ROBERT B. JONES, Jr., Magistrate Judge.
This matter is before the court on Plaintiff's motion for judgment on the pleadings [DE-19] pursuant to Rule 12(c) of the Federal Rules of Civil Procedure and the Commissioner's motion to remand [DE-22], to which the Plaintiff filed a response in opposition [DE-23]. Plaintiff Christopher B. Harshman ("Claimant") filed this action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3) seeking judicial review of the denial of his application for a period of disability and Disability Insurance Benefits ("DIB"). The time for filing responsive briefs has expired and the pending motions are ripe for adjudication. Having carefully reviewed the administrative record and the motions and memoranda submitted by the parties, it is recommended that Claimant's Motion for Judgment on the Pleadings be allowed, Defendant's Motion for Remand be denied, and the final decision of the Commissioner be reversed and the case remanded for an award of benefits.
On March 2, 2007, Plaintiff protectively filed an application for a period of disability and DIB, alleging disability beginning July 5, 2006. (R. 116-17). The claim was denied initially and upon reconsideration. (R. 45-46). On October 12, 2007, Claimant requested a hearing before an administrative law judge ("ALJ") (R. 62-64), and on July 30, 2009, ALJ Richard Perlowski held a hearing at which Claimant, represented by counsel, and a vocational expert ("VE") appeared and testified. (R. 28-44). On September 11, 2009, ALJ Perlowski issued an unfavorable decision (R. 10-27), and on July 20, 2010, the Appeals Council denied Claimant's request for review (R. 1-5). On October 25, 2010, Claimant filed an action in this court, and on October 18, 2011, the court allowed Claimant's motion, because the ALJ failed to address the fact that Claimant was receiving Medicaid or that he had been approved for disability benefits by a state agency, and remanded the case to the Commissioner for further proceedings. (R. 633-42); Harshman v. Astrue, No. 5:10-C458 ("Harshman I"), 2011 WL 4957371 (E.D.N.C. Oct. 18, 2011) (Dever, C.J.).
Claimant filed a second application for disability and DIB on February 10, 2010, also alleging disability beginning July 5, 2006, which ALJ Edward Bowling denied on June 21, 2011. (R. 615-32). The Appeals Council granted review of the subsequent claim and consolidated it with the remanded claim from Harshman (R. 643-48). In the interim, Claimant filed a third claim on June 28, 2011, which the Appeals Council determined was rendered a duplicate claim by its action on the prior two claims, and the AKJ was directed to associate the file and issue a new decision on the associated claim. Id. On November 5, 2012, ALJ Perlowski held a second hearing at which Claimant, represented by counsel, and a VE appeared and testified. (R. 573-91). On February 4, 2013, the ALJ issued an unfavorable decision. (R. 555-72). On November 26, 2013, the Appeals Council denied Claimant's request for review. (R. 542-46). On January 31, 2014, Claimant filed his second action in this court, and the Commissioner filed a consent motion for remand for the purpose of allowing the ALJ to "further evaluate the Plaintiff's medically determinable impairment compromise of a nerve root or spinal cord" and to consider evidence relevant to Listing 1.04A. Harshman v. Colvin, No. 5:14-CV-52-FL ("Harshman II"), [DE-35] at 2-3 (E.D.N.C. Sept. 10, 2014). The court reversed the Commissioner's decision and remanded the case for further proceedings, specifically ordering the ALJ to "consider the medical evidence to see if the Plaintiff's impairment meets or medically equals the criteria of 20 C.F.R. Part 404, Subpart P, App. 1, § 1.04," Listing 1.04A. Id., [DE-36] (E.D.N.C. Sept. 10, 2014) (Flanagan, J.); (R. 764-71).
On February 9, 2015, the Appeals Council remanded the case, directing assignment to a different ALJ to "[p]rovide further evaluation of whether the severity of the claimant's back impairments meets or equals the requirements of Listing 1.04." (R. 774-75). On June 10, 2015, ALJ Lisa Hall held a hearing at which Claimant, represented by counsel, and a VE appeared and testified. (R. 717-40). On February 3, 2016, ALJ Hall issued an unfavorable decision. (R. 691-716). On May 16, 2016, Claimant filed the instant action seeking review of the now-final administrative decision.
