ANDREW P. RODOVICH, Magistrate Judge.
This matter is before the court on petition for judicial review of the decision of the Commissioner filed by the plaintiff, Langawa Hampton-Lewis, on July 5, 2017. For the following reasons, the decision of the Commissioner is
The plaintiff, Langawa Hampton-Lewis, filed applications for Disability Insurance Benefits and Supplemental Security Income on June 3, 2013, alleging a disability onset date of October 1, 2012. (Tr. 18). The Disability Determination Bureau denied Hampton-Lewis's applications initially on August 15, 2013, and again on reconsideration on October 10, 2013. (Tr. 18). Hampton-Lewis filed a timely request for a hearing on November 11, 2013. (Tr. 18). A video hearing was held on April 29, 2015, before Administrative Law Judge (ALJ) William G. Reamon, and the ALJ issued an unfavorable decision on July 14, 2015. (Tr. 18). The Appeals Council remanded the decision and ordered a new hearing. (Tr. 18). A new hearing was held on January 4, 2017, before ALJ William E. Sampson, and again the All issued an unfavorable decision on January 13, 2017. (Tr. 18-30). Vocational Expert (VE), Thomas A. Gusloff, and Hampton-Lewis testified at the hearing. (Tr. 18). The Appeals Council denied review, making the ALF's decision the final decision of the Commissioner. (Tr. 1-6).
Hampton-Lewis met the insured status requirements of the Social Security Act through December 31, 2016. (Tr. 21). The ALJ issued an unfavorable decision on January 13, 2017, and made findings as to each of the steps in the five-step sequential analysis. (Tr. 18-30). At step one of the five-step sequential analysis for determining whether an individual is disabled, the All found that Hampton-Lewis had not engaged in substantial gainful activity since October 1, 2012, the alleged onset date. (Tr. 21).
At step two, the All determined that Hampton-Lewis had the following severe impairments: osteoarthritis, history of ankle fracture, and bipolar disorder. (Tr. 21). At step three, the ALJ concluded that Hampton-Lewis did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (Tr. 21). The ALJ considered Listings 1.02 and 1.06, and did not find that Hampton-Lewis's osteoarthritis and ankle fracture met or equaled the criteria specified for the listings. (Tr. 22). The ALJ found that there was no evidence in the record that Hampton-Lewis had gross anatomical deformity in any joint or lacked the ability to ambulate or perform fine or gross movements effectively. (Tr. 22). The ALJ cited evidence from the record that Hampton-Lewis had a normal gait on several occasions. (Tr. 22).
Next, the All determined that the severity of Hampton-Lewis's mental impairment did not meet or medically equal Listing 12.04. (Tr. 22). In finding that Hampton-Lewis did not meet the above listing, the ALJ considered the paragraph B criteria for mental impairments which required at least two of the following:
(Tr. 22). The ALJ defined a marked limitation as more than moderate but less than extreme and repeated episodes of decompensation, each of extended duration, as three episodes within one year or once every four months with each episode lasting at least two weeks. (Tr. 22).
The All determined that Hampton-Lewis had mild restrictions in activities of daily living. (Tr. 22). Hampton-Lewis indicated that she sometimes went two or three days before bathing or combing her hair. (Tr. 22). Yet, the All noted that otherwise she reported no problems with her personal care. (Tr. 22). Also, she reported that she was able to wash dishes, do laundry, sweep, drive, and shop. (Tr. 22).
Next, the All concluded that Hampton-Lewis had moderate restrictions in social functioning. (Tr. 22). Hampton-Lewis indicated that she did not have any issues getting along with family members, friends, neighbors, or others. (Tr. 22). Moreover, she reported that she regularly talked to friends and family members on the phone. (Tr. 22).
Finally, the ALJ found that Hampton-Lewis had moderate difficulties in concentration, persistence, or pace. (Tr. 22). The ALJ noted that Hampton-Lewis completed four or more years of college and had a history of performing skilled work. (Tr. 23). Hampton-Lewis indicated that she can follow written and spoken instructions well. (Tr. 23). The All considered the State agency consultants' opinion that Hampton-Lewis had no severe mental impairments. (Tr. 23). Thus, the ALJ found that Hampton-Lewis had no restrictions in maintaining concentration, persistence, or pace. (Tr. 23). Moreover, the All found that Hampton-Lewis did not experience any episodes of decompensation. (Tr. 23). Because Hampton-Lewis did not have two marked limitations or one marked limitation and repeated episodes of decompensation, the All determined that she did not satisfy the paragraph B criteria. (Tr. 23). Additionally, the ALJ concluded that she did not satisfy the paragraph C criteria. (Tr. 23).
