KAROLINE MEHALCHICK, Magistrate Judge.
This is an action brought under Section 1383(c) of the Social Security Act and 42 U.S.C. § 405(g), seeking judicial review of the final decision of the Deputy Commissioner for Operations of the Social Security Administration (hereinafter, "the Deputy Commissioner") denying Plaintiff Morris Forster Minter's ("Minter") claims for supplemental security income ("SSI") under Title XVI of the Social Security Act. (Doc. 1). The matter has been referred to the undersigned United States Magistrate Judge to prepare a report and recommendation pursuant to the provisions of 28 U.S.C. § 636(b) and Rule 72(b) of the Federal Rules of Civil Procedure. For the reasons expressed herein, and upon detailed consideration of the arguments raised by the parties in their respective briefs, it is respectfully recommended that the Deputy Commissioner's decision be
On September 5, 2013, Minter filed an application for Title XVI benefits, respectively. (Tr. 101; Doc. 10-3 p. 5). In this application, Minter claimed disability beginning September 1, 2010. Id. The Social Security Administration initially denied Minter's claim on January 10, 2014. Id. Minter filed a request for a hearing before an Administrative Law Judge ("ALJ") on February 24, 2014. Id. The hearing was held on August 30, 2015, before ALJ Scott M. Staller. (Tr. 188-192; Doc. 10-5 p. 20-24). Also attending the hearing was vocational expert ("VE") Andrew Caporale. (Tr. 101; Doc. 10-3 p. 5).
In a written opinion dated October 15, 2015, the ALJ determined that Minter was not disabled and therefore not entitled to the benefits sought. (Tr. 110; Doc. 10-3 p. 14). Minter appealed the decision of the ALJ to the Appeals Council, who, on March 8, 2017, denied Minter's request for review. (Tr. 1; Doc. 10-2 p. 2). On April 28, 2017, Minter filed the instant action. (Doc. 1). The Deputy Commissioner responded on July 3, 2017, providing the requisite transcripts from the disability proceedings on August 10, 2015. (Doc. 9; Doc. 10-3). The parties then filed their respective briefs (Doc. 11; Doc. 12; Doc. 13), with Minter alleging that two errors warranted reversal or remand. (Doc. 11 p. 2). On July 29, 2015, Minter amended his alleged onset date of disability to July 30, 2014. (Tr. 285; Doc. 10-7 p. 54).
In his disability benefits application, Minter listed the following conditions as impairments limiting his ability to work: post-traumatic stress disorder, attention deficit disorder, carpal tunnel, tennis elbow, arthritis, depression, anxiety, bipolar disorder, shoulder, neck, and ankle pain, cervical disc disease, and seizures. (Tr. 262; Doc. 10-7 p. 31).
The earliest medical record with which the Court is provided is from September 30, 2010, when Minter attended an appointment with his treating primary care physician, Dr. Stephen Henderson ("Dr. Henderson"), for back pain, neck pain, memory loss, and fatigue. (Tr. 501; Doc. 10-12 p. 4). The record indicates that Minter treated with Dr. Henderson from at least September 30, 2010 until January 22, 2015. (Tr. 501-576, 693-730; Doc. 10-12 p. 4-79; Doc. 10-14 p. 3-40). Throughout the course of Dr. Henderson's treatment of Minter, he diagnosed Minter with various impairments. On March 2, 2011, Minter was assessed with lumbago due to back pain from lumbar disc disease, cervicalgia, and anxiety. (Tr. 505; Doc. 10-12 p. 8). Minter had actually been admitted to the ER on February 3, 2011 because of chest pain and shortness of breath that came about while he was loading a truck at work.
On April 11, 2011, Dr. Henderson diagnosed Minter with carpal tunnel syndrome and ulnar nerve entrapment. (Tr. 514; Doc. 10-12 p. 17). Dr. Henderson noted on April 13, 2012 that Minter had attention deficit disorder ("ADD") and had been suffering from it for years. (Tr. 530-531; Doc. 10-12 p. 33-34). Dr. Henderson's notes indicate that Minter's ADD causes him to have behavioral problems at work, to be aggravated by distractions and stress, to be frustrated easily, to frequently lose/forget things, to be inattentive, to be distracted easily, to be restless, and to have difficulty waiting his turn. (Tr. 531; Doc. 10-12 p. 34).
