United States District Court, E.D. Pennsylvania
MEMORANDUM AND ORDER
ELIZABETH T. HEY, U.S.M.J.
Kiana Stephens (“Plaintiff”) seeks review,
pursuant to 42 U.S.C. § 405(g), of the
Commissioner's decision denying her claim for
supplemental security income
(“SSI”). For the reasons that follow, I conclude
that the decision of the Administrative Law Judge
(“ALJ”) denying benefits is not supported by
substantial evidence and will remand the case for further
proceedings pursuant to sentence four of 42 U.S.C. §
filed for SSI on October 6, 2014, claiming that she became
disabled on October 29, 2011, due to a combination of
physical and mental disorders. Tr. at 98, 160-66,
Id. at 187. The application was denied initially,
id. 103-06, and Plaintiff requested an
administrative hearing before an ALJ, id. at 156,
which took place on June 21, 2017. Id. at 33-57. On
August 14, 2017, the ALJ found that Plaintiff was not
disabled. Id. at 12-28. The Appeals Council denied
Plaintiff's request for review on July 10, 2018,
id. at 1-3, making the ALJ's August 14, 2017
decision the final decision of the Commissioner. 20 C.F.R.
commenced this action in federal court on September 12, 2018.
Doc. 1. The matter is now fully briefed and ripe for review.
Docs. 12 & 13.
prove disability, a claimant must demonstrate an
“inability to engage in any substantial gainful
activity by reason of any medically determinable physical or
mental impairment . . . which has lasted or can be expected
to last for . . not less than twelve months.” 42 U.S.C.
§ 423(d)(1). The Commissioner employs a five-step
1. Whether the claimant is currently engaged in substantially
2. If not, whether the claimant has a “severe
impairment” that significantly limits her physical or
mental ability to perform basic work activities;
3. If so, whether based on the medical evidence, the
impairment meets or equals the criteria of an impairment
listed in the “listing of impairments, ” 20
C.F.R. pt. 404, subpt. P, app. 1, which results in a
presumption of disability;
4. If the impairment does not meet or equal the criteria for
a listed impairment, whether, despite the severe impairment,
the claimant has the residual functional capacity
(“RFC”) to perform her past work; and
5. If the claimant cannot perform her past work, then the
final step is to determine whether there is other work in the
national economy that the claimant can perform.
See Zirnsak v. Colvin, 777 F.3d 607, 610 (3d Cir.
2014); see also 20 C.F.R. § 416.920(a)(4).
Plaintiff bears the burden of proof at steps one through
four, while the burden shifts to the Commissioner at the
fifth step to establish that the claimant is capable of
performing other jobs in the local and national economies, in
light of her age, education, work experience, and RFC.
See Poulos v. Comm'r of Soc. Sec., 474 F.3d 88,
92 (3d Cir. 2007).
court's role on judicial review is to determine whether
the Commissioner's decision is supported by substantial
evidence. 42 U.S.C. § 405(g); Schaudeck v.
Comm'r of Soc. Sec., 181 F.3d 429, 431 (3d
Cir. 1999). Therefore, the issue in this case is whether
there is substantial evidence to support the
Commissioner's conclusions that Plaintiff is not disabled
and is capable of performing jobs that exist in significant
numbers in the national economy. Substantial evidence is
“such relevant evidence as a reasonable mind might
accept as adequate to support a conclusion, ” and must
be “more than a mere scintilla.”
Zirnsak, 777 F.2d at 610 (quoting Rutherford v.
Barnhart, 399 F.3d 546, 552 (3d Cir. 2005)). The court
has plenary review of legal issues. Schaudeck, 181
F.3d at 431.
ALJ's Findings and Plaintiff's
found that Plaintiff suffered from several severe impairments
at the second step of the sequential evaluation;
Post-Traumatic Stress Disorder (“PTSD”), right
hip injury status post open reduction with internal fixation
(“ORIF”), migraines, depression, and anxiety.
