Summary
In Bradford, this Court recognized that the Ninth Circuit Court of Appeals has held that an ALJ is precluded from interpreting raw medical data in formulating a claimant's RFC.
Summary of this case from Wilson v. Comm'r of Soc. Sec. Admin.Opinion
CV-21-00232-TUC-SHR (JR)
08-18-2022
Mikah Bradford, Plaintiff, v. Commissioner of Social Security Administration, Defendant.
REPORT AND RECOMMENDATION
Honorable Jacqueline M. Rateau United States Magistrate Judge.
Plaintiff Mikah Lorene Bradford (“Plaintiff' or “Bradford”) brought this action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3), seeking judicial review of a final decision by the Commissioner of Social Security (“Commissioner”). The matter is ripe for review. (Doc. 22, 23, 24.) Based on the pleadings and the administrative record (“AR”) submitted to this Court, the Magistrate Judge recommends the District Court, after its independent review, reverse the decision of the ALJ and remand this matter for further proceedings.
BACKGROUND
Procedural History
In July 2018, Bradford filed an application for Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act (Act), 42 U.S.C. §§ 416(i), 423(d), alleging a disability onset date of April 1, 2009. (AR 168.) Bradford's application was denied initially and on reconsideration. (AR 102-05, 109-12.) On Bradford's request, a hearing was held before an Administrative Law Judge (“ALJ”). (AR 38-62.) The ALJ determined Bradford was not disabled in a decision dated June 18, 2020. (AR 14-30.) Braford's request for review by the Appeals Council was declined thus making the ALJ's decision final for judicial review. (AR 1-4.) See 42 U.S.C. §§ 405(g), 1383(c)(3).
Bradford has prior applications which could not be reopened. (AR 14.) The ALJ determined whether Bradford was under a disability since July 5, 2018, the date her latest application was filed. (AR 15.)
The ALJ's Decision
At step one, the ALJ determined Bradford had not engaged in substantial gainful activity since July 5, 2018, the application date. (AR 17.) At step two, the ALJ determined Bradford suffered from the severe impairments of diabetes mellitus, obesity, migraine headaches, interstitial lung disease, obstructive sleep apnea, gastroparesis, borderline intellectual functioning, and learning disorder. Id. At step three, the ALJ determined Bradford did not suffer from an impairment or combination of impairments that met or equaled a listed impairment. (AR 20.) After step three but before step four, the ALJ determined Bradford's RFC as follows:
[T]he claimant ha[s] the residual functional capacity to perform a range of light work as defined in 20 CFR 416.967(b), in that she can lift, carry, push or pull 20 pounds occasionally and 10 pounds frequently' however she can stand and/or walk 4 hours in an 8-hour workday for 30 minutes at a time; can frequently balance; can occasionally] climb ramps and stairs; stoop, kneel, crouch, or crawl; cannot climb ladders, ropes, or scaffolds; cannot work around hazards such as unprotected heights or work in proximity to exposed, moving mechanical parts; cannot work with exposure to temperature extremes or humidity, or atmospheric conditions as those are rated and defined in the Selected Characteristics of Occupations (SCO); and can perform simple, routine tasks.(AR 22-23.) At step four, the ALJ determined Bradford had no past relevant work. (AR 28.) At step five, based on vocational expert (“VE”) testimony, the ALJ found Bradford was able to perform other work such as routine clerk, marking clerk and addresser. (AR 28-29.)
Brief Factual History
Bradford was born in 1988 and is a younger person in the eyes of the administration. (AR 168.) She has a twelfth grade education and last worked in a grocery store in 2008 and 2009. (AR 190.) She has no past relevant work. (AR 28.)
Bradford testified at the administrative hearing that she never obtained a driver license because she had been sick too often. (AR 45.) Her health insurance provides transportation to doctor's appointments or a family member drives her. (AR 45.) Her single instance of employment at a grocery store ended when she got sick and the grocery store closed. (AR 46.) She testified to suffering many health difficulties including headaches, diabetes, gastritis, pancreatitis, and lower back pain. Id. According to Bradford, her biggest health issue was a case of acute pancreatitis in 2017. (AR 46-47.) Her headaches interfere with her ability to function. (AR 47-48.) She experiences nausea and suffers weight gain as a result of excess insulin and her body's failure to digest food due to gastritis. (AR 49.) She testified that she feels pain in her stomach and admitted to overusing her prescribed pain medication in the past. (AR 50-51.) She sometimes needs assistance with her personal care. (AR 51-52.) She endorses being isolated and not leaving the house other than to attend her medical appointments. (AR 52.) Her medical problems interfere with her daily activities every day. (AR 54.)
