ROBERT W. PRATT, District Judge.
Plaintiff, Robin Diane Hulen, filed a Complaint in this Court on December 5, 2011, seeking review of the Commissioner's decision to deny her claim for Social Security benefits under Title II and Title XVI of the Social Security Act, 42 U.S.C. §§ 401 et seq. and 1381 et seq. This Court may review a final decision by the Commissioner. 42 U.S.C. § 405(g).
In the Notice of Decision — Unfavorable dated March 4, 2011, the Administrative Law Judge recited the procedural history of the case to that point:
The ALJ went on to note that a second hearing was held on December 21, 2010. Tr. at 11.
As noted, on August 27, 2010, the Appeals Council issued a Notice of Order of Appeals Council Remanding Case to Administrative Law Judge. Tr. at 97-99. The Appeals Council found the ALJ had erred by failing to evaluate Plaintiff's credibility as required by Social Security Ruling (SSR) 96-7p, and by failing to evaluate Plaintiff's obesity as required by SSR 02-1p. Regarding the obesity evaluation, the Appeals Council judges wrote:
Tr. at 98-99. The order of the Appeals Council was, among other things, that on remand, the ALJ was to "evaluate the claimant's obesity in accordance with Social Security Ruling 02-1p." Tr. at 99.
Tr. at 17. The ALJ wrote: "Despite her increasing weight gain, there was no mention of concerns of obesity or any effects upon her other impairments." The ALJ wrote that he considered Plaintiff's degenerative arthritis of the knees and obesity in finding that Plaintiff is limited to light work. He went on: "She does not demonstrate pain or limitation of such severity as to prevent this limited range of light work activity. She does not seek regular medical care and the consultative examination in 2007, revealed minimal findings upon examination." Tr. at 18. The ALJ wrote: "Although the undersigned has given her allegations of physical and mental functional limitations some credit, and have considered her obesity with her other impairments, there is no evidence of limitations more than those indicated in the RFC above." The ALJ found that Plaintiff is able to perform her past relevant work as a housekeeper. Tr. at 19. The ALJ found that Plaintiff is not disabled nor entitled to the benefits for which she applied. Tr. at 21.
Although the Court has read each page of the evidence in this case, an entry by entry summary of the medical records will not add to the Court's analysis. Plaintiff was treated for various medical problems at the University of Iowa Hospitals and Clinics and at the Davenport (Iowa) Medical Center. Plaintiff was treated for right knee pain for which the diagnoses were chondromalacia and/or degenerative joint disease. She also sought mental health care at Vera French Community Mental Health Center in Davenport Iowa. At the mental health center, Plaintiff sought treatment from both psychiatrists and other mental health professionals for depression, anxiety, post traumatic stress disorder, agoraphobia and panic attacks, and for personal relationship problems. An Appendix to Plaintiff's brief which summarizes each of the medical record entries was quite helpful to the Court as it sorted out the voluminous record.
On November 14, 2007, Plaintiff was seen for a consultative physical examination by Stanley Rabinowitz, M.D. at the request of Disability Determination Services. Tr. at 790-93. Dr. Rabinowitz also attached a range of motion chart. Tr. at 794-95. The doctor wrote: "The following medical history was provided for my review: None." Tr. at 790. Plaintiff reported a 33 year history of bilateral knee pain
Tr. at 790. On physical examination, Plaintiff's height was recorded a 58 inches and her weight was 170 pounds. It was noted that Plaintiff wore bilateral knee braces, and used a cane for assistance in walking. Tr. at 791. "There was crepitus and pain evident on examination of the knees. There was full range of motion and mild warmth on examination of the knees. No instability, contracture or paravertebral muscle spasm was evident." The doctor's impression was: "History of advanced degenerative joint disease, knees, bilateral with [possible] pigmented villondular synovitis." Tr. at 792. The doctor offered no opinion of Plaintiff's residual functional capacity.
On November 14, 2007, Plaintiff was seen by Susan R. Wood, Ed. S. for a psychological evaluation. Tr. at 796-801. Ms. Wood noted that no records had been given her for review. Tr. at 796. It was noted that Plaintiff was living in a homeless shelter. Tr. at 798. At the conclusion of her report, Ms. Wood wrote:
Tr. at 800-01. Diagnoses, on Axis I, were: Panic disorder without agoraphobia; social phobia, generalized; posttraumatic stress disorder, by history; and, rule out bipolar disorder. Tr. at 801. A review of the records from Vera French Mental Health Center, reveals that Plaintiff was, in fact, treated for depression, both unipolar and bipolar, as well as for panic disorder with agoraphobia. These records, however, were not available to Ms. Wood. Neither Ms. Wood nor the doctors at Vera French were asked to offer an opinion regarding Plaintiff's mental residual functional capacity.
Owen v. Astrue, 551 F.3d 792, 798 (8th Cir.2008.)
Brock v. Astrue, 674 F.3d 1062, 1063 (8th Cir.2012).
In short, a reviewing court should neither consider a claim de novo, nor abdicate its function to carefully analyze the entire record. Wilcutts v. Apfel, 143 F.3d 1134, 1136-37 (8th Cir.1998) citing Brinker v. Weinberger, 522 F.2d 13, 16 (8th Cir. 1975).
