JACQUELINE CHOOLJIAN, Magistrate Judge.
On July 26, 2012, plaintiff John A. Marshall ("plaintiff") filed a Complaint seeking review of the Commissioner of Social Security's denial of plaintiff's application for benefits. The parties have consented to proceed before a United States Magistrate Judge.
This matter is before the Court on the parties' cross motions for summary judgment, respectively ("Plaintiff's Motion") and ("Defendant's Motion"). The Court has taken both motions under submission without oral argument.
Based on the record as a whole and the applicable law, the decision of the Commissioner is REVERSED and the case is REMANDED for immediate payment of benefits.
On March 15, 2004, plaintiff filed applications for Supplemental Security Income and Disability Insurance Benefits. (Administrative Record ("AR") 93, 660). Plaintiff asserted that he became disabled on or about June 20, 2001, due to "HIV — seizures." (AR 93, 105, 660). On April 30, 2006, an Administrative Law Judge ("First ALJ") examined the medical record and heard testimony from plaintiff (who was represented by counsel). (AR 641-56). On May 12, 2006, the First ALJ determined that plaintiff was not disabled through the date of the decision. (AR 55-59).
On January 29, 2007, the Appeals Council granted review and vacated the May 12, 2006 decision, in part, because the step four assessment that plaintiff could perform "the full range of light work" conflicted with the findings of the First ALJ at step two that plaintiff had severe impairments of "ataxia, history of seizures and deficits in motor skills" — which, the Appeals Council noted, commonly involve the need for seizure precautions, balance problems, and dexterity difficulties. (AR 62-63). The Appeals Council remanded the matter with instructions to, inter alia, reevaluate plaintiff's residual functional capacity "and provide appropriate rationale with specific references to evidence of record in support of the assessed limitations." (AR 62-63) (citing 20 C.F.R. §§ 404.1527(f), 416.927(f); Social Security Ruling ("SSR") 96-8p
On April 11, 2008, the First ALJ again determined that plaintiff was not disabled through the date of the decision. (AR 15-23). The Appeals Council denied plaintiff's application for review of that decision. (AR 6).
On December 21, 2009, this Court entered judgment reversing and remanding the case for further proceedings essentially because it determined that the First ALJ had materially erred in failing to consider the opinions of plaintiff's treating physician, Dr. J. Scott Morrow. (AR 681-90). The Appeals Council in turn remanded the case to a different Administrative Law Judge ("Second ALJ") for further administrative proceedings. (AR 693-95).
On September 8, 2011, the Second ALJ examined the medical record, heard brief testimony from plaintiff, ordered a consultative psychological evaluation of plaintiff, and continued the hearing. (AR 886-93). At a supplemental hearing on February 8, 2012, the Second ALJ heard further testimony from plaintiff (who was represented by counsel) and a vocational expert. (AR 869-85).
On March 28, 2012 the Second ALJ determined that plaintiff was not disabled through the date of the decision. (AR 660-72). Specifically, the Second ALJ found: (1) plaintiff suffered from the following severe impairments: history of seizure disorder and human immunodeficiency virus infection ("HIV") (AR 664); (2) plaintiff's impairments, considered singly or in combination, did not meet or medically equal a listed impairment (AR 666-67); (3) plaintiff retained the residual functional capacity to perform light work
To qualify for disability benefits, a claimant must show that the claimant is unable "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."
In assessing whether a claimant is disabled, an ALJ is to follow a five-step sequential evaluation process:
The claimant has the burden of proof at steps one through four, and the Commissioner has the burden of proof at step five.
Pursuant to 42 U.S.C. section 405(g), a court may set aside a denial of benefits only if it is not supported by substantial evidence or if it is based on legal error.
To determine whether substantial evidence supports a finding, a court must "`consider the record as a whole, weighing both evidence that supports and evidence that detracts from the [Commissioner's] conclusion.'"
Plaintiff contends that a remand is warranted, in part, because the Second ALJ failed to list gait ataxia (i.e., difficulty coordinating the movements required for normal ambulation) as a severe impairment at step two, failed properly to evaluate the medical opinion evidence, and consequently posed an incomplete hypothetical question to the vocational expert. (Plaintiff's Motion at 20-28). The Court agrees. As the Court cannot find such errors harmless, a remand is warranted.
At step two of the sequential evaluation process, plaintiff has the burden to present evidence of medical signs, symptoms and laboratory findings
Step two is "a de minimis screening device [used] to dispose of groundless claims."
In Social Security cases, courts employ a hierarchy of deference to medical opinions depending on the nature of the services provided. Courts distinguish among the opinions of three types of physicians: those who treat the claimant ("treating physicians") and two categories of "nontreating physicians," namely those who examine but do not treat the claimant ("examining physicians") and those who neither examine nor treat the claimant ("nonexamining physicians").
