MICHELLE H. BURNS, Magistrate Judge.
Pending before the Court is Plaintiff Donald N. Pancho, Sr.'s appeal from the Social Security Administration's final decision to deny his claim for disability insurance benefits and supplemental security income. After reviewing the administrative record and the arguments of the parties, the Court now issues the following ruling.
On August 20, 2008, Plaintiff filed applications for disability insurance benefits and supplemental security income pursuant to Titles II and XVI of the Social Security Act, alleging disability beginning February 1, 2008. (Transcript of Administrative Record ("Tr.") at 117-128, 19.) His application was denied initially and on reconsideration. (Tr. at 62-65, 19.) On April 29, 2009, he requested a hearing before an Administrative Law Judge ("ALJ"). (Tr. at 85-86, 19.) A hearing was held on June 10, 2010. (Tr. at 34-61, 19.) On July 21, 2010, the ALJ issued a decision in which she found that Plaintiff was not disabled. (Tr. at 16-33.) Thereafter, Plaintiff requested review of the ALJ's decision. (Tr. at 14-15.)
The Appeals Council denied Plaintiff's request, (Tr. at 1-6), thereby rendering the ALJ's decision the final decision of the Commissioner. Plaintiff then sought judicial review of the ALJ's decision pursuant to 42 U.S.C. § 405(g).
The Court must affirm the ALJ's findings if the findings are supported by substantial evidence and are free from reversible legal error.
In determining whether substantial evidence supports a decision, the Court considers the administrative record as a whole, weighing both the evidence that supports and the evidence that detracts from the ALJ's conclusion.
In order to be eligible for disability or social security benefits, a claimant must demonstrate an "inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." 42 U.S.C. § 423(d)(1)(A). An ALJ determines a claimant's eligibility for benefits by following a five-step sequential evaluation:
At step one, the ALJ determined that Plaintiff had not engaged in substantial gainful activity since February 1, 2008 — the alleged onset date. (Tr. at 21.) At step two, she found that Plaintiff had the following severe impairments: diabetes mellitus with neuropathy, morbid obesity, degenerative disc disease of the lumbar spine, and sleep apnea. (Tr. at 21-24.) At step three, the ALJ stated that Plaintiff did not have an impairment or combination of impairments that met or medically equaled an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1 of the Commissioner's regulations. (Tr. at 24.) After consideration of the entire record, the ALJ found that Plaintiff retained "the residual functional capacity to perform light work . . . except for occasional postural functions, but no climbing of ladders, ropes or scaffolds or unprotected heights; avoid concentrated exposure to extreme cold or hazards; no more than occasional pushing/pulling activity with the lower extremities; requires a sit/stand option; and has mental capacity for simple work."
In his brief, Plaintiff contends that the ALJ erred by: (1) failing to properly consider his subjective complaints; and (2) failing to properly weigh medical source opinion evidence. Plaintiff requests that the Court remand for determination of benefits.
Plaintiff argues that the ALJ erred by rejecting his subjective complaints in the absence of clear and convincing reasons for doing so.
To determine whether a claimant's testimony regarding subjective pain or symptoms is credible, the ALJ must engage in a two-step analysis. "First, the ALJ must determine whether the claimant has presented objective medical evidence of an underlying impairment `which could reasonably be expected to produce the pain or other symptoms alleged.' The claimant, however, `need not show that her impairment could reasonably be expected to cause the severity of the symptom she has alleged; she need only show that it could reasonably have caused some degree of the symptom.'"
In weighing a claimant's credibility, the ALJ may consider many factors, including, "(1) ordinary techniques of credibility evaluation, such as the claimant's reputation for lying, prior inconsistent statements concerning the symptoms, and other testimony by the claimant that appears less than candid; (2) unexplained or inadequately explained failure to seek treatment or to follow a prescribed course of treatment; and (3) the claimant's daily activities."
Having reviewed the record along with the ALJ's credibility analysis, the Court finds that the ALJ failed to properly support her decision to discredit Plaintiff's allegations with specific, clear and convincing reasons. When attempting to refute Plaintiff's testimony with the objective medical evidence, the ALJ clearly relies on Plaintiff's apparent noncompliance with his diabetic medication (Tr. at 22, 26-27), yet she spends the entirety of her discussion addressing isolated, non-related portions of the record showing Plaintiff's normal movement, normal strength, and normal heart functioning. (Tr. at 25-26.) For example, the ALJ states that Plaintiff had "complete normal movement on the neck, shoulders, elbows, wrists, fingers, hips, and ankles. He walked without an ambulatory support device. He had normal posture and sat without alternating positions . . . [and] had 5/5 strength throughout (Exhibit 1F)." (Tr. at 25.) The ALJ addressed a medical report stating that Plaintiff's motor strength was "5/5 all over. Lumbar spine range of motion was intact except for lumber extension and rotation, which produced a slight painful arc of motion (Exhibit 14F/14-15)." (Tr. at 25.) The ALJ goes on to discuss Plaintiff's "normal heart functioning" and the lack of "obvious signs of a stroke." (Tr. at 26.)
