ANN AIKEN, District Judge.
Plaintiff Shawn Cleveland Smith brings this action for judicial review of a final decision for the Commissioner of Social Security denying his application for Supplemental Security Income ("SSI") benefits under Title XVI of the Social Security Act ("Act"). This court has jurisdiction pursuant to 42 U.S.C. § 405(g) and 42 U.S.C. § 1383(c) (3). For the reasons below, this case is remanded for further proceedings.
On September 15, 2010, plaintiff filed his application for SSI. Tr. 258. After the application was denied initially and upon reconsideration, plaintiff timely requested a hearing before an administrative law judge ("ALJ"). Tr. 145. On May 15, 2013, a hearing was held before the Honorable John T. Molleur; plaintiff was represented by counsel and testified therein. The ALJ also heard testimony from a vocational expert ("VE"). Tr. 62-96. The ALJ issued a decision on June 4, 2013 finding plaintiff not disabled within the meaning of the Act. Tr. 19-33. After the Appeals Council declined review, plaintiff filed a complaint in this court. Tr. 1-3.
Born on November 1, 1969, plaintiff was 29 years old on the alleged onset date of disability and 43 years old at the time of the hearing. Tr. 62, 277. Plaintiff dropped out of school in the eighth or ninth grade, but eventually earned a GED. Tr. 68. He has a limited work history, last working for three weeks in 2003 as a sorter at a recycling center. Tr. 282. Plaintiff indicated he stopped working to enter a drug treatment program. Tr. 281. Plaintiff alleges disability beginning on February 15, 1999 due to left arm paralysis, anxiety, depression, and cervical spine problems.
The court must affirm the Commissioner's decision if it is based on proper legal standards and the findings are supported by substantial evidence in the record.
The initial burden of proof rests upon the plaintiff to establish disability.
The Commissioner has established a five-step sequential process for determining whether a person is disabled.
At step two, the Commissioner determines whether the plaintiff has a "medically severe impairment or combination of impairments."
At step three, the Commissioner determines whether the impairment meets or equals "one of a number of listed impairments that . . . are so severe as to preclude substantial gainful activity."
At step four, the Commissioner determines whether the plaintiff can still perform "past relevant work." 20 C.F.R. § 416.920(e). If plaintiff can work, he is not disabled. If he cannot perform past relevant work, the burden shifts to the Commissioner. At step five, the Commissioner must establish that the plaintiff can perform other work that exists in the national economy.
At step one of the five step sequential evaluation process, the ALJ found plaintiff had not engaged in substantial gainful activity since the application date. Tr. 21. At step two, the ALJ determined that plaintiff has the following severe impairments: "degenerative disc disease of the cervical spine status post discectomy, Hepatitis C, bipolar disorder, and substance abuse."
Because plaintiff did not establish disability at step three, the ALJ next evaluated how plaintiff's impairment affected his ability to work. The ALJ resolved that plaintiff had the residual functional capacity ("RFC") to perform light work,
Tr. 25. At step four, the ALJ found plaintiff had no past relevant work. Tr. 31. At step five, the ALJ determined that jobs existed in significant numbers in the national and local economy which plaintiff could perform despite his impairments. Tr. 32-33. Accordingly, the ALJ concluded plaintiff was not disabled within the meaning of the Act. Tr. 33.
Plaintiff alleges that the ALJ erred by: (1) failing to find plaintiff meets Listing § 1.04A; (2) erroneously finding plaintiff's symptom testimony not credible; (3) omitting from the RFC a restriction regarding interaction with authority figures; and (4) improperly evaluating plaintiff's left arm limitations. Pl.'s Br. 5-6.
Plaintiff argues that at step three of the sequential evaluation process, the ALJ erred by failing to find plaintiff's impairments met or equaled Listing § 1.04A, which addresses disorders of the spine with evidence of nerve root compression.
