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Rosa v. Berryhill

United States District Court, E.D. Pennsylvania

January 31, 2018

LILLIAN ROSA, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         Lillian Rosa was denied Social Security benefits by decision of an Administrative Law Judge (“ALJ”). Rosa argues that the unfavorable decision was reached in error. Specifically, Rosa alleges that the ALJ failed to properly weigh medical opinion evidence, resulting in a subsequent failure to accurately convey her work-related limitations to a testifying vocational expert.

         After careful review of the record, I find that the ALJ erred by improperly discounting the medical opinion of Rosa's treating psychiatrist. Accordingly, I respectfully recommend that Rosa's request for review be granted, the final decision of the Acting Commissioner be reversed, and the case be remanded for further proceedings consistent with this Report and Recommendation.


         Rosa filed a claim for disability insurance benefits (“DIB”) on June 27, 2013. R. 113-20. Her application was denied at the initial level on September 18, 2013. R. 58-61. Rosa then requested a hearing with an ALJ. R. 62-63.

         The ALJ hearing was held in Elkins Park, Pennsylvania on February 11, 2015. R. 33-48. Rosa testified at the hearing, where she was represented by counsel. R. 33-48. A neutral vocational expert also testified at the hearing. R. 33.

         After the hearing, the ALJ issued an unfavorable disability decision on April 21, 2015. R. 15-32. In response to the unfavorable decision, Rosa requested Appeals Council review. R. 13-14. The Appeals Council denied Rosa's request on July 15, 2016 (R. 6-10), making the ALJ's decision the final decision of the Acting Commissioner. 20 C.F.R. § 404.981. This exhausted Rosa's administrative remedies.

         This request for review pursuant to 42 U.S.C. § 405(g) followed. The matter was referred to me for a Report and Recommendation. ECF No. 17.


         A. Rosa's Personal Background and Work History

         Rosa was born in 1971, making her forty-two years old at the time of her DIB application. R. 113. She resides in a house in Philadelphia with her husband, her father, and her sister. R. 131. She speaks and understands English. R. 131. Rosa completed her education through the twelfth grade, then completed a one-year medical assistant certification program. R. 133.

         Rosa stopped working entirely in October of 2012. R. 133. Most recently, Rosa was employed at an ophthalmologist's office as a technician. R. 134. She testified that the job consisted of assisting the ophthalmologist with patient visits. R. 39-40. Rosa voluntarily terminated her employment because, as she puts it, “I didn't get along with certain people at the job and especially my boss.” R. 40. At the time she quit, Rosa had worked at the ophthalmologist's office for less than one year. R. 40. After Rosa quit, she applied for and was determined eligible for unemployment compensation after her employer failed to contest the application. R. 40. The administrative record indicates that Rosa received unemployment compensation from the fourth quarter of 2012 through the second quarter of 2013. R. 126. Rosa applied for DIB in June 2013, around the time her unemployment compensation payments stopped. R. 126.

         Prior to her employment in the ophthalmologist's office, Rosa worked for Main Line Healthcare as a medical assistant. R. 121-22. Rosa testified that she held that job “for more than 15 years.”[1] R. 41. During her tenure with Main Line Healthcare, Rosa transferred to different worksites four times. R. 41. Rosa ultimately resigned because she “just couldn't get along with [her] bosses” and “just couldn't take the stress” of the job. R. 41. Rosa informed the state disability evaluator that she was unemployed for approximately ten months between the two jobs. R. 134.

         Rosa described the tasks associated with her two past jobs as substantially similar. At both jobs, she worked eight-hour days on a full-time basis. R. 140, 141. Both jobs required Rosa to perform a combination of walking, standing, sitting, and other postural movements for eight hours each day. R. 140, 141. Both jobs required Rosa to frequently lift up to twenty-five pounds and to assist in lifting patients of various weights. R. 140, 141. Rosa employed technical knowledge or skills, wrote reports, and used machines, tools, or equipment in both jobs. R. 140, 141. The testifying vocational expert characterized Rosa's past work as skilled work performed at a light exertional level. R. 45.

         B. Subjective Evidence of Impairments

         Rosa applied for DIB alleging a plethora of physical and mental health impairments. R. 132. Rosa's alleged physical impairments included three herniated discs in her neck, carpal tunnel syndrome in both hands, arthritis in her knee, and a weight of 170 pounds at 5'3” tall. R. 132. Rosa also alleged seven discrete mental health impairments: depression, anxiety, post-traumatic stress disorder, panic attacks, mood swings, mood disorder, and bipolar disorder. R. 132. To support her alleged impairments, Rosa testified at her hearing, submitted medical records, and provided a medical opinion from her treating psychiatrist. Meanwhile, Rosa's husband Joangel Aletriz completed a Function Report, a Third-Party Function Report, and a Supplemental Function Questionnaire on Rosa's behalf.[2] R. 142-60.

