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Stephens v. Saul

United States District Court, E.D. Pennsylvania

July 25, 2019

ANDREW SAUL, Commissioner of Social Security[1]


          ELIZABETH T. HEY, U.S.M.J.

         Kendall 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”).[2] 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. § 405(g).


         Plaintiff 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, 187.[3] 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. § 416.1472.

         Plaintiff 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.[4]


         To 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 process, evaluating:

1. Whether the claimant is currently engaged in substantially gainful activity;
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).

         The 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.


         A. ALJ's Findings and Plaintiff's Claims

         The ALJ 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, [5] 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.

         Plaintiff 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.

         B. Summary of Medical Evidence

         Plaintiff 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[6] and continues to suffer with chronic pain. Tr. at 336.[7] 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 ADHD[8]and wanted to begin mental health treatment and resume taking Adderall.[9] Id. at 316.

         On July 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[10] 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).[11] 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.[12] Plaintiff made no migraine complaints in May 2017. Id. at 564.

         During 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.[13] 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.[14] Id. at 722-24.

         Ziba 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.

         Plaintiff 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[15] and intermittent explosive disorder (“IED”).[16] 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.[17]

         In 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[18] and PTSD. Tr. at 671-720. Originally, she was prescribed Seroquel and Zoloft.[19] Id. at 671. In December 2016, Dr. Smith increased Plaintiff's dosage of Seroquel. Id. at 676. In January 2017, Dr. Smith added Prozac[20] for depression. Id. at 681. In February, Dr. Smith increased Prozac and added prazosin[21] 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.[22] 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.

         On 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, ...

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