JOHN W. LUNGSTRUM, District Judge.
Plaintiff seeks review of a decision of the Commissioner of Social Security (hereinafter Commissioner) denying disability insurance benefits (DIB) and supplemental security income (SSI) under sections 216(i), 223, 1602, and 1614(a)(3)(A) of the Social Security Act. 42 U.S.C. §§ 416(i), 423, 1381a, and 1382c(a)(3)(A) (hereinafter the Act). Finding error in the Commissioner's assessment regarding Plaintiff's mental residual functional capacity (RFC), the court ORDERS that the decision is REVERSED, and that judgment shall be entered pursuant to the fourth sentence of 42 U.S.C. § 405(g) REMANDING the case for further proceedings.
Plaintiff applied for DIB in October 2007, and for SSI in February 2008, alleging disability beginning January 25, 2005. (R. 8, 98-112). The applications were denied initially and upon reconsideration, and Plaintiff requested a hearing before an Administrative Law Judge (ALJ). (R. 8, 39-42, 62-64). Plaintiff's request was granted, and Plaintiff appeared with counsel for a hearing before ALJ Robert J. Burbank on May 12, 2009. (R. 19). Although a vocational expert also appeared at the hearing, testimony was taken only from Plaintiff. (R. 8, 19-38).
After the hearing, ALJ Burbank issued a decision on October 2, 2009 finding that although Plaintiff is unable to perform his past relevant work, there are jobs in the national economy in significant numbers that Plaintiff is able to perform. (R. 8-18). Consequently, he determined that Plaintiff is not disabled within the meaning of the Act, and denied his applications. (R. 18). Plaintiff sought, but was denied Appeals Council review of the hearing decision. (R. 1-4). Therefore, the ALJ's decision is the final decision of the Commissioner. (R. 1);
The court's jurisdiction and review are guided by the Act.
An individual is under a disability only if that individual can establish that he has a physical or mental impairment which prevents him from engaging in any substantial gainful activity, and which is expected to result in death or to last for a continuous period of at least twelve months.
The Commissioner uses a five-step sequential process to evaluate disability. 20 C.F.R. §§ 404.1520, 416.920 (2009);
The Commissioner next evaluates steps four and five of the sequential process— determining whether claimant can perform his past relevant work; and whether, when considering vocational factors of age, education, and work experience, claimant is able to perform other work in the economy.
Plaintiff claims numerous errors in the ALJ's assessment of Plaintiff's RFC, including errors in assessing the credibility of Plaintiff's allegations of pain, in evaluating medical opinions, and in evaluating limitations resulting from Plaintiff's mental impairments. The Commissioner argues that Plaintiff's claims are without merit because the ALJ applied the correct legal standard and properly explained his findings, and that substantial record evidence supports those findings. The court finds that remand is necessary because the ALJ erred in evaluating the limitations resulting from Plaintiff's mental impairments. Therefore, it need not address the remaining errors alleged by Plaintiff, and Plaintiff may make those arguments before the Commissioner on remand.
Plaintiff argues that Finding 5 of the decision, "`the residual functional capacity to perform the full range of sedentary work . . . with limitations to simple to intermediate work,' . . . is not a proper RFC determination." (Pl. Br. 4-5) (quoting Finding 5 of the ALJ's decision). He argues that "limitations to simple to intermediate work" is not a sufficient function-by-function assessment of mental abilities as defined in the regulations and as required by Social Security Ruling 96-8p and the POMS (the Social Security Administration's Program Operations Manual System).
The Commissioner argues that Plaintiff's argument lacks merit. (Comm'r Br. 4). He notes that the ALJ limited Plaintiff to "simple to intermediate work" due to his mental impairments.
The court agrees with Plaintiff. It finds that the ALJ did not articulate a function-by-function assessment of Plaintiff's mental abilities; that the finding that Plaintiff has "limitations to simple to intermediate work" is not explained or defined in the decision with relation to mental functional abilities; and that the court is unable to find a definition or meaning for the term "limitations to simple to intermediate work." Consequently, the court is unable to determine the precise range of work of which the ALJ found Plaintiff is capable and it is, therefore, unable to determine whether the ALJ's finding is supported by substantial evidence in the record.