20 C.F.R. Part 404, Subpt. P, App. 1, § 1.04A. The instant case does not involve the lower back; accordingly, in order to meet the listing, plaintiff must show: (1) neuro-anatomic distribution of pain; (2) limitation of the motion of the spine; and (3) motor loss with sensory or reflex loss.
The parties dispute whether Listing § 1.04A further requires that (4) the relevant findings be present in a single examination, and (5) a threshold severity level be met. Plaintiff argues Listing § 1.04A does not require each element to be present in a single examination. Pl.'s Br. 7; Pl.'s Reply 2-3;
Defendant contends plaintiff does not meet the listing because the relevant findings were "spread over four years." Def.'s Br. 6. In support, defendant notes the Commissioner issued an Acquiescence Ruling ("AR") following the
On September 23, 2015, the SSA issued an AR pertaining to
As such, it is clear that SSA policy requires the severity and durational thresholds be met in order to meet Listing § 1.04A. Like Social Security Rulings, AR's are "binding on all components of the SSA." 20 C.F.R. § 402.35(b). While SSA policy and rulings do not carry the full force of law, the Supreme Court has held that an agency's interpretation of its own regulations is entitled to substantial deference.
The Commissioner also contends Listing § 1.04A is subject to additional severity requirements pursuant to the statutory introduction section for the musculoskeletal system.
However, other courts have chosen not to impose the ambulatory or fine and gross movement provisions mentioned in the introduction to the musculoskeletal system regulations.
First, although the introduction defines the terms "ambulate effectively" and "perform fine and gross movements effectively," neither the introduction to § 1.00 nor the text of Listing § 1.04A state that the terms are necessarily requisites for the listings that follow.
Next, as a matter of construction, the text of the regulations would include redundant language if the introductory section of § 1.00 established additional requirements regarding ambulation or fine/gross movements. Listing § 1.02B, for example, explicitly requires a claimant to establish a condition which results in "inability to perform fine and gross movements effectively, as defined in 1.00B2c." 20 C.F.R., Pt. 404, Subpt. P, App. 1, § 1.02A, B. Similarly, Listings §§ 1.02A, 1.03, and 1.04C require a claimant establish a condition which results in "inability to ambulate effectively, as defined in 1.00B2b."
Further, the ALJ himself did not indicate that § 1.00B2 applied to § 1.04A. The ALJ explains, "[i]n order to meet or equal § 1.04, the claimant must produce evidence . . of nerve root compression, limited range of motion, or motor loss accompanied by sensory or reflex loss and positive straight leg raising." Tr. 22. The ALJ also notes, "inability to ambulate effectively[] as defined in § 1.00B2b" is a requirement to meet "a listing" under § 1.04, although the ALJ omitted a portion of the statute, as § 1.00B2a explains functional loss may be due to inability to effectively ambulate or inability to effectively perform fine and gross movements.
The ALJ's perfunctory analysis of Listing § 1.04A does not address any requirement arising under § 1.00B2, nor does the ALJ indicate explicitly or implicitly that plaintiff did not meet the listing because he failed to establish a requirement under §§ 1.00B2b or c. Tr. 22-23. Rather, the ALJ simply noted, "the finding that the claimant does not meet or equal listing § 1.04A or any other listing is supported by the state agency medical consultants' opinions." Tr. 22. Accordingly, even assuming Listing § 1.04A required a showing of inability to effectively ambulate or perform fine/gross movements, the ALJ did not invoke that rationale in finding the listing was not met.
Based on the foregoing, the court finds that in order to meet Listing § 1.04A, plaintiff must establish (1) evidence of nerve root compression characterized by neuro-anatomic distribution of pain; as well as the following severity requirements: (2) limitations of motion of the spine; and (3) motor loss ("atrophy with associated muscle weakness or muscle weakness") accompanied by sensory or reflex loss. 20 C.F.R. Pt. 404, Subpt. P, App. 1, § 1.04A. Further, the findings must be present simultaneously, as explained in AR 15-1(4). Additionally, plaintiff must establish the impairment(s) satisfies the 12-month durational requirement. 20 C.F.R. §§ 404.1525(c)(4), 416.925(c)(4); AR 15-1(4), at *5.