Tr. at 15. The ALJ found that Plaintiff did not have
an impairment or combination of impairments that met the
Listings, id. at 15,  and that Plaintiff retained the
RFC to perform light work except she is limited to lifting
and/or carrying up to twenty pounds occasionally; sitting for
six hours, standing for four hours, and walking for four
hours in an eight-hour workday; occasionally performing
postural activities; no pushing and/or pulling with the
bilateral lower extremities; she must avoid exposure to
dusts, odors, fumes, toxins, and pulmonary irritants; and can
perform simple repetitive tasks with occasional changes in
the work setting and occasional contact with the public and
coworkers. Id. at 17. At the fourth step of the
evaluation, the ALJ found that Plaintiff could not return to
her past relevant work. Id. at 26. However, at the
fifth step, based on the testimony of a vocational expert
(“VE”), the ALJ concluded that Plaintiff could
perform work that exists in significant numbers in the
national economy. Id. at 27-28.
claims that the ALJ failed to properly consider the mental
health record, the opinions of her treating psychiatrist and
therapist, and Plaintiff's testimony, resulting in a
deficient RFC determination, which, in turn, corrupted the
VE's testimony. Doc. 12 at 6-24. In addition, Plaintiff
argues that, in determining whether her impairments met
Listing 12.15, the ALJ failed to consider whether her
physical and mental impairments in combination met the
Listing and substituted her own opinion for that of
Plaintiff's treatment providers. Id. at 24-27.
Summary of Medical Evidence
suffered a right hip injury in 2009, when she fell off a
third-floor balcony and fractured her hip, for which she
underwent ORIF surgery and continues to suffer with chronic pain.
Tr. at 336. Plaintiff treated at the Mazzoni Center
for both physical and mental health impairments during the
relevant period, including treatment for hormone replacement
therapy, Human Immunodeficiency Virus (“HIV”)
care, and chronic hip pain. Id. at 301-36. In March
2014, Plaintiff complained of “serious concentration
issues, ” and indicated that she had previously been
diagnosed with ADHDand wanted to begin mental health treatment
and resume taking Adderall. Id. at 316.
18, 2014, Plaintiff was hit in the head with a beer bottle
and knocked unconscious for ten to fifteen seconds.
Tr. at 311; see also id. at 40
(Plaintiff's testimony regarding the assault). During an
office visit to the Mazzoni Center on July 31, 2014, Maxwell
Parrish, CRNP, noted that Plaintiff complained of an ongoing
headache, poor concentration, difficulty sleeping, and
concern over emotional effects of the attack. Id. at
311-14. According to the treatment notes for September 2014,
Plaintiff had a history of migraines, but had been
migraine-free for many years until the July 2014 assault,
when she had an increase in headaches, an aura, nausea, and
photophobia. Id. at 308. She was prescribed
sumatriptan for treatment of the headaches.
Id. Reviewing the records from the Mazzoni Center,
it appears that Plaintiff's complaints of and treatment
for headaches alleviated by August 2015. See id. at
587-90 (treatment note with no complaints of headache and no
mention of sumatriptan). Plaintiff again began complaining of
migraines to Mr. Parrish in March 2017, at which time Mr.
Parrish prescribed ibuprofen and referred her to neurology.
Id. at 569. Plaintiff made no migraine complaints in
May 2017. Id. at 564.
the relevant period, Plaintiff sought treatment for
persistent right hip pain. See tr. at 394-409
(records from Regional Orthopedic Associates November 7, 2011
through March 25, 2014), 645-46 (records from Daniel Coachi,
M.D., dated May 1, 2017 and June 6, 2017). Plaintiff had an
exacerbation of hip pain in March 2017, for which Mr. Parrish
referred her to pain management and orthopedics. Id.
at 569. A subsequent CT scan showed a tear of the superior
labrum. Id. at 599. Mr. Parrish's
notes indicate that Plaintiff was in pain management for her
right hip pain in May 2017, needed to follow up with an
orthopedist, and was considering physical therapy.
Id. at 564. On June 9, 2017, Farrah Altuve, PA-C, of
Penn Orthopedics, injected Plaintiff's right hip with
lidocaine and Depomedrol. Id. at 722-24.
