Opinion
Civil Action 3:20-CV-02452
01-18-2022
ENAS ANDERSON, Plaintiff, v. KILOLO KIJAKAZI, [1] Defendant.
(MEHALCHICK, M.J.)
REPORT AND RECOMMENDATION
(BRANN, J.)
This is an action brought under Section 1383(c) of the Social Security Act and 42 U.S.C. § 405(g), seeking judicial review of the final decision of the Commissioner of Social Security (hereinafter, “the Commissioner”) denying Plaintiff Enas Anderson (“Anderson”)'s claims for a period of disability and disability insurance benefits (“DIB”) and supplemental security income (“SSI”) under Titles II and XVI of the Social Security Act. (Doc. 1). The matter has been referred to the undersigned United States Magistrate Judge to prepare a report and recommendation pursuant to the provisions of 28 U.S.C. § 636(b) and Rule 72(b) of the Federal Rules of Civil Procedure. For the reasons expressed herein, and upon detailed consideration of the arguments raised by the parties in their respective briefs, it is respectfully recommended that the Commissioner's decision be vacated and remanded.
I. Background and Procedural History
On December 27, 2018, Anderson filed applications for Title II and Title XVI benefits, respectively. (Doc. 14-5, at 2). In these applications, Anderson claimed disability beginning December 1, 2017. (Doc. 14-5, at 2). Anderson's claims were initially denied by the Social Security Administration (“SSA”) on March 13, 2019. (Doc. 14-2, at 13). Anderson filed a request for a hearing before an Administrative Law Judge (“ALJ”) on April 25, 2019. (Doc. 14-2, at 13). The hearing was held on December 18, 2019, before ALJ Richard E. Guida. (Doc. 14-2, at 12). In a written opinion dated January 22, 2020, the ALJ determined that Anderson was not disabled and therefore not entitled to the benefits sought. (Doc. 14-2, at 24). Anderson appealed the decision of the ALJ to the Appeals Council, who, on October 27, 2020, denied Anderson's request for review. (Doc. 14-2, at 2).
On December 29, 2020, Anderson commenced the instant action. (Doc. 1). The Commissioner responded on June 28, 2021, providing the requisite transcripts from the disability proceedings. (Doc. 13; Doc. 14). The parties then filed their respective briefs, with Anderson alleging that substantial evidence does not support the ALJ's decision, warranting reversal or remand. (Doc. 15; Doc. 16; Doc. 17).
II. Standards of Review
To receive benefits under Titles II or XVI of the Social Security Act, 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 12 months.” 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A); 20 C.F.R. §§ 404.1509, 416.909. 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 significant numbers in the national economy. 42 U.S.C. §§ 423(d)(2)(A), 1382c(a)(3)(B); 20 C.F.R. §§ 404.1505(a), 416.905(a). Additionally, to be eligible under Title II, a claimant must have been insured for disability insurance benefits. 42 U.S.C. § 423(a)(1)(a); 20 C.F.R. § 404.131.
A “physical or mental impairment” is defined as an impairment resulting from “anatomical, physiological, or psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques.” 42 U.S.C. §§ 423(d)(3), 1382c(a)(3)(D).
A. Administrative Review
In evaluating whether a claimant is disabled as defined in the Social Security Act, the Commissioner follows a five-step sequential evaluation process. 20 C.F.R. §§ 404.1520(a), 416.920(a). Under this process, the Commissioner must determine, in sequence: (1) whether the claimant is engaged in substantial gainful activity; (2) whether the claimant has a severe impairment; (3) whether the claimant's impairment meets or equals a listed impairment; (4) whether the claimant is able to do past relevant work, considering his or her residual functional capacity (RFC); and (5) whether the claimant is able to do any other work that exists in significant numbers in the national economy, considering his or her RFC, age, education, and work experience. 20 C.F.R. §§ 404.1520(a), 416.920(a). The claimant bears the initial burden of demonstrating a medically determinable impairment that prevents him or her from doing past relevant work. 20 C.F.R. §§ 404.1512(a), 416.912(a). Once the claimant has established at step four that he or she cannot do past relevant work, the burden then shifts to the Commissioner at step five to show that jobs exist in significant numbers in the national economy that the claimant could perform that are consistent with his or her RFC, age, education, and past work experience. 20 C.F.R. §§ 404.1512(a)(1), 416.912(a)(1).
