KAROLINE MEHALCHICK, Magistrate Judge.
This is an action brought under Sections 205(g) and 1631(c)(3) of the Social Security Act, 42 U.S.C. § 405(g) and 42 U.S.C. § 1383(c)(3), seeking judicial review of the final decision of the Commissioner of Social Security ("Commissioner") denying Plaintiff Gina Bempkins's claims for a period of disability and disability insurance benefits ("DIB") and supplemental security income ("SSI") under Titles II and XVI of the Social Security Act.
On May 31, 2011, Ms. Bempkins protectively filed applications for benefits under Titles II and XVI of the Social Security Act asserting an onset date of April 1, 2008, at which time she was 42 years old.
On remand, Bempkins again appeared and testified before ALJ Hardiman. Specifically, Bempkins testified at an administrative hearing on April 9, 2014 along with VE Karen Kane. (Doc. 12-2, at 25, 53-75). Bempkins was represented by counsel at the second ALJ hearing, as she has been throughout these proceedings. (Doc. 12-2, at 25, 53-75). In a written decision dated August 7, 2014, the ALJ denied Bemkins's claims once again upon finding that Bempkins was capable of adjusting to a full range of work with certain nonexertional limitations for which there exists a significant number of jobs in the national economy. (Doc. 12-2, at 22-38). On October 7, 2014, Bempkins again requested the Appeals Counsel to review the ALJ's decision. (Doc. 12-2, at 44-52). The Appeals Council denied her second request for review on April 15, 2016, thus affirming the ALJ's August of 2014 decision as the final decision of the Commissioner subject to judicial review by this Court. (Doc. 12-2, at 2-4).
Bempkins initiated this action by filing a complaint, through counsel, on June 14, 2016. (Doc. 1). In her complaint, Bempkins alleges that the ALJ's decision was "not supported by substantial evidence and . . . contrary to law and regulation." (Doc. 1, ¶ 7). As relief she requests that this Court reverse the ALJ's decision and award benefits, or in the alternative, remand this case for a new administrative hearing. (Doc. 1, at 3-4). After service of the complaint, the Commissioner filed an answer together with a certified transcript of the entire record of the administrative proceedings on September 12, 2016. (Doc. 11; Doc. 12). In her answer, the Commissioner asserts that the ALJ's findings of fact are supported by substantial evidence and that the decision was made in accordance with the law and regulations. (Doc. 11, ¶ 9). This matter has been fully briefed by the parties and is now ripe for decision. (Doc. 15; Doc. 16).
In order to receive benefits under Title II or Title XVI of the Social Security Act, a claimant must demonstrate an "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 which has lasted or can be expected to last for a continuous period of not less than 12 months." 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A). To satisfy this requirement, a claimant must have a severe physical or mental impairment
In evaluating whether a claimant is disabled as defined in the Social Security Act, the Commissioner follows a five-step sequential evaluation process. 20 C.F.R. § 404.1520(a); 20 C.F.R. § 416.920(a). Under this process, the Commissioner must determine, in sequence: (1) whether the claimant is engaged in substantial gainful activity; (2) whether the claimant has a severe impairment; (3) whether the claimant's impairment meets or equals a listed impairment;
In reviewing the Commissioner's final decision denying a claimant's application for benefits, the Court's review is limited to determining whether the findings of the final decision-maker are supported by substantial evidence in the record. See 42 U.S.C. § 1383(c)(3) (incorporating 42 U.S.C. § 405(g) by reference); Johnson v. Comm'r of Soc. Sec., 529 F.3d 198, 200 (3d Cir. 2008); Ficca v. Astrue, 901 F.Supp.2d 533, 536 (M.D. Pa. 2012). Substantial evidence "does not mean a large or considerable amount of evidence, but rather such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Pierce v. Underwood, 487 U.S. 552, 565 (1988) (internal quotations omitted). Substantial evidence is less than a preponderance of the evidence but more than a mere scintilla. Richardson v. Perales, 402 U.S. 389, 401 (1971). A single piece of evidence is not substantial evidence if the ALJ ignores countervailing evidence or fails to resolve a conflict created by the evidence. Mason v. Shalala, 994 F.2d 1058, 1064 (3d Cir. 1993). In an adequately developed factual record, however, substantial evidence may be "something less than the weight of the evidence, and the possibility of drawing two inconsistent conclusions from the evidence does not prevent [the ALJ's decision] from being supported by substantial evidence." Consolo v. Fed. Maritime Comm'n, 383 U.S. 607, 620 (1966). "In determining if the Commissioner's decision is supported by substantial evidence the court must scrutinize the record as a whole." Leslie v. Barnhart, 304 F.Supp.2d 623, 627 (M.D. Pa. 2003). The question before the Court, therefore, is not whether Bempkins is disabled, but whether the Commissioner's finding that she is not disabled is supported by substantial evidence and was reached based upon a correct application of the relevant law. See Arnold v. Colvin, No. 3:12-CV-02417, 2014 WL 940205, at *1 (M.D. Pa. Mar. 11, 2014) ("[I]t has been held that an ALJ's errors of law denote a lack of substantial evidence."); Burton v. Schweiker, 512 F.Supp. 913, 914 (W.D. Pa. 1981) ("The [Commissioner]'s determination as to the status of a claim requires the correct application of the law to the facts."); see also Wright v. Sullivan, 900 F.2d 675, 678 (3d Cir. 1990) (noting that the scope of review on legal matters is plenary); Ficca, 901 F. Supp. 2d at 536 ("[T]he court has plenary review of all legal issues decided by the Commissioner.").
