United States District Court, M.D. Pennsylvania
MARTIN C. CARLSON, Magistrate Judge.
In this case we are asked to consider whether substantial evidence supports an ALJ's decision denying benefits to the plaintiff, when the ALJ's decision: (1) rejected the opinion of the plaintiff's treating physician; (2) relied upon the opinion of a consulting medical source to conclude that the plaintiff could do light work without addressing aspects of that opinion which would have prevented the plaintiff from performing light work; and (3) included a form of ad hoc lay medical analysis by the ALJ expressed in terms that have been repeatedly rejected and criticized by the courts. Finding that these errors, in combination, lead us to conclude that the ALJ's decision is not supported by substantial evidence, and we will order that this case be remanded for further consideration by the Commissioner.
II. Statement of Facts and of The Case
The plaintiff, Rita Reader, was 47 years old at the time of the alleged onset of her disability and has a sixth grade education. (Tr. 57, 141, 160.) On January 11, 2010, Reader applied for Social Security disability benefits, alleging an onset of disability beginning in October 2009 based upon a constellation of severe impairments including obesity, degenerative disc disease and fibromyalgia. (Tr. 22.)
Reader's disability claim was supported by the opinion of her primary treating physician, Dr. Kemberling, who had treated Reader for approximately six years and opined that it would be "almost impossible for her, even with accommodations, to hold gainful employment due to her medical problems." (Tr. 249.) Dr. Kemberling consistently described Reader's limitations in terms that were both detailed and disabling. Thus, in January 2010, Dr. Kemberling rated Reader's pain on a 1-to-10 scale, at 8-10 and her fatigue at 9-10. He concluded that in an 8-hour work day, Reader could sit for 1 hour at a time, for a total of 2 hours, could stand/walk for 1 hour at a time, for a total of 2 hours, could frequently lift and carry 5 pounds and could occasionally lift and carry 10 pounds. Dr. Kemberling found that Reader could not use her arms for reaching including overhead; could not kneel, bend, stoop, or push/pull; and would need to avoid temperature extremes. (Tr. 307-309, 311.)
In an updated Multiple Impairment Questionnaire dated October 29, 2010, Dr. Kemberling stated that Reader's anxiety caused physical symptoms such as heart racing, shortness of breath, and shaking. He also noted that Reader's neck pain continued to be burning and stabbing, with her back pain now referred to her leg. Reader was also experiencing numbness and tingling in her face and persistent joint pain that was exacerbated by sitting, standing, walking, lifting, bending, reaching, working at the computer, and weather changes. (Tr. 797-799, 804.)
Reader's reported level of pain and discomfort was also corroborated by testing performed by Dr. DelVecchio, her treating rheumatologist. On April 27, 2010, Dr. DelVecchio examined Reader and found that she experienced pain on 14 of 18 fibromyalgia tender points. (Tr. 277-78, 455.)
As part of the disability assessment process Reader's physical limitations were also evaluated on May 5, 2010, by Dr. Wendy Rissinger, a State Agency Examining Consultant. Following this examination, Dr. Rissinger opined that in an 8-hour workday, Reader could stand or walk for a total of 4 hours and could sit 8 hours provided she could alternate sitting/standing at her option. Dr. Rissinger also concluded that Reader could frequently lift 10 pounds and could frequently carry 2-3 pounds; could occasionally lift and carry 25 pounds, and could bend, kneel, stoop, crouch, balance, and climb. (Tr. 635-636.) While many of these exertional restrictions were consistent with an ability to perform light work,  at least one of the exertional restrictions found by Dr. Rissinger-that Reader was limited to carrying 2-3 pounds- would have restricted Reader to performing sedentary work.
On November 18, 2010, a hearing was held before an Administrative Law Judge (ALJ) on Reader's disability application. At this hearing, the ALJ received Reader's medical records. In addition, Reader and a vocational expert testified at this proceeding. (Tr. 53-82.) At this hearing Reader testified that she stopped working in October, 2009, because it became too difficult and painful for her to carry out her duties and stated that she cannot work because of burning, radiating pain that goes from the base of her skull into her neck, right shoulder, and upper back. Reader described pain that was constant but varied in intensity, and significantly interfered with her sleep and activities of daily living. (Tr. 58-62, 67, 69-70.) Thus, Reader's testimony was entirely consistent with the exertional limits found by her treating physician.
On December 14, 2010, the ALJ issued a decision denying Reader's application for benefits. (Tr. 17-28.) In this decision the ALJ found that Reader suffered from the following severe ailments: obesity, degenerative disc disease and fibromyalgia. (Tr. 22.) The ALJ, however, rejected the opinion of Reader's treating physician over the past six years that these ailments were disabling, finding that opinions to be insufficiently supported by treatment records. (Tr. 23.) Instead, the ALJ stated that he gave "great weight" to the opinion of the examining state agency physician, Dr. Rissinger. (Tr. 25.) Yet, while the ALJ indicated that he afforded Dr. Rissinger's opinion great weight, the ALJ arrived at a residual functional capacity assessment that was, in at least one material respect, inconsistent with Dr. Rissinger's opinion. Specifically, the ALJ determined that plaintiff retained the residual functional capacity to perform light work "which allows for a change of position from sitting/standing at least every 20 minutes no climbing ladders/scaffolds or crawling and only occasional kneeling, stooping and balancing." (Tr. 23.) This conclusion was inconsistent with Dr. Rissinger's opinion that Reader was limited to carrying 2-3 pounds, an opinion which would restrict Reader to performing sedentary work. The ALJ's decision did not address, or reconcile, this apparent inconsistency between the reported reliance on Dr. Rissinger's opinion, and the contradictions between that medical opinion and the ALJ's findings.
Finally, the ALJ discounted Reader's own complaints of persistent pain, in a fashion which seemed to express a lay medical opinion, stating:
In this case, the claimant's case in establishing disability is directly dependent on the element of pain which is of an intractable nature. Pain is subjective and difficult to evaluate, both quantitatively and qualitatively. Nevertheless, most organic diseases produce manifestations other than pain and it is possible to evaluate the underlying processes and degree of resultant impairment by considering all of the symptoms. Generally, when an individual has suffered pain over an extended period, there will be observable signs such as a significant loss of weight, an altered gait or limitation of motion, local morbid changes, or poor coloring or station. In the present case, the claimant has complained of pain over an extended period of time. None of the above signs of chronic pain are evidence. While not conclusory by itself, this factor contributes to the determination that the claimant is not disabled as a result of pain.
Thus, the ALJ's decision in this case rested on three central findings: First, the ALJ rejected the opinion of Reader's primary treating physician. Second, the ALJ purported to place great weight on a consulting examining source, but then without explanation did not include all of the limitations found by that source when reaching a judgment regarding Reader's residual functional capacity. Finally, the ALJ discounted Reader's complaint based upon a lay, ad hoc medical opinion regarding how Reader's pain should manifest itself.
After exhausting her administrative appeals of this adverse ALJ decision, Reader filed this civil action seeking judicial review of the ALJ's disability determination. (Doc. 1.) The parties have fully briefed this matter, (Docs. 8 and 9.), and this case is now ripe for resolution. For the reasons set forth below, we find that it is necessary for this matter to be remanded
A. Standards of Review-The Roles of the Administrative Law ...