STANDARD OF REVIEW
The Commissioner employs a five-step sequential process to evaluate DIB claims. 20 C.F.R. § 404.1520; see also Heckler v. Campbell, 461 U.S. 458, 460-462 (1983). To establish disability the claimant bears the burden of showing she (1) is not working; (2) has a severe physical or mental impairment; (3) the impairment meets or equals the requirements of a listed impairment; and (4) claimant's RFC precludes her from performing her past work. 20 C.F.R. § 404.1520(a)(4). At step five, the burden shifts to the Commissioner to show that the claimant has the RFC to perform other work that exists in substantial numbers in the national economy. Hoopai v. Astrue, 499 F.3d 1071, 1074 (9th Cir. 2007). If the Commissioner conclusively finds the claimant “disabled” or “not disabled” at any point in the five-step process, she does not proceed to the next step. 20 C.F.R. § 404.1520(a)(4).
“The ALJ is responsible for determining credibility, resolving conflicts in medical testimony, and for resolving ambiguities.” Andrews v. Shalala, 53 F.3d 1035, 1039 (9th Cir. 1995) (citing Magallanes v. Bowen, 881 F.2d 747, 750 (9th Cir. 1989)). The findings of the Commissioner are meant to be conclusive if supported by substantial evidence. 42 U.S.C. § 405(g). Substantial evidence is “more than a mere scintilla but less than a preponderance.” Tackett v. Apfel, 180 F.3d 1094, 1098 (9th Cir. 1999) (quoting Matney v. Sullivan, 981 F.2d 1016, 1018 (9th Cir. 1992)). The court may overturn the decision to deny benefits only “when the ALJ's findings are based on legal error or are not supported by substantial evidence in the record as a whole.” Aukland v. Massanari, 257 F.3d 1033, 1035 (9th Cir. 2001). This is so because the ALJ “and not the reviewing court must resolve conflicts in the evidence, and if the evidence can support either outcome, the court may not substitute its judgment for that of the ALJ.” Matney, 981 F.2d at 1019 (quoting Richardson v. Perales, 402 U.S. 389, 400 (1971)); Batson v. Comm'r of Soc. Sec. Admin., 359 F.3d 1190, 1198 (9th Cir. 2004). The Commissioner's decision, however, “cannot be affirmed simply by isolating a specific quantum of supporting evidence.” Sousa v. Callahan, 143 F.3d 1240, 1243 (9th Cir. 1998) (citing Hammock v. Bowen, 879 F.2d 498, 501 (9th Cir. 1989)). Reviewing courts must consider the evidence that supports as well as detracts from the Commissioner's conclusion. Day v. Weinberger, 522 F.2d 1154, 1156 (9th Cir. 1975).
A claimant is "disabled" for the purpose of receiving benefits if she is unable to engage in any substantial gainful activity due to an impairment which has lasted, or is expected to last, for a continuous period of at least twelve months. 42 U.S.C. § 423(d)(1)(A); 20 C.F.R. § 404.1505(a). "The claimant bears the burden of establishing a prima facie case of disability." Roberts v. Shalala, 66 F.3d 179, 182 (9th Cir. 1995), cert. denied, 517 U.S. 1122 (1996); Smolen v. Chater, 80 F.3d 1273, 1289 (9th Cir. 1996).
ISSUES ON REVIEW
While Bradford alleges disability based on a number of medical issues, it is her “chronic pancreatitis and resulting conditions that are the subject of [her] appeal . . .” (Doc. 22 at 3.) Bradford raises two issues for review. First, she claims the ALJ failed to provide clear and convincing reasons supported by substantial evidence for discounting her symptom testimony. (Doc. 22 at 2.) Second, she claims that the ALJ failed to fully and fairly develop the record. Id. This Court agrees with Bradford on her second claim of error.
As more fully explained below, this Court finds that the record is not fully developed and that the ALJ improperly interpreted raw medical data in formulating Bradford's RFC. As a result, the RFC is not supported by substantial evidence. Accordingly, this Court recommends that the decision of the ALJ be reversed and the matter be remanded for further development.
DISCUSSION
Record Development and Interpretation of Raw Medical Data
On September 26, 2018, state agency medical consultant Jerry L. Dodson, M.D., issued a not disabled determination at the initial review level. (AR 65-81.) Dr. Dodson's assessment indicates that in July 2017, Bradford underwent a splenectomy and partial pancreatectomy due to chronic pancreatitis due to hyperlipidemia and hypertriglyceridemia. (AR 73.) Dr. Dodson opined that Bradford was limited to performing work at the sedentary level. (AR 80.) On January 31, 2019, state agency medical consultant John Fahlberg, M.D., issued a not disabled determination at the reconsideration level. (AR 85-100.) Dr. Fahlberg noted Bradford's “significant] issues with pancreatitis in the past 2010 and another surgery in mid[-]2017.” (AR 97.) Dr. Fahlberg opined that Bradford was limited to performing work at the sedentary level. (AR 100.)