Plaintiff raises two arguments. First, that the ALJ improperly discredited Plaintiff's complaints of pain, substituting his judgment for that of the treating physician, and failing to follow SSR 96-7p, as required by the Appeals Council Order of Remand. Second, Plaintiff argues that the ALJ erred by failing to properly evaluate
As noted above, on remand the ALJ was instructed to evaluate Plaintiff's obesity pursuant to SSR 02-1p, 2000 WL 628049 (S.S.A.). Although the ALJ noted that he considered Plaintiff's obesity, his analysis is unsupported by any evidence whatsoever. For example, SSR 02-1p states that obesity is a medical condition diagnosed on the basis of a body mass index (BMI) which is the ratio of weight in kilograms to the square of height in meters. The SSR states that three levels of obesity are recognized: Level I includes BMIs of 30.0-34.9; level II includes BMIs of 30.0-39.0; and, level III, termed "extreme" obesity includes BMIs greater than or equal to 40. The greater the level, the greater the risk for obesity related impairments. Here, the Commissioner has determined that Plaintiff's severe impairments include obesity. However, There is no medical evidence in the record which precisely establishes what is Plaintiff's BMI or what is her level of obesity. On October 27, 2009, Plaintiff's weight was reported to be 183 pounds and her height is 4 feet, 11 inches. Tr. at 880. A rough calculation provides a BMI of 37.0, but that is hardly evidence on which to support a finding of disabled or not disabled. Furthermore, Plaintiff testified that she has been gaining weight, but there is no medical evidence to support such a statement. A remand to obtain medical evidence to answer these questions is appropriate and necessary given the previous order of remand from the Appeals Council.
A proper understanding of the level of obesity is necessary at two places in the sequential evaluation. At step 3, according to the SSR, obesity may be a factor in both "meets" and "equals" determinations. "For example, obesity may increase the severity of coexisting or related impairments to the extent that the combination of impairments meets the requirements of a listing. This is especially true of musculoskeletal, respiratory, and cardiovascular impairments, including mental disorders." In the case at bar, Plaintiff suffers from both musculoskeletal and mental disorders. Obesity could be a factor in each of those coexisting impairments, but there is no medical evidence to support such a finding one way or the other.
Discussing the evaluation of obesity at steps 4 and 5 of the sequential evaluation, the SSR states:
In the case at bar, Plaintiff suffers from both degenerative joint disease and from a mental impairment both of which may be
In McCoy v. Schweiker, 683 F.2d 1138, 1147 (8th Cir.1982)(en banc), the Court wrote: "Probably the most important issue will be the question of RFC ..." The Court went on: "The RFC that must be found ... is not the ability merely to lift weights occasionally in a doctor's office; it is the ability to perform the requisite physical acts day in and day out, in the sometimes competitive and stressful conditions in which real people work in the real world." While an ALJ is charged with determining a residual functional capacity based on all the evidence, it is a medical question and must be supported by some medical evidence. Lauer v. Apfel, 245 F.3d 700, 704 (8th Cir.2001). SSR 96-8p merely echoes the 8th Circuit with respect to the importance of RFC in analyzing disability claims. Additionally, a credibility finding cannot substitute for medical evidence to support a finding that a claimant has a residual functional capacity to work. Soth v. Shalala, 827 F.Supp. 1415, 1417 (S.D.Iowa 1993).
On remand, if the relevant information cannot be obtained from Plaintiff's treating physicians, either because she is not currently seeing physicians or because they are not equipped to provide such assessments, Plaintiff must be referred to consultative physicians who have access to all of her medical records and who are asked to opine on the questions necessary for the ALJ to make an informed decision which is supported by substantial evidence on the record as a whole. This is true for Plaintiff's physical, as well as mental, impairments.
Expert testimony will also be necessary to establish the correct onset of disability date. As noted in the ALJ's opening remarks and findings, Plaintiff applied for both Title II and Title XVI benefits in September 2009. An onset of disability date of February 9, 2006 was alleged. In order for Plaintiff to be entitled to Title II benefits, disability must be established before the end of December 2007.
On remand work and cooperation will be required by the ALJ and Plaintiff's counsel. See Battles v. Shalala, 36 F.3d 43, 44-45 (8th Cir.1994):
This Court knows of no reason why counsel cannot, and should not, assist the ALJ, as well as his client, by obtaining evidence to support the claimant's case.
Finally, the Court would remind the Commissioner of the admonition by the Court of Appeals for the 8th Circuit in Landess v. Weinberger, 490 F.2d 1187, 1190 (8th Cir.1974):
The Court has considered the evidence which supports, as well as the evidence which detracts from the decision made by the ALJ. After applying the balancing text noted in Gavin v. Heckler, 811 F.2d 1195, 1199 (8th Cir.1987), and cases cited therein, this Court holds that the final decision of the Commissioner is not supported by substantial evidence on the record as a whole. This case, therefore, is remanded to the Commissioner for further development of the record and for a new decision consistent with this opinion.
The judgment to be entered will trigger the running of the time in which to file an application for attorney's fees under 28 U.S.C. § 2412(d)(1)(B) (Equal Access to Justice Act). See also, McDannel v. Apfel, 78 F.Supp.2d 944 (S.D.Iowa 1999) (discussing, among other things, the relationship between the EAJA and fees under 42 U.S.C. § 406 B), and LR 54.2(b)
IT IS SO ORDERED.