MEMORANDUM OPINION AND ORDER1

MONTE C. RICHARDSON, Magistrate Judge.

THIS CAUSE is before the Court on Plaintiff's appeal of an administrative decision denying his application for Supplemental Security Income ("SSI"). Following an administrative hearing held on February 27, 2017, the assigned Administrative Law Judge ("ALJ") issued a decision, finding Plaintiff not disabled since November 20, 2013, the protective filing date of the application.2 (Tr. 14-28, 52-81.) Based on a review of the record, the briefs, and the applicable law, the Commissioner's decision is REVERSED and REMANDED.

I. Standard

The scope of this Court's review is limited to determining whether the Commissioner applied the correct legal standards, McRoberts v. Bowen, 841 F.2d 1077, 1080 (11th Cir. 1988), and whether the Commissioner's findings are supported by substantial evidence, Richardson v. Perales, 402 U.S. 389, 390 (1971). "Substantial evidence is more than a scintilla and is such relevant evidence as a reasonable person would accept as adequate to support a conclusion." Crawford v. Comm'r of Soc. Sec., 363 F.3d 1155, 1158 (11th Cir. 2004). 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. Edwards v. Sullivan, 937 F.2d 580, 584 n.3 (11th Cir. 1991); Barnes v. Sullivan, 932 F.2d 1356, 1358 (11th Cir. 1991). The district court must view the evidence as a whole, taking into account evidence favorable as well as unfavorable to the decision. Foote v. Chater, 67 F.3d 1553, 1560 (11th Cir. 1995); accord Lowery v. Sullivan, 979 F.2d 835, 837 (11th Cir. 1992) (stating the court must scrutinize the entire record to determine the reasonableness of the Commissioner's factual findings).

II. Discussion

Plaintiff raises two issues on appeal. First, Plaintiff argues that the ALJ failed to properly evaluate his symptoms in accordance with Social Security Ruling ("SSR") 16-3p, and failed to take into consideration his inability to afford medical treatment, as he was a homeless person with no income and no medical insurance. Second, Plaintiff argues that the ALJ's findings regarding his mental limitations are not supported by substantial evidence. The Court finds that a remand is required as to the first issue and, therefore, does not address the second issue.

A. Standard for Evaluating Pain and Other Subjective Symptoms

When a claimant seeks to establish disability through his own testimony of pain or other subjective symptoms, the Eleventh Circuit's three-part "pain standard" applies. Holt v. Sullivan, 921 F.2d 1221, 1223 (11th Cir. 1991) (per curiam). "If the ALJ decides not to credit such testimony, he must articulate explicit and adequate reasons for doing so." Id.

Id.

Once a claimant establishes that his "pain is disabling through objective medical evidence that an underlying medical condition exists that could reasonably be expected to produce the pain," pursuant to 20 C.F.R. § 416.929, "all evidence about the intensity, persistence, and functionally limiting effects of pain or other symptoms must be considered in addition to the medical signs and laboratory findings in deciding the issue of disability." Foote, 67 F.3d at 1561; see also SSR 16-3p3 (stating that after the ALJ finds a medically determinable impairment exists, the ALJ must analyze "the intensity, persistence, and limiting effects of the individual's symptoms" to determine "the extent to which an individual's symptoms limit his or her ability to perform work-related activities").

As stated in SSR 16-3p:

SSR 16-3p.

"[A]n individual's attempts to seek medical treatment for symptoms and to follow treatment once it is prescribed" will also be considered "when evaluating whether symptom intensity and persistence affect the ability to perform work-related activities." Id. "[I]f the frequency or extent of the treatment sought by an individual is not comparable with the degree of the individual's subjective complaints, or if the individual fails to follow prescribed treatment that might improve symptoms, [the adjudicator] may find the alleged intensity and persistence of an individual's symptoms are inconsistent with the overall evidence of record." Id. However, the adjudicator "will not find an individual's symptoms inconsistent with the evidence in the record on this basis without considering possible reasons he or she may not comply with treatment or seek treatment consistent with the degree of his or her complaints." Id. In considering an individual's treatment history, the adjudicator may consider, inter alia, one or more of the following:

Id.

B. The ALJ's Decision

At step two of the five-step sequential evaluation process, the ALJ found that Plaintiff had the following severe impairments: Gitelman's syndrome with hypokalemia and hypomagnesemia, hypothyroidism, chronic obstructive pulmonary disease ("COPD"), and affective and anxiety disorders.5 (Tr. 19.) Then, the ALJ found that Plaintiff was capable of performing less than the full range of sedentary work:

(Tr. 21-22.)

