HOLLY B. FITZSIMMONS, Magistrate Judge.
Plaintiff Alicia M. Sherry brings this action pursuant to 42 U.S.C. §405(g), seeking review of a final decision of the Commissioner of Social Security which denied her application for Disability Insurance Benefits ("DIB") of the Social Security Act, 42 U.S.C. §401
For the reasons set forth below, plaintiff's Motion for Judgment on the Pleadings
The procedural history of this case is not disputed. Plaintiff protectively filed an application for DIB on November 6, 2013, alleging disability as of April 11, 2013.
On March 11, 2016, Administrative Law Judge ("ALJ") Susan Smith held a hearing, at which plaintiff appeared with an attorney and testified. [Tr. 48-74]. Vocational Expert ("VE") Joseph Atkinson also testified at the hearing. [Tr. 68-74]. On April 12, 2016, the ALJ found that plaintiff was not disabled, and denied her claim. [Tr. 16-32]. Plaintiff filed a timely request for review of the hearing decision on April 4, 2016. [Tr. 12-14]. On August 28, 2017, the Appeals Council denied review, thereby rendering ALJ Smith's decision the final decision of the Commissioner. [Tr. 1-5]. The case is now ripe for review under 42 U.S.C. §405(g).
Plaintiff, represented by counsel, timely filed this action for review and moves to reverse and/or remand the Commissioner's decision.
The review of a social security disability determination involves two levels of inquiry.
The Court does not reach the second stage of review — evaluating whether substantial evidence supports the ALJ's conclusion — if the Court determines that the ALJ failed to apply the law correctly.
"[T]he crucial factors in any determination must be set forth with sufficient specificity to enable [a reviewing court] to decide whether the determination is supported by substantial evidence."
It is important to note that in reviewing the ALJ's decision, this Court's role is not to start from scratch. "In reviewing a final decision of the SSA, this Court is limited to determining whether the SSA's conclusions were supported by substantial evidence in the record and were based on a correct legal standard."
Under the Social Security Act, every individual who is under a disability is entitled to disability insurance benefits.
To be considered disabled under the Act and therefore entitled to benefits, Ms. Sherry must demonstrate that she is unable to work after a date specified "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). Such impairment or impairments must be "of such severity that [s]he is not only unable to do h[er] previous work but cannot, considering h[er] age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy." 42 U.S.C. §423(d)(2)(A);
There is a familiar five-step analysis used to determine if a person is disabled.
"Through the fourth step, the claimant carries the burdens of production and persuasion, but if the analysis proceeds to the fifth step, there is a limited shift in the burden of proof and the Commissioner is obligated to demonstrate that jobs exist in the national or local economies that the claimant can perform given his residual functional capacity."
"In assessing disability, factors to be considered are (1) the objective medical facts; (2) diagnoses or medical opinions based on such facts; (3) subjective evidence of pain or disability testified to by the claimant or others; and (4) the claimant's educational background, age, and work experience."
Following the above-described five step evaluation process, ALJ Smith concluded that plaintiff was not disabled under the Social Security Act. [Tr. 16-32]. At step one, the ALJ found that plaintiff had not engaged in substantial gainful activity since April 11, 2013, the alleged onset date. [Tr. 21].
At step two, the ALJ found that plaintiff had cervical spine disc herniation without myelopathy; thoracic spine disc herniation without myelopathy; lumbar spine disc herniation without myelopathy, status post anterior lumbar discectomy at L5-S1 with partial corpectomy and fusion with hardware; carpal tunnel syndrome, status post bilateral carpal tunnel release; cubital tunnel syndrome; and tenosynovitis, all of which are severe impairments under the Act and regulations.
At step three, the ALJ found that plaintiff's impairments, either alone or in combination, did not meet or medically equal the severity of one of the listed impairments in 20 C.F.R. Pt. 404, Subpart P, Appendix 1. [Tr. 24-25]. The ALJ specifically considered Listings 1.02 (major dysfunction of a joint(s) (due to any cause), 1.04 (disorders of the spine) and 11.00 (neurological disorders). [Tr. 24-25]. The ALJ also conducted a psychiatric review technique and found that plaintiff had a mild restriction in activities of daily living, social functioning, and concentration, persistence or pace. [Tr. 23-24]. The ALJ found no episodes of decompensation. [Tr. 24].
Before moving on to step four, the ALJ found plaintiff had the RFC
[Tr. 25].
At step four, the ALJ found plaintiff was unable to perform any past relevant work. [Tr. 31]. At step five, after considering plaintiff's age, education, work experience and RFC, the ALJ found that jobs existed in significant numbers in the national economy that plaintiff could perform. [Tr. 31-32].
The ALJ concluded that plaintiff had not been under a disability from April 11, 2013, the alleged onset date of disability, through April 12, 2016, the date of the ALJ's decision.
