United States District Court, M.D. Pennsylvania
MEMORANDUM DOCS. 1, 10, 11, 12, 13, 14
GERALD B. COHN, Magistrate Judge.
The above-captioned action is one seeking review of a decision of the Commissioner of Social Security ("Commissioner") denying the application of Plaintiff April Gray for supplemental security income ("SSI") and disability insurance benefits ("DIB") under the Social Security Act, 42 U.S.C. §§401-433, 1382-1383 (the "Act"). Plaintiff has been diagnosed with depression, generalized anxiety disorder, bipolar disorder, borderline personality disorder, and post-traumatic stress disorder. Objective evidence demonstrated impairments in social functioning and concentration, persistence, and pace. Every medical source opinion in the record indicated moderate limitations overall in concentration, persistence, and pace, and several specific categories, such as following instructions, maintaining attention for extended periods of time, and working without being distracted. The ALJ made specific findings that Plaintiff had difficulty, inter alia, finishing tasks and concentrating. However, the ALJ did not include any nonexertional limitations in evaluating Plaintiff's residual functional capacity ("RFC") beyond restricting social interaction and limiting her to unskilled work. The ALJ did not include any additional limitations in following instructions, simple or routine work, concentration, persistence, or pace. The ALJ found that unskilled work sufficiently accounted for Plaintiff's other limitations. The only rationale offered by the ALJ were two treatment notes, prior to the alleged onset date, that Plaintiff had intact memory.
Plaintiff asserts that a limitation to unskilled work is not sufficiently specific to account for her difficulties in concentration, persistence and pace. Third Circuit precedent requires an ALJ to include restrictions specific to nonexertional limitations, including concentration, persistence, and pace, unless the record otherwise suggests that no additional limitations are necessary. Burns v. Barnhart , 312 F.3d 113 (3d Cir. 2002); Ramirez v. Barnhart , 372 F.3d 546, (3d Cir. 2004). Here, the record does not otherwise suggest that no additional limitations are necessary, where the ALJ pointed only to two treatment notes prior to the alleged onset date despite objective and opinion evidence during the relevant period documenting Plaintiff's limitations. Ramirez squarely addressed this issue, and found that an ALJ"s limitation to simple tasks was insufficient to account for moderate limitations in concentration, persistence, and pace. Ramirez remanded the case to the ALJ for further findings. Defendant has offered no legitimate reason to find that Ramirez does not apply in this case. For the foregoing reasons, the Court concludes that the ALJ's decision lacks substantial evidence, grants Plaintiff's appeal, vacates the decision of the Commissioner, and remands for further proceedings.
II. Procedural Background
On July 14, 2010, Plaintiff filed an application for SSI under Title XVI of the Act and for DIB under Title II of the Act. (Tr. 204-225). On December 21, 2010, the Bureau of Disability Determination denied these applications (Tr. 126-135), and Plaintiff filed a request for a hearing on January 4, 2011. (Tr. 136-37). On July 28, 2011, an ALJ held a hearing at which Plaintiff- who was represented by an attorney-and a vocational expert ("VE") appeared and testified. (Tr. 23-87). On September 21, 2011, the ALJ found that Plaintiff was not disabled and not entitled to benefits. (Tr. 8-22). On November 25, 2011, Plaintiff filed a request for review with the Appeals Council (Tr. 7), which the Appeals Council denied on May 17, 2013, thereby affirming the decision of the ALJ as the "final decision" of the Commissioner. (Tr. 1-6).
On July 17, 2013, Plaintiff filed the above-captioned action pursuant to 42 U.S.C. § 405(g) to appeal the decision of the Commissioner. (Doc. 1). On November 19, 2013, the Commissioner filed an answer and administrative transcript of proceedings. (Docs. 9, 10). On January 13, 2014, Plaintiff filed a brief in support of his appeal ("Pl. Brief"). (Doc. 12). On February 14, 2014, Defendant filed a brief in response ("Def. Brief"). (Doc. 13). On February 24, 2014, Plaintiff filed a brief in reply ("Pl. Reply"). (Doc. 14). On April 29, 2014, the Court referred this case to the undersigned Magistrate Judge. Both parties consented to the referral of this case for adjudication to the undersigned on June 9, 2014, and an order referring the case to the undersigned for adjudication was entered on June 10, 2014. (Doc. 16, 17, 18).
