United States District Court, M.D. Pennsylvania
March 12, 2014
KATHERINE STRICKLAND, Plaintiff,
MICHAEL J. ASTRUE, Commissioner of Social Security, Defendant.
CHRISTOPHER C. CONNER, Chief District Judge.
Presently before the court in the above-captioned matter are the complaint (Doc. 1) of plaintiff Katherine Strickland ("Strickland") seeking review of a decision of the Commissioner of Social Security ("Commissioner") denying Strickland's claim for social security and disability benefits, the Commissioner's answer (Doc. 6) thereto, and the transcript (Doc. 7) of administrative proceedings. The issues are fully briefed, (Docs. 11-12), and the matter is ripe for review. For the reasons that follow, the court will vacate the Commissioner's decision and remand the above-captioned matter for further proceedings, as necessary, and issuance of a new decision.
I. Factual and Procedural History
Katherine Strickland ("Strickland") was born on January 12, 1963, and was forty-five (45) years old at the time of alleged disability onset. (Tr. at 157). The record reveals that Strickland received her high school diploma and has relevant past work experience as a call center customer service representative, which is considered light, semi-skilled work. (Id. at 63, 157). She currently resides with her fiance and daughter. (Id. at 41-42).
Strickland protectively filed for disability insurance benefits ("DIB") on November 14, 2008, and for supplemental security income ("SSI") on November 30, 2008. (Id. at 119-28). Strickland alleges that various impairments, individually and in combination, render her totally disabled and unable to engage in any gainful employment. (Id. at 38-39). Specifically, she asserts that the following impairments substantially limit her functional abilities: fibromyalgia, degenerative joint disease in the knees, depression, migraine headaches, diabetes, reflux disease, irritable bowel syndrome, and chronic pain. (Id. at 18-19). The administration denied Strickland's initial application for benefits on August 4, 2009. (Id. at 97-105). The administrative law judge ("ALJ") thereafter held a hearing and heard testimony from Strickland and a vocational expert. (Id. at 31-66).
During the hearing, Strickland testified at length with respect to subjective complaints. Regarding physical symptoms, Strickland reported waking up "every morning... feeling like I've been run over by a truck during the night." (Id. at 48). Strickland ranked her daily pain level "at a four or five depending on the area of my body" on a scale from zero to ten. (Id. at 58). Strickland stated that she feels nearly constant pain in the joints of her shoulders, elbows, hips, knees, ankles, and wrists. (Id. at 49). She testified that she misses school "anywhere from five to six, six to eight times a month" because her fibromyalgic pain prevents her from leaving her home. (Id. at 55). She also testified that she experiences migraine headaches, "at least four a month, " which are controlled by medication if caught in time, (id. at 53, 55), and that she was once hospitalized for a migraine which persisted for four (4) days. (Id. at 54). She stated that she suffers from frequent diarrhea as a result of irritable bowel syndrome. (Id.) According to Strickland, she experiences flare ups of diarrhea two or three days per week, each resulting in trips to the bathroom "anywhere from eight to 12 times a day in a work day." (Id. at 57).
With respect to her mental symptoms, Strickland stated that she has been treating with a priest, who is also a licensed psychologist, as therapy for situational depression, which she surmises is a result of her mother passing away, her son's deployment to Iraq, her ex-husband going to jail for abusing her daughter, and "not being able to do what I used to do." (Id. at 50-51). Strickland also explained that although she is generally good at retaining information, she sometimes struggles to recall information she has learned. (Id. at 48).
With respect to daily activities and abilities, Strickland testified that she can only lift a half gallon of milk and can handle walking for a short grocery store trip. (Id. at 52). Strickland testified that she can stand for approximately fifteen minutes and can sit for half an hour before she needs to move. (Id. at 53). At the time of the hearing, Strickland reported that she was in school full time at the Fortis School, four days per week, studying to become a medical assistant technician. (Tr. at 44-45). She testified that she is "doing very well" in school; however, she explained that the school is not very accommodating about poor attendance, and she was "in danger of being thrown out" for missing too much time. (Id.). She explained that while at school, she must stand up and walk around up to four times each morning and afternoon. (Id.) Strickland testified that her daughter handles all household chores. (Id.) Strickland reported that she recently attended a gathering of her former classmates in Philadelphia and that she took a trip to the Poconos with her fiance where they went to dinner, walked the complex, and then "stayed pretty much in" because of a snow storm. (Tr. at 43-44).
