VIRGINIA EMERSON HOPKINS, District Judge.
Plaintiff Debra A. Cole-Smith ("Ms. Cole-Smith") 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. Cole-Smith 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. Cole-Smith was a forty-nine-year-old female at the time of her hearing before the administrative law judge (the "ALJ") held on April 26, 2010. (Tr. 75, 60). In terms of education, Ms. Cole-Smith completed the twelfth grade and a year of college. (Tr. 67). Ms. Cole-Smith also obtained a cosmetology degree. (Id.). Ms. Cole-Smith's prior vocational experience includes positions as a home health assistant, a dispatcher, and a nursing assistant at a nursing home. (Tr. 74-75).
Ms. Cole-Smith protectively applied for DIB January 10, 2008. (Tr. 12, 101). She maintains that she became disabled on December 25, 2007, due to back disorders and other unspecified arthropathies (i.e., joint diseases). (Tr. 12, 101); see New Webster's Dictionary and Thesaurus & Medical Dictionary 898 (1991) (defining arthropathy as "any joint disease"). Her claim was denied initially on February 27, 2008. (Tr. 12, 101).
Ms. Cole-Smith filed a request for a hearing on March 12, 2008. (Tr. 110). A hearing before the ALJ was held on April 26, 2010, in Birmingham, Alabama. (Tr. 12, 60).
On July 29, 2010, the ALJ concluded Ms. Cole-Smith was not disabled as defined by the Act and denied her DIB application. (Tr. 12-32). On August 27, 2010, Ms. Cole-Smith submitted a request for review of the ALJ's decision, which was received on August 30, 2010. (Tr. 5). On June 15, 2011, the Appeals Council denied review. As a result, the ALJ's disability determination that was adverse to Ms. Cole-Smith became the final decision of the Commissioner. (Tr. 1).
On August 15, 2011, Ms. Cole-Smith initiated her lawsuit asking this court to review the ALJ's decision. (Doc. 1). On January 5, 2012, Ms. Cole-Smith filed a brief (Doc. 9) in support of her appeal, and on February 2, 2012, the Commissioner answered with his responsive brief. (Doc. 10). Ms. Cole-Smith 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. Cole-Smith had not engaged in substantial gainful activity since the alleged onset date of her disability, i.e., December 25, 2007. (Tr. 30 ¶ 1). 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 has the following `severe' impairments of tennis elbow; very slight narrowing of the left hip joint with phleboliths in the left pelvis and carpal tunnel syndrome." (Tr. 30 ¶ 3). Accordingly, the ALJ concluded that Ms. Cole-Smith 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. Cole-Smith 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. 31 ¶ 3). Ms. Cole-Smith does not challenge this determination on appeal.
Regarding Ms. Cole-Smith's residual functional capacity ("RFC"), the ALJ found:
(Tr. 31 ¶ 5).
In support of his RFC determination, the ALJ gave little weight to the physical capacities evaluation of Ms. Cole-Smith (Tr. 411-13) performed by the consultative examiner Guy B. Dewees ("Dr. Dewees"). (See Tr. 29 "These forms, however, are simply not consistent with his own narrative or other documents contained in the evidence of record, and are entitled to little persuasion.")). Based upon his medical assessment, Dr. Dewees determined that Ms. Cole-Smith "would be unable to sustain an eight hour work day." (Tr. 29).
Against this backdrop, and in reliance upon testimony from a vocational expert, the ALJ concluded that Ms. Cole-Smith's impairments prevented her from performing past relevant employment. (Tr. 29; Tr. 31 ¶ 9). Because of the ALJ's finding that Ms. Cole-Smith was unable to perform past relevant work, it was necessary to continue to step five of the sequential analysis. (Tr. 29-30).
Using the Medical-Vocational Guidelines as a framework and relying upon testimony from the vocational expert, the ALJ determined that Ms. Cole-Smith was capable of "performing light and sedentary jobs which exist in significant numbers in the national economy." (Tr. 30). Examples of such possible light positions included employment as an information clerk and control area checker. (Id.). Potential sedentary employment was as a surveillance system monitor. (Id.). Accordingly, the ALJ concluded Ms. Cole-Smith was not disabled as defined by the Social Security Act, and denied her DIB claim. (Tr. 30; Tr. 32).
