Opinion
CIVIL 1:22-CV-352
10-31-2022
AMANDA ROSENBERRY, Plaintiff v. KILOLO KIJAKAZI, Acting Commissioner of Social Security[1], Defendant
Brann, Chief Judge.
REPORT AND RECOMMENDATION
Martin C. Carlson, United States Magistrate Judge.
I. Introduction
Social Security appeals are judged by a deferential standard of review, but the courts have imposed a clear burden of articulation upon an ALJ in order to facilitate this review. At a minimum, this articulation responsibility means that the ALJ's decision must provide a logical nexus between any factual findings and ultimate functional capacity and disability determinations. This principle applies with particular force when a claimant's disability claim rests upon an assessment of the combined effects of both physical and emotional impairments. In this setting an ALJ must make specific, well-articulated findings in order to deny a claim for benefits. Failure to fully address the claimant's emotional and physical impairments may compel a remand of the case for further consideration by the Commissioner.
So it is here.
Amanda Rosenberry applied for disability benefits citing an array of emotional and physical impairments. Every medical expert who examined Rosenberry's treatment records concluded that she suffered from a number of psychological impairments, including depression, anxiety PTSD and adjustment disorder and obsessive-compulsive disorder. Rosenberry had treated for these conditions for years and, while these experts disagreed as to the severity of Rosenberry's symptoms, every treating or examining medical expert stated that these impairments would result in moderate to extreme limitations on her ability to work.
Despite this evidence supporting Rosenberry's mental impairments, the ALJ who denied Rosenberry's claim concluded at Step 2 of the sequential analysis of Rosenberry's claim that none of these emotional impairments reached the de minimis severity threshold impairment prescribed by Social Security regulations. Moreover, while the ALJ's decision concluded in a sweeping fashion that none of these psychological conditions met the minimal standard of severity, which simply required a showing of “something beyond a ‘slight abnormality which would have no more than a minimal effect on the Plaintiff's ability to do basic work activities,” McCrea v. Comm'r of Soc. Sec., 370 F.3d at 357, 360 (3d Cir. 2004), the ALJ's decision stated that all of these emotional impairments were being taken into account when fashioning a residual functional capacity (RFC) assessment for Rosenberry. (Tr. 14). Yet, notwithstanding the assertion that Rosenberry's emotional impairments were being taken into account in determining whether she retained the capacity to work, the ALJ's decision made absolutely no accommodation for these impairments when fashioning a residual functional capacity (RFC) assessment for Rosenberry. (Tr. 16).
In our view, more is needed here. The ambiguities and inconsistencies in the consideration of these emotional impairments are not adequately addressed, analyzed, or even fully acknowledged at this juncture. Accordingly, for the reasons set forth below, we recommend that the district court remand this case for further consideration by the Commissioner.
II. Factual Background and Procedural History
A. Rosenberry's Clinical History
The appeal raises several legal issues, however, because we recommend that a remand is necessary due solely to the failure to sufficiently address the plaintiff's emotional impairments, a matter which did not receive adequate consideration in the ALJ's decision, we will focus upon this issue when assessing the medical evidence.
On June 24, 2020, Amanda Rosenberry filed for disability and supplemental security income benefits pursuant to Titles II and XVI of the Social Security Act, alleging a date of onset of disability on January 1, 2020. (Tr. 11). Rosenberry was born in March of 1980 and was 39 years old at the time of the alleged onset of her disability, making her a younger worker under the Commissioner's regulations. (Tr. 22). Rosenberry had a high school education and some cosmetology training. (Tr. 42). She had previously worked as a cosmetologist and school cafeteria kitchen worker. (Tr. 22, 42-3). According to Rosenberry she had become disabled due to the combined effects of a series of physical and emotional impairments, including psoriasis and psoriatic arthritis as well as depressive disorder, generalized anxiety disorder, adjustment disorder, obsessive-compulsive disorder, and post-traumatic stress disorder (PTSD). (Tr. 14).
