Opinion
3:21-cv-025
06-23-2022
ANITA LYNN H.-J.,[1] Plaintiff, v. COMMISSIONER OF THE SOCIAL SECURITY ADMINISTRATION, Defendant.
DECISION AND ENTRY
PETER B. SILVAIN, JR. UNITED STATES MAGISTRATE JUDGE
Plaintiff Anita Lynn H.-J. brings this case before the Court challenging the Social Security Administration's denial of her application for Supplemental Security Income (SSI). This case is before the Court upon Plaintiff's Statement of Errors (Doc. #12), the Commissioner's Memorandum in Opposition (Doc. #15), Plaintiff's Reply (Doc. #16), and the administrative record. (Doc. #10).
I. Background
The Social Security Administration provides Supplemental Security Income to individuals who are under a “disability,” among other eligibility requirements. Bowen v. City of New York, 476 U.S. 467, 470 (1986); see 42 U.S.C. § 1382(a). The term “disability” encompasses “any medically determinable physical or mental impairment” that precludes an applicant from performing “substantial gainful activity.” 42 U.S.C. § 1382c(a)(3)(A); see Bowen, 476 U.S. at 46970.
In the present case, Plaintiff applied for benefits on May 15, 2018, alleging disability due to several impairments, including worsening of depression, bipolar disorder, increased panic attacks, increased anxiety attacks, high blood pressure, and muscle spasms in her back. After Plaintiff's application was denied initially and upon reconsideration, she requested and received a hearing before Administrative Law Judge (ALJ) Stuart Adkins. Thereafter, the ALJ issued a written decision, addressing each of the five sequential steps set forth in the Social Security Regulations. See 20 C.F.R. § 416.920. He reached the following main conclusions:
Step 1: Plaintiff has not engaged in substantial gainful employment since May 15, 2018, the application date.
Step 2: She has the severe impairments of obesity; hypertension; gastroesophageal reflux disease (GERD); chronic obstructive pulmonary disease (COPD); osteoarthritis, knees; degenerative disc disease, lumbar spine; bipolar disorder; depression; anxiety; and panic disorder.
Step 3: She does not have an impairment or combination of impairments that meets or equals the severity of one in the Commissioner's Listing of Impairments, 20 C.F.R. Part 404, Subpart P, Appendix 1.
Step 4: Her residual functional capacity (RFC), or the most she could do despite her impairments, see Howard v. Comm'r of Soc. Sec., 276 F.3d 235, 239 (6th Cir. 2002), consists of “light work... except: can lift and/or carry 20 pounds occasionally and 10 pounds frequently; can stand and/or walk for about 6[]hours and sit for about 6 hours in an 8-hour workday; would be permitted to alternate between sitting and standing every 30 minutes while at the workstation; can never climb ladders, ropes, or scaffolds; can occasionally climb ramps and stairs; can occasionally stoop, kneel, crouch, and crawl; occasional exposure to dusts, odors, fumes, and pulmonary irritants; should avoid unprotected heights and dangerous machinery; limited to performing
simple, routine tasks; but not at a production rate pace; limited to occasional interaction with supervisors and coworkers; but no interaction with the general public; only simple, work-related decisions; and only occasional changes to a routine work setting, defined as one-to-two changes per week.”
She is unable to perform any past relevant work.
Step 5: She can perform a significant number of jobs that exist in the national economy.
(Doc. #10-2, PageID #s 54-60). Based on these findings, the ALJ concluded that Plaintiff was not under a benefits-qualifying disability since May 15, 2018, the date the application was filed. Id. at 61.
The evidence of record is adequately summarized in the ALJ's decision (Doc. #10, PageID #s 55-59), Plaintiff's Statement of Errors (Doc. #12), the Commissioner's Memorandum in Opposition (Doc. #15), and Plaintiff's Reply (Doc. #16). To the extent that additional facts are relevant, they will be summarized in the discussion section below.