B. Judicial Review
The Court's review of the Commissioner's final decision denying a claimant's application for benefits is limited to determining whether the findings of the final decision maker are supported by substantial evidence in the record. See 42 U.S.C. §§ 405(g), 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) (internal quotations omitted). The quantum of proof 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 if the ALJ ignores countervailing evidence or fails to resolve a conflict created by such evidence. Mason v. Shalala, 994 F.2d 1058, 1064 (3d Cir. 1993). 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).
The question before the Court, therefore, is not whether Johnston was disabled, but whether the Commissioner's determination that Johnston was 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.”); Burton v. Schweiker, 512 F.Supp. 913, 914 (W.D. Pa. 1981) (“The [Commissioner]'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). “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). If “the ALJ's findings of fact . . . are supported by substantial evidence in the record, ” the Court is bound by those findings. Knepp v. Apfel, 204 F.3d 78, 83 (3d Cir. 2000).
III. The ALJ's Decision
In a decision dated October 27, 2020, the ALJ determined Anderson “has not been under a disability, as defined in the Social Security Act, from December 1, 2017, through the date of this decision.” (Doc. 14-2, at 24). The ALJ reached this conclusion after proceeding through the five-step sequential analysis required by the Social Security Act. See 20 C.F.R. §§ 404.1520, 416.920(a). The ALJ determined that Anderson met the insured status requirements of the Social Security Act through June 20, 2020. (Doc. 14-2, at 15).
A. Step One
At step one, an ALJ must determine whether the claimant is engaging in substantial gainful activity (“SGA”). 20 C.F.R §§ 404.1520(a)(4)(i), 416.920(a)(4)(i). If a claimant is engaging in SGA, the Social Security Regulations (“SSR”) deem them not disabled, regardless of age, education, or work experience. 20 C.F.R. §§ 404.1520(b), 416.920(b). SGA is defined as work activity-requiring significant physical or mental activity-resulting in pay or profit. 20 C.F.R. §§ 404.1572, 416.972. In making this determination, the ALJ must consider only the earnings of the claimant. 20 C.F.R. §§ 404.1574, 416.974. The ALJ determined Anderson “has not engaged in [SGA] since December 1, 2017, the alleged onset date.” (Doc. 14-2, at 15). Thus, the ALJ's analysis proceeded to step two.
B. Step Two
At step two, the ALJ must determine whether the claimant has a medically determinable impairment that is severe or a combination of impairments that are severe. 20 C.F.R. §§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii). If the ALJ determines that a claimant does not have an “impairment or combination of impairments which significantly limits [their] physical or mental ability to do basic work activities, [the ALJ] will find that [the claimant] does not have a severe impairment and [is], therefore not disabled.” 20 C.F.R. §§ 1520(c), 416.920(c). If a claimant establishes a severe impairment or combination of impairments, the analysis continues to the third step. Here, the ALJ found that the medical evidence of record established the presence of the following medically determinable severe impairments: “anxiety disorder; major depressive disorder (MDD); and intellectual disability.” (Doc. 14-2, at 15).
C. Step Three
At step three, the ALJ must determine whether the severe impairment or combination of impairments meets or equals the medical equivalent of an impairment listed in the version of 20 C.F.R. Part 404, Subpt. P, App. 1 that was in effect on the fate of the ALJ's decision (20 C.F.R. §§ 404.1520(a)(4)(iii), 404.1525, 404.1526, 416.920(a)(4)(iii), 416.925, 416.926). The sections in this appendix are commonly referred to as “listings.” If the ALJ determines that the claimant's impairments meet these listings, then the claimant is considered disabled, otherwise the ALJ must proceed to and analyze the fourth step of the sequential analysis. 20 C.F.R. §§ 404.1520(d), 416.920(d). The ALJ considered listings related disorders); 12.05 (intellectual disorder); and 12.06 (anxiety and obsessive-compulsive disorders). (Doc. 14-2, at 16). The ALJ determined that none of Anderson's impairments, considered individually or in combination, met or equaled the criteria of listings in the version of 20 C.F.R. Part 404, Subpart P, Appendix 1 (20 C.F.R. §§ 404.1520(d), 404.1525, 404.1526, 416.920(d), 416.925, and 416.926). (Doc. 14-2, at 16).
