MADELINE COX ARLEO, District Judge.
Before this Court is Plaintiff Florence Belfiore's request for review, pursuant to 42 U.S.C. §§ 1383(c)(3), 405(g), of the Commissioner of Social Security Administration's ("Commissioner") denial of Plaintiff's applications for Disability Insurance Benefits and Supplemental Security Income Benefits (collectively, "Disability Benefits"). Plaintiff argues that (1) the Commissioner's decision was not supported by substantial evidence; and (2) the Commissioner committed legal error in denying Plaintiff's claim for Disability Benefits. For the reasons set forth in this Opinion, the Court finds that the Commissioner's decision is beyond meaningful judicial review. Accordingly, the Commissioner's decision must be
This Court has jurisdiction to review the Commissioner's decision under 42 U.S.C. § 405(g). This Court must affirm the Commissioner's decision if there exists substantial evidence to support the decision. 42 U.S.C. § 405(g);
"[T]he substantial evidence standard is a deferential standard of review."
In determining whether there is substantial evidence to support the Commissioner's decision, the Court must consider "(1) the objective medical facts; (2) the diagnoses of expert opinions of treating and examining physicians on subsidiary questions of fact; (3) subjective evidence of pain testified to by the claimant and corroborated by family and neighbors; and (4) the claimant's educational background, work history, and present age."
In order to determine whether a claimant is disabled, the Commissioner must apply a fivestep test. 20 C.F.R. § 404.1520(a)(4). First, it must be determined whether the claimant is currently engaging in "substantial gainful activity." 20 C.F.R. § 404.1520(a)(4)(i). "Substantial gainful activity" is defined as work activity, both physical and mental, that is typically performed for either profit or pay. 20 C.F.R. § 404.1572. If it is found that the claimant is engaged in substantial gainful activity, then he or she is not disabled and the inquiry ends.
At the third step, the Commissioner must determine whether there is sufficient evidence showing that the claimant suffers from a listed impairment or its equivalent. 20 C.F.R. § 404.1520(a)(4)(iii). If so, a disability is conclusively established and the claimant is entitled to benefits.
Under 42 U.S.C. § 405(g) and Third Circuit precedent, this Court is permitted to "affirm, modify, or reverse the [Commissioner's] decision with or without a remand to the [Commissioner] for a rehearing."
This case arises out of Plaintiff's November 19, 2007, applications for disability insurance benefits and supplemental security income, which were denied both initially on June 6, 2008, and on reconsideration on August 28, 2008. (Tr. 77-79, 139-46). Plaintiff then sought review before an administrative law judge, and a hearing before the Honorable Richard West (the "ALJ") occurred on March 19, 2010. (Tr. 40). Following the hearing, the ALJ issued a decision on June 24, 2010, in which he found that Plaintiff was not disabled because she was capable of performing past relevant work based on her current RFC. (
Plaintiff is a 58-year-old woman who alleged in her applications for Disability Benefits that she became disabled on June 15, 2006. (Tr. 139, 144). Prior to the onset of her alleged disability, Plaintiff appears to have worked as a factory worker in a number of different industries. (
Plaintiff claimed in her initial application that she suffers from tendinitis in her left shoulder, which prevents her from lifting her arm above a certain level. (Tr. 156). She lives with her daughter and grandson, and she spends her days caring for her grandson and tending to the family cat. (Tr. 164-65). Plaintiff alleges that her condition prevents her from performing any house or yard work tasks that require lifting, and she specifically states that she cannot lift more than five pounds at a time. (Tr. 166, 168). In addition, Plaintiff states that the pain in her arm adversely affects her ability to sleep and to perform simple tasks such as getting dressed, fixing her hair, and driving. (Tr. 165). Plaintiff further avers that sitting for extended periods of time causes her discomfort. (Tr. 168). As a result of her claimed inability to have full use of her left arm, Plaintiff also appears to suffer from depression and anxiety. (Tr. 170-71).
