The opinion of the court was delivered by: David Stewart Cercone United States District Judge
Plaintiff Daniel J. Natale brought this action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3) for review of the final determination of the Commissioner of Social Security ("Commissioner") denying his application for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") under Titles II and XVI of the Social Security Act ("Act"), 42 U.S.C. §§ 401-433, 1381-1383f. Presently before the court are cross-motions for summary judgment based on the record developed at the administrative level. After careful consideration of the decision of the Administrative Law Judge ("ALJ"), the briefs of the parties, and the entire record, it is clear that the substantial evidence as a whole demonstrates only that Plaintiff is disabled within the meaning of the Act. Accordingly, Plaintiff's motion will be granted, Defendant's motion will be denied, and the matter will be remanded with direction to grant benefits consistent with the recognition that Plaintiff was disabled on or before December 4, 2004.
Plaintiff protectively filed for DIB and SSI on March 12, 2004, alleging disability as of February 15, 2004 due heart disease and depression. (R.94-96, 126, 138, 428-32.) The state agency denied his claims on July 21, 2005. (R. 43-44, 427.) At Plaintiff's request a hearing was held before ALJ David Hatfield on May 17, 2005 where Plaintiff, who was represented by counsel, and a vocational expert testified. (R. 452-497.) On September 7, 2005, the ALJ issued a decision finding Plaintiff not disabled. (R. 48-55.) On May 23, 2006, the Appeals Council vacated the September 7, 2006 decision and remanded the case for further proceedings because the recording of the hearing was largely inaudible. (R. 6-8) The Appeals Council also ordered the ALJ to update the treatment evidence on claimant's condition, expressly evaluate the State Agency non-examining medical source opinions, and to further consider Plaintiff's residual functional capacity and set out his findings in a function by function analysis.(R. 81-82.)
A supplemental hearing was held on April 12, 2007, at which Plaintiff, who was represented by counsel, and a vocational expert testified. (R. 503-531.). On June 6, 2007, ALJ Paul R. Sacks issued a decision finding Plaintiff not disabled. (R. 24-33). On December 30, 2007, Plaintiff filed an appeal to the Appeals Council, who denied Plaintiff's request for review on February 14, 2008. (R. 8-12.) The instant action followed.
III. STATEMENT OF THE CASE
Plaintiff was born on February 6, 1956, making him forty-eight years of age at the time of his asserted onset of disability and fifty-one years of age on the date of the ALJ's decision. (R 504.) Plaintiff received his GED and completed a welding course. (R. 32, 509.) Plaintiff's past relevant work includes serving as a food service and sales representative and as a maintenance man. (R. 510.)
On February 28, 2004, Plaintiff was admitted to the hospital complaining of chest pain and was seen by Dr. Elizabeth Piccone. (R. 212-213.) Plaintiff's cardiac enzymes were negative and no changes were noted in his electrocardiogram ("EKG"), so he was discharged on February 29, 2004. Id. He was scheduled, however, for an outpatient stress test the following day. (R. 221.) Plaintiff suffered severe chest pain during the test and abnormal EKG response to exercise. Id. The test revealed myocardial ischemia in the left ventricular septal wall and a global ejection fraction of forty-three percent. (R. 221, 323.) Dr. Flores-Paras determined that Plaintiff was suffering from unstable angina, coronary artery disease, general anxiety disease, general anxiety disorder and hypertension. (R. 326.) A cardiac catheterization was ordered for Plaintiff for the same day. Id.
Plaintiff underwent a cardiac catheterization, which indicated three areas of blockage requiring a triple coronary artery bypass. (R.216-217, 334-335.) On March 4, 2004, Dr. George Magovern performed bypass surgery on Plaintiff and placed him on Lopressor, Lipitor, Celexa, aspirin, and Wygesic. (R. 294). At a follow-up appointment with Dr. Piccone on April 7, 2004, Plaintiff reported normal post-surgical pain, but not other issues. (R. 293). A follow-up with Dr. Magovern yielded similar findings reflecting Plaintiff was doing well and had no complaints. (R.295).
On May 10, 2004, Plaintiff completed a disability report indicating that he was capable of cooking, doing laundry, and driving, but could not do yard work or gardening.(R. 154-164). He also indicated he could vacuum and climb steps as long as he stopped to rest and could dress, shower, change and make the bed without resting. Id. With respect to his emotional symptoms, Plaintiff reported being irritable and depressed and having a difficult time making plans, a hard time getting up in the morning, and trouble focusing. Id. He also indicated that he did not like change but could make decisions on his own and experienced days when he was too nervous to go to work and sometimes had difficulty getting along with co-workers and supervisors. Id. With respect to his physical symptoms, Plaintiff reported experiencing a great deal of fatigue and daily chest and muscle pain and pain from bending, lifting, and getting up from the lying position. Id.
