KIRTAN KHALSA, Magistrate Judge.
Claimant Jimmy Ray Banegas ("Mr. Banegas") alleges that he became disabled on November 5, 2010, at the age of fifty-six because of knee arthritis, shoulder arthroscopy, oculopharyngeal muscular dystrophy, arthritis, right shoulder injury, loss of strength in legs, weakness in arms, difficulty swallowing, and vision problems due to droopy eyelids. (Tr. 169-70, 206.
On May 15, 2013, Mr. Banegas protectively filed an application for Social Security Disability Insurance Benefits ("DIB") under Title II of the Social Security Act (the "Act"), 42 U.S.C. § 401 et seq. (Tr. 169-70.) Mr. Banegas's application was initially denied on August 6, 2013. (Tr. 92, 82-91, 105-08.) It was denied again at reconsideration on August 29, 2013. (Tr. 93-103, 104, 110-14.) On March 10, 2014, Mr. Banegas requested a hearing before an Administrative Law Judge ("ALJ"). (Tr. 115-16.) The ALJ conducted a hearing on December 11, 2015. (Tr. 55-81.) Mr. Banegas appeared in person at the hearing with attorney Gary Martone. (Id.) The ALJ took testimony from Mr. Banegas (Tr. 60-73), and an impartial vocational expert ("VE"), Shelley K. Eike. (Tr. 74-80.) On January 20, 2016, the ALJ issued an unfavorable decision. (Tr. 10-22.)
On April 8, 2016, the Appeals Council issued its decision denying Mr. Banegas's request for review and upholding the ALJ's final decision. (Tr. 1-6.) On May 31, 2016, Mr. Banegas timely filed a Complaint seeking judicial review of the Commissioner's final decision. (Doc. 1.)
We review the Commissioner's decision to determine whether the factual findings are supported by substantial evidence in the record and whether the correct legal standards were applied. 42 U.S.C. § 405(g); Hamlin v. Barnhart, 365 F.3d 1208, 1214 (10
In considering an application for disability insurance benefits, the Commissioner uses a five-step sequential evaluation process. 20 C.F.R. §§ 404.1520; Bowen v. Yuckert, 482 U.S. 137, 140 (1987). The claimant bears the burden of establishing a prima facie case of disability at steps one through four. 20 C.F.R. §§ 404.1520(a)(4)(i-iv); Grogan v. Barnhart, 399 F.3d 1257, 1261 (10
The ALJ made his decision that Mr. Banegas was not disabled at step four of the sequential evaluation. He found that Mr. Banegas had the residual functional capacity to perform light work as defined in 20 CFR 404.1567(b) except as follows:
(Tr. 17.) Based on the RFC and the testimony of the VE, the ALJ concluded that Mr. Banegas was capable of performing his past relevant work as a gate guard and security guard and that he was therefore not disabled. (Tr. 22.)
Mr. Banegas asserts three arguments in support of his Motion as follows: (1) the ALJ erred by failing to consider his oculopharyngeal muscular dystrophy ("OMD") and related symptoms in determining the RFC; (2) the ALJ erred by failing to make a function-by-function assessment; and (3) the ALJ erred at step four in finding that Mr. Banegas could return to his past relevant work. The Court agrees that the ALJ failed to properly consider Mr. Banegas's non-severe impairment of OMD and related symptoms in determining his RFC, and the decision of the Commissioner is therefore reversed.
The ALJ determined at step two that Mr. Banegas had severe impairments of right shoulder rotator cuff tear, subacromial impingement and intra-articular tear of biceps tendon status port surgical repair; degenerative arthritis of the right knee; and coronary artery disease status post stenting. (Tr. 16.) The ALJ also determined that Mr. Banegas suffered from non-severe impairments of left inguinal hernia status post surgical repair, OMD, hypertension, hyperlipidemia, visual disturbances (fallen eyelids) and obstructive sleep apnea (OSA). (Id.) In discussing Mr. Banegas's OMD, the ALJ explained that
(Tr. 16.) The ALJ concluded that, other than Mr. Banegas's obstructive sleep apnea, the medical record evidence revealed no work related functions limitation based on his non-severe impairments and it appeared that "they have all resolved, are managed with treatment, were diagnosed by a non-acceptable medical source or they do not meet the durational requirements." (Id.) The ALJ made no other findings in his determination regarding Mr. Banegas's OMD or related symptoms.
The relevant medical evidence reveals that on May 1, 2004, Mr. Banegas presented to Dr. Javed Iqbal of Neurology Associates of Mesilla Valley, PC, with symptoms of droopy eyes, difficulty swallowing, and weakness in his upper and lower extremities. (Tr. 394-95.) Dr. Iqbal noted that Mr. Banegas had been previously evaluated in his office and diagnosed with OMD. (Id.) Mr. Banegas complained that his symptoms were gradually worsening. (Tr. 394.) On physical exam, Dr. Iqbal noted, inter alia, that Mr. Banegas had bilateral ptosis (drooping eyelids) and mild proximal weakness in his upper and lower extremities. (Tr. 395.) Dr. Iqbal indicated that OMD was a "progress of muscular dystrophy," and that there was no specific treatment. (Id.) He further indicated that Mr. Banegas could undergo surgery for his eyelids, could undergo esophageal dilatation for his swallowing problems, and could try physical therapy for his leg and arm weakness. (Id.) Dr. Iqbal instructed Mr. Banegas to return as needed. (Id.)
