MATTHEW W. BRANN, District Judge.
The above-captioned action is one seeking review of a decision of the Acting Commissioner of Social Security ("Commissioner")
SSI is a federal income supplement program funded by general tax revenues (not social security taxes). It is designed to help aged, blind or other disabled individuals who have little or no income. Insured status is irrelevant in determining a claimant's eligibility for supplemental security income benefits.
Snyder applied protectively for SSI on November 7, 2012, alleging disability beginning January 1, 2010. (Tr. 102).
Snyder filed a complaint in this Court on August 12, 2016. (Doc. 1). The Commissioner filed an answer on October 13, 2016. (Doc. 8). After supporting and opposing briefs were submitted (Docs. 10-12), the appeal
Snyder was born on July 9, 1979, has a limited education, and is able to communicate in English. (Tr. 109). She has not engaged in substantial gainful activity since the alleged amended onset date of December 19, 2012. (Tr. 104). Snyder has the following severe impairments: panic disorder, multiple sclerosis, tremor and obesity. (
When considering a social security appeal, the Court has plenary review of all legal issues decided by the Commissioner.
The plaintiff must establish that there is some "medically determinable basis for an impairment that prevents him from engaging in any substantial gainful activity for a statutory twelve-month period."
Snyder appeals the ALJ's determination on three grounds: (1) substantial evidence does not support the ALJ's residual functional capacity ("RFC") finding; (2) the ALJ did not properly weigh the medical opinion evidence; and (3) substantial evidence does not support the ALJ's credibility assessment.
The ALJ went through each step of the sequential evaluation process and (1) found that Snyder had not engaged in substantial gainful activity since December 19, 2012, the alleged amended onset date; (2) found that Snyder had the severe impairments of panic disorder, multiple sclerosis, tremor and obesity; (3) found that Snyder's impairments did not meet or equal a listed impairment; and (4) concluded that while Snyder does not have past relevant work, she could perform light work with several limitations. (Tr. 102-11). Specifically, in addressing Snyder's RFC, the ALJ found that:
(Tr. 106).
The Court will initially address Snyder's first and second arguments together because they are interrelated. The ALJ must consider all of the relevant evidence and give a clear explanation to support his findings when determining the RFC.
The record in this case contains three medical opinions, the first from Mahmood Nasir, M.D. who performed a consultative exam on April 15, 2013 (Tr. 452-60); the second from a psychological consultative examination with Michael Keil, Ph.D. on April 29, 2013 (Tr. 462-72); and finally one from Snyder's family practitioner, David Wampler, M.D. on September 15, 2014 (Tr. 562-67). In his decision, the ALJ accorded little weight to the opinion of Dr. Nasir, partial weight to Dr. Keil's opinion, and limited weight to Dr. Wampler's opinion. (Tr. 108-09). The significance of this weighing of the medical opinions is that the ALJ made a determination of Snyder's RFC without relying on the medical opinions of any of the medical doctors who provided a medical opinion.
Specifically, Dr. Nasir assessed Snyder capable of lifting and carrying up to 10 pounds occasionally, able to sit, stand and walk no more than one hour each in an 8 hour workday, occasional reaching, handling, fingering, feeling, pushing/pulling, climbing stairs, stooping, kneeling, crouching and crawling, and no climbing ladders/scaffolds and balancing. (Tr. 108, 455-60). Dr. Nasir also opined that Snyder should avoid exposure to unprotected heights, moving mechanical parts, extreme cold and heat, and capable of no more than occasionally operating a motor vehicle, and occasional exposure to humidity and wetness, dust, odors, fumes, pulmonary irritants, and vibrations. (Tr. 108, 459). Dr. Nasir also noted that "[a]ctivities result in pain in head, neck, back and also has numbness in hand." (Tr. 108, 460).