On June 12, 2012, Minter was assessed by Dr. Henderson as having PTSD and neuropathy, and because of Minter's PTSD, Dr. Henderson referred Minter for psychological treatment. (Tr. 534; Doc. 10-12 p. 37). On January 14, 2013, Dr. Henderson reported that Minter was suffering from bipolar disease. (Tr. 547; Doc. 10-12 p. 50). On October 8, 2013, Dr. Henderson ordered an MRI for further evaluation of Minter's lumbar spine due to the worsening of Minter's spinal stenosis at L4-L5 and disc disease. (Tr. 693; Doc. 10-14 p. 3). Minter had the MRI of his lumbar spine
On January 13, 2014, Dr. Henderson reported that Minter's neck pain had improved. (Tr. 703; Doc. 10-14 p. 13). On June 12, 2014, Minter scheduled a visit so that Dr. Henderson could fill out a form to justify short term disability due to Minter's chronic lower back pain. (Tr. 709; Doc. 10-14 p. 19). Dr. Henderson specifically commented in his notes that Minter was presently unable to work "in view of chronic lower back pain," however, it is unclear whether it is Dr. Henderson's opinion, or a recitation of what Minter claimed. Id.
Dr. Henderson noted at Minter's January 22, 2015 physical appointment that Minter is a well-known patient of his with a history of "chronic anxiety, low back pain from lumbar disc disease, active smoker, attention deficit disorder, [and] significant social issues."
Minter has also been assessed with gastroesophageal reflux disease ("GERD"), (Tr. 547; Doc. 10-12 p. 50), hiatal hernia, hypertension. (Tr. 552; Doc. 10-12 p. 55), right shoulder AC joint osteoarthritis (Tr. 603; Doc. 10-12 p. 106), adenomatous polyp (which was removed) (Tr. 607; Doc. 10-12 p. 110), irritable bowel syndrome, esophageal stenosis, "edema in the popliteal muscle with large intramuscular cysts." (Tr. 703; Doc. 10-14 p. 13), ankle pain, (Tr. 718; Doc. 10-14 p. 28), rotator cuff tendinitis, (Tr. 719; Doc. 10-14 p. 29), and hepatitis C, (Tr. 732; Doc. 10-14 p. 42).
With regard to Minter's mental health, Minter started treating with psychiatrist Dr. Ajith Potluri ("Dr. Potluri") on September 10, 2012. (Tr. 419; Doc. 10-10 p. 74). As a result of his initial evaluation with Dr. Potluri, Minter was assessed with bipolar disease, chronic PTSD, ADD without hyperactivity, and a GAF score
On November 13, 2013, Dr. Potluri completed a mental impairment questionnaire, in which Dr. Potluri opined that Minter has: a GAF score of 60
On January 8, 2014, state agency psychological consultant Dr. Thomas Fink completed a residual functional capacity assessment of Minter finding that Minter was not more than moderately limited in various mental functions concerning understanding, memory, concentration, persistence, and social interactions. (Tr. 162-166; Doc. 10-4 p. 7-11).
On September 9, 2014, Minter started treating with psychiatrist Dr. Jagdeep Kaur, ("Dr. Kaur") for psychotherapy. (Tr. 626-628; Doc. 10-13 p. 15-17). The record shows that Minter treated with Dr. Kaur from September 9, 2014 through June 2, 2015. (Tr. 626-653; Doc. 10-13 p. 15-42). Dr. Kaur's notes throughout his treatment of Minter give the impression that Minter was stable under his current regimen, and during his last documented visit with Dr. Kaur on June 2, 2015, Minter reported that he was fine. (Tr. 626-653; Doc. 10-13 p. 15-42). Dr. Kaur also maintained throughout Minter's treatment that Minter had a GAF score of 60. (Tr. 627, 630, 634, 638, 642, 647, 651; Doc. 10-13 p. 16, 19, 23, 27, 31, 36, 40).
