United States District Court, M.D. Pennsylvania
MEMORANDUM Docs. 1, 7, 8, 9, 10
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 Dwayne Edward Wetzel ("Plaintiff") 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 filed the present application in December of 2010, shortly after being diagnosed with multiple sclerosis ("MS"), although Plaintiff had been exhibiting symptoms of MS since as early as June of 2007. Plaintiff claimed that his MS symptoms and treatment caused him fatigue and pain that would preclude him from working a full eight-hour workday. However, the ALJ concluded that Plaintiff's MS did not cause any additional limitations whatsoever beyond those caused by his other physical impairments, which included a seizure disorder and obesity. The ALJ found that Plaintiff could perform light work on a regular and continuing basis, eight hours a day, five days a week.
In June of 2007, Plaintiff began experiencing one of the most characteristic MS symptoms, namely, worsening of neurological functioning with increased heat, as he suffered a seizure at work on one particularly hot day. After Plaintiff lost his job, his symptoms improved and he remained seizure-free with normal gait, reflexes, strength, and sensation through 2008. However, by early 2009, Plaintiff began reporting steady weight gain, tearfulness, tiredness, and achiness. Fatigue, pain, and mental status changes are also symptoms of MS. In mid-2009, Plaintiff had another exacerbation during heat, when he had a non-seizure-related fall while mowing his lawn. He began experiencing vision problems, an indication of MS, for which he unsuccessfully underwent surgery in December of 2009. In early 2010, Plaintiff began exhibiting increased reflexes, and in November of 2010, he reported jerking in his legs. Both are characteristic of MS.
In December of 2010, an MRI of the brain indicated lesions that were most consistent with MS, and Plaintiff began interferon therapy. Through 2011, Plaintiff continued exhibiting increased reflexes and also exhibited decreased sensation, a positive Babinski test, gait dysfunction, depression, and anxiety. He underwent physical therapy for gait dysfunction secondary to multiple sclerosis and began psychiatric treatment for his declining mental health condition. Physical therapy notes indicate that Plaintiff could only walk for seven to fifteen minutes at a time and psychiatric progress notes indicate that Plaintiff's global assessment of functioning ("GAF") remained at or below 50, in the severe range. On mental status examinations, Plaintiff was generally disheveled; with psychomotor retardation or agitation; restricted and flat affect; dysthymic, angry, and irritable mood; and impaired cognition, judgment, insight, and concentration. He was diagnosed at a consultative examination with borderline intellectual ability. Plaintiff reported that his interferon shots made him fatigued and sore for up to three days and that he needed frequent naps throughout the day.
The administrative law judge ("ALJ") was required to give Plaintiff's claims of MS-related fatigue serious consideration, and rejected them without adequate explanation. The ALJ relied on Plaintiff's purportedly normal physical examinations, but fails to mention multiple objective abnormalities documented on examination. Moreover, even normal physical examinations would not contradict his claims of fatigue and pain. The ALJ also mischaracterizes Plaintiff's gait as normal and fails to mention that he attended physical therapy to correct his gait. Thus, the ALJ was not entitled to rely on an alleged lack of objective findings.
The ALJ notes that Plaintiff's seizure disorder and mental impairments were stable, but this is unrelated to his MS symptoms and treatment. The ALJ also incorrectly characterizes Plaintiff's mental impairments as stable with normal mental status examination. Thus, the ALJ was not entitled to rely on the stability of Plaintiff's seizure disorder and mental impairments to reject his claims of MS-related fatigue. Similarly, the ALJ notes that Plaintiff's mental health treatment has been conservative, but Plaintiff's conservative mental health treatment does not contradict his claims of MS-related fatigue.
A state agency physician who neither treated nor examined Plaintiff concluded that he could perform light work for a full eight-hour workday. However, this physician mischaracterized Plaintiff's gait as normal and erroneously concluded that he did not attend physical therapy. The physician also mischaracterized the record as documenting a limitation from cold environments, instead of hot environments. The physician's opinion does not mention Plaintiff's claims of fatigue from his MS medication.
