WALLACE CAPEL, Jr., Magistrate Judge.
Plaintiff, Nevalyn Virginia Teague, applied for supplemental security income benefits under Title XVI of the Act, 42 U.S.C. §§ 1381 et seq. Her application was denied at the initial administrative level. Plaintiff then requested and received a hearing before an Administrative Law Judge ("ALJ"). Following the hearing, the ALJ issued a decision in which she found Plaintiff not disabled at any time through the date of the decision. Tr. 34. The Appeals Council rejected Plaintiff's request for review of the ALJ's decision. Tr. 1-5. The ALJ's decision consequently became the final decision of the Commissioner of Social Security ("Commissioner").
Under 42 U.S.C. § 423(d)(1)(A), a person is entitled to disability benefits when the person is unable to
42 U.S.C. § 423(d)(1)(A).
To make this determination, the Commissioner employs a five-step, sequential evaluation process. See 20 C.F.R. §§ 404.1520, 416.920 (2006).
McDaniel v. Bowen, 800 F.2d 1026, 1030 (11th Cir. 1986).
The burden of proof rests on a claimant through Step 4. See Phillips v. Barnhart, 357 F.3d 1232, 1237-39 (11th Cir. 2004). A claimant establishes a prima facie case of qualifying disability once they have carried the burden of proof from Step 1 through Step 4. At Step 5, the burden shifts to the Commissioner, who must then show there are a significant number of jobs in the national economy the claimant can perform. Id.
To perform the fourth and fifth steps, the ALJ must determine the claimant's Residual Functional Capacity (RFC). Id. at 1238-39. RFC is what the claimant is still able to do despite his impairments and is based on all relevant medical and other evidence. Id. It also can contain both exertional and nonexertional limitations. Id. at 1242-43. At the fifth step, the ALJ considers the claimant's RFC, age, education, and work experience to determine if there are jobs available in the national economy the claimant can perform. Id. at 1239. To do this, the ALJ can either use the Medical Vocational Guidelines
The grids allow the ALJ to consider factors such as age, confinement to sedentary or light work, inability to speak English, educational deficiencies, and lack of job experience. Each factor can independently limit the number of jobs realistically available to an individual. Phillips, 357 F.3d at 1240. Combinations of these factors yield a statutorily-required finding of "Disabled" or "Not Disabled." Id.
The Court's review of the Commissioner's decision is a limited one. This Court must find the Commissioner's decision conclusive if it is supported by substantial evidence. 42 U.S.C. § 405(g); Graham v. Apfel, 129 F.3d 1420, 1422 (11th Cir. 1997). "Substantial evidence is more than a scintilla, but less than a preponderance. It is such relevant evidence as a reasonable person would accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 401 (1971). See also Crawford v. Comm'r of Soc. Sec., 363 F.3d 1155, 1158 (11th Cir. 2004) ("Even if the evidence preponderates against the Commissioner's findings, [a reviewing court] must affirm if the decision reached is supported by substantial evidence."). A reviewing court may not look only to those parts of the record which support the decision of the ALJ, but instead must view the record in its entirety and take account of evidence which detracts from the evidence relied on by the ALJ. Hillsman v. Bowen, 804 F.2d 1179 (11th Cir. 1986).
Walker v. Bowen, 826 F.2d 996, 999 (11th Cir. 1987).