D. Residual Functional Capacity
Between steps three and four, the ALJ determines the claimant's residual functional capacity (“RFC”), crafted upon consideration of the medical evidence provided. At this intermediate step, the ALJ considers all claimant's symptoms and “the extent to which [they] can reasonably be accepted as consistent with the objective medical evidence and other evidence.” 20 C.F.R. §§ 404.1529(a), 416.929(a). This involves a two-step inquiry according to which the ALJ must (1) determine whether an underlying medically determinable mental impairment or impairments could reasonably be expected to produce the claimant's symptoms; and, if so, (2) evaluate the intensity, persistence, and limiting effects of the claimant's symptoms to determine the extent to which they limit the claimant's functional limitations. See 20 C.F.R. §§ 404.1529(b)-(c), 416.929(b)-(c).
Anderson alleged that his impairments caused the following symptoms: thoughts of suicide, anxiety, depression, frustration, sad mood, feelings of worthlessness, flashbacks to a history of sexual assault, lack of energy and motivation, and feeling isolated. (Doc. 14-2, at 21). After examining his statements and the medical evidence, the ALJ found that Anderson's impairments could reasonably be expected to cause the alleged symptoms, but that his statements about the intensity, persistence, and the limiting effects of the symptoms were not entirely credible. (Doc. 14-2, at 20). The ALJ then went on to detail Anderson's medical records and treatment history. (Doc. 14-2, at 20-22).
Considering all evidence in the record, the ALJ determined that, during the relevant period, Anderson had the RFC “to perform a full range of work at all exertional levels, ” subject to the following non-exertional limitations:
[Anderson] is limited to simple and routine tasks involving only simple, work-related decisions, and with few, if any, work place changes, no production pace work, and only occasional interaction with supervisors, coworkers, and the public.
(Doc. 14-2, at 19).
E. Step Four
Step four requires the ALJ to determine whether the claimant had, during the relevant period, the RFC to perform the requirements of his or her past relevant work regardless of the claimant's age, education, and work experience. 20 C.F.R. §§ 404.1520(a)(4)(iv), 416.920(a)(4)(iv). Past relevant work is work that the claimant has done within the past 15 years, that was substantial gainful activity, and that lasted long enough for the claimant to learn how to do it. 20 C.F.R. §§ 404.1560(b), 416.920(a)(4)(iv). The ALJ considers whether the claimant retains the capacity to perform the particular functional demands and job duties of the past relevant work, either as the claimant actually performed it or as ordinarily required by employers throughout the national economy. Garibay v. Comm'r of Soc. Sec., 336 Fed.Appx. 152, 158 (3d Cir. 2009) (quoting SSR 82-6). “If the claimant can perform his [or her] past relevant work despite his limitations, he [or she] is not disabled.” Hess, 931 F.3d at 202 (citing 20 C.F.R. § 404.1520(a)(4)(iv)); see also 20 C.F.R. § 416.920(a)(4)(iv). Here, the ALJ noted that Anderson has no past relevant work. (Doc. 14-2, at 23). Therefore, the ALJ moved on to step five.
F. Step Five
At step five of the sequential analysis process, an ALJ considers the claimant's age, education, and work experience to see if a claimant can make the adjustment to other work. 20 C.F.R. § 404.1520(a)(4)(v); 20 C.F.R. § 416.920(a)(4)(v). These factors are not considered when evaluating a claimant's ability to perform past relevant work. 20 C.F.R. § 404.1560(b)(3); 20 C.F.R. § 416.960(b)(3). If a claimant has the ability to make an adjustment to other work, he or she will not be considered disabled. 20 C.F.R. § 404.1520(a)(4)(v); 20 C.F.R. § 416.920(a)(4)(v).
