THOMAS E. ROGERS, III, Magistrate Judge.
This is an action brought pursuant to Section 205(g) of the Social Security Act, as amended, 42 U.S.C. Section 405(g), to obtain judicial review of a "final decision" of the Commissioner of Social Security, denying Plaintiff's claim for Supplemental Security Income (SSI). The only issues before the Court are whether the findings of fact are supported by substantial evidence and whether proper legal standards have been applied. This case is before the court pursuant to Local Rule 83.VII.02, D .S.C., concerning the disposition of Social Security cases in this District on consent of the parties. 28 U.S.C. § 636(c).
The Plaintiff filed an application on April 13, 2010 for SSI, alleging disability since March 15, 2009. A hearing was held by an Administrative Law Judge ("ALJ") on November 10, 2011. The ALJ found in a decision dated February 16, 2012, that Plaintiff was not disabled. The Appeals Council denied Plaintiff's request for review. Plaintiff filed this action on July 15, 2013, in the United States District Court for the District of South Carolina.
Plaintiff was born on December 29, 1967, and was 42 years old on the date the application was filed. (Tr. 25). Plaintiff has a high school education and past relevant work experience as a floor department manager and a flooring installer. (Tr. 25). In his brief, Plaintiff indicates that he alleges disability due to the following impairments: lower extremity swelling, lumbar radiculopathy, angina, diabetes, hiatal hernia, anxiety, nausea and vomiting, Hepatitis C, abdominal pain, pancreatitis, chronic pain, tingling, both feet, low back pain, sciatica, lumbar disc disease, numbness and tingling (hands), hands, right knee problems, arthritis, hypertension, lumbar HNP, neuritis or radiculitis, migraines, hydrocephalus/headaches/vision loss.
In the decision of February 16, 2012, the ALJ found the following:
(Tr. 14-27).
The Commissioner argues that the ALJ's decision was based on substantial evidence and that the phrase "substantial evidence" means "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion."
The general procedure of a Social Security disability inquiry is well established. Five questions are to be asked sequentially during the course of a disability determination. 20 C.F.R. §§ 404.1520, 1520a (1988). An ALJ must consider (1) whether the claimant is engaged in substantial gainful activity, (2) whether the claimant has a severe impairment, (3) whether the claimant has an impairment which equals a condition contained within the Social Security Administration's official listing of impairments (at 20 C.F.R. Pt. 404, Subpart P, App. 1), (4) whether the claimant has an impairment which prevents past relevant work and (5) whether the claimant's impairments prevent him from any substantial gainful employment.
Under 42 U.S.C. §§ 423 (d)(1)(A) and 423(d)(5) pursuant to the Regulations formulated by the Commissioner, the plaintiff has the burden of proving disability, which is defined as 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."
If an individual is found not disabled at any step, further inquiry is unnecessary. 20 C.F.R. § 404.1503(a).
A claimant is not disabled within the meaning of the Act if he can return to his past relevant work as it is customarily performed in the economy or as the claimant actually performed the work. SSR 82-62. The claimant bears the burden of establishing his inability to work within the meaning of the Social Security Act. 42 U.S.C. § 423 (d)(5). He must make a
Once an individual has established an inability to return to his past relevant work, the burden is on the Commissioner to come forward with evidence that the plaintiff can perform alternative work and that such work exists in the regional economy. The Commissioner may carry the burden of demonstrating the existence of jobs available in the national economy that the plaintiff can perform despite the existence of impairments which prevent the return to past relevant work by obtaining testimony from a vocational expert.
The Plaintiff argues that the ALJ erred in his decision. Specifically, Plaintiff raises the following arguments in his brief, quoted verbatim:
(Plaintiff's brief, p. 4).
In his initial issue, Plaintiff essentially argues that the Commissioner's step two finding is not supported by substantial evidence. The Commissioner disagrees and posits that the there is substantial evidence to support the ALJ's determination that Plaintiff's heart and pancreas impairments were not medically determinable impairments. For the reasons that follow, the court agrees that the ALJ's determination at Step Two of the sequential process is unsupported by substantial evidence, which impacts the remaining steps of the sequential process. Therefore, the court addresses this issue first.
Prior to the relevant period,
On July 12, 2010, an MRI was performed of Plaintiff's lumbar spine. (Tr. 599). The MRI identified nerve impingement at the S1 nerve root and a disc protrusion at L4-5 with root contact without obvious impingement. (Tr. 600). Plaintiff underwent a third surgery on August 17, 2010. (Tr. 621-22). Post-surgery records indicated that Plaintiff took post-op well, and walked without assistance. (Tr. 610). He was also informed that he could gradually return to normal activities, and short, frequent walks were good for his recovery. (Tr. 611). At a follow-up appointment two weeks later, Stephen R. Gardener, M.D., noted that Plaintiff's gait and motor strength were normal. (Tr. 649). On September 27, 2010, Dr. Gardener noted that Plaintiff had a normal gait and motor strength, but that he might have to undergo myelography. (Tr. 647).
Post-surgery, physical examinations of Plaintiff were unremarkable. On October 7, 2010 Plaintiff had a normal range of motion and strength in all his musculoskeletal systems. (Tr. 665). December 5, 2010, Plaintiff denied back pain (Tr. 675), his back was not tender (Tr. 676), and he had a normal alignment in his spine. However, in November of 2011, Plaintiff reported that his back pain was worse (Tr. 773).