In regard to the impact of Minter's impairments, during his August 10, 2015 hearing, Minter testified that the pain he experiences in his lower back is constant and that it moves to other parts of his body causing him to have trouble moving around and lifting things. (Tr. 124; Doc. 10-3 p. 28). Minter also testified at his hearing, that his bipolar disorder interferes with his concentration and his ability to maintain interest in what he is doing. (Tr. 125; Doc. 10-3 p. 29). Minter further testified that he is not a social person and does not trust people; he is able to prepare simple meals; he can dress himself but he has problems with putting on his socks and shoes; he can bathe himself but has problems washing his hair; he sometimes does vacuuming; and he will only go to the grocery store if it is necessary because he is averse to being around groups of people. (Tr. 125-127; Doc. 10-3 p. 29-31).
To receive benefits under Title XVI of the Social Security Act, the claimant must demonstrate an inability to "engage in any substantial gainful activity 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 twelve months." 42 U.S.C. § 1382c(a)(3)(A). To satisfy this requirement, the claimant must have a severe physical or mental impairment that makes it impossible to do his or her previous work or any other substantial gainful activity that exists in significant number in the national economy. 42 U.S.C. § 1382c(a)(3)(B).
In evaluating the question of whether a claimant is under a disability as it is defined in the Social Security Act, the Commissioner follows a five-step sequential evaluation process. 20 C.F.R. § 416.920(a). Under this process, the Commissioner must determine, in sequence: (1) whether the claimant is engaged in substantial gainful activity; (2) whether the claimant has a severe impairment; (3) whether the claimant's impairment meets or equals the severity of an impairment listed in 20 C.F.R. § 404, Subpart P, Appendix 1 ("Listing of Impairments"); (4) whether the claimant is able to do his past relevant work, considering his current residual functional capacity ("RFC");
When reviewing the Commissioner's final decision denying a claimant's application for benefits, this Court's review is limited to the question of whether the findings of the final decision-maker are supported by substantial evidence in the record. See 42 U.S.C. § 1383(c)(3) (incorporating 42 U.S.C. § 405(g) by reference); Johnson v. Comm'r of Soc. Sec., 529 F.3d 198, 200 (3d Cir. 2008); Ficca v. Astrue, 901 F.Supp.2d 533, 536 (M.D.Pa. 2012). Substantial evidence "does not mean a large or considerable amount of evidence, but rather such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Pierce v. Underwood, 487 U.S. 552, 565 (1988). Substantial evidence is less than a preponderance of the evidence but more than a mere scintilla. Richardson v. Perales, 402 U.S. 389, 401 (1971). A single piece of evidence is not substantial evidence if the ALJ ignores countervailing evidence or fails to resolve a conflict created by the evidence. Mason v. Shalala, 994 F.2d 1058, 1064 (3d Cir. 1993). But in an adequately developed factual record, substantial evidence may be "something less than the weight of the evidence, and the possibility of drawing two inconsistent conclusions from the evidence does not prevent [the ALJ's decision] from being supported by substantial evidence." Consolo v. Fed. Maritime Comm'n, 383 U.S. 607, 620 (1966). "In determining if the Commissioner's decision is supported by substantial evidence the court must scrutinize the record as a whole." Leslie v. Barnhart, 304 F.Supp.2d 623, 627 (M.D.Pa. 2003). The question before this Court, therefore, is not whether the claimant is disabled, but whether the Commissioner's finding that the claimant is not disabled is supported by substantial evidence and was reached based upon a correct application of the relevant law. See Arnold v. Colvin, No. 3:12-CV-02417, 2014 WL 940205, at *1 (M.D.Pa. Mar. 11, 2014) ("[I]t has been held that an ALJ's errors of law denote a lack of substantial evidence.") (alterations omitted); Burton v. Schweiker, 512 F.Supp. 913, 914 (W.D.Pa. 1981) ("The Secretary's determination as to the status of a claim requires the correct application of the law to the facts."); see also Wright v. Sullivan, 900 F.2d 675, 678 (3d Cir. 1990) (noting that the scope of review on legal matters is plenary); Ficca, 901 F.Supp.2d at 536 ("[T]he court has plenary review of all legal issues . . . .").