The ALJ made vocational determinations that Anderson was 20 years old on the alleged onset date and was defined as a younger individual age 18-49, on the alleged onset date by the SSR. 20 C.F.R. § 404.1563; 20 C.F.R. § 416.963. (Doc. 14-2, at 23). The ALJ also noted that Anderson “has at least a high school education and is able to communicate in English” as considered in 20 C.F.R. § 404.1564; 20 C.F.R. § 416.964. (Doc. 14-2, at 23). The ALJ determined that upon consideration of these factors, Anderson's RFC, and the testimony of a vocational expert, “there are jobs that exist in significant numbers in the national economy that the claimant can perform.” 20 C.F.R. §§ 404.1569; 404.1569(a); 20 C.F.R. §§ 416.969; 416.969(a). (Doc. 14-2, at 23). The ALJ specifically identified occupations of a marker, garment sorter, and racker with positions ranging from 23, 000 to 53, 000 nationally. (Doc. 14-2, at 41).
As a result of the foregoing analysis, the ALJ determined that Anderson was not disabled and denied Anderson's applications for benefits. (Doc. 14-2, at 24).
IV. Discussion
On appeal, Anderson asserts that substantial evidence does not support the ALJ's mental health treatment evaluation. (Doc. 15, at 4). Specifically, Anderson argues that the ALJ failed to advance the record regarding his lack of medical treatment and that the ALJ improperly found that his subjective statements were inconsistent with the record. (Doc. 15, at 5-6). In response, the Commissioner argues that the ALJ fully accounted for Anderson's limitations in making the RFC determination by restricting Anderson to work at all exertional levels with additional mental limitations. (Doc. 16, at 16). Moreover, the Commissioner argues that substantial evidence supports the ALJ's proper consideration of regulatory factors in finding that Anderson's subjective statements were inconsistent with the record. (Doc. 16, at 16).
A. The ALJ Erred in Their Evaluation of Subjective Statements
Anderson argues that the ALJ failed to properly consider his subjective statements and his lack of treatment for his mental impairments. (Doc. 15, at 5-6). In response, the Commissioner argues that “[a]lthough [Anderson] had some positive mental reports and findings, he was alert, oriented, cooperative, calm and fairly groomed with a fair manner of relating overall with others . . .” (Doc. 16, at 2). Further, the Commissioner asserts that “[a]lthough the record supports functional limitations for [Anderson], the [ALJ] fully accounted for these limitations in the [RFC] assessment . . . .” (Doc. 16, at 1). However, a review of the record evidences that the ALJ erred in applying the relevant legal standards to the facts of this case.
As this matter involves a claim filed after March 27, 2017, the new regulatory framework governing the evaluation of medical opinions applies to the ALJ's evaluation of the medical opinions in the record. See Revisions to Rules Regarding the Evaluation of Medical Evidence, 82 Fed.Reg. 5844 (Jan. 18, 2017) (technical errors corrected by 82 Fed.Reg. 15, 132-01 (Mar. 27, 2017)); see also 82 Fed.Reg. 15263 (March 27, 2017); 82 Fed.Reg. 16869 (corrective notice) (explaining that SSR 96-2p and 96- 5p do not apply to newly filed or pending claims after March 27, 2017). Under the new regulations, rather than assigning weight to medical opinions, the Commissioner will articulate “how persuasive” he or she finds the medical opinions. 20 C.F.R. §§ 404.1520c(b), 416.920c(b). The Commissioner's consideration of medical opinions is guided by the following factors: supportability; consistency; relationship with the claimant (including the length of the treatment relationship, the frequency of examinations, the purpose of the treatment relationship, the extent of the treatment relationship, and the examining relationship); specialization of the medical source; and any other factors that tend to support or contradict the opinion. 20 C.F.R. §§ 404.1520c(c), 416.920c(c). The most important of these factors is the “supportability” of the opinion and the “consistency” of the opinion. 20 C.F.R. §§ 404.1520c(b)(2), 416.920c(b)(2).
The ALJ must explain how he or she considered the “supportability” and “consistency” of a medical source's opinion. 20 C.F.R. §§ 404.1520c(b)(2), 416.920c(b)(2). Generally, the ALJ may, but is not required to, explain his or her consideration of the other factors, but if there are two equally persuasive medical opinions about the same issue that are not exactly the same, then the ALJ must explain how he or she considered the other factors. 20 C.F.R. §§ 404.1520c(b)(3), 416.920c(b)(3). To facilitate judicial review, the ALJ's decision must be accompanied by “a clear and satisfactory explication of the basis on which it rests” and the ALJ must indicate which evidence was accepted, which evidence was rejected, and the reasons for rejecting certain evidence. Cotter v. Harris, 642 F.2d 700, 704, 706-707 (3d Cir. 1981).
