VIRGINIA EMERSON HOPKINS, District Judge.
Plaintiff Linda Owens Kennedy ("Ms. Kennedy") brings this action pursuant to 42 U.S.C. §§ 216(i) and 223 of the Social Security Act (the "Act"). She seeks review of a final adverse decision of the Commissioner of the Social Security Administration (hereinafter "Commissioner" or "Secretary"), who denied her application for Disability Insurance Benefits ("DIB"). Ms. Kennedy timely pursued and exhausted her administrative remedies available before the Commissioner. The case is ripe for review pursuant to 42 U.S.C. § 405(g), § 205(g) of the Act.
Ms. Kennedy was a forty-eight-year-old female at the time of her video hearing before the administrative law judge (the "ALJ") held on June 18, 2009. (Tr. 14, 36, 26). During this proceeding, the ALJ did not inquire about Ms. Kennedy's level of education. Ms. Kennedy's prior vocational experience includes positions as a cafeteria cashier and bank teller. (Tr. 33).
Ms. Kennedy protectively applied for DIB June 9, 2007. (Tr. 14, 36). She maintains that she became disabled on October 2, 2005, due to lumbar degenerative back disease and mild carpal tunnel syndrome. (Tr. 14, 36). Her claim was denied initially on August 9, 2007. (Tr. 14, 36).
Ms. Kennedy filed a request for a hearing on August 16, 2007. (Tr. 44). A video hearing before the ALJ was held on June 18, 2009, with Ms. Kennedy appearing in Birmingham, Alabama. (Tr. 14, 26).
On December 14, 2009, the ALJ concluded Ms. Kennedy was not disabled as defined by the Act and denied her DIB application. (Tr. 14-22). On December 21, 2009, Ms. Kennedy submitted a request for review of the ALJ's decision, which was received on January 7, 2010. (Tr. 8, 9). On May 5, 2011, the Appeals Council denied review. As a result, the ALJ's disability determination became the final decision of the Commissioner. (Tr. 1).
On July 1, 2011, Ms. Kennedy initiated her lawsuit with this court asking for a review of the ALJ's decision. (Doc. 1). On December 16, 2011, Ms. Kennedy filed a brief (Doc. 7) in support of her appeal, and on February 6, 2012, the Commissioner answered with his responsive brief. (Doc. 9). Ms. Kennedy elected not to file a reply. This court has carefully considered the record, and for the reasons stated below, reverses the Commissioner's denial of benefits, and remands the case for further development and consideration.
The court's review of the Commissioner's decision is narrowly circumscribed. The function of this court is to determine whether the decision of the Commissioner is supported by substantial evidence and whether proper legal standards were applied. Richardson v. Perales, 402 U.S. 389, 390 (1971); Wilson v. Barnhart, 284 F.3d 1219, 1221 (11th Cir. 2002). This court must "scrutinize the record as a whole to determine if the decision reached is reasonable and supported by substantial evidence." Bloodsworth v. Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983). This court will determine that the ALJ's opinion is supported by substantial evidence if it finds "such relevant evidence as a reasonable person would accept as adequate to support a conclusion." Id. Substantial evidence is "more than a scintilla, but less than a preponderance." Id. Factual findings that are supported by substantial evidence must be upheld by the court.
The ALJ's legal conclusions, however, are reviewed de novo, because no presumption of validity attaches to the ALJ's determination of the proper legal standards to be applied. Davis v. Shalala, 985 F.2d 528, 531 (11th Cir. 1993). If the court finds an error in the ALJ's application of the law, or if the ALJ fails to provide the court with sufficient reasoning for determining that the proper legal analysis has been conducted, the ALJ's decision must be reversed. Cornelius v. Sullivan, 936 F.2d 1143, 1145-46 (11th Cir. 1991).
To qualify for disability benefits and establish her entitlement for a period of disability, the claimant must be disabled as defined by the Act and the Regulations promulgated thereunder.