With respect to these emotional impairments, Rosenberry's treatment records were replete with references to her anxiety and depression. Thus, caregivers first noted signs of intermittent anxiety and depression as early as October of 2014. (Tr. 371). Throughout 2015 and 2016, Rosenberry's treatment providers consistently noted that she displayed anxiety during clinical encounters. (Tr. 374, 377, 380, 383, 386, 391).
By October of 2017, Rosenberry's primary treating physician, Dr. McDermott, diagnosed her as suffering from adjustment disorders with depressed mood and mixed emotional features. (Tr. 432). This diagnosis remained a consistent refrain throughout clinical encounters with Rosenberry from 2017 through 2021. (Tr. 435, 438, 441, 444, 447, 450, 456, 459, 463, 507, 510, 533, 1104, 1107, 1110). Treatment notes during this period underscored the severity of these mental health symptoms. For example, on December 12, 2019, Rosenberry reported that she was struggling with the ebb and flow of her mood and stated that her depression was constantly there. (Tr. 459). On October 1, 2020, she stated that she had begun experiencing more obsessive-compulsive disorder symptoms, (Tr. 510), and by November 2, 2020, clinicians were reporting that she was anxious, nervous, and displayed decreased concentration. (Tr. 533-34). On March 2, 2021, it was noted that Rosenberry's depression was not well-controlled. (Tr. 1110).
By April 1, 2021, Rosenberry described the exacerbation of her emotional impairments to Dr. McDermott who reported that:
As far as depressive symptoms are concerned, patient reports feeling depressed, hopeless, and helpless, worsening over the past couple of years. Reports appetite as good and energy level as poor/low/tired all the time. Reports having difficulty with motivation,
performing tasks, and poor concentration. Reports experiencing feelings of worthlessness or excessive guilt. Reports passive suicidal thoughts; denies currently experiencing active suicidal or homicidal thoughts, plans, or intent.....
As far as anxiety symptoms are concerned, patient reports experiencing worry and excessive apprehension, for more hours out of the day than not, for more days out of the week than not, worsening in the past 5 years, starting in her 20's. Not wanting to leave the house, having to check things several times, certain things are not plugged in, having to double check everything before leaving again and at bed. Reports experiencing irritability; muscle tension - jaw, neck, back; at times feeling restlessness/keyed-up/or on-edge; experiencing difficulty concentrating; and reports having periods in which his/her mind goes blank. Reports experiencing sleep disturbances such as: difficulty falling asleep/taking about 1 hour to make sure wood stove and house is okay before going to bed staying asleep, restless sleep, or unsatisfying sleep. Reports experiencing symptoms of severe panic, such as panic attacks, feeling like she is suffocating. Reports experiencing anxiety symptoms when socializing with others - husband having people over, or going out in public, can't stand being on the highway. Reports experiencing symptoms of anxiety or panic when engaging in public. Denies experiencing current fears or phobias. Reports history of past trauma; re-experiencing/reliving past event; or experiencing nightmares regarding the past event. Re-experiencing past relationships, having flashbacks, a couple times a week. Has triggers. Reports experiencing obsessional thoughts or compulsive behaviors/rituals. Checking and rechecking, worsening.(Tr. 1130). One month later, on May 4, 2021, Rosenberry stated that she was “still struggling with depressive symptoms, high anxiety, compulsive behaviors and is grinding her teeth.” (Tr. 1162).
This clinical record led a number of medical experts to opine that Rosenberry suffered from severe emotional impairments. At the outset, from a longstanding treatment perspective spanning years, Dr. McDermott twice opined regarding the disabling effects of Rosenberry's emotional impairments. In October of 2020 Dr. McDermott completed a questionnaire which stated that in his opinion Rosenberry suffered moderate impairments in her ability to understand, recall, and apply information as well as her ability to adapt herself in a work setting. (Tr. 528). Dr. McDermott also opined that Rosenberry was markedly impaired in her ability to interact with others, concentrate, and maintain pace. (Id.) In Dr. McDermott's view, Rosenberry's emotional impairments would lead to chronic absenteeism, with the plaintiff missing four or more days of work each month. (Id.)