In response, defendant argues plaintiff failed to show that the requisite findings manifested simultaneously. Def.'s Br. 6-7. Plaintiff responds that all the relevant findings were reported during an examination by John Ellison, M.D. on November 20, 2010. Pl.'s Reply 3-4. Dr. Ellison noted an MRI from December 2009 showed "C6-7 herniated disk with compromise on the left," satisfying the threshold inquiry. Tr. 397. The doctor also noted complaints of neck and left arm pain, which satisfies the first prong of Listing § 1.04A.
On the neurologic exam, Dr. Ellison found plaintiff's coordination was "slightly impaired in the left hand." Tr. 399. The doctor also reported "weakness and atrophy left triceps 4/5, extension left wrist and fingers 4/5, possible mild atrophy left pectoral[.]"
Other findings consistent with Dr. Ellison's are found elsewhere in the record. Robert Buza, M.D., noted neck and left arm pain along with numbness, tingling, and weakness, although the doctor also reported "good motion of the cervical spine." Tr. 684-85. On April 9, 2013, Kenneth M. Little, M.D. found foraminal stenosis at C6-7, 4/5 left biceps and triceps strength, and deltoid and triceps atrophy. Tr. 593. Although Dr. Little did not report ROM findings, he noted plaintiff's "debilitating" pain, neurologic defecits, and muscle atrophy, prompting the doctor to recommend surgical intervention.
Although the ALJ summarized the November 20, 2011 examination by Dr. Ellison, the ALJ failed to assess whether Dr. Ellison's findings met or equaled Listing § 1.04A. Tr. 22-23, 27-28. Instead, the ALJ noted that the state agency medical consultants determined plaintiff did not meet or equal Listing § 1.04A, and adopted their findings. Tr. 22-23. Despite the evidence that Dr. Ellison found all of the requisites satisfied on November 20, 2011, the ALJ also explained, erroneously, that plaintiff failed to submit evidence to refute the opinions of the state agency consultants. Tr. 23.
As such, the ALJ erred by failing to review plaintiff's particular symptoms as they relate to Listing § 1.04A. At step three, the ALJ is compelled to "review the symptoms . . . and make specific findings essential to the conclusion."
Plaintiff argues the ALJ erroneously discredited his impairment allegations. The Ninth Circuit relies on a two-step process for evaluating the credibility of a claimant's testimony about the severity and limiting effect of the stated symptoms.
The ALJ found "inconsistencies in the record" that diminished plaintiff's credibility. Tr. 29. Specifically, the ALJ explained plaintiff reported last working for pay in 2005, but other evidence of record suggested he last worked in 2004 repairing windshields, and was subsequently "doing lots of labor `under the table.'"
The ALJ also impugned plaintiff's credibility because his "subjective complaints and alleged limitations are not consistent with the objective examination reports." Tr. 29. The ALJ explained, "he alleged a great deal of atrophy in his left upper extremity, but it is his non-dominant extremity and the physical examination showed only minimal differences in size." Tr. 29-30. In his decision, the ALJ does not provide citations to the allegedly inconsistent objective reports. As discussed above, plaintiff's doctors noted muscle atrophy in his left extremity on more than one occasion. For example, Dr. Little reported "left deltoid and triceps atrophy" on April 9, 2013, and listed "presence of muscle atrophy" as a factor weighing in favor of surgical intervention. Tr. 593. At least some atrophy was present years earlier, as Dr. Ellison found left triceps atrophy and "possible atrophy left pectoral" in November 2010. Tr. 399.
The Ninth Circuit has repeatedly held, "a claimant is not required to show that her impairment could reasonably be expected to cause the severity of symptoms she alleged; she need only show that it could reasonably have caused some degree of the symptoms."
