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McGuire v. Berryhill

United States District Court, M.D. Pennsylvania

April 11, 2019

LYNN MARIE McGUIRE, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          Brann Judge

          REPORT AND RECOMMENDATION

          MARTIN C. CARLSON UNITED STATES MAGISTRATE JUDGE.

         I. Introduction

         In this case we are called upon to evaluate an Administrative Law Judge (ALJ), Social Security disability determination which is unusual in at least five material respects. First, this disability determination reflected apparent confusion by the ALJ regarding the onset date of the claimant's disability. Second, in finding that McGuire was not disabled, the ALJ rejected the opinion of McGuire's treating source regarding her physical impairments, and instead fashioned a physical residual functional capacity assessment for McGuire which enjoyed no medical opinion support. Third, when evaluating McGuire's mental and emotional residual functional capacity, the ALJ rejected a treating source opinion in favor of the judgment of a non-treating, non-examining source who never considered the opinion of the physician who actually was providing mental health care to McGuire. The ALJ then fashioned a mental RFC which exceeded all of this opinion evidence. Fourth, the ALJ precluded McGuire's spouse from testifying at the administrative hearing, and then largely discounted the testimony of McGuire's lay witnesses in the decision denying benefits to the claimant. Fifth, the ALJ concluded that McGuire's claims of disabling anxiety and depression were not severe at Step 2 of the disability analysis process despite the extensively documented history that McGuire suffered from these emotional impairments. The ALJ also wholly discounted another documented impairment, incontinence, in this Step 2 analysis.

         Viewed in combination we conclude that these five factors sufficiently undermine confidence in the disability determination in this case that a remand is appropriate. Therefore, we recommend that the district court remand this case for further consideration by the Commissioner.

         II. Statement and Facts of the Case

         Lynn McGuire is a woman in her 40's, (Tr. 25), who faces a host of personal, medical and psychological challenges. McGuire is the mother of a profoundly autistic, adult son, who is unable to care for his daily needs. (Tr. 45-6.) Thus, the burden of basic care for this adult child falls on McGuire and her family. (Id.)

         Beyond this personal family hardship McGuire suffers from a constellation of chronic, and progressive, medical and emotional impairments. Physically, she suffers from degenerative disc disease and diabetes, conditions that are complicated by her morbid obesity. (Tr. 17.) At least some of these medical conditions have become progressively more severe over time. For example, McGuire's obesity is well-documented, and grew progressively more serious over time, with her reported weight increasing from 260 pound to 287 pounds between 2013 and 2016. (Tr. 44, 440, 449, 457, 460.) McGuire also suffered from a related medical complication which would have significantly affected her ability to work-incontinence. According to McGuire this condition caused her to frequently soil herself during the week, a medical complaint which was confirmed by those lay witnesses who were closest to McGuire, including her father. (Tr. 65.)

         During the period of her claimed disability, McGuire was treated by Dr. David Mouallem. Dr. Mouallem twice provided Social Security with medical opinion statements attesting to the disabling character of McGuire's medical conditions. (Tr. 571, 525.) As Dr. Mouallem most recently explained:

Lynn McGuire has been a long standing patient in my office who continues to follow with psychiatry as well as myself on a regular basis. As previously state[d] she suffers from multiple serious medical conditions including Type II Diabetes melitus, essential hypertension and anxiety disorder. She continues to suffer from bipolar disease and major depression. She is currently being aggressively treated by psychiatry for these debilitating illnesses. Her condition has not improved and in fact has shown evidence of decline despite treatment. Lynn is compliant with the treatment plan presented to her and continues to show a willingness to recover from her multiple ailments. At this time Lynn is unable to return to work in any capacity. Furthermore I do not feel that Lynn will ever be able to return to work on a full time basis due to multiple medical issues. In my opinion, with a reasonable degree to medical certainty, Lynn meets all of the requirements for full disability benefits.

(Tr. 525.)