After consideration of the entire record, the All then assessed Hampton-Lewis's residual functional capacity (RFC) as follows:
(Tr. 23). The ALJ explained that in considering Hampton-Lewis's symptoms he followed a twostep process. (Tr. 24). First, he determined whether there was an underlying medically determinable physical or mental impairment that was shown by a medically acceptable clinical or laboratory diagnostic technique that reasonably could be expected to produce Hampton-Lewis's pain or other symptoms. (Tr. 24). Then, he evaluated the intensity, persistence, and limiting effects of the symptoms to determine the extent to which they limited Hampton-Lewis's functioning. (Tr. 24).
The All, after consideration of the evidence, determined that Hampton-Lewis's medically determinable impairments could reasonably be expected to cause the alleged symptoms. (Tr. 24). However, her statements concerning the intensity, persistence, and limiting effects of her symptoms were not entirely consistent with the medical evidence and other evidence in the record. (Tr. 24). The ALJ found that the record indicated that in terms of Hampton-Lewis's alleged physical impairments she was more than minimally limited, but not disabled. (Tr. 24). He noted that she had engaged in relatively little treatment. (Tr. 25). She underwent surgery on her right ankle on September 20, 2013, but as of October 17, 2013 she was described as healing well and having full range of motion, as well as functional strength. (Tr. 25). Also, the ALJ found that the medical records documented few functional limitations. (Tr. 25). Hampton Lewis had full muscle strength in her upper and lower extremities. (Tr. 25). The All noted that the records indicated that Hampton-Lewis had a normal gait; was able to stoop and squat without difficulty; and was able to get on and off the examination table without difficulty and did not require assistance. (Tr. 25). Also, she was able to stand from a sitting position without difficulty and did not appear to be in acute distress. (Tr. 25).
Next, in considering Hampton-Lewis's mental impairments the ALJ noted that she had a history of mental health treatment. (Tr. 25). However, the All indicated that Hampton-Lewis had not been hospitalized for mental health reasons since her alleged onset date. (Tr. 25). The All noted that Hampton-Lewis's mental health records indicated that she only had been partially compliant with her medication. (Tr. 26). However, at the time of the decision the ALJ found that she was compliant with her medication and her most recent record reported that she was "functioning okay." (Tr. 26).
As for the opinion evidence, the All assigned considerable weight to the opinions of the State agency medical consultants. (Tr. 26). The State agency medical consultants determined that Hampton-Lewis was limited to work at the medium exertional level with additional postural limitations. (Tr. 26). Next, the ALJ assigned some weight to the opinions of the State agency psychological consultants. (Tr. 27). The State agency psychological consultants found that Hampton-Lewis did not have a mental impairment. (Tr. 27). The ALJ assigned little weight to the opinions of Hampton-Lewis's treating physicians, Dana Marlowe, MD, and Kular Rajnishpaul, MD. (Tr. 27).
At step four, the ALJ found that Hampton-Lewis was unable to perform any past relevant work. (Tr. 28). Considering Hampton-Lewis's age, education, work experience, and RFC, the AU concluded that there were jobs in the national economy that she could perform, including cleaner/housekeeping (200,000 jobs nationally), linen grader (50,000 jobs nationally), and marker (200,000 jobs nationally). (Tr. 29-30). The AU found that Hampton-Lewis had not been under a disability, as defined in the Social Security Act, from October 1, 2012 through the date of this decision, January 13, 2017. (Tr. 30).
The standard for judicial review of an ALF's finding that a claimant is not disabled within the meaning of the Social Security Act is limited to a determination of whether those findings are supported by substantial evidence. 42 U.S.C. §
Disability and supplemental insurance benefits are available only to those individuals who can establish "disability" under the terms of the Social Security Act. The claimant must show that she is unable "to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." 42
Hampton-Lewis has requested that the court reverse the ALF's decision and award benefits, or in the alternative remand the matter for additional proceedings. In her appeal, Hampton-Lewis has argued that: (1) the ALJ did not support the physical RFC with substantial evidence; (2) the mental RFC was internally inconsistent, not supported by substantial evidence, and did not properly accommodate her limitations in concentration, persistence, or pace; (3) the All did not evaluate her treating physicians' opinions according to 20 CFR § 404.1527; and (4) the ALJ did not properly analyze her subjective allegations according to SSR 16-3p.