Monfared, M.D., conducted a consultative examination for the
Administration on March 26, 2015, which included an
assessment of Plaintiff's range of motion, ability to do
work-related activities, and examination report. Tr.
at 382-93. The doctor diagnosed physical conditions including
right hip pain, ambulatory dysfunction, chronic migraines,
asthma, history of AIDS, HIV, constipation, and insomnia,
and found that Plaintiff had normal range of motion except
that her right hip forward flexion was 60 degrees out of 100
degrees. Id. at 383, 393. He opined that Plaintiff
could never lift and carry up to ten pounds, and was only
able to sit for fifteen minutes and stand for five minutes in
a workday, and could not walk for any period. Id. at
385. Dr. Monfared found Plaintiff required a cane to
ambulate, and could never use her right foot to operate foot
controls. Id. at 385, 386.
also treated for mental health issues at the Mazzoni Center
from approximately February 2015 through June 2016, where she
saw Scott Stevens, M.D., and therapist Jasper Liem, LCSW, who
diagnosed her with moderate recurrent major depression,
chronic PTSD and intermittent explosive disorder
(“IED”). Tr. at 411-554. Throughout her
treatment with Dr. Stevens, the doctor noted normal or
unremarkable mental status exams (“MSEs”).
Id. at 416-17 (9/30/15), 434 (8/5/15), 444
(6/24/15), 463 (4/29/15), 475 (3/17/15), 499 (4/26/16), 507
(4/12/16). This is consistent with therapist Liem's notes
for the same period which indicated that Plaintiff had
progressed and “appear[ed] very stable and [was]
utilizing coping skills and support network effectively and
appropriately” and indicated “she could be ready
for discharge in the next 2 months” in February 2016.
Id. at 527. Two months later, Mr. Liem noted that
Plaintiff's behavior was active and agitated and her
affect was anxious, sad, and tearful. Id. at 515.
Plaintiff was discharged from therapy on June 12, 2016, when
Plaintiff reached the end of her two-year treatment term and
her therapist left practice. Id. at 488. Therapist
Liem completed a Mental Impairment Questionnaire a year
later, on June 16, 2017, indicating that Plaintiff had
moderate limitations in her ability to understand, remember,
or apply information, extreme limitations in her abilities to
interact with others and adapt or manage herself, and marked
limitation in her ability to concentrate, persist, or
maintain pace. Id. at 651.
November 2016, Plaintiff began mental health treatment at
JFK, where she was treated by Buster Smith, M.D., and
therapist Lisa Pozzi, and diagnosed with bipolar II
disorder and PTSD. Tr. at 671-720.
Originally, she was prescribed Seroquel and
Zoloft. Id. at 671. In December 2016,
Dr. Smith increased Plaintiff's dosage of Seroquel.
Id. at 676. In January 2017, Dr. Smith added
Prozac for depression. Id. at 681. In
February, Dr. Smith increased Prozac and added
prazosin for Plaintiff's nightmares.
Id. at 686. In March, Dr. Smith again increased
Plaintiff's dosage of Seroquel. Id. at 691. On
many occasions throughout this period, Dr. Smith found
Plaintiff's concentration/attention to be distractable or
variable. Id. at 672 (12/1/16 - distractable), 678
(12/15/16 - distractable), 688 (Jan. 24, 2017 - variable),
693 (March 23, 2017 - distractable). In a treatment summary
on May 23, 2017, Ms. Pozzi explained that Plaintiff
“presents as anxious and stressed” and noted that
her concentration “is variable and is affected by mood
lability and migraines.” Id. at 654. Dr. Smith
completed a Medical Source Statement of Ability to Do
Work-Related Activities (Mental) on May 24, 2017, in which he
found that Plaintiff has moderate limitations in her ability
to understand and remember simple instructions, marked
limitation in her ability to carry out simple instructions,
and extreme limitation in her ability to make judgments on
simple work-related decisions, understand, remember, and
carry out complex instructions, and make judgments on complex
work-related decisions. Id. at 639. The doctor also
found Plaintiff had extreme limitations in interacting with
the public, co-workers, or supervisors, and in responding
appropriately to usual work situations and changes in a
routine work setting. Id. at 640.
March 12, 2015, Sandra Banks, Ph.D., reviewed Plaintiff's
record at the initial consideration stage and found that
Plaintiff suffered from affective, anxiety, and organic
mental disorders, which caused mild limitations in activities
of daily living and social functioning, ...