The treating physician's opinion is not, however, necessarily conclusive as to either a physical condition or the ultimate issue of disability.
If, at step four, the claimant meets his burden of establishing an inability to perform past work, the Commissioner must show, at step five, that the claimant can perform some other work that exists in "significant numbers" in the national economy (whether in the region where such individual lives or in several regions of the country), taking into account the claimant's residual functional capacity, age, education, and work experience.
The vocational expert's testimony may constitute substantial evidence of a claimant's ability to perform work which exists in significant numbers in the national economy when the ALJ poses a hypothetical question that accurately describes all of the limitations and restrictions of the claimant that are supported by the record.
In a Physician Statement dated October 28, 2002, Dr. J. Scott Morrow, plaintiff's treating physician, essentially opined that plaintiff could lift and carry no weight, could stand/walk 2-4 hours in an 8-hour day, and could sit less than 6 hours in an 8-hour day with breaks. (AR 193-96).
On July 11, 2011 Dr. Ursula Taylor, a state-agency examining physician, performed an Independent Internal Medicine Evaluation which included an examination of plaintiff. (AR 763-68). In her July 2011 report, Dr. Taylor diagnosed plaintiff with traumatic brain injury ("TBI") and HIV, observed that plaintiff had "trouble with balance and coordination" (i.e., plaintiff appeared "somewhat generally unsteady," at one point "almost fell off the examination table," had trouble performing a "tandem walk," "ambulated with only mild antalgia," and had mild leg stiffness which suggested possible "movement disorder"), and opined, in pertinent part, that due to a "history of traumatic brain injury, seizures and trouble with balance and coordination," plaintiff (i) could only lift/carry 20 pounds occasionally and 10 pounds frequently; (ii) could walk and stand up to four hours out of an eight-hour day, but was limited to at most standing/walking 20 minutes at any one time "due to general unsteadiness"; (iii) could not balance; (iv) could occasionally stoop, kneel, crouch, and crawl; (v) could occasionally climb stairs and ramps; (vi) could never climb ladders and scaffolds; (vii) was limited to frequent reaching in all directions and above shoulder level, gross handling, fine fingering, feeling, pushing and pulling in both hands; and (viii) was limited to frequent use of feet. (AR 767-68).
The Second ALJ found that plaintiff had a history of prior right leg fracture which was "not [] severe" because the record did not show that plaintiff experienced "any pain or other functional limitation related to [the] condition." (AR 665). The Second ALJ stated that his finding was consistent with the report of a January 31, 2003 Internal Medicine Examination of plaintiff, in which Dr. Raymond Lee, a state-agency examining physician, stated that while plaintiff had "a mild noticeable slight limp with gait," plaintiff denied having any related pain, plaintiff had no evidence of obvious bony abnormalities on examination, and there were no physical limitations related to plaintiff's limp. (AR 665) (citing Exhibit 3F at 4 [AR 172]). The Second ALJ stated that his finding was also supported by the July 2011 opinions of Dr. Taylor, who "did not diagnose [plaintiff] with any medical condition related to [plaintiff's] lower extremities, and did not report that [plaintiff exhibited] any physical functional limitations related to his lower extremities." (AR 665) (citing Exhibit 10F at 4-5 [AR 766-67]).
The Court finds that a remand is warranted because the Second ALJ erred in assessing the severity of plaintiff's impairments and evaluating the medical opinion evidence, and the errors cannot be deemed harmless since the Second ALJ did not adequately account for all of plaintiff's medical impairments in later steps of the sequential evaluation process.
First, plaintiff has presented evidence which suggests that gait ataxia was a severe impairment. For example, as noted above, Dr. Taylor found that plaintiff had limitations in his abilities to walk, stand and do postural activities due to trouble with balance and coordination. (AR 766-67). In a November 29, 2004 Physician Statement, Dr. Kalvin Yu, another treating physician, stated that plaintiff had "periodic gait ataxia — will not improve per neurologist" and opined that plaintiff had "mild physical limitations" with "documented cerebellar degeneration which may affect his long-term motor skills." (AR 193-94). Dr. Miguel Valdas-Sueiras, also a treating physician, noted plaintiff's coordination as "slowed" and that plaintiff's gait reflected "mild difficulty" with tandem walking and "dystonic posturing with ambulation." (AR 221, 239, 296, 541). A physician at the Venice Family Clinic also noted that plaintiff had a "wide based" gait and decreased ambulation bilaterally. (AR 813, 817). In light of the foregoing, the Court cannot conclude that plaintiff's gait ataxia had no more than a minimal effect on plaintiff's ability to work.