Dr. McDermott made similar findings six months later in April of 2021. (Tr. 1135-43). By the Spring of 2021 Dr. McDermott found that Rosenberry's mental condition had worsened significantly. According to the doctor, Rosenberry now experienced extreme difficulties interacting with others; marked limitations in understanding and applying information as maintaining concentration; and moderate limitations in adapting herself in a work setting. (Tr. 1142). Dr. McDermott continued to express the view that Rosenberry would frequently be absent from work due to her mental impairments, and would miss four or more days of work each month. (Id.)
On September 1, 2020, an independent examining source, Dr. Leah Bielski, confirmed that Rosenberry suffered from significant emotional impairments. (Tr. 471-78). According to Dr. Bielski, Rosenberry was moderately impaired in a host of work related mental spheres of activity, including understanding complex instructions, interacting with others, and responding to changes in a routine work setting. (Tr. 476-77). Thus, Rosenberry was diagnosed with a series of emotional impairments for more than five years. Moreover, every medical professional who actually treated or examined her concluded that these emotional impairments resulted in limitations on her ability to work, which ranged between moderate and marked.
Cast against this body of clinical and opinion evidence, all of which suggested that Rosenberry faced significant emotional impairments, were two opinions by nontreating non-examining sources, Drs. Rings and Jonas, who both found that Rosenberry's mental impairments were not severe and resulted in only mild impairments. (Tr. 69, 81-2, 99-100, 118-19).
It was against the backdrop of this evidence, much of which underscored the severity of Rosenberry's emotional impairments, that this case came to be heard by an ALJ.
B. ALJ Proceedings
On May 7, 2021, an ALJ conducted an administrative hearing in Rosenberry's case. (Tr. 35-62). Rosenberry and a vocational expert both testified at this hearing. (Id.) Following this hearing, on June 7, 2021, the ALJ issued a decision in Rosenberry's case, denying her disability benefit application. (Tr. 8-24).
In this decision, the ALJ first determined that Rosenberry met the insured requirements of the Act through March 31, 2025. (Tr.14). At Step 2 of the sequential analysis, which governs Social Security disability determinations, the ALJ concluded that Rosenberry's psoriasis and psoriatic arthritis were severe conditions but flatly rejected the notion that Rosenberry suffered from any severe emotional impairments. On this score, the ALJ reached a series of striking conclusions. First, the ALJ summarily discounted Rosenberry's psychological impairments, stating that:
The claimant's medically determinable mental impairments of depressive disorder, generalized anxiety disorder, adjustment disorder, obsessive-compulsive disorder, and post-traumatic stress disorder, considered singly and in combination, do not cause more than minimal limitation in the claimant's ability to perform basic mental work activities and are therefore nonsevere.(Tr. 14).
This Step 2 determination necessarily discounted the treating source opinions of Dr. McDermott and failed to mention the consultative examination report findings of Dr. Bielski, both of whom described Rosenberry's mental impairment as severe. Instead, the ALJ seemingly embraced the views expressed by the non-treating and non-examining physicians and characterized her mental limitations as mild. (Tr. 1415).
Moreover, while the ALJ stated that “[t]he undersigned considered all of the claimant's medically determinable impairments, including those that are not severe, when assessing the claimant's residual functional capacity,” (Tr. 14), in fact the residual functional capacity assessment crafted by the ALJ made absolutely no accommodation for Rosenberry's well-documented emotional impairments. Instead, this RFC simply provided that:
After careful consideration of the entire record, the undersigned finds that the claimant has the residual functional capacity to perform light work as defined in 20 CFR 404.1567(b) and 416.967(b) and she can occasionally balance, stoop, kneel, crouch, crawl, and climb ramps and stairs; and never climb ladders, ropes, or scaffolds. She has no limits feeling bilaterally; can occasionally handle and finger bilaterally; and can occasionally reach above shoulder level bilaterally. She should avoid concentrated exposure to extreme cold and even moderate exposure to wetness.(Tr. 16).