In her August of 2014 decision denying Bempkins's applications for benefits, the ALJ assessed Bempkins's case at each step of the five-step sequential evaluation process before concluding that Bempkins was "not disabled" because she could perform work that exists in the national economy. (Doc. 12-2, at 22-38).
At step one of the sequential evaluation process, the ALJ found that Bempkins had not engaged in substantial gainful activity since filing her application for benefits on May 31, 2011, or for several years beforehand. (Doc. 12-2, at 28).
At step two, the ALJ found that the medical evidence of record established the presence of the following medically-determinable severe impairments during the relevant period: depressive disorder, mood disorder, and posttraumatic stress disorder. (Doc. 12-2, at 28). The ALJ also considered several other impairments alleged by Bempkins, but determined that none of these alleged impairments qualified as medically-determinable severe impairments as defined in the regulations. (Doc. 12-2, at 28-29).
At step three, the ALJ found that during the relevant period, Bempkins did not have an impairment or combination of impairments that met or medically equaled the severity of an impairment listed in the version of 20 C.F.R. Part 404, Subpart P, Appendix 1 that was in effect on the date the ALJ issued her decision. (Doc. 12-2, at 30-32). Specifically, the ALJ determined that the severity of Bempkins's mental impairments, considered in combination, did not meet listings 12.04 or 12.06. (Doc. 12-2, at 30-32).
Between steps three and four, the ALJ assessed Bempkins's RFC. (Doc. 12-2, at 32-37). Bempkins alleged that her impairments caused symptoms such as chronic pain, insomnia, and hand cramps. (Doc. 12-2, at 28). After examining her statements and the medical evidence, the ALJ found that Bempkins's medically-determinable impairments could reasonably be expected to cause the alleged symptoms, but that her statements about the intensity, persistence, and the limiting effects of the symptoms were not entirely credible. (Doc. 12-2, at 35). The ALJ reviewed Bempkins's medical record and treatment history, including mental health therapy. (Doc. 12-2, at 33-37). In doing so, the ALJ considered and weighed medical opinions by the following sources: treating physician Elizabeth A. Gernhardt ("Dr. Gernhardt"), nontreating consultative examiner John F. Callahan ("Dr. Callahan"), nonexaming state agency medical consultant John Shane ("Dr. Shane"), and nonexamining independent medical consultant Lee Besen ("Dr. Besen"). (Doc. 12-2, at 28-30, 33-35; Doc. 12-8, at 41-73; Doc. 12-9, at 2-12; Doc. 12-10; Doc. 12-11, at 2-37, 47-86; Doc. 12-12, at 2-58, 78-90). Finally, the ALJ also considered Bempkins's global assessment of functioning ("GAF") scores and a third-party statement from Bempkins's mother. (Doc. 12-2, at 36-37).
Dr. Gernhardt has been Bempkins's primary care physician since approximately July of 2000. (Doc. 12-8, at 41-73). The ALJ noted that Dr. Gernhardt prepared two assessments of Bempkins, one in February of 2010 and a second in September of 2011. (Doc. 12-2, at 35; Doc. 12-8, at 44-48; Doc. 12-10, at 7-8). The ALJ did not address the first assessment because it had already been considered as part of the record in one of Bempkins's earlier disability claims. (Doc. 12-2, at 35). As for the second assessment, the ALJ claimed that Dr. Gernhardt opined that Bempkins had "substantially less than a sedentary level of function."