When finally addressing Plaintiff's diabetic condition, the ALJ summarily concludes that Plaintiff was not compliant with treatment, either in terms of monitoring his blood sugars or taking his diabetic medication as prescribed. The ALJ stated, in pertinent part:
(Tr. at 25-26.) The ALJ then cited to Sections 404.1530 and 416.930 of the Code of Federal Regulations, stating, "in order to get benefits, claimant must follow treatment prescribed by his physician if that treatment can restore his ability to work. When claimant does not follow prescribed treatment without a good reason, he will not be found disabled. In this case, the claimant has been noncompliant with his diabetic medication on a regular basis." (Tr. at 26.)
Plaintiff objects to the ALJ's reliance on his alleged noncompliance with medical treatment as reason for her decision to discount the intensity and duration of his pain complaints. Social Security Ruling 96-7p outlines the criteria for evaluating a claimant's credibility and provides that claims of pain may be deemed less credible where the "frequency of treatment is inconsistent with the level of complaints, or if the medical reports or records show that the individual is not following the treatment as prescribed and there are no good reasons for this failure." The Ruling further provides that:
Here, the ALJ failed to seek an explanation from Plaintiff as to why he had allegedly been noncompliant with his diabetic medication, and the evidence of record on this issue is, at best, conflicting. Indeed, the record documents financial constraints, a lack of understanding regarding treatment, and, contrary to the conclusion of the ALJ, compliance with the prescribed medication regimen on various occasions. (Tr. at 571, 363, 318, 543, 564-66, 355, 535.) Thus, the Court finds that the ALJ's failure to explore these explanations was in violation of SSR 96-7p.
Likewise unavailing is the ALJ's reliance on Plaintiff's activities of daily living used to discredit his testimony. The ALJ's analysis consists of the following three sentences:
(Tr. at 26.) The Court finds that the ALJ fails to draw a connection between Plaintiff's reported sporadic activities of daily living, which included napping for four hours during the day (Tr. at 51), and the ability to sustain work considering his diabetes mellitus with neuropathy, morbid obesity, degenerative disc disease of the lumbar spine, and sleep apnea. Indeed, this Circuit has made clear that the mere fact that a claimant engages in normal daily activities "does not in any way detract from her credibility as to her overall disability. One does not need to be `utterly incapacitated' in order to be disabled."
Plaintiff contends that the ALJ erred by failing to properly weigh medical source opinion evidence. Specifically, Plaintiff argues that the ALJ failed to provide legally sufficient reasons to reject Dr. Bahr's medical opinion, which concluded that Plaintiff could not meet the demands of any sustained work activity.
"The ALJ is responsible for resolving conflicts in the medical record."
If a treating physician's opinion is not contradicted by the opinion of another physician, then the ALJ may discount the treating physician's opinion only for "clear and convincing" reasons.
Since the opinion of treating physician, Dr. Bahr, was contradicted by examining physician, Dr. Richard Palmer, reviewing state agency physician, Dr. John Fahlberg, and other objective medical evidence, the specific and legitimate standard applies.
Historically, the courts have recognized the following as specific, legitimate reasons for disregarding a treating or examining physician's opinion: conflicting medical evidence; the absence of regular medical treatment during the alleged period of disability; the lack of medical support for doctors' reports based substantially on a claimant's subjective complaints of pain; and medical opinions that are brief, conclusory, and inadequately supported by medical evidence.
According to the record, Dr. Bahr treated Plaintiff for the following conditions: uncontrolled diabetes with neuropathy; back and knee pain; morbid obesity; and sleep apnea. (Tr. at 387-88, 314-15, 363-64, 331-32, 484-85, 480-81, 472-73, 462-63.) Dr. Bahr found that Plaintiff's obesity warranted surgical intervention — specifically, gastric bypass surgery. (Tr. at 364.)
On April 14, 2009, Dr. Bahr completed a Medical Assessment of Ability to do Work-Related Physical Activities and opined that, in an eight-hour day, Plaintiff can sit, stand, and walk less than two hours each, and can lift less than 20 pounds occasionally and less than 15 pounds frequently. (Tr. at 442-43.) When asked if the limitations noted in her April 4, 2009 report could reasonably be expected to result from objective clinical or diagnostic findings which have been documented in Plaintiff's medical records, Dr. Bahr stated "Yes" and attributed Plaintiff's limitations to degenerative changes in the spine and obstructive sleep apnea. (Tr. at 443.)