First, Hampton-Lewis has argued that the All did not support the physical RFC with substantial evidence. "The RFC is an assessment of what work-related activities the claimant can perform despite his limitations."
SSR 96-8p (footnote omitted). Thus, as explained in this section of the Ruling, there is a difference between what the ALJ must contemplate and what he must articulate in his written decision. "The ALJ is not required to address every piece of evidence or testimony presented, but he must provide a `logical bridge' between the evidence and his conclusions."
The All assessed Hampton-Lewis's physical RFC as follows:
(Tr. 23). The ALJ afforded some weight to the opinions of the non-examining State agency reviewing physicians who found that Hampton-Lewis was limited to work at the medium exertional level with additional postural limitations. (Tr. 26). However, the All further limited Hampton-Lewis to the light exertional level based on her ankle surgery. (Tr. 26).
Hampton-Lewis contends that the ALJ, by rejecting the State agency physicians' limitations, determined the physical RFC without any support from medical opinions expressed by a doctor. However, an ALJ is not required to rely solely on medical opinions to determine the RFC.
The last State agency opinions were rendered on October 9, 2013. Therefore, Hampton-Lewis has indicated the State agency medical consultants review of the record did not include evidence from her ankle arthroscopy with extensive debridement and repair when they determined that she could perform medium work. (Tr. 173, 697-99). She contends that the ALJ interpreted significant evidence that was rendered subsequent to the State agency's opinion himself in determining that she could perform light work. Thus, Hampton-Lewis asserts that All improperly rendered an independent assessment of the medical evidence.
The Commissioner contends that the ALF's findings were supported by the opinions of the State agency physicians, Drs. Brill and Eskonen, as well as Hampton-Lewis's own complaints of pain. Moreover, the Commissioner asserts that the ALJ considered evidence subsequent to Drs. Brill and Eskonen's opinions and determined that the evidence did not include any medical opinions of disabling physical functional limitations. Finally, the Commissioner contends that it was Hampton-Lewis's burden to produce evidence of a disability and that the ALJ was free to interpret record evidence, including medical evidence.
However, Hampton-Lewis has argued that ALJ failed to analyze and omitted several allegations that were supportive of a more restrictive RFC. For example, Hampton-Lewis contends that the ALJ failed to consider that she had trouble standing for extended periods, the need to elevate her leg, and that she frequently was drowsy throughout the day. Hampton-Lewis has indicated that her testimony that she could walk only a couple blocks before her ankle would swell was consistent with the medical evidence subsequent to the State agency physicians' opinions. She asserts that her ankle surgery and her diagnosis of trochanteric bursitis corroborate her issues with standing and walking.
Additionally, Hampton-Lewis has argued that the All did not explain how he decided between occasional or frequent stooping restriction, nor did the All identify any analysis or reasoning underlying his conclusion. Hampton-Lewis asserts that the All did not cite to specific evidence that suggested that she could engage in those postural activities occasionally, but not less.
The court may not reweigh the evidence. Rather, the court must determine if the ALJ has supported his decision with substantial evidence and provided an adequate explanation. The ALJ found that Hampton-Lewis could perform light work, which required her to be on her feet for up to six hours out of the workday; occasionally climb ramps and stairs, balance, stoop, kneel, and crawl; and lift up to 20 pounds. (Tr. 23). The All relied on the State agency medical consultants' opinions in determining the RFC. However, as noted earlier the State agency consultants did not consider Hampton-Lewis's 2013 ankle arthroscopy with extensive debridement and repair. Therefore, the All limited her to light level of exertion based on her ankle surgery, but agreed with the State agency medical consultants that her physical impairments were not disabling.
The All may not have pointed directly to evidence in the record that indicated that Hampton-Lewis could engage in the specific postural activities, yet the All discussed the medical evidence at length. "An All must build an accurate and logical bridge from the evidence to his conclusion, but he need not provide a complete written evaluation of every piece of testimony and evidence." See
Next, Hampton-Lewis has argued that the mental RFC failed to account for her moderate restrictions in concentration, persistence, or pace and her reaction to stress. The ALF's RFC assessment and the hypothetical posed to the VE must incorporate all of the claimant's limitations supported by the medical record.
The ALJ determined that Hampton-Lewis had mild limitations in daily living, moderate limitations in social functioning, and moderate limitations in concentration, persistence, or pace. (Tr. 22). In assessing Hampton-Lewis's mental residual functional capacity, the All limited Hampton-Lewis to work involving simple, routine, and repetitive tasks; occasional interaction with coworkers, supervisors, and the public; and few workplace changes. (Tr. 23).