II. Standard of Review
Judicial review of an ALJ's decision is limited to whether the ALJ's findings are supported by substantial evidence and whether the ALJ applied the correct legal standards. Blakley v. Comm'r of Soc. Sec., 581 F.3d 399, 406 (6th Cir. 2009); see Bowen v. Comm'r of Soc. Sec., 478 F.3d 742, 745-46 (6th Cir. 2007). Substantial evidence is such “relevant evidence that a reasonable mind might accept as adequate to support a conclusion.” Gentry v. Comm'r of Soc. Sec., 741 F.3d 708, 722 (6th Cir. 2014) (citing Rogers v. Comm'r of Soc. Sec., 486 F.3d 234, 241 (6th Cir.2007)). It is “less than a preponderance but more than a scintilla.” Id.
The second judicial inquiry-reviewing the correctness of the ALJ's legal analysis-may result in reversal even if the ALJ's decision is supported by substantial evidence in the record. Rabbers v. Comm'r of Soc. Sec., 582 F.3d 647, 651 (6th Cir. 2009). Under this review, “a decision of the Commissioner will not be upheld where the [Social Security Administration] fails to follow its own regulations and where that error prejudices a claimant on the merits or deprives the claimant of a substantial right.” Bowen, 478 F.3d at 746 (citing Wilson v. Comm'r of Soc. Sec., 378 F.3d 541, 546-47 (6th Cir. 2004)).
III. Discussion
In her Statement of Errors, Plaintiff alleges that the ALJ erred in his analysis of the medical evidence and opinions. (Doc. #12, PageID #s 739-40). Specifically, Plaintiff argues that ALJ Adkins erred in rejecting the opinion of her treating source, Darshan Singh, M.D., and instead credited the opinions of the non-examining state agency opinions even though they had not reviewed substantial objective evidence. Id. The Commissioner maintains that the ALJ followed the law throughout his decision and appropriately found Dr. Singh's opinion to be least persuasive while developing an RFC based in the evidence and accommodating of Plaintiff's various impairments. (Doc. #15, PageID #s 754-62).
It is well-settled that the plaintiff bears the ultimate burden of proof as to the existence and severity of the limitations caused by her impairments. Cruse v. Comm'r of Soc. Sec., 502 F.3d 532, 545 (6th Cir. 2007). It is equally accepted, however, that it is the ALJ who bears the burden to develop the administrative record upon which his decision rests. Lashley v. Sec'y of Health and Human Servs., 708 F.2d 1048, 1051-52 (6th Cir. 1983). This duty arises because “[s]ocial security proceedings-unlike judicial ones-are inquisitorial, not adversarial.” Chester v. Comm'r of Soc. Sec., No. 11-1535, 2013 WL 1122571, at *8 (E.D. Mich. Feb. 25, 2013); see also, Sims v. Apfel, 530 U.S. 103, 110-11 (2000) (“Social Security proceedings are inquisitorial rather than adversarial. It is the ALJ's duty to investigate facts and develop the arguments both for and against granting benefits.”).
Further, while there is “no bright line test” for determining whether the ALJ has failed to fully develop the record, Lashley, 708 F.2d at 1052, matters are subject to remand if the “ALJ makes a finding of work-related limitations based on no medical source opinion or an outdated source opinion that did not include consideration of a critical body of objective medical evidence.” Kizys v. Comm'r of Soc. Sec., No. 3:10 CV 25, 2011 WL 5024866, at *1-3 (N.D. Ohio Oct. 21, 2011). Under these circumstances, the ALJ's obligation to develop the record may be satisfied, without obtaining additional evidence, if the evidence involves “relatively little physical impairment” such that the ALJ can render “a commonsense judgement about functional capacity.” Deskin v. Comm r of Soc. Sec., 605 F.Supp.2d 908, 912 (N.D. Ohio 2008). This, however, would only apply in a “limited” number of cases “when the medical evidence is so clear, and so undisputed, that an ALJ would be justified in drawing functional capacity conclusions from such evidence without the assistance of a current medical source.” Harris v. Comm'r of Soc. Sec., No. 15-10966, 2016 WL 8114128, at *10 (E.D. Mich. Mar. 2, 2016), report and recommendation adopted sub nom., No. 15-CV-10966, 2016 WL 2848422 (E.D. Mich. May 16, 2016) (citations omitted).
