NANCY A. VECCHIARELLI, Magistrate Judge.
Plaintiff, Gretchen L. Walker ("Plaintiff"), challenges the final decision of Defendant, Carolyn W. Colvin, Acting Commissioner of Social Security ("Commissioner"), denying her applications for Period of Disability ("POD"), Disability Insurance Benefits ("DIB"), and Supplemental Security Income ("SSI") under Titles II and XVI of the Social Security Act,
On November 30, 2011, Plaintiff filed her applications for POD, DIB, and SSI, alleging a disability onset date of October 1, 2007. (Transcript ("Tr.") 11.) The application was denied initially and upon reconsideration, and Plaintiff requested a hearing before an administrative law judge ("ALJ"). (Id.) On May 30, 2013, an ALJ held Plaintiff's hearing. (Id.) Plaintiff participated in the hearing, was represented by counsel, and testified. (Id.) A second hearing was held on December 6, 2013, during which Plaintiff, with counsel, participated and testified. (Id.) A vocational expert ("VE") also participated and testified. (Id.) On February 6, 2014, the ALJ found Plaintiff not disabled. (Tr. 22.) On February 24, 2015, the Appeals Council declined to review the ALJ's decision, and the ALJ's decision became the Commissioner's final decision. (Tr. 1.) On June 19, 2015, Plaintiff filed her complaint to challenge the Commissioner's final decision. (Doc. No. 1.) The parties have completed briefing in this case. (Doc. Nos. 11, 12, 13.)
Plaintiff asserts the following assignments of error: (1) The ALJ erred in failing to evaluate Plaintiff's severe impairment of fibromyalgia as required by Social Security Ruling (S.S.R.) 12-2p, and (2) the ALJ's Step Three evaluation was insufficient to support the disability determination.
Plaintiff was born in July 1979 and was 28-years-old on the alleged disability onset date. (Tr. 20) She had at least a high school education and was able to communicate in English. (Id.) She had past relevant work as a waitress. (Tr. 19.)
In November 2009, Plaintiff treated with Gary Petty, M.D., for chronic wrist and hand pain, numbness and tingling in her fingers, mild fatigue, and migraine headaches. (Tr. 416.) Dr. Petty prescribed medication and ordered tests. (Tr. 419.)
Plaintiff returned to Dr. Petty in December 2009 and reported that her wrists continued to hurt and Prednisone provided little relief. (Tr. 409.) Plaintiff said that a healthcare provider previously diagnosed ulnar nerve neuropathy and osteoarthritis. (Id.) She described her osteoarthritis as mildly uncomfortable but nonprogressive. (Id.) During a physical examination, Plaintiff complained of pain with bilateral wrist range of motion. (Tr. 410.) None of her major joints were tender. (Id.)
In April 2010, Plaintiff followed up with Dr. Petty for arm pain, asthma, fatigue, and bronchitis. (Tr. 406.) On examination Plaintiff's arms and hands were mildly tender. (Tr. 407.) During testing, Plaintiff made a poor effort to squeeze her hands. (Id.)
During July 2010, neurologist M. Barry Louden, M.D., evaluated Plaintiff due to pain and numbness in her arms and legs. (Tr. 386.) Dr. Louden explained that a 2009 EMG showed mild left and mild to moderate right ulnar neuropathies but no evidence of generalized neuropathy. (Id.) Plaintiff grimaced when Dr. Louden lightly touched her arms and hands and deeply touched her legs. (Id.) Dr. Louden indicated there was "clear profound give-way resistance to muscle strength testing everywhere." (Id.) Plaintiff's gait was normal, though she moved slowly and grimaced when she moved from sitting to standing. (Tr. 387.) Dr. Louden could not explain the origin of Plaintiff's pain and opined that based on the examination, Plaintiff was exaggerating her symptoms. (Id.)
