Opinion
No.: 1:20-cv-01055-jay
2022-02-17
Kimberly WILLIAMS, Plaintiff, v. Kilolo KIJAKAZI, Acting Commissioner of Social Security, Defendant.
ORDER REVERSING THE DECISION OF THE COMMISSIONER AND REMANDING PURSUANT TO SENTENCE FOUR OF 42 U.S.C. § 405(G)
Jon A. York, UNITED STATES MAGISTRATE JUDGE
Plaintiff Kimberly Williams brought this action pursuant to 42 U.S.C. § 405(g) seeking judicial review of the final decision of the Commissioner of Social Security (the "Commissioner" or "Defendant") denying her application for disability insurance benefits under Title II of the Social Security Act [D.E. 1, 18]. Defendant has responded in opposition [D.E. 23], Plaintiff has replied [D.E. 24] and this matter is now ripe. For the reasons stated below, Plaintiff's motion is GRANTED. The decision of the Commissioner is REVERSED AND REMANDED for further proceedings consistent with this Order.
ADMINISTRATIVE PROCEEDINGS
On March 4, 2016, Plaintiff applied for disability insurance benefits under Title II of the Act, 42 U.S.C. §§ 401 - 434. Plaintiff alleged disability as of September 15, 2015, when she was 41 years old (Tr. 211-12, 274). Plaintiff's claims were denied initially and on reconsideration (Tr. 84, 101-02). On March 11, 2019, following a hearing, an Administrative Law Judge (ALJ) found that Plaintiff was not under a "disability" as defined in the Act (Tr. 15-24). On January 28, 2020, the Appeals Council denied Plaintiff's request for further review (Tr. 1-3).
Plaintiff has exhausted her administrative remedies, and the ALJ's decision stands as the final decision of the Commissioner. Section 205(g) of the Act, 42 U.S.C. § 405(g) provides for judicial review of a "final decision" of the Commissioner subject to judicial review. Plaintiff timely filed the instant action [D.E. 1].
FACTUAL BACKGROUND
Education and Employment Background
Plaintiff was born on September 3, 1974 and was 41 years old on her alleged onset date of September 15, 2015 (Tr. 274). Plaintiff is able to communicate in English and had at least a high school education (Tr. 23). Plaintiff alleged she was disabled due to Ramsey Hunt syndrome, trigeminal neuralgia, chronic pain, depression, and anxiety (Tr. 17). Plaintiff has past relevant work as a licensed practical nurse, insurance salesperson, retail salesclerk, and pharmacy technician (Tr. 22).
Medical Records
Plaintiff [D.E. 18, 24] and Defendant [D.E. 23] both discuss the medical evidence they believe is relevant in their respective briefs. The ALJ discussed Plaintiff's medical records for the relevant time period as well (Tr. 15-24). While there is no need to summarize the medical records herein, the relevant records have been comprehensively reviewed.
Hearing Testimony
Plaintiff was represented by attorney Steve Beal in the hearing on December 17, 2018 (Tr. 15). Plaintiff and the Vocational Expert both testified (Tr. 414-442). The transcript of the testimony from the hearing has been carefully reviewed.
The Court notes that the Commissioner has erroneously filed a hearing transcript from an unrelated Claimant, however, the transcript for Plaintiff's hearing has also been filed.
APPLICABLE LAW AND THE ALJ'S FINDINGS
Applicable Law
Under 42 U.S.C. § 405(g), a claimant may obtain judicial review of any final decision made by the Commissioner after a hearing to which he or she was a party. "The court shall have the power to enter, upon the pleadings and transcript of the record, a judgment affirming, modifying, or reversing the decision of the Commissioner of Social Security, with or without remanding the cause for a rehearing." 42 U.S.C § 405(g). The court's review is limited to determining whether there is substantial evidence to support the Commissioner's decision, id. , and whether the correct legal standards were applied. Key v. Callahan , 109 F.3d 270, 273 (6th Cir. 1997) ; see also Landsaw v. Sec'y of Health & Human Servs. , 803 F.2d 211, 213 (6th Cir. 1986).
