ERIN L. SETSER, Magistrate Judge.
Plaintiff, Clethia Ann Harris, brings this action pursuant to 42 U.S.C. § 405(g), seeking judicial review of a decision of the Commissioner of the Social Security Administration (Commissioner) denying her claims for a period of disability and disability insurance benefits (DIB) under the provisions of Title II of the Social Security Act (Act). In this judicial review, the Court must determine whether there is substantial evidence in the administrative record to support the Commissioner's decision.
Plaintiff protectively filed her current application for DIB on November 1, 2012, alleging an inability to work since October 12, 2012, due to degenerative bone loss in the spine, ruptured discs, bone spurs, arthritis in the spine and bulging discs. (Doc. 12, pp. 69, 144). An administrative video hearing was held on November 22, 2013, at which Plaintiff appeared with counsel and testified. (Doc. 12, pp. 45-64).
By written decision dated February 28, 2014, the ALJ found that during the relevant time period, Plaintiff had an impairment or combination of impairments that were severe. (Doc. 12, p. 34). Specifically, the ALJ found Plaintiff had the following severe impairments: a disorder of the back, neck, and bilateral knees; and obesity. However, after reviewing all of the evidence presented, the ALJ determined that Plaintiff's impairments did not meet or equal the level of severity of any impairment listed in the Listing of Impairments found in Appendix I, Subpart P, Regulation No. 4. (Doc. 12, p. 37). The ALJ found Plaintiff retained the residual functional capacity (RFC) to:
(Doc. 12, p. 38). With the help of a vocational expert, the ALJ determined Plaintiff could perform her past relevant work as a bookkeeper. (Doc. 12, p. 41).
Plaintiff then requested a review of the hearing decision by the Appeals Council, which after reviewing additional medical evidence submitted by Plaintiff, denied that request on July 31, 2015. (Doc. 12, p. 4). Subsequently, Plaintiff filed this action. (Doc. 1). This case is before the undersigned pursuant to the consent of the parties. (Doc. 7). Both parties have filed appeal briefs, and the case is now ready for decision. (Docs. 9, 11).
The Court has reviewed the entire transcript. The complete set of facts and arguments are presented in the parties' briefs, and are repeated here only to the extent necessary.
This Court's role is to determine whether the Commissioner's findings are supported by substantial evidence on the record as a whole.
It is well-established that a claimant for Social Security disability benefits has the burden of proving her disability by establishing a physical or mental disability that has lasted at least one year and that prevents her from engaging in any substantial gainful activity.
The Commissioner's regulations require her to apply a five-step sequential evaluation process to each claim for disability benefits: (1) whether the claimant has engaged in substantial gainful activity since filing her claim; (2) whether the claimant has a severe physical and/or mental impairment or combination of impairments; (3) whether the impairment(s) meet or equal an impairment in the listings; (4) whether the impairment(s) prevent the claimant from doing past relevant work; and (5) whether the claimant is able to perform other work in the national economy given her age, education, and experience.
Of particular concern to the undersigned is the ALJ's RFC determination. RFC is the most a person can do despite that person's limitations. 20 C.F.R. § 404.1545(a)(1). It is assessed using all relevant evidence in the record.
In the present case, the ALJ determined Plaintiff is able to perform sedentary work with limitations. In making this determination, the ALJ pointed out that no treating physician opined as to Plaintiff's abilities, and that two non-examining medical consultants opined that Plaintiff was able to perform light work with limitations. While the ALJ did reduce Plaintiff's RFC to sedentary work, a review of the record reveals that the non-examining medical consultants did not have the evidence regarding Plaintiff's bilateral knee impairments before them when they opined as to Plaintiff's capabilities. A review of the record reveals that Plaintiff was seen by Dr. Mark W. Powell in July of 2013. (Doc. 12, pp.426-431). The Court notes that at that time, Dr. Powell recommended that Plaintiff "use a walker and toe-touch weight bear only on the left lower extremity due to the osteochondral lesion in her right knee." (Doc. 12, p. 429). The record further reveals that Plaintiff testified at the administrative hearing in November of 2013, that Dr. Powell had completed the forms for her to receive a handicap license plate because she was unable to walk one hundred feet without having to stop and rest; that she had to use a cane to get around at all times; and that even with the use of a brace on each knee her knees would buckle. (Doc. 12, p. 53). The record is void of a medical opinion by either an examining or non-examining medical professional regarding Plaintiff's bilateral knee impairments which at times have required the use of a walker during the time period in question. After reviewing the record, the Court finds remand necessary for the ALJ to more fully and fairly develop the record with respect to Plaintiff's physical RFC.
On remand, the ALJ is directed to address interrogatories to a medical professional requesting that said physician review Plaintiff's medical records; complete a RFC assessment regarding Plaintiff's capabilities during the time period in question; and give the objective basis for the opinion so that an informed decision can be made regarding Plaintiff's ability to perform basic work activities on a sustained basis. The ALJ may also order a consultative examination, in which, the consultative examiner should be asked to review the medical evidence of record, perform examinations and appropriate testing needed to properly diagnosis Plaintiff's condition(s), and complete a medical assessment of Plaintiff's abilities to perform work related activities.
With this evidence, the ALJ should then re-evaluate Plaintiff's RFC and specifically list in a hypothetical to a vocational expert any limitations that are indicated in the RFC assessments and supported by the evidence.
Accordingly, the Court concludes that the ALJ's decision is not supported by substantial evidence, and therefore, the denial of benefits to the Plaintiff should be reversed and this matter should be remanded to the Commissioner for further consideration pursuant to sentence four of 42 U.S.C. § 405(g).