In making this finding, the ALJ discussed Plaintiff's subjective complaints and daily activities, the treatment notes, the objective medical records, Dr. Choksi's examination findings and opinions, and the opinions of the State agency non-examining physicians, Dr. Hodes and Dr. Johnson. (Tr. 22-26.) The ALJ summarized Plaintiff's testimony, in part, as follows:

(Tr. 22.)

The ALJ determined that although Plaintiff's medically determinable impairments could reasonably be expected to cause the alleged symptoms, Plaintiff's "complaints suggest[ed] a greater severity of impairment than [could] be shown by the objective medical evidence alone," and that Plaintiff's "statements concerning the intensity, persistence and limiting effects of these symptoms [were] only partially consistent with the medical evidence and other evidence in the record." (Tr. 22-23.) The ALJ explained, in relevant part:

(Tr. 23-26.)

The ALJ added that he had "accommodated some of the complaints that [were] not well documented in the medical evidence," such as Plaintiff's "alleged chronic incontinence, which [was] only partially consistent and accommodated by allowing restroom breaks each hour with facilities within a reasonable distance." (Tr. 26.) The ALJ concluded that although Plaintiff "would not be able to perform the type of labor intensive landscaping and construction work he ha[d] performed in the past on a part-time basis, he would be able to perform jobs within the substantially reduced range of sedentary exertion work articulated." (Id.)

C. Pertinent Hearing Testimony

At the February 27, 2017 hearing, Plaintiff testified that he had been told by a kidney specialist, Dr. Maria Theresa de Jesus, that "there was no sure treatment for [his Gitelman's syndrome]" and that it was "a guessing game." (Tr. 61.) Plaintiff explained:

(Tr. 62-63.)

Although Plaintiff was able to see Dr. de Jesus while he was admitted at the Villages Hospital, he has been on a waiting list to see a kidney specialist at the Heart of Florida since 2012. (Tr. 65-66.) He testified that he cannot afford to see a kidney specialist at Shands. (Tr. 65.) He never worked full-time (Tr. 59), and at the time of the hearing, he was temporarily homeless, sleeping on friends' couches (Tr. 56; see also Tr. 147-48).

Plaintiff testified that he has constant muscle spasms all over his body due to low potassium and magnesium levels. (Tr. 60, 64-65 ("It's whatever muscle I'm working out or using at that time, it's going to cramp and it's going to have muscle spasms.").) Plaintiff stated that regardless of whether he is inside or outside, his potassium leaks out when he uses the bathroom and/or sweats. (Tr. 60, 62-64.) If he does not do anything, except eat and watch TV, it is "controllable." (Tr. 66.) Plaintiff tries to compensate by drinking Gatorade and eating bananas. (Tr. 64.) He stated that his supplements are ineffective and, in combination with the potassium-rich foods, they only make "the cramping more bearable." (Tr. 62, 66.)

Plaintiff testified that the potassium supplements cause constant heartburn and the magnesium supplements cause him to "spend the majority of the day in the bathroom." (Tr. 61, 67 (stating that Plaintiff "end[s] up on the toilet . . . off and on all day" — "at least five to six hours a day").) Plaintiff stated that even Imodium is ineffective for his diarrhea. (Tr. 67; see also Tr. 325 ("My medicine makes me have diarrhea every day."); Tr. 329 (listing diarrhea as a side effect of the magnesium medications).) Plaintiff testified that he has been warned to rush to the hospital if he experiences lightheadedness or chest pains due to the risk of heart attack, heart failure, or stroke. (Tr. 65, 68.)

D. Analysis

"Failure to follow prescribed medical treatment disqualifies a claimant from receiving [SSI] benefits." Dawkins v. Bowen, 848 F.2d 1211, 1212 (11th Cir. 1988).6 However, "a claimant's inability to afford a prescribed medical treatment excuses noncompliance." Id. "Thus[,] while a remediable or controllable medical condition is generally not disabling, when a `claimant cannot afford the prescribed treatment and can find no way to obtain it, the condition that is disabling in fact continues to be disabling in law.'" Id. at 1213.

Here, the ALJ substantially relied on Plaintiff's non-compliance with prescribed medical treatment without considering his inability to afford treatment, which is well documented in the record. (See, e.g., Tr. 359 ("The claimant's financial situation precludes him from having extensive specialist treatment with a renal clinic, despite his primary doctor's attempt to set this up[.]"); Tr. 471 (noting that Plaintiff declined genetic testing, which would require "significant amount of money," and indicated that he would try to apply for Medicaid); Tr. 589 (noting that Plaintiff was at "100% level of poverty"); Tr. 773 (noting, on October 24, 2016, that Plaintiff "has not had money or insurance to follow up with [a medical doctor] or get his [prescription] filled[,] so [he] has been ge[t]ting his care" through emergency room visits); Tr. 776 (noting that Plaintiff would need laboratory testing done when he could afford it); Tr. 785 ("Patient has been advised to go to Shands Hospital[,] but for reasons of insurance [that] has not been possible."); Tr. 813 (stating that Plaintiff is homeless and his family has turned its back on him); Tr. 823 (noting "financial problems due to being unemployed").)