The ALJ was not persuaded by the opinions of the state agency medical consultants. (AR 26.) The ALJ reasoned that while Drs. Dodson and Fahlberg supported their findings through discussion of the record and the relevant evidence “they did not have access to the complete record as it now exists when formulating their assessments.” Id. The ALJ further reasoned that “the longitudinal examination findings objectively reflect that the claimant lacks any significant ongoing functional deficits.” Id. (citing Ex 24F/58, Ex 5F/2, Ex 6F/5, 143, Ex 10F/6, Ex 11F/4, Ex 12F/5, Ex 14F/2, Ex 16F/6, Ex 20F/14. Ex 21F/25, Ex 24F/21, 91, 173.) In formulating Bradford's RFC, the ALJ reasoned, inter alia:
Exhibits 14F/2 and 16F/6 are not contained in the certified record on appeal. The Court also notes that only 14 pages of Exhibit 13F, a 131 page exhibit, are contained in the certified record on appeal and that Exhibit 17F also incomplete and missing the first 18 pages.
Regarding the claimant's allegations related to pancreatitis, while it is documented within the record, the related objective evidence does not reflect that this impairment more than minimally limited the claimant for 12 months or greater during the period in question. The record does indicate a history of pancreatitis, and that the claimant underwent a splenectomy, distal pancreatectomy, a cyst gastromy take down in July 2017. (Ex 1F/10,50). However, this was well before the claimant's protective filing date, and there is no sign of a need for such procedures, or significant treatment in general, during the period in question. In fact, diagnostic imaging performed during the relevant time period was not even suggestive of the existence of pancreatitis. (Ex 10F/51, Ex 18F/84). During one of the claimant's hospitalizations, there was a suggestion of pancreatitis, but the claimant did not receive treatment for this condition; rather, that hospitalization appeared related to leukocytosis and vaginosis. (Ex 18F/12). Finally, longitudinal examination findings are not reflective of the consistent objective findings reflective of a form of this impairment that would be expected to limit the claimant's functioning for at least a 12-month period. (Ex 4F/58, Ex 5F/2, Ex 6F/143, Ex 10F/6, 24, 27, Ex 11F/4, Ex 12F/5, Ex 14F/2, Ex 15F/8, Ex 16F/6, Ex 20F/14, Ex 24F/21, 91.)(AR 17.)
As mentioned, Exhibits 14F/2 and 16F/6 are not contained in the certified record on appeal. Neither is Exhibit 15F/8.
As support for her claim that the ALJ failed to fulfill her obligation to fully develop the documentary record regarding her pancreatitis condition, Plaintiff points out that the ALJ had opinion evidence from the two state agency medical consultants with a most recent opinion date of January 2019. (Doc. 22 at 13-15; AR 85-101.) She asserts that “[a]fter that point, well over a thousand pages of medical records were added to the file, including [an] October 2019 CT showing pancreatic atrophy.” (Doc. 22 at 13.) She urges that the record is ambiguous and inadequate to allow for a proper evaluation without a medical opinion that “interpreted] over a year's worth of voluminous and complicated medical records.” Id. at 14. She points out that Bradford's counsel requested review by a medical expert but counsel's request was denied. (Doc. 22 at 14, citing AR 247.) She also points out that her pancreatic CT scans for the years 2017, 2018, and 2019 all report atrophy of the pancreas and while “[a] a layperson can speculate that a physician would find this piece of medical information more or less significant . . . without expert opinion, this is mere speculation.” (Doc. 24 at 4.)
Defendant argues that the ALJ appropriately relied on the opinions of the state agency medical consultants. (Doc. 23 at 11.) Defendant points out that on counsel's request, the ALJ held the record open after the administrative hearing and later admitted Exhibit 24F thereby discharging her duty to develop the record. Id. (citing AR 42.) Defendant urges that the record is not ambiguous or insufficient contending that the two state agency medical consultant opinions from Dr. Dodson and Dr. Fahlberg provided a sufficient basis for the ALJ to conclude that Plaintiff's pancreatitis did not impose any significant limitations on her ability to work. (Doc. 23 at 11.) Defendant urges that the ALJ's discussion of the findings in a January 2020 pancreas CT scan showing resection of the pancreatic tail but otherwise normal pancreas is sufficient to support her conclusion that Plaintiff did not have severe or disabling pancreatitis symptoms during the relevant period. Id. at 12.