Plaintiff was forty-three years old at the time of the hearing before the ALJ. Tr. 43. Plaintiff was enrolled in special education classes since the first grade and she completed the ninth grade. Id. Plaintiff's past relevant work experience was as a "fast food worker," "cleaner/housekeeper," and "landscape laborer." Tr. 32. Following the administrative hearing, and employing the five-step process, the ALJ found Plaintiff "has not engaged in substantial gainful activity since September 30, 2009, the application date." (Step 1) Tr. 25. At Step 2, the ALJ found that Plaintiff suffers from the following severe impairments: "history of alcohol and cocaine addiction, not material and in reported remission; bipolar, schizoaffective disorder; status post injury to left upper forearm; status post injury to left knee; lumbar radiculopathy; and borderline intellectual functioning." Id. The ALJ then found that Plaintiff's "does not have an impairment or combination of impairments that meets or medically equals one of the listed impairments listed in 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 416.920(d), 416.925 and 416.926)." Id. Next, the ALJ found that Plaintiff
Tr. 27. The ALJ then concluded that Plaintiff "is unable to perform any past relevant work." (Step 4) Tr. 32. At Step 5, the ALJ found that, "[c]onsidering the claimant's age, education, work experience, and residual functional capacity," and after consulting with a VE, "there are jobs that exist in significant numbers in the national economy that the claimant can perform." Tr. 32. The ALJ identified the following occupations as examples: "garment bagger," "cleaner/housekeeper,"
Plaintiff presents two issues for this court's consideration in review of the ALJ's decision: 1) whether "[t]he Commissioner's decision should be reversed, because there is absolutely no support for the ALJ's RFC assessment as the record is devoid of any physical RFC assessments from any physician whatsoever"; and 2) whether "[t]he Commissioner's decision should be reversed, because while the ALJ purportedly relied on the opinion of [] Dr. Linda Duke, the decision selectively relied on portions of this opinion without explaining why all of the opinion was not accepted." Pl.'s Br. (Doc. 12) at 6. The court will address each argument below.
Plaintiff challenges the ALJ's RFC determination, arguing that "there is absolutely no support for the ALJ's RFC assessment as the record is devoid of any physical RFC assessments from any physicians whatsoever." Pl.'s Br. (Doc. 12) at 6. Thus, Plaintiff contends that "[d]ue to the ALJ's failure to obtain a physical capabilities evaluation from an examining source, . . . this court [should] reverse the ALJ's decision and remand her case for proper consideration of physical limitations." Id. at 10. The Plaintiff points the court to Coleman v. Barnhart, 264 F.Supp.2d 1007 (S.D. Ala. 2003), arguing that in Coleman, the district court "found it `unclear' how: `the ALJ found plaintiff could meet the threshold physical requirements of medium work, in absence of a physical capabilities evaluation (`PCE') completed by a treating or examining physician, particularly in light of plaintiff's numerous severe impairments." Pl.'s Br. (Doc. 12) at 8 (quoting Coleman, 264 F. Supp. 2d at 1010). However, a number of cases disagree with Coleman
Indeed, the United States Court of Appeals for the Eleventh Circuit has held that the ALJ's RFC assessment may be supported by substantial evidence, even in the absence of an opinion from an examining medical source about Plaintiff's functional capacity. See, e.g., Green v. Soc. Sec. Admin., 223 F. App'x 915, 923 (11th Cir. 2007) (unpublished opinion) (finding the ALJ's RFC assessment supported by substantial evidence where he rejected treating physician's opinion properly and formulated the plaintiff's RFC based on treatment records, without a physical capacities evaluation by any physician); see also Dailey v. Astrue, 2012 WL 3206482, at *9 (S.D. Ala. July 18, 2012) ("an ALJ may reach an RFC determination in appropriate circumstances on a record that does not include an RFC opinion from a treating or examining medical source." (citing Griffin v. Astrue, 2008 WL 4417228, at *10 (S.D. Ala. Sept. 23, 2008) ("While Plaintiff asserts that a physician's RFC assessment was required, she has not demonstrated that the ALJ did not have enough information to enable him to make a RFC determination, nor has she pointed to any medical evidence which suggests that the ALJ's RFC assessment is incorrect."))). Accordingly, this argument lacks merit.
Next, Plaintiff argues that "[t]he Commissioner's decision should be reversed because, while the ALJ purportedly relied on the opinion of [] Dr. Linda Duke, the decision selectively relied on portions of this opinion without explaining why all of the opinion was not accepted." Pl.'s Br. (Doc. 12) at 10. Specifically, Plaintiff argues that "[t]he ALJ previously acknowledged Dr. Duke's opinion that `[c]orrective supervision should be provided simply and supportively' (Tr. 26, 511-514). Inexplicably, after giving this opinion from Dr. Duke `great weight' and specifically stating that her opined limitations were accommodated by the foregoing residual functional capacity,' the ALJ then made an RFC assessment which failed to include the significant limitation highlighted above (Tr. 27, 31). Furthermore, the ALJ failed to address or resolve this significant inconsistency between Dr. Duke's opinion and the RFC assessment in her decision." Pl.'s Br. (Doc. 12) at 11. Plaintiff essentially argues the ALJ erred by failing to incorporate into her RFC finding, and the subsequent hypothetical to the VE, Plaintiff's moderate impairments in social functioning.
