ROBERT L. MILLER, Jr., District Judge.
Sharon Pope seeks judicial review of the final decision of the Commissioner of Social Security denying her applications for disability insurance benefits and Supplemental Security Income under the Social Security Act, 42 U.S.C. §§ 423 and 1381 et seq. The court has jurisdiction over this action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). For the reasons that follow, the court reverses and remands this case to the Social Security Administration for further proceedings.
Ms. Pope asserted disability as of April 26, 2009 due to cirrhosis and diabetes. Her applications were denied initially, on reconsideration, and after an administrative hearing at which she was represented by a non-attorney representative.
In evaluating Ms. Pope's claim of disability, the ALJ considered the medical evidence presented at the hearing and testimony from Ms. Pope and a vocational expert, Thomas Dunleavy. The ALJ found that Ms. Pope had both severe physical impairments (cirrhosis of the liver, diabetes, alcohol dependence, chronic obstructive pulmonary disease (COPD), hypertension, and obesity) and non-severe impairments (back pain and gastrointestinal problems), but that her impairments alone and in combination didn't meet or equal the requirements of a listed impairment, or preclude her from performing a limited range of light work and her past relevant work as a fast food worker and waitress.
When the Appeals Council denied Ms. Pope's request for review, the ALJ's decision became the final decision of the Commissioner of Social Security.
Ms. Pope contends that the ALJ gave too little weight to the opinions of the agency's consulting medical expert (Dr. Slodki) and her treating physicians (Drs. Kirby and Chand), failed to consider the combined effect of her impairments, and didn't adequately explain why her statements about the intensity, persistence and limiting effects of her symptoms weren't credible. The court agrees.
The issue before the court isn't whether Ms. Pope is disabled, but whether substantial evidence supports the ALJ's decision that she isn't disabled.
"In considering whether a claimant's condition meets or equals a listed impairment, an ALJ must discuss the listing [or listings] by name and offer more than a perfunctory analysis of the listing."
"Whether a claimant's impairment equals a listing is a medical judgment, and an ALJ must consider an expert's opinion on the issue."
If the basis of Dr. Slodki's opinion wasn't readily discernable or the ALJ needed clarification, she "ha[d] a duty to solicit additional information to flesh out" the consulting medical expert's opinion.
The ALJ's analysis of the medical opinions offered by Ms. Pope's treating physician and orthopedic surgeon, Dr. Karl Kirby and Dr. Kishan Chand, is flawed in the same way.
Dr. Kirby completed a questionnaire in December 2010, in which he stated that he treated Ms. Pope between September 16, 2010 and November 23, 2010. Dr. Kirby didn't identify the frequency of treatment, but the medical records before the ALJ showed that he saw Ms. Pope on October 22, 2010 for a routine gynecological exam and on November 23, 2010 for a follow-up evaluation of her diabetes.
Ms. Pope's treating orthopedic surgeon, Dr. Chand, completed a questionnaire in January 2011, in which he stated that Ms. Pope had been diagnosed with chondromalacia patella, osteoarthritis in the lumbar spine and left knee, chronic knee pain, COPD, and obesity, and that he had treated her once a month from October 25, 2010 to January 17, 2011. Dr. Chand opined that Ms. Pope could frequently lift up to ten pounds; could carry up to five pounds frequently and carry ten to twenty pounds occasionally; could sit for four hours (on and off) in an eight-hour day, and stand or walk for up to one hour (on and off); and had no limits on reaching, fine manipulations, grasping, or twisting. He reported that her prognosis was "fair", but that Ms. Pope frequently experienced pain, fatigue or other symptoms severe enough to interfere with attention and concentration, that she would need to take one or two ten to fifteen minute breaks in an eight-hour work day to rest; and that she was likely to miss work two to three times a month as a result of her impairments or treatment. Dr. Chand also opined that Ms. Pope would need to avoid temperature extremes, humidity and dust; couldn't push or pull anything over ten pounds; and couldn't kneel, bend, or stoop.
The ALJ gave no weight to either Dr. Kirby's or Dr. Chand's assessment of Ms. Pope's functional capacity. The ALJ noted that neither Dr. Kirby nor Dr. Chand had a longitudinal treatment relationship with Ms. Pope, and that their opinions were inconsistent with Ms. Pope's December 2010 report of "only very mild pain", and with other medical records that "generally indicate[d] normal findings," showed only mild arthritis in her lower facet joints, and indicated that her back and knee pain were "recent symptoms."
A treating physician's opinion is entitled to "controlling weight" if it's "well supported by medical findings and not inconsistent with other substantial evidence in the record."
The ALJ might have identified a sufficient basis for rejecting Dr. Kirby's assessment of Ms. Pope's impairments — he'd seen her only twice, didn't provide medical findings to support his opinion, and reached conclusions that were generally inconsistent with other evidence in the record. The same can't be said for her analysis of Dr. Chand's opinion.
The ALJ's decision doesn't adequately address the relevant factors set out in 20 C.F.R. § 404.1527(c)(2) with respect to Dr. Chand's assessment of Ms. Pope's spine and knee impairments, and so is insufficient. It appears that she gave little or no weight to Dr. Chand's status as an orthopedic surgeon, or that he treated Ms. Pope for three months for impairments related to his expertise (spine and knee pain), or that his assessment of Ms. Pope's functional capacity was consistent with other medical evidence in the record, most notably the opinion offered by the agency's consulting medical expert, Dr. Slodki. If the ALJ needed clarification, she could have solicited additional information from both Dr. Chand and Dr. Slodki. She didn't do so.
Ms. Pope contends that the ALJ also failed to consider the effects of her impairments in combination in determining her residual functional capacity and ability to perform her past relevant work. The court agrees.
An ALJ must consider the aggregate effects of all of the claimant's impairments in the residual functional capacity assessment, including those that are non-severe.
To the extent the ALJ's decision about the severity of Ms. Pope's impairments and her residual functional capacity was premised on her assessment of Ms. Pope's credibility, it is insufficient, too. The ALJ employed boilerplate language in explaining her credibility determination:
She concluded that Ms. Pope's testimony regarding the severity and limiting effects of her impairments wasn't "fully credible" because it wasn't supported by objective medical evidence and because of "several inconsistencies in the record and in the claimant's testimony at the hearing," regarding whether she continued to drink after March 2008, whether she worked after 2007, and whether she was actually adhering to a low-salt, diabetic diet or only "trying" to adhere to the diet.
The ALJ's credibility determination is premised in large part on her rejection of the corroborating medical opinions offered by Drs. Slodki, Chand, and Kirby, and her assessment of the medical evidence was inadequate. Courts have justly criticized the boilerplate language employed in this case because of its unhelpfulness.
The use of the boilerplate language doesn't require reversal, if the ALJ points to information that justifies her credibility determination, see
Whether Ms. Pope's statements are credible and whether she is capable of performing her past relevant work or other jobs are questions for the ALJ, not the court.
Neither substantial evidence nor an adequate discussion of the issues support the ALJ's findings with respect to the severity and limiting effects of Ms. Pope's physical impairments. When the court can't see an "accurate and logical bridge between the evidence and the result," remand is required.
Accordingly, the final decision of the Commissioner of Social Security is REVERSED and the matter REMANDED.
SO ORDERED.