The ALJ found at step two of the sequential evaluation process that Plaintiff has severe mental impairments of "cognitive disorder and depression." (R. 10). At page five of the decision, he summarized and discussed the evidence regarding mental impairments. (R. 12). In that discussion, the ALJ considered: Plaintiff's allegations regarding mental impairments, the report of a consultative psychological evaluation performed by Dr. Carroll Ohlde on April 14, 2008 at the request of the state agency; treatment notes regarding mental health treatment Plaintiff received at the advice of counsel from the Mental Health Center of East Central Kansas between August 20, 2008 through May 11, 2009; the report of a neuropsychological evaluation completed by Dr. Eric Ecklund-Johnson upon referral by Plaintiff's treating physician; and a medical source statement completed by Plaintiff's treating psychologist at the Mental Health Center of East Central Kansas, Dr. Maureen Burns. (R. 12). The court quotes here the ALJ's summary of the reports of Dr. Ohlde, Dr. Ecklund-Johnson, and Dr. Burns:
(R. 12).
At step three, the ALJ considered the four broad mental functional areas identified in the Commissioner's psychiatric review technique and found that Plaintiff has "mild" restrictions in activities of daily living; "mild" difficulties in social functioning; "moderate" difficulties in concentration, persistence or pace; and no episodes of decompensation of extended duration. (R. 13). The ALJ explained his finding of "moderate" difficulties in concentration, persistence or pace:
(R. 13).
The ALJ went on to explain that the limitations identified in the four broad mental functional areas "are not a residual functional capacity assessment but are used to rate the severity of mental impairments at steps 2 and 3 of the sequential evaluation process." (R. 13-14). He explained:
(R. 14).
In finding number five, the ALJ assessed Plaintiff with the RFC "to perform the full range of sedentary work . . . with limitations to simple to intermediate work." (R. 14). In explaining his RFC assessment, the ALJ noted that Dr. Burns's opinion that Plaintiff had "marked limitations in most all areas of function" was given "little weight" because (1) the limitations are not reflected in Dr. Burns's treatment notes: (2) Dr. Burns had only occasional contact with Plaintiff between August and December, 2008, and no contact with Plaintiff in 2009 until the day before the ALJ's hearing, May 11, 2009; and (3) the limitations are not supported by all of the record evidence. (R. 16). He found that the reports of Dr. Ohlde and Dr. Ecklund-Johnson "reflect the ability to do simple to intermediate work."
The ALJ stated his agreement with the medical opinions of the state agency medical consultants.
(R. 16). He found that the evidence received into the record after the consultants stated their opinions "did not provide any new or material information that would alter any finding about the claimant's residual functional capacity." (R. 17).
In his step three analysis, the ALJ stated Plaintiff "is capable of simple and intermediate tasks." (R. 13). In his RFC assessment, the ALJ found Plaintiff is limited "to simple to intermediate work" (R. 14), and stated that the reports of Dr. Ohlde and Dr. Ecklund-Johnson "reflect the ability to do simple to intermediate work." (R. 16). The court notes three errors in these findings.
First, there is no explanation or discussion of if, whether, or how the term "simple
In fact, the court notes that "task" is defined as "a specific piece or amount of work."
Second, and relatedly, the ALJ did not define the terms or cite to administrative, legal, or medical authority which establishes the meaning of the terms. Further, the Commissioner does not cite and the court is unable to locate (and is unaware of the existence of) authority establishing the terms as administrative, legal, or medical terms of art with a particular meaning. Moreover, the meaning of the terms is not apparent on their face or apparent based upon the common understanding of the words involved. In context, "simple and intermediate tasks" and "simple to intermediate work" may refer to the relative degree of difficulty of the tasks or of the work based upon any qualitative mental factor such as skill, intelligence, cognition, education, comprehension, memory, attention, or numerous unknown other factors which have not been defined or identified in the decision. Because the particular qualitative mental factor or factors intended by the ALJ are not identified or explained in the decision, the court is unable to determine how the ALJ intended the terms to be applied, and is unable to determine whether substantial record evidence supports the ALJ's finding.
Third, the ALJ did not explain how he arrived at the finding that Plaintiff is "capable of simple and intermediate tasks." (R. 13). He merely found that Plaintiff has "moderate" difficulty with concentration, persistence, or pace; noted that Plaintiff reported problems with memory, concentration, and completing tasks, but that neuropsychological evaluation showed only mild cognitive impairment; and concluded that Plaintiff is capable of simple and intermediate tasks.
