SHARON L. GLEASON, District Judge.
On or about July 20, 2015, Shewanda L. Jackson-Moten filed an application for Disability Insurance Benefits ("DIB") under Title II of the Social Security Act ("the Act"),
Ms. Jackson-Moten filed an opening brief seeking reversal of the agency decision and remand for a de novo hearing and new decision.
A decision by the Commissioner to deny disability benefits will not be overturned unless it is either not supported by substantial evidence or is based upon legal error.
The Act provides for the payment of disability insurance to individuals who have contributed to the Social Security program and who suffer from a physical or mental disability.
The Act further provides:
The Commissioner has established a five-step process for determining disability within the meaning of the Act.
Before proceeding to step four, a claimant's residual functional capacity ("RFC") is assessed. Once determined, the RFC is used at both step four and step five. An RFC assessment is a determination of what a claimant is able to do on a sustained basis despite the limitations from her impairments, including impairments that are not severe.
The ALJ concluded that Ms. Jackson-Moten was not disabled at any time from June 6, 2009, the alleged onset date, through March 31, 2014, the date last insured.
Ms. Jackson-Moten was born in 1977; she is 41 years old.
Although Ms. Jackson-Moten's medical records date back to 2005, the Court's review of the record is primarily focused on the period from the date of the previous application denial on December 16, 2011 through the date last insured of March 31, 2014.
The following are the relevant medical records:
In February 2011 and from approximately June to October 2011, Ms. Jackson-Moten sought mental health care at Anchorage Neighborhood Health Center. Providers observed that she was alert and oriented with linear thought processes, memory intact, and speech of appropriate rate, volume, and tone to conversation.
On August 4, 2011, Ms. Jackson-Moten saw Megan Engler, PAC, at Anchorage Neighborhood Health Center as a follow up from a recent emergency room visit after panic attacks. She reported having panic attacks 2-3 times per day, lasting one to two hours. She reported right-sided numbness that contributed to her panic. PAC Engler noted that Ms. Jackson-Moten was oriented to time, place, and person with a dysthymic mood and normal affect.
On October 6, 2011, Ms. Jackson-Moten reported going to the emergency room the previous day for anxiety/panic attack symptoms. She reported taking "hydroxyzine only occasionally as needed."
On February 24, 2014, Ms. Jackson-Moten saw Ronald Christensen, M.D., a family practitioner, for a consultative evaluation. She reported her "main complaint" on that day was "multi-joint arthralgias involving her neck, shoulders, low back, right hip and leg, and specifically her right foot." On physical examination, Dr. Christensen observed that Ms. Jackson-Moten's lungs were clear with no wheezing, rales, or rhonchi. Dr. Christensen also observed that Ms. Jackson-Moten had good range of motion in her hips, knees, elbows, wrists, and hands, but "slightly limited range of motion" in the cervical spine and shoulders and pain "at the extremes of range of motion." He noted that Ms. Jackson-Moten "could not stand on her right toes," but could balance on each foot and do "nearly a full squat." Dr. Christensen noted that Ms. Jackson-Moten had 5/5/ motor strength and a coordinated gait, but it was "antalgic favoring the right leg." He also noted an "intermittent tremor of her right hand." He assessed Ms. Jackson-Moten with a history of multi-joint arthralgia "of unclear etiology"; neck pain with a normal x-ray of the cervical spine; chronic low back pain; history of depression that was currently untreated; history of irritable bowel syndrome; and right foot pain with "underlying degenerative joint disease at the first metatarsophalangeal joint and bilateral pes planus." Dr. Christensen opined that Ms. Jackson-Moten was "generally functional in her activities of daily living insomuch as she could get on and off the exam table and perform all of the physical examination tasks." He opined that she appeared "to be capable of at least light activity."