Substantial evidence is "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Buxton v. Halter , 246 F.3d 762, 772 (6th Cir. 2001) (quoting Richardson v. Perales , 402 U.S. 389, 91 S.Ct. 1420, 28 L.Ed.2d 842 (1971) ). It is "more than a mere scintilla of evidence, but less than a preponderance." Bell v. Comm'r of Soc. Sec. , 105 F.3d 244, 245 (6th Cir. 1996) (citing Consolidated Edison Co. v. NLRB , 305 U.S. 197, 229, 59 S.Ct. 206, 83 L.Ed. 126 (1938) ). The Commissioner, not the court, is charged with the duty to weigh the evidence, to make credibility determinations and resolve material conflicts in the testimony, and to decide the case accordingly. Walters v. Comm'r of Soc. Sec. , 127 F.3d 525, 528 (6th Cir. 1997) ; Crum v. Sullivan , 921 F.2d 642, 644 (6th Cir. 1990) ; Garner v. Heckler , 745 F.2d 383, 387 (6th Cir. 1984). When substantial evidence supports the Commissioner's determination, it is conclusive, even if the substantial evidence also supports the opposite conclusion. Warner v. Comm'r of Soc. Sec. , 375 F.3d 387, 390 (6th Cir. 2004) ; Foster v. Halter , 279 F.3d 348, 353 (6th Cir. 2001) ; Mullen v. Bowen , 800 F.2d 535, 545 (6th Cir. 1986).
The ALJ's Findings
The ALJ's decision contains, in part, the following pertinent findings and conclusions:
1. Claimant meets the insured status requirements of the Social Security Act through December 31, 2020.
2. Claimant has not engaged in substantial gainful activity since September 15, 2015, the alleged onset date ( 20 CFR 404.1571 et seq. ).
3. Claimant has the following severe impairments: Ramsey Hunt syndrome /trigeminal neuralgia /chronic pain, depression, and anxiety ( 20 CFR 404.1520(c) ).
4. Claimant does not have an impairment or combination of impairments which meets or medically equals the severity of one of the impairments in 20 CFR Part 404, Subpart P, Appendix 1 ( 20 CFR 404.1520(d), 404.1525, 404.1526 ).
5. After careful consideration of the entire record, the undersigned finds that Claimant has the residual functional capacity to perform light work as defined in 20 CFR 404.1567(b) except Claimant can frequently climb, balance, stoop, kneel, crouch and crawl; no exposure to workplace hazards such as unprotected heights or dangerous machinery; no more than occasional interactions with the general public, co-workers and supervisors; and occasional changes in work settings.
6. Claimant is unable to perform any past relevant work ( 20 CFR 404.1565 ).
7. Claimant was born on September 3, 1974 and was 41 years old, which is defined as a younger individual age 18-49, on the alleged disability onset date ( 20 CFR 404.1563 ).
8. Claimant has at least a high school education and is able to communicate in English ( 20 CFR 404.1564 ).
9. Transferability of job skills is not material to the determination of disability because using the Medical-Vocational Rules as a framework supports a finding that Claimant is "not disabled," whether or not Claimant has transferable job skills.
10. Considering Claimant's age, education, work experience, and residual functional capacity, there are jobs that exist in significant numbers in the national economy that Claimant can perform.
11. Claimant has not been under a disability, as defined in the Social Security Act, from September 15, 2015, through the date of this decision ( 20 CFR 404.1520(g) ).
ANALYSIS
The Social Security Act authorizes "two types of remand: (1) a post judgment remand in conjunction with a decision affirming, modifying, or reversing a decision of the [Commissioner] (a sentence-four remand); and (2) a pre-judgment remand for consideration of new and material evidence that for good cause was not previously presented to the [Commissioner] (a sentence-six remand)." Faucher v. Sec'y of Health and Human Servs. , 17 F.3d 171, 174 (6th Cir. 1994) (citing 42 U.S.C. § 405(g) ). Under a sentence-four remand, the court has the authority to "enter, upon the pleadings and transcript of the record, a judgment affirming, denying, or reversing the decision of the [Commissioner], with or without remanding the cause for a hearing." 42 U.S.C. § 405(g). Where there is insufficient support for the ALJ's findings, "the appropriate remedy is reversal and a sentence-four remand for further consideration." Morgan v. Astrue , No. 10-207, 2011 WL 2292305, at *8 (E.D. Ky. June 8, 2011) (citing Faucher , 17 F.3d at 174 ).
