STEVEN J. McAULIFFE, District Judge.
Pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3), claimant, Jodie Nickerson, moves to reverse the Acting Commissioner's decision denying her applications for Disability Insurance Benefits under Title II of the Social Security Act, 42 U.S.C. § 423, and Supplemental Security Income Benefits under Title XVI, 42 U.S.C. §§ 423, 1381-1383c (the "Act"). The Acting Commissioner objects and moves for an order affirming her decision.
For the reasons discussed below, claimant's motion is granted, and the Acting Commissioner's motion is denied.
In November of 2012, claimant filed applications for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI"), alleging that she was disabled and had been unable to work since November of 2009. Claimant was 34 years old at the time of her alleged onset of disability. Her applications were denied, and claimant requested a hearing before an Administrative Law Judge ("ALJ").
In May of 2014, claimant, her attorney, and an impartial vocational expert appeared before an ALJ, who considered claimant's applications de novo. On July 7, 2014, the ALJ issued his written decision, concluding that claimant was not disabled, as that term is defined in the Act, at any time prior to the date of his decision. Claimant then sought review by the Appeals Council, which denied her request for review. Accordingly, the ALJ's denial of claimant's applications for benefits became the final decision of the Commissioner, subject to judicial review. Subsequently, claimant filed a timely action in this court, asserting that the ALJ's decision is not supported by substantial evidence.
Claimant then filed a "Motion to Reverse" the decision of the Acting Commissioner (document no. 8). In response, the Acting Commissioner filed a "Motion for an Order Affirming the Decision of the Commissioner" (document no. 11). Those motions are pending.
Pursuant to this court's Local Rule 9.1, the parties have submitted a joint statement of stipulated facts which, because it is part of the court's record (document no. 12), need not be recounted in this opinion. Those facts relevant to the disposition of this matter are discussed as appropriate.
Pursuant to 42 U.S.C. § 405(g), the court is empowered "to enter, upon the pleadings and transcript of the record, a judgment affirming, modifying, or reversing the decision of the Commissioner of Social Security, with or without remanding the cause for a rehearing." Factual findings and credibility determinations made by the Commissioner are conclusive if supported by substantial evidence.
An individual seeking SSI and/or DIB benefits is disabled under the Act if she 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).
In assessing a disability claim, the Commissioner considers both objective and subjective factors, including: (1) objective medical facts; (2) the claimant's subjective claims of pain and disability, as supported by the claimant's testimony and/or that of other witnesses; and (3) the claimant's educational background, age, and work experience.
42 U.S.C. § 423(d)(2)(A).
With those principles in mind, the court reviews claimant's motion to reverse and the Acting Commissioner's motion to affirm her decision.
In concluding that Nickerson was not disabled within the meaning of the Act, the ALJ employed the mandatory five-step sequential evaluation process described in 20 C.F.R. §§ 404.1520 and 416.920.
The ALJ then determined that Nickerson's impairments, regardless of whether they were considered alone or in combination, did not meet or medically equal one of the impairments listed in Part 404, Subpart P, Appendix 1.
Next, the ALJ concluded that Nickerson retained the residual functional capacity ("RFC") to perform the exertional demands of light work, as defined in 20 CFR 404.1567(b) and 416.967(b): "she can lift and/or carry 20 pounds occasionally and 10 pounds frequently; stand and walk for 6 hours in the workday; sit for 8 hours in the work days; push and pull occasionally with her lower extremities; frequently balance; occasionally climb stairs, stoop and crouch; should never climb ladders, kneel or crawl; should avoid unprotected heights; and is limited to unskilled and semi-skilled work, for which she is able to concentrate, persist and pace for the typical two hour segments of time during a normal work day and work week." Admin. Rec. at 23-24.
In light of those restrictions, and relying on the testimony of the vocational expert, the ALJ concluded that Nickerson was capable of performing her past relevant work as a day program worker.
Nickerson challenges the ALJ's decision, arguing that the ALJ erred by mishandling the medical opinion evidence, and improperly evaluating her credibility. She further takes issue with the ALJ's step five determination. Nickerson's argument regarding the medical opinion evidence is persuasive, and dispositive. Accordingly, the court need not address her remaining arguments.
"An ALJ must take into account the medical opinions in a claimant's case record when making a disability determination."
In the ALJ's evaluation of Nickerson's depression, somatoform disorder and anxiety disorders under Section 12.06, Section B, he considered the medical opinions of three practitioners. The ALJ assigned the most weight to the opinion of non-examining state agency psychologist, Dr. Jan Jacobsen. Admin. Rec. at 22. Dr. Jacobsen reviewed Nickerson's medical records on February 15, 2013, and concluded that she had only moderate limitations in maintaining concentration, persistence and pace. Dr. Jacobsen further opined that Nickerson retained the ability to understand and remember simple to moderately detailed tasks, and to sustain attention to perform tasks for extended two-hour periods throughout the day. Admin. Tr. at 94.