On February 28, 2014, Ms. Jackson-Moten saw Kathleen Michaud, Ph.D., for a psychological evaluation. Dr. Michaud diagnosed Ms. Jackson-Moten with post-traumatic stress disorder (PTSD); major depressive disorder, recurrent, severe; and generalized anxiety disorder. Dr. Michaud rated Ms. Jackson-Moten's Global Assessment of Functioning score as 45. She observed that Ms. Jackson-Moten was well-groomed; her speech was of normal rate and tone and was logical and coherent; she made good eye contact; her mood was dysthymic and affect appropriate. Dr. Michaud also noted that Ms. Jackson-Moten was oriented to person, place, time, and situation and appeared to be of average intelligence or higher with concentration, abstract thinking, working memory, expressive and receptive language intact, but with mildly impaired rote and short-term memory. Her long-term memory appeared intact and her insight and judgment were good. Ms. Jackson-Moten reported that she got up and went to work on some days. She reported that on the days she did not work she would "sit around the house, read on my kindle, and wait until the kids come home, feed my son, and go to bed at 4 or 5pm." She reported being able to bath and dress on her own; drive; shop for herself "if she's only buying for one meal;" and could participate in childcare and take care of her finances "although her husband [took] care of money matters." Dr. Michaud also noted that Ms. Jackson-Moten had participated in "limited psychotherapy, and currently does not take medications she is prescribed as she does not like the side effects, and it appears she has some fear of misusing medication as a means of self-harm, although she denied current suicidal ideation." Dr. Michaud opined that Ms. Jackson-Moten met the criteria for posttraumatic stress disorder, major depressive disorder, and generalized anxiety disorder.
On March 14, 2014, Laura Jones, a state agency reviewing psychologist, opined that Ms. Jackson-Moten had a mild restriction of her activities of daily living; moderate difficulties maintaining social functioning; mild difficulties maintaining concentration, persistence, or pace; and no episodes of decompensation.
On April 15, 2015, Ms. Jackson-Moten saw Gregory Gerboth, M.D., a pulmonologist. Dr. Gerboth noted that Ms. Jackson-Moten had "a new significant enlargement of her hilar on chest x-ray with changes that are certainly most consistent with sarcoidosis, but the pain she is experiencing seems to be somewhat disproportioned to what we may expect to see with sarcoidosis, as this is typically [ ] something that does not cause a lot of pain." On physical examination, Dr. Gerboth did not "hear any wheezing," although he noted "a definite loud rasp that almost sounds like stridors." Dr. Gerboth scheduled a CT scan.
On April 16, 2015, Ms. Jackson-Moten had a CT scan of the chest. The CT scan showed "[b]ilateral hilar, subcarinal, and superior mediastinal adenopathy, likely sarcoidosis or lymphoma."
On May 1, 2015, Ms. Jackson-Moten had a biopsy of the right lower lobe of the lung. The pathology report's final diagnosis was "[b]ronchial mucosa with focal granuloma suspicious but not diagnostic of sarcoidosis; special stains are negative for microorganisms; recommend clinical correlation."
On July 29, 2015, Ms. Jackson-Moten had a lower third esophagus biopsy. The biopsy showed "[m]ildly hyperplastic squamous esophageal mucosa consistent with reflux esophagitis."
On August 17, 2015, Ms. Jackson-Moten saw Tonya Caylor, M.D., at Hillside Family Medicine. Dr. Caylor prescribed Zoloft for anxiety. She also noted that "[o]nce Dr. Gerboth has your sarcoid controlled on another medication, you may be able to wean off the Prednisone which will also likely help your anxiety and panic attacks."
On August 28, 2015, Ms. Jackson-Moten had a chest x-ray. The x-ray showed "[n]o active disease" and "[p]erihilar and mediastinal adenopathy, slightly decreased from the prior study."
On December 1, 2015, Ron Feigin, M.D., a state agency reviewing physician, provided a mental RFC assessment as of Ms. Jackson-Moten's date last insured of March 31, 2014. He opined that Ms. Jackson-Moten was moderately limited in her ability to understand and remember detailed instructions; carry out detailed instructions; maintain attention and concentration for extended periods; work in coordination or proximity to others; complete a normal workday without interruptions from psychologically based symptoms; and perform at a consistent pace. Dr. Feigin opined that Ms. Jackson-Moten was also moderately limited in her ability to accept instructions and respond appropriately to criticism; get along with coworkers; and respond appropriately to changes in the work setting.
