CHARLES H. WEIGLE, Magistrate Judge.
This is a review of a final decision of the Commissioner of Social Security denying Plaintiff Yvonne Tate's application for benefits. In accordance with the analysis below, it is
Plaintiff applied for Title II benefits in November 2008, alleging disability due to "heart and kidney problems," as well as "back pain, neck pain, hand numbness, and shortness of breath." (Pl.'s Br., Doc. 13, p. 4). Although the Commissioner determined that Plaintiff was "disabled," she also determined that Plaintiff's disability did not begin until March 3, 2010. Plaintiff, at her administrative hearing, alleged an earlier onset date of October 25, 2008, and Plaintiff's claims in the instant appeal all relate to that earlier date. (R. 32-33). Specifically, Plaintiff argues that records from Caduceus Occupational Medicine ("Caduceus"), to which the reviewing administrative law judge ("ALJ") failed to assign weight, compel a finding of "disabled" during the relevant period. Because the ALJ should have accorded substantial or considerable weight to the Caduceus records absent clearly-articulated good cause to the contrary, and because this Court may not uphold the ALJ's decision on the basis of post-hoc rationalizations, Plaintiff's case must be reversed remanded to the Commissioner for further proceedings.
The courts have a narrow role in reviewing claims brought under the Social Security Act. Judicial review is limited to a determination of whether the Commissioner's decision is supported by "substantial evidence," as well as whether the correct legal standards were applied. Walker v. Bowen, 826 F.2d 996, 1000 (11th Cir. 1987).
"Substantial evidence" is defined as "more than a scintilla," and as "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 401 (1971). In determining whether substantial evidence supports the Commissioner's decision, a court may not decide the facts anew, reweigh the evidence, or substitute its judgment for that of the Commissioner. Bloodsworth v. Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983). Rather, courts may only scrutinize the record to assess the reasonableness of the Commissioner's factual findings. Id. Even if the evidence in the record preponderates against the Commissioner's decision, that decision must be affirmed if it is supported by substantial evidence.
The courts review questions of law de novo, and the Commissioner's "[f]ailure to apply the correct legal standards or to provide the reviewing court with the sufficient basis to determine that the correct legal principles have been followed is grounds for reversal." Wiggins v. Schweiker, 679 F.2d 1387, 1389 (11th Cir. 1982). But see Diorio v. Heckler, 721 F.2d 726, 728 (11th Cir. 1983) (applying the harmless error doctrine in the context of a Social Security appeal).
Persons are "disabled" for the purposes of receiving benefits under the Social Security Act if they are unable to engage in any substantial gainful activity due to a medically determinable physical or mental impairment which is expected to result in death or which has lasted or is expected to last for a continuous period of at least twelve months. 42 U.S.C. § 423(d)(1)(A).
When evaluating a claimant's alleged disability, the Commissioner typically follows a five-step "sequential evaluation process." 20 C.F.R. § 416.920(a)(4). At step one, the Commissioner determines whether the claimant is currently engaged in substantial gainful activity. At step two, the Commissioner determines whether the claimant has a severe medically determinable physical or mental impairment or combination of impairments that meets the duration requirement. This step has been described as a "reasonable administrative convenience designed to screen out groundless claims," Stratton v. Bowen, 827 F.2d 1447, 1452 (11th Cir. 1987), and the Eleventh Circuit has repeatedly noted that the failure of an ALJ to find a particular impairment "severe" at step two is generally harmless because "the finding of any severe impairment whether or not it results from a single severe impairment or a combination of impairments . . . is enough to satisfy step two." (Heatley v. Comm'r, 382 Fed. App'x 823, 824-25 (11th Cir. 2010) (quoting Jamison v. Bowen, 814 F.2d 585, 588 (11th Cir. 1987)) (punctuation omitted.
At step three, the Commissioner determines whether the claimant's impairments meet or equal the severity of one or more of the "listings" in 20 C.F.R. Part 404, Subpart P, Appendix 1. If so, the claimant is "disabled." If not, the Commissioner assesses the claimant's residual functional capacity ("RFC"), and then proceeds to step four where, she evaluates the claimant's ability to perform past relevant work. At step five, the Commissioner evaluates the claimant's ability to adjust to "other work." A finding, at either step four or step five, that a claimant is capable of working precludes a finding of "disabled."