III. Standard of Review
When reviewing the denial of disability benefits, the Court must determine whether substantial evidence supports the denial. Brown v. Bowen , 845 F.2d 1211, 1213 (3d Cir. 1988); Johnson v. Commissioner of Social Sec. , 529 F.3d 198, 200 (3d Cir. 2008). Substantial evidence is a deferential standard of review. See Jones v. Barnhart , 364 F.3d 501, 503 (3d Cir. 2004). Substantial evidence "does not mean a large or considerable amount of evidence." Pierce v. Underwood , 487 U.S. 552, 564 (1988). Substantial evidence requires only "more than a mere scintilla" of evidence, Plummer v. Apfel , 186 F.3d 422, 427 (3d Cir. 1999), and may be less than a preponderance. Jones , 364 F.3d at 503. If a "reasonable mind might accept the relevant evidence as adequate" to support a conclusion reached by the Commissioner, then the Commissioner's determination is supported by substantial evidence. Monsour Med. Ctr. v. Heckler , 806 F.2d 1185, 1190 (3d Cir. 1986); Hartranft v. Apfel , 181 F.3d 358, 360 (3d Cir. 1999); Johnson , 529 F.3d at 200.
IV. Sequential Evaluation Process
To receive disability or supplemental security benefits, 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). The Act requires that a claimant for disability benefits show that he has a physical or mental impairment of such a 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, regardless of whether such work exists in the immediate area in which he lives, or whether a specific job vacancy exists for him, or whether he would be hired if he applied for work.
42 U.S.C. § 423(d)(2)(A); 42 U.S.C. § 1382c(a)(3)(B).
The Commissioner uses a five-step evaluation process to determine if a person is eligible for disability benefits. See 20 C.F.R. § 404.1520; see also Plummer , 186 F.3d at 428. If the Commissioner finds that a Plaintiff is disabled or not disabled at any point in the sequence, review does not proceed. See 20 C.F.R. § 404.1520. The Commissioner 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 from 20 C.F.R. Part 404, Subpart P, Appendix 1; (4) whether the claimant's impairment prevents the claimant from doing past relevant work; and (5) whether the claimant's impairment prevents the claimant from doing any other work. See 20 C.F.R. §§ 404.1520, 416.920. Before moving on to step four in this process, the ALJ must also determine Plaintiff's residual functional capacity ("RFC"). 20 C.F.R. §§ 404.1520(e), 416.920(e).
The disability determination involves shifting burdens of proof. The claimant bears the burden of proof at steps one through four. If the claimant satisfies this burden, then the Commissioner must show at step five that jobs exist in the national economy that a person with the claimant's abilities, age, education, and work experience can perform. Mason v. Shalala , 994 F.2d 1058, 1064 (3d Cir. 1993). The ultimate burden of proving disability within the meaning of the Act lies with the claimant. See 42 U.S.C. § 423(d)(5)(A); 20 C.F.R. § 416.912(a).
V. Relevant Facts in the Record
Plaintiff was born on April 1, 1981 and was classified by the regulations as a younger individual through the date of the ALJ decision. 20 C.F.R. § 404.1563. (Tr. 29). She has a limited (tenth grade) education and past relevant work as a shipping/receiving clerk, car salesperson, and day worker. (Tr. 40). Plaintiff ran away from a dysfunctional family in 1997, when she was fifteen, and was unable to complete her education. (Tr. 587, 595). She was raped when she was sixteen by a friend's cousin, who went to jail. (Tr. 587. 595). In 2000, she entered into a relationship with her now ex-boyfriend and had her first child. (Tr. 371, 587, 595). She had two more children with him, but he was severely physically abusive to her, kicking and hitting her in the head. (Tr. 587, 595). By June of 2008, Plaintiff had left him and was living on her own, but was incarcerated shortly thereafter for theft by deception. (Tr. 397). Her mental health diagnoses include major depressive disorder, generalized anxiety disorder ("GAD"), bipolar disorder, borderline personality disorder, and post-traumatic stress disorder ("PTSD"). She also has scoliosis, a large disc herniation with significant stenosis that touches her nerve roots, "minimal" degenerative changes, and obesity. (Tr. 410, 550).
On March 12, 2007, Plaintiff saw Jannis VanArsdale, CRNP, at Yorktown Family Medicine for worsening depression and anxiety. (Tr. 387). She had been off her anti-depressant medication and birth control since the beginning of the year because she could not afford them, and was ten weeks pregnant. (Tr. 387). Ms. VanArsdale spent forty-five minutes counseling her on the stresses of her life and "just allowed her to cry and talk." (Tr. 387). On February 21, 2008, Plaintiff saw Ms. Van Arsdale. (Tr. 420). She had many stressors, was tired all the time, and had no energy to do anything. (Tr. 420). Ms. Van Arsdale prescribed Zoloft. (Tr. 420).
