JANET F. KING, Magistrate Judge.
Plaintiff in the above-styled case brings this action pursuant to § 205(g) of the Social Security Act, 42 U.S.C. § 405(g), to obtain judicial review of the final decision of the Commissioner of the Social Security Administration which denied his disability application. For the reasons set forth below, the court
Plaintiff Barry Leonard Wise filed an application for supplemental security income on March 13, 2012, alleging that he became disabled on January 12, 2011. [Record ("R.") at 198, 348-56]. After Plaintiff's application was denied initially and on reconsideration, an administrative hearing was held on August 12, 2013. [R. at 214-41, 287-99]. The Administrative Law Judge ("ALJ") issued a decision on November 7, 2013, denying Plaintiff's applications, and the Appeals Council denied Plaintiff's request for review on April 23, 2015. [R. at 8-14, 195-206]. Plaintiff filed a complaint in this court on June 29, 2015, seeking judicial review of the Commissioner's final decision. [Doc. 3].
The ALJ found that Plaintiff has osteoarthritis of the hip and osteoarthritis of the right knee. [R. at 200]. Although these impairments are "severe" within the meaning of the Social Security regulations, the ALJ found that Plaintiff does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. [R. at 201]. Plaintiff was found to be incapable of performing any of his past relevant work. [R. at 205]. However, the ALJ concluded that there are jobs that exist in significant numbers in the national economy that Plaintiff can perform. [R. at 205-06]. The ALJ, therefore, found that Plaintiff has not been under a disability since March 13, 2012, the date the application was filed. [R. at 206].
The decision of the ALJ [R. at 198-206] states the relevant facts of this case as modified herein as follows:
The claimant was 49 years old on the date his disability application was filed. He has past relevant work as a forklift operator and a general laborer. A review of the record reveals that the claimant has a history of lower back and hip pain. Records from Grady Health System show that he reported back pain radiating to his right knee. The back pain was shooting, constant, and worse with bending and walking. He displayed pain with flexion of his hip, and his examination was positive for crepitus on right knee flexion. His physical examination was otherwise unremarkable with normal range of motion noted. Radiological studies taken in April of 2011 revealed degenerative changes of the spine and osteoarthritis of the right hip. Studies of his knee were unremarkable. The claimant was instructed to use over-the-counter medication. (Exhibits 2F, 3F, 4F, 9F and 12F).
In April 2011, the claimant submitted to a physical consultative evaluation with Tiffany S. Lee, M.D., with complaints of disability secondary to hypertension, arthritis, and hepatitis C. He reported that his arthritic pain affected his hips and knees, was constant, and rated 10 out of a possible 10. He also reported being diagnosed with depression. He was noted as being in no acute distress and, upon examination, had an unremarkable presentation with full range of motion globally, 5/5 grip and pinch, and normal motor strength. His gait and station were normal, and he neither required nor used an assistive device. The claimant was able to climb on and rise from the chair/exam table from a standing to sitting position and a sitting to standing position without assistance. There were no signs of claudication noted, and the claimant's mental status was unremarkable with appropriate mood and affect reported. After the evaluation, Dr. Lee reported that the claimant had significant physical limitations or restrictions. (Exhibit 5F).
The claimant returned to Dr. Lee in May of 2012 for a second physical consultative evaluation at which time he added complaints of shortness of breath, diaphoresis, and headaches in the occipital area and above his right eye. He stated that he had two to three headaches per week. He reported that his hip and knee pain caused him to almost fall five to six times a day and that his pain was relieved with over the counter medication. Upon examination, his uncorrected visual acuity was 20/20 OD and 20/25 OS and his blood pressure was 200/120. He displayed decreased range of motion of his lumbar spine and his bilateral knees. That said, he was able to squat farther than noted during his first examination: 3/4 of the distance versus 1/2 of the distance a year earlier. The claimant ambulated with an abnormal gait and station but did not use an assistive device. Radiological studies revealed severe right and mild left osteoarthritis of the hips, very mild degenerative changes of the right knee, and unremarkable films of the lumbar spine. After the evaluation, Dr. Lee reported the following:
(Exhibit 7F).
On September 26, 2012, the claimant submitted to a physical consultative evaluation with Diana Whiteman, M.D. Upon examination, bilateral crepitus was noted with the claimant reporting joint pain in his hands, knees, and hips. He also reported tenderness to palpation over the bilateral SI joint with no range of motion limitations. The claimant's uncorrected visual acuity was noted as being 20/40 OD and 20/40 OS, and his blood pressure was reported as 156/94. His physical examination was otherwise unremarkable. After the evaluation, Dr. Whiteman reported the following:
(Exhibit 8F).
