MADELINE COX ARLEO, District Judge.
This Court has jurisdiction to review the Commissioner's decision under 42 U.S.C. § 405(g). The Commissioner's application of legal precepts is subject to plenary review,
"[T]he substantial evidence standard is a deferential standard of review."
In determining whether there is substantial evidence to support the Commissioner's decision, the Court must consider: "(1) the objective medical facts; (2) the diagnoses of expert opinions of treating and examining physicians on subsidiary questions of fact; (3) subjective evidence of pain testified to by the Plaintiff and corroborated by family and neighbors; and (4) the Plaintiff's educational background, work history, and present age."
Under the Social Security Act ("the Act"), disability is defined as the "inability 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 has lasted or can be expected to last for a continuous period of not less than 12 months." 42 U.S.C. § 416(i)(1). Pursuant to her authority under the Act, the Commissioner has promulgated extensive regulations governing claims for DIB. The Commissioner applies a five-step test to determine whether a claimant is disabled within the meaning of the Act. 20 C.F.R. § 404.1520(a)(4). If at any stage of the five-step procedure the Commissioner determines "that the claimant is or is not disabled," the analysis ends and "does not proceed to the next step."
At step one, the Commissioner must determine whether the claimant is currently engaged in "substantial gainful activity." 20 C.F.R. § 404.1520(a)(4)(i). "Substantial gainful activity" is work activity involving physical or mental activities that are "usually done for pay or profit, whether or not a profit is realized." 20 C.F.R. § 404.1572. If the claimant is not engaged in substantial gainful activity, the analysis proceeds to step two.
At step two, the Commissioner must determine whether the plaintiff's claimed impairment or combination of impairments are "severe" within the meaning of the Act. 20 C.F.R. § 404.1520(a)(4)(ii). The regulations provide that a severe impairment is one that "significantly limits [the claimant's] physical or mental ability to do basic work activities." 20 C.F.R. § 404.1520(c). In determining whether an adult plaintiff's psychological impairments are "severe," the Commissioner must apply the "special technique" or "Psychiatric Review Technique" mandated by 20 C.F.R. § 404.1520a. Under this technique, if the plaintiff's pertinent symptoms, signs, and laboratory findings suggest that the plaintiff has a medically determinable mental impairment, the Commissioner must then evaluate the degree of functional limitation arising from the mental impairment.
At step three, the Commissioner must determine whether the plaintiff's severe impairments meet or medically equal one of the impairments in the Listings.
Before proceeding to step four, the Commissioner must evaluate the plaintiff's residual functional capacity ("RFC"). 20 C.F.R. § 404.1520(a)(4)(iv). A plaintiff's RFC "is the most [the plaintiff] can still do despite [their] limitations." 20 C.F.R. § 404.1545(a)(1). In considering the plaintiff's RFC, the Commissioner must consider "all medically determinable impairments of which [she] is aware, including [plaintiff's] medically determinable impairments that are not `severe.'" 20 C.F.R. § 404.1545(a)(2).
At step four, the Commissioner must determine whether the plaintiff can perform their past relevant work given their RFC. 20 C.F.R. § 404.1520(a)(4)(v);
Plaintiff filed for DIB on June 5, 2013, alleging disability since March 8, 2013. Administrative Transcript ("Tr.") 151, ECF No. 5. The Commissioner initially disapproved his claim on November 15, 2013, and disapproved it again on reconsideration. Tr. 93-97, 99-101. On March 28, 2014, Plaintiff requested that an Administrative Law Judge review his claims. Tr. 104-05. On June 23, 2015, Plaintiff appeared at a hearing before the ALJ in Newark, New Jersey. Tr. 26-75. A non-attorney representative appeared on behalf of Plaintiff. Tr. 28, 103. On October 27, 2015, the ALJ denied Plaintiff's claim. Tr. 10-25. Plaintiff requested review by the Appeals Council on November 23, 2015, Tr. 148, but the Council denied review on May 31, 2018. Tr. 1-5. This action followed.
As of his alleged onset date, Plaintiff was a sixty-four-year-old man. Tr. 171. He completed one year of college in 1976, and from November 1989 until his alleged onset date in 2013, operated a street sweeper for the Public Works Department of the City of Plainfield, New Jersey, with the title of assistant supervisor. Tr. 39, 176.
In a function report dated July 29, 2013, Plaintiff reported significant limitations. Tr. 187-88. He could not walk for more than 50 yards before needing to rest for fifteen minutes. Tr. 188. While he could stand, he could not do so "for a length of time." Tr. 184. While Plaintiff attributed some limitations to his chemotherapy,
Beginning in August 2005, Plaintiff sought treatment from Complete Care for lower back pain. Tr. 230. Doctors there diagnosed him with a lumbar strain and placed him on modified duty, limiting him to "sitting work only." Tr. 229. Plaintiff continued to seek treatment for this condition through December of 2006, when he complained of worsened pain. Tr. 228.
The bulk of the medical records deal with Plaintiff's colon cancer and treatment. On January 24, 2013, a colonoscopy discovered an obstructing mass in Plaintiff's sigmoid colon. Tr. 231. Biopsies revealed the mass to be a moderately differentiated adenocarcinoma. Tr. 233. On March 8, 2013, Dr. Suraj Alva performed a resection operation on Plaintiff to remove the adenocarcinoma. Tr. 251-54. Plaintiff tolerated the surgery "very well from a surgical standpoint," but subsequently underwent chemotherapy treatments under the care of Dr. Sophie Morse. Tr. 263, 334. Dr. Morse's treatment notes show that Plaintiff complained of nausea, vomiting, fatigue, pain in his neck, inability to move his left arm, and diarrhea while undergoing chemotherapy. Tr. 333. Plaintiff also developed neuropathy, Tr. 331, 332, 318, and reported memory problems. Tr. 318. Dr. Morse's treatment notes show Plaintiff's neuropathy fluctuating from not present at a visit on October 31, 2014, to partially returning by April 2, 2015. Tr. 376. In a function report based on an exam from November 11, 2013, Dr. Morse opined that Plaintiff had no limitations in his ability to perform work related activities, but also noted that he did not have mental or physical impairments, other than those related to his chemotherapy. Tr. 340.
