WILLIAM S. DUFFEY, Jr., District Judge.
This matter is before the Court on Magistrate Judge Janet F. King's Final Report and Recommendation [15] ("R&R"). The R&R recommends the Court reverse and remand the final decision of the Commissioner of the Social Security Administration ("Commissioner") denying Plaintiff Barry Leonard Wise's ("Plaintiff") application for supplemental security income ("SSI").
On March 13, 2002, Plaintiff filed his SSI application, alleging that he became disabled on January 12, 2011. (Record [8] ("R.") at 198, 348-56). The Social Security Administration ("SSA") denied Plaintiff's application initially and on reconsideration. On August 12, 2013, Plaintiff appeared at a hearing before an Administrative Law Judge ("ALJ"). (R. at 214-41, 287-99). On November 7, 2013, the ALJ issued a decision denying Plaintiff's SSI claim and, on April 23, 2015, the Appeals Council denied Plaintiff's request for review. (R. at 8-14, 195-206). On June 29, 2015, Plaintiff filed his Complaint [3], seeking judicial review of the Commissioner's final decision.
Plaintiff, who worked previously as a forklift operator and a general laborer, was 49 years old when he filed his SSI application. On April 29, 2011, Plaintiff told doctors he felt back pain radiating to his right knee. The back pain was shooting, constant, and worse with bending and walking. During his physical examination, he experienced pain with flexion of his hip, and tested positive for crepitus on right knee flexion. His examination was otherwise unremarkable and his range of motion was normal. (
On August 18, 2011, Plaintiff underwent a "disability examination" with Doctor Tiffany S. Lee. Plaintiff told the doctor he suffered from multiple chronic conditions, including hypertension, arthritis, and hepatitis C. He rated the intensity of his arthritic pain as 10 out of 10, and said it was constant and affected his hips and knees. He also said he suffered from depression. Doctor Lee noted he was not in acute distress and had full range of motion, a 5/5 grip and pinch, and normal motor strength. His gait and station were normal and, according to the doctor's notes, he did not use an assistive device for stability. Plaintiff was able, without assistance, to use and rise from the chair and exam table. There were no signs of claudication, and Plaintiff's mental status appeared normal. Based on the evaluation, Doctor Lee concluded that Plaintiff had "significant physical limitations or restrictions." (
On May 25, 2012, Plaintiff returned to Doctor Lee for a second physical evaluation. Plaintiff complained about shortness of breath, diaphoresis, and headaches in the occipital area and above his right eye. He said he had two to three headaches per week. He reported that his hip and knee pain caused him to "almost fall[]" five or six times a day, and that his pain was relieved with over-the-counter medication. His uncorrected visual acuity was 20/20 OD and 20/25 OS and his blood pressure was 200/120. Although his lumbar spine and bilateral knees showed decreased range of motion, he was able to squat farther than noted during his first examination. The doctor's notes state that Plaintiff's gait and station were abnormal but that he did not use an assistive device. Radiological studies revealed severe right and mild left osteoarthritis of the hips, mild degenerative changes of the right knee, and unremarkable films of the lumbar spine. After the evaluation, Doctor Lee reported the following:
(
On September 26, 2012, Plaintiff had a physical evaluation with Doctor Diana Whiteman. The doctor noted that Plaintiff had bilateral knee crepitus with decreased range of motion. Plaintiff reported joint pain in his hands, knees and hips. Plaintiff also reported tenderness to palpation over the bilateral SI joint, but did not show limitations in his range of motion. Plaintiff's uncorrected visual acuity was 20/40 OD and 20/40 OS, and his blood pressure was 156/94. His physical examination was otherwise unremarkable. Doctor Whiteman reported that Plaintiff's gait was steady and that he "was ambulating today without any assistive device." The doctor's report also stated:
(
On January 31, 2013, Plaintiff visited Grady Memorial Hospital, complaining of rib pain after 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 said he had run out of his blood pressure medication. His blood pressure was 200/108. He stated that he smoked cigarettes but planned on quitting. Plaintiff was prescribed medication and discharged. (
On February 22, 2013, Plaintiff returned to Grady Memorial Hospital, reporting an injury to his left knee after twisting it while walking down stairs. He said that his knee would sometimes "give" and that he ran out of the medication he was given on his January 2013, visit. Radiological studies of Plaintiff's left knee showed mild osteoarthritis, especially in the patellofemoral compartments. His knee exam was "limited by acuity of pain" but revealed "antalgic gait, reduced range of motion, . . . [and] patellar tenderness." He was prescribed a non-steroidal anti-inflammatory and was instructed to rest and use ice packs. The doctor noted Plaintiff had refills remaining on his previous prescription. Plaintiff stated that he did not fill the prescription for financial reasons but that he would now borrow money to do so. (
During follow up visits to Grady Memorial Hospital, Plaintiff continued to report pain in his hip and knee. In May 2013, an MRI of Plaintiff's left knee showed "a large radial tear with associated complex tears involving the posterior horn of the medial meniscus which extend into the body. Subsequent extrusion of the medial meniscus is present." (R. at 563). On July 14, 2013, he was examined by doctor Margarita Ramos-Gonzalez, who wrote a treatment plan that included a "cane for comfort," non-steroidal anti-inflammatories, and ice and heat. The doctor also stressed that he should lose weight and, based on x-rays and MRIs, confirmed that Plaintiff suffered from osteoarthritis of the hip and knee. Doctor Ramos-Gonzalez contacted a social worker to help Plaintiff obtain a cane. (
On November 7, 2013, the ALJ issued a decision denying Plaintiff's SSI claim on the basis that Plaintiff is not disabled. The ALJ made the following findings of fact and conclusions of law:
(R. at 198-206).