In a decision dated October 15, 2015, the ALJ determined Minter "has not been under a disability, as defined in the Social Security Act, since July 30, 2014, the amended alleged onset date." (Tr. 110; Doc. 10-3 p. 14). The ALJ reached this conclusion after proceeding through the five-step sequential analysis required by the Social Security Act. See 20 C.F.R. § 416.920(a).
At step one, an ALJ must determine whether the claimant is engaging in substantial gainful activity ("SGA"). 20 C.F.R. § 416.920(a)(4)(i). If a claimant is engaging in SGA, the regulations deem them not disabled, regardless of age, education, or work experience. 20 C.F.R. § 416.920(b). SGA is defined as work activity—requiring significant physical or mental activity—resulting in pay or profit. 20 C.F.R. § 416.972. In making this determination, the ALJ must consider only the earnings of the claimant. 20 C.F.R. § 416.974. The ALJ determined Minter "has not engaged in [SGA] since July 30, 2014, the amended alleged onset date." (Tr. 103; Doc. 10-3 p. 7). Thus, the ALJ's analysis proceeded to step two.
At step two, the ALJ must determine whether the claimant has a medically determinable impairment that is severe or a combination of impairments that are severe. 20 C.F.R. § 416.920(a)(4)(ii). If the ALJ determines that a claimant does not have an "impairment or combination of impairments which significantly limits [the claimant's] physical or mental ability to do basic work activities, [the ALJ] will find that [the claimant does] not have a severe impairment and [is], therefore, not disabled." 20 C.F.R. § 416.920(c). If a claimant establishes a severe impairment or combination of impairments, the analysis continues to the third step.
The ALJ found Minter has severe impairments of: "degenerative disc disease of the lumbar spine; degenerative disc disease of the cervical spine; osteoarthritis of the right shoulder; bipolar disorder; post-traumatic stress disorder (PTSD); and attention deficit disorder." (Tr. 103; Doc. 10-3 p. 7). The ALJ also noted non-severe impairments of: benign rectal polyps. Id.
At step three, the ALJ must determine whether the severe impairment or combination of impairments meets or equals the medical equivalent of an impairment listed in 20 C.F.R. Part 404, Subpt. P, App. 1 (20 C.F.R. §§ 416.920(d); 416.925; 416.926). If the ALJ determines that the claimant's impairments meet these listings, then the claimant is considered disabled. 20 C.F.R. § 416.920(a)(4)(iii). The ALJ determined that none of Minter's impairments, considered individually or in combination, met or equaled a Listing. (Tr. 103; Doc. 10-3 p. 7). Specifically, the ALJ considered Listings 1.02 (major dysfunction of a joint); 1.04 (disorders of the spine); 14.09 (inflammatory arthritis); 12.02 (organic mental disorders); 12.04 (affective disorders); and 12.06 (anxiety related disorders). (Tr. 103-104; Doc. 10-3 p. 7-8).
Between steps three and four, the ALJ determines the claimant's residual functional capacity ("RFC"), crafted upon consideration of the medical evidence provided. The ALJ determined that Minter:
(Tr. 105-106; Doc. 10-3 p. 9-10).