The Regulations provide a five-step process for determining whether a claimant is disabled. 20 C.F.R. § 404.1520(a)(4)(i-v). The Commissioner must determine in sequence:
Pope v. Shalala, 998 F.2d 473, 477 (7th Cir. 1993) (citing to former applicable C.F.R. section), overruled on other grounds by Johnson v. Apfel, 189 F.3d 561 (7th Cir. 1999); accord McDaniel v. Bowen, 800 F.2d 1026, 1030 (11th Cir. 1986). "Once the claimant has satisfied steps one and two, she will automatically be found disabled if she suffers from a listed impairment. If the claimant does not have a listed impairment but cannot perform her work, the burden shifts to the Secretary to show that the claimant can perform some other job." Pope, 998 F.2d at 477; accord Foote v. Chater, 67 F.3d 1553, 1559 (11th Cir. 1995). The Commissioner must further show that such work exists in the national economy in significant numbers. Foote, 67 F.3d at 1559.
The ALJ found Ms. Kennedy had not engaged in substantial gainful activity since the alleged onset date of her disability, i.e., October 2, 2005. (Tr. 16 ¶ 2). Thus, the claimant satisfied step one of the five-step test. 20 C.F.R. § 404.1520(b).
Under step two, the ALJ concluded that "[t]he claimant ha[s] the following severe impairments: degenerative disc disease and pain disorder." (Tr. 16 ¶ 3 (citation omitted)). Accordingly, the ALJ concluded that Ms. Kennedy satisfied the second step of the sequential disability evaluative process. 20 C.F.R. § 404.1520(c).
At step three, the ALJ determined that Ms. Kennedy did not have an impairment or a group of impairments that met or medically equaled one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (Tr. 18 ¶ 4). Ms. Kennedy does not challenge this determination on appeal.
Regarding Ms. Kennedy's residual functional capacity ("RFC"), the ALJ found:
(Tr. 18 ¶ 5). As the ALJ summarized his RFC finding, "the claimant remains capable of performing unskilled work activity at the sedentary exertional level."
Against this backdrop, and in reliance upon testimony from a vocational expert, the ALJ concluded that Ms. Kennedy's impairments prevented her from performing past relevant employment. (Tr. 21; Tr. 21 ¶ 6). Because of the ALJ's finding that Ms. Kennedy was unable to perform past relevant work, it was necessary to continue to step five of the sequential analysis. (Tr. 21-22).
Using the Medical-Vocational Guidelines as a framework and relying upon testimony from the vocational expert, the ALJ determined that Ms. Kennedy was capable of performing certain unskilled sedentary jobs which exist in significant numbers in the national economy. (Tr. 32). Examples of such possible sedentary positions included employment as final assembler and a simple information clerk. (Id.). Accordingly, the ALJ concluded Ms. Kennedy was not disabled as defined by the Social Security Act, and denied her DIB claim. (Tr. 22; Tr. 22 ¶ 11).
In this appeal, Ms. Kennedy raises several different issues, including whether the ALJ erred in his partial rejection of the medical source opinion
The lack of a medical source opinion or a physical capacities evaluation conducted by a physician that substantiates Ms. Kennedy's ability to perform a reduced range of unskilled sedentary work given her severe impairments constitutes reversible error. Such an omission from the record is significant to the substantial evidence inquiry pertaining to the ALJ's RFC determination. See, e.g., Rohrberg v. Apfel, 26 F.Supp.2d 303, 311 (D. Mass. 1998) ("The ALJ failed to refer to—and this Court has not found—a proper, medically determined RFC in the record.").
The court acknowledges that the ALJ did refer within his opinion to the medical records from a physician, Dr. Beau Bagley ("Dr. Bagley"), pertaining to his consultative examination of Ms. Kennedy. (See Tr. 17-18 (summarizing medical evidence from Dr. Bagley's examination conducted on August 4, 2007); Tr. 20 ("rel[ying] on the physical examination findings of Dr. Bagley" in determining Ms. Kennedy's RFC)). However, such documentation from Dr. Bagley is reported merely as raw physical findings applicable to Ms. Kennedy. (See, e.g., Tr. 219-22).
