GREGORY G. HOLLOWS, Magistrate Judge.
Plaintiff seeks judicial review of a final decision of the Commissioner of Social Security ("Commissioner") denying her application for Supplemental Security Income ("SSI") under Title XVI of the Social Security Act ("Act"). On May 15, 2012, the undersigned ordered further briefing on the issue of whether the ALJ should have analyzed whether plaintiff met Listing 7.02 or whether her non-compliance with treatment excused the ALJ from this analysis. The parties have now submitted further briefing which has been considered. For the reasons that follow, plaintiff's Motion for Summary Judgment is GRANTED IN PART, the Commissioner's Cross Motion for Summary Judgment is DENIED, and this matter is remanded to the ALJ for further findings as directed in this opinion. The Clerk is directed to enter judgment for plaintiff.
Plaintiff, born March 11, 1958, applied on May 22, 2008, for disability benefits, with a protective filing date of April 8, 2008. (Tr. at 114, 17.) Plaintiff alleged she was unable to work since April 1, 2008, due to multiple pulmonary problems including shortness of breath, blood clots and high blood pressure. (
(Tr. at 19-25.)
Plaintiff has raised the following issues: A. Whether the Commissioner Erred in Failing to Analyze Whether Plaintiff's Condition Meets or Equals Listing 7.02 for Chronic Anemia; B. Whether the Commissioner Erred in Failing to Meaningfully Analyze the Impact of Plaintiff's Severe Anemia Due to Heavy Vaginal Bleeding Resulting in Multiple Blood Transfusions and Hospitalizations; C. Whether the Commissioner Erred in Concluding that Plaintiff was not Credible and Non-compliant in Not Having a Hysterectomy; and D. Whether the Commissioner Erred in Relying on the Opinions of Medical Providers Who Were Not Aware of her Multiple Blood Transfusions as her Condition Significantly Worsened After the Records were Collected at the Initial and Reconsideration Levels.
The court reviews the Commissioner's decision to determine whether (1) it is based on proper legal standards pursuant to 42 U.S.C. § 405(g), and (2) substantial evidence in the record as a whole supports it.
Plaintiff contends that the ALJ erred in failing to analyze whether plaintiff met the listing for chronic anemia.
The Regulations' "Listing of Impairments" ("Listings") lists impairments to thirteen categories of body systems which are severe enough to preclude any gainful activity.
At the third step of the disability analysis, the ALJ determines whether a person's condition either "meets" or "equals" a listing. A mere diagnosis of a listed impairment is not sufficient. Specific findings included in each listing also must be met.
Plaintiff contends that the ALJ, although acknowledging that plaintiff required "many blood transfusions," failed to analyze whether plaintiff met Listing 7.02.
This listing provides:
Chronicity is indicated by "persistence of the condition for at least 3 months" and the "laboratory findings cited must reflect the values reported on more than one examination over that 3-month period."
Plaintiff asserts that the medical records reflect her hematocrit level of less than thirty percent over an almost two-year period, that she underwent five blood transfusions over a one-year period, with two sets of transfusions only weeks apart. Plaintiff also argues that the state agency physicians, upon whom the ALJ relied, were not aware of plaintiff's blood transfusions. Because the ALJ did not analyze whether plaintiff met this listing, plaintiff contends that pursuant to SSR 96-6p, the case must be remanded for the ALJ to call a medical expert on this issue.
The Commissioner argues that plaintiff has not met Part A of the listing because she did not require blood transfusions once every two months and "the anemia had not caused significant damage to a body system."
The ALJ presumably did not consider Listing 7.02 because she only stated that she had considered Listing 3.02A for chronic obstructive pulmonary disease. (Tr. at 19.) The ALJ did spend a good portion of the opinion discussing plaintiff's menorrhagia and anemia, however. She referred to plaintiff's history of menorrhagia and anemia, and her blood transfusions, but noted that plaintiff had not been compliant with medication and treatment. (Tr. at 21.) For example, the ALJ noted that although a hysterectomy was recommended, it had not been scheduled. Although plaintiff had received an intra-uterine device,
Although significantly there are no gynecological records in the file, the records submitted indicate that Listing 7.02 should have been considered by the ALJ. Plaintiff had chronic anemia based on hematocrit readings at 30% or less on October 4, 2007, (tr. 184), April 4, 2008 (tr. 182), May 12, 2008 (tr. at 180), July 31, 2008 (tr. at 249), August 1, 2008 (tr. 334), September 11, 2008 (tr. 224, 230), October 6, 2008 (tr. 246), July 17, 2009 (tr. 317), July 18, 2009 (tr. 305), July 19, 2009 (tr. 315), September 10, 2009 (tr. 356), September 12, 2009 (tr. 356), September 16, 2009 (tr. 366.) Plaintiff was taking Coumadin during the period from April 2008 to October 2008; however, her hematocrit levels continued at the same low levels after this time. The record indicates that the first recommended blood transfusion was on April 14, 2008, but plaintiff refused at that time. (Tr. at 174, 182.) Plaintiff then began complying with recommended transfusions and received them on August 22, 2008, September 12, 2008, February 10, 2009, June 4, 2009, and July 18, 2009. (Tr. at 249, 233, 367-68, 404, 303-04.)