A court must affirm the Commissioner's decision unless it rests on an incorrect legal standard or is unsupported by substantial evidence. 42 U.S.C. § 405(g) ; McClanahan v. Comm'r of Soc. Sec. , 474 F.3d 830, 833 (6th Cir. 2006) (citations omitted). Substantial evidence is "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Buxton v. Halter , 246 F.3d 762, 772 (6th Cir. 2001) (quoting Richardson v. Perales , 402 U.S. 389, 91 S.Ct. 1420, 28 L.Ed.2d 842 (1971) ). It is "more than a mere scintilla of evidence, but less than a preponderance." Bell v. Comm'r of Soc. Sec. , 105 F.3d 244, 245 (6th Cir. 1996) (citing Consolidated Edison Co. v. NLRB , 305 U.S. 197, 229, 59 S.Ct. 206, 83 L.Ed. 126 (1938) ). If there is substantial evidence to support the Commissioner's findings, they should be affirmed, even if the court might have decided facts differently, or if substantial evidence would also have supported other findings. Smith v. Chater , 99 F.3d 780, 782 (6th Cir. 1996) ; Ross v. Richardson , 440 F.2d 690, 691 (6th Cir. 1971). The court may not re-weigh evidence, resolve conflicts in evidence, or decide questions of credibility. Garner , 745 F.2d at 387. The substantial evidence standard allows considerable latitude to administrative decision makers because it presupposes that "there is a ‘zone of choice’ within which the Commissioner can act, without the fear of court interference." McClanahan , 474 F.3d at 833 (quoting Buxton , 246 F.3d at 772 ).
The court may consider any evidence in the record, regardless of whether it has been cited by the ALJ. Heston v. Comm'r of Soc. Sec. , 245 F.3d 528, 535 (6th Cir. 2001). The court may not, however, consider any evidence that was not before the ALJ for purposes of substantial evidence review. Foster v. Halter , 279 F.3d 348, 357 (6th Cir. 2001). Furthermore, the court is under no obligation to scour the record for errors not identified by the claimant, Howington v. Astrue , No. 2:08-CV-189, 2009 WL 2579620, at *6 (E.D. Tenn. Aug. 18, 2009) (stating that assignments of error not made by claimant were waived), and arguments not raised and supported in more than a perfunctory manner may be deemed waived, Woods v. Comm'r of Soc. Sec. , No. 1:08-CV-651, 2009 WL 3153153, at *7 (W.D. Mich. Sept. 29, 2009) (citing McPherson v. Kelsey , 125 F.3d 989, 995–96 (6th Cir. 1997) ) (noting that conclusory claims of error without further argument or authority may be considered waived).
When a court determines that the Commissioner's decision must be reversed, it may immediately award Plaintiff benefits "only if all essential factual issues have been resolved and the record adequately establishes a plaintiff's entitlement to benefits." Faucher , 17 F.3d at 176 (citations omitted). "A judicial award of benefits is proper only where the proof of disability is overwhelming or where the proof of disability is strong and evidence to the contrary is lacking." Id. These factors are not present in this case and, therefore, an immediate award of benefits is not appropriate. However, a remand pursuant to sentence four of § 405(g) is appropriate because all essential issues have not been resolved.
Argument
Plaintiff argues that this matter should be reversed and remanded. She asserts that the ALJ made a number of harmful errors, including that he ALJ failed to properly weigh the opinion of Dr. Henderson, Plaintiff's primary care physician, and that the ALJ did not provide an adequate explanation for rejecting Plaintiff's testimony about her pain as well as her medication side effects [D.E. 18, D.E. 24].
