REPORT AND RECOMMENDATION TO GRANT PLAINTIFF'S APPEAL AND TO REVERSE AND REMAND DECISION OF COMMISSIONER
GERALD B. COHN, Magistrate Judge.
This matter is before the undersigned United States Magistrate Judge for a report and recommendation. John A. Jasinski ("Plaintiff"), seeks judicial review of the Commissioner of the Social Security Administration's decision finding of not disabled. As set forth below, the undersigned recommends to GRANT Plaintiff's appeal and REVERSE and REMAND the Commissioner's decision in this case.
I. STANDARD OF REVIEW
To receive disability or supplemental security benefits under the Social Security Act ("Act"), a claimant bears the burden to 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 12 months." 42 U.S.C. § 423(d)(1)(A); accord 42 U.S.C. § 1382c(a)(3)(A).
The Act further provides that an individual:
shall be determined to be under a disability only if his physical or mental impairment or impairments are of such severity that he is not only unable to do his previous work but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy, regardless of whether such work exists in the immediate area in which he lives, or whether a specific job vacancy exists for him, or whether he would be hired if he applied for work.
42 U.S.C. §§ 423(d)(2)(A), 1382c(a)(3)(B). Plaintiff must demonstrate the physical or mental impairment "by medically acceptable clinical and laboratory diagnostic techniques." 42 U.S.C. §§ 423(d)(3), 1382c(a)(3)(D).
Social Security regulations implement a five-step sequential process to evaluate a disability claim. 20 C.F.R. §§ 404.1520, 416.920. The process requires an ALJ to decide whether an applicant (1) is engaged in "substantial gainful activity;" (2) suffers from a "severe medically determinable physical or mental impairment;" (3) suffers from "an impairment(s) that meets or equals one" listed in the regulation's appendix; (4) has a residual functional capacity ("RFC") allowing for performance of "past relevant work;" and (5) can "make an adjustment to other work." Rutherford v. Barnhart, 399 F.3d 546, 551 (3d Cir. 2005).
If at any of the steps a determination exists that a plaintiff is or is not disabled, evaluation under a subsequent step is not necessary. 20 C.F.R. § 404.1520(a)(4). The claimant bears the burden of proof at steps one through four. See Rutherford, 399 F.3d at 551. If the claimant satisfies this burden, then the Commissioner must show at step five that jobs exist in the national economy that a person with the claimant's abilities, age, education, and work experience can perform. Id.
In reviewing a decision of the Commissioner, the Court is limited to determining whether the Commissioner has applied the correct legal standards and whether the decision is supported by substantial evidence. See e.g., 42 U.S.C. § 405(g) ("Court shall review only the question of conformity with such regulations and the validity of such regulations"). Substantial evidence is a deferential standard of review. See Jones v. Barnhart, 364 F.3d 501, 503 (3d Cir. 2004). 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) (quoting Consolidated Edison Co. v. NLRB, 305 U.S. 197, 229 (1938)); see also Johnson v. Commissioner of Social Sec., 529 F.3d 198, 200 (3d Cir. 2008). Substantial evidence is "less than a preponderance" and "more than a mere scintilla." Jesurum v. Sec'y of U.S. Dep't of Health & Human Servs., 48 F.3d 114, 117 (3d Cir. 1995) (citing Richardson v. Perales, 402 U.S. 389, 401 (1971)).
The Court may neither re-weigh the evidence nor substitute its judgment for that of the fact-finder. Rutherford, 399 F.3d at 552. The Court will not set the Commissioner's decision aside if it is supported by substantial evidence, even if the Court would have decided the factual inquiry differently. Hartranft v. Apfel, 181 F.3d 358, 360 (3d Cir. 1999) (citing 42 U.S.C. § 405(g)).
II. BACKGROUND
A. Procedural History
On June 8, 2015, Plaintiff filed an application for Disability Insurance Benefits ("DIB") pursuant to Title II of the Act, alleging disability since May 15, 2014.1 (Tr. 15). In June 2017, an ALJ held a hearing where Plaintiff and a Vocational Expert ("VE") testified. (Tr. 26-54). On October 20, 2017, the ALJ issued a decision finding Plaintiff not disabled. (Tr. 12-25). Plaintiff was fifty-two years old at the time of the ALJ's decision. (Tr. 20, 22). In September 2018, the Appeals Council denied Plaintiff's request for review (Tr. 1-6), making the ALJ's decision the Commissioner's final decision for purposes of judicial review. See 20 C.F.R. §§ 416.1481; 422.210(a). This action followed.