Having assessed a claimant's RFC, at step four the ALJ must determine whether the claimant has the RFC to perform the requirements of their past relevant work. 20 C.F.R. § 416.920(a)(4)(iv). A finding that the claimant can still perform past relevant work requires a determination that the claimant is not disabled. 20 C.F.R. § 416.920(a)(4)(iv). Past relevant work is defined as work the claimant has done within the past 15 years, that was substantial gainful activity, and that lasted long enough for the claimant to learn how to do it. 20 C.F.R. § 416.960(b). If the claimant cannot perform past relevant work or has no past relevant work, then the analysis proceeds to the fifth step. The ALJ determined Minter is unable to perform his past relevant work. (Tr. 109; Doc. 10-3 p. 13). The ALJ noted past relevant work as a construction worker and a grinder, but the exertional requirements of each exceeded Minter's RFC. Id.
At step five of the sequential analysis process, an ALJ considers the claimant's age, education, and work experience to see if a claimant can make the adjustment to other work. 20 C.F.R. § 416.920(a)(4)(v). These factors are not considered when evaluating a claimant's ability to perform past relevant work. 20 C.F.R. § 416.960(b)(3). If a claimant has the ability to make an adjustment to other work, the claimant will not be considered disabled. 20 C.F.R. § 416.920(a)(4)(v). The ALJ made the vocational determination that Minter was 50 years old on the amended alleged onset date, defined as an individual closely approaching advanced age by the regulations. 20 C.F.R. §416.963. (Tr. 109; Doc. 10-3 p. 13). The ALJ also noted that Minter "has at least a high school education and is able to communicate in English" as considered in 20 C.F.R. §416.964. Id. The ALJ determined that upon consideration of these factors, Minter's RFC, and the testimony of a vocational expert, "there are jobs that exist in significant numbers in the national economy that the claimant can perform." Id. The ALJ specifically identified occupations of cleaner/housekeeping, conveyor line bakery worker, potato chip sorter, final assembler, table worker, and carding machine operator. (Tr. 110; Doc. 10-3 p. 14).
As a result of this analysis, the ALJ determined that Minter was not disabled and denied Minter's applications for benefits. (Tr. 110; Doc. 10-3 p. 14).
Minter advances two main arguments on appeal. First, he asserts that the ALJ's assignment of weight to the opinion of treating psychiatrist Dr. Potluri is not supported by substantial evidence. (Doc. 11 p. 7). Second, Minter asserts that the ALJ's credibility assessment of Minter is not supported by substantial evidence. (Doc. 11 p. 15). In response, the Deputy Commissioner contends that the ALJ's decision is supported by substantial evidence and is in accordance with the law and regulations. (Doc. 9 p. 3-4).
Minter asserts that the ALJ's assignment of limited weight to treating psychiatrist Dr. Potluri's opinion contained in the November 13, 2013 mental impairment questionnaire is not supported by substantial evidence. (Doc. 11 p. 7). Specifically, Minter argues that "the ALJ failed to provide a supported rationale for not according significant weight to Dr. Potluri's opinion." (Doc. 11 p. 10).
The regulations define medical opinions as "statements from physicians and psychologists or other acceptable medical sources that reflect judgments about the nature and severity of [a claimant's] impairment(s), including [a claimant's] symptoms, diagnosis and prognosis, what [a claimant] can still do despite impairments(s), and [a claimant's] physical or mental restrictions." 20 C.F.R. § 416.927(a)(2). Regardless of its source, the ALJ is required to evaluate every medical opinion received. 20 C.F.R. § 416.927(c).
The ALJ must consider the factors outlined in 20 C.F.R. § 416.927(c) when the ALJ is deciding what weight to accord competing medical opinions. Generally, treating source opinions are entitled to more weight than non-treating source opinions because treating sources tend to have more extensive interaction with a claimant. 20 C.F.R. § 416.927(c); 20 C.F.R. § 404.1502 (defining "treating source"). Sometimes the medical opinion of a treating source may actually be entitled to controlling weight. 20 C.F.R. § 416.927(c)(2) (explaining when a source's opinion is controlling). If no medical opinion is entitled to controlling weight, the ALJ must consider, where applicable, the following factors in deciding the weight assigned to any non-controlling medical opinions: length of the treatment relationship and frequency of examination; nature and extent of the treatment relationship; the extent to which the source presented relevant evidence to support his or her medical opinion, and the extent to which the basis for the source's conclusions were explained; the extent to which the source's opinion is consistent with the record as a whole; whether the source is a specialist; and any other factors brought to the ALJ's attention. 20 C.F.R. § 416.927(c).
