Opinion
CV122-029
05-18-2023
VALARIE MARSHALL, Plaintiff, v. KILOLO KIJAKAZI, Acting Commissioner of Social Security Administration, Defendant.
MAGISTRATE JUDGE'S REPORT AND RECOMMENDATION
BRIAN K. EPPS UNITED STATES MAGISTRATE JUDGE
Plaintiff appeals the decision of the Acting Commissioner of Social Security (“the Commissioner”) denying her applications for Disability Insurance Benefits (“DIB”) under the Social Security Act. Upon consideration of the briefs, the record evidence, and the relevant statutory and case law, the Court REPORTS and RECOMMENDS, pursuant to sentence four of 42 U.S.C. § 405(g), the Commissioner's final decision be REVERSED and that the case be REMANDED to the Commissioner for further consideration in accordance with this opinion.
I. BACKGROUND
Plaintiff applied for DIB on June 18, 2019, alleging a disability onset date of May 2, 1017. Tr. (“R.”), p. 15, 18, 118, 215-16, 252. Plaintiff last met the insured status requirements of the Social Security Act for DIB on March 31, 2020. R. 18; doc. no. 13, p. 4 (“Pl.'s Br.”). Plaintiff was forty-seven years old at her alleged disability onset date and fifty-one years old when the Administrative Law Judge (“ALJ”) issued the decision currently under consideration. R. 28, 315. Plaintiff obtained a high school education, and, prior to her alleged disability, accrued a relevant work history as a shift sergeant and corrections officer at a prison. R. 12, 84, 307-12, 1010.
Plaintiff initially applied for disability benefits based on a combination of alleged impairments, including obesity, degenerative disc disease of the cervical and lumbar spine, lumbar laminectomy, pituitary adenoma status post resection, migraine headaches, chondromalacia of the left knee, osteoarthritis of the right knee, depression, and anxiety. R. 19, 242-67. Plaintiff requested a hearing before an ALJ, and the ALJ held a hearing on October 8, 2020. R. 15. At the hearing, the ALJ heard testimony from Plaintiff, who appeared with counsel, as well as from Robert G. Piper, a Vocational Expert (“VE”). R. 38. The ALJ issued an unfavorable decision on March 29, 2021, finding Plaintiff not disabled, and, on January 12, 2022, the Appeals Council (“AC”) denied her request for review. R. 1-6, 12-36.
Applying the sequential process required by 20 C.F.R. § 404.1520, the ALJ found:
1. The claimant did not engage in substantial gainful activity during the period from her alleged onset date of May 2, 2017, through her date last insured of March 31, 2020 (20 CFR 404.1571 et seq.).
2. The claimant had the following severe impairments: obesity, degenerative disc disease of the cervical and lumbar spines status post cervical fusion at ¶ 4-5 and C5-6 and a lumbar laminectomy for spinal cord stimulator placement (20 CFR 404.1520(c)).
3. The claimant did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 404.1520(d), 404.1525 and 404.1526).
4. After careful consideration of the entire record, the undersigned finds that, through the date last insured, the claimant had the residual functional capacity [RFC] to perform a less than full range of light work as defined in 20 CFR 404.1567(b) in that she can occasionally lift and/or carry, including upward
pulling of twenty (20) pounds, and can frequently lift and or carry including upward pulling of ten (10) pounds. The claimant can sit for six (6) hours in an eight (8) hour workday with normal breaks and stand and/or walk with normal breaks for four (4) hours in an eight (8) hour workday but no greater than thirty minutes at one time with the ability to sit and change positions for a few minutes without being off tasks. She can frequently push and or pull operation of foot controls consistent with the lift and carry restrictions of twenty (20) and ten (10) pounds. The claimant can occasionally climb ramps and stairs, balance, stoop, kneel, and crouch, but can never crawl or work on ladders, ropes, or scaffolds, no work at unprotected heights or work around dangerous machinery. She is limited to no more than frequent exposure to humidity, heavy vibrations, fumes, odors, dust gases, and poor ventilation. Through the date last insured, the claimant was unable to perform any past relevant work (20 CFR 404.1565).
5. Through the date last insured, considering the claimant's age, education, work experience, and residual functional capacity, there were jobs that existed in significant numbers in the national economy that the claimant could have performed (20 CFR 404.1569 and 404.1569(a)). Therefore, the claimant was not under a disability, as defined in the Social Security Act, at any time from May 2, 2017, the alleged onset date, through March 31, 2020, the date last insured (20 CFR 404.1520(g)).R. 15-30.
