judge (ALJ), the exhibits filed and the administrative record, and the pleadings and memoranda submitted by the parties in this case. Oral argument has not been requested.
For the reasons that follow, the decision of the Commissioner is
On October 22, 2002, the Commissioner found Plaintiff disabled as of April 1, 2002 and awarded her Supplemental Security Income benefits. R. 13, 64. In 2010, the state agency conducted a continuing disability review and concluded Plaintiff was no longer disabled as of June 10, 2010. R. 63-68, 80-92. Plaintiff challenged that decision and, on appeal, a hearing was held on June 7, 2012, before Administrative Law Judge Curt Marceille (hereinafter referred to as "ALJ"). R. 36. In a decision dated June 14, 2012, the ALJ found Plaintiff's disability had ended on June 10, 2010. R.10-29. Plaintiff timely filed a Request for Review of the ALJ's decision, which the Appeals Council denied on April 3, 2012. R. 1. Plaintiff filed this action for judicial review on November 14, 2013. Doc. No. 1.
On June 10, 2010, the date the ALJ found her disability had ceased, Plaintiff was forty-two years old. R. 47. She has a high school education and no history of past relevant work. R. 42, 439.
As the ALJ noted, the Commissioner originally found Plaintiff disabled in 2002 based upon marked limitations caused by her anxiety/panic disorder. R. 16. The ALJ found that, as of June 10, 2010, Plaintiff's suffered from the impairments of mood disorder, not otherwise specified; degenerative disc disease; degenerative joint disease of the right shoulder; history of Morton's neuroma on foot; esophagitis; gastritis; and hemorrhoids, which were severed, but were not severe enough to meet or medically equal one of the impairments listed in Appendix 1, Subpart P, Regulations No. 4. R. 15. The ALJ further found that medical improvement occurred as of June 10, 2010. R. 17. Specifically, while marked limitations caused by an anxiety/panic disorder previously caused Plaintiff's disability, the ALJ found that her present mental residual functional capacity (RFC) allowed her to perform simple, repetitive, and routine tasks, with no more than occasional changes in the work setting and interactions with coworkers, supervisors, and the public. R. 17. The ALJ found that Plaintiff's physical RFC as of June 10, 2010 enabled her to perform light-level work with no more than occasional stooping, crouching, balancing, kneeling, and overhead reaching with the right shoulder; no concentrated exposure to pulmonary irritants; and no climbing of stairs, ramps, ladders, ropes, or scaffolds. R. 18. Considering Plaintiff's vocational profile and RFC, the ALJ applied the Medical-Vocational Guidelines (the grids), 20 C.F.R. Pt. 404, Subpt. P, App. 2, and, based on the testimony of the vocational expert ("VE"), the ALJ concluded that Plaintiff could perform work existing in significant numbers in the national economy as cleaner/housekeeper, agricultural produce sorter, and officer helper at the light level; and escort vehicle driver, ticket checker, and surveillance system monitor at the sedentary level. R. 27-28. Accordingly, the ALJ determined that Plaintiff's disability ceased as of June 10, 2010. R. 29.
Plaintiff now asserts two points of error. First, she argues that the ALJ erred in considering Plaintiff's credibility and in wrongly assuming Plaintiff did not seek treatment for nearly seven years despite evidence to the contrary. Second, Plaintiff contends the ALJ erred by failing to give the opinions of her treating physician's proper weight and determining an RFC which was not based on substantial evidence. For the reasons explained below, the decision of the Commissioner is
The scope of this Court's review is limited to determining whether the ALJ applied the correct legal standards, McRoberts v. Bowen, 841 F.2d 1077, 1080 (11
"If the Commissioner's decision is supported by substantial evidence, this Court must affirm, even if the proof preponderates against it." Phillips v. Barnhart, 357 F.3d 1232, 1240 n. 8 (11
If the claimant is entitled to disability benefits, the Commissioner is required to conduct a periodic review to determine whether those benefits should continue. See 20 C.F.R. § 404.1594(a). If there has been medical improvement related to the claimant's ability to work, the benefits cease. Id. Medical improvement is defined as "any decrease in the medical severity of [the claimant's] impairment(s) which was present at the time of the most recent favorable medical decision that [the claimant was] disabled or continued to be disabled." 20 C.F.R. § 404.1594(b)(1). A decrease in severity determination must be based on improvements in the claimant's symptoms, signs or laboratory findings. Id.