Having reached an RFC determination which failed to consider in any fashion Rosenberry's emotional impairments, the ALJ concluded at Step 4 that Rosenberry could not perform her past relevant work but found at Step 5 that she retained the ability to perform other jobs that existed in significant numbers in the national economy and denied this disability application. (Tr. 22-24).
This appeal followed. (Doc. 1). On appeal, Rosenberry raises a number of challenges to the ALJ's decision, and specifically argues that the ALJ failed to adequately analyze and address her emotional limitations and impairments. We find that the ALJ's analysis of this issue is deficient in that it is inadequate and internally inconsistent. On these facts, as discussed below, we conclude that the ALJ's burden of articulation has not been met in this appeal, and therefore this case will be remanded for further consideration and evaluation of the medical evidence.
III. Discussion
A. Substantial Evidence Review - the Role of this Court
When reviewing the Commissioner's final decision denying a claimant's application for benefits, this Court's review is limited to the question of whether the findings of the final decision-maker are supported by substantial evidence in the record. See 42 U.S.C. §405(g); 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). Substantial evidence 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 evidence if the ALJ ignores countervailing evidence or fails to resolve a conflict created by the evidence. Mason v. Shalala, 994 F.2d 1058, 1064 (3d Cir. 1993). But 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). “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).
The Supreme Court has underscored for us the limited scope of our review in this field, noting that:
The phrase “substantial evidence” is a “term of art” used throughout administrative law to describe how courts are to review agency factfinding. T-Mobile South, LLC v. Roswell, 574 U.S.--,----, 135 S.Ct. 808, 815, 190 L.Ed.2d 679 (2015). Under the substantial-evidence standard, a court looks to an existing administrative record and asks whether it contains “sufficien[t] evidence” to support the agency's factual determinations. Consolidated Edison Co. v. NLRB, 305 U.S. 197, 229, 59 S.Ct. 206, 83 L.Ed. 126 (1938) (emphasis deleted). And whatever the meaning of “substantial” in other contexts, the threshold for such evidentiary sufficiency is not high. Substantial evidence, this Court has said, is “more than a mere scintilla.” Ibid.; see, e.g., Perales, 402 U.S. at 401, 91 S.Ct. 1420 (internal quotation marks
omitted). It means-and means only-“such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Consolidated Edison, 305 U.S. at 229, 59 S.Ct. 206. See Dickinson v. Zurko, 527 U.S. 150, 153, 119 S.Ct. 1816, 144 L.Ed.2d 143 (1999) (comparing the substantial-evidence standard to the deferential clearly-erroneous standard).Biestek v. Berryhill, __ U.S. __, 139 S.Ct. 1148, 1154, 203 L.Ed.2d 504 (2019).
The question before this Court, therefore, is not whether the claimant is disabled, but rather whether the Commissioner's finding that she is 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.”) (alterations omitted); Burton v. Schweiker, 512 F.Supp. 913, 914 (W.D. Pa. 1981) (“The Secretary'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); Ficca, 901 F.Supp.2d at 536 (“[T]he court has plenary review of all legal issues ....”).
Several fundamental legal propositions which flow from this deferential standard of review. First, when conducting this review “we are mindful that we must not substitute our own judgment for that of the fact finder.” Zirnsak v. Colvin, 777 F.3d 607, 611 (3d Cir. 2014) (citing Rutherford v. Barnhart, 399 F.3d 546, 552 (3d Cir. 2005). Thus, we are enjoined to refrain from trying to re-weigh the evidence. Rather our task is to simply determine whether substantial evidence supported the ALJ's findings. However, we must also ascertain whether the ALJ's decision meets the burden of articulation demanded by the courts to enable informed judicial review. Simply put, “this Court requires the ALJ to set forth the reasons for his decision.” Burnett v. Comm'r of Soc. Sec. Admin., 220 F.3d 112, 119 (3d Cir. 2000).