Plaintiff's Social Security adjudicator contacted his primary care physician, Dr. Abul-Ela, on June 28, 2004. (R.148.) Dr. Abul-Ela indicated that he had last seen Plaintiff of June 6, 2004 at which point Plaintiff had no chest pain complaints, but reported dyspnea on exertion. (R.286). Dr. Abul-Ela opined that Plaintiff was still very ill, which was partially compensated for with medications, and was only capable of a low level of activity. Id. Dr. Abu-Ela also reported that Plaintiff was experiencing some depression due to his illness and inability to work and was switched from Celexa to Effexor and was doing much better on Effexor. Id.
On July 2, 2004, Dr. D.S. Kar, M.D. completed a Physical Functional Capacity Evaluation after a review of Plaintiff's records. (R. 262-270). Dr. Kar opined that Plaintiff was capable of lifting ten pounds occasionally, less than ten pounds frequently, could stand/walk at least two hours in an eight-hour work day, sit for about six hours in an eight-hour work day, and was unlimited in his ability to push or pull. (R. 263). He also indicated that Plaintiff had no postural, manipulative, environmental, or visual limitations. (R. 264-266).
Dr. Roger Glover, Ph.D., completed a Psychiatric Review Technique form on July 13, 2004. (R. 271). After reviewing Plaintiff's records, Dr. Glover indicated that Plaintiff suffered from Depressive Disorder, NOS, but that the impairment was not severe. (R. 271, 274). Dr. Glover opined that Plaintiff had mild restrictions in the activities of daily living and in maintaining concentration, persistence, and pace; no difficulties in maintaining social functioning, and no episodes of decompensation.*fn1 (R.258-59).
On August 31, 2004, Plaintiff underwent a diagnostic assessment from a therapist for intake into People In Need at which time Plaintiff reported his medical history and history of drug and alcohol addiction. (R. 303). Upon mental examination, the therapist reported that Plaintiff's mental status was casual, clean, cooperative, engaged, friendly, unimpaired, mildly depressed, and anxious. (R. 305). The therapist indicated that Plaintiff was a moderate risk to himself and had a Global Assessment of Functioning ("GAF") of 60.*fn2 Id. Plaintiff reported that he was experiencing depression, anxiety, guilt, and fear and agreed to undergo psychiatric evaluation and therapy. (R. 306).
On September 11, 2004, Plaintiff underwent a psychological assessment by Dr. Gaurav Gandotra, M.D., who later became Plaintiff's treating psychologist at People In Need. (R. 308-309). Plaintiff reported that he had first been treated for depression in 1998 and had been sober since June 2004. (R. 308). Plaintiff also indicated that he was having difficulty sleeping, some mood swings, racing thoughts, anxiety, trouble focusing, was "being edgy," and was anhedonic and anergic. Id. Plaintiff admitted to suicidal thoughts through the previous two months, and agreed to pass any guns he had in his home on to his cousin. Id. Plaintiff also reported some hypomania symptoms. Id. Upon mental examination, Dr. Gandotra noted that Plaintiff had a depressed mood and congruent affect. (R. 309). Dr. Gandotra diagnosed Plaintiff with major depressive disorder, recurrent, severe without psychosis*fn3 , rule out bipolar II, rule out adjustment disorder with depressed mood, rule out mood disorder, and rule out substance induced mood disorder. Id. Dr. Gandotra recommended putting Plaintiff on Lexapro and a sleep aid, Trazadone and advised a continuation of outpatient psychotherapy. Id.
On September 19, 2004, Dr. Piccone completed a form relating to Plaintiff's functional capacity on a scale developed by the American Heart Association. (R. 291). She placed Plaintiff as a Class II patient indicating cardiac disease resulting in only slight limitations of physical activity. Id. Dr. Piccone noted that Plaintiff was comfortable at rest, but ordinary physical activity could result in fatigue, palpitation, dyspnea, or anginal pain. Id. At a follow-up appointment on October 6, 2004, she reported that Plaintiff was "doing quite well from a cardiovascular standpoint" but was significantly depressed. (R. 310). Plaintiff reported that he was not experiencing chest pain, pressure, dizziness or lightheadedness, or exertional shortness of breath. Dr. Piccone found no palpitations and the rest of the examination was normal. Id. Dr. Piccone stopped Plaintiff's Atenolol secondary to his depression. Id.