“Light work” is defined as:
lifting no more than 20 pounds at a time with frequent lifting or carrying of objects weighing up to 10 pounds. Even though the weight lifted may be very little, a job is in this category when it requires a good deal of walking or standing, or when it involves sitting most of the time with some pushing and pulling of arm or leg controls. To be considered capable of performing a full or wide range of light work, you must have the ability to do substantially all of these activities. If someone can do light work, we determine that he or she can also do sedentary work, unless there are additional limiting factors such as loss of fine dexterity or inability to sit for long periods of time.20 C.F.R. § 404.1567(b).
Because the AC did not disturb the ALJ's finding, the Commissioner's decision became “final” for the purpose of this judicial review. 42 U.S.C. § 405(g). Plaintiff filed the current civil action requesting reversal or remand of the adverse decision. (Doc. no. 1.)
Plaintiff argues (1) the ALJ erred when he did not acknowledge Plaintiff's chronic pain syndrome and somatic symptom disorder as impairments; (2) such impairments cause important limitations in the four areas of mental functioning; and (3) the ALJ erred when he relied on objective evidence to discount Plaintiff s testimony. See Pl.'s Br.; doc. no. 15 (“Pl.'s Reply”). The Commissioner maintains the ALJ's decision is supported by (1) substantial evidence that Plaintiff's impairments did not meet or equal a listing; (2) the ALJ properly found Plaintiff only had mild mental health limitations and properly concluded Plaintiff did not experience psychological work-related limitations; and (3) substantial evidence supports the ALJ's subjective symptom finding. See doc. no. 14 (“Comm'r's Br.”).
II. STANDARD OF REVIEW
Judicial review of social security cases is narrow and limited to the following questions: (1) whether the Commissioner's findings are supported by substantial evidence, and (2) whether the Commissioner applied the correct legal standards. Lewis v. Callahan, 125 F.3d 1436, 1439 (11th Cir. 1997). When considering whether the Commissioner's decision is supported by substantial evidence, the reviewing court may not decide the facts anew, reweigh the evidence, or substitute its judgment for the Commissioner's. Moore v. Barnhart, 405 F.3d 1208, 1211 (11th Cir. 2005); Cornelius v. Sullivan, 936 F.2d 1143, 1145 (11th Cir. 1991). Notwithstanding this measure of deference, the Court remains obligated to scrutinize the whole record to determine whether substantial evidence supports each essential administrative finding. Bloodsworth v. Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983).
The Commissioner's factual findings should be affirmed if there is substantial evidence to support them. Barron v. Sullivan, 924 F.2d 227, 230 (11th Cir. 1991). Substantial evidence is “more than a scintilla, but less than a preponderance: ‘[i]t is such relevant evidence as a reasonable person would accept as adequate to support a conclusion.'” Martin v. Sullivan, 894 F.2d 1520, 1529 (11th Cir. 1990) (quoting Bloodsworth, 703 F.2d at 1239). If the Court finds substantial evidence exists to support the Commissioner's factual findings, it must uphold the Commissioner even if the evidence preponderates in favor of the claimant. Crawford v. Comm'r of Soc. Sec., 363 F.3d 1155, 1158-59 (11th Cir. 2004). Finally, the Commissioner's findings of fact must be grounded in the entire record; a decision that focuses on one aspect of the evidence and disregards other contrary evidence is not based upon substantial evidence. McCruter v. Bowen, 791 F.2d 1544, 1548 (11th Cir. 1986).
The deference accorded the Commissioner's findings of fact does not extend to her conclusions of law, which enjoy no presumption of validity. Brown v. Sullivan, 921 F.2d 1233, 1236 (11th Cir. 1991) (holding that judicial review of the Commissioner's legal conclusions are not subject to the substantial evidence standard). If the Commissioner fails either to apply correct legal standards or to provide the reviewing court with the means to determine whether correct legal standards were in fact applied, the Court must reverse the decision. Wiggins v. Schweiker, 679 F.2d 1387, 1389 (11th Cir. 1982).
III. DISCUSSION
The case should be remanded because the ALJ failed to consider whether somatic symptom disorder and chronic pain syndrome cause Plaintiff to suffer more than mild limitations in the four functional areas of (1) understanding, remembering, or applying information; (2) interacting with others; (3) concentrating, persisting, or maintaining pace; and (4) adopting or managing oneself. The ALJ found any limitations in these four areas caused by depression and anxiety were mild, citing Plaintiff's description of her daily activities during the disability hearing, several normal mental status examinations, and the absence of formal mental health treatment.