On December 11, 2015, Mr. Banegas testified at the administrative hearing regarding his OMD. (Tr. 66-72.) When questioned about his right shoulder, Mr. Banegas described a greater loss of function with his right arm due to his right shoulder rotator cuff tear, i.e., his ability to lift and reach, but testified that he had a significant amount of loss of strength in both arms due to muscular dystrophy. (Tr. 66-67.) He also testified that while the degenerative arthritis in his right knee causes pain and impacts his ability to walk, he had loss of strength in both legs due to muscular dystrophy. (Tr. 68-69.) He testified that he used a cane for approximately three years to stabilize himself on uneven ground and to have something to hold onto until he could sit down in the event his legs started to give out. (Tr. 69, 71.) Finally, Mr. Banegas testified that his condition had caused his eyelids to fall quite a bit, narrowing his eyes and making it more difficult to see someone standing in front of him and affecting his peripheral vision. (Tr. 70.) Mr. Banegas testified he intended to seek surgery for his drooping eyelids. (Id.)
In determining a claimant's RFC, the ALJ should first assess the nature and extent of the claimant's physical and mental limitations. 20 C.F.R. §§ 404.1545(b) and (c). The ALJ is required to consider all of the claimant's impairments, including impairments that are not severe. See 20 C.F.R. §§ 404.1545(a)(2); see also Wilson v. Astrue, 602 F.3d 1136, 1140 (10
The ALJ improperly relied on his step two findings as a substitute for an adequate RFC analysis. Wells, 727 F.3d at 1071 (citing 20 C.F.R. § 404.1545(a)(2)). The regulations require more. Id. An ALJ is required to consider the combined effect of all the claimant's impairments, including those that are non-severe, in assessing his RFC. Langley, 373 F.3d at 1124. Here, the ALJ did not discuss Dr. Iqbal's record, did not make any specific findings regarding Mr. Banegas's OMD and related symptoms, and did not include any limitations based on Mr. Banegas's extremity weakness or bilateral ptosis. Further, the ALJ's explanation at step two for excluding Mr. Banegas's OMD related symptoms in his RFC assessment is not supported by substantial evidence. The ALJ stated that the medical evidence of record revealed no work related functional limitations from any of the other non-severe impairments because they had either resolved, were managed with treatment, were diagnosed only by a non-acceptable medical source, or did not meet the durational requirement. (Tr. 16.) Here, Dr. Iqbal, an acceptable medical source, diagnosed Mr. Banegas's OMD, described it as progressive, and indicated there was no specific treatment for it. As such it was not resolved nor was it being managed with treatment. Additionally, this impairment met the durational requirement having been diagnosed sometime prior to May 1, 2013.
The Commissioner's arguments that the ALJ did not err in his RFC assessment are unavailing. The Commissioner first argues that the ALJ properly discounted Mr. Banegas's complaints related to his OMD because he had not received any treatment for it or the symptoms he alleged resulted from it. (Doc. 22 at 9-10.) Setting aside that the ALJ noted this at step two in finding this impairment was non-severe, the ALJ nonetheless failed to explain precisely what treatment Mr. Banegas had not received given Dr. Iqbal's note that there was no specific treatment for OMD. (Tr. 395.) Additionally, Dr. Iqbal's indications regarding what Mr. Banegas could do to address his OMD related symptoms did not rise to the level of prescribed treatment that Mr. Banegas failed to follow. As such, it would be error for the ALJ to discount Mr. Banegas's subjective reports on that basis. See Thompson v. Sullivan, 987 F.2d 1482, 1490 (10
The Commissioner next argues that the record did not support any specific limitations arising from OMD that should have been incorporated in the RFC. (Doc. 22 at 11.) The Administrative Record, however, does not contain a functional assessment prepared by any treating physician or consultative examiner that evaluated Mr. Banegas's specific limitations to do work-related physical activities based on any of his severe and non-severe impairments.
Finally, the Commissioner argues that the ALJ had already deemed Mr. Banegas's subjective reports regarding his limitations to be less than reliable because of his activities of daily living. (Doc. 22 at 8-9, 11.) An adverse credibility finding does not excuse the ALJ's failure to consider Mr. Banegas's OMD related symptoms in the first instance. See Thompson v. Sullivan, 987 F.2d 1482, 1488-91 (describing three-part inquiry for evaluating impairment related subjective complaints and factors to be considered in determining credibility). That aside and being mindful that deference to the fact-finder's assessment of credibility is the general rule, the Court is not persuaded that the ALJ's credibility determination based on Mr. Banegas's daily activities was closely and affirmatively linked to the evidence. Wilson, 602 F.3d at 1144 (quoting Kepler v. Chater, 68 F.3d 387, 391 (10
For the foregoing reasons, the Court finds that the ALJ failed to apply the correct legal standard in determining Mr. Banegas's RFC because he failed to consider the effects of Mr. Banegas's non-severe impairment of OMD and related symptoms on his ability to do work- related activities. This is reversible error. Wilson, 602 F.3d at 1140. Additionally, the Court is not persuaded that the ALJ's error is harmless. Here, Mr. Banegas is of advanced age.
The Court will not address Mr. Banegas's remaining claims of error because they may be affected by the ALJ's treatment of this case on remand. Wilson v. Barnhart, 350 F.3d 1297, 1299 (10
For the reasons stated above, Mr. Banegas's Motion to Reverse and Remand for Rehearing (Doc. 20) is