Defendant argues that the physicians' notes indicate no basis for presumptive disability. The ALJ relies in part on the various physicians who were not aware of plaintiff's blood transfusions, however. Dr. Sharma did not have any medical records when he examined plaintiff. (Tr. at 194-99.) At this exam, conducted October 11, 2008, plaintiff had not yet received three blood transfusions. The ALJ also relied on the State agency medical consultant's reports which do not reflect awareness of plaintiff's blood transfusions. One such report, dated July 8, 2008, was written before plaintiff had received any transfusions. It notes only that plaintiff was not compliant. (Tr. at 187.) Another report, although dated November 6, 2008, does not reference any transfusions, indicating that the reviewer was not aware of them. (Tr. at 218-19.) Based on this evidence, plaintiff appears to have met the listing, and the ALJ should have analyzed it.
In regard to failure to follow treatment, which may be grounds to find that a listing is not met, the record indicates that although plaintiff refused to get a transfusion in April, 2008, she did become compliant and received five transfusions after that initial refusal, after being provided with alternatives to surgery, and advised that she must be compliant or risk death. (Tr. at 173-74.) Plaintiff also accepted medications. (
Defendant's own citation in its supplemental briefing concedes that even if an ALJ finds a failure to follow a prescribed course of treatment, the ALJ must nevertheless analyze whether the plaintiff meets or equals a listing.
Social Security Ruling 86-8 provides in part:
This ruling presumes that a listing is met before evidence to the contrary is considered.
Furthermore, Social Security Ruling 82-59, specifically addressing "failure to follow prescribed treatment," "only appl[ies] to claimants who would otherwise be disabled within the meaning of the Act."
SSR 82-59.
Based on the aforementioned authority and the record referenced herein, the ALJ erred in failing to consider whether plaintiff met listing 7.02. Based on the evidence submitted, the undersigned finds that plaintiff did meet this listing and is entitled to benefits.
The decision whether to remand a case for additional evidence or simply to award benefits is within the discretion of the court.
The only remaining question is whether, based on plaintiff's age, her anemia based on menorrhagia may have resolved with the conclusion of menopause. Therefore, remand is ordered for the purpose of obtaining a medical expert opinion as to the permanency of this condition, whether the condition continued, and for how long. Benefits will be awarded for a closed period to be determined based on the medical expert's opinion.
Plaintiff's other assignments of error have been addressed to the extent appropriate within this opinion. Those issues not addressed are not pertinent to the decision to remand.
Accordingly, plaintiff's Motion for Summary Judgment is GRANTED in part pursuant to Sentence Four of 42 U.S.C. § 405(g); the Commissioner's Cross Motion for Summary Judgment is DENIED; and this matter is remanded for further findings in accordance with this order. The Clerk is directed to enter Judgment for plaintiff.
The claimant bears the burden of proof in the first four steps of the sequential evaluation process.
The underlying regulation, 20 C.F.R. § 416.930 (and companion regulation 20 C.F.R. § 404.1530 under Title II) similarly provides:
Both 20 C.F.R. § 416.930 and SSR 82-59 identify specific acceptable reasons for declining to following prescribed treatment, some of which may be present here.
20 C.F.R. § 416.930(c) sets forth the following examples of acceptable reasons for declining to following prescribed treatment:
Additional acceptable reasons for declining to following prescribed treatment set forth in SSR 82-59 include, but are not limited to: fear of surgery that is so great that the treating physician decides the plaintiff is not a satisfactory candidate, where "a physician has advised the chances of obtaining good surgical results are poor," or where there is an inability to pay for prescribed treatment and free community resources are unavailable.