On August 27, 2010, Plaintiff reported to Dr. Petty that a family doctor had diagnosed fibromyalgia after performing a tender points test. (Tr. 403.) Plaintiff said that she experienced "moderate" pain in her tender points and joint stiffness. (Id.) Plaintiff had tried anti-inflammatories but was not taking any medication because "nothing work." (Id.) Following a physical examination, Dr. Petty reported that Plaintiff had tenderness in "many pressure points in the arms, back, chest, thighs, and calves." (Tr. 404.) She experienced pain with range of motion in both shoulders and elbows. (Id.) Dr. Petty opined that Plaintiff exaggerated her pain with some movements and winced or grimaced at barely being touched. (Id.) For fibromyalgia, Dr. Petty prescribed exercise as tolerated and heat therapy. (Tr. 405.)
On April 13, 2012, Plaintiff presented to the emergency department at Marietta Memorial Hospital with complaints of neck pain, facial numbness, and sharp pain in her arms and legs. (Tr. 465.) Plaintiff explained that her symptoms had been ongoing for two years and a physician told her that she may have fibromyalgia. (Id.) Plaintiff had not been taking medication. (Id.) Plaintiff's diagnosis included fibromyalgia. (Id.) Daniel Jarrell, D.O., noted that Plaintiff's symptoms were diffuse and not specific, and her physical examination was generally unremarkable. (Tr. 466.) Dr. Jarrell advised Plaintiff that if she was not improving, she needed to follow through with a primary care physician and a neurologist. (Id.)
Plaintiff sought emergency room treatment on June 24, 2012, for frequent falls and weakness in her arms and legs. (Tr. 514.) Plaintiff had not been taking any medication. (Id.) Diagnostic testing and examination findings were generally unremarkable. (Tr. 514, 516-17.) Plaintiff was discharged in improved condition on June 26, 2012, after healthcare providers administered Neurontin and Solu-Medrol. (Tr. 514.) Frederic Humphrey, D.O., scheduled Plaintiff for an outpatient nerve conduct study, prescribed Neurontin, and advised her to take over-the-counter medication for pain or discomfort. (Id.) Plaintiff's final diagnoses were recurrent myalgia with history of fibromyalgia and bronchial asthma. (Id.)
In April 2013, Plaintiff established care with Katrina Barnes, M.D., at Memorial Health System's Family Practice. (Tr. 507.) Plaintiff complained that it was becoming harder for her to walk and to "do anything." (Id.) Plaintiff last treated with Dr. Petty in 2010, and he had diagnosed fibromyalgia. (Id.) She had difficulty walking due to weakness and falls. (Tr. 509.) She could not drive, would not go to the store by herself, and had to sit on a stool to perform activities of daily living. (Id.) Plaintiff complained of muscle weakness, numbness, tremors, ataxia, and parenthesis. (Id.) She denied back and joint pain. (Id.) On examination, Plaintiff exhibited decreased strength, but Dr. Barnes could not determine whether Plaintiff truly had muscle weakness or was making a poor effort. (Tr. 510.) Dr. Barnes diagnosed a tremor and muscle weakness. (Tr. 511.) The doctor opined that many of Plaintiff's symptoms appeared to be neurological in origin. (Id.) Dr. Barnes referred Plaintiff to neurology and planned to evaluate Plaintiff's prior medical records. (Id.)
On April 29, 2013, Dr. Louden reevaluated Plaintiff for diffuse weakness and fluctuating numbness. (Tr. 655.) Plaintiff complained of very little pain, although she mentioned aching joints and fatigue. (Id.) She indicated that she had "fixed numbness laterally distal to the right knee" and sometimes had to drag her right leg. (Id.) Dr. Louden recounted that a 2009 EMG suggested bilateral ulnar neuropathies but a 2012 EMG did not suggest abnormalities. (Id.) Plaintiff displayed profound give-way resistance during muscle strength testing, especially with forward neck flexion. (Id.) Plaintiff's reflexes and sensation were intact. (Id.) Dr. Louden could not find evidence of an underlying neurologic illness. (Tr. 656.)
Plaintiff sought emergency room care for spasms and paresthesias in August 2013. (Tr. 512.) She declined to undergo testing. (Tr. 513.)
In January 2012 state agency physician Lynne Torello, M.D., reviewed the record. (Tr. 68-74.) Dr. Torello opined that Plaintiff could perform a range of light work, including lifting and carrying up to ten pounds frequently and 20 pounds occasionally. (Tr. 71.) Plaintiff could also sit, stand, or walk for more than six hours in an eight-hour workday. (Id.) She could occasionally climb, balance, stoop, kneel, crouch, or crawl. (Tr. 72.) Dr. Torello recommended environmental limitations. (Id.) During March 2012, state agency physician Leon Hughes, M.D., reviewed the updated record and affirmed Dr. Torello's findings. (Tr. 92.)
