VIRGINIA EMERSON HOPKINS, District Judge.
Mary Cannon ("Ms. Cannon") brings this action pursuant to 42 U.S.C. § 405(g), § 205(g) of the Social Security Act. She seeks review of the decision of the Commissioner of the Social Security Administration (the "Commissioner") denying her application for supplemental security income ("SSI").
Ms. Cannon was 50 years old at the time of her hearing before the administrative law judge ("ALJ"). (Tr. 82). She completed the tenth grade (Tr. 163), and later received her GED. (Tr. 98). Her past work experiences include employment as a fast-food chain store manager, commercial cleaner, and box packager. (Tr. 19, 41). Ms. Cannon claims she became disabled on February 28, 2001, due to leg swelling and aching, arthritis in her hands and feet, knots atop her feet, sleeplessness, swelling in her hands and arms, and a history of carpel tunnel syndrome and surgery in her left hand resulting in loss of strength.
Ms. Cannon filed her application for SSI benefits on March 22, 2007. (Tr. 120). It was denied on July 27, 2007. (Tr. 121). The Social Security Administration received Ms. Cannon's request for a hearing on September 26, 2007 (Tr. 126), and that hearing was held on April 22, 2009. (Tr. 128). Following that hearing, the ALJ concluded that Ms. Cannon was not disabled and denied her application on June 8, 2009. (Tr. 21). After having her request for review denied by the Appeals Council (Tr. 1), Ms. Cannon filed this action seeking review of the ALJ's decision. (Doc. 1). 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 his entitlement for a period of disability, a claimant must be disabled as defined by the Social Security 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. Id.
The ALJ found that Ms. Cannon had not engaged in substantial gainful activity since her application date of March 22, 2007. (Tr. 14). The ALJ then determined Ms. Cannon was suffering from several severe impairments, and specifically listed hypertension, obesity, history of carpel tunnel syndrome, a history of fracture of the 5th right metatarsal (i.e., a foot fracture), and depression disorder. (Id.) The ALJ also noted that Ms. Cannon had recently been diagnosed with diabetes mellitus, but found that condition to be non-severe. (Id.).
The ALJ determined that these impairments, when considered individually or in combination, did not meet or equal one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (Id.) Ms. Cannon does not contest this particular finding on appeal.
Next, the ALJ considered Ms. Cannon's residual functional capacity ("RFC"), and found that:
(Id. ).
In support of his RFC determination, the ALJ gave little weight to the physical capacities evaluation of Ms. Cannon (Tr. 362) performed by her treating physician, Dr. Stephen A. Branning ("Dr. Branning"). (Tr. 18)("The undersigned gives little weight to most of Dr. Branning's April 14, 2009 assessment forms."). Based upon his medical assessment, Dr. Branning determined that Ms. Cannon "could not lift and/or carry more than 10 pounds occasionally, could not do any sitting, standing or walking in an 8-hour day, and could never do any pushing/pulling, climbing, balancing, or gross or fine manipulation." Additionally, Dr. Branning's physical capacity evaluation indicated "that [Ms. Cannon] could only occasionally bend, stoop, and reach, and could not work around hazardous machinery or dust/allergens/fumes, etc." (Tr. 362).
As an additional factor in making his RFC determination, the ALJ stated that he gave "more weight to the state agency medical consultant opinion in July 2007 that the claimant could perform a wide range of medium work (Exhibit B8F) [i.e., Tr. 245] than to Dr. Branning's April 2009 assessments." (Tr. 18). The ALJ did, however, note that the state agency medical consultant had never examined or treated Ms. Cannon, but, nevertheless, concluded that the consultant's assessment was "more consistent with the record as a whole." (Id.).
Regarding Ms. Cannon's mental functioning, the ALJ gave little weight to the results of the consultative psychological examination performed by John R. Haney, Ph.D. ("Dr. Haney"). Rather, the ALJ gave great weight to the consultative medical examination conducted by Will R. Crouch, M.D. ("Dr. Crouch") and the opinion of the non-examining state agency medical consultant. (Tr. 19).
Against this backdrop, the ALJ concluded that Ms. Cannon could not perform her past relevant work, which was more strenuous than her residual functional capacity permitted. (Tr. 19). Because of this, the ALJ then had to proceed to the fifth prong of the sequential analysis, and determine whether the claimant was capable of performing any jobs in the national economy.
In the final step, the ALJ considered Ms. Cannon's residual functional capacity, age, education, and work experience, and determined that there are a significant number of jobs in the national economy that Ms. Cannon is capable of performing. (Tr. 20). Relying on the expertise of a vocational expert, the ALJ provided examples of such jobs, including packing line worker, nut and bolt assembler, and garment sorter. (Tr. 20). Accordingly, the ALJ concluded Ms. Cannon was not disabled as defined by the Social Security Act, and denied her SSI claim. (Tr. 21).