On January 31, 2013, the claimant presented to Grady Memorial Hospital with complaints of rib pain secondary to being mugged and kicked in the ribs. He reported that he usually takes over the counter medication for pain but that it was not working. He also stated that he had run out of his blood pressure medication. His blood pressure was 200/108. He indicated that he smoked cigarettes but planned on quitting. The claimant was prescribed medication and discharged. He returned in February of 2013 reporting an injury to his left knee. He stated that his knee would give. He stated that he ran out of the medication he was given during his January 2013 visit. Radiological studies of the claimant's left knee showed mild osteoarthritis which was more prominent in the patellofemoral compartments. He was instructed to use ice packs and rest the injured area as much as possible. He was given a prescription for a non-steroidal anti-inflammatory. It was noted that he had refills on his previous prescription. He stated that he did not fill it for financial reasons but that he would borrow money and fill the prescription. (Exhibit 10F).
During follow up visits to Grady Hospital, the claimant reported continued hip and knee pain. In July of 2013, he acknowledged that he did not use ice/heat or exercise. A cane was suggested for comfort, and he was instructed to use ice/heat and non-steroidal anti-inflammatories. It was also stressed that he lose weight. It was noted that x-rays and MRIs confirmed osteoarthritis of the hip and knee. (Exhibits 11F, 13F, 14F, 15F, and 16F).
The claimant testified that he has pain that is severe to the point it interferes with concentration and ability to watch TV or read. However, he also testified that he spends much of the day playing chess and checkers outside the mission. He stated that he always uses a cane since he was given it in July 2012, but the consultative examination records from September of 2012 specifically note that he had no assistive device. The claimant testified that he could not raise his arms overhead, but he had no real answer for why he was able to raise them over his head during his consultative evaluations. The claimant generally presented with full range of motion of all joints. Of note is the fact that the claimant reported doing odd jobs like mowing lawns, which is contrary to his reports of disability. The claimant complained of headaches, but this was during a time that he was noncompliant with his medication and his blood pressure was elevated to 200/120.
Additional facts will be set forth as necessary during discussion of Plaintiff's arguments.
An individual is considered to be disabled if he 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[.]" 42 U.S.C. § 423(d)(1)(A). The impairment or impairments must result from anatomical, psychological, or physiological abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques and must be of such severity that the claimant is not only unable to do his previous work but cannot, considering age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy.
"We review the Commissioner's decision to determine if it is supported by substantial evidence and based upon proper legal standards."
"The burden is primarily on the claimant to prove that he is disabled, and therefore entitled to receive Social Security disability benefits."
The ALJ made the following findings of fact and conclusions of law:
1. The claimant has not engaged in substantial gainful activity since March 13, 2012, the application date. (20 C.F.R. § 416.971, et seq.).
2. The claimant has the following severe impairments: osteoarthritis of the hip and osteoarthritis of the right knee. (20 C.F.R. § 416.920(c)).
3. The claimant does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (20 C.F.R. §§ 416.920(d), 416.925, and 416.926).
4. The claimant has the residual functional capacity to perform light work as defined in 20 C.F.R. § 416.967(b) except that the claimant should: be able to alternate sitting/standing every 30 minutes while remaining at workstation; only occasionally climb, stoop, kneel, crouch, and crawl.
5. The claimant is unable to perform any past relevant work. (20 C.F.R. § 416.965).
6. The claimant was born on December 17, 1962, and was 49 years old, which is defined as a younger individual age 18-49, on the date the application was filed. The claimant subsequently changed age category to closely approaching advanced age. (20 C.F.R. § 416.963).
7. The claimant has at least a high school education and is able to communicate in English. (20 C.F.R. § 416.964).
8. Transferability of job skills is not material to the determination of disability because using the Medical-Vocational Rules as a framework supports a finding that the claimant is "not disabled," whether or not the claimant has transferable job skills. (
9. Considering the claimant's age, education, work experience, and residual functional capacity, there are jobs that exist in significant numbers in the national economy that the claimant can perform. (20 C.F.R. §§ 416.969 and 416.969(a)).
10. The claimant has not been under a disability, as defined in the Social Security Act, since March 13, 2012, the date the application was filed. (20 C.F.R. § 416.920(g)).
[R. at 198-206].
Plaintiff Wise argues that the court should reverse the ALJ's decision denying his claim for disability benefits. [Doc. 12]. According to Plaintiff, the ALJ's residual functional capacity ("RFC") assessment was not supported by substantial evidence and was the product of legal error. [
"The residual functional capacity is an assessment, based upon all of the relevant evidence, of a claimant's remaining ability to do work despite his impairments. . . . Along with his age, education and work experience, the claimant's residual functional capacity is considered in determining whether the claimant can work."
The ALJ in the present case found that Plaintiff has the RFC to perform light work as defined by the relevant Social Security regulation except that he is limited to jobs allowing him to alternate sitting/standing every 30 minutes while remaining at his workstation and that he can only occasionally climb, stoop, kneel, crouch, and crawl. [R. at 201]. Plaintiff argues that the ALJ's RFC assessment erroneously failed to include Plaintiff's use of a cane. [Doc. 12 at 8-12]. The issue is significant because at the administrative hearing, the VE testified that Plaintiff would not be able to perform any jobs in the regional or national economy if he required the use of a cane for standing or walking. [R. at 235].