As the Court of Appeals has noted on this score:
In Burnett, we held that an ALJ must clearly set forth the reasons for his decision. 220 F.3d at 119. Conclusory statements ... are insufficient. The ALJ must provide a “discussion of the evidence” and an “explanation of reasoning” for his conclusion sufficient to enable meaningful judicial review. Id. at 120; see Jones v. Barnhart, 364 F.3d 501, 505 & n. 3 (3d Cir.2004). The ALJ, of course, need not employ particular “magic” words: “Burnett does not require the ALJ to use particular language or adhere to a particular format in conducting his analysis.” Jones, 364 F.3d at 505.Diaz v. Comm'r of Soc. Sec., 577 F.3d 500, 504 (3d Cir. 2009).
Thus, in practice ours is a twofold task. We must evaluate the substance of the ALJ's decision under a deferential standard of review, but we must also give that decision careful scrutiny to ensure that the rationale for the ALJ's actions is sufficiently articulated to permit meaningful judicial review.
B. Initial Burdens of Proof, Persuasion, and Articulation for the ALJ
To receive benefits under the Social Security Act by reason of disability, 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); 42 U.S.C. §1382c(a)(3)(A); see also 20 C.F.R. §§404.1505(a), 416.905(a). 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 the national economy. 42 U.S.C. §423(d)(2)(A); 42 U.S.C. §1382c(a)(3)(B); 20 C.F.R. §§404.1505(a), 416.905(a). To receive benefits under Title II of the Social Security Act, a claimant must show that he or she contributed to the insurance program, is under retirement age, and became disabled prior to the date on which he or she was last insured. 42 U.S.C. §423(a); 20 C.F.R. §404.131(a).
In making this determination at the administrative level, the ALJ follows a five-step sequential evaluation process. 20 C.F.R. §§404.1520(a), 416.920(a). Under this process, the ALJ must sequentially determine: (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 his or her past relevant work; and (5) whether the claimant is able to do any other work, considering his or her age, education, work experience and residual functional capacity (RFC). 20 C.F.R. §§404.1520(a)(4), 416.920(a)(4).
Between Steps 3 and 4, the ALJ must also assess a claimant's RFC. RFC is defined as “that which an individual is still able to do despite the limitations caused by his or her impairment(s).” Burnett v. Comm'r of Soc. Sec., 220 F.3d 112, 121 (3d Cir. 2000) (citations omitted); see also 20 C.F.R. §§404.1520(e), 404.1545(a)(1), 416.920(e), 416.945(a)(1). In making this assessment, the ALJ considers all of the claimant's medically determinable impairments, including any non-severe impairments identified by the ALJ at step two of his or her analysis. 20 C.F.R. §§404.1545(a)(2), 416.945(a)(2).
Once the ALJ has made this determination, our review of the ALJ's assessment of the plaintiff's RFC is deferential, and that RFC assessment will not be set aside if it is supported by substantial evidence. Burns v. Barnhart, 312 F.3d 113, 129 (3d Cir. 2002); see also Metzger v. Berryhill, No. 3:16-CV-1929, 2017 WL 1483328, at *5 (M.D. Pa. Mar. 29, 2017), report and recommendation adopted sub nom. Metzgar v. Colvin, No. 3:16-CV-1929, 2017 WL 1479426 (M.D. Pa. Apr. 21, 2017); Rathbun v. Berryhill, No. 3:17-CV-00301, 2018 WL 1514383, at *6 (M.D. Pa. Mar. 12, 2018), report and recommendation adopted, No. 3:17-CV-301, 2018 WL 1479366 (M.D. Pa. Mar. 27, 2018).
At Steps 1 through 4, the claimant bears the initial burden of demonstrating the existence of a medically determinable impairment that prevents him or her in engaging in any of his or her past relevant work. Mason, 994 F.2d at 1064. Once this burden has been met by the claimant, it shifts to the Commissioner at Step 5 to show that jobs exist in significant number in the national economy that the claimant could perform that are consistent with the claimant's age, education, work experience, and RFC. 20 C.F.R. §§404.1512(f), 416.912(f); Mason, 994 F.2d at 1064.