The Commissioner has indicated that the State agency psychologists, Drs. Joelle Larsen and Kenneth Neville, found that Hampton-Lewis could "learn, remember and comprehend simple instructions, and can complete tasks;" "interact appropriately with coworkers, supervisors, and the public in typical work settings;" "handle routine changes found in the workplace;" and "appears capable of completing semiskilled tasks." (Tr. 139, 163). The Commissioner contends that the ALJ considered the State agency psychologists' opinions and determined that Hampton-Lewis was more limited. Thus, the ALJ considered the other record evidence and found that she had more severe mental functional limitations.
Hampton-Lewis's treating psychiatrist, Dr. Rajnishpaul Kular, found that Hampton-Lewis had serious limitations in working in coordination with others; completing a normal workday without interruption; accepting instruction and responding appropriately to supervisors' criticism; performing at a consistent pace; responding appropriately to change in a routine work setting; and dealing with normal work stress. (Tr. 948). Additionally, Hampton-Lewis's other treating psychiatrist, Dr. Dana Marlowe, also found that Hampton-Lewis was seriously limited in her ability to deal with normal stress. (Tr. 1008). The ALJ did not account for Hampton-Lewis's limitation in dealing with stress. The All cannot ignore evidence that undermines his ultimate conclusions.
Despite the ALF's reliance on Drs. Larsen and Neville's findings, courts repeatedly have held terms like "simple, repetitive tasks" alone do not exclude from the VE's consideration those positions that present significant problems with concentration, persistence, or pace.
Moreover, the ALJ asked the VE, "[h]owever, due to impairment related symptoms such as fatigue, due to the side effects of medications, this individual would be off task 20 percent of the workday. Would there be any jobs?" (Tr. 71). The VE answered, "[n]o, that would be beyond what employers would tolerate, and the person wouldn't be able to sustain any competitive work if they were operating at 20 percent off task." (Tr. 71). The ALJ considered the issue of off-task time when posing the hypothetical to the VE, but then he failed to provide any analysis of whether, for example, Hampton-Lewis was limited by any off-task allowances and, if so, for how long. See, e.g.,
The All has failed to offer any explanation for why he did not account for her fatigue in the RFC analysis. The Commissioner did not address this argument. Therefore, without any explanation the court is unable to trace the ALJ's path of reasoning. The ALJ has failed to provide a "logical bridge" between the evidence and the RFC conclusion, requiring remand. See
The All gave little weight to the opinions of Hampton-Lewis's treating psychiatrists, Drs. Marlowe and Kular. A treating source's opinion is entitled to controlling weight if the "opinion on the issue(s) of the nature and severity of [the claimant's] impairment(s) is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence" in the record. 20
"`[O]nce well-supported contradicting evidence is introduced, the treating physician's evidence is no longer entitled to controlling weight' and becomes just one more piece of evidence for the ALJ to consider."
If the ALJ decides that the treating physician's opinion should not be given controlling weight, the ALJ is "required by regulation to consider certain factors in order to decide how much weight to give the opinion."
First, Hampton-Lewis has argued that the All failed to evaluate the opinions of Drs. Marlowe and Kular according to the requirements of 20 C.F.R. § 404.1527. Hampton-Lewis's arguments focus on the ALF's evaluation of Dr. Kular's findings. Hampton-Lewis contends that the ALJ neither considered the length of Dr. Kular's and Hampton-Lewis's relationship nor the extent of the relationship. Dr. Kular began treating Hampton-Lewis in 2012 and saw her every four to six weeks. (Tr. 946). "When the treating source has seen you ... long enough to have obtained a longitudinal picture of your impairment, we will give the medical source's medical opinion more weight ..." 20
Moreover, the ALJ assigned some weight to the State agency psychological consultants. Generally, an ALJ affords more weight to the opinion of an examining source than the opinion of a non-examining source, but the ultimate weight given depends on the opinion's consistency with the objective medical evidence, the quality of the explanation, and the source's specialty.
The ALJ discounted Dr. Kular's opinion because despite her extreme work preclusive limitation, she only assessed Hampton-Lewis with a GAF score of 55. However, the ALJ indicated that he assigned little weight to opinions expressed as GAF scores because a GAF score is not dispositive for Social Security disability purposes. Furthermore, the All found that the social limitations found by Dr. Kular were inconsistent with Hampton-Lewis's report that she got along well with family, friends, neighbors, or others. The ALJ indicated that Dr. Kular's finding that Hampton-Lewis had extreme mood swings and was hospitalized due to them was inconsistent with the medical history in her own treatment notes that did not reflect hospitalization since 2005.