In all other cases, the ALJ must fulfill his obligation to develop a complete record by utilizing the tools provided in the regulations for ordering additional opinion evidence, such as “recontact[ing] the treating source, order[ing] a consultative examination, or hav[ing] a medical expert testify at the hearing.” Deskin, 605 F.Supp.2d 908 at 912. At base, the “key inquiry” in these circumstances is whether the ALJ “fully and fairly developed the record through a conscientious probing of all relevant facts.” Bryant v. Comm'r of Soc. Sec., No. 3:15-CV-354, 2017 WL 489746, at *3-5 (S.D. Ohio Feb. 7, 2017) (Newman, M.J.) (quotation marks and citation omitted), report and recommendation adopted sub nom., No. 3:15-CV-354, 2017 WL 713564 (S.D. Ohio Feb. 22, 2017) (Rice, D.J.).
In this case, Leon Hughes, M.D. and Steve McKee, M.D., two non-examining state agency physicians, reviewed Plaintiff's files and authored opinions in September 2018 and January 2019, respectively. (Doc. #10-3, PageID #s 152, 164). Both physicians found that Plaintiff was capable of light exertional work with postural limitations of frequently climbing ramps or stairs, occasionally kneeling, crawling, stooping, and crouching, and never climbing ropes, ladders, or scaffolds. They also concluded that she could have no exposure to dangerous hazards. Id. In reviewing these opinions, ALJ Adkins found both to be “most persuasive” on the basis that they were “mostly consistent with the overall objective evidence,” but that “some evidence including updated x-ray imaging suggests somewhat greater limitations to postural movements.” Id.
The only other opinions on Plaintiff's physical RFC that were provided were that of her treating psychiatrist, Darshan Singh, M.D.. (Doc. #10-7, PageID #s 517-18, 704-09). In May 2017, Dr. Singh completed a “Basic Medical” form where he noted Plaintiff's mental health impairments as including mood, depression, and anxiety. (Doc. #10, PageID #s 517-18). Dr. Singh also indicated that Plaintiff's health status was “poor but stable.” Id. at 517. Dr. Singh further noted that Plaintiff was “unable to engage in any substantially gainful activity” due to medical impairments. Id. at 518. In April 2020, Dr. Singh completed a “Medical Assessment of Ability To Do Work-Related Activities (Physical) form. (Doc. #10-8, PageID #s 704-09). On the form, Dr. Singh indicated that Plaintiff's left arm weakness and pain would limit her to lifting 8 to 10 totaling no more than 5 hours in a workday. Id. at 704-05. He further noted that Plaintiff would be unable to stand or walk for more than 15 minutes at a time for a total of 3 hours a day because of her dyspnea, low back pain, right knee pain, and osteoarthritis of both knees. Id. at 705. Dr. Singh also opined that Plaintiff's numbness and tingling in her lower extremities and knees would prevent her from sitting any longer than 15 to 30 minutes at a time for a total of 3.5 to 4 hours in a workday. Id. He concluded that she could occasionally stoop but that she could never climb, balance, crouch, kneel, or crawl because of her alternate lowering side when standing, degenerative disc disease and spondylosis from L3 to S1, and degenerative grade 2 spondylolisthesis of L4 on L5. Id. at 706. Additionally, Dr. Singh indicated that Plaintiff's restricted range of motion and pain would prevent her from reaching, pushing, and pulling. Id. Finally, Dr. Singh opined that Plaintiff's impairments or treatment would cause her to be absent more than 3 time a month and that she did not have the RFC to complete tasks at a sedentary exertional level on a sustained basis. Id. at 708.
In reviewing Dr. Singh's opinions, ALJ Adkins averred that his opinions were “contradicted by two other physicians of record, and Dr. Singh does not treat [Plaintiff] for physical ailments nor is there evidence that Dr. Singh either examined [Plaintiff] or reviewed her treatment notes for her physical complaints. (Doc. #10-2, PageID #59). As a result, ALJ Adkins concluded that Dr. Singh's opinions were “least persuasive” as they were “inconsistent with objective treatment notes, physical examination findings, and with the severity of the mild diagnostic findings.” Id.