Although the ALJ generally follows five steps in evaluating a claim of disability, see 20 C.F.R. §§ 404.1520, 416.920, if the issue is "medical improvement" and cessation of disability benefits, the ALJ must follow additional steps. 20 C.F.R. § 416.994. The Social Security regulations provide an eight-step sequential evaluation process for determining if a claimant's disability continues. See 20 C.F.R. § 404.1594(f). First, the claimant must not be engaged in "substantial gainful activity." Second, it must be determined whether the claimant's severe impairment meets or equals the severity of a listed impairment. If the claimant's condition meets or equals the level of severity of a listed impairment, the claimant's disability continues.
If the severe impairment does not equal or meet the severity of a listed impairment, the examiner proceeds to the third step, namely, an assessment of whether there has been medical improvement of the claimant's condition. Fourth, if there has been medical improvement, it must be determined if that improvement is related to the ability to do work.
If there has not been medical improvement, the examiner proceeds to the fifth step to determine whether any exceptions listed in 20 C.F.R. § 404.1594(d) and (e) apply. Sixth, if there has been medical improvement, it must be determined whether the claimant has a severe impairment or combination of impairments. If the severe impairment does not equal or meet the severity of a listed impairment, the examiner proceeds to the seventh step, an assessment of the claimant's residual functional capacity; the assessment measures whether a claimant can perform past relevant work despite her impairment. If the claimant is unable to do past relevant work, the examiner proceeds to the eighth and final step of the evaluation process to determine whether, in light of her RFC, age, education and work experience, the claimant can perform other work. § 20 C.F.R. 404.1594(f)(1)-(8).
Plaintiff contends the ALJ erred in considering Plaintiff's credibility and wrongly assuming she did not seek any medical treatment for nearly seven years, from 2002 through 2009, when the full set of records from Dr. Mathur's office
The Commissioner contends that substantial evidence supports the ALJ's finding of medical improvement, and his RFC finding for the period beginning June 10, 2010, because the ALJ was not required to defer to Plaintiff's subjective complaints or adopt the opinion of (either) Dr. Mathur and Plaintiff failed to prove that her subject complaints were fully credible. The Commissioner argues, "as part of her burden of proving she is disabled, Plaintiff must establish, through objective evidence, that her subjective complaints are credible. See 20 C.F.R. § 416.1512(a)."
As an initial matter, the Commissioner's description, which appears to shift the burden to Plaintiff to show she remains disabled, is erroneous. When considering a case for termination or cessation of benefits, as occurred here, the burden is on the Commissioner to prove that the claimant is no longer disabled as of the cessation date because the Plaintiff had experienced "medical improvement." See Simpson v. Schweiker, 691 F.2d 966, 969 (11
Plaintiff contends that the ALJ mistakenly assumed she failed to obtain any medical treatment from 2002 through 2009 since there were no treatment records in the Administrative Record for those dates, even though she informed the SSA twice that she had started treatment with Dr. Mathur in 2004. Plaintiff testified that her impairments included bipolar disorder, attention deficit disorder, panic, anxiety, schizophrenia, agoraphobic tendencies, and pain issues from "head to toe." R. 40. She testified that she continues to have daily panic attacks; she did psychotherapy
The ALJ found in Plaintiff's case that "medical improvement" had occurred as of June 10, 2010. R. 17. He determined that the medical evidence supported a finding that, as of June 10, 2010, there had been a decrease in medical severity of the impairment present at the time of the comparison point decision ("CPD"), primarily because there was a lack of treatment records. R. 17. The ALJ states that he does not have available the "formal, function-by-function" RFC prepared at the time of the CPD and instead uses the "disability hearing officer's formulation of what the RFC must have been at the time of the CPD." R. 15. He cites the transmittal (R. 64) which contained the "basis code" of A63 for anxiety related disorder, however, the transmittal form completed by Dr. Eeltink referred specifically to the Psychiatric Review Technique form she completed dated October 2002 (R. 310-26) and it does contain the mental RFC as completed by Dr. Eeltink. R. 324-25. In the Mental RFC, Dr. Eeltink, the state agency reviewing psychologist, opined Plaintiff was markedly limited in the ability to maintain attention and concentration for