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Phillips v. Berryhill

United States District Court, E.D. Pennsylvania

May 22, 2017

NANCY A. BERRYHILL, Acting Commissioner of Social Security [1] Defendant




         On 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.''[2] [ECF 3]. The referenced final adverse decision was rendered by Defendant Carolyn W. Colvin, then the Acting Commissioner of Social Security (''Defendant'' or ''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[3] of both feet.

         On 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].

         Consistent 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].

         After a 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.


         The 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.

         In 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).[4]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.), [5] 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 scaffolding. (Id.).


         To 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 step three.
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'').[6] 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 ...

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