There is an undeniable medical aspect to an RFC determination, since that determination entails an assessment of what work the claimant can do given the physical limitations that the claimant experiences. Yet, when considering the role and necessity of medical opinion evidence in making this determination, courts have followed several different paths. Some courts emphasize the importance of medical opinion support for an RFC determination and state that “[r]arely can a decision be made regarding a claimant's residual functional capacity without an assessment from a physician regarding the functional abilities of the claimant.” Biller, 962 F.Supp.2d at 778-79 (quoting Gormont v. Astrue, Civ. No. 11-2145, 2013 WL 791455 at *7 (M.D. Pa. Mar. 4, 2013)). In other instances, it has been held that “[t]here is no legal requirement that a physician have made the particular findings that an ALJ adopts in the course of determining an RFC.” Titterington v. Barnhart, 174 Fed.Appx. 6, 11 (3d Cir. 2006). Further, courts have held in cases where there is no evidence of any credible medical opinion supporting a claimant's allegations of disability that “the proposition that an ALJ must always base his RFC on a medical opinion from a physician is misguided.” Cummings v. Colvin, 129 F.Supp.3d 209, 214-15 (W.D. Pa. 2015).
These seemingly discordant legal propositions can be reconciled by evaluation of the factual context of these decisions. Those cases, which emphasize the importance of medical opinion support for an RFC assessment, typically arise in the factual setting like that presented here, where well-supported medical sources have opined regarding limitations that would support a disability claim, but an ALJ has rejected the medical opinion that supported a disability determination based upon a lay assessment of other evidence. Biller, 962 F.Supp.2d at 778-79. In this setting, these cases simply restate the commonplace idea that medical opinions are entitled to careful consideration when making a disability determination, particularly when those opinions support a finding of disability. In contrast, when no medical opinion supports a disability finding or when an ALJ is relying upon other evidence, such as contrasting clinical or opinion evidence or testimony regarding the claimant's activities of daily living to fashion an RFC courts have adopted a more pragmatic view and have sustained the ALJ's exercise of independent judgment based upon all of the facts and evidence. See Titterington, 174 Fed.Appx. 6; Cummings, 129 F.Supp.3d at 214-15. In either event, once the ALJ has made this determination, our review of the ALJ's assessment of the plaintiff's RFC is deferential, and that RFC assessment will not be set aside if it is supported by substantial evidence. Burns v. Barnhart, 312 F.3d 113; see also Metzger v. Berryhill, 2017 WL 1483328, at *5; Rathbun v. Berryhill, 2018 WL 1514383, at *6.
The ALJ's disability determination must also meet certain basic substantive requisites. Most significant among these legal benchmarks is a requirement that the ALJ adequately explain the legal and factual basis for this disability determination. Thus, in order to facilitate review of the decision under the substantial evidence standard, the ALJ's decision must be accompanied by “a clear and satisfactory explication of the basis on which it rests.” Cotter v. Harris, 642 F.2d 700, 704 (3d Cir. 1981). Conflicts in the evidence must be resolved and the ALJ must indicate which evidence was accepted, which evidence was rejected, and the reasons for rejecting certain evidence. Id. at 706-707. In addition, “[t]he ALJ must indicate in his decision which evidence he has rejected and which he is relying on as the basis for his finding.” Schaudeck v. Comm'r of Soc. Sec., 181 F.3d 429, 433 (3d Cir. 1999).
C. Step 2 Analysis
In this case we are called upon to consider whether the ALJ erred at Step 2 of this sequential analysis when the ALJ deemed none of Rosenberry's well-documented emotional impairments to be severe. We must also consider whether the ALJ then sufficiently considered the combined effects of all of these physical impairments when crafting an RFC for the plaintiff.