III. ISSUES AND ANALYSIS
On appeal, Plaintiff alleges the following errors: (1) The ALJ erred in failing to consider the limitations from Plaintiff's neuralgia of the right foot, bony deformity and periosteal thickening in the lateral aspect of the mid great toe, and degenerative joint disease of the great toe MTP joint, which the ALJ found to be severe impairments; (2) the ALJ erred in failing to consider the limitations from Plaintiff's back pain, radiculopathy, degenerative disc disease of the neck, and bilateral carpal tunnel syndrome, which the ALJ found to be non-medically determinable impairments; (3) the ALJ erred in weighing the medical opinions in determining Plaintiff's RFC; and (4) the ALJ erred in failing to consider the Grid Rules, in light of the opinions of Plaintiff's treating sources, and the Consultative Exam Physician, all of whom placed Plaintiff at sedentary or less in terms of his exertional limitations. (Pl. Br. at 1-2) (Doc. 7).
A. Medical Opinions in the Record, Plaintiff's Non-Medically Determinable Impairments, and the RFC Finding
Plaintiff contends the ALJ erred considering Plaintiff's impairments when formulating the RFC. (Pl. Br. at 4-18). Plaintiff also argues the ALJ erred in assessing weight to the medical opinions of record. (Pl. Br. 18-23). In the decision, the ALJ made the following observations regarding Plaintiff's severe and non-medically determinable impairments, the RFC finding, and the medical opinions of record:
The claimant has the following severe impairments: Neuralgia of the Right Foot; Minimal Bony Deformity/Periosteal Thickening in the lateral aspect of the mid great toe metatarsal; and mild degenerative joint disease of the great toe MTP joint ...
It is noted that the claimant has alleged back/neck problems and carpal tunnel syndrome. The claimant was also diagnosed with bilateral carpal tunnel syndrome, degenerative disc disease of the neck, and radiculopathy. However, there are no imaging studies and/or electrodiagnostic studies that substantiate the presence of these conditions. In light of this, the [ALJ] finds no medically determinable impairments including bilateral carpal tunnel syndrome and the lumbar/cervical spine ...
the claimant has the RFC to perform light work as defined in 20 CFR 404.1567(b)2 except no climbing of ladders/ropes/scaffolds and no more than occasional performance of all other postural activities. The claimant must avoid concentrated exposure to hazards ...
In filing for disability benefits, the claimant has alleged foot problems have limited his ability to sustain consistent employment. In a September 2015 Adult Function Report, the claimant reported that neck pain, back pain, and right foot pain limit his ability to sustain consistent employment. The claimant further reported that his impairments affected his ability to lift, bend, stand, walk, sit, kneel, and complete tasks. In particular, the claimant reported that he was able to lift twenty pounds, but only walk for one hour. In January 2016 disability documentation, the claimant reported having extreme pain and swelling when walking and standing on his right foot. At the June 2017 disability hearing, the claimant continued to report of limitations associated with a 1978 motorcycle accident resulting in multiple surgeries along with a heel amputation. The claimant also reported having gout. In particular, he testified he cannot bend his toes along with having pain and numbness. The claimant also testified that he utilized his crutches two times per week. He also indicated that he was only able to walk for three to four minutes and stand only one to two minutes. The claimant also reported having surgery in 2008 for bilateral carpal tunnel syndrome. He testified that he still experienced numbness/cramps in the hands on a daily basis. The claimant reported that he had back pain radiating to the right leg and neck pain radiating to both shoulders and the right arm. He also indicated that he had sleep problems and drops things frequently along with having problems walking on uneven surfaces ...
Overall, the full longitudinal record supports the above physical limitations due to right lower extremity impairments. In particular, the claimant has presented a history of right lower extremity problems.
