United States District Court, M.D. Pennsylvania
MEMORANDUM OPINION
Martin
C. Carlson, United States Magistrate Judge
I.
Introduction
In 2013
Mindy Caswell applied for Social Security disability
benefits, alleging that she had become disabled due to an
array of medical impairments including spinal conditions,
fibromyalgia, and carpal tunnel syndrome. In Caswell's
case, the ALJ summarily discounted her fibromyalgia diagnosis
at Step 2 of the five-step analysis prescribed for Social
Security appeals, finding that Caswell's fibromyalgia was
not a “severe” impairment. The ALJ reached this
conclusion even though the treating source who diagnosed
Caswell as suffering from fibromyalgia had opined that she
was totally disabled due to her spinal disorders and this
condition. Further, having discounted this diagnosis of
fibromyalgia at Step 2 of its analysis, it is unclear
whether, and to what extent, the ALJ evaluated the degree of
impairment experienced by Caswell due to fibromyalgia at any
subsequent stages of the disability analysis in this case.
Moreover, in addition to discounting the severity of
Caswell's fibromyalgia at Step 2, the ALJ's decision
made no reference whatsoever to a separate diagnosis that
Caswell suffered from carpal tunnel syndrome as part of its
Step 2 analysis, or at any point in the decision denying
Caswell's application for disability benefits.
In our
view, the ALJ's Step 2 assessment of these two diagnosed
conditions, which entirely failed to mention one condition,
carpal tunnel syndrome, and neglected to rate a second
condition, fibromyalgia, as severe was particularly
problematic since: “It is well-settled that this step
two medically determinable-severity inquiry is a
‘de minimus screening device to dispose of
groundless claims.' McCrea v. Comm. of Soc.
Sec., 370 F.3d 357, 360 (3d Cir. 2004); Newell v.
Comm. of Soc. Sec., 347 F.3d 541, 546 (3d Cir. 2003).
Accordingly, ‘[a]ny doubt as to whether this showing
has been made is to be resolved in favor of the
applicant' id.” Velazquez v.
Berryhill, No. 3:17-CV-317, 2017 WL 5560426, at *5 (M.D.
Pa. Nov. 2, 2017), report and recommendation adopted sub
nom. Pagan v. Berryhill, No. 3:17CV0317, 2017 WL 5559914
(M.D. Pa. Nov. 17, 2017). For the reasons set forth below, in
this case, we find that the failure to adequately or
accurately address these conditions at Step 2, coupled with
the uncertainty concerning the degree to which these
impairments were then considered at subsequent stages of the
disability assessment process, leads us to conclude that this
case should be remanded to the Commissioner for further
proceedings consistent with this Memorandum Opinion.
II.
Statement of Facts
On
April 30, 2013, Mindy Caswell applied for disability
insurance benefits under Title II of the Social Security Act,
alleging an onset of disability beginning on February 7,
2009. (Tr. 20.) Caswell's disability application
described impairments which she alleged limited her ability
to stand, walk, sit, lift, carry, and use her arms and legs
to manipulate items. Caswell attributed these allegedly
disabling limitations to a number of medical conditions,
including spinal disorders, fibromyalgia, and bilateral
carpal tunnel syndrome. (Id.)
Clinical
and diagnostic evidence confirmed that Caswell suffered from
these medical conditions. With respect to Caswell's
spinal conditions and fibromyalgia, this medical evidence and
diagnoses were longstanding and were verified by several
medical sources. (Tr. 392, 491, 577, 597, 624, 628, 647,
(fibromyalgia) 331, 337, 395, 467, 495 (arthritis), 650, 659
(cervical spondylosis)). As for Caswell's bilateral
carpal tunnel syndrome, the initial clinical notation
describing this diagnosis is found in a February 2016
treatment record, but that notation described this ailment as
a pre-existing condition, since it indicated that Caswell was
“diagnosed with CTS” and indicated that she had
at some previous time “gotten splints which provide
some relief.” (Tr. 647.)
The
medical records in this case also disclosed that
Caswell's primary treating source, Dr. Dana, regarded the
combination of these condition to be: (1) medically
determinable; (2) severe; and (3) disabling. In particular,
on October 21, 2014 and June 22, 2015, Dr. Dana submitted
medical reports which opined that Caswell could only sit for
2 hours per day, stand for 1 hour per day, and walk for 30
minutes per day. According to Dr. Dana, Caswell could only
sit for 30 minutes at a time without interruption and could
only stand or walk for 20 minutes at a time without
interruption. Dr. Dana also limited Caswell to only
occasional reaching, handling, fingering, feeling, pushing,
and pulling; occasional use of the right foot to operate foot
controls and found that she could never use the left foot to
operate foot controls. Dr. Dana further opined that Caswell
could only occasionally climb stairs and ramps, climb ladders
or scaffolds, and balance and should never stoop, kneel,
crouch, or crawl. Dr. Dana also enjoined Caswell to refrain
from exposure to unprotected heights, moving mechanical
parts, operating a motor vehicle, humidity and wetness,
pulmonary irritants, extreme cold, extreme heat, and
vibrations. (Tr. 480-5, 564-70.)
