LOUISE W. FLANAGAN, District Judge.
This matter comes before the court on the parties' cross motions for judgment on the pleadings. (DE 23, 27). In this posture, the issues raised are ripe for ruling. For the reasons that follow, the court grants plaintiff's motion, denies defendant's motion, and remands the matter to defendant pursuant to sentence four of 42 U.S.C. § 405(g) for further proceedings.
Plaintiff protectively filed concurrent applications for supplemental security income and disability insurance benefits on July 22, 2009, alleging disability beginning March 1, 2007. This application was denied initially and upon reconsideration. A hearing was held before an Administrative Law Judge ("ALJ") who determined that plaintiff was not disabled during the relevant time period in a decision dated July 28, 2011. On October 15, 2012, the Appeals Council denied plaintiff's request for review of the ALJ decision, and plaintiff filed this action on December 6, 2012, for review of the final decision of the Commissioner.
The court has jurisdiction under 42 U.S.C. § 405(g) to review the Commissioner's final decision denying benefits. The court must uphold the factual findings of the ALJ "if they are supported by substantial evidence and were reached through application of the correct legal standard."
The ALJ's determination of eligibility for Social Security benefits involves a five-step sequential evaluation process, which asks whether:
In this matter, the ALJ performed the sequential evaluation. At step one, the ALJ found that plaintiff was not engaged in gainful employment. At step two, the ALJ found that plaintiff had the following severe impairments: lumbar and cervical spine degenerative disc disease, obesity, degenerative joint disease of the right knee, post-traumatic stress disorder, and finger injury. However, at step three, the ALJ further determined that plaintiff did not have an impairment or combination of impairments severe enough to meet or medically equal one of the impairments in the regulations. Prior to proceeding to step four, the ALJ determined that plaintiff had the residual functional capacity ("RFC") to perform light work, subject to the following limitations: (1) ability to alternate between sitting and standing every 30 minutes ("sit/stand option"); (2) no more than occasional postural activities; (3) no constant use of the left upper extremity; and (4) work limited to simple, routine, repetitive tasks with no more than occasional interaction with others. The ALJ determined that plaintiff could not perform his past relevant work, but that plaintiff could adjust to the demands of other employment opportunities existing in significant numbers in the national economy, based upon testimony of a vocational expert (VE). Accordingly, the ALJ determined that plaintiff was not under a disability during the relevant time period.
Plaintiff raises five assignments of error in his motion. First, plaintiff argues that the ALJ erred in omitting material facts regarding plaintiff's mental impairment. Second, plaintiff maintains that the ALJ impermissibly made a mental RFC finding without obtaining either an RFC assessment from a medical expert or additional information from plaintiff's treating physician. Third, plaintiff argues that the ALJ failed to mention plaintiff's borderline intellectual functioning. Fourth, plaintiff contends that the ALJ erred in failing to inquire regarding the conflict between the DOT and the VE's testimony regarding sit/stand options. Fifth, plaintiff asserts that the ALJ should have conducted a function-by-function analysis.
Plaintiff argues that the ALJ failed to discuss probative facts regarding plaintiff's mental impairment. In particular, plaintiff argues that the ALJ failed to discuss records regarding plaintiff's June 2011 hospitalization for major depressive disorder, at which time plaintiff was assigned Global Assessment of Functioning Score ("GAF") of 30.
An ALJ must consider "all relevant and available clinical signs and laboratory findings" in assessing a claimant's functional limitation. 20 C.F.R. § 404.1520a(c)(1). An ALJ has discretion to reject GAF scores in favor of other evidence, where, for example, the medical records include limited information about the basis of those scores or how they limit Plaintiff's ability to function at work.
A GAF score is relevant evidence of a claimant's degree of functioning, which "must be considered along with all the other relevant evidence of record."
Here, the ALJ failed to address plaintiff's GAF scores in his decision. Instead, he characterized treatment notes assessing plaintiff with a GAF of 46—i.e., "serious symptoms . . . [or] serious impairment in social, occupational, or school functioning"—as evidence of "improvement" without mention of the score, which provides conflicting evidence that plaintiff still suffered some degree of impairment. (Tr. 36). The fact that plaintiff reported improvement in symptoms as of March 2010 demonstrates only the state of plaintiff's condition relative to his earlier symptoms, but says nothing of the severity of his symptoms overall. In addition, the records in which plaintiff's later GAF score of 30 is reported — suggesting "serious impairment in communication or judgment . . . [or] inability to function in almost all areas" — are described by the ALJ, without more, as plaintiff's hospitalization "after complaining of severe depressive and anxious symptoms." (Tr. 37). This is an insufficient explanation of evidence weighing against the ALJ decision to enable meaningful review.