Second, the Second ALJ's decision does not expressly address plaintiff's alleged gait ataxia. The Second ALJ did note that plaintiff had a "history of [] prior right leg fracture." Nonetheless, the Second ALJ found the impairment non-severe in part because Dr. Taylor purportedly "did not report that [plaintiff] exhibit[ed] any physical functional limitations related to his lower extremities." (AR 665) (citing Exhibit 10F at 4-5 [AR 766-67]). As noted above, however, Dr. Taylor opined that plaintiff had multiple functional limitations related to his lower extremities (i.e., walking, standing and postural movement) due, in part, to plaintiff's apparent "trouble with balance and coordination." (AR 767). The Second ALJ's incorrect characterization of the medical evidence calls into question the validity of both the Second ALJ's evaluation of the severity of plaintiff's impairments and the Second ALJ's decision as a whole.
Third, the Second ALJ failed properly to consider significant and probative medical opinion evidence which, in part, addressed plaintiff's medical condition (i.e., gait ataxia). For example, although the Second ALJ stated that he "generally concur[red]" with Dr. Taylor's July 2011 evaluation of plaintiff (AR 665), the Second ALJ's residual functional capacity assessment for plaintiff did not account for several functional limitations Dr. Taylor identified for plaintiff. For example, Dr. Taylor opined that plaintiff could "walk and stand no more than four hours out of an eight-hour day due to trouble with balance and coordination and general unsteadiness" and that plaintiff could stand and walk for no more than 20 minutes at any one time, again "due to general unsteadiness. . . ." (AR 767). In contrast, the Second ALJ determined that plaintiff could perform work at the "light exertional level" (AR 667), which generally involves standing or walking for up to six hours out of an eight-hour workday.
In addition, although the Second ALJ also stated that he concurred with the evaluations provided by Dr. Morrow (AR 669), the Second ALJ failed properly to consider such evaluations and/or account in plaintiff's residual functional capacity assessment for several functional limitations identified therein. For example, like the First ALJ, the Second ALJ here erroneously attributes to Dr. Morrow the opinions in Dr. Yu's November 29, 2004 physician statement. (AR 193-94). Even so, Dr. Yu opined that plaintiff's lifting/carrying was limited to
Fourth, since the hypothetical question the Second ALJ posed to the vocational expert did not include the aforementioned limitations and restrictions (AR 667), the Court cannot conclude that the vocational expert's testimony based on such incomplete hypothetical, which the Second ALJ adopted, was substantial evidence supporting the Second ALJ's determination at step five that plaintiff could perform any of the representative occupations.
Finally, the Court cannot find the Second ALJ's errors harmless. The Court cannot conclude that the vocational expert would have opined (or that the Second ALJ relying upon such opinion would have determined) that plaintiff could perform other work which exists in significant numbers in the national economy if the Second ALJ had included in the hypothetical question posed to the vocational expert the significant limitations found by Dr. Morrow which, as noted above, essentially precluded even sedentary work. Similarly, Dr. Taylor's opinions that plaintiff could stand and walk for no more than 20 minutes at any one time, together with Dr. Morrow's limitations, also suggest that plaintiff might need to take additional unscheduled breaks during an eight-hour workday. At the February 8, 2012 hearing, however, the vocational expert testified that there would be no work available if plaintiff (or a hypothetical individual with the same characteristics as plaintiff) required three additional 10 minute breaks in a day. (AR 884). Defendant points to no persuasive evidence in the record which otherwise could support the Second ALJ's determination at step five that plaintiff was not disabled.
When a court reverses an administrative determination, "the proper course, except in rare circumstances, is to remand to the agency for additional investigation or explanation."
Here, the Court concludes that plaintiff's case should be reversed and remanded for immediate payment of benefits. Although defendant argues, in a conclusory fashion, that the Court should remand the case for further administrative proceedings (Defendant's Motion at 30), such arguments do not persuade the Court that a remand would be fruitful or fair. First, as discussed above, the Second ALJ failed to account for significant and probative medical evidence in which doctors essentially opined that plaintiff suffered from disabling impairments. Second, defendant points to no outstanding issues that must be resolved before a determination of disability can be made in this case. Third, as noted above, the record reflects that a person who suffered the significant limitations identified by Drs. Taylor and Morrow would be precluded from all work. Therefore, it is clear that the Second ALJ would be required to find plaintiff disabled if the Second ALJ fully credited such opinion evidence.
It would not be fair to plaintiff to afford the Commissioner a third opportunity properly to evaluate the medical opinion evidence and assess plaintiff's residual functional capacity — issues that were material to the Second ALJ's ultimate disability determination.
For the foregoing reasons, the decision of the Commissioner of Social Security is reversed and the case is remanded for immediate payment of benefits.
LET JUDGMENT BE ENTERED ACCORDINGLY.