Beginning in July 2014, Plaintiff also sought care from various providers at a local Veterans' Affairs ("VA") hospital. On September 30, 2014, Dr. Suniti Sebastian diagnosed Plaintiff with hyperlipidemia and hypertension, noted that Plaintiff had recently reported "feelings of sadness," and referred him to VA mental health professionals. Tr. 416. Plaintiff saw VA social worker Barry Dueker on December 24, 2014, who found his mood to be "mildly depressed" but that his insight and judgment were good. Tr. 413. At a follow up appointment on January 14, 2015, Mr. Dueker found Plaintiff depressed. Tr. 411. Psychiatrist Marie Frino saw Plaintiff on February 4, 2015, diagnosed him with adjustment disorder with depressed mood, and prescribed him medication to treat it. Tr. 410. At a follow up visit on March 10, 2015, Dr. Frino continued Plaintiff's adjustment disorder medication, and noted that Dr. Nicholas Cunicella,
On June 23, 2015, Plaintiff appeared at a hearing before the ALJ. He testified that he could drive for about an hour at a time, go grocery shopping, and attend church services. Tr. 36. Although he was significantly more limited while he was undergoing chemotherapy, Plaintiff testified that as of the hearing, he could do much more. During chemotherapy, Plaintiff lost his hair, developed black patches on his hands, reported a lack of stamina, and could not dress himself. Tr. 41, 42-43. He reported being so fatigued that he was unable to do more than lie down all day. Tr. 46. As of the hearing, Plaintiff testified that he can dress and cook for himself, and that he can do housework or yard work for about 30 to 45 minutes. Tr. 45. However, he reported that even months after ceasing chemotherapy, he could only sit, stand or walk for 30 minutes at a time and could carry only 20-30 pounds. Tr. 54-55. He estimated that in a typical day, he could only sit or stand for a total of about four hours.
Plaintiff also testified that his memory suffered during the chemotherapy, and it had not fully recovered following treatment. Tr. 50. During chemotherapy, Plaintiff testified that his memory lapses were sufficiently serious as to prevent him from "convers[ing] with other folks," and that despite improvement, he was still experiencing them daily.
In terms of recreation, Plaintiff reported that he can play the drums for an hour, at most two hours in a day. Tr. 49. He reported taking vacations to Jamaica in June of 2014 and to Aruba in June 2015, each time for six days, and regularly attends church and a local social club in Plainfield. Tr. 52.
The ALJ determined that Plaintiff met the insured status requirements under the Act through June 30, 2014, and at step one, found that Plaintiff had not engaged in any substantial gainful activity since the alleged onset date. Tr. 15.
At step two, the ALJ determined that Plaintiff did not have any severe impairments.
Applying this procedure, the ALJ determined that Plaintiff's colon cancer, hypertension, hyperlipidemia, back and left knee pain, adjustment disorder, and depression were "medically determinable." Tr. 15-16. However, because Plaintiff's treating oncologist only determined that Plaintiff was unable to work from March to May 2013, the ALJ found that Plaintiff's colon cancer did not meet the durational requirement for impairments in 20 C.F.R. § 404.150, and thus "did not result in a significant limitation of function for a consecutive period of twelve months." Tr. 19. As for Plaintiff's other physical conditions, the ALJ concluded, without analysis, that Plaintiff's "other physical conditions are managed through medication, exercise, and medical monitoring and have not significantly impaired his function for a period of twelve months."
As for Plaintiff's mental impairments, the ALJ considered the four functional areas in § 12.00C of the Listing of impairments, 20 C.F.R. Pt. 404, Subpt. P, App. 1, and concluded that Plaintiff had mild limitations in concentration, persistence, or pace, but no limitation in any other area. Tr. 19-20. She thus concluded that Plaintiff was not under any severe limitations from his alleged onset date through his date last insured, and denied the claim at step two of the five step analysis.
Plaintiff contends that the ALJ erred in denying his claim at step two. The Court agrees.
As noted above, at step two, the ALJ must determine whether a plaintiff's impairment is "severe." 20 C.F.R. § 404.1520(a)(4)(ii). "The step-two inquiry is a
SSR 85-28, 1985 WL 56856 at *3. In conjunction with the plaintiff's low burden, the ALJ is required to conduct "an evaluation of the effects of the impairment(s) on the person's ability to do basic work activities," and a finding that "an impairment(s) is not severe requires a careful evaluation of the medical findings which describe the impairment(s) and an informed judgment about its (their) limiting effects on the individual's physical and mental ability(ies) to perform basic work activities."
Given the combination of the low burden and requirement of careful evaluation, "the Commissioner's determination to deny an applicant's request for benefits at step two should be reviewed with close scrutiny."
Here, the ALJ did not carefully evaluate the limiting effects of any of Plaintiff's conditions other than his colon cancer. While the ALJ correctly noted that Plaintiff's treating oncologist opined that, as of November 19, 2013, Plaintiff's colon cancer did not pose any limitations as to Plaintiff's ability to engage in physical work-related activities, Tr. 340, the same oncologist incorrectly noted that Plaintiff had "no [other] physical or mental limitations" at that time.
Instead, the ALJ gave only a cursory review to Plaintiff's other physical impairments.
Because the ALJ insufficiently analyzed whether Plaintiff was suffering from any severe impairments, the Commissioner's determination is