Chest x-rays performed on December 27, 2009 and July 6, 2010 were unremarkable. (Tr. 501, 601). On April 8, 2010, Plaintiff presented to Baptist Easley Hospital ("Easley"), complaining of dull chest discomfort and swelling in his ankle. (Tr. 654). An echocardiogram revealed that he had mildly decreased left ventricle function and ejection fraction. (Tr. 652). A physical examination was unremarkable other than trace swelling. (Tr. 654). A stress test was unremarkable, and Plaintiff's ejection fraction was 53%. (Tr. 656). Chest x-rays were also normal. (Tr. 668). Joseph Quinn, M.D., noted mild congestive heart failure. (Tr. 659, 667). On April 12, 2010, Plaintiff presented to St. Francis Hospital complaining of chest pain. (Tr. 704). A physical examination of his chest was unremarkable. (Tr. 705). Extensive blood work up was performed, which yielded no results, and he was prescribed Darvocet, which is generally used to treat mild to moderate pain. (Tr. 779-11). During the relevant period, Plaintiff followed up with a cardiologist, who noted that his edema had resolved. (Tr. 672). In July, August, and September 2010, Plaintiff denied any chest pain. (Tr. 640, 647, 649). Plaintiff returned to Easley on December 5, 2010, complaining of mild chest pain. (Tr. 675). He denied shortness of breath, nausea, vomiting, cough, fatigue, anxiety, syncope, palpitations, back pain, headache, dizziness, neck pain, altered vision, altered speech, altered coordination, lethargy, a suspected foreign body, abdominal pain, fever, chills, weight gain, hemoplysis, dysuria, diarrhea, or blood in his stool. (Tr. 675). A workup, including chest x-rays, an echocardiogram, and blood work, revealed no significant abnormalities. (Tr. 676-77). He was diagnosed with Pleuritic chest pain, prescribed 12 tabs of Percocet, and discharged. (Tr. 677). On November 30, 2011, it was noted that Plaintiff claimed to have been hospitalized for congestive heart failure in 2010. (Tr. 773). At that time, questionable congestive heart failure and chronic pancreatitis were noted by Dr. William Anderson.
On February 7, 2010, prior to the relevant period, Plaintiff presented to Sundar Natarajan, M.D., at St. Francis Hospital, complaining of nagging abdominal pain that had persisted since he had his gallbladder removed in December of 2009. (Tr. 479-82, 733-34). An MRI was performed, and Plaintiff's pancreas was unremarkable. (Tr. 520). Lab work performed did not support a diagnosis of pancreatitis. (Tr. 528). On April 4, 2010, Plaintiff presented for a follow-up regarding his abdominal pain, claiming that it was caused by his pancreas. (Tr. 542-43). A physical examination was unremarkable. (Tr. 542). Hepatitis C was ruled out as a cause of his abdominal pain. (Tr. 543). Isaac Gaines, M.D., stated that the objective findings only supported a diagnosis of Gastroesophageal Reflux Disease ("GERD"). (Tr. 543). Dr. Gaines, a gastroenterologist, stated that a CT scan "showed no evidence of any pancreatic disease."
Step two of the sequential evaluation requires the ALJ to "consider the medical severity of [a claimant's] impairment(s)." 20 C.F.R. §§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii). The claimant bears the burden at this step to show that he has a severe impairment.
20 C.F.R. §§ 404.1521(b), 416.921(b). "[A]n impairment can be considered as not severe only if it is a slight abnormality which has such a minimal effect on the individual that it would not be expected to interfere with the individual's ability to work, irrespective of age, education, or work experience." Evans v. Heckler, 734 F.2d 1012, 1014 (4th Cir.1984) (emphasis in original) (internal quotation marks omitted).
At step two, the ALJ found that Plaintiff had the following severe impairments: status post three back surgeries, hepatitis C and GERD. The ALJ concluded that "claimant's allegations of pancreatitis and heart problems to be non-medically determinable as there is no medical evidence in the record containing either as a diagnosis." (Emphasis added). In reaching this conclusion, the ALJ indicated that "Dr. Gaines noted that there is no evidence that the claimant has any pancreatic disease. Additionally, a stress test from Baptist Easley Hospital showed normal wall motion, no evidence of stree induced ischemia, and an ejection fraction of 53%."
Plaintiff argues that there is medical evidence in the records of pancreatitis and/or heart problems. Specifically, Plaintiff asserts that treating physician Cecil Y. Brown, M.D., provides that the Claimant has a "Secondary disabling diagnosis" of pancreatitis. (Tr. 567). In addition, Plaintiff argues that there is evidence including several hospital visits for pancreatitis and two for heart/chest pain problems as follows:
Here, Plaintiff highlights numerous records during and around the relevant time period that Plaintiff contends support his position that his claimed pancreatitis and heart problems are medically determinable impairments. Plaintiff argues that although he was not given a pancreatitis diagnosis every time he went to the hospital for abdominal pain, his symptoms were identical to occasions close in time when he was diagnosed with pancreatitis. Plaintiff asserts a similar argument for Plaintiff's claimed congestive heart failure, i.e. that he was diagnosed with congestive heart failure in October and then presented with the same symptoms in December.
Although the ALJ provided specific reasons for finding Plaintiff's alleged impairments of pancreatitis and heart problems were not medically determinable impairments, there is arguably contradictory evidence in the record, which was not acknowledged or addressed by the ALJ. The ALJ's decision does not make clear whether he considered the records highlighted by Plaintiff and as such, this court is unable to discern whether the ALJ's decision is supported by substantial evidence.
Based on the foregoing, the court is constrained to conclude that this matter should be remanded for further consideration of Plaintiff's impairments at step two and the impact on the remaining sequential process. Furthermore, in light of the court's determination that this matter be remanded for further consideration, the court need not address Plaintiff's remaining issues, as they may be rendered moot on remand.
Accordingly, pursuant to the power of the Court to enter a judgment affirming, modifying, or reversing the Commissioner's decision with remand in social security actions under sentence four of Sections 205(g) and 1631 (c) (3) of the Social Security Act, 42 U.S.C. Sections 405 (g) and 1338 (c) (3), it is,