As in Dawkins, the ALJ's conclusion that Plaintiff retained the RFC to return to work seems "inextricably tied to the finding of noncompliance," Dawkins, 848 F.2d at 1214. (See Tr. 25 ("The treatment records generally indicate that the condition is controlled with potassium and magnesium supplements when he is medication compliant.") (emphasis added); Tr. 25-26 ("At the hospital, he is quickly stabilized after IV supplementation, if he accepts treatment and is discharged.") (emphasis added); Tr. 23 ("When he does accept treatment at [the emergency room], he is quickly stabilized with IV potassium supplementation and released[.]") (emphasis added); see also Tr. 23 ("His potassium was especially low[,] but he refused IV supplementation and signed out against the doctor [sic] recommendation[.] . . . He expressed concern about his potassium level and complained of chest pain[,] but he refused lab work, imaging studies or any other care and again signed out [against medical advice.]") (emphasis added).)

Although the ALJ noted Plaintiff's inability to afford his prescribed supplements (Tr. 23), the ALJ did not seem to consider the impact of Plaintiff's poverty, homelessness, and lack of medical insurance on his non-compliance with treatment recommendations. Instead, the ALJ pointed out that Plaintiff's treatment has been "mostly conservative and non-aggressive." (Tr. 26.) However, the ALJ does not identify (and the record does not seem to include) any recommendations for more aggressive or less conservative treatment of Plaintiff's impairments. As Plaintiff could not afford to see a specialist at a renal clinic (see Tr. 506, 553, 589, 595, 601, 603, 605, 715), it is unclear what, if any, treatment options were available for his hypokalemia (see Tr. 785 ("I [] have no experience with this syndrome and cannot really provide any suggestion.")). As Dr. de Jesus7 explained to Plaintiff, even if he went to a university hospital for treatment of his Gitelman's syndrome, it would still be "a guessing game" because "there was no sure treatment" for this syndrome. (Tr. 61-62; see also Tr. 813 ("[T]he medicine makes me worry about going back and forth to the hospital because the medicine is not treating me completely. . . . Right now, they're pretty much guessing on how to treat it.").)

Although the ALJ states that Plaintiff's Gitelman's syndrome appears "fairly well controlled with the potassium and magnesium supplements" (Tr. 23), Dr. de Jesus told Plaintiff that his potassium level would never be normal (Tr. 471), and her statement seems supported by the laboratory results in the record. While normal potassium levels range from 3.5 to 5.0, Plaintiff's levels were: 3.4 on August 7, 2014 (Tr. 537); 3.2 on January 30, 2015 and May 1, 2015 (Tr. 577, 610); 2.8 on June 1, 2015 (Tr. 735); 2.4 on May 15, 2016 (Tr. 642, 644); 3.1 on June 10, 2016 (Tr. 725); 2.9 on September 2, 2016 and September 3, 2016 (Tr. 667, 672); 3.1 on September 4, 2016 (Tr. 683); 2.5 on October 16, 2016 (Tr. 773); 2.6 on December 7, 2016 (Tr. 784); and 2.1, 2.7, 2.8, and 3.4 on December 8, 2016 (Tr. 781, 783-85, 796). (Cf. Tr. 553 (noting a potassium level of 3.9 on September 2, 2014 after a high dose of potassium as well as a potassium sparing diuretic).) Also contrary to the ALJ's statement that Plaintiff "has not had recurrent hospitalizations" (Tr. 23), a December 2016 progress note shows that Plaintiff was in the hospital for three days and had been hospitalized twice in the previous month. (Tr. 809.) Plaintiff was also admitted for chest pain and other hypokalemia-related, acute symptoms on a number of other occasions, including on January 31, 2015, May 15, 2016, August 10, 2016, and September 3, 2016. (Tr. 584, 637, 639-40, 659-660, 787.)

The ALJ also notes instances when Plaintiff "refused IV supplementation and signed out against [medical advice]" and "refused lab work, imaging studies or any other care." (Tr. 23.) While it is true that in May 2016, Plaintiff signed out from the hospital against medical advice, the record shows that he left, because his "[m]other needed the car he was driving to go to work at Walmart." (Tr. 643.) During that same visit, Plaintiff was initially unable to tolerate the high dose of potassium, but he was able to absorb the lower dose without complaint, and was discharged in stable condition. (Tr. 637, 639-40.) In August 2016, after Plaintiff left the Villages Regional Hospital, the record shows that he went to Putnam Hospital, where he received potassium and was discharged. (Tr. 787.)