Limited weight was accorded to this medical opinion by the ALJ because he found that the restrictions were overstated in comparison to the limited examination findings and treatment required by Snyder, including her treating neurologist. (Tr. 109). Additionally, the ALJ reasoned that Dr. Nasir appeared to rely on Snyder's complaints rather than his examination findings in making the above restrictions. (
Next, the ALJ gave partial weight to the opinion of Dr. Keil. (Tr. 109). Dr. Keil opined that Snyder had mild and moderate restrictions in performing work-related tasks, and rated her with a global assessment of functioning ("GAF") of 40-50. (Tr. 109, 465). Dr. Keil further opined that Snyder "would be expected to be present variably and produce interference in most work settings in the context of her multiple sclerosis, as is found with most individuals with diagnosis of MS. Her panic disorder alone would be expected to produce significant interference with instrumental activities, including vocational activities. . . ." (Tr. 465). In assigning this opinion only partial weight, the ALJ reasoned that the GAF score is not supported by the mental status examination findings, the claimant's limited need for mental health treatment and the claimant's admission that she tries to keep busy most of the time. (Tr. 109).
Finally, the ALJ accorded limited weight to Dr. Wampler, Snyder's family practitioner. Dr. Wampler opined that Snyder was incapable of even "low stress" jobs, expected to be absent from work more than four days per month, was unable to stand/walk or sit longer than 2 hours each in an 8 hour workday, and has significant and persistent disorganization of motor function in two extremities and significant reproducible fatigue with muscle weakness on repetitive activity. (Tr. 109, 564-67). Moreover, Dr. Wampler opined that Snyder was capable of lifting and carrying less than 10 pounds occasionally, and never lifting or carrying 10 pounds or greater. (Tr. 566).
In assigning limited weight to this opinion, the ALJ stated that Dr. Wampler's treatment and examination notes do not support his conclusions and restrictions and that Dr. Wampler's conclusions are "clearly overstated." (Tr. 109). The ALJ reasoned that Snyder was treated conservatively, that she declined referral to physical therapy, reported exercising regularly, presented with appropriate musculoskeletal range of motion and strengths, had normal station and gait, and normal judgment and orientation. (Tr. 109). The ALJ provides that the above frequency and degree of treatment is not what "one would expect from an individual with the alleged symptoms reported. . . ." (Tr. 108).
I find that substantial evidence does not support the ALJ's ultimate determination. The ALJ's decision to discredit, at least partially, every opinion of every medical doctor's RFC assessment of Snyder left the ALJ without a single medical opinion to rely upon in reaching a RFC determination. "Rarely can a decision be made regarding a claimant's residual functional capacity without an assessment from a physician regarding the functional abilities of the claimant."
Here, not one medical opinion proffers that Snyder is capable of light work's physical exertion requirements. 20 C.F.R. § 404.1567(b) states that light work "involves lifting no more than 20 pounds at a time with frequent lifting or carrying of objects weighing up to 10 pounds." Dr. Nasir assessed Snyder capable of lifting and carrying up to 10 pounds occasionally while Dr. Wampler similarly opined Snyder's limitation to be less than 10 pounds occasionally. (Tr. 455, 566). No doctor opined that Snyder is capable of lifting up to 20 pounds at a time or frequently lifting or carrying weight up to 10 pounds. Similarly, both Dr. Nasir and Dr. Wampler opined that Snyder is unable to stand/walk more than 1 or 2 hours, respectively, in an 8 hour work day. (Tr. 456, 565). The ALJ failed to point to any specific medical evidence that would support a contrary opinion on Snyder's standing/walking capabilities, and as a result, it appears that the ALJ was forced to reach a RFC determination without the benefit of any medical opinion. Accordingly, the ALJ's conclusion is not supported by substantial evidence.
I also find that the ALJ impermissibly engaged in a lay interpretation of the medical evidence in stating that the frequency and degree of Snyder's treatment is not what "one would expect from an individual with the alleged symptoms reported . . ." despite the contrary medical opinions offered by Doctors Nasir, Keil, and Wampler. As suggested by Plaintiff, if the ALJ believed that all of the medical opinions were inadequate or inconsistent, rather than engage in his own lay analysis, the ALJ should have requested a clarification as to the limitations opined by the medical doctors, rather than engaging in speculation or stating his own lay opinion of the medical evidence.
Therefore, remand on this basis is necessary. I decline to address Snyder's other allegations of error, as remand may produce a different result on this claim, making discussion of them moot.
Based upon a review of the record, it is determined that the Commissioner's decision to deny Snyder's SSI claim under Title XVI is not supported by substantial evidence. Therefore, pursuant to 42 U.S.C. § 405(g), this Court will vacate the Commissioner of Social Security's decision and remand this case for further proceedings. An appropriate Order follows.