The ALJ never mentioned the thorough psychiatric evaluation and progress notes prepared by William S. Schiff, PsyD, who diagnosed Plaintiff with, and treated her for, somatic symptom disorder and chronic pain syndrome during three appointments in December 2019, January 2020, and February 2020. R. 2028, 2041-42. Dr. Schiff conducted an exhaustive psychological examination of Plaintiff during the first appointment. Plaintiff scored in the high to very high range in the areas of somatic complaints, pain complaints, functional complaints, and symptom dependency. Id. Dr. Schiff made the following observations among others in the assessment:
The patient reported a broad pattern of pain that is associated with illness symptoms and the perception of disability. Her pain, somatic, and functional complaints were considered high, very high, and extremely high, respectively. She endorsed 21 of the 26 somatic complaints items and report pain in 7 out of the 10 body areas. She also reported extreme peak pain, which she perceives as disabling and intolerable. Of greater concern is the fact that she perceives even the mildest pain she experienced in the last month as intolerable and disabling. Her range of highest to lowest pain in the last month is about average.R. 2039-2040. In the same report, Dr. Schiff explained Plaintiff reported constant and significant pain throughout her body, and because she perceived such pain, Plaintiff “has significantly decreased or stopped activities related to understanding/communicating, getting around, self-care, getting along with people, household activities, and participation in society ....” R. 2029. Dr. Richard Epter also diagnosed Plaintiff with somatic symptom disorder and chronic pain syndrome. R. 1438, 1442, 2032.
Plaintiff's testimony at the October 8, 2020, hearing is consistent with the medical opinions of Drs. Schiff and Epter and suggests more than mild limitations. Plaintiff testified she constantly suffers from migraines, cannot do anything at home because she is always hurting, and must sit down because of the pain. R. 43-44. Plaintiff has undergone numerous surgeries, receives Botox injections, and is on an array of medications for her constant pain. R. 47-48. Plaintiff does not perform daily chores and does not want to take care of herself. R. 51. The pain causes her to lose focus, and she experiences lengthy crying spells approximately ten to twelve times a week. R. 52. Because the crying spells have occurred in public, she avoids going out except for quick trips to the grocery store. R. 52. She never socializes and occasionally cooks. R. 52-54, 58.
At step four, the ALJ should have considered both (1) Plaintiff's testimony that her pain severely limits her ability to work and perform even the most basic life activities and (2) Dr. Schiff's expert opinion that Plaintiff suffers from severe mental health conditions that make her truly believe her symptoms are real and she is completely disabled. Remand is necessary for proper consideration of the combined effects of all of Plaintiff's impairments, including all severe and non-severe mental impairments, in formulating the RFC. Heatly v. Comm'r of Soc. Sec., 382 Fed.Appx. 823, 825 (11th Cir. 2010) (per curiam); see also 20 C.F.R. § 404.1545(a)(2) (“If you have more than one impairment. We will consider all of your medically determinable impairments of which we are aware, including your medically determinable impairments that are not ‘severe,' . . . when we assess your residual functional capacity.”).
Citing 20 C.F.R. § 404.1513(a)(2), the government argues the ALJ had no duty to evaluate Plaintiff's chronic pain syndrome and somatic symptom disorder, as diagnosed by Dr. Schiff, because a “mere diagnosis is not considered a medical opinion.” Comm'r's Br., p. 8. However, as the detailed description above makes clear, Dr. Schiff's thorough evaluation qualifies as an acceptable medical opinion under 20 C.F.R. § 404.1513(a)(2). While the ALJ need not articulate the weight given to any medical opinion, the ALJ must consider all relevant medical opinions. Heatly, 382 Fed.Appx. at 825; Phillips v. Barnhart, 357 F.3d 1232, 1238 (11th Cir. 2004) (The ALJ must consider “all the relevant medical and other evidence.”).
The Court offers no opinion on what a complete and accurate review of the administrative record might conclude on Plaintiff's disability application. Indeed, the Court cannot now engage in an administrative review that was not done in the first instance by the Commissioner. Mills v. Astrue, 226 Fed.Appx. 926, 931-32 (11th Cir. 2007) (per curiam) (acknowledging evidence in the record not mentioned by the ALJ may support administrative decision but concluding that court could not “say the error was harmless without re-weighing the evidence,” which would require “conjecture that invades the province of the ALJ”); see also Martin v. Heckler, 748 F.2d 1027, 1031 (5th Cir. 1984) (noting it to be “inappropriate on judicial review for the first time to apply administrative criteria not themselves considered by the [Commissioner]”). Because the ALJ's decision is not supported by substantial evidence and remand is warranted, the Court need not address Plaintiff's remaining contentions. See Demenech v. Sec'y of Dep't of Health and Human Servs., 913, F.3d 882, 884 (11th Cir. 1990) (per curiam) (declining to address all issues where case due to be remanded on dispositive issue identified and discussed in detail).
IV. CONCLUSION
For the reasons set forth above, the Court REPORTS and RECOMMENDS, pursuant to sentence four of 42 U.S.C. § 405(g), the Commissioner's final decision be REVERSED and that the case be REMANDED to the Commissioner for further consideration in accordance with this opinion.
SO REPORTED and RECOMMENDED.