The Commissioner argues plaintiff alleged that his left arm was paralyzed, which contradicted exam findings showing diminished strength and sensation. Def.'s Br. 14. Indeed, in his original disability report, plaintiff listed "left arm paralysis, anxiety, depression, cervical spine" as limiting his ability to work. Tr. 281. Later, in his appeal worksheet, plaintiff indicated that since his original report, his left arm paralysis had worsened. Tr. 308. During the hearing, plaintiff explained he had "a bone deformity pushing up against my spinal cord, which was causing partial paralysis throughout my arms, especially my left arm." Tr. 72. Nevertheless, the Commissioner's argument fails for two reasons.
First, the ALJ did not indicate plaintiff's credibility was inconsistent based on allegations of paralysis. Once again, the court may not affirm the decision based on grounds the ALJ did not invoke.
The ALJ further discredited plaintiff because "the consultative examiner gave [plaintiff] a high GAF score, and [plaintiff's] mental status examinations during the relevant period appear to be fairly good except for an episode when he was on suicide watch. . . ." Tr. 30. In support of the ALJ's finding, the Commissioner notes plaintiff "complained of disabling depression and anxiety . . [although] the mental health evidence was relatively benign." Def.'s Br. 14. However, the ALJ's rationale is internally inconsistent. During the hearing, plaintiff explained his mental health history, including periods of suicidal ideation. Tr. 83-85. He further explained that he no longer has suicidal ideation, and is now "optimistic about my life." Tr. 85. The ALJ provided no specific reasons to question the veracity of plaintiff's claims of feeling depressed or worthless in the past. To the contrary, the ALJ acknowledged plaintiff had been on "suicide watch" at least once, and also found he suffers from the severe impairment of bipolar disorder at step two of the sequential evaluation process. Tr. 21. Bipolar disorder, which was once called "manic depression," is generally characterized by cycling symptoms of depression and mania.
Finally, the ALJ invoked plaintiff's substance abuse as a reason to impugn his credibility. Plaintiff argues the mere assertion of use/abuse of substances does not fall within the scope of acceptable credibility evaluation. Def.'s Br. 16 (quoting
Based on the foregoing, none of the rationales provided by the ALJ meet the legal threshold of specific, clear and convincing. The ALJ's credibility finding is, therefore, erroneous.
Plaintiff alleges the ALJ failed to adequately account for certain social functioning limitations in formulating plaintiff's RFC. Specifically, plaintiff contends the ALJ erred by not including any limitation on interacting with supervisors, despite the opinions of state agency non-examining physicians Bill Hennings, Ph.D. and Joshua Boyd, Ph.D. Pl.'s Br. 12. Drs. Hennings and Boyd opined, in part, that plaintiff "is intimidated by authority figures, and so would benefit from an understanding supervisor." Tr. 113, 131.
Plaintiff argues that because the ALJ accorded the opinions of Drs. Hennings and Boyd "substantial weight," and in fact found "claimant is more limited in social functioning with the general public and in the ability to handle stress than the state agency consultants opined," it was error to omit a limitation regarding interaction with authority figures in the workplace. Pl.'s Br. 12. In support, plaintiff cites Social Security Ruling ("SSR") 85-15, which states "[a]ny impairment-related limitations created by an individual's response to demands of work . . . must be reflected in the RFC assessment." SSR 85-15,
Defendant argues the ALJ was not compelled to include "an understanding supervisor" in the RFC formulation because rather than characterize it as a requirement or limitation, the doctors explained only that plaintiff "would benefit from an understanding supervisor." Tr. 113, 131; Def.'s Br. 10. The Commissioner's argument is well taken, as a number of courts have found no error where an ALJ omits from the RFC recommendations that are not stated as imperatives.
