United States District Court, E.D. Pennsylvania
I. QUIÑONES ALEJANDRO, J.
September 22, 2015, Plaintiff Karen Phillips
(''Plaintiff'') filed a counseled complaint
in which she ''seeks judicial review pursuant to 42
U.S.C. 405(g) of an adverse decision of the defendant which
became final'' and ''has exhausted
administrative remedies.'' [ECF 3]. The referenced
final adverse decision was rendered by Defendant Carolyn W.
Colvin, then the Acting Commissioner of Social Security
''Commissioner''), and denied Plaintiffs
application for supplemental security income
(''SSI'') benefits under Title XVI of the
Social Security Act (the ''Act''), 42 U.S.C.
§§ 1381-1383f Plaintiff claimed that her disability
was based on a combination of mental impairments diagnosed as
major depressive disorder (''MDD'') and
post-traumatic stress disorder (''PTSD''),
and physical impairments diagnosed as chronic obstructive
pulmonary disease, asthma, and hyperkeratosis of both feet.
February 8, 2016, Plaintiff filed a motion for summary
judgment and request for review, in which she argued,
inter alia, that the Administrative Law Judge
(''ALJ'') committed the following errors when
the ALJ improperly denied her SSI application; to
wit: the ALJ (a) ignored pertinent evidence regarding
Plaintiffs mental and physical impairments; (b) discounted
certain medical testimony when assessing Plaintiffs residual
function capacity (''RFC'') at step four of
the five-step sequential analysis; and (c) incorrectly relied
on the opinion testimony of the vocational expert
(''VE''). [ECF 11]. Defendant filed a
response in opposition to Plaintiffs motion, [ECF 12], to
which Plaintiff filed a reply brief. [ECF 15].
with 28 U.S.C. § 636(b)(1)(B) and Local Rule 72.1, this
matter was randomly referred to United States Magistrate
Judge Timothy R. Rice (the ''Magistrate
Judge'') for a Report and Recommendation
(''R&R''). [ECF 16]. On August 18,
2016, the Magistrate Judge filed the R&R and recommended
that Plaintiffs request for review be denied. [ECF 17].
Plaintiff filed timely objections to the R&R, [ECF 18],
and Defendant filed a response. [ECF 20].
comprehensive de novo review of Plaintiff s
objections, the R&R, Defendant‘s responses, and the
administrative record, for the reasons set forth herein, this
Court finds merit to Plaintiffs first two objections and,
therefore, remands this matter to the Commissioner for
further proceedings consistent with this Memorandum Opinion.
factual history of this case is set forth in the R&R, and
will not be recounted herein except as necessary to advance
the discussion of the issues presented.
support of her SSI application and claims of mental and
physical impairments or disability, Plaintiff presented
medical evidence which has been summarized as follows:
Plaintiff first sought mental health treatment on January 9,
2013. At that time, she was evaluated by clinician Amy Marlow
(''Marlow'') at Wedge Medical Center
(''Wedge''). (R. at 369).Marlow noted that
Plaintiff presented for intake with a history of depression
and difficulty dealing with unsettling events from her past,
(id), which included a rape at gunpoint and sexual
abuse by her stepfather starting at the age of thirteen.
(Id. at 381-82). Plaintiff also reported symptoms of
mood swings, persistent feelings of sadness, crying spells,
psychosomatic problems, fearfulness, and emotional outbursts.
(Id. at 369). Marlow diagnosed Plaintiff with,
inter alia, PTSD, alcohol dependence, seizures,
sleep problems, and anemia, (id. at 380), assigned
her a global assessment of functioning (GAF) score of 45,
(id.),  and recommended a treatment plan that
included a psychiatric evaluation and outpatient therapy.
(Id. at 384).
Plaintiff completed a psychiatric evaluation with Dr. Minda
Magundayao (''Dr. Magundayao''), a
psychiatrist at Wedge, on the same day. (Id.). Dr.
Magundayao reported that Plaintiff was neat, cooperative, and
oriented, with a constricted, anxious, and depressed affect.
(Id.). Dr. Magundayao diagnosed Plaintiff with PTSD
and MDD without psychosis, (id. at 386), and
recommended weekly individual therapy sessions and monthly
medication reviews as needed. (Id. at 388). There is
no evidence that Plaintiff attended any therapy sessions in
2013. (See Id. at 430).