The court must review the Commissioner's findings of fact with deference, but may reverse when those findings are not supported by substantial evidence. See Martin v. Sullivan, 894 F.2d 1520, 1529 (11th Cir. 1990) (citing Graham v. Bowen, 790 F.2d 1572, 1574-75 (11th Cir. 1986)). In making that determination, the 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)). Ms. Cannon argues that the ALJ's findings were not supported by substantial evidence because the ALJ "substitut[ed] his own judgment for that of the her treating physician Dr. Stephen A. Branning and the ALJ's own disability determination service consultative psychologist, Dr. John R. Haney." (Doc. 8 at 10). Upon review, the court finds that the ALJ's disability decision is not supported by substantial evidence, and remands the case for further development and consideration.
In this appeal, Ms. Cannon primarily asserts that the ALJ substituted his own judgment for that of Ms. Cannon's treating physician, Dr. Branning, and the consulting psychiatrist, Dr. Haney, and that in doing so, he committed reversible error. Generally, the Eleventh Circuit has held that "[a]n ALJ sitting as a hearing officer abuses his discretion when he substitutes his own uninformed medical evaluations for those of a claimant's treating physicians." Marbury v. Sullivan, 957 F.2d 837, 840 (11th Cir. 1992).
Regardless of the merits of this particular contention, the court finds that the ALJ's disability determination is not supported by substantial evidence because of the lack of an underlying medical opinion by a physician in support of the ALJ's RFC determination that Ms. Cannon is capable of performing light work with additional restrictions given her collection of severe physical and mental impairments and her non-severe diabetes. Accordingly, the court agrees with Ms. Cannon that, under the circumstances of her case, the ALJ committed reversible error.
The court has been unable to locate a medical source opinion
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),
Thus, when an ALJ makes an RFC determination about a claimant, who, like Ms. Cannon, has a complex medical history and who suffers from several severe impairments, without the benefit of a supporting medical source statement or a physical capacities evaluation, he risks substituting his own medical judgment for that of a physician, and, regardless, lacks substantial evidence to support his disability determination.
Against the above analysis, the ALJ could not have used Dr. Branning's physical capacity evaluation (Tr. 362) to make his RFC determination because he specifically discounts that opinion. In particular, the ALJ found that Dr. Branning's assessment was inconsistent with the medical records as a whole. Additionally, Dr. Branning concluded differently than the ALJ that Ms. Cannon was physically capable of performing light exertional work. Therefore, such medical documentation cannot constitute substantial evidence in support of the ALJ's RFC determination.
The ALJ also cannot point solely to the physical summary supplied by R. Glenn Carmichael ("Dr. Carmichael"), a non-examining state agency consultative physician, to support his RFC determination. (Tr. 245). After conducting a paper review, Dr. Carmichael concluded on July 26, 2007, that Ms. Cannon could perform medium work "with safety precautions [and avoiding] excessive heat and cold. (Id.). In formulating his RFC for Ms. Cannon, the ALJ indicated that he "[gave] more weight to the state agency medical consultant opinion . . . (Exhibit B8F)." (Tr. 18).
One problem with the ALJ's reliance upon this summary is that Dr. Carmichael's opinion does not reflect that he factored in the vocational impact of Ms. Cannon's foot fracture, an impairment the ALJ found to be severe. Instead, Dr. Carmichael identifies only Ms. Cannon's severe level II obesity, hypertension, and carpal tunnel syndrome in providing his exertional opinion. (Tr. 245).
Another issue with Dr. Carmichael's assessment is that Ms. Cannon's diabetes diagnosis is not referenced. Although the ALJ found this condition to be not severe, when determining disability "[t]he ALJ must consider the applicant's medical condition taken as a whole." Jamison v. Bowen, 14 F.2d 585, 588 (11th Cir. 1987); see 20 C.F.R. § 404.1545(a)(2) ("We will consider all of your medically determinable impairments of which we are aware, including your medically determinable impairments that are not `severe,' as explained in §§ 404.1520(c), 404.1521, and 404.1523, when we assess your residual functional capacity."); cf. Jamison, 14 F.2d at 588 ("At step three the ALJ must determine if the applicant has a severe impairment or a combination of impairments,
Finally, based upon the Eleventh Circuit's decision in Sharfarz v. Bowen, 825 F.2d 278 (11th Cir. 1987), the court questions whether a vocational opinion from a non-examining physician like Dr. Carmichael can constitute substantial evidence in support of an RFC finding. See Sharfarz, 825 F.2d at 280 ("The only opinions that indicated that appellant could meet the medium work requirements of 20 C.F.R. 404.1567(c) (1986) were those of the nonexamining physicians, Drs. Thomas and Register. Their opinions were entitled to little weight, however, and
Dr. Crouch's medical records also do not provide sufficient detail regarding Ms. Cannon's exertional abilities to support the ALJ's RFC determination. (Tr. 221-23). As explained above, when a doctor's records contain only clinical findings and diagnoses that are not couched in terms of a claimant's exertional abilities, then, as a general proposition, the ALJ does not have the expertise to formulate an RFC based on those bare medical records.