In this appeal, Ms. Cole-Smith raises several different issues, including whether the ALJ erred in his rejection of the medical source opinion
In Sharfarz v. Bowen, 825 F.2d 278 (11th Cir. 1987), the Eleventh Circuit explained:
Sharfarz, 825 F.2d at 279-80 (emphasis added).
Here, the ALJ has committed legal error because his RFC determination is in apparent conflict with the above rules applicable to medical source opinions and, regardless, his decision is not supported by substantial evidence. Preliminarily, the ALJ's explanation for disregarding Dr. Dewees's examination-based opinion is flawed and difficult to follow. (Tr. 29; see also Tr. 411-13; Tr. 415-18). Moreover, his dubious rationale for dismissing Dr. Dewees's opinion is not defended by the Commissioner. (See generally Doc. 9).
In an effort to explain why he discounted Dr. Dewees's report, the ALJ indicated that the "forms . . .
The ALJ further reasoned:
(Tr. 29 (emphasis added)). Thus, while the ALJ confusingly acknowledged that Dr. Dewees's vocational evaluation of Ms. Cole-Smith "deserve[d] consideration," he nonetheless gave little weight to it,
As for the ALJ's third point about Dr. Dewees's "quite heav[y]" reliance upon Ms. Cole-Smith's subjective allegations of pain, while, if true,
In fact, the only other physical capacity assessment that the court was able to locate in the record consistent with the ALJ's determination that Ms. Cole-Smith was able to perform a reduced range of light and sedentary work was one performed by a non-examining agency medical consultant named Mark Swink ("Mr. Swink") on February 27, 2008. (Tr. 338-45). The ALJ made no mention of this non-examining report generated by a non-physician in his opinion.
However, when the court compares some of the work-related restrictions ultimately placed upon Ms. Cole-Smith by the ALJ with Mr. Swink's evaluation (compare Tr. 341 (finding limitations with respect to gross and fine manipulation), with Tr. 31 ¶ 5 ("She should be permitted to sit or stand at her option and
Alternatively to running afoul of Sharfarz, the lack of a medical source opinion or a physical capacities evaluation conducted by a physician that substantiates Ms. Cole-Smith's ability to perform a reduced range of light/sedentary work given her severe impairments constitutes reversible error.
The court acknowledges that the ALJ did refer within his opinion to a host of records from various medical providers pertaining to Ms. Cole-Smith. (See Tr. 17-27 (summarizing medical evidence spanning from August 8, 2007, to April 19, 2010)). However, for the most part, such documentation is reported merely as raw physical findings applicable to Ms. Cole-Smith. (See, e.g., Tr. 320-29 (collection of medical records from UAB Medical West); Tr. 371-76 (collection of physical examination and recommendation records from Joe L. Gerald, M.D., relating to carpal tunnel diagnosis); Tr. 394-402 (collection of medical records from ACIPCO Medical Group, including X-ray results and radiology report)). Moreover, with the sole exception of the documents provided by Dr. Dewees (which the ALJ disregarded), none of these records includes an opinion about the impact of Ms. Cole-Smith's impairments in
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 is not able to discern Ms. Cole-Smith'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. Cole-Smith is not able to perform relevant past work given the additional job-related restrictions that the ALJ placed on her at the light/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. Cole-Smith by a physician that corroborates the ALJ's determination that she is capable of performing light and sedentary work with certain non-exertional restrictions despite her severe physical impairments of (i) tennis elbow; (ii) very slight narrowing of the left hip joint with phleboliths in the left pelvis; and (iii) carpal tunnel syndrome, 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. Cole-Smith can perform light and sedentary work with certain non-exertional restrictions is not supported by substantial evidence. Accordingly, the decision of the Commissioner is due to be reversed on the basis of this alternative reasoning, 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(b) (current through April 19, 2012).