extended periods, and to perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances; and in the ability to complete a normal work day and work week without interruptions from psychologically based symptoms. R. 324-25. Her written comments noted Plaintiff's treatment for anxiety, her statements that she will not get on a bus, a psychiatric evaluation which described her as hyperactive, irritable, flighty, anxious, impulsive, restless, and agitated, which was very similar to Dr. McClure's MSE; and reports that her father takes care of everything; she only goes out with a companion and she tends to stay in her room. R. 326. The ALJ fails to discuss, no less discuss or apply, any of Dr. Eeltink's limitations as stated in the Mental RFC. R. 324-25. Most importantly, in determining whether Plaintiff had shown "medical improvement" or whether there was "any decrease in the medical severity of her impairments," the ALJ failed to utilize or consider Plaintiff's Mental RFC from the CPD.
Records from 2001-2002 (at the CPD) indicate Plaintiff was receiving treatment from the Devereux Treatment Network Outpaitent Program at 34 years of age; her two children (ages 13 and 11) lived with her ex-husband; and she had been in foster care as a child from age 11 after living with aunts, uncles, and grandparents; she "had been abused, neglected and abandoned as a child." R. 281, 328
The ALJ based his finding of "medical improvement," not on a comparison of 2002 mental health records to those of 2010, but exclusively on the lack of mental health treatment records, finding:
R. 17, 22, 24 (emphasis added).
The Commissioner argues, consistent with the ALJ's finding, that Plaintiff's limited treatment history for her mental health condition after 2002 is inconsistent with her claim of continuing disability. The Commissioner appears to misplace the burden on Plaintiff to show her disability is continuing rather than on the Commissioner to show she has medically improved. The Commissioner cites the ALJ's finding that, coinciding with her award of disability benefits, Plaintiff discontinued treatment with a mental health specialist in 2002. R. 22, 284, 434, 436, 439. The Commissioner argues that the ALJ did consider Plaintiff's explanations for the lapse in mental health treatment — her anxiety and lack of transportation — but found them less than credible, noting that neither anxiety nor lack of transportation prevented Plaintiff from receiving medical treatment for her physical impairments from several sources. R. 24, 41-43, 46. The ALJ found:
R. 24 (emphasis added). The Commissioner also points to the ALJ's determination that Plaintiff was eligible for Medicaid during the period she received benefits, so treatment was available to her, and the primary care physicians' treatment records, dating back to 2009, did not support a finding of disabling mental limitations. R. 17, 21-22, 397-410, 474-519, 554-61, 566-78. The Commissioner argues that the ALJ's finding that Dr. Mathur prescribed medication and did not record that Plaintiff experienced debilitating "panic attacks" is supported by substantial evidence. R. 17, 41-43, 397-410, 474-19, 554-61, 566-78.
The Commissioner does not dispute that there was a lack of records between 2002 to 2009, or that the omission of these records could be precisely because the SSA (ODAR) had not requested them, but argues instead that such an argument is "speculative because the record does not reflect the dates of Dr. Mathur's treatment records the agency requested." It is clearly the Commissioner's obligation, under the unusual circumstances of this case involving a claimant already determined to be disabled with panic attacks and anxiety, to carefully and conscientiously obtain Plaintiff's records, particularly in this case, where Plaintiff has repeatedly stated that she has received treatment during the time period at issue and the lack of records is the basis for finding she has "medically improved." "Once evidence has been presented which supports a finding that a given condition exists it is presumed in absence of proof to the contrary that the condition has remained unchanged." Simpson, 691 F.2d at 969 (citing Rivas v. Weinberger, 475 F.2d 255, 258 (5
The Commissioner puts inordinate weight on counsel's affirmative response to the ALJ's question regarding whether counsel's brief and updated (early 2012) treatment records "completed the record," in that counsel also made a point of stating just a moment before that Plaintiff's "family doctor [has] been treating her for the last . . . 10 years." R. 39 (emphasis added). The Commissioner argues that, while the ALJ has a duty to develop a full and fair record, "this does not absolve Plaintiff of the burden of proving her claim and producing evidence to support it." The Commissioner persists in placing the burden on Plaintiff and misapplying the standard used in cessation cases.