         Dr. Mouallem's medical opinion noted that he believed that McGuire was disabled due to a combination of medical and psychiatric impairments, and in fact McGuire has an extensively documented history of mental health treatment. This mental health treatment history began in the Fall of 2011when McGuire was seen by Dr. Jyoti Shah “due to her severe depressive state.” (Tr. 470.) At that initial psychiatric encounter, Dr. Shah evaluated assessed McGuire as having a Global Assessment of Functioning or GAF score of 25.[1] Dr. Shah provided on-going mental health treatment to McGuire since this initial clinical encounter with the severely depressed McGuire in 2011. The records of these medical encounters are noteworthy in several respects. First, these records consistently describe McGuire as suffering from three related mental health conditions, bi-polar disorder, depression and anxiety. (Tr. 399, 401, 404, 406, 663, 666, 667, and 671.) Moreover, despite years of on-going treatment Dr. Shah consistently rated the severity of McGuire's symptoms as moderately impairing her social and occupational functioning, assigning GAF scores of 51-60 to McGuire on multiple occasions. (Tr. 283, 286, 399, 405, 665, 671, 678, 684, 688.)

         In 2013, Dr. Shah, a second treating source for McGuire, opined that she was disabled due to these mental health impairments. (Tr. 470.) In his medical opinion letter Dr. Shah explained that McGuire was “diagnosed with Bipolar II Disorder, Major Depressive Disorder and Generalized Anxiety Disorder with panic symptoms.” (Id.) Dr. Shah explained that:

Ms. McGuire was hospitalized in the fall of 2011 due to her severe depressive state. Since her discharge from the hospital, she continue[d] to participate In regular therapy sessions with a licensed behavioral therapist and psychiatric follow-up with me, which includes medication management, crisis intervention and supportive therapy. While treatment is ongoing, Ms. McGuire has not fully responded to treatment and continues to have significant emotional impairment.

(Id.)

         Dr. Shah also specifically tied McGuire's emotional impairments to her inability to meet the mental demands of the workplace, stating that: “I have worked with her employer to give her a modified work schedule, different job assignments etc. however, none of these Interventions had lasting effect on her overall psychiatric well being.” (Id.) Given the failure of these interventions Dr. Shah concluded based upon his years of treatment that: “Ms. McGuire can't hold any gainful employment and her illnesses are chronic and permanently disabling. Her conditions are lifelong and of sufficient severity to be permanently disabling.” (Id.)

         These expert medical opinions, in turn, were buttressed by the lay testimony of those closest to McGuire, her father and her spouse. McGuire's father confirmed he fragile physical and emotional state, explained her inability to perform basic activities of daily living, and described the limitations which her frequent incontinence created for McGuire. (Tr. 63-66.) McGuire's spouse submitted a third-party report, (Tr. 208-215), which provided further confirmation of the disabling character of this constellation of impairments, stating that: “Lynn's depression and emotional problems pervade all aspects of her life. She is chronically fatigued and prone to alternating bouts of deep depression and emotional outbursts. Her physical ailments compound these problems.” (Tr. 208.)

         It was against this medical, emotional and psychological backdrop that McGuire submitted this, her second[2] application for Social Security disability benefits pursuant to Titles II and XVI of the Social Security Act on January 14, 2015. (Tr. 15.) At McGuire's request, a hearing regarding this application was held before an Administrative Law Judge (ALJ) on March 15, 2016. (Tr. 31-72.) At this hearing two lay witnesses, McGuire's father and spouse, stood ready to testify to the disabling effect of her impairments. The ALJ, however, instructed McGuire that he would only hear from one lay witness. (Tr. 62.) Having limited McGuire to a sole lay witness, her father, the ALJ also took testimony from McGuire herself and from a Vocational Expert. (Id.)

         On August 9, 2016, the ALJ then issued a decision denying McGuire's application for benefits. (Tr. 12-26.) At the outset, this decision reflected some apparent confusion regarding the alleged onset date of McGuire's disability, describing that onset date at various times as either March of 2012 or July of 2013. (Tr. 15, 16, 17.) This confusion appeared to stem, in part, from the fact that the ruling on McGuire's prior disability application was res judicata as to any claims predating July 2013.