On March 24, 2016, Ms. Jackson-Moten went to the emergency department at Alaska Regional Hospital. She reported a "productive cough, generalized malaise, and a headache that began 2 days ago." She also reported that she stayed "at home usually, but assisted her husband delivering newspapers for the last several days." On physical examination, Ms. Jackson-Moten had normal breath and heart sounds; was alert and oriented to person, place, and time; and had a normal mood and affect. Ms. Jackson-Moten was diagnosed with bronchitis and prescribed Tylenol, prednisone for five days, and azithromycin. Ms. Jackson-Moten also had a chest x-ray taken. The x-ray showed an "[i]nterval increase in right paratracheal and bilateral perihilar adenopathy. The pattern and distribution [are] consistent with the clinical diagnosis of sarcoidosis. No evidence of acute cardiopulmonary disease."
On March 6, 2017, Ms. Jackson-Moten saw Linda Pope, M.D., at Providence Health & Services. Dr. Pope prescribed an albuterol inhaler, a fluticasone-salmeterol inhaler, azithromycin, as well as hydrocodone-acetaminophen (Norco).
Ms. Jackson-Moten attended a hearing before ALJ Hebda on March 17, 2017 without an attorney or other representative.
Harvey Alpern, M.D., testified as a medical expert based on his review of the records. He identified Ms. Jackson-Moten's medically determinable impairments, but he opined that they did not meet or equal a listing. He opined initially that Ms. Jackson-Moten was capable of sitting, standing, and walking six out of eight hours, but revised his opinion for standing and walking to two out of eight hours based on Ms. Jackson-Moten's testimony that she had received a shot in both hips in the past year "which didn't work." Dr. Alpern also opined that Ms. Jackson-Moten could lift 20 pounds occasionally; 10 pounds frequently; "occasionally postural, all of them"; occasionally lift overhead on the right side; occasionally push and pull with the right upper extremity; never climb ropes or ladders; and "no concentrated dust, fumes, or irritants." He testified that his opinions applied to the time period before March of 2014.
Colette Valette, a clinical psychologist, also testified as a medical expert based on her record review. She reported that Ms. Jackson-Moten had major depressive disorder, recurrent; generalized anxiety disorder; and post-traumatic stress disorder. The ALJ directed Dr. Valette to focus her opinion on the period from December 17, 2011 to March 2014. Dr. Valette testified that Ms. Jackson-Moten's mental health impairments did not meet or equal any of the listings. She opined that Ms. Jackson-Moten had mild limitations understanding, remembering, or applying information; no limitations interacting with others; no limitations with concentrating, persisting, or maintaining pace; and mild limitations adapting and managing herself. Dr. Valette noted that Ms. Jackson-Moten could perform her daily activities, including driving, paying bills, working on the computer, and taking care of her children. She also noted that in 2011, Ms. Jackson-Moten had a "remote history of being noncompliant with her medications."
William Weiss testified as the vocational expert. He noted that, based on the ALJ's hypothetical of light work with limitations, including "avoidance of all irritants such as fumes, odors, dusts," Ms. Jackson-Moten would be capable of her past work as a payday loan manager or similar position because "it's indoor work" so she would not "have to deal with any dusts, gasses, et cetera" and "the only thing that would preclude the past work would be possibly to include cologne and perfume, but that would be the only issue." Ms. Jackson-Moten also questioned Mr. Weiss. She asked if an employee with "problems with the dust, and the cologne, and the cigarettes, and things like that" would be employable. Mr. Weiss responded that "typically workplaces do not allow smoking" and if the individual was "a supervisor" he or she could ask employees not to wear cologne or perfume. When Ms. Jackson-Moten asked Mr. Weiss about smoking outside the premises that is "still within the premises or very close to," Ms. Weiss answered that "typically that's not allowed in the premises" and "I don't know, I'm not a physician . . . I couldn't really respond."
Ms. Jackson-Moten is represented by counsel. In her opening brief, Ms. Jackson-Moten asserts that the ALJ: (1) "erred at step two to the extent [he] found anxiety not severe . . . with respect to her past relevant work environments"; (2) erred at step four "because sarcoidosis prevents Ms. Moten from returning to past relevant work"; and (3) failed to "fully and fairly develop the record generally, and with particular focus on the environmental conditions of Ms. Moten's past relevant work."
Ms. Jackson-Moten asserts that the ALJ did not fully and fairly develop the record. Specifically, she argues that the ALJ failed to fully and fairly develop the record "with particular focus on the environmental conditions of Ms. Moten's past relevant work."