After the hearing, the ALJ issued a decision finding that Strickland is not disabled. (Id. at 13-26). Specifically, the ALJ concluded that Strickland has the residual functional capacity ("RFC") to perform sedentary work with enumerated limitations. (Id. at 20-21). The vocational expert testified that various unskilled jobs exist in the national and local economy within these limitations. (Id. at 64-69). On June 20, 2012, the Social Security Appeals Council denied Strickland's request for review of the ALJ's decision. (Id. at 1-5). On August 14, 2012, having exhausted her administrative remedies, Strickland commenced this civil action to challenge the decision of the ALJ pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3).
II. Standard of Review
District courts have jurisdiction to review decisions of the Commissioner denying disability insurance benefits or supplemental social security income based upon 42 U.S.C. § 405(g). See id. ("Any individual... may obtain review of [any final decision of the Commissioner] by a civil action commenced within sixty days after the mailing to him of such decision."). When considering such an appeal, district courts have plenary review of all legal issues decided by the Commissioner. Poulos v. Comm'r of Soc. Sec. , 474 F.3d 88, 91 (3d Cir. 2007); Schaudeck v. Comm'r of Soc. Sec. , 181 F.3d 428, 431 (3d Cir. 1999); Krysztoforski v. Chater , 55 F.3d 857, 858 (3d Cir. 1995). Judicial review of the Commissioner's findings of fact is much more limited: the test is deferential and tasks the court to determine whether the factual findings are supported by "substantial evidence." 42 U.S.C. § 405(g) ("The findings of the [Commissioner] as to any fact, if supported by substantial evidence, shall be conclusive."); see Fargnoli v. Massanari , 247 F.3d 34, 38 (3d Cir. 2001) ("Where... findings of fact are supported by substantial evidence, we are bound by those findings, even if we would have decided the factual inquiry differently."); see also Mason v. Shalala , 994 F.2d 1058, 1064 (3d Cir. 1993); Brown v. Bowen , 845 F.2d 1211, 1213 (3d Cir. 1988).
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) (quoting Consolidated Edison Co. v. N.L.R.B. , 305 U.S. 197, 229 (1938)); Johnson v. Comm'r of Soc. Sec. , 529 F.3d 198, 200 (3d Cir. 2008); Hartranft v. Apfel , 181 F.3d 358, 360 (3d Cir. 1999). Substantial evidence is "more than a mere scintilla, " but less than a preponderance, of the evidence. Brown , 845 F.2d at 1213 (citing Stunkard v. Sec'y of Health & Human Servs. , 841 F.2d 57, 59 (3d Cir. 1988)). 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 an administrative agency's finding from being supported by substantial evidence." Consolo v. Fed. Mar. Comm'n , 383 U.S. 607, 620 (1966).
Substantial evidence exists only "in relationship to all the other evidence in the record, " Cotter v. Harris , 642 F.2d 700, 706 (3d Cir. 1981), and "must take into account whatever in the record fairly detracts from its weight." Universal Camera Corp. v. N.L.R.B. , 340 U.S. 474, 488 (1971). "When a conflict in the evidence exists, the ALJ may choose whom to credit but cannot reject evidence for no reason or for the wrong reason.'" Plummer v. Apfel , 186 F.3d 422, 429 (3d Cir. 1999) (quoting Mason , 994 F.2d at 1066). The ALJ must indicate which evidence was accepted, which evidence was rejected, and the reasons for rejecting certain evidence. Johnson , 529 F.3d at 203; Cotter , 642 F.2d at 706-07. Therefore, the district court must scrutinize the record as a whole on appeal. Smith v. Califano , 637 F.2d 968, 970 (3d Cir. 1981); Dobrowolsky v. Califano , 606 F.2d 403, 407 (3d Cir. 1979).
III. Sequential Evaluation Process
To receive disability benefits, social security claimants 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). An individual is considered to be "unable to engage in substantial gainful activity" when "his physical or mental impairment or impairments are of such severity that he is not only unable to do his previous work but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy." 42 U.S.C. § 423(d)(2)(A).