Here, none of Dr. Crouch's documents includes an opinion about Ms. Cannon's impairments in vocational terms, attaches a physical capacities evaluation of her, or otherwise unambiguously suggests that she can perform a reduced range of light work. See, e.g., Rohrberg, 26 F. Supp. 2d at 311 ("Where the `medical findings in the record merely diagnose [the] claimant's exertional impairments and do not relate these diagnoses to specific residual functional capabilities such as those set out in 20 C.F.R. § 404.1567(a) . . . [the Commissioner may not] make that connection himself.'" (quoting Rosado v. Sec'y of Health & Human Servs., 807 F.2d 292, 292 (1st Cir. 1986))).
Instead, such records amount only to "raw physical findings" the caliber of which this court has previously found to be ineffective evidence for corroborating an RFC. Cole-Smith, 2012 WL 1946776, at *6. Like the medical records in Cole-Smith, the physical examination supplied by Dr. Crouch and seemingly relied upon by the ALJ does not provide an indication of how Ms. Cannon fits into the residual functional capacity scheme outlined in 20 C.F.R. § 404.1567.
For example, Dr. Crouch's written summary on Ms. Cannon's blood pressure, medication, height, weight, whether her "fundoscopic exam" reveals "hemorrhages, exudates, AV nicking, [or] pappilledema," and the extent of her "thyromegaly," (Tr. 222-23), does not give the ALJ a basis for determining Ms. Cannon's physical RFC. Although Dr. Crouch does address Ms. Cannon's range of motion in her wrists and ankles, her capacity to walk and squat, and her ability to get off and on the exam table (Tr. 223), such reporting is not the equivalent of a physical capacity evaluation that specifies a claimant's exertional abilities as they relate to 20 C.F.R. § 404.1567.
Dr. Crouch's reporting is particularly vague with regard to Ms. Cannon's ability to lift, the extent of her walking ability, and her capacity to push and pull. Comparable to Cole-Smith, Rogers, Manso-Pizarro, and other similar cases, a lay person such as an ALJ is not able to discern Ms. Cannon's work-related exertional abilities and appropriate non-exertional restrictions based upon the unfiltered information contained in her medical records. Thus, because there was no suitable physical capacity evaluation or other medical documentation that relates Ms. Cannon's medical information to her functional abilities, the court finds that the ALJ must have erroneously made an RFC determination by interpreting the bare medical findings on his own.
Moreover, the lack of a medically-determined physical RFC that supports the ALJ's RFC determination is particularly critical here when, undisputably, Ms. Cannon is not able to perform relevant past work given the additional job-related restrictions that the ALJ placed on her at the light 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. Cannon by a physician that corroborates the ALJ's determination that she is capable of performing light work with certain non-exertional restrictions despite her physical impairments of (i) severe hypertension; (ii) severe obesity; (iii) severe carpal tunnel syndrome; and (iv) non-severe diabetes, 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. Cannon can perform light 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.
In addition to her severe physical impairments, the ALJ also determined that Ms. Cannon suffers from severe depression. In conducting a consultative mental examination of Ms. Cannon, Dr. Haney, a specialist, opined that she "appeared quite depressed" and that her "ability to function in most jobs appeared moderately to severely impaired due to the patient's physical and emotional limitations." (Tr. 226). Regarding Ms. Cannon's work-related restrictions relating to her depressive condition, the ALJ disregarded Dr. Haney's findings over Dr. Crouch's medical examination and the mental residual functional capacity assessment provided by a state agency medical consultant, Aileen McAlister, M.D. ("Dr. McAlister") on July 17, 2007. (Tr. 241-44). In Dr. McAlister's report, she opined that Ms. Cannon was not significantly limited in most areas of mental functioning or only just moderately limited in others. (Tr. 241-42).
The ALJ's reliance upon Dr. Crouch's report to substantiate the vocational impact of Ms. Cannon's severe depression is flawed for the same reasons that the court found it to be inadequate to sustain the ALJ's physical RFC finding-Dr. Crouch's raw physical findings are not the equivalent of a functional assessment of Ms. Cannon's mental abilities. Indeed, there is no indication that Dr. Crouch ever even considered Ms. Cannon's severe depression as a diagnosis, much less its impact in vocational terms.
In crediting the opinion of Dr. McAlister over that of Dr. Haney, the ALJ indicated that he gave "great weight to the state agency medical consultant opinion in July 2007 that the claimant had no more than moderate mental restrictions since it is compatible with the record." (Tr. 19). The ALJ provided no explanation of why he found Dr. McAlister's assessment to be "compatible with the record."
825 F.2d at 279-280 (emphasis added).
The court concludes that the ALJ's assignment of more weight to the opinion of Dr. McAlister runs afoul of Sharfarz because, after obtaining the results of the consultative examination that he ordered to develop the record further, his decision to favor the prior opinion by Dr. McAlister lacks any elaboration,
Furthermore, having disregarded Dr. Haney's opinion, no other functional proof provided by a physician exists in the record to corroborate the ALJ's mental RFC determination for Ms. Cannon. Therefore, the disability decision of the ALJ is alternatively due to be remanded because the ALJ's mental RFC finding for Ms. Cannon is deficiently supported.
Based upon the court's evaluation of the evidence in the record and the submissions of the parties, this 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.