Plaintiff, however, disputes this finding, alleging that the opinions provided by Drs. Hughes and McKee were not based on a review of the substantial objective evidence in the record. (Doc. #12, PageID #739). In contrast, Dr. Singh did review later x-ray evidence of Plaintiff's spine and based his exertional limitations on those findings. Id. (citing Doc. #10-8, PageID #706). Indeed, in support of her claim, Plaintiff submitted additional medical records from August 2019 through April 2020, for which Drs. Hughes and McKee-who authored their opinions in September 2018 and January 2019-did not have the benefit of reviewing. (See Doc. #10-8, PageID #s 710-31). Significantly, this evidence included numerous examinations with abnormal findings, including August 26, 2019 x-rays of the left foot showing osteoarthritis and diffuse soft tissue swelling without evidence of acute osseous abnormalities; April 16, 2020 x-rays of the lumbar spine showing degenerative disc disease and spondylosis from L3 to S1 as well as degenerative grade 2 spondylolisthesis of L4 on L5; and April 16, 2020 x-rays showing mild osteoarthritis of both knees. Id. at 715-28. As such, these medical records constitute “a critical body of objective medical evidence” for which Drs. Hughes and McKee did not consider, thus necessitating further development of the record. Kizys, 2011 WL 5024866, at *2.
Further, this is not a case where the evidence “shows relatively little physical impairment” such that ALJ Adkins was able to make a “commonsense judgment” about Plaintiff's functional capacity without the assistance of a medical opinion. See Deskin, 605 F.Supp.2d at 912. On the contrary, the additional x-rays submitted by Plaintiff primarily involve treatment for her lower back and knee impairments, both of which ALJ Adkins himself found to constitute severe impairments. (Doc. #10-2, PageID #54). Indeed, in reviewing this evidence, ALJ Adkins acknowledged that the additional records indicated that Plaintiff had additional x-rays “reveal[ing] degenerative findings and spondylosis” as well as osteoarthritis. Id. at 57. Curiously, despite acknowledging that the “updated x-ray imaging suggests somewhat greater limitations to postural movements” than what Drs. Hughes and McKee found, ALJ Adkins rejected the greater limitations provided by Dr. Singh on the basis that he was a mental health specialist and does not treat Plaintiff's physical impairments. See id. at 59. ALJ Adkins then proceeded, without the aid of a medical opinion, to reject Dr. Singh's limitations and impose his restrictions based on his own review of the x-ray imaging. See id. This determination, however, was not his to make. While it is the function of the ALJ to ultimately assess a plaintiff's RFC, it is the function of a medical expert to interpret these types of raw medical data “in terms that the ALJ, who is not a medical professional, may understand[.]” Griffin v. Astrue, No. 3:07-cv-447, 2009 WL 633043, at *10 (S.D. Ohio Mar. 6, 2009) (Rose, D.J.). Therefore, if Dr. Singh was not qualified to interpret Plaintiff's x-ray imaging, ALJ Adkins was certainly not either. Despite the fact that it is generally up to the discretion of the ALJ as to whether to call an expert to testify, the Court may overturn that discretion where, as here, “it appears that the use of a medical consultant was necessary -rather than simply helpful -- in order to allow the ALJ to make a proper decision.” Young v. Comm'r of Soc. Sec., No. 2:10-CV-960, 2011 WL 2923695, at *6 (S.D. Ohio June 20, 2011) (Kemp, M.J.), report and recommendation adopted, No. 2:10-CV-960, 2011 WL 2942983 (S.D. Ohio July 20, 2011) (Frost, D.J.) (internal citations omitted).