In this case, Anderson argues that the ALJ failed to question Anderson regarding the reason he did not allegedly comply with his recommended mental health treatment. (Doc. 15, at 5-6). “In the case of mental impairment, ” like anxiety, “a lapse in treatment or failure to treat alone is not a basis for finding that the claimant is not disabled.” Wooten v. Astrue, No. 11-CV-7592, 2012 WL 6601397, *4 (E.D. Pa. Dec. 17, 2012). While the ALJ may infer the lack of medical treatment for Anderson's mental impairments is due to the lack of severity of the symptoms, the ALJ is charged with inquiring and addressing the reasons before reaching such a conclusion. See e.g., Newell v. Comm'r of Soc. Sec., 347 F.3d 541, 547 (3d Cir. 2003); Warne v. Saul, No. 3:19-CV-01489, 2020 WL 6787162, at *12-13 (M.D. Pa. Oct. 2, 2020), report and recommendation adopted, No. 3:19-CV-1489, 2020 WL 6781932 (M.D. Pa. Nov. 18, 2020); S.S.R. 16-3P. The lack of development of the record regarding the extent of Anderson's mental impairments prevents addressing this issue.
According to Third Circuit jurisprudence, “ALJs have a duty to develop a full and fair record in social security cases.” Ventura v. Shalala, 55 F.3d 900, 902 (3d Cir. 1995). Generally, an ALJ must not “find an individual's symptoms inconsistent with the evidence in the record on [the basis of non-compliance with treatment] without considering possible reasons he or she may not comply with treatment or seek treatment consistent with the degree of his or her complaints.” S.S.R. 16-3p at *9. The ALJ “may need to contact the individual regarding the lack of treatment or, at an administrative proceeding, as to why he or she has not complied with or sought treatment in a manner consistent with his or her complaints.” S.S.R. 16-3p at *9. In Newell, the Third Circuit noted that under SSR 96-7p:
[T]he adjudicator must not draw any inferences about an individual's
symptoms and their functional effects from a failure to seek or pursue regular medical treatment without first considering any explanations that the individual may provide, or other information in the case record, that may explain infrequent or irregular medical visits or failure to seek medical treatment.
347 F.3d at 547 (quoting SSR 96-7p at *5-6).
Valid alternative reasons for not seeking treatment can include when a claimant's mental impairments prevent him or her from understanding “the appropriate treatment for or the need for consistent treatment of his or her impairment, ” when a claimant cannot afford treatment, or when a claimant is not “aware that he or she has a disorder that requires treatment.” S.S.R. 16-3p at *10; see Newell, 347 F.3d at 547 (claimant could not afford treatment). Lay evidence of a claimant's subjective statements need not be corroborated by contemporaneous medical evidence to be credible. See Basinger v. Heckler, 725 F.2d 1166, 1169 (8th Cir. 1984) (lay evidence must be considered even if uncorroborated by medical evidence).
In relevant part, Anderson suffers from anxiety and depression. (Doc. 14-2, at 15-16). In his disability report appeal form, Anderson stated that he has “short term memory, learning disorder to the point it causes me anxiety and depression.” (Doc. 14-6, at 47). During the December 18, 2019, administrative hearing, the ALJ did not ask Anderson about his subjective reports of anxiety and depression or question him about his history of mental health treatment. (Doc. 14-2, at 31-44). According to the medical record from March 5, 2019, Stacy Trogner, Psy.D. (“Dr. Trogner”), evaluated Anderson's mental status and intelligence. (Doc. 14-8, at 22). Dr. Trogner diagnosed Anderson with unspecified anxiety disorder and mild intellectual disability and recommended that Anderson pursue individual psychological therapy, psychiatric intervention, and medical follow-up as needed. (Doc. 14-8, at 23). Further, Dr. Trogner determined that Anderson's “[p]rognosis is guarded, given his mental health and cognitive impairments and lack of current mental health treatment.” (Doc. 14-8, at 23).