Moreover, with the sole exception of the physician's assessment of pain form provided by Dr. Moon (Tr. 386) (which the ALJ disregarded as "not well-supported by his own treatment notes and [a]s inconsistent with the longitudinal record" (Tr. 20)),
As another district judge of this court aptly explained the RFC issue in the context of an ALJ who comparably determined, without the benefit of a physical capacities evaluation conducted by a physician, that the claimant was not disabled:
Rogers v. Barnhart, No. 3:06-CV-0153-JFG, (Doc. 13 at 5) (N.D. Ala. Oct. 16, 2006) (emphasis added); see also Manso-Pizarro, 76 F.3d at 17 ("With a few exceptions (not relevant here),an ALJ, as a lay person, is not qualified to interpret raw data in a medical record." (emphasis added) (citing Perez v. Sec'y of Health & Human Servs., 958 F.2d 445, 446 (1st Cir.1991))); Rohrberg, 26 F. Supp. 2d at 311 ("An ALJ is not qualified to assess a claimant's RFC on the basis of bare medical findings, and as a result an ALJ's determination of RFC without a medical advisor's assessment is not supported by substantial evidence." (emphasis added) (citing Rodriguez v. Sec'y of Health & Human Servs., 893 F.2d 401, 403 (1st Cir.1989))); cf. Giddings v. Richardson, 480 F.2d 652, 656 (6th Cir. 1973) ("To meet such a prima facie case it is not sufficient for the government to rely upon inconclusive medical discussion of a claimant's problems without relating them to the claimant's residual capacities in the field of employment.") (emphasis added).
Comparable to Rogers, Manso-Pizarro, and other similar cases, a lay person such as an ALJ or Ms. Parker, the state agency consultant, is not able to discern Ms. Kennedy's work-related exertional abilities and appropriate non-exertional restrictions based upon the unfiltered information contained in her medical records. Moreover, the lack of a medically-determined physical RFC that supports the ALJ's RFC determination is particularly critical here when, undisputably, Ms. Kennedy is not able to perform relevant past work given the additional job-related restrictions that the ALJ placed on her at the sedentary exertional level. As the undersigned has previously recognized in another fifth-step burden decision that similarly resulted in a remand for further development of the claimant's functional abilities:
Clemmons v. Barnhart, No. 3:06-CV-1058-VEH, (Doc. 22 at 11) (N.D. Ala. June 11, 2007); cf. Reeves v. Heckler, 734 F.2d 519, 522 n.1 ("It is reversible error for an ALJ not to order a consultative examination when such an evaluation is necessary for him to make an informed decision." (citing Ford v. Sec'y of Health & Human Servs, 659 F.2d 66, 69 (5th Cir.1981) (Unit B))).
Therefore, in the absence of a medical source statement and/or any physical capacities evaluation conducted on Ms. Kennedy by a physician that corroborates the ALJ's determination that she is capable of performing sedentary work with certain non-exertional restrictions despite her severe impairments of degenerative disc disease and pain disorder, the record has not been adequately developed. See, e.g., Cowart v. Schweiker, 662 F.2d 731, 732 (11th Cir. 1981) (citing Thorne v. Califano, 607 F.2d 218, 219 (8th Cir. 1979)); see also Sobolewski v. Apfel, 985 F.Supp. 300, 314 (E.D.N.Y. 1997) ("The record's virtual absence of medical evidence pertinent to the issue of plaintiff's RFC reflects the Commissioner's failure to develop the record, despite his obligation to develop a complete medical history.").
Likewise, the ALJ's determination that Ms. Kennedy can perform sedentary work with certain non-exertional restrictions is not supported by substantial evidence. Accordingly, the decision of the Commissioner is due to be reversed, and the case remanded for further proceedings consistent with this memorandum opinion.
Based upon the court's evaluation of the evidence in the record and the submissions of the parties, the court finds that the Commissioner's final decision is not supported by substantial evidence. Accordingly, the decision of the Commissioner will be remanded by separate order.
20 C.F.R. § 404.1567(a) (current through April 19, 2012).