The scope of judicial review of a final agency decision regarding disability benefits under the Social Security Act ("Act"), 42 U.S.C. § 301 et seq., is limited to determining whether substantial evidence supports the Commissioner's factual findings and whether the decision was reached through the application of the correct legal standards. See Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987). "The findings of the Commissioner . . . as to any fact, if supported by substantial evidence, shall be conclusive. . . ." 42 U.S.C. § 405(g). Substantial evidence is "evidence which a reasoning mind would accept as sufficient to support a particular conclusion." Laws v. Celebrezze, 368 F.2d 640, 642 (4th Cir. 1966). While substantial evidence is not a "large or considerable amount of evidence," Pierce v. Underwood, 487 U.S. 552, 565 (1988), it is "more than a mere scintilla . . and somewhat less than a preponderance." Laws, 368 F.2d at 642. "In reviewing for substantial evidence, [the court should not] undertake to re-weigh conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the [Commissioner]." Mastro v. Apfel, 270 F.3d 171, 176 (4th Cir. 2001) (quoting Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996), superseded by regulation on other grounds, 20 C.F.R. § 416.927(d)(2)). Rather, in conducting the "substantial evidence" inquiry, the court's review is limited to whether the ALJ analyzed the relevant evidence and sufficiently explained his or her findings and rationale in crediting the evidence. Sterling Smokeless Coal Co. v. Akers, 131 F.3d 438, 439-40 (4th Cir. 1997).
The disability determination is based on a five-step sequential evaluation process as set forth in 20 C.F.R. § 404.1520 under which the ALJ is to evaluate a claim:
Albright v. Comm'r. of the SSA, 174 F.3d 473, 475 n.2 (4th Cir. 1999). "If an applicant's claim fails at any step of the process, the ALJ need not advance to the subsequent steps." Pass v. Chater, 65 F.3d 1200, 1203 (4th Cir. 1995) (citation omitted). The burden of proof and production during the first four steps of the inquiry rests on the claimant. Id. At the fifth step, the burden shifts to the ALJ to show that other work exists in the national economy which the claimant can perform. Id.
When assessing the severity of mental impairments, the ALJ must do so in accordance with the "special technique" described in 20 C.F.R. § 404.1520a(b)-(c). This regulatory scheme identifies four broad functional areas in which the ALI rates the degree of functional limitation resulting from a claimant's mental impairment(s): activities of daily living; social functioning; concentration, persistence or pace; and episodes of decompensation. Id. § 404.1520a(c)(3). The ALJ is required to incorporate into his written decision pertinent findings and conclusions based on the "special technique." Id. § 404.1520a(e)(3).
Applying the above-described sequential evaluation process, the ALJ found Claimant "not disabled" as defined in the Act. At step one, the ALJ found that Claimant had not engaged in substantial gainful activity since the alleged onset date of July 5, 2006 through the date last insured of December 31, 2011 (the date by which Claimant must establish disability). (R. 695, 697). Next, the ALJ determined that the Plaintiff had the severe impairments of congenital fusion of C4-5, degenerative disc disease of the thoracic and lumbar spine, carpal tunnel syndrome, and chronic pain syndrome, as well as the non-severe impairment of depression. (R. 697-701). However, at step three, the ALJ concluded these impairments were not severe enough, either individually or in combination, to meet or medically equal one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (R. 701).
Prior to proceeding to step four, the AU assessed Claimant's residual functional capacity ("RFC") finding Claimant has the ability to perform a reduced range of light work
(R. 702-06). In making this assessment, the ALJ found Claimant's statements about his limitations not entirely credible. (R. 703). At step four, the ALJ found that Claimant was no longer able to perform his past relevant work as a highway maintenance worker. (R. 706). However, at step five, the ALJ determined Claimant could engage in other employment that is available in significant numbers in the national economy. (R. 706-07).
Claimant contends the ALJ erred by finding his impairments do not meet or medically, equal Listing 1.04A for spinal disorders, and requests that the ALJ's decision be reversed for an award of benefits. Pl.'s Mem. [DE-20] at 12-17; Pl.'s Resp. [DE-23] at 1-4. The Commissioner concedes the ALJ did not evaluate certain evidence under the appropriate legal standards, but asserts that remand is the appropriate remedy rather than reversal. Def.'s Mot. [DE-22] at 1-2.
The Fourth Circuit in Radford v. Colvin examined the remedies available to the district court upon review of an ALJ's decision:
Radford v. Colvin, 734 F.3d 288, 295 (4th Cir. 2013) (some internal citations and quotation marks omitted).