Plaintiff returned to Wedge in September 2014 because she
continued to experience symptoms of depression. (Id.
at 403). She was evaluated by Dr. April Colbert
(''Dr. Colbert''), (id), a
psychiatrist, who noted that Plaintiff reported she continued
to experience flashbacks and nightmares, inconsistent
sleeping patterns, and racing thoughts. (Id.). Dr.
Colbert diagnosed Plaintiff with MDD and PTSD, and assigned
her a GAF score of 55. (Id. at 414). The doctor
recommended weekly therapy sessions and that Plaintiff join a
support group. (Id. at 416). Plaintiff attended six
of sixteen scheduled therapy appointments between September
2014 and March 2015, and has since abandoned therapy.
(Id. at 402-03). Of note, neither Dr. Magundayao nor
Dr. Colbert completed an RFC assessment, or indicated that
Plaintiff suffered any work-related limitations as a result
of her mental health diagnoses.
Plaintiff was evaluated by a consultative examiner, Dr.
Floyretta Pinkard (''Dr. Pinkard''), on March
12, 2014, on a referral from the Social Security
Administration (''SSA''). (Id. at
241-49). Dr. Pinkard noted that Plaintiff complained of
bunions on both of her feet which caused her constant pain.
(Id. at 241). Dr. Pinkard diagnosed Plaintiff with
bilateral foot bunions, depression, a seizure disorder,
asthma, and hypertension. (Id. at 244). Dr. Pinkard
reported Plaintiffs gait and stance as normal, that she
walked without the use of an assistive device, and that she
was in no acute distress. (Id. at 250). Dr. Pinkard
completed a Medical Source Statement of Ability to
Work-Related Activities (Physical) form (''Medical
Source Statement''), (id. at 245-249),
opining that Plaintiff: could lift and/or carry up to 20
pounds on occasion, (R. at 245); stand and walk a total of
two hours in an eight-hour work day, (id. at 246);
occasionally climb stairs/ramps, balance, stoop, kneel crouch
and crawl (id. at 248); and never climb ladders or
qualify for SSI benefits, a claimant must prove a disability;
i.e., that she has 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
twelve months.'' 42 U.S.C. § 1382c(a)(3)(A). To
determine whether a claimant is disabled, an ALJ must employ
a five-step sequential evaluation process (''the
five-step sequential analysis''), as outlined in the
Social Security Regulations (the
''Regulations''). See 20 C.F.R.
§ 416.920(a)(4). The five-step sequential analysis must
be followed in order, and if the claimant is determined to
be, or not to be, disabled at a particular step of the
evaluation process, the evaluation does not proceed to the
next step. Id. The five-step sequential analysis
requires the ALJ to consider the following:
At step one, [the ALJ] must determine whether the claimant is
currently engaging in substantial gainful activity. If the
claimant is found to be engaged in substantial activity, the
disability claim will be denied; otherwise the evaluation
proceeds to step two.
At step two, the [the ALJ] must determine whether the
claimant has an impairment that is severe or a combination of
impairments that is severe. If the claimant fails to show
that the impairment or combination of impairments is
''severe, '' claimant is ineligible for
disability benefits; otherwise, the evaluation proceeds to
At step three, the [the ALJ] must determine whether the
claimant‘s impairment or combination of impairments is
of a severity sufficient to meet or medically equal the
criteria listed in Part 404, Subpart P, Appendix 1 (the
''Listings''). If the claimant does not suffer
from a listed impairment or its equivalent, the analysis
proceeds to steps four and five.
At step four, the ALJ must first consider whether the
claimant retains the residual functional capacity to perform
past relevant work. The claimant bears the burden of
demonstrating an inability to return to past relevant work.
If the claimant is unable to resume [his] former occupation,
the evaluation moves to the final step. At step five, the ALJ
must determine whether the claimant, consistent with the
claimant‘s medical impairments, age, education, past
work experience, and residual functional capacity, is capable
of performing other available work in the national economy.
The ALJ must analyze the cumulative effect of all the
claimant‘s impairments in determining whether claimant
is capable of performing work and is not disabled.
See Id. §§ 416.920(a)(4)(i)-(v);
Dismuke v. Comm'r of Soc. Sec, 309 F.
App‘x 613, 615-16 (3d Cir. 2009); see also Plummer
v. Apfel,186 F.3d 422, 428 (3d Cir. 1999). A claimant
bears the burden of proving steps one through four by
substantial evidence. See Plummer, 186 F.3d at 428.
At step five, the burden shifts to the Commissioner.
Id. at 428. Here, after an evidentiary hearing ...