Plaintiff first argues that the RFC assessment was not supported by substantial evidence and was legally erroneous. An ALJ has the responsibility to determine a claimant's RFC based on all the evidence of record. 20 C.F.R. §§404.1545(a)(1), 416.945(a)(1). The RFC is an assessment of "the most [the disability claimant] can still do despite [his or her] limitations." 20 C.F.R. §404.1545(a)(1), 416.945(a)(1). Although "[t]he RFC determination is reserved for the commissioner . . . an ALJ's RFC assessment is a medical determination that must be based on probative evidence of record. . . . Accordingly, an ALJ may not substitute his own judgment for competent medical opinion."
Plaintiff argues that "the ALJ rejected all of the medical opinions of record and relied solely on her lay interpretation of bare medical findings to make the physical residual functional capacity determination. [The ALJ's] lay determination did not constitute substantial evidence, and remand is warranted for proper consideration." [Doc. #14-1 at 21]. The Court agrees.
The administrative record in this case contains numerous detailed treatment records, medical opinions from treating and examining sources that relate the medical evidence to what plaintiff can and cannot do functionally. Plaintiff accurately points out that there are numerous disability assessments supported by functional limitation by her treating providers in the record and there is no dispute that plaintiff was disabled from returning to her work as a CNA. [Tr. 31]. It is also undisputed that plaintiff did not work after the April 11, 2013 motor vehicle accident, that the injuries sustained were due to the accident, that conservative treatment did not relieve her symptoms and that she underwent three surgeries.
Plaintiff began treatment with orthopedist Dr. A. Marc Tetro in October 2013, for injuries sustained in the motor vehicle accident resulting in bilateral cubital tunnel syndrome, bilateral carpal tunnel syndrome and bilateral hand diffuse flexor tenosynovitis. [Tr. 276]. During the treatment relationship, Dr. Tetro found that plaintiff "was unable to work and would be considered disabled with regards to the usual occupation." [Tr. 277 (October 16, 2013); Tr. 271 (November 27, 2013); Tr. 424 (January 10, 2014); Tr. 427 (January 17, 2014); Tr. 432 (February 28, 2014); Tr. 437 (March 18, 2014). In October 2014, Dr. A. Marc Tetro performed bilateral carpal tunnel release surgery after conservative care failed to provide relief of symptoms or improvement. [Tr. 443-46]. By December 2014, Dr. Tetro found that plaintiff had no disability "with regards to her bilateral hands/wrists; however patient may have restrictions for other motor vehicle related body part injuries by other physicians." [Tr. 458]. The ALJ gave some weight to Dr. Tetro's opinion that plaintiff was disabled "from her work as a certified nurse's assistant . . . However, it is vague and addressed the ultimate issue of disability, which is reserved for the Commissioner. In addition, Dr. Tetro's notes show that the claimant did well after carpal tunnel release surgery." [Tr. 30].
To Dr. Pratibha Bansal's November 20, 2013 opinion that plaintiff had a 75% temporary impairment, the ALJ assigned "little weight because it was stated in connection with different standards and does not provide a function-by-function assessment." [Tr. 30, 565].
To Consultative Examiner Dr. John Schwab's January 14, 2014, opinion, the ALJ assigned "little weight as it was based on a one-time evaluation that occurred before the claimant underwent fusion surgery and it does not account for the full extent of the claimant's injuries." [Tr. 30, 385-88].
Of significance is the opinion of plaintiff's spinal surgeon, Dr. CameronHuckell. Plaintiff's spinal injuries were initially treated by Dr. Mikhail Strut shortly after the motor vehicle accident in April 2013. [Tr. 251-63]. Throughout the treating relationship, Dr. Strut opined that plaintiff had a "total temporary disability for now" and was unable to return to her job. [Tr. 264 (April 22, 2013); Tr. 256 (May 6, 2013); Tr. 258 (June 3, 2013); Tr. 261 (July 1, 2013); Tr. 263, 265 (August 20, 2013)]. Her care was transferred to orthopedist Dr. Huckell in September 2013. [Tr. 280-83]. Dr. Huckell's treatment notes include detailed notations of physical examination of plaintiff's musckuloskeletal system (including gait, physical inspection, range of motion, strength, straight leg raises), neurologic system (including deep tendon reflexes, sensation and pathologic reflexes), and her psychiatric status. [Tr. 282, 377, 440, 449, 462, 467, 472, 477, 482, 488, 493, 755]. During this period, Dr. Huckell also opined that plaintiff was temporarily disabled as a result of the accident. [Tr. 283 (September 20, 2013); Tr. 378 (December 19, 2013)]. Beginning in April 2014, and again in March 24, 2015, Dr. Huckell opined that plaintiff had a "permanent partial disability at this time as a result of the motor vehicle accident dated 4/11/13. We recommend an FCE [functional capacity evaluation] for specific work restrictions." [Tr. 441 (April 24, 2014), Tr. 450 (October 8, 2014), Tr. 463 (December 22, 2014), Tr. 468 (January 22, 2015), Tr. 473 (March 24, 2015), Tr. 478 (June 22, 2015)]. In treatment notes dated March 24, 2015, Dr. Huckell noted that plaintiff was "still unable to perform her job as a certified nursing assistant and in the long run I think she should look for a less strenuous type of work." [Tr. 471]. In June 2015, the doctor noted that despite epidural injections, physical therapy, chiropractic therapy and pain management, plaintiff's "symptoms continued to progress" and she was "considering her surgical options." [Tr. 478]. On July 30, 2015, Dr. Huckell noted that plaintiff reported "significant lumbar and thoracic pain." [Tr. 481]. "[S]he has failed extensive conservative care. She now has intractable and intolerable pain and I consider her to be a reasonable candidate for anterior lumbar discectomy, partial corpectomies and fusion using cage, plate and BMP at L5-S1."