The ALJ employs a five-step process in evaluating DIB and SSI claims. 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). The process requires the ALJ to query, in sequence, whether the claimant: (1) is engaging in "substantial gainful activity"; (2) has an impairment that is "severe" or a combination of impairments that is severe; (3) has an impairment or combination of impairments that meets or equals the criteria of a "listed impairment" or "listing"; (4) has the "residual functional capacity" ("RFC") to return to his or her past work; and (5) if not, whether he or she can perform other work in the national economy. 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). The burden of proof rests with the claimant throughout the first four steps and with the Commissioner at step five. Kangas v. Bowen , 823 F.2d 775, 777 (3d Cir. 1987).
At step four, the Commissioner determines the claimant's RFC. 20 C.F.R. §§ 404.1520(a)(4)(iv), 416.920(a)(4)(iv). An RFC represents the claimant's maximum remaining ability to do sustained work activities in an ordinary work setting on a regular and continuing basis. See Social Security Ruling ("SSR") 96-8p, 61 Fed. Reg. 34474, 34475 (July 2, 1996). The RFC assessment must include a discussion of the individual's abilities. Id .; 20 C.F.R. §§ 404.1545, 416.945; Fargnoli , 247 F.3d at 40 (defining RFC as that which an individual is still able to do despite the limitations caused by his or her impairment(s)). If the claimant does not have the RFC to perform his or her past relevant work, or the claimant has no past relevant work, the burden at step five shifts to the Commissioner to prove that the claimant can perform other work in the national economy. See Kangas , 823 F.2d at 777 (citing 20 C.F.R. §§ 404.1520(f), 416.920(f)).
As noted above, the ALJ in the matter sub judice conducted an evidentiary hearing and took testimony from the claimant and a vocational expert. The ALJ applied the sequential evaluation process and concluded that Strickland is not disabled under the Act and thus not entitled to disability benefits. In step one, the ALJ found that Strickland has not engaged in substantial gainful activity since March 25, 2008, the alleged onset date of her disability. (Tr. at 18). In the second step, the ALJ found that Strickland suffers from the following severe impairments: fibromyalgia, degenerative joint disease of the knees, and depression. (Id.)
Next, in step three, the ALJ held that Strickland's impairments do not separately or in combination meet or equal a listed impairment. (Id. at 19-20). The ALJ first considered whether Strickland satisfies the criteria of listing 1.02(A), pertaining to major dysfunction of a joint, but concluded that no objective medical evidence demonstrates that Strickland's chronic joint pain results in an inability to ambulate effectively. (Id. at 19). The ALJ also considered whether Strickland's mental impairment satisfies the criteria of listing 12.04, pertaining to affective disorders. (Id. at 20). The ALJ observed that Strickland does not satisfy the criteria of Paragraph B, which requires objective medical evidence of at least two of the following: marked restriction of activities of daily living, marked difficulties in maintaining social functioning, marked difficulties in maintaining concentration, persistence, or pace, or repeated episodes of decompensation, each of extended duration. (Id.) The ALJ also concluded that Strickland does not satisfy the criteria of Paragraph C, which requires medical evidence that the claimant has experienced repeated episodes of decompensation, each of extended duration, suffers from a residual disease process that has resulted in such marginal adjustment that even a minimal increase in mental demands or change in the environment would be predicted to cause the individual to decompensate, or has a current history of 1 or more years' inability to function outside a highly supportive living arrangement, with an indication of continued need for such an arrangement. (Id.)
In concluding that Strickland does not meet the criteria of these listings, the ALJ made the following pertinent observations: First, that Strickland experiences only mild restriction in her daily living activities, noting that she lives with her fiance and adult daughter, is able to maintain her home with their assistance, and experiences no difficulty with personal care. (Id.) Second, that Strickland has no difficulties in social functioning. (Id.) Third, that Strickland experiences moderate difficulties with regard to concentration, persistence, and pace, observing that she "has depression, which by its nature interferes with an individual's ability to concentrate, persist, and maintain pace." (Id.) The ALJ observed that Strickland has not experienced any episodes of decompensation. (Id.) For these reasons, the ALJ concluded that Strickland's severe impairments neither collectively nor individually meet or equal a listed impairment. (Id.)
