Caswell v. Berryhill

          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 ...