With respect to the finding that Plaintiff can do "simple to intermediate work," the ALJ's explanation fares only slightly better, for there, at least, the ALJ stated that he was in agreement with the medical opinions of the state agency medical consultants, and that the reports of Dr. Ohlde and Dr. Ecklund-Johnson reflect the ability to do simple to intermediate work. (R. 16). However, once again he did not explain how the reports of the medical consultants or of Dr. Ohlde and Dr. Ecklund-Johnson establish that Plaintiff is capable of "simple to intermediate work."
The nearest support the court can find for the ALJ's finding is in the mental RFC assessment of the state agency psychologist, Dr. Carol Adams. (R. 351-54) (Ex. B8F). In that assessment, Dr. Adams found Plaintiff "Not Significantly Limited" in eighteen of twenty mental functional abilities. (R. 351-52). She found Plaintiff "Moderately Limited" in the ability to understand and remember detailed instructions, and in the ability to carry out detailed instructions. (R. 351). The ALJ noted that mental restrictions found by the state agency consultants "included moderate limitations in the ability to understand, remember and carry out detailed instructions." (R. 16) (citing Ex. B8F). In her narrative RFC assessment, Dr. Adams opined regarding Plaintiff's understanding and memory: "The claimant can understand and follow
On their faces, at least, the reports of Dr. Ohlde and Dr. Ecklund-Johnson do not establish unequivocally that Plaintiff is capable of "simple to intermediate work" as the ALJ found. As is potentially relevant here, the ALJ noted that Dr. Ohlde reported Plaintiff's attention, concentration, social skills, adaptation, and persistence were "adequate," and that Plaintiff had the ability to understand and carry out simple and difficult instructions. (R. 12). As to Dr. Ecklund-Johnson, the ALJ found that his report "reflected a mild decline in selected aspects of cognitive ability," but that performance of tasks which are
Moreover, the reports of Dr. Ohlde and Dr. Ecklund-Johnson are far more nuanced than the summaries provided by the ALJ. For example (and by no means the only problem with the ALJ's summary), the court is unable to find support for the ALJ's statement that Dr. Ohlde's report noted the ability to understand and carry out simple and difficult instructions. Rather, the report stated that Plaintiff "was alert and able to respond to and understand questions and instructions and
As the parties agree, and as the ALJ noted, the Commissioner has clarified the difference between evaluating the severity of mental limitations at steps two and three of the sequential evaluation based upon the four broad functional areas identified in the psychiatric review technique and thereafter assessing mental RFC. Soc. Sec. Ruling (SSR) 96-8p, West's Soc. Sec. Reporting Serv., Rulings 147 (Supp. 2011). "The mental RFC assessment used at steps 4 and 5 of the sequential evaluation process requires a more detailed assessment [than the step two and three analysis] by itemizing various functions contained in the broad categories found in" the four mental functional areas.
As Plaintiff's brief suggests, the Commissioner has provided a form for documentation of the mental RFC assessment at the initial and reconsideration review levels within the agency—Form SSA-4734-F4-SUP. POMS Sections DI 24510.060 — DI 24510.90; (R.351-54) (form completed in this case). That form lists twenty basic mental abilities organized into four divisions: Understanding and Memory, Sustained Concentration and Persistence, Social Interaction, and Adaptation.
As Plaintiff asserts, and the Commissioner does not dispute, an RFC assessment requires a function-by-function analysis of a claimant's work-related mental abilities, including the mental activities listed in 20 C.F.R. §§ 404.1545(c), 416.945(c). SSR 96-8p, West's Soc. Sec. Reporting Serv., Rulings 143 (Supp. 2011). The activities listed in 20 C.F.R. § 404.1545(c) and § 416.945(c) are among the twenty mental activities identified in the Commissioner's mental RFC assessment form. While the court is aware of no requirement that an ALJ must utilize the Commissioner's Mental RFC Assessment form in assessing RFC, or must address each of the twenty mental activities identified therein in performing a function-by-function analysis of a claimant's mental abilities, had the ALJ in this case used the form as a guide or a checklist, or at least used terms identified in that form in making his mental RFC assessment, it is likely that the court would be able to understand the findings reached and would be able to determine whether substantial record evidence supports the decision. As discussed herein, the court is unable to ascertain the meaning of the ALJ's RFC finding that Plaintiff is limited to "simple to intermediate work," leaving the decision unreviewable, and necessitating remand for a proper function-by-function analysis and explanation of the ALJ's findings.