Under the substantial evidence standard of review, the Court will affirm conclusions by the ALJ where a reasonable mind could accept the relevant as adequate to deny benefits. However, a single piece of evidence is not sufficiently substantial when it is overwhelmed by other evidence. Moreover, the ALJ is required to acknowledge and address contradictory evidence to allow the Court to meaningfully review the ALJ decision. Here, the ALJ failed to acknowledge significant contradictory evidence of Plaintiff's gait dysfunction and other symptoms of his impairments and did not provide an explanation for dismissing Plaintiff's claimed medication side effects. This precludes meaningful review by the Court. The Court cannot determine whether substantial evidence supports the ALJ's denial of benefits. Specifically, the Court cannot determine whether substantial evidence supports the ALJ's conclusion that Plaintiff could stand or walk for six hours out of an eight-hour work day and that Plaintiff could regularly attend work, eight-hours a day, five days a week. For the foregoing reasons, the Court will grant Plaintiff's appeal, vacate the decision of the Commissioner, and remand for further proceedings.
II. Procedural Background
On December 28, 2010, Plaintiff filed an application for DIB and SSI under the Social Security Act, 42 U.S.C. §§401-433, 1382-1383 (the "Act"). (Tr. 84-99). On August 22, 2011, the Bureau of Disability Determination denied these applications (Tr. 60-69), and Plaintiff filed a request for a hearing on September 27, 2011. (Tr. 72-73). On May 1, 2012, an ALJ held a hearing at which Plaintiff - who was represented by an attorney - and a vocational expert ("VE") appeared and testified. (Tr. 28-49). On June 27, 2012, the ALJ found that Plaintiff was not disabled and not entitled to benefits. (Tr. 8-27). On August 31, 2012, Plaintiff filed a request for review with the Appeals Council (Tr. 7), which the Appeals denied on October 23, 2013, thereby affirming the decision of the ALJ as the "final decision" of the Commissioner. (Tr. 1-6).
On December 9, 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 March 4, 2014, the Commissioner filed an answer and administrative transcript of proceedings. (Docs. 7, 8). On April 18, 2014, Plaintiff filed a brief in support of his appeal ("Pl. Brief"). (Doc. 9). On May 21, 2014, Defendant filed a brief in response ("Def. Brief"). (Doc. 10). On July 7, 2014, the parties consented to transfer of this case to the undersigned for adjudication. (Doc. 14). The matter is now ripe for review.
II. Standard of Review
When reviewing the denial of disability benefits, the Court must determine whether substantial evidence supports the denial. Johnson v. Comm'r of Soc. Sec., 529 F.3d 198, 200 (3d Cir. 2008); Brown v. Bowen, 845 F.2d 1211, 1213 (3d Cir. 1988). 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 Consol. Edison Co. of New York v. N.L.R.B., 305 U.S. 197, 229 (1938)). In other words, substantial evidence requires "more than a mere scintilla" but is "less than a preponderance." 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)).
III. 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).
IV. Relevant Facts in the Record
Plaintiff was born on December 3, 1970, and was classified by the Regulations as a younger individual through the date of the ALJ decision. (Tr. 32). 20 C.F.R. § 404.1563. Plaintiff has at least a high school education and past relevant work as a corrugator operator. (Tr. 20, 32).
Plaintiff began suffering seizures in 1992 and came under the care of Dr. John B. Chawluk, M.D. (Tr. 154, 240, 422). On August 24, 2006, Plaintiff followed-up with Dr. Chawluk. (Tr. 163). Plaintiff was being treated for seizures with Zonegran and Dilantin. (Tr. 163). His physical examination was normal. (Tr. 163). Plaintiff reported having a seizure a few weeks earlier "due to sleep deprivation caused by overtime demands at his job, " but was otherwise "doing well." (Tr. 163). He had "no problems" adjusting to Zonegram as an addition to Dilantin. (Tr. 163). His physical examination was normal. (Tr. 163). Plaintiff's Zonegram was increased and he was limited to working no more than forty hours per week. (Tr. 163). Plaintiff followed-up with Dr. Chawluk approximately every six months. (Tr. 163-67, 207-223). On January 4, 2007, Plaintiff remained seizure free with normal physical examinations, although he reported issues with obesity and sleep apnea. Id.
On June 19, 2007, Plaintiff reported having a seizure while at work at a factory that was not air-conditioned. (Tr. 165). He was instructed to remain hydrated "in the extreme heat environment he [was] exposed to." (Tr. 165). On May 16, 2008, Plaintiff reported that he had lost his job. (Tr. 167). However, Plaintiff reported "feeling much better" because he had less stress. (Tr. 167).
On January 13, 2009, Plaintiff established care with Dr. Matthew Kraynak, D.O., a primary care provider. (Tr. 303). Plaintiff reported steady weight gain and indicated that he followed with Dr. Chawluk for his seizure disorder. (Tr. 303). Dr. Kraynak ...