Next, the All noted that Dr. Kular did not assess Hampton-Lewis with the same limitations as Dr. Marlowe. However, the All specifically did not point to the inconsistencies between the two opinions. Dr. Kular found that Hampton-Lewis had serious limitations in working in coordination with others; completing a normal workday without interruption; accepting instructions and responding appropriately to supervisors' criticism; performing at a consistent pace; responding appropriately to changes in a routine work setting; and dealing with normal work stress. (Tr. 948). Additionally, Dr. Kular found that Hampton-Lewis had similar serious limitations in understanding, remembering, and carrying out detailed instructions and with dealing with the stress of semi-skilled and skilled work. (Tr. 949). Dr. Kular opined that Ms. Hampton-Lewis would need to be absent from work more than four days per month due to her impairments. (Tr. 950).
Dr. Marlowe found serious limitations in Hampton-Lewis's ability to maintain attention for a two hour segment; maintain regular attendance; sustain an ordinary routine without special supervision; complete a normal workday without psychological interruptions; respond appropriately to changes in a routine work setting; deal with normal work stress; understanding, remembering, and carrying out detailed instructions as well as dealing with the stress of semiskilled and skilled work. (Tr. 1008-09). Dr. Marlowe opined that Hampton-Lewis would need to miss three days of work per month due to her impairments. (Tr. 1009).
The court finds that the All may have found sound reasons for not giving Dr. Kular's opinion controlling weight. However, the ALJ erred by assigning the opinion little weight without considering the regulatory factors under 20 C.F.R. § 404.1527(c). The ALJ has failed to consider the length of Dr. Kular's and Hampton-Lewis's relationship or the extent of their relationship, which are two factors that weigh heavily in favor of assigning controlling weight to Dr. Kular. Moreover, the ALJ failed to consider the consistency of the medical opinions with the opinions of other the other treating and reviewing medical sources. See
Finally, Hampton-Lewis has argued that the All failed to analyze her pain pursuant to SSR 16-3p. An ALF's evaluation of subjective symptoms will be upheld unless it is patently wrong.
Under SSR 16-3, the All first must determine whether the claimant has a medically determinable impairment that could reasonably be expected to produce her symptoms. SSR 16-3p, 2016 WL 1119029, at *2. Then, the All must evaluate the "intensity, persistence, and functionally limiting effects of the individual's symptoms to determine the extent to which the symptoms affect the individual's ability to do basic work activities." SSR 16-3p, 2016 WL 1119029, at *2. An individual's statements about the intensity and persistence of the pain may not be disregarded because they are not substantiated by objective medical evidence. SSR 16-3p, 2016 WL 1119029 at *5. In determining the ability of the claimant to perform work-related activities, the ALJ must consider the entire case record, and the decision must contain specific reasons for the finding. SSR 16-3p, 2016 WL 1119029, at *4, 9. The All must weigh the claimant's subjective complaints, the relevant objective medical evidence, and any other evidence of the following factors:
See
Hampton-Lewis has argued that the ALJ did not specifically discuss which allegations he found credible and those he found incredible. She contends that the ALJ summarized her subjective allegations and did not explain why they were not consistent with the evidence of record. Moreover, she asserts that the ALJ ignored her limitations in daily activities. Also, she has indicated that the All did not consider her good work history. However, a good work history "is still just one factor among many, and it is not dispositive."
The Commissioner contends that the All has asserted valid reasons to support his credibility finding. First, the Commissioner notes that the ALJ considered the objective medical evidence in determining that Hampton-Lewis's subjective complaints were unreliable. Moreover, the All noted that Hampton-Lewis engaged in relatively little treatment. (Tr. 25). Therefore, he considered her treatment, other than medication, for relief of pain or other symptoms. 20
The court is not finding the All subjective symptom analysis was patently wrong. However, since this matter is being remanded on different issues the ALJ may reconsider Hampton-Lewis's subjective allegations and indicate what symptoms he finds credible and those he finds not credible.
Hampton-Lewis has requested that the court remand for an award of benefits. An award of benefits is appropriate "only if all factual issues involved in the entitlement determination have been resolved and the resulting record supports only one conclusion—that the applicant qualifies for disability benefits."
Based on the foregoing reasons, the decision of the Commissioner is