However, the evidence of record fails to demonstrate the presence of greater physical limitations than those found in the above RFC for a number of reasons. First, an imaging study of record is not consistent with greater limitations than found above. In particular, a January 21, 2016 x-ray of the right foot and ankle showed only a "minimal bony deformity versus periosteal thickening in the lateral aspect of the mid medial joint space narrowing of the great toe MTP joint. Second, the claimant's treatment history during the relevant period is without record of surgical intervention, physical therapy, prolonged hospitalization, and/or frequent emergency room visit. Further, at this point, the claimant only utilizes over the counter medication. Finally, the claimant's reported capabilities are not consistent with greater limitations than found above. In particular, in a September 2015 Adult Function Report, the claimant reported having no problem with personal care. He further indicated that he was able to prepare his own meals and clean his house. The claimant also reported as being able to cook, clean, do some shopping, and dress/bathe himself. At the June 2017 disability hearing, although asserting limitations as to daily activities, the claimant reported he did laundry once a week, vacuumed three rooms weekly, and shopped once monthly. In light of this imaging study, the above treatment history, and the reported capabilities, the [ALJ] finds the above physical limitations. For these reasons, State Agency Medical Consultant, Hong S. Park, M.D. opined that the claimant was limited to light work activity with other postural and environmental limitations.
(Tr. 17-20). The ALJ noted Disability Determination Services consultant Hong S. Park, M.D. found Plaintiff could perform light work with postural and environmental limitations. (Tr. 20). On November 23, 2015, Dr. Park noted Plaintiff filed the initial claim for disability on June 8, 2015 due to the following conditions: "partially amputated heel right foot, right foot issues." (Tr. 55). Plaintiff contends the ALJ did not assign a particular weight to this opinion. (Pl. Br. at 12). The Code of Federal Regulations discusses the requirements for ALJs reviewing medical opinions for claims filed before March 27, 2017:
(c) How we weigh medical opinions. Regardless of its source, we will evaluate every medical opinion we receive. Unless we give a treating source's medical opinion controlling weight under paragraph (c)(2) of this section, we consider all of the following factors in deciding the weight we give to any medical opinion.
(1) Examining relationship. Generally, we give more weight to the medical opinion of a source who has examined you than to the medical opinion of a medical source who has not examined you.
(2) Treatment relationship. Generally, we give more weight to medical opinions from your treating sources, since these sources are likely to be the medical professionals most able to provide a detailed, longitudinal picture of your medical impairment(s) and may bring a unique perspective to the medical evidence that cannot be obtained from the objective medical findings alone or from reports of individual examinations, such as consultative examinations or brief hospitalizations
...
(i) Length of the treatment relationship and the frequency of examination. Generally, the longer a treating source has treated you and the more times you have been seen by a treating source, the more weight we will give to the source's medical opinion. When the treating source has seen you a number of times and long enough to have obtained a longitudinal picture of your impairment, we will give the medical source's medical opinion more weight than we would give it if it were from a non-treating source.
(ii) Nature and extent of the treatment relationship. Generally, the more knowledge a treating source has about your impairment(s) the more weight we will give to the source's medical opinion. We will look at the treatment the source has provided and at the kinds and extent of examinations and testing the source has performed or ordered from specialists and independent laboratories ...
(3) Supportability. The more a medical source presents relevant evidence to support a medical opinion, particularly medical signs and laboratory findings, the more weight we will give that medical opinion. The better an explanation a source provides for a medical opinion, the more weight we will give that medical opinion. Furthermore, because non-examining sources have no examining or treating relationship with you, the weight we will give their medical opinions will depend on the degree to which they provide supporting explanations for their medical opinions. We will evaluate the degree to which these medical opinions consider all of the pertinent evidence in your claim, including medical opinions of treating and other examining sources.
(4) Consistency. Generally, the more consistent a medical opinion is with the record as a whole, the more weight we will give to that medical opinion.
(5) Specialization. We generally give more weight to the medical opinion of a specialist about medical issues related to his or her area of specialty than to the medical opinion of a source who is not a specialist.
(6) Other factors. When we consider how much weight to give to a medical opinion, we will also consider any factors you or others bring to our attention, or of which we are aware, which tend to support or contradict the medical opinion. For example, the amount of understanding of our disability programs and their evidentiary requirements that a medical source has, regardless of the source of that understanding, and the extent to which a medical source is familiar with the other information in your case record are relevant factors that we will consider in deciding the weight to give to a medical opinion.
20 C.F.R. § 416.927(c). Even if the Court inferred the ALJ relied on the opinion of the Disability Determination Services consultant, despite the ALJ's failure to assign a particular weight to the opinion, Dr. Park also did not consider or discuss the impairments the ALJ found non-medically determinable, namely Plaintiff's back pain, radiculopathy, degenerative disc disease of the neck, and bilateral carpal tunnel syndrome. (Tr. 17-18, 55-63).