In sum, although there are instances when Plaintiff left without treatment (Tr. 584, 659-60, 791), the ALJ does not seem to consider the reasons therefor. Where, as here, the record is underdeveloped as to whether Plaintiff's financial status prevented him from receiving treatment, the Court is unable to determine whether the ALJ's credibility determination and RFC assessment are supported by substantial evidence. See Henry v. Comm'r of Soc. Sec., 802 F.3d 1264, 1269 (11th Cir. 2015) (per curiam) ("It is impossible to review whether the ALJ's decision is supported by substantial evidence if the record is not fully and fairly developed."). As explained in Henry:

Id. at 1268-69. As in Henry, the ALJ in the present case does not seem to consider any explanation for Plaintiff's failure to pursue further treatment, despite multiple references in the record to lack of insurance and lack of financial resources.

Further, the ALJ here notes that when Plaintiff accepts treatment, "he is quickly stabilized with IV potassium supplementation." (Tr. 23.) However, the laboratory results cited earlier do not seem to indicate stabilization. In fact, the only kidney specialist that Plaintiff saw, stated that his potassium level would never be normal. (Tr. 471.) Plaintiff was in and out of the emergency department not only because there was "no sure treatment" for his Gitelman's syndrome and the doctors who saw him had no experience with it (Tr. 61-62, 785, 813), but also because he could not afford a consult with a kidney specialist at a renal clinic.

In addition, in finding that Plaintiff's "condition is controlled with potassium and magnesium supplements" (Tr. 25), the ALJ does not seem to consider the side effects from the treatment. Although the ALJ notes Plaintiff's "alleged chronic incontinence," which he accommodates by "allowing restroom breaks each hour with facilities within a reasonable distance" (Tr. 26), he does not even mention Plaintiff's chronic diarrhea, which is also documented in the record (see, e.g., Tr. 325, 329, 781, 797, 809). Plaintiff testified that as a result of the magnesium supplements, he spends at least five to six hours a day in the bathroom, despite also taking Imodium. (Tr. 61, 67, 325.) The ALJ did not mention this testimony and did not seem to consider it in his credibility determination or in his RFC assessment.

Based on the foregoing, the Court cannot conclude that the ALJ's decision is supported by substantial evidence. Because the ALJ's conclusion that Plaintiff was not disabled seems "inextricably tied to the finding of noncompliance" with recommended treatment, the ALJ erred by failing to consider Plaintiff's inability to afford treatment. Dawkins, 848 F.2d at 1214. To the extent the ALJ found that Plaintiff's ability to work was restored as long as he followed any prescribed treatment, such a finding does not seem supported by substantial evidence, as shown above. Id. at 1213.

In light of this conclusion and the possible change in the RFC assessment, the Court finds it unnecessary to address Plaintiff's arguments regarding his mental limitations. See Jackson v. Bowen, 801 F.2d 1291, 1294 n.2 (11th Cir. 1986) (per curiam); Freese v. Astrue, 2008 WL 1777722, at *3 (M.D. Fla. Apr. 18, 2008); see also Demenech v. Sec'y of the Dep't of Health & Human Servs., 913 F.2d 882, 884 (11th Cir. 1990) (per curiam). However, on remand, the ALJ is directed to reconsider Plaintiff's mental impairment(s) and any resulting limitations.

Accordingly, it is ORDERED:

1. The Commissioner's decision is REVERSED and REMANDED pursuant to sentence four of 42 U.S.C. § 405(g), with instructions to the ALJ to: (a) reconsider Plaintiff's symptoms and inability to afford medical treatment in accordance with SSR 16-3p; (b) reconsider Plaintiff's mental impairment(s) and any resulting limitations; (c) reevaluate Plaintiff's RFC assessment, if necessary; and (d) conduct any further proceedings deemed appropriate.

2. The Clerk of Court is directed to enter judgment accordingly, terminate any pending motions, and close the file.

3. In the event that benefits are awarded on remand, any § 406(b) or § 1383(d)(2) fee application shall be filed within the parameters set forth by the Order entered in In re: Procedures for Applying for Attorney's Fees Under 42 U.S.C. §§ 406(b) & 1383(d)(2), Case No. 6:12-mc-124-Orl-22 (M.D. Fla. Nov. 13, 2012). This Order does not extend the time limits for filing a motion for attorney's fees under the Equal Access to Justice Act, 28 U.S.C. § 2412.

DONE and ORDERED.