The ALJ assessed Strickland's RFC at step four and opined that Strickland has an RFC to perform sedentary work, with the following limitations: (1) no more than occasional postural maneuvers to include balancing, stooping, kneeling, crouching, crawling, and climbing on ramps or stairs; (2) no climbing on ladders, ropes, and scaffolding; (3) no more than occasional pushing and pulling with the lower extremities to include the operation of foot pedals; (4) no exposure to fumes, odors, dust, gases, chemical irritants, environments with poor ventilation, extreme temperatures, and extreme dampness and humidity; (5) no more than simple, routine tasks, not performed in a fast-paced production environment, involving only simple, work-related decisions, and in general, relatively few work place changes; (6) no exposure to hazards such as dangerous machinery or unprotected heights; and (7) no more than occasional fingering, gross handling, feeling, overhead reaching, pushing, or pulling with the upper extremities, to include the operation of hand levers, overhead work, and prolonged writing and keyboard work. (Id. at 20-24). The ALJ concluded that given this RFC, Strickland is unable to perform her past relevant work as a customer service representative or waitress. (Id. at 24).
Based on Strickland's age, work experience, education, and RFC, in addition to the testimony of a vocational expert, the ALJ found that she is able to perform sedentary work and identified the following representative occupations: video monitor, telephone information clerk, and order clerk. (Id. at 24). The vocational expert opined, and the ALJ found, that these jobs exist in significant numbers in the local and national economies. (Id.) As a result, the ALJ held that Strickland is not disabled as defined by the Social Security Act, 42 U.S.C. § 401 et seq.
In the instant appeal, Strickland alleges that the ALJ had no reasonable basis to reject her testimony as to the frequency and intensity of pain associated with her fibromyalgia, the frequency with which she experiences diarrhea, and the frequency and intensity of her migraine headaches. In essence, Strickland attacks the ALJ's credibility findings with respect to her subjective testimony, asserting that her complaints of pain are supported by objective record evidence which was altogether ignored by the ALJ. After reviewing the administrative record and the ALJ's decision, the court concludes that the ALJ failed to adequately explain his rejection of certain probative medical records and Strickland's subjective testimony and will accordingly remand the matter to the ALJ.
When a disability determination turns on an assessment of the level of a claimant's pain, the Social Security Regulations provide a framework under which a claimant's subjective complaints are to be measured. See 20 C.F.R. §§ 404.1529, 416.929. Such cases require the ALJ to "evaluate the intensity and persistence of the pain or symptom, and the extent to which it affects the individual's ability to work." Hartranft v. Apfel , 181 F.3d 358, 362 (3d Cir. 1999). Cases involving an assessment of subjective reports of pain "obviously require the ALJ to determine the extent to which a claimant is accurately stating the degree of pain or the extent to which he or she is disabled by it." Id . (citing 20 C.F.R. § 404.1529(c)).
Under the regulations, symptoms such as pain, shortness of breath, and fatigue will only be considered to limit a claimant's ability to perform work activities if such symptoms result from an underlying physical or mental impairment that has been demonstrated to exist by medical signs or laboratory findings. 20 C.F.R. §§ 404.1529(a), 416.929(a). Once a medically determinable impairment which results in such symptoms is found to exist, the ALJ evaluates the intensity and persistence of the symptoms to determine their impact on the claimant's ability to work. 20 C.F.R. §§ 404.1529(c), 416.929(c). In doing so, the ALJ considers the medical evidence of record in addition to the claimant's testimony. See 20 C.F.R. §§ 404.1529(c)(2)-(3), 416.929(c)(2)-(3). Social Security Ruling ("SSR") 96-7p provides instructions for evaluating the credibility of a claimant's statements regarding subjective symptoms:
In general, the extent to which an individual's statements about symptoms can be relied upon as probative evidence in determining whether the individual is disabled depends on the credibility of the statements. In basic terms, the credibility of an individual's statements about pain or other symptoms and their functional effects is the degree to which the statements can be believed and accepted as true. When evaluating the credibility of an individual's statements, the adjudicator must consider the entire case record and give the specific reasons for the weight given to the individual's statements.
SSR 96-7p (July 2, 1996). In addition, SSR 96-4p provides that:
Once the existence of medically determinable physical or mental impairment(s) that could reasonably be expected to produce the pain or other symptoms alleged has been established on the basis of medical signs and laboratory findings, allegations about the intensity and persistence of the symptoms must be considered with the objective medical abnormalities, and all other evidence in the case record, in evaluating the functionally limiting effects of the impairment(s).