(AR 2829-3001)
“In Social Security cases the ALJ has a special duty to fully and fairly develop the record and to assure that the claimant's interests are considered.” Brown v. Heckler, 713 F.2d 441, 443 (9th Cir. 1983) (citing Thompson v. Schweiker, 665 F.2d 936, 941 (9th Cir.1982)). The ALJ's duty exists even where a claimant is represented by counsel. Brown, 713 F.2d at 443 (citing Driggins v. Harris, 657 F.2d 187, 188 (8th Cir. 1981)). The ALJ's duty to develop the record is triggered by ambiguous evidence or a record that is inadequate to allow for proper evaluation of the evidence. Tonapetyan v. Halter, 242 F.3d 1144, 1150 (9th Cir. 2001). The ALJ may discharge her duty “in several ways, including subpoenaing the claimant's physicians, submitting questions to the claimant's physicians, continuing the hearing, or keeping the record open after the hearing to allow supplementation of the record.” Id.
This Court rejects the Commissioner's argument that the ALJ sufficiently discharged her duty to develop the record when she held the record open and took submission of Exhibit 24. Bradford argues that the ALJ erred in failing to obtain a medical opinion to interpret the additional medical records that post-date the opinions of the two state agency medical consultants. (Doc. 22 at 13.) The Commissioner does not squarely address Bradford's argument but contends that “Plaintiff's lay interpretation of this imaging does not establish a basis for remand.” (Doc. 23 at 12.) However, as explained below, the Court agrees with Bradford that the ALJ committed reversible error when she, as a lay person, improperly considered raw medical data in formulating Bradford's RFC.
“An RFC is the most a plaintiff can do despite their limitations and is based upon all relevant evidence in the record, including medical records, medical source statements, and symptom testimony.” Howell v. Kijakazi, No. 20-CV-2517-BLM, 2022 WL 2759090, at *7 (S.D. Cal. July 14, 2022) (citing 20 C.F.R. § 404.1545(a)(1)-(3)). “The responsibility for making th[e RFC] assessment is within the purview of the [ALJ].” Howell, 2022 WL 2759090, at *7) (citing 20 C.F.R. § 404.1546(c)); see also Vertigan v. Halter, 260 F.3d 1044, 1049 (9th Cir. 2001) (“It is clear that that it is the responsibility of the ALJ, not the claimant's physician, to determine the residual functional capacity.”). While an ALJ's RFC determination need not precisely reflect any particular provider's opinion, “[b]arring a few exceptions, an ALJ must have a doctor's opinion of a claimant's functional capacity in order for there to be substantial evidence supporting the decisions.” Howell, 2022 WL 2759090, at *7. (citations omitted.)
An ALJ is precluded from interpreting raw medical data in formulating a claimant's RFC. See Howell, 2022 WL 2759090, at *7 (citing Day, 522 F.2d at 1156 (finding ALJ not qualified as a medical expert and therefore could not permissibly go outside the record to consult medical textbooks for the purpose of making his own assessment of the claimant's physical condition)). The district court in Howell noted that MRIs, radiological studies, and X-rays have been recognized as raw medical data. Howell, 2022 WL 2759090, at *7 (citing Mack v. Saul, No. 1:18-CV-01287-DAD-BAM, 2020 WL 2731032, at *2 (E.D. Cal. May 26, 2020) (duty to develop where the ALJ improperly determined RFC after considering MRIs and radiological studies absent a doctor's opinion regarding the effect on plaintiff's ability to work on a function-by-function basis)); see also Escudero v. Comm'r of Soc. Sec., No. 1:18-CV-01136-EPG, 2019 WL 4917634, *2 (E.D. Cal. Oct. 4, 2019) (finding RFC not based on substantial evidence where the ALJ considered x-rays and records indicating Plaintiff's diabetes diagnoses post-dated the accepted physician's opinion on which the ALJ based the RFC)). “Such records generally reflect only the findings, impressions, and medical diagnoses, which are difficult for a lay person to interpret.” Howell, 2022 WL 2759090, at *7 (citing Escudero, 2019 WL 4917634, at *2 (finding “descriptions of medical documents post-dating the physician's opinions appear to be very medical in nature and not susceptible to a lay understanding.”)).