On December 4, 2004, Dr. Gandotra completed a form indicating that Plaintiff met the criteria for Listing 12.04 for Affective Disorders. (R.297-299.) Dr. Gandotra indicated that Plaintiff was experiencing disturbance of mood coupled with a full or partial manic or depressive syndrome as evidenced by his anhedonia, sleep disturbance, decreased energy, feelings of guilt or worthlessness, difficulty concentrating and thoughts of suicide. (R. 297). Dr. Gandotra opined that Plaintiff was suffering from extreme restrictions in the activities of daily living, marked restrictions in the maintaining of social functioning, marked deficiencies in concentration, persistence, or pace, and four or more episodes of decompensation. (R. 298). Dr. Gandotra further noted that there were repeated periods of decompensation present, each of extended duration, and that the residual disease process had resulted in such a marginal adjustment that even a minimal increase in mental demands or change in the environment would be predicted to cause Plaintiff to decompensate. (R. 299).
On February 12, 2005, Plaintiff attended a follow-up appointment with Dr. Gandotra. (R.301-302). Dr. Gandotra reported that Plaintiff's depression and anxiety were "better controlled" since his last visit, but also noted that Plaintiff was still experiencing depression stints lasting four days or more out of the blue when he would think about his financial situation. (R. 301). During these episodes, Plaintiff would isolate himself, not want to do anything, and spend most of his time in bed. Id. Dr. Gandotra noted that Plaintiff had poor concentration, anhedonia, and low energy levels. During the mental status exam, Dr. Gandotra noted that Plaintiff's affect had improved and that his major depressive disorder, recurrent, severe was in partial remission.*fn4 Id. Plaintiff's Lexapro was increased. (R. 302).
On April 9, 2005, Plaintiff had another follow-up appointment with Dr. Gandotra. (R.398). At this visit, Plaintiff reported doing much better than before, but still experiencing "down times."(R. 398). Plaintiff denied any overt signs of depression and denied suicidal or homicidal ideation. Id. Upon mental examination, Dr. Gandotra noted that Plaintiff's mood was better and his affect congruent. Id. He continued to indicate that Plaintiff's condition was in partial remission and Plaintiff was continued on Lexapro. Id.
On May 14, 2005, Dr. Gandotra composed a letter indicating that Plaintiff had been seen for a follow-up visit. (R. 108). Dr. Gandotra indicated that Plaintiff had been diagnosed with major depressive disorder and was being treated with Lexapro. (R. 108). He further indicated that Plaintiff was experiencing symptoms of depressed mood, anhedonia, isolation, tearfulness, poor self-esteem, and sleep and appetite disturbances. Id. Dr. Gandotra reported that "[e]ven minor stress exacerbates these symptoms causing patient to isolate himself to a room all by himself for extended periods of time." Id. Dr. Gandotra further noted that "[p]atient in spite of having shown intermittent periods with transient improvement of neurovegitative symptoms of depression, continues to have a severe debilitating pattern of depression affecting him biologically as well as psycho-socially." Id.
At his May 21, 2005 follow-up appointment with Dr. Gandotra, Plaintiff reported that he was not doing well physically and that this was affecting his mental health. (R. 396). Plaintiff indicated that his mood was fluctuating from good to down, but that he had overall improvement especially with respect to suicidal ideation. Id. Dr. Gandotra indicated that Plaintiff was still experiencing periods of isolation, anergia, and anhedonia. Id. Upon mental examination, Dr. Gandotra noted that Plaintiff had fairly good eye contact and fair insight and judgment. Id. Dr. Gandotra continued Plaintiff on Lexapro and told him that he would have to switch psychiatrists as Dr. Gandotra was leaving People In Need. Id.
On July 8, 2005, Plaintiff had a follow-up appointment with Dr. Piccone for his heart condition. (R. 313, 379). Dr. Piccone noted that Plaintiff was somewhat fatigued and had occasional chest pain. Id. She further noted that Plaintiff had begun smoking a half a pack of cigarettes a day again. Id. Otherwise, Plaintiff's examination was normal. Id. Dr Piccone ordered testing and encouraged Plaintiff to stop smoking. Id.
On July 16, 2005, Plaintiff was seen by Dr. Daniel Monti, M.D. at People In Need. Plaintiff reported doing okay and having a stable mood since his last visit with Dr. Gandotra. (R. 312). Plaintiff discussed his stressors and indicated that they occasionally made him more depressed, hopeless, and helpless. Id. Dr. Monti indicated that Plaintiff was compliant with his medications, but was experiencing sleep difficulties and was not taking Vistaril because of dizziness. Id. Dr. Monti also indicated that Plaintiff had daytime somnolence on medication, manic symptoms of energy and no need for sleep, increased energy, anhedonia, and changes in his judgment. Id. Dr. Monti reported that Plaintiff had episodes of isolation, lack of energy, and anhedonia, but had improved substantially overall. Id. Upon mental examination Dr. Monti indicated that Plaintiff was in a good mood at the time, but might experience variations with social problems. He also indicated that he wanted to rule out mood disorder ...