A January 31, 2007, report with respect to an MRI of Plaintiff's left shoulder revealed no obvious abnormalities in the arm. (
In a May 22, 2008, consultative examination ordered by the Division of Disability Determination, Dr. Justin Fernando diagnosed Plaintiff with tendinitis of the left shoulder, but he found her prognosis to be good. (Tr. 290). Specifically, Dr. Fernando first noted that the diagnosis of adhesive capsulitis was not supported by the MRIs performed on Plaintiff's shoulder. (Tr. 288). Dr. Fernando did, however, observe limited range of motion in the left shoulder (Plaintiff could not lift the arm above 90 degrees), along with a difference in size in the left arm in comparison to the right due to an apparent "inflammatory reaction." (Tr. 289-90). Dr. Fernando further stated that Plaintiff "requires anti-inflammatories and injection of long-acting steroid at the site of the left deltoid tubercle. It would also be wise to immobilize the left arm in a sling." (Tr. 290-91).
In denying Plaintiff's claim in the first instance on June 6, 2008, the Commissioner considered the January 31, 2007, MRI report, Plaintiff's medical records submitted by Dr. DeGuzman, and the consultative examination performed by Dr. Fernando. (Tr. 80). In consideration of those records, the Commissioner acknowledged that Plaintiff did indeed suffer from tendinitis of the left shoulder; however, the Commissioner found that Plaintiff's condition did not limit her ability to use her limbs. (
On October 22, 2008, Plaintiff requested a hearing before an ALJ, which occurred on March 19, 2010. (Tr. 40-72, 88). Following the hearing, the ALJ issued his decision on June 24, 2010, finding that Plaintiff was not disabled. (Tr. 18-25). In making that determination, the ALJ held that Plaintiff's disability claim failed at step four of the sequential analysis—that is, given Plaintiff's RFC, the ALJ found that Plaintiff was capable of performing her past relevant work. (Tr. 23-24). In the alternative, the ALJ determined that even if Plaintiff were not capable of performing her past relevant work, jobs existed in significant numbers in the national economy that Plaintiff could perform in light of her age, education, work experience, and RFC. (Tr. 24). Thus, the ALJ held that a finding of no disability was warranted at both steps four and five of the sequential analysis.
Also at issue on this appeal, however, is the ALJ's finding at step three that neither Plaintiff's individual impairments nor a combination of her impairments met or medically equaled one of the listed impairments in 20 C.F.R. Subpart P, Appendix 1 ("Appendix 1"). (Tr. 21). First, the Court notes that the ALJ found at step two that Plaintiff suffers from several severe impairments (1) chronic degeneration and pain in her left shoulder; (2) degenerative disc disease in her back; and (3) spinal stenosis. (Tr. 20).
Having made that step-three determination, the ALJ moved on to the RFC analysis at step four. There, the ALJ found that claimant was capable of performing light work as defined at 20 C.F.R. 404.1567(b) and 416.967(b), with the following limitations (1) Plaintiff could lift and carry only ten pounds frequently; and (2) Plaintiff could sit, stand, and walk for six hours in an eight hour workday, but could not perform any overhead reaching with her left arm. (
The ALJ relied heavily upon the May 22, 2008, report of Dr. Fernando, giving that report "[g]reat weight" after finding Dr. Fernando's opinion to be "consistent with the overall evidence." (
Next, the ALJ considered whether Plaintiff was capable of performing her past relevant work in light of her RFC. In determining that Plaintiff was capable of performing her past relevant work as a ticketer, the ALJ relied upon the opinion of a vocational expert, who found that an individual with Plaintiff's RFC would be able to perform such a job. (
With respect to the ALJ's finding at step three that Plaintiff's impairments or combination of impairments did not meet a listed impairment, the Court finds that determination to be supported by substantial evidence. The ALJ stated that he specifically considered whether Plaintiff met Listing 1.04 for spinal disorders, but rejected that listing because Plaintiff is capable of ambulating effectively and performing gross movements. (Tr. 21). Plaintiff's acknowledged spinal disorders of degenerative disc disease and spinal stenosis are both explicitly referenced in Listing 1.04, but there is no evidence in the record to suggest that Plaintiff has lost the ability to ambulate effectively or perform gross movements as those terms are defined at 1.00B2b and 1.00B2c. Indeed, both Plaintiff's own statements and the medical evidence demonstrate that Plaintiff is capable of walking effectively—although she experiences some discomfort—and performing fine and gross movements with her right arm. (
An entirely different matter, however, is whether there is substantial evidence to support the ALJ's finding that Plaintiff's combination of impairments does not medically equal a listed impairment. Because the ALJ has failed to adequately explain the reasoning for his determination, the Court finds that it is unable to conduct a meaningful judicial review of whether that determination is supported by substantial evidence in the record.