         At her hearing, Rosa provided no testimony describing her alleged physical impairments, perhaps because neither the ALJ nor Rosa's attorney inquired about her physical conditions. R. 33-48. Rosa did, however, testify regarding the impact her alleged mental health issues have on her daily life. Rosa stated that she has five dogs in her house, two of which are primarily hers. R. 37. These two dogs spend most of their time in Rosa's room with her. R. 37. Since her dogs are paper trained, Rosa need not walk them. R. 37. Rosa testified that she spends most of her day in bed at home with the dogs. R. 38. Rosa's husband performs all household chores, including caring for the dogs. R. 38, 144.

         Rosa testified that she takes Xanax to fall asleep every night then sleeps until early afternoon each day. R. 42. Sometimes, Rosa testified, she goes two or three days without bathing, which she attributed to depression. R. 43. When questioned about her ability to focus, Rosa reported that she cannot focus to read “like I used to.” R. 43. Rosa also stated that her “memory's not that good.” R. 43.

         Rosa testified that she does very little outside the house. She never leaves the house unless accompanied by her husband. R. 42. Social situations make Rosa feel very uncomfortable, and she “ha[s] to take medicine before [she] leaves the house.” R. 42. She has limited contact with her children, other family members, and friends. R. 38-39. Rosa also testified as to her difficulties working with others, difficulties that have led to her quitting her two most recent jobs. R. 39-41.

         Rosa testified that her doctor prescribed various medications for her mental health impairments. R. 44. Using a list of medications compiled by Rosa, the ALJ established that Rosa took Xanax, Latuda, clonidine, Tenex, Trileptal, and Anafranil at various times. R. 44-45. Rosa's treating psychiatrist prescribed all of these medications. R. 44-45. When asked whether medication improved her condition, Rosa responded “Sometimes I don't think it does.” R. 45. Rosa reported that her medications made her tired and fatigued. R. 42.

         In addition to Rosa's testimony, her husband, Joangel, completed three Function Reports. The Function Reports paint a painful portrait of Rosa's daily life. Joangel wrote that Rosa is afraid to do things on her own (R. 143), has a hard time controlling her anger (R. 143), gets very confrontational with people, especially bosses and men (R. 143), isolates herself in her bedroom (R. 143), sleeps a lot and cries a lot (R. 144), feeds the dogs but leaves the remainder of their care to Joangel (R. 144), used to work out frequently and maintain a positive outlook but is now subject to losing her temper (R. 144), has to be reminded to change her clothes and take a bath (R. 144), relies on Joangel to comb her hair and cook her meals (R. 144), relieves herself in a “commode” kept in the bedroom because she does not like walking to the bathroom at night (R. 144), must be reminded to take her medications (R. 145), does no cooking and no house work (R. 145), is afraid to go out on her own and only leaves the house if Joangel accompanies her (R. 146), shops infrequently, and then only for dog food and cereal (R. 146), cannot pay bills or manage money due to memory problems (R. 146-47), has recently gained fifty pounds after she stopped exercising (R. 147), attends religious meetings twice each week, but only after Joangel pleads with her to go (R. 147, 157), has stopped talking to the people who open their doors when she and Joangel evangelize door-to-door (R.157), has trouble getting along with others when she does not take her medication (R. 148), can only walk two blocks before her anxiety increases and she begins getting irritated with the people around her (R. 148), can only pay attention for thirty minutes at a stretch and cannot finish what she starts (R. 148), does not handle stress well (R. 149), does not like change (R. 149), and has disruptive nightmares, one so intense that she bit Joangel's arm in her sleep, drawing blood (R. 150).

         Joangel completed another Function Report form reiterating much of what he conveyed in the first form, with a few additions worth noting. R. 153-60. Regarding Rosa's dogs, Joangel reported that “she doesn't even walk them they go out on deck [and] son picks up crap.” R. 154. Attesting to Rosa's issues falling asleep at night, Joangel wrote that “she can't sleep unless she takes her Xanax if not she's up all night doing nothing talking to her dogs like if they were people.” R. 154. Joangel reported that he tries to motivate Rosa and, with the help of Rosa's sister, can occasionally get Rosa to walk around the block or sit on the porch before she returns to her bedroom. R. 155. According to Joangel, Rosa “sucks at following instruction” and he “ha[s] to be on top of her like a child.” R. 158. Joangel also reported that Rosa was “crying all the time and angry always stating she wants to die [and] hates life.” R. 151.