On March 28, 2019, Janel Maguire, PA-C (“Dr. Maguire”), evaluated Anderson. (Doc. 14-8, at 32). Dr. Maguire is Anderson's primary health care provider. (Doc. 14-8, at 32). Dr. Maguire noted that Anderson reported functional limitations, including depression, suicidal and/or passive thoughts about death, sleep disturbance, anxiety, PTSD, which affect Anderson's daily activity, causing him to lack energy and motivation. (Doc. 14-8, at 32). Additionally, the evaluation states that Anderson has never been on psychiatric medication, but that Anderson would like to try medication. (Doc. 14-8, at 32). Dr. Maguire noted that Anderson had a healthy-appearing, well-nourished, and well-developed appearance; had cooperative and calm behavior; fluent and clear speech; and had alert and oriented cognition. (Doc. 14-8, at 33). Additionally, Dr. Maguire noted that Anderson had poor eye contact; sullen and sad affect; thoughts of self-harm; and wore two different shoes. (Doc. 14-8, at 33). Dr. Maguire diagnosed Anderson with major depressive disorder and started Anderson on 20mg of fluoxetine. (Doc. 14-8, at 33). Additionally, Dr. Maguire referred Anderson to meet with a therapist the next day and scheduled a follow-up appointment for medication management on or around April 11, 2019. (Doc. 14-8, at 33). However, the record does not reflect any documentation of follow-up for medication management with Dr. Maguire or a psychiatrist or any other outpatient health counseling.
The ALJ found that Anderson's mental impairments do not meet the required severity to find that Anderson is disabled, as defined in the Social Security Act, because “there is no documentation that he has been in ongoing medical or mental health treatment” and Anderson has not required emergency or inpatient treatment for any exacerbations, cognitive rehabilitation, or partial hospitalization. (Doc. 14-2, at 16, 21). First, the ALJ recognized that Anderson “was diagnosed with depression and anxiety in early 2019, ” however, he “only began mental health treatment for reports of isolation in March 2019, the same month as the consultative examination, and there is no evidence that he has returned for further medication management or pursued the recommended behavioral health treatment.” (Doc. 14-2, at 16-17). Next, the ALJ found that Dr. Trogner's opinion was persuasive because her medical opinion was supported by and consistent with her evaluation and with Anderson's lack of treatment for his alleged symptoms. (Doc. 14-2, at 21). Finally, the ALJ stated that Anderson's “primary care provider started him on an antidepressant and recommended behavioral health treatment with a therapist. However, the record does not reflect any documentation of follow-up for medication management with his primary care provider or a psychiatrist or any outpatient behavioral health counseling.” (Doc. 14-2, at 21).
In this case, the ALJ failed to consider or inquire into “possible reasons [Anderson] may not comply with treatment or seek treatment consistent with the degree of [his] complaints.” S.S.R. 16-3p at *9; see Newell, 347 F.3d at 547-48 (explaining that where an individual provides a reason for failing to seek treatment, the ALJ should not infer that no disability existed based on the lack of medical records); Ventura, 55 F.3d at 902 (“ALJs have a duty to develop a full and fair record in social security cases.”). During the administrative hearing, the ALJ failed to inquire into Anderson's subjective reports of experiencing anxiety and depression or his history of mental health treatment. (Doc. 14-2, at 31-44). Further, the ALJ did not examine why Anderson failed to seek additional mental health treatment or question Anderson about his intentions to seek out such treatment. (Doc. 14-2, at 31-44). Despite finding that Dr. Trogner's opinion was “persuasive, ” the ALJ did not mention that she diagnosed Anderson with unspecified anxiety disorder and mild intellectual disability, and that she recommended that Anderson pursue individual psychological therapy, psychiatric intervention, and medical follow-up as needed. (Doc. 14-8, at 23). Moreover, the ALJ did not refer to Dr. Maguire by name and failed to describe the consistency or supportability of Dr. Maguire's opinion, which stated that Dr. Maguire diagnosed Anderson with major depressive disorder and started him on 20mg of fluoxetine. (Doc. 14-8, at 33).