The Commissioner asserts that Plaintiff's treatment was largely conservative and that the Dr. Henderson's opinion was assigned little weight because the doctor primarily treated her for physical impairments. The Commissioner explains that while Dr. Henderson prescribed medication for Plaintiff's anxiety disorder, his examination findings did not indicate significant psychiatric abnormalities supportive of his opinion. As to claims regarding Plaintiff's testimony about her pain, the Commissioner rebuts that the "recitation of symptoms" alone does not support a finding of disability, and that her treatment was modest. [D.E. 23 at 14].
This claim was filed prior to March 27, 2017, and thus is covered by the treating physician rule and 20 C.F.R. §§ 404.1527 and 416.927. C.F.R. §§ 404.1527(c); 416.927(c), contains six factors which should guide an ALJ's analysis. The ALJ assesses the medical source's treatment experience with the claimant. The more familiar the source is with the claimant, the more weight that will be given to the source's opinion. The ALJ will also consider whether medical source's opinion is consistent with other evidence and opinions, the extent to which the source has offered objective support for his or her findings, the source's specialty, and "other factors," like the extent to which the source is familiar with other information in the claimant's case. See 20 C.F.R §§ 404.1527(c)(2), 416.927(c)(2) (2015).
Here, the ALJ failed to meet the requirements of the treating physician rule in his discussion. The ALJ and Commissioner discounted Dr. Henderson's opinion regarding Plaintiff's mental health as he was a primary care doctor rather than a specialist. Yet not only was Dr. Henderson Plaintiff's treating doctor who saw her frequently for an extended period of time, but also, Dr. Henderson's opinion was consistent with and supported by other evidence in the record, including Dr. Wilson's psychological evaluation. Dr. Wilson concluded that Plaintiff "presents credibly, validly and consistently, as an individual with panic attacks and depression either caused by or exacerbated by her reported multiple medical difficulties, chronic pain, reduced mobility and resulting situational stressors" (Tr. 351). This observation, and Plaintiff's documented diagnoses from multiple sources, are in stark contrast to the Commissioner's indication that Plaintiff has merely recited symptoms. Both the ALJ and the Commissioner seem to miss the issues of this case, and point to Plaintiff's normal ambulation, for example, as support for the decision, rather than providing a meaningful discussion of Plaintiff's documented diagnosis of facial nerve pain, and anxiety and depression caused by or exacerbated by her documented chronic pain. Rather than receiving conservative treatment as the Commissioner urges, Plaintiff testified that her prescribed medications include Gabapentin or Neurontin, Trileptal, Cymbalta for depression, Oxycodone for pain, and Ativan for anxiety and panic attacks (Tr. 425). Moreover, neither the ALJ nor Commissioner offered meaningful discussion of the reported side effects of her medication, including drowsiness, on her ability to work. This is especially pertinent given that Plaintiff lost her job due to falling asleep at work because her medications make her drowsy. This lack of analysis is not harmless error and accordingly, a remand pursuant to sentence four of § 405(g) is appropriate. On remand, in addition to giving good reasons for the weight assigned to Plaintiff's treating physician, the ALJ should fully address Plaintiff's pain medications, their functional limitations, and any side effects from the medications in making an RFC determination, as well provide a substantive discussion regarding Plaintiff's testimony and any credibility issues in order to ensure a properly formulated RFC.
Finally, the Court notes that the ALJ characterized Plaintiff's headaches/migraines as "non-severe," and the Commissioner urges that these impairments were controlled with medication, while evidence in the record indicates that Plaintiff's migraines may have had more than a minimal effect on Plaintiff's ability to meet the basic demands of work activity. On remand, the ALJ is directed to revisit the issue of Plaintiff's migraines and their severity.
In summary, the combination of errors by the ALJ in this case lead the Court to find that the record was not adequately developed, the residual functional capacity assessment in this case is not supported by substantial evidence, and the RFC was not formulated in accordance with correct legal standards. The decision of the Commissioner is REVERSED , and the action is REMANDED pursuant to sentence four of 42 U.S.C. § 405(g) for another hearing consistent with this Order.