On July 2, 2013, Sushil Sethi, M.D., conducted a physical examination of Plaintiff. (Tr. 657.) Plaintiff complained of profound weakness in her legs and left arm. (Id.) On examination, Plaintiff's hips and ankles had a normal range of motion, but her knee range of motion was limited. (Tr. 658.) She walked on her tiptoes and heels without an ambulatory aid, and her gait was normal. (Id.) Plaintiff's shoulder blades and suprascapular area were mildly tender and she had some limitation in her shoulder range of motion. (Id.) Her range of motion in her elbows and wrists was normal. (Id.) She could grasp, pinch, and manipulate without issue. (Id.) Her coordination was intact and her upper extremities had no muscle weakness or atrophy. (Id.) Plaintiff's neurological examination was normal. (Tr. 659.) Dr. Sethi opined that Plaintiff had non-specific neurological complaints of lost motor and sensory abilities with no particular diagnosis and no clinical findings of fibromyalgia or a neurological disorder. (Tr. 659.) Plaintiff could sit for four to six hours, walk or stand for three to four hours, and carry up to 20 to 25 pounds frequently and 30 to 50 pounds occasionally. (Id.)
During a May 2013 hearing, Plaintiff testified that she had worked as a waitress, but stopped because she dropped things. (Tr. 48.) Her arms and hands became weak and numb. (Tr. 48, 58.) Plaintiff could not perform any work because she had difficulty using her hands to open or hold items and could not sit for long periods of time. (Tr. 48.) She experienced fatigue as well as numbness in her legs. (Id.)
Plaintiff did light cleaning around the home while taking breaks. (Tr. 49.) She made dinner but received help cutting or mixing. (Id.) She could not drive a vehicle or push a shopping cart. (Tr. 55.) She could stand for about a minute and walk about four or five feet. (Tr. 50.) Plaintiff's medical providers had not prescribed an ambulatory device. (Id.) She could sit for five minutes before a tingling sensation started in her legs and her feet went numb. (Id.)
The ALJ concluded the May 2013 hearing because additional evidence was needed. (Tr. 59.) The ALJ requested that Plaintiff undergo a consultative physical examination given the absence of medical treatment in the case. (Id.)
The ALJ conducted a second hearing in December 2013. (Tr. 28.) Plaintiff again testified that she had difficulty holding or opening things. (Tr. 33.) Her right hand went numb while eating. (Id.) These problems occurred three or four times a week. (Tr. 34.) Plaintiff experienced numbness in her right foot on a daily basis. (Id.) If she sat with her legs bent, her feet would tingle or burn and sometimes turn red or purple. (Id.) She had muscle spasms in her shoulders. (Id.)
Patricia Posey, a vocational expert, testified at Plaintiff's December 2013 hearing. The ALJ asked the VE to assume a hypothetical individual of Plaintiff's age, education, and work experience. (Tr. 37.) The individual could lift 50 pounds occasionally and 25 pounds frequently. (Id.) The individual could stand and walk six hours in an eight hour day; frequently climb ramps and stairs; occasionally climb ladders, ropes, and scaffolds; and frequently balance, stoop, kneel, crouch, and crawl. (Tr. 37-38.) The individual could have occasional exposure to fumes, odors, dust, gasses, poorly ventilated areas, and hazards. (Tr. 38.) The VE testified that the individual would be able to perform Plaintiff's past relevant work, in addition to such jobs as a cleaner and a stocker (Id.)
A claimant is entitled to receive benefits under the Social Security Act when she establishes disability within the meaning of the Act.
The Commissioner reaches a determination as to whether a claimant is disabled by way of a five-stage process.
The ALJ made the following findings of fact and conclusions of law:
(Tr. 13-21.)
Judicial review of the Commissioner's decision is limited to determining whether the Commissioner's decision is supported by substantial evidence and was made pursuant to proper legal standards.