On March 10, 2008, Plaintiff had an initial assessment at Wellspan Behavioral Health. (Tr. 393). She was depressed, anxious, and reported poor relationships, but her appearance, memory and concentration, and energy were within normal limits. (Tr. 393). Her insight and judgment were fair. (Tr. 393). She was diagnosed with major depression, recurrent, and assessed a GAF of 55. (Tr. 394). On March 19, 2008, Plaintiff followed-up at Wellspan. (Tr. 400). She discussed her poor finances and credit and her desire to eventually live on her own and get away from the abusive father of her children. (Tr. 400). She had mild impairments in depression, sadness, energy, motivation, social and family problems, anxiety, activities of daily living, and job performance. (Tr. 400).
On April 23, 2008, Plaintiff reported that she had been fired that morning. (Tr. 399). She had been in jail the night before because of theft by deception. (Id.). She explained that she had been going through hard times financially and "wasn't thinking." (Id.). She was extremely upset, tearful, appeared remorseful, embarrassed, and ashamed. (Id.). She had severe impairments in depression, anxiety, and job performance. (Id.). She had moderate impairments in social and family problems. (Id.). She had mild impairments in thinking, memory, or concentration, impulsiveness, aggressiveness, recklessness, or self-injurious behavior, appetite, energy, motivation, and activities of daily living. (Id.).
On May 8, 2008, Plaintiff followed-up at Wellspan. (Tr. 398). She reported "terrible guilt" for her legal problems. (Id.). She had severe impairments in job performance, moderate impairments in depression, sadness, anxiety, activities of daily living, sleep, social and family problems, energy, and motivation. (Id.). She had mild impairments in thinking, memory, or concentration, impulsiveness, aggressiveness, recklessness, or self-injurious behavior. (Id.).
On June 5, 2008, Plaintiff followed-up at Wellspan Behavioral Health. (Tr. 397). She discussed the many stresses in her life, including having her car repossessed, her upcoming court date, and leaving the abusive father of her children. (Tr. 397). She had moderate impairments in depression, sadness, anxiety, social and family problems, and job performance. (Tr. 397). She had mild impairments in energy, motivation, thinking, memory, concentration, activities of daily living, sleep, and appetite. (Tr. 397). She had made no progress in her treatment goals. (Id.).
On June 17, 2008, Plaintiff followed-up at Wellspan. (Tr. 396). She had been to Court and offered three months in jail, but she was trying to get a better plea. (Id.). She was fearful of going to jail, losing her job, and being away from her children. (Id.). She had moderate impairments in depression, sadness, anxiety, and social and family problems. (Id.). She had mild impairments in energy, motivation, thinking, memory, concentration, activities of daily living, sleep, and appetite. (Tr. 396). She had made no progress in her treatment goals. (Id.).
On July 17, 2008, Plaintiff followed-up at Wellspan. She discussed her independence, finances and her relationship with her children's father. (Tr. 395). She had moderate impairments in depression, sadness, anxiety, and social and family problems. (Id.). She had mild impairments in energy and motivation, thinking, memory, concentration, activities of daily living, job performance, sleep, and appetite. (Id.). She had made no progress in her treatment goals. (Id.).
On July 13, 2008, Plaintiff was evaluated at Wellspan by Dr. Ramana G. Surya, D.O. (Tr. 369). Plaintiff was still taking Zoloft. (Tr. 369). She complained of depression symptoms, including trouble concentrating. (Tr. 369). Her boyfriend was in jail with a protective order against him. (Tr. 369). She had no thought disorder, grossly intact cognition, and fair insight and judgment. (Tr. 369). She was assessed a GAF of 50. (Tr. 370). Plaintiff followed-up on July 23, 2008. (Tr. 371). She had many stresses-she had broke up with the father of her children, moved, was sleeping on an air mattress, her baby was sick and teething, and her legal problems continued. (Tr. 368). She was given a trial of Lamictal. (Tr. 371).
On January 4, 2009, Plaintiff followed up at Wellspan. (Tr. 368). She had been incarcerated for her retail theft charge and was never able to fill her prescription for Lamictal, so she was given a new trial. (Tr. 368). She was still on house arrest. (Tr. 368). She had been struggling to ...