"Agency regulations require the ALJ to use the `special technique' dictated by the PRTF [Psychiatric Review Technique Form] for evaluating mental impairments." Moore v. Barnhart, 405 F.3d 1208, 1213 (11th Cir. 2005) (citing 20 C.F.R. § 404.1520a-(a)). "This technique requires separate evaluations on a four-point scale of how the claimant's mental impairment impacts four functional areas: `activities of daily living; social functioning; concentration, persistence, or pace; and episodes of decompensation.'" Id. (quoting 20 C.F.R. § 404.1520a-(c)(3-4)). The ALJ is required "to complete a PRTF and append it to the decision, or incorporate its mode of analysis into his findings and conclusions. Failure to do so requires remand." Id. at 1214 (citing other circuits for this holding).
In this case, the ALJ incorporated into her analysis the results of a PRTF completed by Dr. Duke. The ALJ found Plaintiff has "moderate restriction" in activities of daily living; "moderate difficulties" in social functioning; "moderate difficulties" with regard to concentration, persistence, or pace; and "no episodes of decompensation." (Tr. 26-27).
The ALJ must consider all of Plaintiff's limitations, including those found in the special technique. Moore, 405 F.3d at 1214. See also Trebilcock v. Barnhart, 2004 WL 2378856, *4, n. 4 (D.Me. Oct. 25, 2004) ("[o]ne would expect a finding of mild to moderate difficulty in social functioning at the PRTF stage to manifest itself in parallel findings at the [RFC] assessment stage"). Since it is not clear how Plaintiff's limitation regarding "Corrective supervision" does or not affect her work limitations, the RFC does not accurately account for all limitations arising from Plaintiff's mental impairment.
Furthermore, because the ALJ's hypothetical to the VE was identical to the ALJ's RFC, the hypothetical question was not a comprehensive description of Plaintiff's limitations or restrictions, and the ALJ's decision is, therefore, not supported by substantial evidence. See, e.g., Winschel v. Comm'r of Soc. Sec., 631 F.3d 1176, 1180 (11th Cir. 2011) (finding that hypothetical posed to the VE was required to include claimant's moderate limitations in maintaining concentration, persistence, and pace); Pendley v. Heckler, 767 F.2d 1561 (11th Cir. 1985) (holding that the ALJ's decision is not supported by substantial evidence when hypothetical used by VE does not include fully all of claimant's limitations); Manley v. Comm'r of Soc. Sec., 2013 WL 2449297, at *6 (M.D. Fla. 2013) (finding "the ALJ's decision is internally inconsistent, in that although she found Plaintiff had moderate limitations in concentration, persistence and pace based on Psychologist[]'s report, without explanation, she failed to include these moderate limitation in concentration in Plaintiff's RFC."). While it is true that when posing a hypothetical question to the VE, "the ALJ is not required to include findings in the hypothetical that the ALJ properly rejects," Wright v. Comm'r of Soc. Sec., 327 F. App'x 135, 137 (11th Cir. 2009) (citing Crawford v. Comm'r of Soc. Sec., 363 F.3d 1155, 1161 (11th Cir. 2004)), in this case, the ALJ did not reject Dr. Duke's finding. To the contrary, the ALJ's opinion indicates that she adopted Dr. Duke's opinions and accorded them great weight. Without a proper hypothetical to the VE, the court cannot speculate as to how this limitation affects Plaintiff's ability to work. Accordingly, this case is due to be remanded back to the ALJ.
The Court has carefully and independently reviewed the record and concludes that, for the reasons given above, the decision of the Commissioner is REVERSED and the case REMANDED for further proceedings consistent with this opinion. A separate judgment will issue.