In this setting, a series of special considerations are triggered. Step 2 of this sequential analysis is often the first substantive benchmark an ALJ must address and is governed by familiar legal standards:
With respect to this threshold showing of a severe impairment, the showing required by law has been aptly described in the following terms: “In order to meet the step two severity test, an impairment need only cause a slight abnormality that has no more than a minimal effect on the ability to do basic work activities. 20 C.F.R. §§ 404.1521, 416.921; S.S.R. 96-3p, 85-28. The Third Circuit Court of Appeals has held that the step two severity inquiry is a ‘de minimis screening device to dispose of groundless claims.' McCrea v. Comm. of Soc. Sec.,370 F.3d 357, 360 (3d Cir. 2004); Newell v. Comm. of Soc. Sec., 347 F.3d 541, 546 (3d Cir. 2003). ‘Any doubt as to whether this showing has been made is to be resolved in favor of the applicant.' Id. ” Velazquez v. Astrue, No. 07-5343, 2008 WL 4589831, *3 (E.D.Pa., Oct.15, 2008). Thus, “[t]he claimant's burden at step two is ‘not an exacting one.' McCrea v. Comm'r of Soc. Sec., 370 F.3d 357, 360 (3d Cir.2004). This step should be ‘rarely utilized' to deny benefits. Id. at 361. Rather, ... [a]n individual should be denied benefits at step two only if the
impairment he presents is a ‘slight abnormality' that has ‘no more than a minimal effect on [his] ability to work.' Id.” Kinney v. Comm'r of Soc. Sec., 244 Fed.Appx. 467, 469-70 (3d Cir.2007). Accordingly, “[d]ue to this limited function, the Commissioner's determination to deny an applicant's request for benefits at step two should be reviewed with close scrutiny.” McCrea v. Commissioner of Social Sec., 370 F.3d 357, 360 (3d Cir.2004).Dotzel v. Astrue, No. 1:12-CV-1281, 2014 WL 1612508, at *4 (M.D. Pa. Apr. 22, 2014). Furthermore,
[E]ven if an ALJ erroneously determines at step two that one impairment is not “severe,” the ALJ's ultimate decision may still be based on substantial evidence if the ALJ considered the effects of that impairment at steps three through five. However, where it appears that the ALJ's error at step two also influenced the ALJ's RFC analysis, the reviewing court may remand the matter to the Commissioner for further consideration. See Nosse v. Astrue, No. 08-[CV-1173, 2009 WL 2986612, *10] (W.D.Pa. Sept.17, 2009).
McClease v. Comm. of Soc. Sec., No. 8-CV-1673, 2009 WL 3497775, *10 (E.D. Pa. Oct. 28, 2009); see also Salles v. Comm. of Soc. Sec., 229 Fed. App'x 140, 145, n. 2 (3d Cir. 2007) (citing Rutherford v. Barnhart, 399 F.3d 546, 553 (3d Cir. 2005) (“Because the ALJ found in Salles's favor at Step Two, even if he had erroneously concluded that some of her impairments were non-severe, any error was harmless.”).Stouchko v. Comm'r of Soc. Sec., No. 1:12-CV-1318, 2014 WL 888513, at *10 (M.D. Pa. Mar. 6, 2014). Simply put, “because step two is to be rarely utilized as basis for the denial of benefits, [] its invocation is certain to raise a judicial eyebrow.” McCrea v. Comm'r of Soc. Sec., 370 F.3d 357, 361 (3d Cir. 2004) (citing SSR 85-28, 1995 WL 56856, at *4 (“Great care should be exercised in applying the not severe impairment concept”)).
It is against these benchmarks that we assess the instant case.
D. This Case Should Be Remanded.
This case has an unusual procedural posture. This appeal involves an ALJ's threshold Step 2 determination that Rosenberry's longstanding emotional impairments that had been found to be severe by every treating and examining medical source were not severe. The ALJ then couples this flawed Step 2 analysis with an RFC determination which makes no accommodations for Rosenberry's emotional limitations.
Given these errors, we believe that a remand of this case for a more thorough consideration of this claim is appropriate. We reach this conclusion because we recognize, as many courts have acknowledged, that this Step 2 analysis is simply a de minimis screening device for disposing of plainly groundless claims. Given the limited role which a Step 2 evaluation plays in this disability determination process, we are cautioned that all reasonable doubts regarding the sufficiency of a claim at Step 2 are to be resolved in favor of the claimant. Newell v. Comm'r of Soc. Sec., 347 F.3d 541, 547 (3d Cir. 2003).
