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Hull v. Berryhill

United States District Court, M.D. Pennsylvania

July 24, 2018

KATINA D. HULL, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         Pending before the Court is Plaintiff's appeal from the Acting Commissioner's denial of Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act (“Act”) and Supplemental Security Income (“SSI”) under Title XVI of the Act. (Doc. 1.) Plaintiff protectively filed applications on March 4, 2014, alleging disability beginning on November 24, 2012. (R. 15.) After Plaintiff appealed the initial May 16, 2014, denial of the claims, hearings were held by Administrative Law Judge (“ALJ”) Theodore Burock on February 12, 2016, and August 19, 2016. (R. 38-71.) ALJ Burock issued his Decision on March 29, 2017, concluding that Plaintiff had not been under a disability, as defined in the Social Security Act (“Act”) from November 24, 2012, through the date of the Decision. (R. 26.) Plaintiff requested review of the ALJ's decision which the Appeals Council denied on December 15, 2017. (R. 1-6.) In doing so, the ALJ's decision became the decision of the Acting Commissioner. (R. 1.)

         Plaintiff filed this action on January 2, 2018. (Doc. 1.) She asserts in her supporting brief that the Acting Commissioner's determination should be reversed or remanded for the following reasons: 1) the ALJ erred in finding Plaintiff's mental health conditions do not meet Section 12.04 of the Listings; 2) the ALJ erred in failing to accord proper weight to Plaintiff's treating mental health providers in reaching a residual functional capacity (“RFC”) assessment; and 3) the ALJ's RFC findings are not supported by substantial evidence. (Doc. 11 at 27-39.) For the reasons discussed below, the Court concludes Plaintiff's appeal is properly granted.

         I. Background

         Plaintiff was born on June 20, 1973, and was thirty-nine years old on the alleged disability onset date. (R. 25.) She has a high school education and past relevant work as a nurse assistant and bank clerk. (Id.) The March 19, 2014, Disability Report indicates Plaintiff alleged that her ability to work was limited by bipolar disorder, anxiety, back issues, arthritis, and generalized pain. (R. 259.)

         A. Medical Evidence

         Given the extensive record in this case and the limited scope of the issues raised in Plaintiff's appeal of the Acting Commissioner's decision, the Court will provide a brief summary of medical evidence to provide context for discussion. Specific evidence relevant to claimed errors will be considered in the context of the arguments raised.

         From February 2016 through January 2015, Plaintiff received primary care at Ketytone Family Practice. (Doc. 11 at 6.) During that time she was treated for various conditions including lumbar and cervical spine pain with radiculopathy, high blood pressure, anxiety, depression, bilateral knee pain, foot pain, dizziness, and diabetes. (Doc. 11 at 6.) She received primary care at Summit Primary care from July 2015 through March 2016. (R. 1523-41.)

         Plaintiff treated at Summit Pain Medicine from July 18, 2012, through July 27, 2016, initially reporting to Amanpreet Sandhu, M.D., that she had injured her back in 2010. (Doc. 11 at 11.) She was first treated for chronic low back pain and was referred for physical therapy. (R. 385.) Physical therapy initially helped but was discontinued because of aggravated symptoms including increased lumbosacral pain which worsened with prolonged standing, walking, and sitting. (Doc. 11 at 12.) By May 2013, Plaintiff reported good pain relief with repeated L5-S1 epidural injections but she began to complain of constant neck pain that radiated to her shoulders and intermittent headaches after exacerbation of neck pain. (Doc. 11 at 13.) Plaintiff had cervical epidural steroid injections in June 2013, and in July Plaintiff reported good neck pain relief but increased lower back symptoms. (Id.) Following August and September 2013 intra-articular facet joint injections at ¶ 4-5 and L5-S1, Plaintiff reported that her low back pain was well controlled but she still had intermittent muscle spasms. (Id. at 14.) In December 2012, Plaintiff resumed regular activities without significant exacerbation of her symptoms and was told to return to the pain clinic as needed. (Id.) By August 2014, Plaintiff's bilateral L5 radiculopathy had returned and she again received injections which helped the low back pain. (Id.)

         In December 2014, Plaintiff reported increasing neck and lower back pain with some spasms. (Id.) Plaintiff continued to receive injections periodically with varying pain symptoms reported through 2015. (Id. at 15.) In early 2016, Plaintiff reported a flare of lower back pain secondary to prolonged sitting after driving to Harrisburg for a disability hearing. (Id.) With reports in March 2016 of progressive worsening of low back symptoms, radicular pain, and increased neck pain, Plaintiff was scheduled for lumbar facet and caudal injections. (Doc. 11 at 15.) At Plaintiff's five visits to Summit Pain Medicine from April 19, 2016, through July 27, 2016, she reported improvement as well as ongoing significant functional limitations. (Id. at 16.)