In considering whether a claimant's combination of impairments medically equals an Appendix 1 listing, the Commissioner has directed ALJ's to receive and lend appropriate weight to expert opinion evidence on the issue. SSR 96-6p, 1996 WL 374180, at *3 (July 2, 1996). In general, this requirement is satisfied whenever the record contains a Disability Determination Transmittal Form or a Cessation or Continuance of Disability or Blindness form.
In this Court's opinion, there does exist such additional medical evidence in this case that may change the State medical expert's initial finding of non-equivalence, since the dated State medical expert reports do not incorporate later assessments of Plaintiff's condition. Indeed, Dr. Fernando's May 22, 2008, report deals only with Plaintiff's left shoulder impairment and makes no mention of her back impairments. (
While the Court is of the opinion that this additional medical evidence could reasonably be expected to have an impact on whether a medical expert for the State would consider Plaintiff's combination of impairments to be medically equivalent to a listed impairment, the relevant opinion here is that of the ALJ. The ALJ may ultimately determine that this additional medical evidence would not change the initial finding of non-equivalence, but the ALJ must explicitly state the reasons for such an opinion. On remand, therefore, the ALJ is directed to determine whether in his opinion the additional medical evidence may change the State's earlier finding of nonequivalence with an Appendix 1 listing. If the ALJ determines that the additional medical evidence does not have such an effect, he must provide an adequate explanation for that opinion. If, on the other hand, the ALJ finds that the additional medical evidence may change the earlier finding of non-equivalence, the ALJ must incorporate an updated expert medical opinion into a renewed and complete analysis of whether Plaintiff's combination of impairments is equivalent to a listed impairment.
As noted previously, the ALJ determined that the Plaintiff was capable of performing light work as defined at 20 C.F.R. § 404.1567(b), with limitations on her ability to lift and carry any object over ten pounds and on her ability to reach overhead with her left arm. (
First, the Court finds problematic the boilerplate language contained in the ALJ's opinion stating that "claimant's statements concerning the intensity, persistence and limiting effects of these symptoms are not credible to the extent they are inconsistent with the above [RFC]." (Tr. 22). Courts have scrutinized such language, since it implies that the ALJ improperly decided the claimant's RFC first and determined the credibility of the claimant's testimony second based on that RFC.
Irrespective of the effect of the boilerplate language, however, the Court finds the ALJ's analysis to be inadequate. In determining a claimant's RFC, the ALJ is required to consider all relevant evidence.
In this case, the ALJ fell far short of meeting this standard. The ALJ's analysis consists almost entirely of a recitation of the evidence in the record, without any accompanying explanation of how each piece of evidence factored into the ultimate RFC determination. (Tr. 21-23). Indeed, the only pieces of evidence for which the ALJ gives any semblance of an explanation of the role they played in his decision were the medical opinions of Drs. DeGuzman and Fernando. (
The ALJ similarly fails to adequately explain his decision to give "great weight" to Dr. Fernando's report. (Tr. 22). Indeed, the ALJ simply provides a blow-by-blow recitation of Dr. Fernando's findings, followed by the bare conclusion that Dr. Fernando's "opinion is consistent with the overall evidence." (
Most troubling, however, is the ALJ's bizarre recitation of the medical records developed subsequent to Dr. Fernando's report that indicate a significant worsening of Plaintiff's various medical conditions. (Tr. 23). The ALJ merely mentions these records without providing any context or any indication of how they factored into his ultimate RFC determination. (
The ALJ is therefore directed to provide an adequate analysis of Plaintiff's RFC in accordance with both the Commissioner's rules and regulations and this Court's Opinion.
Because the Court finds that the ALJ's decision beyond meaningful judicial review, the Commissioner's disability determination is