The ALJ has an "independent `duty to fully and fairly develop the record and to assure that the claimant's interests are considered.'"
In his decision, ALJ Hebda found Ms. Jackson-Moten's right shoulder osteoarthritis and sarcoidosis were severe during the time period between December 2011 and March 31, 2014. He determined that Ms. Jackson-Moten's major depressive disorder, generalized anxiety disorder, post-traumatic stress disorder, and all other medically determinable physical impairments were non-severe.
Even though the ALJ found Ms. Jackson-Moten's anxiety non-severe at Step Two, he had a duty to consider the combined effect of all of Ms. Jackson-Moten's impairments.
Because the ALJ acknowledged Ms. Jackson-Moten's sarcoidosis was a severe medically determinable impairment, "all medically determinable impairments must be considered in the remaining steps of the sequential analysis."
Ms. Jackson-Moten also correctly points out that the ALJ should have explained the meaning of "date last insured" to her at the March 17, 2017 hearing.
In light of the reasons set forth above, the Court finds that the ALJ failed to fully and fairly develop the record.
Ms. Jackson-Moten alleges that the ALJ erred at Step Four in his five-step process for determining disability. She alleges that the ALJ did not "address her past work environments" and incorrectly presumed that her past work environments were "irritant free" based on a "determination that Mr. Weiss's speculative notions about past relevant work conditions should be preferred over the first-person testimony of Ms. Moten who actually worked in those past relevant working environments."
At Step Four of an ALJ's disability determination process, "claimants have the burden of showing that they can no longer perform their past relevant work."
Here, the ALJ found that Ms. Jackson-Moten had severe impairments of right shoulder osteoarthritis and sarcoidosis. Based thereon, ALJ Hebda concluded that Ms. Jackson-Moten could perform light work with exceptions, including avoiding "all exposure to irritants, such as fumes, odors, dusts, and gases." Comparing the RFC with the physical and mental demands of her past work, the ALJ determined Ms. Jackson-Moten was able to perform her past work as generally performed. He relied on the testimony of the vocational expert to determine that "a person with [Ms. Jackson-Moten]'s current residual functional capacity could perform the payday loan manager, tech support, and Subway manager positions."
First, the RFC is an individual's "maximum remaining ability to do sustained work-related physical and mental activities in an ordinary work setting on a regular and continuing basis," and "must include a discussion of the individual's abilities on that basis."
The Dictionary of Occupational Titles ("DOT") and Selected Characteristics of Occupations Defined in the Revised Dictionary of Occupational Titles ("SCO") describe Ms. Jackson's past jobs of payday loan manager (DOT 241.137-010), tech support (DOT 952.364-010), and Subway manager (DOT 185.137-010). For each of these jobs, the "atmospheric conditions"
Upon questioning at the hearing by Ms. Jackson-Moten, Mr. Weiss did not fully address the effect of smoking or other odors on Ms. Jackson-Moten's combination of physical and mental impairments. Specifically, when asked by Ms. Jackson-Moten about smoking outside work premises, Mr. Weiss answered, "typically [smoking is] not allowed in the premises" and "I don't know, I'm not a physician . . . I couldn't really respond."
This is a factual matter that could potentially prevent Ms. Jackson-Moten from continuing her past work as actually performed or generally performed.
Because the ALJ did not consider smoke or other odors despite determining Ms. Jackson-Moten must avoid all exposure to them, the ALJ's Step Four determination lacks adequate factual findings and is not supported by substantial evidence. Accordingly, remand for further proceedings on this basis is also warranted.
The "ordinary remand rule" applies to disability cases. Under this rule, if "the reviewing court simply cannot evaluate the challenged agency action on the basis of the record before it, the proper course, except in rare circumstances, is to remand to the agency for additional investigation or explanation."
The Court, having carefully reviewed the administrative record, finds that the ALJ's determinations are not free from legal error. Accordingly, IT IS ORDERED that Ms. Jackson-Moten's request for relief at Docket 13 is GRANTED, the Commissioner's final decision is VACATED, and the case is REMANDED to the SSA for further proceedings consistent with this decision.
The Clerk of Court is directed to enter a final judgment accordingly.
There is no indication in the record of the March 2017 hearing that the ALJ explained the concept of "date last insured" to Ms. Jackson-Moten.