Simply put, while Plaintiff's x-ray reports “may appear minimal to the lay person, the ALJ was not qualified to translate this medical data into functional capacity determinations.” Mabra v. Comm'r of Soc. Sec., No. 2:11-CV-00407, 2012 WL 2319245, at *9 (S.D. Ohio June 19, 2012) (Preston Deavers, M.J.), report and recommendation adopted, No. 2:11-CV-00407, 2012 WL 3600127 (S.D. Ohio Aug. 21, 2012) (Sargus, D.J.). This is especially true in this case where ALJ Adkins rejected the limitations provided by Dr. Singh's review of the x-rays on the basis that he is not qualified as a mental health specialist to review Plaintiff's physical ailments. Thus, being faced with a critical body of objective medical evidence involving Plaintiff's severe impairments, without the aid of any medical expert of record for which he deemed qualified, ALJ Adkins was obligated to develop a complete record by ordering additional opinion evidence. See Deskin, 605 F.Supp.2d at 912. Here, ALJ Adkins “could have solicited the opinion of a medical expert, ordered an additional consultative exam, or sent the MRIs, surgical records, and other records back to the state agency reviewing physician[s] for an updated assessment. However, no such steps were taken.” Gentry v. Comm'r of Soc. Sec., No. 1:17 CV 1182, 2018 WL 4305213, at *5 (N.D. Ohio Sept. 10, 2018) (internal citations and quotations omitted). Instead, ALJ Adkins based Plaintiff's RFC on his own interpretation of the raw medical data from August 2019 onward. See id. As a result, his RFC determination is not supported by substantial evidence.
Accordingly, for the above reasons, Plaintiff's Statement of Errors is well taken.
In light of the above discussion, and the resulting need to remand this case, an in-depth analysis of Plaintiff's other challenges to the ALJ's decision is unwarranted.
IV. Remand
A remand is appropriate when the ALJ's decision is unsupported by substantial evidence or when the ALJ failed to follow the Administration's own regulations and that shortcoming prejudiced the plaintiff on the merits or deprived the plaintiff of a substantial right. Bowen, 478 F.3d at 746. Remand may be warranted when the ALJ failed to provide “good reasons” for rejecting a treating medical source's opinions, see Wilson, 378 F.3d at 545-47; failed to consider certain evidence, such as a treating source's opinions, see Bowen, 478 F.3d at 747-50; failed to consider the combined effect of the plaintiff's impairments, see Gentry, 741 F.3d at 725-26; or failed to provide specific reasons supported by substantial evidence for finding the plaintiff lacks credibility, see Rogers, 486 F.3d at 249.
Under sentence four of 42 U.S.C. § 405(g), the Court has authority to affirm, modify, or reverse the Commissioner's decision “with or without remanding the cause for rehearing.” Melkonyan v. Sullivan, 501 U.S. 89, 99 (1991). Consequently, a remand under sentence four may result in the need for further proceedings or an immediate award of benefits. E.g., Blakley, 581 F.3d at 410; Felisky v. Bowen, 35 F.3d 1027, 1041 (6th Cir. 1994). The latter is warranted where the evidence of disability is overwhelming or where the evidence of disability is strong while contrary evidence is lacking. Faucher v. Sec'y of Health & Human Servs., 17 F.3d 171, 176 (6th Cir. 1994).
A judicial award of benefits is unwarranted in the present case because the evidence of disability is not overwhelming and the evidence of disability is not strong while contrary evidence is lacking. However, Plaintiff is entitled to a remand of this case to the Social Security Administration pursuant to sentence four of § 405(g) due to the problems discussed above. On remand, the ALJ should be directed to evaluate the evidence of record, including the medical source opinions, under the applicable legal criteria mandated by the Commissioner's Regulations and Rulings and by case law; and to evaluate Plaintiff's disability claim under the required five-step sequential analysis to determine anew whether Plaintiff was under a disability and whether her application for Supplemental Security Income should be granted.
IT IS THEREFORE ORDERED THAT:
1. Plaintiff's Statement of Errors (Doc. #12) is GRANTED; 2. The Commissioner's non-disability finding is vacated; 3. No finding is made as to whether Plaintiff was under a “disability” within the meaning of the Social Security Act; 4. This matter is REMANDED to the Social Security Administration under sentence four of 42 U.S.C. § 405(g) for further consideration consistent with this Decision and Entry; and 5. The case is terminated on the Court's docket.