On November 4, 2015, Spencer Long, M.D., evaluated Plaintiff for state agency internal medicine consultative examination and completed a medical source statement of ability to do work-related activities (physical). (Tr. 258-71). Dr. Long diagnosed Plaintiff with 1) right foot injury with multiple surgeries and chronic pain of the right foot and ankle; 2) bilateral carpal tunnel syndrome with hand weakness; 3) lower back pain; 4) intermittent numbness of legs; 5) neck pain with degenerative disc disease; and 6) radiculopathy of right arm. (Tr. 260-67). Dr. Long rated Plaintiff's prognosis as fair. (Id. at 260). In the medical source statement, Dr. Long indicated Plaintiff could occasionally lift and carry up to twenty pounds, could sit for thirty minutes without interruption, could stand or walk for ten minutes without interruption, could sit eight hours total per day, could stand and walk thirty minutes total per day, could never reach overhead, could occasionally do other reaching, handling, or push/pull; could never climb stairs, ladders, scaffolds; could occasionally balance and stoop; could never kneel, crouch, or crawl; and could never have exposure to unprotected heights, moving mechanical parts, extreme cold, or extreme heat. (Tr. 262-66). Dr. Long further opined Plaintiff could never operate foot controls with his right foot and occasionally with the left foot. (Id. at 264). Dr. Long opined Plaintiff could not walk a block at a reasonable pace on rough or uneven surfaces. (Id. at 267). Dr. Long noted throughout the medical source statement his findings were due to Plaintiff's right foot injury, pain, and weakness; bilateral carpal tunnel syndrome with hand weakness; back pain; leg weakness; neck pain; degenerative disc disease; and radiculopathy of right arm. (Tr. 262-67).
On April 19, 2017, Constance M. Sweet, M.D., performed an initial evaluation for Plaintiff and completed physical RFC questionnaire. (Tr. 289-94). Dr. Sweet diagnosed Plaintiff with bilateral hand pain/numbness/bilateral foot pain/numbness/cervical spine pain with arm numbness. (Tr. 289). Dr. Sweet opined Plaintiff could not walk a block without rest or severe pain. (Id. at 290). Dr. Sweet indicated Plaintiff could occasionally lift and carry up to twenty pounds, could sit for thirty minutes without interruption, could stand or walk for ten minutes without interruption, could sit or stand/walk two hours total per day, could reach overhead ten percent of the workday, could never climb stairs or ladders, and could never crouch or squat. (Id. at 290-92).
The ALJ assigned little weight to the opinions of Drs. Long and Sweet:
In light of [the] imaging study, the above treatment history, and the reported capabilities, the [ALJ] has accorded little weight to the opinions and conclusions of Spencer Long, M.D., John Salahub, D.P.M., and Constance Sweet, M.D. In particular, Dr. Salahub's and Dr. Sweet's conclusions as to the amount of time the claimant would miss work or be "off-task" are not supported by the above discussed reported capabilities, treatment history, and imaging study. Along with this, Dr. Salahub's limitations as to the neck and hands are not supported by objective studies. Further, Dr. Long's conclusions as to the claimant's standing and walking capabilities are inconsistent with the claimant reported capabilities and the imaging studies above. Finally, these doctors have no treatment history with the claimant — 1) Dr. Long performed a consultative examination with no apparent access to the claimant's treatment records; 2) the claimant was sent to Dr. Salahub by his representative for a one-time examination for the purpose of filling out a disability form; 3) Dr. Sweet performed a one-time examination for the apparent purpose of filling out a disability form and there are no records of this examination.
(Tr. 20). The ALJ noted Drs. Long and Sweet had no treatment history with Plaintiff as a basis to reject their opinions; however, they performed in-person evaluations and the ALJ apparently relied on Dr. Park's opinion, which was performed via a review of records only. Therefore, notwithstanding the opinions of two physicians regarding Plaintiff's impairments of back/neck problems, bilateral carpal tunnel syndrome, degenerative disc disease of the neck, and radiculopathy, the ALJ found these impairments as non-medically determinable and did not consider them when crafting the RFC. Another case in the Middle District of Pennsylvania has articulated the requirement to remand when an ALJ did not discuss limitations stemming from other impairments:
Although the disability determination proceeded beyond step two, here the Court cannot conclude the error was harmless because limitations related to some conditions found non-severe were not included in the RFC. As noted above, Plaintiff testified about functional difficulties related to his neck pain, kidney pain, and headache pain. [The] ALJ does not discuss functional limitations related to these conditions in her RFC analysis, and the Court cannot glean from her discussion that she inferentially found these limitations not credible for specific reasons. Because the Court cannot conclude the ALJ's step two error is harmless, this matter must be remanded to the Acting Commissioner for further consideration.