A medical opinion is defined as “a statement from a medical source about what you can still do despite your impairment(s) and whether you have one or more impairment-related limitations or restrictions in the following abilities.” 20 C.F.R. § 404.1513. Dr. Maguire's opinion is a statement from a medical source and is thus a medical opinion. (Doc. 14-8, at 32). The Commissioner must consider all medical opinions and “evaluate their persuasiveness” based on the “supportability” and “consistency” of a medical source's opinion. 20 C.F.R. §§ 404.1520c(b)(2), 416.920c(b)(2).
While it is possible for the ALJ to infer the lack of medical treatment for Anderson's mental impairments is due to the lack of severity of his symptoms, the ALJ is charged with inquiring and addressing the reasons before reaching such a conclusion. See e.g., Newell, 347 F.3d at 547. The ALJ's determination does not discuss Anderson's failure to pursue treatment that was sought or provided, or how the ALJ considered Anderson's reason in his determination, as SSR 16-3p requires. Nor does the ALJ explain how Anderson's anxiety and depression impacted his mental RFC determination. Before drawing a negative inference from Anderson's lack of seeking mental health treatment for his anxiety and depression, the ALJ was required to question Anderson on the subject. See S.S.R. 16-3p; see also Millard v. Saul, No. 3:19-CV-00850, 2020 WL 1849719, at *5 (M.D. Pa. Apr. 13, 2020) (ALJ did not reference the claimant's lack of follow-up treatment at the administrative hearing, so he was precluded from inferring greater capabilities based on this evidence). Thus, the ALJ failed to provide “a clear and satisfactory explanation of the basis on which it rests, ” as to why he deviated from Anderson's subjective statements regarding the severity of his anxiety and depression. Cotter, 642 F.2d at 704.
Accordingly, the ALJ's decision does not allow the Court to discern whether the ALJ inquired into or addressed the reasons why Anderson failed to seek mental health treatment, and is thus not supported by substantial evidence. SSR 16-3p; see Cotter, 642 F.2d at 704 (ALJ must set forth the reason for his decision). Therefore, it is recommended that the Commissioner's decision be vacated, and that the case be remanded for further proceedings consistent with this report and recommendation.
B. The Court Declines to Address Anderson's Remaining Arguments
Because the Court recommends that the decision be vacated and remanded for further consideration, concluding that the ALJ's disability determination is not supported by substantial evidence, the Court declines to address Anderson's remaining arguments. “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. 2019). The Court's evaluation of Anderson's additional contentions would be futile given that the ALJ's development of the record and reconsideration of Anderson's mental impairments may yield a different result.
V. Remedy
As a final matter, the Court addresses whether this case should be remanded to the Commissioner for further administrative proceedings or whether reversal and an award of benefits is appropriate. The Court has authority to affirm, modify, or reverse the Commissioner's decision “with or without remanding the case for rehearing.” 42 U.S.C. § 405(g); Melkonyan v. Sullivan, 501 U.S. 89, 100-01 (1991). However, the Third Circuit has advised that benefits should only be awarded where “the administrative record of the case has been fully developed and when substantial evidence in the record as a whole indicates that the claimant is disabled and entitled to benefits.” Morales v. Apfel, 225 F.3d 310, 320 (3d Cir. 2000); see generally Fla. Power & Light Co. v. Lorion, 470 U.S. 729, 744 (1985) (“[T]he proper course, except in rare circumstances, is to remand to the agency for additional investigation or explanation.”). Because the ALJ's decision does not allow the Court to discern whether the ALJ inquired into or addressed the reasons why Anderson failed to seek mental health treatment, as required by SSR 16-3p, the undersigned respectfully recommends that further development of the record is required regarding Anderson's lack of mental health treatment, and that the decision of the Commissioner be vacated and that the case be remanded.
VI. Recommendation
Based on the foregoing, it is recommended that the Commissioner's decision be VACATED, and that the case be REMANDED to the Commissioner to fully develop the record, conduct a new administrative hearing, and appropriately evaluate the evidence pursuant to sentence four of 42 U.S.C. § 405(g). It is further recommended that the Clerk of Court be directed to CLOSE this case.
NOTICE
NOTICE IS HEREBY GIVEN that the undersigned has entered the foregoing Report and Recommendation dated January 18, 2022. 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.