Dr. Callahan evaluated Bempkins on August 25, 2011. (Doc. 12-9, at 2-12). In his report, Dr. Callahan opined that Bempkins could lift or carry up to ten pounds occasionally, stand or walk for one-to-two hours, and sit for three-to-four hours in a given day, while also noting that Bempkins had additional postural, physical, and environmental limitations. (Doc. 12-9, at 6-7). The ALJ concluded that Dr. Callahan relied too heavily on Bempkins's own subjective complaints in light of the unremarkable objective findings. (Doc. 12-2, at 35). Accordingly, the ALJ also afforded Dr. Callahan's opinion just limited weight. (Doc. 12-2, at 35).
The ALJ also took into account the opinions of two nonexamining consultants, Dr. Shane and Dr. Besen. Dr. Shane diagnosed Bempkins as primarily suffering from degenerative disc disease ("DDD") of the cervical and lumbar spine, and opined that she could perform a range of sedentary work with postural, push/pull, and environmental limitations. (Doc. 12-2, at 29; Doc. 12-11, at 31-37). The ALJ discounted Dr. Shane's opinion because he did not examine Bempkins in person, did not cite laboratory findings or other evidence to support his conclusions, and relied on Bempkins's subjective complaints. (Doc. 12-2, at 29-30). Specifically, the ALJ noted that Dr. Shane's diagnosis of DDD was not supported by the record and inconsistent with imaging of Bempkins's cervical spine. (Doc. 12-2, at 29-30). The ALJ therefore accorded the opinion little weight. (Doc. 12-2, at 29).
The ALJ also propounded interrogatories to Dr. Besen after her first decision was remanded by the Appeals Council. (Doc. 12-2, at 30; Doc. 12-12, at 78-90). Dr. Besen concluded that Bempkins retained the capacity to perform light work with reduced standing, sitting, and walking, as well as postural and environmental limitations. (Doc. 12-2, at 30; Doc. 12-12, at 78-90). The ALJ again discounted this opinion due to the fact that Dr. Besen did not examine Bempkins in person and did not have objective findings such as imaging or laboratory results to support his conclusions. (Doc. 12-2, at 30). Dr. Besen's opinion thus also was accorded little weight. (Doc. 12-2, at 30).
Based on her consideration of the above medical opinions and of the other relevant evidence of record, the ALJ assessed that, during the relevant period, Bempkins had the RFC to perform a full range of work at all exertional levels but with the following nonexertional limitations:
At step four of the sequential evaluation process, the ALJ found that Bempkins had no past relevant work. (Doc. 12-2, at 37).
At step five, the ALJ considered Bempkins's RFC, age (younger individual), education (high school or above), and work experience to ultimately conclude that jobs existed in significant numbers in the national economy that Bempkins could perform. (Doc. 12-2, at 37-38). The ALJ based her assessment on testimony by VE Kane. (Doc. 12-2, at 38, 67-75). In response to a hypothetical question that mirrors the RFC above, VE Kane testified that an individual of the same age, education, work experience, and assessed RFC as Bempkins could adjust to work in representative occupations such as video monitor— surveillance (DOT #379.367-010), office helper (DOT #239.567-010), order filler (DOT #209.587-034), and laundry worker (DOT #361.685-018). (Doc. 12-2, at 38, 68-69). VE Kane further testified that in the Northeastern Pennsylvania regional economy there are approximately: 200 jobs as a video monitor; 400 jobs as an office helper; 400 jobs as an order filler; and 200 jobs as a laundry worker. (Doc. 12-2, at 38, 68-69). Accordingly, the ALJ concluded that Bempkins was not disabled because she could perform work that exists in significant numbers in the regional and national economies despite the limiting effects of her impairments. (Doc. 12-2, at 38).
Bempkins alleges two errors in arguing that the ALJ's decision denying her applications for benefits is not supported by substantial evidence: (1) that the ALJ improperly found that Bempkins could perform work at all exertional levels, and (2) that the ALJ failed to comply with the Appeals Council's remand order. (Doc. 15, at 9). As relief, Bempkins seeks reversal of the ALJ's decision or alternatively, a remand for a new administrative hearing. (Doc. 1, at 3-4).
Bempkins primarily argues that the ALJ erred by failing to properly weigh the medical opinion evidence, which resulted in a flawed RFC assessment. (Doc. 15, at 9-14). In making the RFC determination, "the ALJ must consider all evidence before him." Burnett v. Comm'r of Soc. Sec. Admin., 220 F.3d 112, 121 (3d Cir. 2000) (citations omitted). Indeed, the regulations mandate that an ALJ "will evaluate every medical opinion . . . receive[d]." 20 C.F.R. §§ 404.1527(c), 416.927(c); see also Burnett., 220 F.3d at 122 ("[T]he ALJ must review all of the pertinent medical evidence, explaining his conciliations and rejections."); Adorno v. Shalala, 40 F.3d 43, 48 (3d Cir. 1994) ("The Secretary must `explicitly' weigh all relevant, probative and available evidence. . . . The Secretary may properly accept some parts of the medical evidence and reject other parts, but she must consider all the evidence and give some reason for discounting the evidence she rejects."). Social Security Ruling ("SSR") 96-5p further clarifies that "opinions from any medical source on issues reserved to the Commissioner must never be ignored," and specifically states that the ALJ's "decision must explain the consideration given to the treating source's opinion(s)."