The Commissioner's conclusions must be affirmed absent a determination that the ALJ failed to apply the correct legal standards or made findings of fact unsupported by substantial evidence in the record.
Plaintiff argues that the ALJ failed to provide sufficient rationale for her finding that Plaintiff's impairments, in particular Plaintiff's fibromyalgia, did not meet or equal a listed impairment. The Commissioner responds that Plaintiff has failed to come forward with evidence showing that she met or medically equaled any listing and that the ALJ's finding is substantially supported.
At the third step in the disability evaluation process, a claimant will be found disabled if his impairment meets or medically equals one of the impairments in the Listings.
S.S.R. 12-2p explains that fibromyalgia is not a listed impairment, and therefore, cannot meet a listing.
Here, the ALJ concluded at Step Two of her analysis that Plaintiff's fibromyalgia, degenerative changes in the cervical spine with chronic neck sprain, and ulnar neuropathy were severe impairments. (Tr. 13-15.) The ALJ then provided the following Step Three analysis:
(Tr. 16.) Plaintiff argues that the ALJ's failure to provide any rationale for the conclusion that her fibromyalgia did not medically equal a listing requires remand. Plaintiff also maintains that the ALJ's analysis of Listings 1.04 and 11.14 was too conclusory to allow for meaningful review.
Plaintiff cites to the Sixth Circuit's decision in
The Sixth Circuit determined that the ALJ had erred in failing to analyze whether the claimant's back impairment satisfied the criteria for any of the Listings in Section 1.00.
In Reynolds, the ALJ generally concluded, in the first paragraph of his analysis, that Plaintiff's impairments did not satisfy the criteria of Listing 1.00 or Listing 12.00, and then proceeded to analyze the criteria of only Listing 12.04, without any further discussion of Listing 1.00. Here, the ALJ did not even mention fibromyalgia or any potentially relevant listing, even after concluding in her Step Two analysis that fibromyalgia was a severe impairment. Application of Reynolds and S.S.R. 12-2p to this case results in the conclusion that the ALJ erred in failing to evaluate Plaintiff's fibromyalgia at Step Three. Without any statement from the ALJ addressing Plaintiff's fibromyalgia, the Court is unable to review the ALJ's Step Three finding. Upon remand, the ALJ must provide some analysis regarding whether Plaintiff's fibromyalgia medically equaled a listing or combined with another impairment to equal a listing. See
Plaintiff also argues that the ALJ's analysis of Listings 1.04 and 11.14 was similar to the ALJ's Step Three discussion in
Plaintiff also argues that the ALJ erred by limiting her consideration of Plaintiff's fibromyalgia to Step Two of the sequential evaluation and by failing to consider fibromyalgia pursuant to S.S.R. 12-2p when formulating the RFC. The Commissioner contends that the ALJ adequately considered Plaintiff's fibromyalgia and cited substantial evidence to support the conclusion that Plaintiff is not disabled.
The RFC is an indication of a claimant's work-related abilities despite his limitations. See
S.S.R. 12-2p outlines the evaluation process for fibromyalgia at each step of the sequential evaluation.
Here, the ALJ discussed evidence related to Plaintiff's fibromyalgia at Step Two of the sequential evaluation. (Tr. 13-15.) This discussion, however, is essentially a longitudinal recitation of Plaintiff's medical history without any evaluation of the evidence or any discussion of what impact, if any, Plaintiff's fibromyalgia has on the RFC. (Id.) In her RFC analysis, the ALJ discussed medical opinions from the state agency examining and reviewing physicians but did not mention any medical evidence related to Plaintiff's fibromyalgia. (Tr. 16-19.) The ALJ's failure to conduct such an evaluation and analysis of the evidence frustrates judicial review and necessitates remand.
The Commissioner argues that the RFC adequately accounts for Plaintiff's limitations and points to medical evidence to support this conclusion. The Commissioner's arguments constitute post hoc rationalizations. "[T]he courts may not accept appellate counsel's post hoc rationalizations for agency action. It is well-established that an agency's action must be upheld, if at all, on the basis articulated by the agency itself."
For the foregoing reasons, the Magistrate Judge recommends that the Commissioner's final decision be REVERSED and REMANDED for proceedings consistent with this opinion.