United States District Court, M.D. Pennsylvania
DAVID L. STAUDT, Plaintiff,
CAROLYN W. COLVIN, ACTING COMMISSIONER OF SOCIAL SECURITY, Defendant.
REPORT AND RECOMMENDATION TO VACATE THE DECISION OF THE COMMISSIONER AND REMAND FOR FURTHER PROCEEDINGS Docs. 1, 12, 13, 17, 20, 21
GERALD B. COHN, Magistrate Judge.
REPORT AND RECOMMENDATION
The above-captioned action is one seeking review of a decision of the Commissioner of Social Security ("Commissioner") denying the application of Plaintiff David L. Staudt for disability insurance benefits ("DIB") and supplemental security income ("SSI") under the Social Security Act, 42 U.S.C. §§401-433, 1382-1383 (the "Act"). Plaintiff asserts disability as a result of mental impairments, including post-traumatic stress disorder ("PTSD") after serving in the Marines, when he was involved in multiple combat situations in Lebanon and witnessed the death of several fellow Marines. Plaintiff asserts that the administrative law judge ("ALJ") erred in evaluating the medical opinions of his treating psychiatrists. The ALJ rejected four consistent opinions by multiple treating psychiatrists with established longitudinal relationships authored between April 19, 2010 and February 16, 2012 in favor of a single opinion by a state agency physician who never examined or treated Plaintiff issued on July 23, 2009. Under the particular facts of this case, the four consistent opinions by treating psychiatrists overwhelm the single opinion by the state agency physician, so the state agency physician's opinion does not provide substantial evidence to reject these opinions. Moreover, the passage of time and significant treatment that occurred after the state agency physician's opinion required the ALJ to independently interpret medical evidence and substitute her lay opinion for that of a medical professional, which is impermissible. Consequently, the ALJ's assignment of weight to the medical opinions and RFC assessment lacks substantial evidence.
Moreover, although Plaintiff filed an application for supplemental security income, which is not related to Plaintiff's date last insured of December 31, 2010, the ALJ generally limits her discussion to the medical evidence prior to Plaintiff's date last insured. She appears to discredit some of the evidence because it falls after Plaintiff's date last insured. She does not discuss any medical evidence after May of 2011, although she did not issue the decision until March 21, 2012. This precludes meaningful review. As a result, the Court recommends that Plaintiff's appeal be granted, the decision of the Commissioner be vacated, and the matter be remanded for further proceedings.
II. Procedural Background
On June 8, 2010, Plaintiff filed an application for DIB under the Act. (192-93). On June 8, 2011, Plaintiff filed an application for SSI under the Act. (Tr. 194-205). On October 29, 2010, the Bureau of Disability Determination Plaintiff's DIB application (Tr. 104-13), and Plaintiff filed a request for a hearing on December 16, 2010. (Tr. 114-15). On February 13, 2012, an ALJ held a hearing at which Plaintiff-who was represented by an attorney-and a vocational expert ("VE") appeared and testified. (Tr. 36-89). On March 21, 2012, the ALJ found that Plaintiff was not disabled and not entitled to benefits. (Tr. 19-35). On April 10, 2012, Plaintiff filed a request for review with the Appeals Council (Tr. 16-18), which the Appeals Council denied on September 12, 2013, thereby affirming the decision of the ALJ as the "final decision" of the Commissioner. (Tr. 4-9).
On December 2, 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 April 24, 2014, the Commissioner filed an answer and administrative transcript of proceedings. (Docs. 12, 13). On May 1, 2014, the Court referred this case to the undersigned Magistrate Judge. On June 5, 2014, Plaintiff filed a brief in support of his appeal ("Pl. Brief"). (Doc. 17). On July 31, 2014, Defendant filed a brief in response ("Def. Brief"). (Doc. 20). On August 13, 2014, Plaintiff filed a brief in reply. (Doc. 21). The matter is now ripe for review.
III. Standard of Review
When reviewing the denial of disability benefits, the Court must determine whether substantial evidence supports the denial. 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, 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. NLRB, 305 U.S. 197, 229 (1938)). Substantial evidence is "less than a preponderance" and requires only "more than a mere scintilla." Jesurum v. Sec'y of U.S. Dep't of Health & Human Servs., 48 F.3d 114, 117 (3d Cir. 1995) (citing Richardson v. Perales, 402 U.S. 389, 401 (1971)).
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 v. Apfel, 186 F.3d 422, 428 (3d Cir. 1999). 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 ("Listing"); (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 November 11, 1962 and was classified by the regulations as a younger individual through the date of the ALJ decision. 20 C.F.R. § 404.1563. (Tr. 28). Plaintiff has at least a high school education and past relevant work as a brick mason. (Tr. 28).
A. Medical Records
Plaintiff received psychological treatment from Dr. Aida Rjepaj, M.D., and Dr. Alan Rohrer, M.D., during the relevant period. ((Tr. 566). Plaintiff established care with Dr. Rjepaj in 2007. He reported being "very hyperactive" and having a hard time slowing down, feeling jumpy and restless, racing thoughts, sleeping only 3-4 hours a night, speaking so fast that people could not understand him, periods of feeling down or depressed with little energy, feeling tired and, exhausted, having difficulty sleeping and mood swings as far back as he could remember. (Tr. 378). He was observed writing in a pressured manner during the visit and he appeared somewhat elated and overly confident. Id. Dr. Rjepaj diagnosed Plaintiff with bipolar disorder II, hypomanic episode, and cocaine dependence, assessed him to have a global assessment of functioning ("GAF") GAF score of 50, and prescribed Depakote. (Tr. 379).
Plaintiff reported a decrease in his symptoms after being prescribed Depakote. Dr. Rjepaj noted that Plaintiff was "very content with the improvement and comments that taking the medication has made a big difference" and "his symptoms have improved remarkably since taking Depakote" (Tr. 374, 376). In May of 2008, Dr. Rjepaj noted that Plaintiff was doing well on medication and that symptoms improved "remarkably" since taking Depakote (Tr. 372).
However, in August of 2008, Plaintiff reported that he was feeling more down and that he fell asleep before remembering to take Depakote. (Tr. 370). Dr. Rjepaj observed that Plaintiff was ruminating. (Tr. 370). Dr. Rjepaj assessed mild, mixed symptoms and prescribed Zoloft. (Tr. 371). In October of 2008, Dr. Rjepaj noted:
[D]oing relatively well and feels stable on the medication. His mood symptoms have overall ameliorated and the patient has only occasional and minor ups and downs. His thoughts are clear and the patient is able to focus and concentrate. The patient eats well but reports fragmented sleep. He experiences frequent dreams from the time he was in the service. The denies any side effects from the medication. There is no evidence of psychotic symptoms.
In January of 2009, Plaintiff reported increased symptoms and problems with medication. (Tr. ...