Rudy v. Berryhill, No. 3:16-CV-1687, 2017 WL 1283911, at *8 (M.D. Pa. Apr. 6, 2017). Similarly, in this case, the ALJ rejected the opinions regarding Plaintiff's impairments, and therefore, did not discuss in the RFC analysis what limitations resulted from Plaintiff's complaints of back/neck problems, bilateral carpal tunnel syndrome, degenerative disc disease of the neck, and radiculopathy.
Thus, the ALJ relied on the disability determination examiner opinion, which did not assess the limitations stemming from Plaintiff's impairments of back/neck problems, bilateral carpal tunnel syndrome, degenerative disc disease of the neck, and radiculopathy in order to deny his disability claim. See Doak v. Heckler, 790 F.2d 26, 29 (3d Cir. 1986) ("No physician suggested that the activity [the claimant] could perform was consistent with the definition of light work set forth in the regulations, and therefore the ALJ's conclusion that he could is not supported by substantial evidence.") Without any medical opinion being credited with regards to all of Plaintiff's limitations, the ALJ impermissibly relied on speculation or lay interpretation of medical evidence to reach the conclusion regarding Plaintiff's RFC. See Morales v. Apfel, 225 F.3d 310, 317-18 (3d Cir. 2000); Ferguson v. Schweiker, 765 F.2d 31, 37 (3d Cir. 1985) (The ALJ may not substitute his own judgment for that of a physician). Therefore, substantial evidence does not support the ALJ's RFC finding when the ALJ did not rely on any medical opinion when deciding Plaintiff's physical limitations stemming from all of his impairments. Accordingly, the ALJ's decision lacks substantial evidence a reasonable mind might accept as adequate to support the conclusion.
B. Other Allegations of Error
Plaintiff's additional claims of error may be remedied through the case's treatment on remand. Thus, the Court declines to address those claims. A remand may produce different results on these claims, making discussion of them moot. Burns v. Colvin, 156 F.Supp.3d 579, 598 (M.D. Pa. 2016). See also Steininger v. Barnhart, 2005 WL 2077375, at *4 (E.D. Pa. Aug. 24, 2005) (declining to address plaintiff's other arguments for remand, "as the ALJ's findings may be revised in any decision issued following the new hearing"); LaSalle v. Comm'r of Soc. Sec., 2011 WL 1456166, at *7 (W.D. Pa. Apr. 14, 2011). Bruce v. Berryhill, 294 F.Supp.3d 346, 364 (E.D. Pa. 2018).
IV. RECOMMENDATION
For the reasons set forth above, the undersigned RECOMMENDS to GRANT Plaintiff's appeal and REVERSE and REMAND the Commissioner's decision in this case.
V. NOTICE
NOTICE IS HEREBY GIVEN that the undersigned has entered the foregoing Report and Recommendation. Any party may obtain a review of the Report and Recommendation pursuant to Rule 72.3, which provides:
Any party may object to a Magistrate Judge's proposed findings, recommendations or report addressing a motion or matter described in 28 U.S.C. § 636(b)(1)(B) or making a recommendation for the disposition of a prisoner case or a habeas corpus petition within fourteen (14) days after being served with a copy thereof. Such party shall file with the clerk of court, and serve on the Magistrate Judge and all parties, written objections which shall specifically identify the portions of the proposed findings, recommendations or report to which objection is made and the basis for such objections. The briefing requirements set forth in Local Rule 72.2 shall apply. A Judge shall make a de novo determination of those portions of the report or specified proposed findings or recommendations to which objection is made and may accept, reject, or modify, in whole or in part, the findings or recommendations made by the magistrate judge. The Judge, however, need conduct a new hearing only in his or her discretion or where required by law, and may consider the record developed before the magistrate judge, making his or her own determination on the basis of that record. The Judge may also receive further evidence, recall witnesses or recommit the matter to the Magistrate Judge with instructions.