On July 11, 2016, the Magistrate Judge issued her R&R. In it, she found that the ALJ's residual functional capacity ("RFC") determination was deficient and not supported by substantial evidence, that the ALJ erroneously evaluated Plaintiff's credibility, and that substantial evidence did not support the ALJ's conclusion that Plaintiff is able to perform work other than his past relevant work. The parties did not file objections to the R&R.
After conducting a careful and complete review of the findings and recommendations, a district judge may accept, reject, or modify a magistrate judge's report and recommendation. 28 U.S.C. § 636(b)(1);
A court must "review the Commissioner's decision to determine if it is supported by substantial evidence and based upon proper legal standards."
An individual is considered 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 must result from anatomical, psychological, or physiological abnormalities that 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.
"The burden is primarily on the claimant to prove that he is disabled, and therefore entitled to receive Social Security disability benefits."
"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 found that Plaintiff has the RFC to perform light work but that he is limited to jobs allowing him to alternate every thirty minutes between sitting and standing, and that he can only occasionally climb, stoop, kneel, crouch, or crawl. (R. at 201). Plaintiff argues that the ALJ's RFC assessment was deficient because it did not state that Plaintiff requires a cane. ([12] at 8-12).
"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." Social Security Ruling 96-9p. In her August 2011, medical report, Doctor Tiffany Lee states that Plaintiff's gait and station were normal and that "[n]o assistive device is used for stability." (R. at 493). In Doctor Lee's May 2012, report, she states that Plaintiff's gate and station were abnormal, that he had crepitus and decreased range of motion in his knees, that he reported "almost falling" five or six times per day, that he should avoid "distance walking" and certain other physical activities, and that he "does not use an assisted device for ambulation." (R. at 513-515). In September 2012, Doctor Whiteman reported that Plaintiff had bilateral knee crepitus with decreased range of motion, that his gait was steady, and that he "was ambulating today without any assistive device." (R. at 525). In February 2013, Plaintiff told doctors that he twisted his knee, radiological studies showed osteoarthritis in his knee, and a knee examination revealed "antalgic gait, reduced range of motion, . . . [and] patellar tenderness." (
The ALJ noted that Plaintiff "stated he always uses a cane since he was given it in July 2012, but the consultative examination notes from September of 2012 specifically notes that he has no assistive device." (R. at 204). The ALJ also stated, without explanation, that a July 2013, treatment note suggested a cane for comfort. (R. at 204). The Magistrate Judge found that the ALJ did not determine expressly whether Plaintiff was prescribed a cane or whether an assistive device was medically necessary. The Magistrate Judge found further that this omission rendered deficient the ALJ's RFC assessment and that the record supports Plaintiff's contention that he requires a cane for walking and standing. (
"At the fifth step [of the disability analysis], the regulations direct the Commissioner to consider the claimant's residual functional capacity, age, education, and past work experience to determine whether the claimant can perform other work besides his past relevant work."
The ALJ found that, under step 5 of disability analysis, Plaintiff is not disabled because "[c]onsidering 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." (R. at 205-206). In reaching this determination, the ALJ relied on VE testimony that a person with Plaintiff's RFC, as defined by the ALJ, could find and perform work in the national economy. (R. at 206, 234-235). However, the VE testified that a person with Plaintiff's RFC, as described by the ALJ, would not be able to perform any jobs in the regional or national economy if he required a cane for standing or walking. The Magistrate Judge found that, because the ALJ's RFC assessment was deficient, the ALJ's finding at step five was not supported by substantial evidence. The Court finds no plain error in this determination.
In evaluating a claimant's subjective symptoms, an ALJ may consider the claimant's daily activities; location, duration, frequency and intensity of the claimant's symptoms; precipitating and aggravating factors; type, dosage, effectiveness, and side effects of any medication the claimant takes to alleviate his symptoms; treatment received and measures used, other than medication, for the relief of symptoms; and any other factors concerning the functional limitations and restrictions due to the claimant's symptoms.
Plaintiff testified and reported to physicians that he has significant difficulty walking, standing, and keeping his balance. (R. at 221-225, 478-479, 491-493, 513-515, 524-526, 555, 561-562, 569). He stated that he has "shooting" and constant pain, that he is significantly limited in his daily activities, that he requires a cane, and that he "almost fall[s]" several times per day. (
The ALJ also stated that "[o]f 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 because Plaintiff testified that he "used to do odd jobs" like cutting the grass, but that this was "years ago," before his health began deteriorating. (R. at 221, 224-225). The Magistrate Judge found that the ALJ's decision to discredit Plaintiff's testimony was based on mistaken beliefs and that remand is necessary so the ALJ can reevaluate Plaintiff's credibility. (R&R at 18-22). The Court finds no plain error in this finding.
For the foregoing reasons,