As pointed out by Bradford, “well over a thousand pages of medical records were added to the file” after the state agency medical consultants rendered their opinions. (Doc. 22 at 13.) Defendant does not dispute this point and urges that the state agency medical consultants' opinions “provided a sufficient basis for the ALJ to conclude that Plaintiff did not have significant symptoms of pancreatitis that would impose any significant limitations in her ability to work.” (Doc. 23 at 11.) This Court rejects the Commissioner's argument for two reasons.
First, as the ALJ recognized, the opinions of the state agency medical consultants were performed before the additional medical records were included in the administrative record. (AR 26.) In other words, the state agency medical examiners did not consider the voluminous additional medical records in rendering their opinions. Second, as stated in her decision, the ALJ was not persuaded by the opinions of the state agency medical consultants for the precise reason that they did not consider the additional medical records. (A R26.) Accordingly, the position taken by the Commissioner that the state agency medical consultants' opinions provided a sufficient basis for the ALJ to conclude that Plaintiff did not have significant symptoms of pancreatitis that would significantly limit her ability to work is untenable.
The Commissioner states that “[t]he ALJ discussed the January 2020 findings, and relied on that recent imaging to support her conclusion that Plaintiff did not have severe or disabling pancreatitis symptoms during the relevant period.” (Doc. 23 at 12.) See also AR 12 (stating, “in fact diagnostic imaging performed during the relevant time period . . .”). The diagnostic imagining referred to by the ALJ is raw medical data. The ALJ also stated that the “longitudinal examination findings objectively reflect that the claimant lacks any significant ongoing functional defects.” (AR 26.) Again, as support for this functional determination the ALJ relied upon the additional medical records that reflect only findings, impressions, and medical diagnoses.
It is undisputed that the additional medical records do not include a medical opinion regarding Bradford's functional capabilities nor do the additional medical records contain an analysis of her function-by-function capabilities. Because a medical opinion is not included within the additional medical records, the ALJ independently evaluated Bradford's functional capacities and improperly substituted her judgment for that of a medical expert. The ALJ's decision to substitute her own judgment for competent a medical opinion was error. See Howell, 2022 WL 2759090, at *8 (finding “ALJ erred by using his own interpretation and judgment of raw medical data to formulate Plaintiff's RFC.”); Mack, 2020 WLK 2731032, at *3 (finding the ALJ “should have fully developed the record by obtaining a medical opinion that considered [the more recent medical records] before determining plaintiff's physical RFC.”); Goodman v. Berryhill, No. 2:17-cv-01228 CKD, 2019 WL 79016, at *7 (E.D. Cal. 2019) (finding the ALJ erred where ALJ herself found the effects of plaintiff's impairments negligible; ALJ should have developed the record and obtained a consultative examination by “a physician who had access to plaintiff's medical records through the November 2014 spinal fracture and its aftermath.”).
In light of the foregoing, this Court finds that the ALJ erred when she failed to obtain a medical opinion to interpret the additional medical records that postdate the state agency medical examiners' opinions and instead used her own interpretation and judgment concerning raw medical data to formulate Bradford's RFC. Accordingly, this Court finds that the ALJ's RFC determination is not supported by substantial evidence.
Remand is Recommended
Upon finding the ALJ committed reversible error, the District Court has the discretion to remand or reverse and award benefits. Mack, 2020 WL 2731032, at *3 (citing McAllister v. Sullivan, 888 F.2d 599, 603 (9th Cir. 1989)). The Ninth Circuit has stated that, “[g]enerally, we direct the award of benefits in cases where no useful purpose would be served by further administrative proceedings, or where the record has been thoroughly developed.”Mack, 2020 WL 2731032, at *3 (quoting Ghokassian v. Shalala, 41 F.3d 1300, 1304 (9th Cir. 1994)). “Where . . . an ALJ makes a legal error, but the record is uncertain and ambiguous, the proper approach is to remand the case to the agency.” Treichler v. Comm 'r of Social Sec. Admin., 775 F.3d 1090, 1105 (9th Cir. 2014); see also Garrison v. Colvin, 759 F.3d 995, 1021 (9th Cir. 2014).
As explained above, this Court finds that the record is not fully developed. Accordingly, remand for further development of the record is recommended.
RECOMMENDATION
This Court determines that remand is required. It is recommended that the District Court, after its independent review, reverse the decision of the ALJ and remand to the Commissioner for further development of the record. Pursuant to Federal Rule of Civil Procedure 72(b)(2), any party may serve and file written objections within fourteen days of being served with a copy of the Report and Recommendation. A party may respond to the other party's objections within fourteen days. No reply brief shall be filed on objections unless leave is granted by the district court. If objections are not timely filed, they may be deemed waived. If objections are filed, the parties should use the following case number: 4:19-CV-232-SHR.