         Plaintiff received mental health treatment at Keystone Behavioral Health (“KBH”) after being referred by her primary care provider in April 2012 due to anxiety. (Doc. 11 at 16.) Plaintiff first saw psychiatrist Iraki Mania, M.D., and later was seen from June 2014 through June 2016 by psychiatrist Kawish Garg, M.D.. (Id. at 16-17.) She also saw licensed counselor Robin Witmer once or twice a month beginning in April 2014. (Id. at 17-18.) Plaintiff states she was seen at KBH over 105 times since her alleged onset date. (Id. at 18.) Psychiatrists diagnosed biploar disorder and generalized anxiety order. (Id.) Records show waxing and waning symptoms and varied presentations during the relevant time. (Id.)

         B. Opinion Evidence

         1. Physical Impairment Opinion

         Angelique High, an examining occupational therapist, performed a functional capacity evaluation in October 2012. (R. 1082-91.) The reason for testing was to determine Palntiff's abilities and limitations for social security disability. (R. 1082.) Ms. High noted that Plaintiff's movements and physiological responses were consistent with maximal effort. (Id.) She concluded generally that Plaintiff was in the sedentary physical demand level. (R. 1083.) Ms. High's specific findings included that Plaintiff was limited to occasional standing work, and she could occasionally do stairs, walk, and sit. (R. 1084-85.) The identified bases for the limitations included lower back pain and decreased lower extremity strength. (Id.)

         2. Mental Impairment Opinions

         In September 2012, Dr. Mania completed a Mental Impairment Questionnaire. (R. 793-98.) He identified bipolar disorder and generalized anxiety order as Plaintiff's diagnoses and assessed a GAF score of 65. (R. 793.) Based on monthly medication management visits of fifteen minutes, he noted that Plaintiff had chronic mood swings; she alternated from depression to irritability; she had trouble sleeping; and she had constant anxiety and restlessness. (Id.) Dr. Mania opined that Plaintiff's prognosis was “good with treatment.” (Id.) He found that Plaintiff would be unable to meet competitive standards in the following areas: maintain attention for a two-hour segment; maintain regular attendance and be punctual within customary, usually strict tolerances; sustain an ordinary routine without special supervision; work in coordination with or proximity to others without interruptions from psychologically based symptoms; perform at a consistent pace without an unreasonable number and length of rest periods; understand and remember detailed instructions; carry out detailed instructions; deal with stress of semiskilled and skilled work; travel in unfamiliar places; and use pubic transportation. (R. 795-96.) Dr. Mania attributed some of these limitations to Plaintiff's severe mood swings, constant anxiety, distractibility, and poor concentration. (R. 796.) Dr. Mania opined that Plaintiff had at most mild restriction in activities of daily living, marked difficulties in maintaining social functioning, marked difficulties in maintaining concentration, persistence or pace, and she had experienced three episodes of decompensation within a twelve month period, each of at least two weeks duration. (R. 797.) He indicated that Plaintiff had “[a]n anxiety related disorder and complete inability to function independently outside the area of one's home.” (Id.) He also opined that Plaintiff would miss work more than four days a month. (Id.)

         John Gavazzi, Psy. D., a State agency psychological consultant, completed a Psychiatric Review Technique (“PRT”) and Mental Residual Functional Capacity Assessment on April 22, 2014. (R. 110-14.) He concluded that Plaintiff had mild restrictions in activities of daily living, moderate difficulties in social functioning, moderate difficulties in maintaining concentration, persistence, or pace, and no repeated episodes of decompensation, each of extended duration. (R. 111.) He also made the following findings: Plaintiff was moderately limited in her ability to understand and remember detailed instructions; she could understand, retain, and follow simple instructions, i.e., perform one and two step tasks and could perform simple, routine, repetitive tasks in a stable environment; she was moderately limited in her ability to carry out detailed instructions; she was moderately limited in her ability to interact appropriately with the general public; and she was moderately limited in her ability to accept instructions and respond appropriately to criticism from supervisors. (R. 112-13.) In narrative form, Dr. Gavazzi explained that “[t]he claimant struggles with social skills. The claimant communicates clearly, relates appropriately to familiar others, and behaves predictably in most social situations. The claimant is able to maintain socially appropriate behavior and can perform the personal care functions needed to maintain an acceptable level of personal hygiene.” (R. 114.) Dr. Gavazzi further explained that “[t]he medical evidence establishes medically determinable impairments of Major Depressive Disorder and Generalized Anxiety Disorder. The claimant has not had any hospitalizations due to mental impairments. The claimant takes psychotropic agents. The claimant does not participate in psychotherapy.” (Id.)