In sum, plaintiff's GAF scores and records of hospitalization provide probative evidence contradicting the ALJ's conclusion, yet the decision does not include the ALJ's reasons for rejecting this evidence. Without a sufficient explanation of the weight given to obviously probative exhibits, it is not possible to determine if the ALJ's decision is supported by substantial evidence.
Plaintiff argues that the ALJ was required to further develop the record when faced with a psychiatric review technique form that deemed the evidence in plaintiff's file to be inconclusive. In particular, Dr. Salmony, who filled out the Psychiatric Review Technique form on September 8, 2010, concluded that there was insufficient evidence to complete the assessment, including the portion assessing functional limitations in daily living, social functioning, and concentration. (Tr. 405, 415).
While an ALJ has a duty to develop the record when necessary for a disability determination, this does not displace the plaintiff's burden of proof at steps one through four.
The SSA arranges for consultative examinations at its own expense,
Moreover, an ALJ is not required to obtain an expert medical opinion before making an RFC assessment.
In short, plaintiff cannot be heard to complain that the record lacks a mental RFC assessment when the absence of any such assessment is due to his own absenteeism. Plaintiff's second assignment of error is therefore rejected.
Plaintiff contends that the ALJ's failure to explicitly mention borderline intellectual functioning in the decision or VE hypothetical was in error. DE-24 at 4. Plaintiff relies upon a January 13, 2010 psychological evaluation, during which Plaintiff scored a composite IQ of 79 on the Kaufman Brief Intelligence test, i.e. "within the borderline range [of intelligence]." Tr. 301-303. As Defendant points out, the psychometric testing performed at the appointment has questionable probative value. The evaluator noted that plaintiff's cooperation and motivation were "limited" but that plaintiff "put forth an adequate effort." Tr. 301. The evaluator also commented, however, that plaintiff's responses on a DSM-IV Axis II checklist were of "questionable validity" and opined that plaintiff had "intentionally attempted to present an excessively negative clinical impression of himself." Tr. 302.
In this case, even crediting plaintiff's assertion that he has borderline intelligence, this impairment is accounted for in the ALJ's VE hypothetical and RFC by virtue of the limitation to simple, routine, repetitive tasks.
Plaintiff argues that the VE's testimony that sit/stand options were available conflicted with the DOT, and that the ALJ was therefore obligated to elicit testimony to explain the conflict. Defendant responds that because the DOT is silent as to sit/stand options, no conflict exists between the VE's testimony and the DOT. Defendant also points out that the ALJ acknowledged that the DOT does not address whether a job has a sit/stand option, but relied upon the VE's experience.
Social Security Ruling 00-4p requires that before an ALJ can rely on VE evidence, the ALJ must inquire on the record whether the testimony is consistent with the DOT, and that if "there is an apparent unresolved conflict . . . the [ALJ] must elicit a reasonable explanation for the conflict," and explain in his decision how the conflict was resolved. SSR 00-4p, 2000 WL 1898704, at *1 (Dec. 4, 2000) (emphasis added). As recognized in SSR 00-4p, however, a conflict between the DOT and VE testimony does not compel the conclusion that the testimony is inaccurate: "DOT lists maximum requirements of occupations as generally performed, not the range of requirements of a particular job as it is performed in specific settings," and the VE therefore "may be able to provide more specific information about jobs or occupations than the DOT."
Here, the ALJ acknowledged in his opinion that the sit/stand option is not addressed in the DOT, but found that the VE's testimony was reliable based upon her "extensive experience placing individuals into jobs while accounting for this limitation." (Tr. 39). This serves to satisfy the burden under step five.
Plaintiff contends that the ALJ erred by not making specific findings regarding plaintiff's ability to lift, carry, push, and pull, along with not specifying how long plaintiff can stand and walk in a day. This court previously has held that "[t]o the extent that the ALJ did not explicitly mention each function, he was not required to do so."
Based on the foregoing, the court GRANTS plaintiff's motion for judgment on the pleadings (DE 23), DENIES defendant's motion for judgment on the pleadings (DE 27) and remands the matter to defendant pursuant to sentence four of 42 U.S.C. § 405(g) for further proceedings consistent with the foregoing directives. The clerk of court is directed to close the case.
SO ORDERED.