Following the five-step sequential evaluation procedure, the ALJ in Plaintiff's case made the following findings. At step one, the ALJ found that Plaintiff had not engaged in substantial gainful activity since October 25, 2008, her alleged onset date. (R. 15). At step two, the ALJ found that Plaintiff suffered from the following "severe" impairments: "Obstructive sleep apnea; High blood pressure; Carpal Tunnel syndrome; Enlarged Heart; Degenerative cervical disc disease; and[] Obesity." (R. 15). At step three, the ALJ found that Plaintiff did not have an impairment or combination of impairments that met or medically equaled one of the "listings" in 20 C.F.R. Part 404, Subpart P, Appendix 1. Therefore, the ALJ assessed Plaintiff's RFC and determined that she could perform:
(R. 16)
Based on this RFC assessment, the ALJ found, at step four, that Plaintiff was unable to perform any of her past relevant work. (R. 20). At step five, however, the ALJ found that Plaintiff could perform the requirements of representative occupations such as "Order Caller," "Marker," and "Laundry Sorter." (R. 21). Therefore, the ALJ found Plaintiff "not disabled" within the meaning of the Social Security Act.
Plaintiff first argues that the ALJ erred at step two by failing to find that Plaintiff suffered from "severe" lumbar spine problems, breathing problems, and lower-extremity pain and swelling. (Pl.'s Br., Doc. 13, pp. 15-19; Reply, Doc. 18, pp. 4-5). As noted above, though, the failure by an ALJ to label an impairment "severe" at step two is not generally grounds for reversal. See Heatley v. Comm'r, 382 Fed. App'x 823, 824-25 (11th Cir. 2010) (quoting Jamison v. Bowen, 814 F.2d 585, 588 (11th Cir. 1987)). While it is true that an ALJ's failure to identify an impairment at step two may evidence the ALJ's failure to consider that impairment at later steps, see, e.g., Lucky v. Astrue, 331 Fed. App'x 634, 640 (11th Cir. 2009), Plaintiff did not make this argument,
Plaintiff's second argument relates to medical records from Caduceus Occupational Medicine (("Caduceus"), where Plaintiff received treatment related to a workplace injury from April 2003 until August 2005. (Exs. 12F, 13F). Some of the Caduceus records expressly limited Plaintiff to pushing, pulling and lifting a maximum of only ten pounds. (R. 390, 392-93, 405, 408, 415, 423-24, 426-27). This ten-pound exertional limitation was based, in part, on a diagnosis of bilateral carpal tunnel syndrome. (R. 390). If accepted as valid, the ten-pound exertional limitation advised by Caduceus would have limited Plaintiff to only "sedentary work" under the applicable regulations. 20 C.F.R. § 404.1567(a) ("Sedentary work involves lifting no more than 10 pounds . . ."). Additionally, because Plaintiff was found not to have skills transferrable to sedentary work, (R. 50), and because "most unskilled sedentary jobs require good use of both hands," Foote v. Chater, 67 F.3d 1553, 1559-60 (11th Cir. 1995) (quoting S.S.R. 83-12), it is not at all clear that Plaintiff would have been capable of performing sedentary work during the relevant period—the period between October 25, 2008 and March 3, 2010.
The ALJ in Plaintiff's case did not expressly evaluate the Caduceus records, and he also implicitly rejected those records by failing to account for the ten-pound exertional limitation in Plaintiff's RFC. (R. 16-17). Rather than limiting Plaintiff to sedentary work, as at least some of the Caduceus records appear to require, the ALJ determined that Plaintiff was limited to and could perform modified light work. 20 C.F.R. § 404.1567(b) ("Light work involves lifting no more than 20 pounds at a time with frequent lifting or carrying of objects weighing up to 10 pounds"). In doing so, the ALJ erred.
There is no dispute among the parties that the Caduceus records are, in fact, the records of a "treating source." (Resp., Doc. 16, p. 9). Similarly, the Commissioner does not appear to contest the notion that the Caduceus records, if given the substantial or considerable weight ordinarily accorded to treating sources,
All of these factors—the date and relevance of the Caduceus records, Plaintiff's prior work history, and Plaintiff's receipt of unemployment benefits
Also pending before the Court is a "Motion to Alter or Amend Pursuant to Federal Rule of Civil Procedure 59(e),"
The Commissioner argued, and continues to argue, that the missing records
In this case, though, neither the records of Dr. Muraina nor those of Dr. Chukwuemeka were at issue given the grounds for relief raised by Plaintiff. Accordingly, the Commissioner's pending Motion is
After careful consideration of the record, it is