Beginning in April 2014, Dr. Huckell recommended a Functional Capacity Assessment for "specific work restrictions." [Tr. 441 (April 24, 2014); Tr. 450 (October 18, 2014); Tr. 463 (December 22, 2014); Tr. 468 (January 22, 2015); Tr. 473 (March 24, 2015); Tr. 478 (June 22, 2015)]. Nevertheless, the ALJ assigned "little weight" to Dr. Huckell's opinion, explaining that
[Tr. 30].
Thus, after assessing all of the medical evidence from plaintiff's treating physicians and assigning their opinions "some" or "little weight" the ALJ considered the vocational expert's reports.
On April 29, 2015, Alan C. Winship, MS Ed., CRC, D-ABVE, CLCP, interviewed plaintiff, reviewed her medical records, and performed vocational testing. [Tr. 210-23]. An Addendum Report was prepared on December 2, 2015, after plaintiff underwent the lumbar discectomy L5-S1, partial corpectomy and fusion using cage, plate and BMP on September 15, 2015, that included a review of additional and post-surgical treatment records from Dr. Huckell. [Tr. 224-26]. Windship opined that "due to the injury and subsequent impairment of Ms. Sherry[] cervical, thoracic and lumbar spine, bilateral carpal tunnel syndrome and bilateral cubital tunnel syndrome that Ms. Sherry[] will have limited success in attempting to return to work without the assistance of a Certified Rehabilitation Counselor." [Tr. 225-26]. He indicated that Ms. Sherry had not been "released to return to work
The ALJ also assigned "little weight" to Mr. Winship's opinion, stating that while she agreed
[Tr. 30-31].
However, the ALJ failed to identify any inconsistent medical evidence to support her findings.
Mr. Winship's reports reflect a thorough examination of Ms. Sherry's residual employability, based not only on the detailed review of her medical records and vocational capacity during the relevant time period, but also on direct personal contact with plaintiff during the interview process. [Tr. 210-23; 224-26]. At the time of both reports, Ms. Sherry had not been cleared to return to work in any form by her surgeon Dr. Huckell. The reports present a detailed explanation of the evidence supporting Mr. Winship's opinion that, given plaintiff's limited residual functional capacity due to the injuries sustained in the accident, she would be unable to perform not just her past relevant work, but "remain[ed] totally disabled in the present time while she recovers from the L5-S1 fusion that she underwent on September 16, 2015." [Tr. 226]. He added that plaintiff would "have limited success in attempting to return to work without the assistance of a Certified Rehabilitation Counselor." [Tr. 225-26]. He further stated that "[i]t remains my professional opinion that once released to participate in vocational rehabilitation services Ms. Sherry[] will require two to three years to complete a program to provide her with job skills consistent with her residual functional capacity" and "[u]pon returning to work, it would be beneficial for Ms. Sherry[] to start on a part-time capacity for approximately 20 hours per week and gradually increase her hours, under the supervision of Dr. Huckell and a rehabilitation counselor, to full-time assuming she finds that she is capable of doing so." [Tr. 226].
SSR 06-03p, 2006 WL 2329939, at *6;
After discounting
Accordingly, the Court finds that the ALJ's conclusion that plaintiff can perform light work with limitations is not supported by substantial evidence and additional administrative proceedings are required. This case is remanded for proper consideration of the RFC in accordance with the medical evidence, treating source opinions, functional assessment and regulations. On remand, the ALJ should develop the record as necessary to obtain opinions as to plaintiff's functional limitations from treating and/or examining sources and thoroughly explain her findings in accordance with the regulations.
For the reasons stated, plaintiff's Motion for Judgment on the Pleadings
In light of the Court's findings above, it need not reach the merits of plaintiff's other arguments. Therefore, this matter is remanded to the Commissioner for further administrative proceedings consistent with this opinion. On remand, the Commissioner shall address the other claims of error not discussed herein.
This is not a Recommended Ruling. The parties consented to proceed before a United States Magistrate Judge [doc. #16] on September 25, 2018, with appeal to the Court of Appeals. Fed. R. Civ. P. 73(b)-(c).
SO, ORDERED.