Plaintiff indicated repeatedly on SSA forms that she had been treated by Dr. Mathur from 2004 through the time she was completing the forms (2011 or 2012). R. 195, 213. She also consistently indicated that Dr. Mathur prescribed all of her medications, thirteen in total by May 2012, including those for mood disorder (Clonapin), anxiety (Xanax), schizophrenia (Seroquel), and migraines (Immitrex). R. 214; see also R. 195-96, 209 ("primary care physician" prescribing same). On SSA forms filled out in spring 2011 (but undated by SSA employee V. Martin R. 206), Plaintiff indicated that she had first seen Dr. Mathur in 2004 and that the date of her most recent visit (prior to completing the form) was on February 2011. R. 208. Plaintiff also indicated that she could no longer do her breathing treatments because she had "lost her Medicaid" as of January 2011. R. 207.
Although Plaintiff authorized her physicians to disclose any and all of her medical records to the Social Security Administration on January 12, 2010 (R. 162) without any limitation on the date of the records, it appears that Dr. Mathur's office did not submit to SSA the full set of Plaintiff's treatment records going back to 2004, when Dr. Mathur began treating Plaintiff. Dr. Uma Mathur's letter submitted to the SSA, dated July 22, 2010, states:
R. 520 (emphasis added). The earliest records submitted to SSA from Dr. Mathur are for treatment in August 2009 (R. 491-92) despite the fact that Plaintiff testified she had received treatment for years, her statements on SSA forms that she had been treated since 2004, and Dr. Mathur's own statement that Plaintiff had been a patient "for many years." Clearly there was an error in collecting the treatment records from the offices of Drs. Mathur. In this instance where there is a presumption that Plaintiff is disabled, and the burden of showing "medical improvement" is on the Commissioner, the collection error falls on the SSA and the ALJ. Without documentation in the Administrative Record that treatment records for the period at issue were properly requested from Dr. Mathur's office, the Commissioner's credibility finding and "medical improvement" finding are not based on substantial evidence. Accordingly, the ALJ's decision to terminate Plaintiff's benefits was not based on substantial evidence.
Plaintiff contends the ALJ erred by failing to give the opinions of her treating physicians proper weight and by determining she had an RFC which was not supported by the relevant evidence. Plaintiff argues that if the ALJ had given Dr. Mathur's opinion more weight, the ALJ would have found that Plaintiff had not shown "medical improvement" since Dr. Mathur's RFC opinion eliminated even sedentary work.
Residual functional capacity is an assessment based on all relevant evidence of a claimant's remaining ability to do work despite her impairments. 20 C.F.R. § 404.1545(a); Lewis v. Callahan, 125 F.3d 1436,1440 (11
The ALJ held that Plaintiff had a residual functional capacity to perform light work except that she was limited to simple repetitive and routine tasks with no more than occasional changes in the work setting and occasional interactions with coworkers, supervisors, and the general public, with occasional stooping, crouching, balancing, kneeling, and overhead reaching with the right shoulder, no concentrated exposure to pulmonary irritants and no climbing of stairs, ramps, ladders, ropes or scaffolds. R. 18.