To show disability under the listings, a claimant may present evidence either that the impairment meets or is medically equivalent to a listed impairment. See Kellough v. Heckler, 785 F.2d 1147, 1152 (4th Cir. 1986); 20 C.F.R. § 404.1526 (regulations for determining medical equivalence). Disability is conclusively established if a claimant's impairments meet all the criteria of a listing or are medically equivalent to a listing. 20 C.F.R. § 404.1520(d). "The [ALJ] . . . is responsible for deciding . . . whether a listing is met or equaled." S.S.R. 96-6p, 1996 WL 374180, at *3 (July 2, 1996). In order to determine whether a medical impairment equals a listing, the ALJ is bound to "consider all evidence in [claimant's] case record about [the] impairment(s) and its effects on [claimant] that is relevant to this finding. . . . [The ALJ] also consider[s] the opinion given by one or more medical or psychological consultants designated by the Commissioner." 20 C.F.R. § 404.1526(c). "For a claimant to qualify for benefits by showing that his . . . combination of impairments is `equivalent' to a listed impairment, he must present medical findings equal in severity to all the criteria for the one most similar listed impairment." Sullivan v. Zebley, 493 U.S. 521, 532 (1990). "A claimant cannot qualify for benefits under the `equivalence' step by showing that the overall functional impact of his unlisted impairment or combination of impairments is as severe as that of a listed impairment." Sullivan, 493 U.S. at 531. "Plaintiffs bear the burden of proving their condition meets a listing and, accordingly, the responsibility of producing evidence to sustain their claims." Rowe v. Astrue, No. 5:07-CV-478-BO, 2008 WL 4772199, at *1 (E.D.N.C. Oct. 28, 2008) (citing Pass v. Chater, 65 F.3d 1200, 1203 (4th Cir. 1995)). Thus, where a claimant "fails to articulate why h[is] medical impairments do, in fact, meet all of the elements of a given listed impairment," he fails to meet his burden. Id. (citing Sullivan, 493 U.S. at 530).
Listing 1.04 addresses disorders of the spine and contains three distinct subsections. 20 C.F.R. pt. 404, subpt. P, app. 1, § 1.04. Both the court's September 10, 2014 remand order and the Appeals Council's February 9, 2015 remand order specifically directed the ALJ to consider the first subsection, Listing 1.04A. (R. 765, 774). To satisfy Listing 1.04A, a claimant must show a disorder of the spine "(e.g., herniated nucleus pulposus, spinal arachnoiditis, spinal stenosis, osteoarthritis, degenerative disc disease, facet arthritis, vertebral fracture), resulting in compromise of a nerve root (including the cauda equina) or the spinal cord" with the following:
Id. § 1.04A; see Drotar v. Colvin, No. 7:13-CV-265-FL, 2015 vn, 965626, at *5 (E.D.N.C. Mar. 4, 2015) (discussing the criteria to meet or equal Listing 1.04A).
The ALJ determined at step three that Claimant's impairments did not meet or medically equal Listing 1.04, explaining as follows:
(R. 701). The Commissioner concedes that the ALJ did not properly evaluate evidence in the record demonstrating that Claimant experienced motor strength loss, reflex deficits, range of motion deficits, and neuro-anatomic distribution of pain. Def.'s Mot. [DE-22] at 1 (citing, e.g., (R. 362) (July 9, 2007 treatment note from Dr. Landau, Claimant's primary care physician, reflecting limited range of motion in the neck and back); (R. 510-11) (May 14, 2007 treatment note from neurological consultation with Dr. Giliani reflecting Claimant experienced a reflex deficit in the left brachioradialis (a forearm muscle) and neck pain with a radicular pattern and parasthesias involving the hand); (R. 1105) (October 15, 2007 treatment note from Dr. Kremer indicating Claimant had complaints of arm tingling and reduced muscle strength in the left arm)). Nevertheless, the Commissioner argues that the record contains evidentiary conflicts, indicating both normal and abnormal findings, and that remand is appropriate under Radford and Social Security Acquiescence Ruling ("AR") 15-1(4) (implementing Radford) so that the ALJ can weigh the conflicting evidence in the first instance. Id. at 2 (citing (R. 997, 1159, 1188, 1312, 1316) (treatment notes from Dec. 2008, Mar. 2010, Mar. 2011, Apr. 2011, and July 2011 indicating normal strength and reflexes)).