         C. Other Mental Health Records Relevant to this Appeal

         Rosa submitted medical records documenting both her physical and mental health impairments. R. 185-310. On appeal to the district court, Rosa does not challenge the ALJ's treatment of her alleged physical impairments. Accordingly, my review focuses exclusively on Rosa's mental health records. The entirety of the objective medical evidence documenting Rosa's mental health impairments consists of treatment notes from treating psychiatrist Alexandra McLean, M.D. (R. 205-52) and a Mental Residual Functional Capacity Questionnaire (“RFC form”) completed by Dr. McLean (R. 201-204, 248-52).[3]

         D. Dr. McLean's Mental Residual Functional Capacity Questionnaire

         Dr. McLean authored an opinion, the RFC form, assessing Rosa's ability to perform certain work-related activities in light of her mental health impairments. R. 248-52. The RFC form contained Dr. McLean's diagnoses, a checklist of symptoms, and a checklist evaluating Rosa's ability to perform specific work-related functions. R. 248-52.

         Dr. McLean averred that she had treated Rosa on a monthly basis since 2009, a period of five years preceding her 2014 opinion. R. 248. Dr. McLean diagnosed Rosa with intermittent explosive disorder and major depressive affective disorder and listed “relationship with sons” as an aggravating environmental stressor. R. 248. Dr. McLean opined that Rosa exhibited “partial response to various medication regimens and psychotherapy” without elaborating on the treatments or Rosa's responses. R. 248. Per Dr. McLean, Rosa was prescribed trileptal (an anticonvulsant used to treat seizures), clonidine (an antihypertensive), Xanax, and Anafranil (used to treat obsessive compulsive disorder). R. 248. “Fatigue” was the only listed side effect of the prescribed medications. R. 248. When prompted to describe clinical findings that demonstrated the severity of Rosa's problems, Dr. McLean wrote: “poor concentration/focus, AO x3, poor judgment, poor impulse control, memory intact, mood down, affect flat.” R. 248. Dr. McLean declared Rosa's prognosis “poor, ” noting that Rosa “cannot get along with peers in a work setting [illegible word] verbal and physical altercations.” R. 248.

         The RFC form provided a list of fifty-six “signs and symptoms” from which Dr. McLean was to identify the ones that applied to Rosa. R. 249. Dr. McLean ticked off twenty of these symptoms, including “[t]houghts of suicide, ” [a]ppetite disturbance with weight change, ” “[r]ecurrent and intrusive recollections or a traumatic experience, which are a source of marked distress, ” [p]aranoid thinking or inappropriate suspiciousness, ” “[p]athological dependence, ” “[s]eclusiveness or autistic thinking, ” and “[p]ersistent irrational fear of a specific object, activity, or situation which results in a compelling desire to avoid the dreaded object, activity or situation.” R. 249.

         Through checked boxes, Dr. McLean opined that Rosa had “[n]o useful ability to function” in the following six areas: work in coordination with or proximity to others without being unduly distracted; complete a normal workday and workweek without interruptions from psychologically based symptoms; perform at a consistent pace without an unreasonable number and length of rest periods; accept instructions and respond appropriately to criticism from supervisors; get along with co-workers or peers without unduly distracting them or exhibiting behavioral extremes; and deal with normal work stress. R. 250. Of the sixteen total categories on the form, Dr. McLean opined that Rosa had “no useful ability to function” in six of them. R. 250.

         Dr. McLean opined that Rosa's impairments would cause her to be absent from work more than four days per month, the most extreme check-box value available on the form. R. 252. Dr. McLean's opinion included a prompt to “describe any additional reasons not covered above why your patient would have difficulty working at a regular job on a sustained basis, ” to which Dr. McLean responded that Rosa “cannot tolerate criticism at all.” R. 252.

         E. The ALJ's Decision and Treatment of Dr. McLean's Opinion

         Based upon the evidence in the record, the ALJ applied the five-step sequential analysis of 20 C.F.R. § 404.1520(a)(4)[4] to assess Rosa's entitlement to Social Security benefits.

         At step one, the ALJ determined that Rosa had not engaged in substantial gainful activity since her alleged disability onset date of October 1, 2012. R. 20.

         At step two, the ALJ concluded that Rosa had the following severe impairments: bipolar affective disorder, depression, anxiety, [5] and degenerative joint disease of the knees and spine. R. 20.

         At step three, the ALJ determined that Rosa “does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments” in the Social Security regulations. R. 21. Because Rosa's challenge turns on the ALJ's evaluation of her alleged mental health impairments, I ...

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