SSR 96-4p (July 2, 1996). The ALJ employed this two-step analysis in his decision and concluded that although Strickland's medically determinable impairments could reasonably be expected to cause the symptoms she alleges, her statements with respect to the intensity, persistence, and limiting effects of those symptoms are not credible to the extent they are inconsistent with or not supported by the medical evidence. (Tr. at 23).
Several inconsistencies in the ALJ's credibility determinations compel the court to remand the matter to the Commissioner. For example, although the ALJ concludes that Strickland's subjective complaints with regard to the frequency and severity of her diarrhea are unsupported by medical evidence, the ALJ nonetheless observes that "medical evidence of record recently noted bowel movements six to seven times per day." (Id. at 19). The ALJ also relies on a note from June of 2009 in concluding that Strickland's symptoms have improved, but ignores a July 2009 note that Strickland was recently treated in the emergency room "for nausea, vomiting, and diarrhea." (Id. at 22). Further, although she acknowledges copious medical records which document Strickland's subjective complaints of fibromyalgic pain, (id. at 21-22, passim (observing, inter alia, limited range of motion due to pain and examinations revealing tenderness)), and her testimony with respect to the disabling degree of her pain, (id. at 23), the decision provides no meaningful discussion of Strickland's complaints or the corroborating medical records. (Id. at 23-24 (discussing migraine headaches, irritable bowel syndrome, osteoarthritis, and depression, but ignoring Strickland's extensive and continuing complaints of fibromyalgic pain).
Although the ALJ need not address every medical note of record, he or she must offer an explanation when rejecting relevant and probative evidence, especially when that evidence supports the claimant's subjective complaints with respect to the severity, persistency, and frequency of her symptoms. See Fargnoli , 247 F.3d at 42 ("[W]e do not expect the ALJ to make reference to every relevant treatment note...."); Hur v. Barnhart , 94 F.Appx. 130, 133 (3d Cir. 2004) ("There is no requirement that the ALJ discuss in its opinion every tidbit of evidence included in the record."). It is true, as the Commissioner alleges, that the ALJ may choose what evidence to credit in the face of conflicting probative evidence, see Plummer , 186 F.3d at 429, but he or she nonetheless must fully explain the reasons for doing so. Fargnoli , 247 F.3d at 42. Absent such an explanation, the reviewing court cannot adequately determine whether the ALJ's rejection of certain evidence was proper. Cotter , 642 F.2d at 706-07 ("Because it is apparent that an [ALJ] cannot reject evidence for no reason or for the wrong reason, an explanation from the ALJ of the reason why probative evidence has been rejected is required so that a reviewing court can determine whether the reasons for rejection were improper.").
Here, the ALJ devotes a single paragraph to measuring Strickland's complaints against the medical evidence and cursorily concludes that the record does not support her consistent and enduring subjective complaints. (Id. at 23-24). In doing so, the ALJ references but ultimately ignores medical evidence which, to a certain degree, supports Strickland's subjective complaints. (Compare id. at 22 (noting claimant's hospitalization in July of 2009 for diarrhea) with id. at 24 (holding that no medical records support Strickland's frequency, persistence, and severity complaints)). In determining Strickland's RFC, the ALJ simply concludes that Strickland's episodic diarrhea has resolved, (see id. at 24), and ignores the copious medical records and testimony supporting Strickland's complaints of persistent fibromyalgic pain. (See id. at 23-24).
Ultimately, the ALJ's failure to adequately explain her rejection of probative evidence undermines the court's confidence in the ALJ's credibility determinations and restricts the court's ability to engage in meaningful appellate review. Cotter , 642 F.2d at 706-07 ("An explanation... of the reason why probative evidence has been rejected is required so that a reviewing court can determine whether the reasons for rejection were improper." (emphasis added)). Although the ALJ may have perfectly acceptable reasons for rejecting Strickland's subjective complaints of fibromyalgic pain and medical evidence with respect to her chronic diarrhea, the court cannot discern those reasons from the ALJ's decision as it currently stands. For this reason, the court must remand the case to the ALJ for a clear and detailed explanation of her reason for rejecting probative medical evidence and testimony. See Fargnoli , 247 F.3d at 42 (courts should "vacate or remand a case where such an explanation is not provided").
For the reasons stated herein, the court will vacate the decision of the Commissioner and remand for further proceedings, as necessary, and issuance of a new decision consistent with this memorandum. An appropriate order shall issue.