These
treating source opinions were disputed by a non-examining,
non-treating source, Dr. Steven Goldstein. Based solely upon
his review of medical records, in May of 2016 at the request
of the ALJ Dr. Goldstein provided a medical assessment of
Caswell. In that evaluation, the only impairments identified
by Dr. Goldstein were cervical spondylosis and degenerative
disc disease, obesity, and osteoarthritis. Dr.
Goldstein's medical opinion therefore did not identify,
consider or address Caswell's fibromyalgia or carpal
tunnel syndrome, both of which had been diagnosed by other
medical sources at the time that Dr. Goldstein issued his
opinion. With his assessment limited in this fashion, Dr.
Goldstein arrived at very different conclusions regarding
Caswell's medical condition and impairments. Thus the
doctor found that Caswell could sit, stand, and walk up to 6
hours per day; and was limited to only occasional overhead
reaching with either hand, but retained the ability to
frequently reach, handle, finger, feel, push and pull. Dr.
Goldstein also stated, that based on his review of the record
and experience, there was not “sufficient credible
clinical or radiographic evidence to support the nature and
the extent of the limitations” assessed by
Caswell's treating providers. (Tr. 636-45.)
It was
against this medical and factual backdrop, which documented
that Caswell suffered from two medically determinable and
potentially severe ailments, fibromyalgia and carpal tunnel
syndrome, that the ALJ conducted a hearing into Caswell's
disability application on April 27, 2016. (Tr. 33-54.)
Caswell testified at this hearing, describing her medical
conditions and impairments. (Id.) No. other
witnesses were heard by the ALJ at this proceeding.
On
August 12, 2016 the ALJ issued a decision denying
Caswell's claim for disability benefits. (Tr. 17-27.) In
this decision, the ALJ first found at Step 1 of the five-step
sequential process that applies to disability claims that
Caswell met the insured status requirement of the Social
Security Act through September 30, 2014. (Tr. 22.) At Step 2,
the ALJ concluded that Caswell's severe impairments were
limited to degenerative disc disease and osteoarthritis.
(Id.) Despite Caswell's long-standing diagnosis
of fibromyalgia, the ALJ dismissed this medical concern in a
summary manner as less than severe, alleging without further
discussion that this condition and all of Caswell's
remaining medical impairments did not impose more than
minimal limitations on her ability to perform basic work
activities for a continuous period of at least 12 months.
(Tr. 22-3.) In the absence of any further discussion or
analysis it is not possible to determine how the ALJ reached
this conclusion. Further, the ALJ's decision made no
mention whatsoever of Caswell's bilateral carpal tunnel
syndrome at Step 2 of this analysis. Thus, we are unable to
ascertain whether the ALJ recognized that Caswell suffered
from this medical condition, evaluated whether the condition
was medically determinable, or weighed its severity.
The
ALJ's subsequent analysis of Caswell's claim did not
cure or clarify this uncertainty created by this truncated
Step 2 assessment. At Step 3, the ALJ found that none of the
identified severe impairments met a listing which would
define her as per se disabled. (Tr. 23.) This
analysis made no mention of Caswell's fibromyalgia or
carpal tunnel syndrome. The ALJ then determined that Caswell
retained the residual functional capacity (“RFC”)
to perform a full range of light work as defined in 20 CFR
404.1567(b), (Id.) The ALJ further concluded at Step
4 of this analytical process that Caswell could not return to
her past work, but found at Step 5 that she could perform
other work in the regional and national economy. (Tr. 26-7.)
The ALJ therefore determined that Caswell was not disabled
and denied this application for disability benefits.
(Id.)
In
reaching these conclusions, the ALJ did not clarify or
correct the very limited treatment afforded to Caswell's
diagnosed fibromyalgia and carpal tunnel syndrome at Step 2
of this sequential analysis. Thus, neither of these
conditions was addressed or discussed in the ALJ's
subsequent evaluation of this disability claim. Furthermore,
in rejecting this claim, the ALJ relied heavily upon the
opinion of the non-treating, non-examining medical source,
Dr. Goldstein, who also failed to acknowledge either of these
diagnosed medical conditions. Moreover, the decision's
analysis of the medical evidence emphasized the lack of
clinical and neurological findings, a form of analysis which
courts have found to be inappropriate in cases involving
fibromyalgia, since fibromyalgia is a medical condition which
afflicts sufferers but leaves few clinical signs. (Tr. 23-6.)
This
appeal followed. (Doc. 1.) On appeal, Caswell argues,
inter alia, that the ALJ erred in summarily
discounting her fibromyalgia and completely failing to
address her carpal tunnel syndrome at Step 2 of this
disability analysis, and then failing to incorporate these
conditions into any RFC and Step 5 assessment of ...