The second opinion was that of Dr. William Swinburne, a consultative psychologist for the Social Security Administration. Dr. Swinburne saw Nickerson for a psychological profile on January 3, 2013. Admin. Rec. 369-374. He diagnosed her with a major depressive disorder (recurrent, moderate), a pain disorder with both psychological factors and general medical condition, and a panic disorder without agoraphobia; he gave Nickerson a Global Assessment of Functioning ("GAF") score of 50.
Finally, the ALJ considered the opinion of Dr. William Dinan, with whom Nickerson met on February 4, 2013, in connection with her application for Aid to the Permanently and Totally Disabled ("APTD"), a state disability program. Regarding Nickerson's concentration, Dr. Dinan described Nickerson as: "erratic, easily distracted, forgetful, pace slow." Admin. Rec. at 256. He diagnosed Nickerson with major depression (mild) and anxiety, and assigned her a GAF score of 65.
The ALJ found that Dr. Swinburne's opinions concerning Nickerson's limitations in maintaining concentration and persistence were not supported by the record. In support of that conclusion, the ALJ stated that Dr. Swinburne "could only [so] conclude based" on Nickerson's self-reporting. Admin. Rec. at 23. He further relied upon the fact that Dr. Douglas Moran, Nickerson's orthopedic specialist, did not mention Nickerson's mental health limitations in his treatment notes; and that Nickerson had "reported a four-month gap [in treatment] to Dr. Moran as being busy and moving."
Regarding Dr. Dinan's and Dr. Delfausse's opinions, the ALJ noted that Dr. Dinan had assessed a GAF of 65, "indicative of mild symptomology and no severe impairment" (admin. rec. at 23), which, he stated, was inconsistent with a finding of marked impairment. On this basis, he declined to weight their opinions concerning Nickerson's marked limitations in concentration and persistence.
Nickerson takes issue with the ALJ's treatment of Dr. Swinburne's opinions. First, Nickerson contends that the ALJ erred in stating that Dr. Swinburne's conclusions were based entirely on Nickerson's subjective reports. Review of the record makes clear that Nickerson is correct: Dr. Swinburne examined Nickerson, and his opinions are substantially based on his own observations. The Commissioner does not meaningfully dispute the point.
Second, Nickerson argues, the ALJ erroneously relied upon a purported "four month gap" in treatment when she was "busy and moving" in support of his determination. The ALJ's "four month gap" observation was derived from evidence that pertains
Nickerson further finds flaw with the ALJ's reliance upon Dr. Moran's treatment notes in support of his determination that Dr. Swinburne's opinions were not supported by the record. She argues that Dr. Moran is an orthopedist who was focused on repairing her knee; it therefore makes little sense for the ALJ to rely on a lack of comment by Dr. Moran on her mental functioning. That argument has some appeal, especially since the ALJ cites to no evidence in the record suggesting that Dr. Moran had either the opportunity to (or an interest in) evaluate Nickerson's mental functioning, or that Nickerson ever raised her mental health limitations and concerns with Dr. Moran.
Finally, Nickerson argues, the ALJ was wrong: Dr. Swinburne's opinion is, in fact, supported by the record. She points to Dr. Delfausse's assessment, which found that Nickerson had marked limitations in concentration and persistence.
Nevertheless, the ALJ's decision can "still pass muster if the other reasons given to accord medical reports little weight are adequately supported."
Assuming that statement alone is sufficient to constitute substantial evidence that would justify discounting the weight assigned to Dr. Swinburne's opinion, the ALJ did not sufficiently explain why that statement would undermine Dr. Swinburne's opinions concerning Nickerson's limitations with respect to concentration and persistence. Further complicating matters is that the record evidence the ALJ erroneously cites in support is a medical record from a primary care visit for ear pain.
In light of the above, the court must conclude the ALJ's decision to afford Dr. Swinburne's opinion little probative weight is not supported by substantial evidence.
For the foregoing reasons, as well as those set forth in the claimant's legal memorandum, claimant's motion to reverse the decision of the Commissioner (document no. 8) is granted, and the Acting Commissioner's motion to affirm her decision (document no. 11) is denied. The Clerk of the Court shall enter judgment in accordance with this order and close the case.
"GAF scores range from 0-100. A GAF score of 41-50 indicates `[s]erious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job).'"