However, this case is distinguishable. In addition to suggesting plaintiff would benefit from an understanding supervisor, both doctors' reports indicated plaintiff was "moderately limited" in his "ability to accept instructions and respond appropriately to criticism from supervisors." Tr. 113, 131. In contrast to the statement "would benefit," "moderately limited" is unequivocally a limitation. As such, the ALJ should have either included the limitation in the RFC, or provided a legally sufficient rationale to reject the opinions. The ALJ did neither. Moreover, as the ALJ indicated plaintiff's social functioning and ability to handle stress were more severely limited than as opined by Drs. Hennings and Boyd, the error is all the more glaring. Although the Commissioner asserts plaintiff "has not accurately characterized the DDS psycchologist opinions," the Commissioner fails to acknowledge that the doctors included the aforementioned moderate limitation.
Additionally, the "moderate limitation" in dealing with authority figures was arguably supported by the opinion of Kay Dieter, M.D. Dr. Dieter opined, in part, that plaintiff's "ability to interact with co-workers, supervisors, and the public . . . may be somewhat limited." Tr. 395. The ALJ generally accorded Dr. Dieter's opinions "substantial weight," however, he accorded only "limited weight" to her opinion regarding plaintiff's ability to interact with supervisors. Tr. 30. In support, the ALJ indicated Dr. Dieter's opinion was "not consistent with the record as a whole."
Plaintiff argues the ALJ failed to adequately account for limitations relative to plaintiff's left upper extremity. Plaintiff contends the ALJ provided internally inconsistent findings in assessing the opinions of state agency medical experts Sharon Eder, M.D., and Neal Berner, M.D. Pl.'s Br. 13-14. Drs. Eder and Berner reviewed the record and determined plaintiff was limited to light work with occasional pushing and pulling with the left upper extremity. Tr. 111, 129. They further found plaintiff limited to "occasional fine and gross manipulative" use of the left upper extremity.
Plaintiff contends frequent reaching, handling, and fingering is inherently foreclosed by the inability to grip, twist, lift, or carry, because handling and fingering "largely overlaps" with gripping, lifting, and carrying. Pl.'s Br. 14. Plaintiff argues that because handling involves "seizing, holding, grasping, turning" and fingering involves "picking, pinching," he cannot "grip, lift or carry" with his upper left extremity.
The ALJ and VE are the adjudicators best situated to identify and resolve any conflict regarding plaintiff's upper extremity limitations. As such, if relevant to the sequential evaluation process, the ALJ should revisit this issue upon remand.
The court has discretion to reverse the Commissioner's final decision and remand for further proceedings or to award benefits.
Here, it is clear the ALJ failed to properly evaluate whether plaintiff met or equaled Listing § 1.04A. Further, the ALJ improperly discredited plaintiff's credibility, which impacted steps three, four, and five of the sequential evaluation process. Nonetheless, outstanding issues necessitate further proceedings. Importantly, although plaintiff established that all of the severity requisites of Listing § 1.04A were met during the November 20, 2010 visit to Dr. Ellison, it remains unclear if and when plaintiff met the Listing's durational requirement. For example, although Dr. Buza reported some of the criteria for Listing § 1.04A in November 2009, the required ROM findings were absent.
Thus, the record requires further development in order to establish if and when plaintiff met the 12-month durational requirement of Listing § 1.04A. In the event the ALJ finds plaintiff does not meet the 12-month durational requirement, the ALJ must then determine if, based on all of plaintiff's symptoms, plaintiff equals Listing § 1.04A. Further, on remand, the ALJ must not rely upon the erroneous credibility findings set forth in the adverse decision of June 4, 2013 when re-evaluating the medical and testimonial evidence. Finally, the plaintiff may proffer additional evidence of his impairment(s) for consideration at the next hearing. Finally, if necessary, the ALJ must resolve the extent of plaintiff's upper extremity limitations and craft a new RFC accordingly.
For the foregoing reasons, the Commissioner's decision is REVERSED and this case is REMANDED for additional proceedings consistent with this opinion.
IT IS SO ORDERED.