Then, on May 4, 2010, Dr. Bahr completed another Medical Assessment of Ability to do Work-Related Physical Activities. (Tr. at 497-98.) Dr. Bahr opined that Plaintiff cannot perform work eight hours a day, five days a week on a regular and consistent basis due to "severe back pain." (Tr. at 497.) Dr. Bahr noted that Plaintiff is limited to sitting, standing, and walking less than two hours each in an eight-hour workday; and limited to lifting less than 20 pounds. (Tr. at 497-98.) When asked if the limitations noted in her May 4, 2010 report could reasonably be expected to result from objective clinical or diagnostic findings which have been documented in Plaintiff's medical records, Dr. Bahr stated "Yes" and, again, attributed Plaintiff's limitations to degenerative changes in the spine and obstructive sleep apnea. (Tr. at 498.)
On November 3, 2008, Plaintiff was examined by Dr. Palmer at the request of the Administration. (Tr. at 269-75.) Plaintiff reported to Dr. Palmer that he suffers insulin-dependent diabetes, peripheral neuropathy, constant pain and throbbing in both shins, and some intermittent pains in his knees. (Tr. at 269-75.) Dr. Palmer noted that there was some slowness due to obesity, and that Plaintiff uses his hands for support when changing positions. (Tr. at 269-75.) Dr. Palmer further noted tandem walking is unsteady; mild crepitations in both knees; neurological examination reveals loss of sensation from the feet to the knees; and absent reflexes throughout both lower extremities. (Tr. at 269-75.) He ultimately diagnosed insulin-dependent diabetes mellitus, peripheral neuropathy, constant dysesthesias affecting the shins, and extreme obesity. (Tr. 269-75.) He opined, however, that Plaintiff has functional abilities consistent with light work. (Tr. 269-75.) Specifically, Dr. Palmer found that Plaintiff could lift 20 pounds occasionally and 10 pounds frequently; could stand and/or walk six hours in an eight-hour workday; and had no limitations sitting in an eight-hour workday. (Tr. at 269-75.)
On December 4, 2008, state agency physician, Dr. Fahlberg, reviewed the medical record and completed a Physical Residual Functional Capacity Assessment indicating that Plaintiff has functional abilities consistent with light work. (Tr. at 276-83.) Specifically, Dr. Fahlberg opined that Plaintiff could lift 20 pounds occasionally and 10 pounds frequently; could stand and/or walk about six hours in an eight-hour workday; and sit about six hours in an eight-hour workday. (Tr. at 276-83.) With regard to postural limitations, Dr. Fahlberg found that Plaintiff could occasionally climb ramps/stairs, balance, stoop, kneel, crouch, and crawl. (Tr. at 276-83.) Dr. Fahlberg further found no manipulative, visual, or communicative limitations. (Tr. at 276-83.)
After considering the medical evidence, the ALJ first addressed Dr. Bahr's medical assessments finding that Plaintiff has limitations that restrict him to less than sedentary work. (Tr. at 26.) The ALJ stated:
(Tr. at 26.) The ALJ then discussed Dr. Palmer's November 3, 2008 Medical Source Statement noted above and concluded, "[t]his opinion is given great weight to the extent that it is consistent with claimant's ability to perform light work." (Tr. at 27.) Lastly, the ALJ addressed Dr. Fahlberg's assessment. The ALJ stated, in pertinent part:
(Tr. at 27.)
Regarding Plaintiff's "severe back pain" and degenerative changes in the spine assessed by Dr. Bahr as the primary reason for Plaintiff's limitations, the Court notes that earlier in her discussion the ALJ found as follows:
(Tr. at 22.)
The ALJ is tasked with determining credibility and resolving conflicts in medical testimony, not this Court.
In light of the objective medical evidence, the Court finds that ALJ provided specific and legitimate reasons, based on substantial evidence in the record, for discounting the opinion of Dr. Bahr.
In summary, the Court finds that although the ALJ properly rejected Dr. Bahr's opinion providing "specific and legitimate reasons that are supported by substantial evidence in the record," the ALJ failed to properly support her decision to discredit Plaintiff's subjective complaints with specific, clear and convincing reasons. Accordingly, the Court finds error and will vacate the ALJ's decision.
Having decided to vacate the ALJ's decision, the Court has the discretion to remand the case for further development of the record or for an award benefits.
Therefore,