         In December 2014, Dr. Garg completed a Mental Impairment Questionnaire identifying diagnoses of bipolar disorder and generalized anxiety. (R. 808.) He noted that Plaintiff was not doing well, she continued to experience unstable mood and emotional lability, she was depressed and unable to concentrate, and she was making very slow progress. (R. 808-09.) Dr. Garg assessed Plaintiff's prognosis to be “guarded/poor” and opined that she would miss work more than three days a month. (R. 809-10.) He further opined that she had marked or extreme limitations in all identified work aptitude categories. (R. 811.) Regarding functional limitations, he found Plaintiff had moderate restrictions in activities of daily living, extreme difficulties in maintaining social functioning, extreme difficulties with concentration, persistence, or pace, and she had four or more episodes of deterioration or decompensation in work or work-like settings which caused her to withdraw from that situation or experience exacerbation of signs and symptoms. (R. 813.)

         Plaintiff and Dr. Mania completed a Pennsylvania Department of Welfare Employability Assessment Form. (R. 1652-53.) In the first section, Plaintiff said she could not work because she had debilitating neck and back pain, she could not sit or stand for long, she had uncontrolled anxiety, she was very forgetful, bipolar disorder was unpredictable, she had bad arthritis, and she had a very weak wrist. (R. 1652.) In the second section of the form, Dr. Mania marked that Plaintiff was permanently disabled with the primary diagnosis of bipolar disorder and secondary diagnosis of generalized anxiety disorder. (R. 1653.)

         3. Third Party Function Report

         William Nieves, Plaintiff's boyfriend for more than eight years, completed a Third Party Function Report on April 4, 2014. (R. 268-75.) He explained that Plaintiff's ability to work was limited because depression caused sadness and random crying, back pain did not allow her to sit or stand for long periods, and anxiety caused her to “freak out around people she is not comfortable around.” (R. 268.) Mr. Nieves indicated Plaintiff's conditions affected her abilities to lift, squat, bend, stand, reach, walk, sit, kneel, and climb stairs. (R. 273.) He also said her memory and concentration were affected, as were her abilities to complete tasks, follow instructions, use her hands, and get along with others. (Id.) In narrative form, he said Plaintiff could not stand or sit for certain lengths of time, she had trouble remembering to do things, she had trouble concentrating and staying focused, and she was easily distracted. (Id.)

         C. Hearing Testimony

         At the February 12, 2016, hearing, Plaintiff's attorney summarized Plaintiff's impairments and stated that Plaintiff's mental health condition met Listing 12.04 for affective disorders and, alternatively, she would be limited to less than a full range of sedentary work based on the 2012 functional capacity assessment, the medical source statements of Drs. Mania and Garg, and the record as a whole. (R. 57-58.) The attorney posited that Plaintiff would need a sit-stand option, she would be incapable of working in coordination with others, her attention and concentration would be such that her productivity would be less than eighty percent of normal, and she would miss at least three days of work per month. (R. 58.)

         Plaintiff testified that she had worked as a babysitter for her niece since her alleged onset date but she had stopped that in late 2015 because it got to be too much. (R. 60.) She said she was in pain all the time, mostly in her low back and in her neck. (Id.) She added that she got pain down her legs and her butt got numb if she sat for too long. (R. 61.) Regarding pain management, Plaintiff said she got injections which modified the pain but she took pain pills continually. (R. 62.) Plaintiff also explained that she had neuropathy which caused numbness and tingling in her fingertips and toes. (R. 64.) When asked about physical activity, Plaintiff said she walked leaning on a cart at the grocery store, she was able to stand for about ten to fifteen minutes, and she slept with the aid of medication. (R. 67-68.)

         Regarding mental health, Plaintiff talked about her depression causing guilt, crying, and lack of hygiene. (R. 65.) She also said her anxiety caused her to get sweaty and fidgety around people--both family and the public--and she just needed to get away from the situation. (R. 66-67.) Plaintiff explained that her mania was associated with money and spending and excessive activity as well as insomnia. (R. 68-69.)

         Because the ALJ had not had a chance to review recently submitted records, he stopped the hearing and planned to have an ...

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