This case is distinguishable from Radford in several material respects. First, in Radford the court found the ALJ's decision regarding the application of Listing 1.04A was "devoid of reasoning" because the ALJ summarily concluded that no listing was met, stating only that Listing 1.04A had been considered in particular and that the state medical examiners had concluded no listing was met. 734 F.3d at 292, 295. Here, at step three, the ALJ made findings regarding the requirements of Listing 1.04A, including that the record was "devoid of evidence of nerve-root compression," "reflects generally intact motor strength and only sporadic, non-sustained instances of reduced motor strength," and that Claimant had "intact reflexes." (R. 701). Furthermore, prior to considering Listing 1.04A, at step two the ALJ engaged in a detailed discussion of Claimant's neck and back impairments. (R. 697-700). The ALJ acknowledged Claimant's "history of musculoskeletal impairments including congenital fusion of C4-5 and degenerative disc disease of the thoracic as well as lumbar spine" and discussed a substantial amount of evidence that would support a finding that Claimant's impairments meet the requirements of Listing 1.04A, including that in late 2005 Claimant experienced "neck pain radiating into the left upper extremity;" in July 2006 on examination Claimant had a "mildly positive impingement sign with 4/5 motor strength in left upper extremity elbow extension" and that his pain was "unrelieved and worsening;" in 2007 Claimant's "complaints of left upper extremity, neck and back pain continued" and in January 2007 Claimant "exhibited decreased left upper extremity strength;" Claimant "reported persistent neck, arm, back and leg pain in December 2008," and exhibited "a limited range of motion in the lumbar spine and neck due to pain;" and in March 2010, a consultative examination revealed "decreased range of neck motion in all directions." (R. 697-99). The ALJ also discussed periods where Claimant demonstrated full range of motion, full motor strength, and normal sensation in the neck and back. Id.
Unlike the ALJ's decision in Radford, the ALJ's decision here states her reasoning; however, in contravention of Radford and AR 15-1(4), the ALJ impermissibly required Claimant to demonstrate the presence of all the Listing 1.04A criteria simultaneously. Because there were periods where some of the symptoms were absent, the ALJ determined Listing 1.04 was not met. (R. 701). The court in Radford explained,
734 F.3d at 294 (citation and internal quotation marks omitted). In most cases, remand would be appropriate to allow the ALJ to further consider Listing 1.04A in light of Radford and AR 15-1(4), but this case is the exception to the rule, presenting the "rare circumstances" justifying reversal and an award of benefits. Id. at 295 (citing Breeden, 493 F.2d at 1011-12 (reversing for award of benefits where case was quite old, record had no need to be reopened, and the case had already been on appeal once before)).
First, this case is old. Claimant filed his first claim for benefits more than ten years ago, and the Commissioner has yet to properly adjudicate it. (R. 116-17). Second, this case is on appeal for the third time. In Harshman II, the court specifically ordered the ALJ on remand to "consider the medical evidence to see if the Plaintiff's impairment meets or medically equals the criteria of 20 C.F.R. Part 404, Subpart P, App. 1, § 1.04," Listing 1.04A. No. 5:14-CV-52-FL, [DE-36] (E.D.N.C. Sept. 10, 2014) (Flanagan, J.); (R. 764-71). The ALJ was given the opportunity to properly address Listing 1.04A, but failed to apply the correct legal standard as set forth in Radford.
There is substantial evidence in the record that Claimant experienced neuro-anatomic distribution of pain, limited range of motion of the spine, and motor loss (atrophy with associated muscle weakness or muscle weakness)
It is evident from the ALJ's stated reasoning at step three and her discussion of the evidence at step two that the she failed to apply the requirements of Listing 1.04A as set forth in Radford and AR 15-1(4) by requiring Claimant to demonstrate the presence of all the Listing 1.04A criteria simultaneously, and her decision that Claimant's cervical spine impairment does not meet Listing 1.04A is not supported by substantial evidence. See McLeod v. Colvin, 625 F. App'x 189, 191 (4th Cir. 2015) (concluding the district court did not abuse its discretion in reversing the Commissioner's decision and directing an award of benefits where, unlike in Radford, ALJ provided reasoning but it was not supported by substantial evidence). Given the age of this claim, the fact that the case has been appealed and remanded twice before (once specifically to consider the issue on which the Commissioner now seeks remand for a second time), and the absence of need to reopen the record, it is recommended that the Commissioner's decision be reversed and the case be remanded for an award of benefits.
For the reasons stated above, it is RECOMMENDED that Plaintiff's motion for judgment on the pleadings [DE-19] be ALLOWED, Defendant's motion for remand be DENIED [DE-22], and the Commissioner's final decision be REVERSED and the case REMANDED for an award of benefits.
IT IS DIRECTED that a copy of this Memorandum and Recommendation be served on each of the parties or, if represented, their counsel. Each party shall have until