Moreover, the ALJ's assignment of weight to each medical opinion must include "a clear and satisfactory explication of the basis on which it rests." Cotter v. Harris, 642 F.2d 700, 704 (3d Cir. 1981). "Where a conflict in the evidence exists, the ALJ may choose whom to credit but `cannot reject evidence for no reason or the wrong reason.'" Plummer v. Apfel, 186 F.3d 422, 429 (3d Cir. 1999) (quoting Mason, 994 F.2d at 1066)); see also Morales v. Apfel, 225 F.3d 310, 317 (3d Cir. 2000). Regardless of which opinions are rejected or accepted, the regulations direct that an ALJ "will always give good reasons in [the ALJ's] decision for the weight [the ALJ gives a] treating source's opinion. 20 C.F.R. § 416.927(c)(2).
Here, treating psychiatrist Dr. Potluri completed a mental impairment questionnaire concerning Minter's RFC and whether he meets a listing. (Tr. 296-301; Doc. 10-8 p. 3-8). In considering this opinion, the ALJ stated that:
(Tr. 108; Doc. 10-3 p. 12).
The Deputy Commissioner asserts that because Dr. Potluri filled out a "check-the-box" form to opine on Minter's condition, Dr. Potluri's opinion is entitled to less "weight than other substantive medical evidence." (Doc. 12 p. 19). The Deputy Commissioner cites to a case from the Western District of Pennsylvania Swentko v. Astrue, No. 2:07-280, 2008 WL 2857986, at *5 (W.D. Pa. July 21, 2008), which quotes Mason v. Shalala, 994 F.2d at 1065 ("[f]orm reports in which a physician's obligation is only to check a box or fill in a blank are weak evidence at best."), in support of her argument. (Doc. 12 p. 19).
In Carter v. Astrue, No. 4:CV-07-2257, 2008 WL 2704535, at *2 (M.D. Pa. July 8, 2008), the Court determined that the use of a form by a treating physician to render a medical opinion was not an adequate ground for the ALJ to outright reject the treating physician's opinion, but such a detail could influence the weight given to the opinion. 2008 WL 2704535, at *2. In this case, Dr. Potluri is a treating physician who filled out a check-the-box form to opine on Minter's condition. The Court finds that this detail does not authorize the ALJ to dismiss Dr. Potluri's opinion without adequate explanation as to why he dismissed it. Dr. Potluri's medical opinion, regardless of its form, must still be addressed properly by the ALJ in accordance with the regulations.
Minter submits that the ALJ failed to provide a supported rationale for not according the opinion of Dr. Potluri opinion significant weight. (Doc. 11 p. 10). Though the Court does not comment on what weight Dr. Potluri's opinion should have been accorded, the Court does find that the ALJ's explanation for the weight that was accorded to Dr. Potluri's opinion is inadequate. The ALJ must include in his decision "a clear and satisfactory explication of the basis on which" his assignment of weight to an opinion rests. Cotter, 642 F.2d at 704. Simply stating that Dr. Potluri's opinion "is not supported by the record as a whole" is a vague explanation that does not demonstrate what the ALJ specifically relied upon in rejecting this opinion. Because the ALJ failed to adequately explain his assignment of weight to treating physician Dr. Potluri's medical opinion, the Court finds that the ALJ's decision denying Minter's claim is not supported by substantial evidence, and thus, remand is warranted. Because the Court recommends that this case be remanded, the Court finds it unnecessary to discuss Minter's remaining arguments. To the extent that any other error occurred, it may be remedied on remand.
Based on the foregoing, it is recommended that the Deputy Commissioner's decision be
Any party may obtain a review of the Report and Recommendation pursuant to Rule 72.3, which provides:
