Opinion
CIVIL ACTION NO. 3:16-cv-0322
11-21-2018
CHRISTINA WHITE, Plaintiff v. CAROLYN W. COLVIN, Defendant
(MARIANI, D.J.) ()
REPORT AND RECOMMENDATION
This is an action brought under Section 205(g) and 1631(c)(3) of the Social Security Act, 42 U.S.C. § 405(g) and 42 U.S.C. § 1383(c)(3), seeking judicial review of the final decision of the Commissioner of Social Security ("Commissioner") denying the claim of Plaintiff Christina White ("Plaintiff") for disability insurance benefits and supplemental security income under Titles II and XVI of the Social Security Act. This matter has been referred to me to prepare a report and recommendation pursuant to 28 U.S.C. § 636(b) and Rule 72(b) of the Federal Rules of Civil Procedure. After reviewing the parties' briefs, the final decision denying Plaintiff's applications and the relevant portions of the administrative transcript, I recommend that Plaintiff's request for relief be GRANTED, that the final decision denying Plaintiff's applications be VACATED, and that this case be REMANDED for a new administrative hearing. I. BACKGROUND AND PROCEDURAL HISTORY
On August 21, 2012, Plaintiff filed applications for disability insurance benefits and supplemental security income under Titles II and XVI of the Social Security Act. (Admin. Tr. 12). In both applications, Plaintiff alleged she became disabled on January 31, 2013 because of the following conditions: bipolar disorder, depression, human immunodeficiency virus (HIV), diabetes mellitus, asthma, anxiety, hypertension, knee pain/arthritis of the knees, ankle pain, and wrist pain. (Admin. Tr. 297); (Admin. Tr. 364); (Admin. Tr. 39, 55). The ALJ also found that Plaintiff had medically determinable conditions of astigmatism, substance abuse disorder (in remission), and post-traumatic stress disorder. (Admin. Tr. 15). Plaintiff alleges that these impairments affect her ability to see, remember, and follow instructions. (Admin. Tr. 310). Plaintiff also testified that she has difficulty standing, lifting, and using her hands. (Admin. Tr. 47).
Plaintiff initially alleged she became disabled on February 1, 2012. (Admin. Tr. 38). During her administrative hearing Plaintiff amended her onset date to January 31, 2013, to coincide with the date of a consultative examination conducted by Psychologist Dawn Crosson, Psy.D. ("Dr. Crosson"). (Admin. Tr. 38); (See also Admin. Tr. 417-423) (consultative examination report and medical source statement by Dr. Crosson).
Plaintiff has a ninth-grade education. (Admin. Tr. 51-52). Her past employment includes work as a hand packer, warehouse laborer, and cook's helper. (Admin. Tr. 24).
On February 22, 2013, Plaintiff's applications were denied at the initial level of administrative review. (Admin. Tr. 161-184). Following the initial denial of her applications, Plaintiff requested an administrative hearing.
On May 21, 2014, a hearing was held before ALJ Sharon Zanotto (the "ALJ"). (See Admin. Tr. 33-92) (transcript of administrative hearing). Plaintiff appeared and testified, with the assistance of counsel, at the hearing. Impartial vocational expert Sheryl Bustin also appeared and testified. On June 6, 2014, the ALJ issued a written decision denying Plaintiff's applications. (Admin. Tr. 12-26).
The record also includes transcripts from two prior administrative hearings, both held in connection with prior applications for benefits. (Admin. Tr. 93-140).
Plaintiff appealed the ALJ's decision to the Appeals Council of the Office of Disability Adjudication and Review ("Appeals Council"). On January 13, 2016, the Appeals Council denied Plaintiff's request for review. (Admin. Tr. 1). This denial makes the ALJ's 2014 decision the final administrative decision subject to judicial review.
On February 23, 2016, Plaintiff filed a timely civil action with this Court. (Doc. 1). In her Complaint, Plaintiff alleges that the ALJ's decision denying her applications for benefits is not supported by substantial evidence and is based on the incorrect application of the law. Id. As relief, she requests that the ALJ's decision be reversed, and that she either be awarded benefits or be granted a new administrative hearing. Id.
On April 27, 2016, the Commissioner filed her Answer. (Doc. 9). The Commissioner maintains that the ALJ's decision contains no legal error and is supported by substantial evidence. Along with her Answer, the Commissioner filed a certified transcript of the administrative proceedings. (Doc. 10, et seq.).
This matter has been fully briefed by the parties and is ripe for resolution. II. STANDARD OF REVIEW
A. SUBSTANTIAL EVIDENCE REVIEW - THE ROLE OF THIS COURT
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. § 405(g); 42 U.S.C. § 1383(c)(3); 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 Plaintiff is disabled, but whether the Commissioner's finding that she 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 . . . .").
B. INITIAL BURDENS OF PROOF, PERSUASION, AND ALJ ARTICULATION
To receive benefits under the Social Security Act by reason of disability, a 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. § 423(d)(1)(A); 42 U.S.C. § 1382c(a)(3)(A); see also 20 C.F.R. § 404.1505(a); 20 C.F.R. § 416.905(a). To satisfy this requirement, a 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 the national economy. 42 U.S.C. § 423(d)(2)(A); 42 U.S.C. § 1382c(a)(3)(B); 20 C.F.R. § 404.1505(a); 20 C.F.R. § 416.905(a). To receive benefits under Title II of the Social Security Act, a claimant must show that he or she contributed to the insurance program, is under retirement age, and became disabled prior to the date on which he or she was last insured. 42 U.S.C. § 423(a); 20 C.F.R. § 404.131(a).
Throughout this Report, I cite to the version of the administrative rulings and regulations that were in effect on the date the Commissioner's final decision was issued. In this case, the ALJ's decision, which serves as the final decision of the Commissioner, was issued on June 6, 2014.
In making this determination at the administrative level, the ALJ follows a five-step sequential evaluation process. 20 C.F.R. § 404.1520(a); 20 C.F.R. § 416.920(a). Under this process, the ALJ must sequentially determine: (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 a listed impairment; (4) whether the claimant is able to do his or her past relevant work; and (5) whether the claimant is able to do any other work, considering his or her age, education, work experience and residual functional capacity ("RFC"). 20 C.F.R. § 404.1520(a)(4); 20 C.F.R. § 416.920(a)(4).
Between steps three and four, the ALJ must also assess a claimant's RFC. RFC is defined as "that which an individual is still able to do despite the limitations caused by his or her impairment(s)." Burnett v. Comm'r of Soc. Sec., 220 F.3d 112, 121 (3d Cir. 2000) (citations omitted); see also 20 C.F.R. § 404.1520(e); 20 C.F.R. § 404.1545(a)(1); 20 C.F.R. § 416.920(e); 20 C.F.R. § 416.945(a)(1). In making this assessment, the ALJ considers all the claimant's medically determinable impairments, including any non-severe impairments identified by the ALJ at step two of his or her analysis. 20 C.F.R. § 404.1545(a)(2); 20 C.F.R. § 416.945(a)(2).
At steps one through four, the claimant bears the initial burden of demonstrating the existence of a medically determinable impairment that prevents him or her in engaging in any of his or her past relevant work. 42 U.S.C. § 423(d)(5); 42 U.S.C. § 1382c(a)(3)(H)(i) (incorporating 42 U.S.C. § 423(d)(5) by reference); 20 C.F.R. § 404.1512; 20 C.F.R. § 416.912; Mason, 994 F.2d at 1064.
Once this burden has been met by the claimant, it shifts to the Commissioner at step five to show that jobs exist in significant number in the national economy that the claimant could perform that are consistent with the claimant's age, education, work experience and RFC. 20 C.F.R. § 404.1512(f); 20 C.F.R. § 416.912(f); Mason, 994 F.2d at 1064.
The ALJ's disability determination must also meet certain basic substantive requisites. Most significant among these legal benchmarks is a requirement that the ALJ adequately explain the legal and factual basis for this disability determination. Thus, to facilitate review of the decision under the substantial evidence standard, the ALJ's decision must be accompanied by "a clear and satisfactory explication of the basis on which it rests." Cotter v. Harris, 642 F.2d 700, 704 (3d Cir. 1981). Conflicts in the evidence must be resolved and the ALJ must indicate which evidence was accepted, which evidence was rejected, and the reasons for rejecting certain evidence. Id. at 706-707. In addition, "[t]he ALJ must indicate in his decision which evidence he has rejected and which he is relying on as the basis for his finding." Schaudeck v. Comm'r of Soc. Sec., 181 F. 3d 429, 433 (3d Cir. 1999). III. ANALYSIS
A. THE ALJ'S DECISION DENYING PLAINTIFF'S APPLICATIONS
In her decision, the ALJ found that Plaintiff met the insured status requirements of Title II of the Social Security Act through December 31, 2013. (Admin. Tr. 14). Then, the ALJ evaluated Plaintiff's applications at each step of the sequential evaluation process.
At step one, the ALJ found that Plaintiff did not engage in substantial gainful activity between January 31, 2013 (Plaintiff's amended alleged onset date), and June 6, 2014 (the date the ALJ issued her decision). (Admin. Tr. 14). At step two, the ALJ found that the record established the existence of the following medically determinable severe impairments: asthma; depression; bipolar disorder; mood disorder; and HIV. (Admin. Tr. 15). The ALJ found that the record established the existence of the following medically determinable non-severe impairments: diabetes mellitus, type 2; astigmatism/presbyopia; hypertension; substance abuse disorder; posttraumatic stress disorder; knee pain; and wrist pain. Id. At step three, the ALJ found that Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. Id.
Between steps three and four, the ALJ evaluated Plaintiff's RFC. She found that, during the relevant period, Plaintiff could engage in sedentary work, as defined by 20 C.F.R. § 404.1567(a) and 20 C.F.R. § 416.967(a) with the following additional restrictions:
occasional crouching, kneeling, stooping, and climbing of ramps and stairs; she is precluded from climbing ropes, ladders, or scaffolds; she can occasionally tolerate dust, fumes, gases, and odors; she is precluded from outdoor work; she is limited to occasional exposure to concentrated cold and humidity; she must avoid all moving mechanical parts on all moving machinery and must avoid work around unprotected heights; and she is limited to occasional interaction with supervisors, coworkers, and the public. She is also limited to only occasional fingering.(Admin. Tr. 17).
At step four, the ALJ found that Plaintiff could not engage in her past relevant work as a hand packer, laborer/stores, and cook's helper because it exceeded the exertional limits her RFC during the relevant period. (Admin. Tr. 24). At step five, the ALJ found that, considering Plaintiff's RFC during the relevant period and vocational factors, there were jobs that existed in significant numbers that Plaintiff could perform. (Admin. Tr. 24). The ALJ specifically identified the following representative occupations as examples to support her decision: call out operator (DOT #237.367-014), dowel inspector (DOT #669.687-014), and carding machine operator (DOT #681.685-030). (Doc. 25). Based on these findings, the ALJ concluded that Plaintiff did not meet the statutory definition of "disabled" under the Social Security Act at any point between January 31, 2013, and June 6, 2014.
In his RFC assessment the ALJ limits Plaintiff to jobs where she would have no exposure to moving mechanical parts on all moving machinery. One of the occupations identified by the VE is carding machine operator (DOT #681.685-030). Although the name of this occupation suggests it would require some exposure to moving machinery, the Dictionary of Occupational Titles and its companion publication the Selected Characteristics of Occupations Defined in the Revised Dictionary of Occupational Titles explain that this occupation involves no exposure to moving mechanical parts. DOT #681.685-030, 1991 WL 678151.
B. WHETHER THE ALJ ERRED AT STEP TWO BY CONFLATING HER ANALYSIS OF SEVERITY AND DURATION
As alluded to in Section I of my Report, Plaintiff did not allege any impairment due to posttraumatic stress disorder during the initial application process. In connection with the initial denial of Plaintiff's applications, non-examining State agency psychological consultant Michael Suminski, Ph.D. ("Dr. Suminski") noted that Plaintiff was diagnosed with bipolar disorder, and panic disorder with agoraphobia. (Admin. Tr. 169). Plaintiff did not allege any impairment due to posttraumatic stress disorder during her administrative hearing.
In her decision, the ALJ found that, "[t]he claimant has posttraumatic stress disorder; however there is no indication in the record that this condition has persisted for at least twelve continuous months." (Admin. Tr. 15).
Plaintiff argues:
In the decision, the ALJ found White's posttraumatic stress disorder (PTSD) to be a non-severe impairments [sic]. (Tr. at 15) The ALJ should have followed the "slight abnormality" standard to assess the severity of this impairment according to SSR 96-3p.(Doc. 12, p. 16).
Had the ALJ appropriately found this impairment severe, it would have impacted the outcome of this case. White was sexually abused from the age of 6- 23 by two men. (Tr. at 417-18, 660) She became physically aggressive and violent towards others. Id. She is paranoid, distrustful and easily agitated due to her past event. Id. Had the ALJ properly considered PTSD as a severe impairment, the ALJ would have been forced to concede that White has severe limitations when interacting with others, which stems from her PTSD.
By considering White's PTSD a non-severe impairment, the ALJ violated 20 CFR § 404.1521 and SSR 96-3p. Therefore, the decision should be reversed or remanded with proper instruction so that White's PTSD can be properly evaluated in light of the evidence within the entire record and in fabrication of the residual functional capacity as required by the regulations.
In response the Commissioner argues:
Plaintiff argues that the ALJ erred in evaluating her mental impairments at step two of the sequential evaluation process because she did not find post-traumatic stress disorder (PTSD) to be "severe" (Pl.'s Br. at 15-16). However, the ALJ explained that she did not find that this condition was "severe" because Plaintiff failed to prove that it met the Act's durational requirement (Tr. 15).(Doc. 16, pp. 4-5).
. . . .
In support of her argument that the ALJ should have found PTSD to be severe, Plaintiff points to Dr. Crosson's psychological consultative examination (Pl.'s Br. at 16, Tr. 417-18), and Dr. Taswir's psychiatric evaluation (Pl.'s Br. at 16, Tr. 660-62). However, neither of these evaluators diagnosed Plaintiff with PTSD. Rather, Dr. Crosson diagnosed bipolar II disorder and panic disorder with agoraphobia (Tr. 420), and Dr. Taswir diagnosed mood disorder, not otherwise specified (Tr. 661). When questioned by the ALJ at her May 21, 2014 administrative hearing, Plaintiff agreed that the reasons she was unable to work were "bipolar, depression, and HIV," and her attorney did not mention PTSD when the ALJ asked him to name any other medically determinable impairments that she should consider in her decision (Tr. 39). Although the record contains a single mention of a diagnosis of PTSD in Plaintiff's February 25, 2014 discharge paperwork from T.W. Ponessa & Associates Counseling (four months prior to the ALJ's decision), there is no evidence that this condition was diagnosed at any other time.
Because Plaintiff failed to prove that her single diagnosis of PTSD, four months prior to the ALJ's decision, met the Act's durational requirement, substantial evidence supports the ALJ's finding that this condition was nonsevere.
At step two of the sequential evaluation process, the ALJ considers whether a claimant's impairment is (1) medically determinable or non-medically determinable, and (2) severe or non-severe. 20 C.F.R. § 404.1520(a)(4)(ii); 20 C.F.R. § 416.920(a)(4)(ii); SSR 85-28, 1985 WL 56856.
Under the Commissioner's regulations, an impairment is "non-severe" if it "does not significantly limit [a claimant's] physical or mental ability to do basic work activities." 20 C.F.R. § 404.1521; 20 C.F.R. § 416.921. Conversely, an impairment is "severe" if it does significantly limit a claimant's physical or mental ability to do basic work activities. The phrase, "significantly limits," however is not synonymous with "disability." Rather, the ALJ's analysis at step two is a threshold test designed to screen out de minimis claims.
In this case, the ALJ appears to conflate the two analytically distinct concepts of severity and duration. Unlike the severity analysis, the question of impairment duration requires the ALJ to evaluate whether the impairment has lasted, or is expected to last, for a continuous period of at least twelve (12) months. 42 U.S.C. § 423(d)(1)(A); 42 U.S.C. § 1382c(a)(3)(A). Other Courts have found legal error when a decision inappropriately conflates the analysis of severity and duration. See Snedeker v. Colvin, No. 3:13-cv-970, 2015 WL 1126598, at *4 (N.D.N.Y. Mar. 12, 2015); Gray v. Astrue, No. 04-cv-3736, 2009 WL 1598798 at *5 (S.D.N.Y. June 8, 2009); Stadler v. Barnhart, 464 F. Supp. 2d 183, 189 (W.D.N.Y. 2006) ("To state that an impairment is not severe because it does not meet the twelve-month requirement, then, is inconsistent with the Commissioner's own interpretation of the regulations."). Because the ALJ improperly conflated the issues of impairment duration with impairment severity at step two, I find that the ALJ's conclusion that Plaintiff's impairment due to PTSD is non-severe because it does not meet the durational requirement is error.
Having found that the ALJ committed legal error at step two, I must next consider whether this error warrants remand. Under the Commissioner's regulations, all impairments, both severe and non-severe, must be accounted for in an ALJ's RFC assessment.
As explained in McClease v. Comm'r of Soc. Sec.,
[E]ven if an ALJ erroneously determines at step two that one impairment is not "severe," the ALJ's ultimate decision may still be based on substantial evidence if the ALJ considered the effects of that impairment at steps three through five. However, where it appears that the ALJ's error at step two also influenced the ALJ's RFC analysis, the reviewing court may remand the matter to the Commissioner for further consideration. See Nosse v. Astrue, No. 08-[CV-1173, 2009 WL 2986612, *10] (W.D. Pa. Sept. 17, 2009).No. 8-CV-1673, 2009 WL 3497775, *10 (E.D. Pa. Oct. 28, 2009); see also Salles v. Comm. of Soc. Sec., 229 F. App'x. 140, 145, n.2 (3d Cir. 2007) ("Because the ALJ found in Salles's favor at Step Two, even if he had erroneously concluded that some of her impairments were non-severe, any error was harmless."). Even though the ALJ found that Plaintiff's PTSD was non-severe, the ALJ was still required to evaluate any limitation resulting from this impairment at each step of the sequential evaluation process. 20 C.F.R. § 404.1545(a)(2) ("We will consider all of your medically determinable impairments of which we are aware, including your medically determinable impairments that are not 'severe,' . . . when we assess your residual functional capacity."); see also 20 C.F.R. § 416.945(a)(2). Therefore, I find that this error is harmless. However, because I have found an alternative basis for remand, I recommend that the ALJ correct this error on remand by properly analyzing Plaintiff's PTSD at step two of the sequential evaluation process.
C. WHETHER THE ALJ PROPERLY EVALUATED THE MEDICAL OPINION EVIDENCE OF RECORD
The Commissioner's regulations define medical opinions as "statements from acceptable medical sources that reflect judgments about the nature and severity of your impairment(s), including your symptoms, diagnosis and prognosis, what you can still do despite impairment(s), and your physical or mental restrictions." 20 C.F.R. § 404.1527(a)(1); 20 C.F.R. § 416.927(a)(1). Regardless of its source, the ALJ is required to evaluate every medical opinion received. 20 C.F.R. § 404.1527(b); 20 C.F.R. § 416.927(b).
In deciding what weight to accord competing medical opinions, the ALJ is guided by factors outlined in 20 C.F.R. § 404.1527(c) and 20 C.F.R. § 416.927(c). Under some circumstances, the medical opinion of a "treating source" may even be entitled to controlling weight. 20 C.F.R. § 404.1527(a)(2) (defining treating source); 20 C.F.R. § 416.927(a)(2); 20 C.F.R. § 404.1527(c)(2) (explaining what is required for a source's opinion to be controlling); 20 C.F.R. § 416.927(c)(2).
Where no medical opinion is entitled to controlling weight, the Commissioner's regulations direct the ALJ to consider the following factors, where applicable, in deciding the weight given to any non-controlling medical opinion: 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. § 404.1527(c); 20 C.F.R. § 416.927(c).
Furthermore, the ALJ's articulation of the weight accorded to each medical opinion must be accompanied by "a clear and satisfactory explication of the basis on which it rests." Cotter, 642 F.2d at 704. This principle applies with particular force to the opinion of a treating physician. See 20 C.F.R. § 404.1527(c)(2); 20 C.F.R. § 416.927(c)(2) ("We will always give good reasons in our notice of determination or decision for the weight we give your treating source's medical opinion."). "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).
1. Whether the ALJ Properly Evaluated the Opinion of Consultative Examiner, Dr. Dawn Crosson
In her brief, Plaintiff addresses the medical opinions in order of significance based on treatment relationship. I have chosen to address them in chronological order as I find that it provides more insight into the basis for each opinion.
On January 31, 2013, Plaintiff was examined by Dr. Crosson in connection with Plaintiff's applications for benefits. (Admin. Tr. 417-423). Dr. Crosson completed a narrative report, and a medical source statement. Id. In her narrative report, under a section called "Effect of Impairment on Functioning," Dr. Crosson stated:
With regard to ability to perform activities of daily living, Ms. White reported that she is unable to attend appointments without a companion. When not in a manic state, she is constantly fatigued and remains in bed. She is able to complete chores when she has bouts of mania. Otherwise, she lacks energy and motivation. Her mood is further impacted by her medical diagnosis.
Socially, Ms. White is isolated and withdrawn. She remains in her room as she is unable to tolerate people.
Regarding impulse control, Ms. White has a history of incarcerations, drug abuse, promiscuity and physical aggression.(Admin. Tr. 420-21). In her medical source statement, Dr. Crosson assessed that Plaintiff's mental impairments would result in the following limitations to her ability to understand, remember and carry out instructions: moderate difficulty carrying out short, simple instructions; moderate difficulty understanding and remembering detailed instructions; moderate difficulty carrying out detailed instructions; moderate difficulty making judgments on simple work-related decisions; and slight difficulty understanding, remembering short, simple instructions. (Admin. Tr. 422-23). Dr. Crosson explained that "Ms. White's memory appears compromised and slow. She has racing thoughts and is anxious." Id. Dr. Crosson assessed that Plaintiff's mental impairments would result in the following workplace social limitations: extreme difficulty interacting appropriately with co-workers; extreme difficulty responding appropriately to pressures in a usual work setting; extreme difficulty responding appropriately to changes in a routine work setting; marked difficulty interacting appropriately with the public; and marked difficulty interacting appropriately with supervisors. Id. Dr. Crosson explained that "Ms. White is impulsive, easily overwhelmed and prone to physical aggression and property destruction." Id.
With regards to concentration, persistence and pace, Ms. White has difficulty sustaining attention. Her memory is poor and she is forgetful.
Ms. White' [sic] may not be able to sustain attention, concentration or pace to satisfactorily perform in an 8 our work day/40 hours per week.
The ALJ accorded "limited" weight to the opinion of Dr. Crosson. She explained:
As for the global assessment of functioning of 38 assessed on January 31, 2013 by Dawn G. Crosson, Psy.D., the consultative psychological examiner, and Dr. Crosson's accompanying assessment finding that the claimant has slight limitations understanding and remembering short, simple instructions, moderate limitations in carrying out short, simple instructions, understanding, remembering and carrying out detailed instructions, and making judgments on simple work-related decisions, marked limitations in interacting appropriately with the public and supervisors, and extreme limitations in interacting appropriately with coworkers. Responding appropriately to work pressures in a usual work setting, and responding appropriately to changes in a routine work setting and that she may not be able to sustain attention, concentration, or pace to satisfactorily perform an 8-hour workday/40 hours per work week (Ex. B-5F), they have been assigned limited weight. Dr. Crosson's assessment was based on a onetime examination of the claimant and was based in large part on the subjective allegations of the claimant, which as already indicated are not entirely credible. Moreover, Dr. Crosson's assessments/opinions are inconsistent with her own above-discussed relatively benign clinical findings and are also not supported by the other substantial evidence of record.(Admin. Tr. 23).
Plaintiff argues:
In this case, the ALJ gave Dr. Crossen's [sic] opinion "little" weight because it was based on a onetime examination of the claimant and
was based in large part on the subjective allegations of the claimant, which as already indicated, are not entirely credible." (Tr. at 23)(Doc. 12, p. 24).
However, Dr. Crossen's [sic] opinion is corroborated by that of the treatment notes from TW Ponessa, Holy Spirit Hospital, Dr. Goldman, and Dr. Crossen's [sic] own observations. Numerous treatment notes indicated that White has marked limitations in social functioning and concentration, persistence, and pace. Medical professionals have noted that White is physically aggressive (Tr. at 417-18); has explosive aggressive behaviors (Tr. at 417-18); has engaged in stabbing, fighting, and assaulting others with razors (Tr. at 417-18, 544); experiences rage, anger, and manic episodes (Tr. at 417-18, 660); and reported homicidal ideations and "has been hurting men for over 20 years (Tr. at 418, 549)."
The Commissioner argues:
Dr. Crosson did not have the benefit of reviewing the other evidence of record, which revealed an extremely limited treatment history for any mental impairments, that Plaintiff had never been fired for a failure to get along with others, and that she had virtually unlimited activities of daily living. The only aspect of the record consistent with Dr. Crosson's extreme limitations was Plaintiff's statements to Dr. Crosson that she was physically aggressive towards others, paranoid, easily agitated and aggravated, had bouts of mania that lasted up to seven days, had auditory hallucination and delusions, often sat in the dark crying due to depression, lacked energy and motivation, had panic attacks with physical manifestations, and was unable to be without a companion on most days (Tr. 417). However, the ALJ justifiably found that these exaggerated subjective complaints were not fully credible (Tr. 20).(Doc. 16, pp. 13-14).
Because the record as a whole did not support Dr. Crosson's opinion that Plaintiff suffered from work-preclusive mental limitations, the ALJ reasonably assigned her opinion only limited weight
The record contains very little evidence relating to Plaintiff's mental health impairments. This lack of evidence may have contributed to the decision of the State agency to order a consultative examination during the initial stage of administrative review. 20 C.F.R. § 404.1519a(b) ("We may purchase a consultative examination . . . when the evidence as a whole is insufficient to allow us to make a determination or decision on your claim."); see also 20 C.F.R. § 416.919a(b).
First, the ALJ observes that Dr. Crosson's assessment was based on a onetime examination of the claimant and relies on this factor as a basis to discount Dr. Crosson's assessment. I do not find that, based on this record, the nature of Dr. Crosson's examining relationship with Plaintiff lends much support to the ALJ's decision to discount the opinion. On this issue, the regulations provide that, "[g]enerally, we give more weight to the opinion of a source who has examined you than to the opinion of a source who has not examined you," and that "[g]enerally, we give more weight to 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)." 20 C.F.R. § 404.1527(c)(1), (2); 20 C.F.R. § 416.927(c)(1), (2). The ALJ in this case, however, discounted the opinions Plaintiff's treating source (Dr. Goldman), nontreating source who examined Plaintiff once (Dr. Crosson), and non-examining source (Dr. Suminski) alike. Although the treating and examining relationship is a factor that may aid the ALJ in choosing between conflicting medical opinions where the medical sources have varying degrees of familiarity with Plaintiff and her history, it lends little support here because no opinion by a source with a closer treating relationship is credited.
Next, the ALJ supports her decision to discount Dr. Crosson's opinion because "Dr. Crosson's assessments/opinions are inconsistent with her own above-discussed relatively benign clinical findings and are also not supported by the other substantial evidence of record." (Admin. Tr. 23). The "above-discussed" clinical findings to which the ALJ refers are as follows:
Dawn G. Crosson, Psy.D. performed a consultative psychological evaluation of the claimant on January 31, 2013. It was noted that the claimant denied a history of psychiatric hospitalizations but did attend outpatient therapy and was discharged because of missing several appointments. Upon mental status examination, she was neatly and appropriately dressed; eye contact was good; rapport was established; rate of speech was normal; there was no evidence of speech impairment; she denied current suicidal ideation; she was able to maintain the topic of conversation; she denied a history of visual hallucinations; social judgment was adequate; and memory appeared to be fair (Ex. B-5F).(Admin. Tr. 20-21). However, Dr. Crosson's complete report of her findings on mental status examination are as follows:
Ms. White was neatly and appropriately dressed. She gave good eye contact and rapport was established. Ms. White's mood was initially irritated and anxious. However, as the interview progressed her mood elevated. Ms. White cried intermittently throughout the interview. Her
rate of speech was normal and there was no evidence of speech impairment.(Admin. Tr. 419-420) (emphasis added). By comparison, the ALJ's discussion of Dr. Crosson's observations omits the most serious symptoms identified in the report, symptoms which may be more supportive of the limitations assessed by Dr. Crosson, including: Plaintiff cried throughout the examination and, although she was not suicidal that day, often thought about "jumping in the river"; auditory hallucinations; homicidal ideation that she had acted upon days earlier by attempting to stab her paramour; and long term memory deficits. Id. The ALJ failed to address these significant symptoms in her treatment of Dr. Crosson's opinion, and merely dismisses them as subjective statements by Plaintiff that are not credible. Given that Dr. Crosson, Dr. Goldman, and Dr. Suminski are in agreement that Plaintiff suffers from limitations beyond what was accounted for by the ALJ at step three and in her RFC assessment, and that these symptoms were recorded in the "mental status examination" section of Dr. Crosson's report (which is a section typically reserved for objective rather than subjective findings by a clinician), I find that the ALJ's stated rationale for discounting Dr. Crosson's opinion is not supported by the record.
Ms. White was able to maintain the topic of conversation.
Ms. White denied current suicidal ideations. Though, she admitted that she often think [sic] about jumping in the river. Ms. White denied a history of visual hallucinations but admitted to having auditory hallucinations. Ms. White reported a history of homicidal ideations as recent as two days ago. She attempted to stab her paramour. Ms. White contracted with the evaluator to not harm herself or others.
Ms. White's abstract thinking appeared adequate as she was able to conceptualize the statement "no use crying over spilt milk" to mean "it's done and over, nothing you can to [sic] change it."
When asked what is the thing to do if she found an addressed sealed envelope with a new stamp on it lying in the street, she relayed that she would "put it in the mailbox" suggesting that her social judgment may be adequate.
Ms. White's insight appears to be reasonable as she recognizes the need for therapy and a medication regime.
Ms. White reported that she thinks most about her grandchildren.
Ms. White's memory appeared to be fair. She becomes upset when she is unable to recall the details of the trauma. She noted long-term memory deficits. She also relayed that her comprehension is substandard.
Ms. White appeared to be a reasonable reporter of the events that occurred.
2. Whether the ALJ Properly Evaluated the Opinion of State Agency Medical Consultant, Dr. Michael Suminski
On February 20, 2013, Dr. Suminski completed a psychiatric review technique ("PRT") evaluation and assessed Plaintiff's mental RFC based on a review of the medical records available as of the date he issued his opinion. (Admin. Tr. 166-67, 168-170). In his PRT evaluation, Dr. Suminski assessed that Plaintiff had medically determinable impairments that did not precisely satisfy the diagnostic criteria ("paragraph A" criteria) of 12.04 and 12.06 of 20 C.F.R. Part 404, Subpart P, Appendix 1. Id. He assessed that Plaintiff's mental impairments resulted in: a moderate restriction of activities of daily living; moderate difficulty maintaining social functioning; moderate difficulty in maintaining concentration, persistence, or pace; and no episodes of decompensation. Id.
In his mental RFC assessment, Dr. Suminski opined that Plaintiff suffered from moderate limitations in the following areas: understanding and remembering detailed instructions; carrying out detailed instructions; maintaining attention and concentration for extended periods; and interacting appropriately with the general public. Id. Dr. Suminski assessed no other significant limitations. Id. He concluded that "[t]he capacity for simple routine work tasks and [competitive placement plan ("CPP")] is intact." (Admin. Tr. 170). In support of this assessment, he explained:
The claimant is [diagnosed] with Bipolar D.O. and Panic D.O. with Agoraphobia. She reportedly receives [outpatient psychiatric treatment] but the [treating physician] did not provide records.
She attended a recent MSCE with Dr. Crosson. The mental status showed that she was nearly [sic] and appropriately dressed and made good eye contact. She denied current [suicidal ideation] but admitted to [homicidal ideation] 2 days prior to the MSCE. Her social judgment was deemed adequate, memory appeared fair. Thus, there are some limitations based on her mental disorders but the narrative report and the [activities of daily living ("ADLs")] show that the capacity for simple routine work tasks and CPP is intact. She is not always compliant with recommended [psychiatric treatment].
She cares for her personal hygiene, prepares meals, does laundry, goes out alone, uses public transportation, shops in stores for food and clothing and manages money. She can be appropriate socially and states that she talks on the phone. She has a friend that she does activities with. The report of Dr. Crosson has some internal inconsistencies. It is thought to have limitations and to overestimate the degree of impairment. The [Medical Source Opinion] appears to be an overestimate of the degree of impairment and is inconsistent with the ADLs.(Admin. Tr. 169-170).
The report of Dr. Crosson is given limited [weight] in the RFC assessment. The claimant's statements are partially credible.
The ALJ accorded "partial" weight to the March 2013 opinion of Dr. Suminski. She explained:
the undersigned has accorded partial weight to the March 20, 2013 opinion of the State agency psychological consultant finding that the claimant's mental impairments result in moderate restriction of activities of daily living, moderate difficulties in maintaining social functioning, moderate difficulties maintaining concentration, persistence, or pace, and no repeated episodes of decompensation, each of extended duration and that she retains the capacity for simple, routine work tasks (Exs. B-3A and B-5A), as the moderate limitations in restriction of activities of daily living and in maintaining concentration, persistence and pace, and the limitation to simple routine work tasks overstate the claimant's functional limitations in light of the relatively benign clinical findings and the limited degree of treatment required for a mental health impairment.(Admin. Tr. 23).
Plaintiff argues:
the state psychological consultant is a non-treating and nonexamining source. Therefore, his opinion is entitled to little, if any, weight because his opinion is not supported by substantial medical evidence of record. In fact, his opinion is contradicted by White's treating and examining sources Dr. Goldman and consultative examiner Dr. Crossen. Opinions from treating sources, like that of Dr. Pilania [sic], are entitled to "great weight [and at times controlling weight], especially when...based on continuing observation of the patient's condition over a prolonged period of time." Morales v. Apfel, 225 F. 3d 310, 317 (3d Cir. 2000); SSR 96-2p. The state agency medical consultant never met nor did he have the opportunity to observe her functioning. Therefore, the ALJ erred by assigning greater weight to his opinion over that of treating and examining sources Dr. Goldman and Dr. Crossen.(Doc. 12, p. 26).
The Commissioner argues:
[I]t is well-established in the Third Circuit that where "the opinion of a treating physician conflicts with that of a non-treating, non-examining physician, the ALJ may choose whom to credit." See Morales v. Apfel, 225 F.3d 310, 317 (3d Cir. 2000). The opinions of state agency physicians are entitled to consideration under the same regulations used to assess other medical opinions. See 20 C.F.R. §§ 404.1527(e), 416.927(e). Where the record provides greater support for a non-examining state agency physician opinion, an ALJ may afford it greater weight than an examining or treating physician opinion. Chandler v. Comm'r of Soc. Sec., 667 F.3d 356, 361-62 (3d Cir. 2011).
The ALJ explained that she found Dr. Suminski's opinion to be entitled to "partial weight" because she agreed that Plaintiff's mental impairments were limiting, but not work-preclusive (Tr. 23). However, the ALJ found Dr. Suminski's assessment to be an overstatement of Plaintiff's limitations in light of the relatively benign clinical findings and the limited degree of treatment that Plaintiff required for a mental impairment (Tr. 23).
The record showed that Plaintiff attended an intake evaluation at the CMU Adult Mental Health Clinic on June 17, 2012, at which a mental status examination revealed normal findings (Tr. 22, 444), her problems were assessed as being "mild," and her GAF score was rated at 55, reflecting only moderate psychological symptoms (Tr. 446). However, it does not appear that she attended any additional appointments. Plaintiff then signed up for counseling at T.W. Ponessa & Associates in February of 2013, but was discharged for noncompliance with her appointment schedule after attending only two counseling sessions (Tr. 575-76). However, it was reported that Plaintiff began filling her idle time with productive and pro-social activities (Tr. 21, 575). In March 2013, Plaintiff started psychiatric treatment at Holy Spirit Hospital, and by November 2013, her mental status examination was reported to be completely normal with her medications, apart from some paranoid thought content (Tr. 21, 672). In January of 2014, Plaintiff again signed up for counseling at T.W. Ponessa, but was discharged for noncompliance after she failed to make any additional appointments after her initial treatment session, despite her therapist's attempts to re-engage her in treatment (Tr. 22, 673). As discussed above, Dr. Crosson reported fairly normal mental status findings at her consultative examination (Tr. 419). This limited history of treatment, and consistently unremarkable objective findings supported the ALJ's assessment that Plaintiff's mental limitations were somewhat less severe than those found by Dr. Suminski.(Doc. 16, pp. 15-17) (internal footnote omitted).
Although the ALJ did not fully adopt Dr. Suminski's opinion, she explained that she found it to be entitled to more weight than Dr. Goodman's and Dr. Crosson's because it was more consistent with the evidence as a whole. Thus the ALJ provided a legally adequate, factually supported reason for the weight that she assigned to the various physician opinions.
As an initial matter, the ALJ's stated rationale for discounting Dr. Suminski's opinion is somewhat vague. Plaintiff argues that this opinion must be discounted because it is not supported under 20 C.F.R. § 404.1527(c)(3) and 20 C.F.R. § 416.927(c)(3) (explaining that the more a medical source presents relevant evidence to support an opinion, the more weight it will be given). I construe this as an argument that the opinion was improperly discounted under this provision. In contrast, the Commissioner asserts that it was properly discounted under 20 C.F.R. § 404.1527(c)(4) and 20 C.F.R. § 416.927(c)(4) (explaining that the more consistent an opinion is with the record as a whole, the more weight it will be given). The actual language used by the ALJ does not reference either consistency or supportability. Instead, she merely notes that "the moderate limitations in restriction of activities of daily living and in maintaining concentration, persistence and pace, and the limitation to simple routine work tasks overstate the claimant's functional limitations in light of the relatively benign clinical findings and the limited degree of treatment required for a mental health impairment." (Admin. Tr. 23). Although ALJs are not required to use particular language in their written decisions, in this case it is difficult to ascertain whether the ALJ intended to discount Dr. Suminski's opinion because it was not supported by the record, or because it was inconsistent with the record.
The mental health records in this case are limited to: Dr. Crosson's January 31, 2013 examination, (Admin. Tr. 417-421); a March 2013 psychiatric evaluation by psychiatrist Rahat Taswir ("Dr. Taswir") and nine (9) follow-up visits (five of which were "no show" appointments), (Admin. Tr. 660-672); and notes from counseling sessions at T.W. Ponessa (Plaintiff began therapy in February 2013, and was discharged in September 2013, then began again in January 2014 and was discharged at the end of February 2014. Both discharges were due to Plaintiff's failure comply with the attendance policy). (Admin. Tr. 575-581, 673-678).
Dr. Crosson's examination report and opinion are summarized in Section III.D.1. of this Report.
Between February 27, 2013 and September 19, 2013, Plaintiff was participating in outpatient therapy at T.W. Ponessa with Therapist Matthew Berliant, LSW ("Therapist Berliant"). (Admin. Tr. 575). Plaintiff's discharge summary reflects that she was diagnosed with: bipolar disorder, not otherwise specified ("NOS"); alcohol abuse, early full remission; cocaine abuse, full remission by self report; cannabis abuse, full remission by self report; sexual abuse of child (victim); posttraumatic stress disorder; and a "rule out" diagnosis of anxiety disorder. Id. As of her discharge, Plaintiff's current GAF score was reported to be 50. Id. It was noted that Plaintiff was being discharged because she missed five (5) sessions without notifying the Therapist in advance. Id. She was encouraged to contact CBHNP and/or Dauphin County MH/MR for other providers in the area. Id.
During his March 2013 examination, Dr. Taswir characterized the history of Plaintiff's mental health impairment as follows:
The patient is s 39-year old single African-American female with a history of mood disorder. She is currently seeing a therapist through TW Ponessa who suggested to her that she should seek help and get on some type of mood stabilizer medication. The patient reports significant issues with anger, rage, which she believes has been getting worse. She recently got into an altercation with a 15-year old and she has been charged with simple assault. She has a history of abusive behavior towards others. She had some self injurious behaviors in her past. At times she hears voices. She denied any command hallucinations. She admitted to racing thoughts and sleep problems. No anxiety attacks, no panic attacks, no obsessive compulsive disorder behavior.(Admin. Tr. 660). On mental status examination, Dr. Taswir reported:
The patient presented as an adequately groomed African-American female who looked her stated age. She came about 20 minutes late for her initial session as she got lost on her way here. Her head was all covered with a black scarf which appeared to be a religious garb to me. She was cooperative with the session, not very expressive. She did not display agitation, aggressiveness. Her affective [sic] was significantly restricted. No suicidal or homicidal thoughts. She reported some auditory hallucination experiences. No command hallucinations. No visual or tactile hallucinations. Thought processing was goal directed, coherent. Insight seemed somewhat limited. History noticeable for impulsive behaviors.(Admin. Tr. 661).
Plaintiff provided a more detailed account of this altercation during her hearing. (Admin. Tr. 80-81). Plaintiff reported that the argument began while she was counseling the fifteen (15) year old son of her best friend's boyfriend that he should not engage in behavior that would jeopardize the child's athletic scholarship. Id. At some point, Plaintiff stood up, someone grabbed her, and she scratched her assailant's face. Id. A melee broke out amongst everyone in the vicinity. Id. At its conclusion Plaintiff was accused of biting someone's face, which Plaintiff vehemently denies. Id. Following the incident, Plaintiff was charged with simple assault. Id.
On April 18, 2013, Dr. Taswir reported in a check-box mental status evaluation that Plaintiff presented with: normal appearance, good hygiene, calm mood, appropriate affect, euthymic (stable) mood, coherent thought processes, normal thought content, no hallucinations, intact memory, and no suicidality or homicidality. (Admin. Tr. 665). The hand-written portion of the treatment note for this examination is illegible. Id.
On May 9, 2013, Dr. Taswir reported in a check-box mental status evaluation that Plaintiff presented with: normal appearance, good hygiene, calm behavior, a restricted affect, frustrated mood, coherent thought process, normal thought content, no hallucinations, intact memory, and no suicidality or homicidality. (Admin. Tr. 666). The handwritten portion of the treatment note reports that Plaintiff had to go to court for simple harassment/assault, and broke up with her boyfriend who she planned to marry. Id. It also notes that she punched a man because he took a "swing" at her. Id.
On August 7, 2013, Dr. Taswir noted that Plaintiff presented with a normal appearance but felt paranoid. (Admin. Tr. 670). Plaintiff reported that she felt like someone was watching her all the time. Id. She also reported that her anger is "better." Id.
On November 13, 2013, Dr. Taswir reported in a check-box mental status evaluation that Plaintiff presented with: normal appearance, good hygiene, calm behavior, appropriate affect, euthymic (stable) mood, coherent thought process, paranoid thought content, no hallucinations, intact memory, and no suicidality or homicidality. (Admin. Tr. 672). Plaintiff reported that everything was going "pretty good," but did have paranoid thoughts. Id. She believed that someone was watching her all the time. Id. Plaintiff was struggling to sleep. Id.
Between January 3, 2014, and February 25, 2014, Plaintiff resumed outpatient therapy at T.W. Ponessa with Therapist Berliant. (Admin. Tr. 673). Plaintiff attended one session and did not schedule a second appointment despite the Therapist's attempts to re-engage her in treatment. Id. Therapist Berliant characterized Plaintiff's current strength and behaviors of concern as follows:
Christine is a 40 year old female who is seeking outpatient counseling and psychiatric services in order to address symptoms of "of [sic]
bipolar and depression." Christine reports the following symptoms: paranoia ("always looking over her shoulder, somebody is always watching" has fear that someone can look through a small crack in the window), fear of being alone, depression, anger (throws stuff, breaks things, cuts things), panic attacks (when startled), and anxiety. . . . No past psychiatric hospitalizations are reported at this time. Current suicidal and/or homicidal ideations are denied. Self-injurious behaviors are denied. Christine reports hallucinations including seeing shadows. She reports hearing things prior to medication management.(Admin. Tr. 674-75). Plaintiff was discharged after 30 days of non-attendance. Id. Upon discharge, Therapist Berliant assessed that Plaintiff's GAF score was 55, and recommended that Plaintiff seek out other local providers. Id.
Returning to the ALJ's rationale, she characterized Dr. Suminski's opinion as an overstatement of Plaintiff's limitations is based on "the relatively benign clinical findings and the limited degree of treatment required for a mental health impairment." (Admin. Tr. 23). Although some of the mental health records in this case can fairly be characterized as "relatively benign," Plaintiff reports more significant symptoms on several occasions. The ALJ did not explain why these severe objective findings were discounted. Furthermore, the ALJ's reasoning that Plaintiff only required a limited degree of treatment is a mischaracterization of the record in this case. It is accurate that Plaintiff did not seek out consistent mental health treatment, however there is little information in the record suggesting that treatment was not required. It appears that Plaintiff was urged to return to treatment. The record contains no information as to why Plaintiff's mental health treatment was irregular. Because the ALJ's evaluation appears to mischaracterize the record, I find that remand is required for further review of Dr. Suminski's opinion.
3. Whether the ALJ Properly Evaluated the Opinion of Treating Source, Dr. John Goldman
On May 2, 2014, Dr. Goldman completed a check-box Human Immunodeficiency Virus (HIV) Infection Medical Assessment Form. (Admin. Tr. 708-713). In his May 2014 assessment, Dr. Goldman noted that Plaintiff's diagnoses were: HIV, asthma, bipolar disorder, depression, history of substance abuse, and insulin dependent diabetes mellitus. Id. Dr. Goldman reported that Plaintiff did not suffer from any of the opportunistic or indicator infections listed on the questionnaire and identified no "other" manifestations of HIV that resulted in significant signs or symptoms. Id. He did, however, identify that Plaintiff suffered from "marked" restrictions of activities of daily living, "marked" difficulties in social functioning, and "marked" difficulties in completing tasks in a timely manner due to deficiencies in concentration, persistence or pace. Id. Dr. Goldman did not, however, explain the basis for this assessment. Therefore, it is not clear whether he attributes the limitations assessed to Plaintiff's HIV, or to the other impairments identified at the beginning of his questionnaire—which include bipolar disorder and depression. Dr. Goldman also reported that Plaintiff's medications of Truvada (prescribed for HIV) and Seroquel (an antipsychotic prescribed for bipolar disorder and depression) caused drowsiness and sedation. Id.
The questionnaire explained: Social Security has provided the following examples of persons with HIV who exhibit "marked" limitations in the above three categories: activities of daily living: an individual with HIV infection who, because of the symptoms such as pain imposed by the illness or its treatment, is not able to maintain a household or take public transportation on a sustained basis without assistance (even though he or she is able to perform some self-care activities) would have marked limitation of activities of daily living. Social functioning: an individual with HIV infection who, because of symptoms or pattern of exacerbation and remission caused by the illness or its treatment, cannot engage in social interaction on a sustained basis (even though he or she is able to communicate with close friends or relatives) would have marked difficulty maintaining social functioning. Difficulties with concentration, persistence, or pace: an individual with HIV infection who, because of HIV related fatigue or other symptoms, is unable to sustain concentration or pace adequate to complete simple work-related tasks (even though he or she is able to do routine activities of daily living) would have marked difficulty completing tasks. (Admin. Tr. 711) (boldface in original).