Social Security Ruling ("SSR") 96-9p provides, in part: "To find that a hand-held assistive device is medically required, there must be medical documentation establishing the need for a hand-held assistive device to aid in walking or standing, and describing the circumstances for which it is needed. . . . The adjudicator must always consider the particular facts of a case." The ALJ presumably found that Plaintiff did not need an assistive device as the ALJ did not include it in the RFC assessment. [R. at 201]. However, the ALJ offered little discussion regarding this finding. The ALJ merely wrote that Plaintiff "stated he always uses a cane since he was given it in July 2012,
At the administrative hearing, it was noted that Plaintiff was ambulating with the use of a cane. [R. at 219]. Plaintiff testified that he began using the cane in the latter part of 2011 or early 2012 and that he uses it every time he stands.
The Commissioner argues that the "ALJ considered Dr. Ramos-Gonzalez's suggestion along with the other evidence to find that Plaintiff had not been prescribed a cane and that it was not medically necessary." [Doc. 13 at 6]. The court disagrees. The ALJ noted the inconsistencies between Plaintiff's testimony about his constant use of a cane and the consultative exams in May and September 2012 which reported that during those times, Plaintiff was ambulating without an assistive device. However, the ALJ offered no explanation regarding Dr. Ramos-Gonzalez's treatment plan for Plaintiff to use a cane. [R. at 562]. The ALJ also did not make a finding or otherwise discuss whether Plaintiff had been prescribed a cane or whether it was medically necessary.
SSR 96-9p, as noted supra, provides that a hand-held assistive device is a medical requirement only if medical documentation establishes the need for a such a device to aid in walking or standing. The Commissioner contends that the record does not indicate that a physician prescribed a cane. [Doc. 13 at 5]. While Dr. Ramos-Gonzalez did not use the word "prescribe," her treatment note indicates that she believed that Plaintiff should use a cane to alleviate pain.
Despite the record evidence, there is no indication in the ALJ's decision that she evaluated, in accordance with SSR 96-9p, whether an assistive device was medically required for Plaintiff to walk or stand. This evaluation is important, as previously noted, because the VE testified at the administrative hearing that no jobs would be available for Plaintiff if he required the use of a cane for standing or walking.
Plaintiff next argues that the ALJ erred when evaluating his credibility. [Doc. 12 at 12-14]. When a claimant seeks to establish disability through subjective testimony of pain, a "pain standard" established by the Eleventh Circuit applies.
Plaintiff testified and reported to physicians that due to pain and weakness in his back, knees, and hips, he has significant difficulty walking, standing, and keeping his balance. [R. at 221-25, 478-79, 491-93, 513-15, 524-26, 555, 561-62, 569]. He stated that he has "shooting" and constant pain, that he is significantly limited in his daily activities and requires the use of a cane, and that he almost falls many times per day. [
The ALJ also misstated the record when she offered reasons for her credibility determination. In her explanation for finding that Plaintiff's claim of disability is not supported by the record, the ALJ wrote, "Of note is the fact [that] the claimant reported doing odd jobs like mowing lawns, which is contrary to his reports of disability." [R. at 204]. This is incorrect. Plaintiff did testify at the administrative hearing that he "used to do odd jobs" like cutting the grass. [R. at 221]. However, Plaintiff made it clear that his performance of these tasks was "years ago," before his health began deteriorating. [
[R. at 224-25].
The Commissioner argues that there is support for the ALJ's finding regarding Plaintiff's daily activities and cites to a function report completed by Plaintiff in July 2012 wherein he described going to Home Depot or a local truck stop in the mornings to look for work. [Doc. 13 at 11; R. at 428]. However, the ALJ did not cite to this evidence in her decision and there is no indication that it factored into her credibility determination. The undersigned "decline[s] . . . to affirm simply because some rationale might have supported the ALJ's conclusion."
In summary, the ALJ's decision to discredit Plaintiff's testimony was based, at least in part, on the ALJ's mistaken belief that Plaintiff performed odd jobs like mowing lawns after his alleged onset of disability. The court cannot assume that the ALJ would have made the same credibility determination if she had correctly understood that these activities took place before Plaintiff's health began deteriorating. Given this error, the undersigned concludes that remand is necessary in order for the ALJ to reevaluate Plaintiff's credibility.
The ALJ is required at the fifth step of the sequential evaluation to determine whether the claimant is able to perform other work besides his past relevant work.
"At the fifth step of the sequential process, an ALJ may rely solely on the testimony of a VE in determining whether work is available in significant numbers in the national economy that a claimant is able to perform."
Based on the forgoing reasons and cited authority, the undersigned
If the District Court adopts the undersigned's recommendation,
All pretrial matters have been concluded with the issuance of this Report and Recommendation in accordance with 28 U.S.C. § 636(b)(1), this Court's Local Rule 72.1, and Standing Order 14-01 (N.D. Ga. August 15, 2014). The Clerk, therefore, is