United States District Court, M.D. Pennsylvania
MARTIN C. CARLSON, Magistrate Judge.
In this case we are asked to consider whether an Administrative Law Judge (ALJ) sufficiently examined the constellation of mental, emotional and medical impairments confronting the plaintiff, a worker who was closely approaching advanced age. Finding that the ALJ's decision did not sufficiently address Riley's mental impairments in assessing her residual functional capacity, and further concluding that the ALJ's treatment of Riley's physical limitations in the residual functional capacity assessment was inadequate and internally inconsistent, we will remand this case for further consideration by the Commissioner.
II. Statement of Facts and of the Case
The plaintiff, Tammy Riley, is a social security disability claimant who has filed claims for Title II Disability benefits on May 11, 2006 (Tr. Pg. 98.), October 25, 2006 (Tr. Pg. 106.) and December 1, 2009 (Tr. Pg. 115.) as well as an application for Supplemental Security Income benefits on November 24, 2009 (Tr. 116.) alleging on each application an onset date of disability of June 21, 2004. While these protracted proceedings were pending Riley attained the age of 50, making her a worker who was closely approaching advanced age. See 20 C.F.R. §§404.1565 and 416.965. As a worker who is closely approaching advanced age, Riley is an individual whose employment prospects are limited, and who may often be entitled to disability benefits by virtue of the combined impact of her age and impairments, a fact which is recognized by the Social Security Administration in the Medical Vocational Guidelines promulgated by that agency. See 20 C.F.R. Part 404, Subpart P, Appendix 2.
A. Riley's Medical Impairments
Riley is also an individual who faces a cascading array of severe medical impairments, including circulation impairments in her lower extremities, degenerative disc disease, degenerative joint disease, a hernia, and obesity. (Tr. 17.) In fact, the Administrative Law Judge who assessed Riley's case specifically found that she suffered from all of these severe physical impairments. (Id.) The ALJ further determined that, by virtue of these physical impairments, Riley was no longer able to return to her former employment as a store laborer. (Tr. 26.)
These physical impairments were thoroughly documented by a state consultative examining physician, Dr. David Wampler. (Tr. 645-653.) Dr. Wampler's assessment of Riley, which was given "significant weight" by the ALJ, (Tr.25.), characterized Riley's prognosis as "poor for any significant change, " (Tr. 649.), based upon her medical conditions. Dr. Wampler further opined that Riley faced a series of severe physical limitations and restrictions on her work activities, stating that she could never bend, stoop, kneel, crouch, balance or climb. (Tr. 653.) Dr. Wampler also concluded that Riley's ability to lift and carry items was severely compromised, stating that could only occasionally lift items weighing between 10 and 25 pounds, and could only occasionally carry items weighing up to 10 pounds. (Tr. 652.) Finally, Dr. Wampler opined that Riley's ability to stand and walk at work was significantly undermined, and medically limited her to 4 hours of standing or walking each day. (Id.)
These limitations, which were found by Dr. Wampler in a report which was afforded great weight by the ALJ, would have limited Riley under social security regulations to performing sedentary work, which is defined as work that "involves lifting no more than 10 pounds at a time and occasionally lifting or carrying articles like docket files, ledgers, and small tools." 20 C.F.R. § 416.967(s). These exertional limitations found by Dr. Wampler would have also specifically excluded light work for Riley under social security regulations since in order to perform light work Riley must be able to do "lift no more than 20 pounds at a time with frequent lifting or carrying of objects weighing up to 10 pounds." 20 C.F.R. § 416.967(b)(emphasis added.) Therefore, Dr. Wampler's finding that Riley could only occasionally carry or lift 10 pound objects seemed to preclude light work for the plaintiff.
B. Riley's Mental and Emotional Impairments
Beyond these undisputed physical impairments experienced by Riley, the ALJ was presented with substantial evidence which showed that Riley also suffered from a series of mental and emotional impairments. Although Riley had graduated from high school, she reported that she had completed her secondary education from home, while she recovered from a severe traumatic brain injury. (Tr. 39.) This brain injury had profound and enduring consequences for Riley, consequences which were documented in 2011 by Dr. Christopher Royer, who examined and assessed Riley. (Tr. 688-694.) As a result of this examination, Dr. Royer diagnosed Riley as suffering from a Cognitive Disorder, Generalized Anxiety Disorder, Pain Disorder and Borderline Intellectual Functioning. (Tr. Pg. 690.) Dr. Royer noted the Riley had IQ testing done in school many years before her alleged onset date showing an IQ range between 109-115. (Tr. 689.) Dr. Royer's IQ testing, however, revealed a significant decline in Royer's intellectual functioning, and disclosed a Verbal IQ of 74, Performance 95 and a Full Scale IQ of 82. (Tr. 690.) It was Dr. Royer's opinion that Riley's IQ had dropped more than fifteen points, and Dr. Royer assigned Riley a Global Assessment of Functioning score of 50, a GAF score which was consistent with a moderate to severe level of intellectual impairment. (Tr. 691.) Dr. Royer also specifically concluded that Riley was moderately limited in carrying out simple instructions, (Tr. 692.), and responding appropriately to the public and co-workers. (Tr. 693.) He further found that she was markedly impaired in exercising judgment on simple work related decisions, understanding, remembering and carrying out complex instructions and making judgments on complex instructions. (Tr. 692.) Finally, he noted she was significantly anxious at the examination and would have a marked impairment in responding appropriately to work situations and changes in a routine or usual work setting. (Tr. 693.)
These findings of severe mental and emotional impairments were independently verified in the medical record presented to the ALJ. A separate Psychiatric Technique Review assessment of Riley's mental health conducted by a state agency psychologist confirmed the severe mental and emotional impairments suffered by Riley, finding that she was moderately impaired both in social functioning, as well as in maintaining concentration, persistence and pace. (Tr. 672.) For an older worker like Riley, whose past work history consisted largely of moderate to heavy labor which was now beyond her physical exertional abilities, this finding significantly restricted her employment prospects.
C. The ALJ's Decision
On October 28, 2011, the ALJ held a hearing regarding Riley's disability claim, a hearing at which Riley and a vocational expert testified. (Tr. 34-91.) In the course of this hearing, the ALJ received into evidence the medical and mental health reports which documented the broad array of physical, mental and emotional impairments confronting Ms. Riley. The ALJ also acknowledged at this hearing that Riley had attained the age of 50 and was now a worker who was closely approaching advanced age. See 20 C.F.R. §§404.1565 and 416.965. Following this hearing, on January 20, ...