With respect to Plaintiff's functional capacity, Dr. Goldman assessed that Plaintiff could: sit up to thirty (30) minutes at one time and for a total of less than two hours per eight-hour workday; stand for up to twenty (20) minutes at one time and for a total of less than two hours per eight-hour workday; walk up to four blocks at one time and walk for a total of less than two hours per eight-hour workday; frequently lift and carry less than ten (10) pounds; occasionally lift and carry ten pounds; and rarely lift or carry twenty (20) pounds. Id. Dr. Goldman also assessed that Plaintiff would frequently experience symptoms which interfere with the attention and concentration needed to perform simple work tasks during a typical workday. Id. He reported that, Plaintiff would not be able to tolerate the following aspects of "work stress": public contact; close interaction with coworkers/supervisors; fast paced tasks (e.g., production line); and exposure to work hazards (e.g., heights or moving machinery). Id.
The questionnaire defines "frequently" as "34% to 66% of an eight-hour working day." (Admin. Tr. 712). --------
In her decision, the ALJ accorded "limited" weight to the May 2014 assessment by Dr. Goldman. She explained:
Limited weight has been accorded to the May 2, 2014 assessment of John Goldman, M.D., a treating physician, finding that the claimant's impairments result in marked restriction of activities of daily living, marked difficulties in maintaining social functioning, and marked difficulties in completing tasks in a timely manner due to deficiencies in concentration, persistence, or pace that she would frequently experience symptoms which interfere with attention and concentration needed to perform even simple work tasks, that she is unable to perform or be exposed to public contact, close interaction with
coworkers/supervisors, fast paced tasks, and exposure to work hazards, that she can sit less than two hours per 8-hour workday and would like [sic] need to take unscheduled breaks three times during an average workday (Ex. B-21F). This assessment is not supported by the relatively benign clinical findings, which establish that the claimant is asymptomatic from an HIV standpoint and that her diabetes mellitus and asthma are controlled with appropriate treatment.(Admin. Tr. 23-24).
Plaintiff argues:
Contrary to the ALJ's reasoning, this opinion is supported by the record as a whole. Numerous treatment notes indicated that White has marked limitations in social functioning and concentration, persistence, and pace. Medical professionals have noted that White is physically aggressive (Tr. at 417-18); has explosive aggressive behaviors (Tr. at 417-18); has engaged in stabbing, fighting, and assaulting others with razors (Tr. at 417-18, 544); experiences rage, anger, and manic episodes (Tr. at 417-18, 660); and reported homicidal ideations and "has been hurting men for over 20 years (Tr. at 418, 549)." Furthermore, Dr. Goldman's opinion is corroborated by that of consultative examiner Dr. Dawn Crossen.(Doc. 12, p. 22).
The Commissioner argues:
Substantial evidence supports the ALJ's decision to give Dr. Goldman's extreme opinion little weight because "[t]his assessment is not supported by the relatively benign clinical findings, which establish that the claimant is asymptomatic from an HIV standpoint and that her diabetes mellitus and asthma are well controlled with appropriate treatment." (Tr. 24). Dr. Goldman's report from March 17, 2014 (just two months prior to Plaintiff's administrative hearing) reflected that Plaintiff's HIV viral load was undetectable on her medications, her blood sugars were well-controlled, and her respiratory effort was normal with her asthma medications (Tr. 686-
91). See 20 C.F.R. §§ 404.1527(c)(5), 416.927(c)(5) ("Generally, the more consistent an opinion is with the record as a whole, the more weight we will give to that opinion."); Kenyon v. Colvin, No. 3:12-CV-1812, 2013 WL 6628057, at *4 (M.D. Pa. Dec. 16, 2013) (Judge Conaboy) (finding that the ALJ properly discounted the weight of the treating physician's opinion because it was inconsistent with the physician's own records). Significantly, Dr. Goldman is a specialist in infectious diseases and internal medicine, and he did not treat Plaintiff for her alleged mental impairments. Therefore, his opinion regarding Plaintiff's mental limitations was entitled to limited weight, at best. See 20 C.F.R. §§ 404.1527(c)(5), 416.927(c)(5) (stating that more weight will be given to a specialist about medical issues related to his area of specialty).(Doc. 16, pp. 10-11).
Returning to the ALJ's rationale for discounting Dr. Goldman's opinion I find that it is not supported by substantial evidence. In support of her decision to discount Dr. Goldman's opinion, the ALJ's only stated rationale was that "assessment is not supported by the relatively benign clinical findings, which establish that the claimant is asymptomatic from an HIV standpoint and that her diabetes mellitus and asthma are controlled with appropriate treatment." (Admin. Tr. 23-24). Therefore, to the extent the Commissioner states an alternative reason for discounting the opinion, such as the fact that Dr. Goldman does not specialize in mental health treatment, I must reject this argument. Schuster v. Astrue, 879 F. Supp. 2d 461, 466 (E.D. Pa, 2012) ("'[t]he ALJ's decision must stand or fall with the reasons set forth in the ALJ's decision;' the Commissioner may not offer a post-hoc rationalization."). In reviewing the reasons set forth by the ALJ, I note that the ALJ assessed the status of Plaintiff's HIV, asthma, and diabetes mellitus, but does not address the diagnoses of bipolar disorder, depression—both of which the ALJ found to be medically determinable and severe at step two - and the extent to which these impairments could result in the limitations assessed by Dr. Goldman. As such, I find that the ALJ's evaluation of Dr. Goldman's opinion is not supported by substantial evidence.
D. PLAINTIFF'S REMAINING ARGUMENTS
Plaintiff also raised the following arguments in her Brief: In this appeal, Plaintiff raises seven (7) arguments:
(1) Did the ALJ err at Step Three by finding that Plaintiff did not meet or equal Listing 12.04 despite her PTSD, Bipolar Disorder, Depressive Disorder, and Mood Disorder?(Doc. 12, p. 2). Because I have found that remand is required for further review of the medical opinion evidence of record, I need not address Plaintiff's remaining arguments. To the extent any further error exists, it can be addressed on remand at the new administrative hearing. IV. RECOMMENDATION
(2) Does substantial evidence support the ALJ's RFC assessment?
(3) Did the ALJ err by improperly evaluating Plaintiff's GAF scores?
(4) Does substantial evidence support the ALJ's credibility evaluation?
(5) Did the Commissioner fail to meet her burden at Step Five to establish that there is other work in the national economy that Plaintiff could perform?
Accordingly, I RECOMMEND that Plaintiff's request for relief be GRANTED as follows:
(1) The Court issue an order remanding this matter to the Commissioner to conduct a new administrative hearing pursuant to sentence four of 42 U.S.C. § 405(g);Date: November 21, 2018
(2) Final Judgment should be issued by a separate order in favor of Christina White and against the Commissioner of Social Security; and,
(3) The Clerk of Court should CLOSE this case.
s/William I . Arbuckle
William I. Arbuckle
U. S. Magistrate Judge
NOTICE
The parties are placed on notice that pursuant to Local Rule 72.3:
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.Date: November 21, 2018
BY THE COURT
s/William I . Arbuckle
William I. Arbuckle
U.S. Magistrate Judge