         The ALJ then found at Step 2 of the sequential analysis that applies to disability cases that McGuire suffered from the following severe impairments: degenerative disc disease, diabetes, bipolar disorder and obesity. (Tr. 117.) Notably, despite the multiple references to McGuire's depression and anxiety disorders in her treatment records, the ALJ did not find these conditions to be severe or medically determinable. (Tr. 18.) Instead, the ALJ asserted that McGuire's treatment records “only support a diagnosis of bipolar disorder.” (Tr. 18.) The ALJ's decision did not reconcile this factual finding with the statement of McGuire's treating psychiatrist, Dr. Shah, that McGuire was “diagnosed with Bipolar II Disorder, Major Depressive Disorder and Generalized Anxiety Disorder with panic symptoms.” (Tr. 470.) This Step 2 assessment of McGuire mental state was particularly curious since previously in 2013 McGuire's depression and anxiety had been found by an ALJ to be severe impairments at Step 2. (Tr. 100.) Likewise, the ALJ's decision discounted her claims of incontinence stating: “The record does not contain evidence of frequent incontinence.” (Tr. 18.) In fact, the record contained evidence that this was an ongoing intractable condition. Specifically, McGuire's father testified on this precise point, as follows:

Q You're aware of the sphincterectomy that has caused some rectal dysfunction and some accidents [for McGuire]. Have you been witness to any issues where she's had accidents at the home?
A Yes.
Q Is it frequent, infrequent, or consistent?
A I would say it's happening on a regular basis. It happens repeatedly.

         Having made these Step 2 determinations, the ALJ went on to conclude at Step 3 of this analysis that none of McGuire's impairments were per se disabling. (Tr. 18-21.) The ALJ then found that McGuire retained the residual functional capacity to perform a limited range of sedentary work. (Tr. 21.) In reaching this conclusion the ALJ misstated and understated the severity of one of McGuire's severe impairments, her obesity, stating that McGuire was 5' 4” tall and weighed 266 pounds, (Tr. 22), when in fact her documented weight was significantly greater, ranging up to a reported 287 pounds. (Tr. 44, 440, 449, 457, 460.)

         The ALJ also rejected every treating source opinion provided by McGuire in drawing this conclusion. Thus, with respect to McGuire's physical impairments, the ALJ gave the treating source opinion of Dr. Mouallem “little weight.” (Tr. 23.) Instead, the ALJ fashioned a physical RFC for McGuire which was unsupported by any competent medical opinion evidence, and was contradicted by the sole physician opinion of record.

         Likewise, the ALJ gave little weight to the opinion of McGuire's treating psychiatrist, Dr. Shah. (Tr. 23-4.) Instead, the ALJ elected to give some greater quantum of credence, which the ALJ described as “partial weight, ” to the opinion of a non-treating, non-examining source a state agency expert, Dr. Diorio. (Tr. 24.) The ALJ expressed a preference for Dr. Diorio's opinion even though Dr. Diorio did not acknowledge or address the contrary view of McGuire's treating psychiatrist in her opinion. (Tr. 115-138.) Moreover, while the ALJ gave “partial weight” to Dr. Diorio's opinion, the ALJ rejected Dr. Diorio's conclusion that McGuire suffered from moderate limitations in social functioning. (Tr. 24.) Thus, the ALJ ultimately arrived at a psychological RFC for McGuire, which like the physical RFC fashioned by the ALJ, exceeded the limitations set forth in all of expert medical opinions in this case.

         Finally, having limited McGuire to a single lay witness at her disability hearing, the ALJ then discounted the statements of both McGuire's father and spouse, summarily concluding that they lacked the medical competence to make these assessments and were biased due to their familial connection to the claimant. (Tr. 24.) This cursory treatment of the lay witnesses did not address in ...


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