DOUGLAS F. McCORMICK, Magistrate Judge.
Plaintiff Everardo Zepeda Caballero appeals from the final decision of the Administrative Law Judge ("ALJ") denying his application for Social Security disability insurance benefits. Because the Court concludes that the ALJ erred in finding that Plaintiff's medically determinable impairments were non-severe, the ALJ's decision is reversed and the matter is remanded for further proceedings consistent with this opinion.
Plaintiff filed his application for benefits on April 8, 2011, alleging disability beginning June 30, 2010. Administrative Record ("AR") 14. The ALJ found that Plaintiff had the following medically determinable impairments: obesity, strain of the cervical and lumbar region, protruded lumbar disc, sprain of the collateral ligaments of the right knee, asthma, hypertension, hypothyroidism, peripheral neuropathy of the right hand, degenerative changes of the feet, and depression. AR 16. However, the ALJ determined that Plaintiff did not have an impairment or combination of impairments that significantly limited his ability to perform basic work-related activities for 12 consecutive months; therefore, the ALJ concluded Plaintiff did not have a severe impairment or combination of impairments.
The parties dispute whether the ALJ's determination at step two of the five-step evaluation process that Plaintiff did not suffer from any severe impairments was erroneous.
At step two, an immediate finding of non-disability is appropriate if a claimant is not suffering from a severe impairment. 20 C.F.R. § 404.1520(a)(4)(ii). Step two thus serves as "a de minimis screening device to dispose of groundless claims."
A severe impairment or combination of impairments exists when these impairments have more than a minimal effect on an individual's ability to do basic work activities.
Plaintiff's medical record includes a January 24, 2012 finding by Dr. Vicente Bernabe, an examining orthopedist, who found that Plaintiff has a "musculoligamentous strain of the cervical and lumbar regions" of his back on the basis of x-rays showing "a slight loss of cervical lordosis" and a "straightening of lumbar lordosis." AR 279-80. Dr. Bernabe found that Plaintiff was limited to lifting and carrying 50 pounds occasionally and 25 pounds frequently. AR 280. He also found that Plaintiff could walk and stand six hours out of an eight-hour workday.
The limitations imposed by Dr. Bernabe's assessment contradicted the findings of Dr. Jeff Sao, who performed an internal medicine examination of Plaintiff on July 7, 2011. AR 254-59. Dr. Sao found no functional limitations, finding that Plaintiff could lift and carry without limitations and could walk or stand without restriction. AR 258. An agency reviewing physician, Dr. J. Hartman, reviewed Dr. Sao's report and agreed that Plaintiff did not have any functional limitations. AR 69.
Plaintiff's medical record also included a June 30, 2011 functional capacity report written by Dr. Cindy Clayton, who evaluated Plaintiff based on a series of functional tests. AR 294-306. For instance, Dr. Clayton observed that Plaintiff reported pain in his lower back during the "standing, walking, lifting, carrying, pushing, pulling, and crawling on hands and knees test(s)." AR 305. Among other notable outcomes, Dr. Clayton reported that Plaintiff could only stand for 15 minutes at a time and could only walk six-tenths of a mile in 30 minutes. AR 302. Based on Plaintiff's performance, Dr. Clayton concluded that Plaintiff was limited in several ways, including to lifting no more than 20 pounds occasionally and 10 pounds frequently and to not standing for more than 15 minutes continuously. AR 305.
The ALJ evaluated this conflicting record by giving "great weight" to the opinions of Drs. Sao and Hartman that Plaintiff does not have a severe impairment or combination of impairments. AR 23. On the other hand, the ALJ used similar language to reject the opinions of Drs. Bernabe, Naiman, and Clayton, concluding that the "overly restrictive limitations" found by these physicians were not "supported by the objective and clinical evidence of record." AR 23, 24. Furthermore, the ALJ faulted each of these physicians for relying "more" on Plaintiff's subjective complaints, which the ALJ found "only partially credible." AR 23, 24. The ALJ concluded that Dr. Sao's opinion was "best supported by the objective evidence." AR 24.
The Court finds problematic the ALJ's reliance on the opinions of Dr. Sao and Dr. Hartman and dismissal of the opinions of Drs. Bernabe, Naiman, and Clayton for two reasons. First, Dr. Sao—on whom Dr. Hartman in turn relied—is an internal medicine specialist, not an orthopedic specialist (like Dr. Bernabe). The regulations require the ALJ to generally give more weight, not less, to the opinion of a specialist about medical issues related to his area of specialty than to the opinion of a source who is not a specialist.
In sum, the Court finds that the medical evidence does not clearly establish that Plaintiff's impairments are non-severe. Accordingly, the Court concludes that the ALJ's step two determination was not supported by substantial evidence in the record.
The decision whether to remand for further proceedings is within this Court's discretion.
A remand is appropriate, however, where there are outstanding issues that must be resolved before a determination of disability can be made and it is not clear from the record that the ALJ would be required to find the claimant disabled if all the evidence were properly evaluated.
For the reasons stated above, the decision of the Social Security Commissioner is REVERSED and the action is REMANDED for further proceedings consistent with this opinion.