SSR 96-6p addresses the weight afforded to treating medical sources, such as Dr. Gernhardt. SSR 96-6p, 1996 WL 374180 (July 2, 1996).
Here, the parties do not dispute that Dr. Gernhardt was Bempkins's lone treating source.
Bempkins further alleges that the ALJ failed to account for the fact that all medical opinions appear to corroborate each other. (Doc. 15, at 12). Each of these medical opinion sources found that Bempkins was more limited than the ALJ ultimately concluded. (Doc. 12-2, at 28-30, 33-35; Doc. 12-8, at 41-73; Doc. 12-9, at 2-12; Doc. 12-10; Doc. 12-11, at 2-37, 47-86; Doc. 12-12, at 2-58, 78-90). Given that "consistency" is one of the factors to be evaluated under 20 C.F.R. §§ 404.1527 and 416.927, the ALJ's failure to consider the consistency among each of these medical opinions renders her evaluations of these opinions lacking in substantial evidence.
The ALJ's evaluation of the four medical source opinions indicates a broader problem in that it appears the ALJ impermissibly engaged in the lay evaluation of medical evidence. See Burns v. Colvin, 156 F.Supp.3d 579, 588 (M.D. Pa. 2016) ("[A]n ALJ may not reject a supported treating source medical opinion with only lay interpretation of medical evidence."). Because the ALJ essentially rejected all medical opinions proffered, she could not rely on any contradictory and contemporaneous medical opinion as is needed to cast aside Dr. Gernhardt's treating source opinion. See Burns, 156 F. Supp. 3d at 588 ("[M]erely citing to contradictory medical evidence, as opposed to contradictory medical opinion, is insufficient."). Instead, the ALJ improperly rejected Dr. Gernhardt's opinion by substituting her own lay interpretation of the medical evidence. (Doc. 12-2, at 35); see Brownawell v. Comm'r Of Soc. Sec., 554 F.3d 352, 357 (3d Cir. 2008) ("The ALJ's rejection of Dr. Picciotto's opinion that Brownawell has no ability to deal with work stresses and maintain concentration in a work environment was improperly based on an alleged inconsistency between Picciotto's treatment notes and his ultimate evaluation."); Morales v. Apfel, 225 F.3d 310, 318 (3d Cir. 2000) ("The ALJ cannot, as he did here, disregard this medical opinion based solely on his own amorphous impressions, gleaned from the record and from his evaluation of the claimant's credibility." (quotation omitted)). The ALJ's decision to afford little weight to Dr. Gernhardt's opinion is without proper evidentiary support given that she likewise rejected all three other medical opinions.
Because Dr. Gernhardt's evaluation of the medical opinion evidence is not supported by substantial evidence, it is respectfully recommended that the Commissioner's decision be vacated and that the case be remanded.
Because the Court recommends remand on the above-stated grounds, it declines to address Bempkins's second ground for relief that the ALJ failed to comply with the Appeals Council's remand order. (Doc. 15, at 15). "A remand may produce different results on these claims, making discussion of them moot." Burns, 156 F. Supp. 3d at 598.
The Court has authority to affirm, modify or reverse the Commissioner's decision "with or without remanding the case for rehearing." 42 U.S.C. § 405(g); Melkonyan v. Sullivan, 501 U.S. 89, 100-01 (1991). However, the Third Circuit has advised that benefits should only be awarded where "the administrative record of the case has been fully developed and when substantial evidence in the record as a whole indicates that the claimant is disabled and entitled to benefits." Morales v. Apfel, 225 F.3d 310, 320 (3d Cir. 2000). See generally Fla. Power & Light Co. v. Lorion, 470 U.S. 729, 744 (1985) ("[T]he proper course, except in rare circumstances, is to remand to the agency for additional investigation or explanation."). Because the Court concludes that it is necessary to further develop the record in the case at bar, the undersigned United States Magistrate Judge respectfully recommends that the decision of the Commissioner be vacated and that the case be remanded for further proceedings.
Based on the foregoing, it is recommended that the Commissioner's decision be