Plaintiff contends that the ALJ erred in failing to fully credit the opinion of her treating physicians, both Drs. Mathur, who opined Plaintiff suffered from Bipolar Disorder, Anxiety/Panic Disorder, COPD, GERD, Schizophrenia, Migraine Headaches, Insomnia, Night Terrors, as well as Degenerative Disc Disease, Degenerative Joint Disease, Neuroma in the feet, Arthritis, Carpal Tunnel Syndrome, and TMJ. R. 563. Dr. R. Mathur opined Plaintiff's ability to understand, remember, and carry out instructions was affected by her impairments; her memory loss was worse due to excess amount of stress; she was moderately limited in her ability to carry out short, simple instructions and markedly limited in carrying out detailed instructions; she would need to write down any detailed instructions and refer to her notes frequently; she was extremely limited in her ability to make judgements on simple work-related decisions; she had marked restrictions interacting appropriately with the public and with supervisors; extreme restrictions interacting with co-workers, responding appropriately to work pressures in a usual work setting, and responding appropriately to changes in a routine work setting. R. 562-63. Dr. Mathur also opined Plaintiff was not able to respond appropriately to supervision, co-workers, and work pressures in a work setting. R. 564.
Plaintiff argues that the ALJ erred in giving the opinions of the consultative psychological examiner, Dr. Mortenson, more weight than either of the opinions of Drs. R. and U. Mathur
R. 25-26.
In contrast, the ALJ found that the psychological consultative examination report of Dr. Mortensen was not "substandard," as Plaintiff's counsel argued at the hearing, because the report was generic and inadequately detailed on the topic of the claimant's specific limitations, but found that "Dr. Mortensen's report lays out specific facts about the claimant's performance on various elements of mental status examination." R. 22. The ALJ further found Dr. Mortensen's report, "especially in combination with the totality of psychological objective and opinion evidence in the record," was sufficient on the topic of the claimant's mental health functioning" and he denied Plaintiff's request for a new psychological evaluation. R. 22. As an initial matter, the ALJ's opinion is internally inconsistent in that he found there is "no record of any treatment of any kind" and yet he found Dr. Mortenson's report to be sufficient "especially in combination with the totality of psychological objective and opinion evidence" of which he had found there was none. In addition, the Court finds that Dr. Mortensen's report was rather cursory compared to others in similar cases in which the person's disability turns exclusively on their mental health, and particularly so in light of the ALJ's finding that there had been no mental health treatment of Plaintiff for the previous ten years, since 2002 — virtually all of the ALJ's mental health determination turned on Dr. Mortenson's cursory report. Compare R. 333-35 (Dr. MacKay-November 2001) with R. 440 (Dr. Mortenson).
Particularly in this case, where Plaintiff's anti-psychotic medications were provided by the primary care physician, the psychological consultative examination was all the more important. As Plaintiff points out, her anxiety and other psychiatric impairments would often interfere with her attempts to get treatment from a mental health physician
The Commissioner contends that remand is not warranted even if there exist additional records predating 2009 showings Dr. Mathur's practice prescribed anti-psychotic medications because it was not treatment from a mental health specialist and would not affect the ALJ's credibility finding. Plaintiff argues that in determining her credibility the ALJ did not follow the requirements of SSR 96-7p, which states that the ALJ must carefully consider Plaintiff's explanations for failure to pursue medical treatment, such as daily activities which "may be structured so as to minimize symptoms to a tolerable level or eliminate them entirely, avoiding physical or mental stressors that would exacerbate the symptoms. . . living with the symptoms, seeing a medical source only as needed for periodic evaluation and renewal of medications. . . [and] the individual may be unable to afford treatment and may not have access to free or low-cost medical services." While it was clearly not ideal for Plaintiff's primary care physicians to be the ones prescribing anti-psychotic drugs to Plaintiff, with Plaintiff's limited resources and Plaintiff's anxiety, agoraphobia and other psychological problems, it does not necessarily undercut her credibility that she chose to see the primary care physicians for medication renewals. As explained above, it was error for the ALJ not to conscientiously obtain the full treatment records from Drs. Mathurs' treatment of Plaintiff. On remand, in addition to obtaining the records from Drs. Mathur, the ALJ will order a detailed consultative examination with particular attention paid by the consultant as to whether Plaintiff suffers from the mental health impairments as opined by Drs. R. and U. Mathur: bipolar disorder, anxiety/panic disorder, schizophrenia, migraine headaches, insomnia, and night terrors.
Accordingly, the Commissioner's decision is