In this case, we believe that there is an inherent confusion and contradiction in the ALJ's Step 2 analysis of the well-documented emotional impairments suffered by Rosenberry and the subsequent decision to craft an RFC for Rosenberry that provided absolutely no accommodations for her longstanding psychological challenges. These ambiguities and inconsistencies stem from several sources.
On this score, the ALJ's Step 2 severity analysis seems at odds with the controlling legal benchmarks governing Step 2 evaluations. Those legal guideposts emphasize for us that this is a de minimis screening standard and “because step two is to be rarely utilized as basis for the denial of benefits, [] its invocation is certain to raise a judicial eyebrow.” McCrea, 370 F.3d at 360-61. In the instant case, the ALJ's Step 2 severity analysis seems to go well beyond the minimal screening role contemplated by the law. The ALJ completely discounted the severity of these emotional impairments, even though they were documented in Rosenberry's treatment history for at least five years. Moreover, in disregarding the severity of these psychological impairments, the ALJ necessarily rejected the medical opinion of every expert who actually saw, examined or treated the plaintiff. In our view more is needed here to reconcile this decision with the legal benchmarks that govern the Step 2 analysis, benchmarks which strongly caution in favor of treating medical conditions as severe.
But even if we accepted the ALJ's initial characterization of all of these impairments as non-severe, there remains an unexplained incongruity in this decision which undermines confidence in the final analysis of this claim. The ALJ stated that “[t]he undersigned considered all of the claimant's medically determinable impairments, including those that are not severe, when assessing the claimant's residual functional capacity.” (Tr. 14). However, the residual functional capacity assessment crafted by the ALJ made absolutely no accommodation for Rosenberry's well-documented emotional impairments. It is difficult to understand how these emotional impairments, taken together and in combination, could not have created at least some functional limitations for Rosenberry. Yet, without any explanation, the ALJ's decision makes no accommodation whatsoever for these significant mental impairments. In the absence of some more thorough analysis of how this constellation of mental concerns affected Rosenberry's ability to meet the emotional demands of the workplace, this apparent incongruity remains unexplained and unaddressed.
Moreover, we find that the incomplete analysis of Rosenberry's emotional impairments is potentially prejudicial in this case, where it is undisputed that the plaintiff also suffers from a series of severe physical impairments. In our view, given these potentially prejudicial ambiguities and inconsistencies in the ALJ's consideration of these emotional impairments, more is needed here to sustain the Commissioner's denial of this claim. It is axiomatic that the ALJ's decision must be accompanied by “a clear and satisfactory explication of the basis on which it rests.” Cotter, 642 F.2d at 704. This means that there must be a logical nexus between the ALJ's factual findings and legal conclusion. That logical bridge is missing here. Therefore, the ALJ's burden of articulation is not met and we recommend that this matter will be remanded for further consideration by the Commissioner.
Yet, while we reach this recommendation, we note that nothing in this Report and Recommendation should be deemed as expressing a judgment on what the ultimate outcome of any reassessment of this evidence should be. Rather, this task should remain the duty and province of the ALJ on remand. Further, having found that a remand is justified on these grounds, we have not addressed any other claimed errors because the ALJ may in the first instance address them upon remand. See McMillan v. Comm'r of Soc. Sec., No. 16-313, 2018 WL 6617841, at *4 (D.N.J. Dec. 18, 2018) (holding the same in finding that a remand was appropriate because the ALJ failed to properly consider the plaintiffs severe obesity impairment at the third step and the fifth step, and thus the Court “need not consider Plaintiff's other arguments at this juncture”); see also Lawrence v. Colvin, No. 15-2851, 2016 WL 1644622, at *10 (D.N.J. Apr. 26, 2016) (holding the same in finding that a remand was appropriate because the ALJ failed to properly consider one of the claimant's disabilities, and thus the ALJ would be required to engage in an entirely new evaluation concerning the claimant's other alleged severe disabilities).
IV. Recommendation
For the foregoing reasons, IT IS RECOMMENDED that this case be REMANDED for further consideration by the Commissioner.
The parties are further placed on notice that pursuant to Local Rule 72.3:
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.