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Evans v. Saul

United States District Court, M.D. Pennsylvania

July 26, 2019

CHRISTINE MARIE EVANS, Plaintiff
v.
ANDREW SAUL, Commissioner of Social Security, Defendant

          Mannion Judge.

          REPORT AND RECOMMENDATION

          Martin C. Carlson United States Magistrate Judge.

         I. Introduction

         It is a cardinal principle of judicial review in Social Security appeals that “[w]hen a conflict in the evidence exists, the ALJ may choose whom to credit but ‘cannot reject evidence for no reason or for the wrong reason.' Mason v. Shalala, 994 F.2d 1058, 1066 (3d Cir.1993).” Plummer v. Apfel, 186 F.3d 422, 429 (3d Cir. 1999). The instant case aptly illustrates this principle.

         In this case the ALJ discounted the plaintiff's disability claim, concluding at Step 2 that Evans suffered from “no severe mental impairments” and stating unequivocally that “the claimant has not been diagnosed with nor sought or received treatment for a mental health impairment.” (Tr. 40.) We find that this was the wrong reason for making this Step 2 determination since, in fact, a treating source had diagnosed Evans as suffering from chronic anxiety, and that treating physician had opined that this mental health condition was totally disabling. (Tr. 2293-2346.)

         The ALJ also found that Evans could return to sedentary or light work, rejecting a medical opinion from a physician, Dr. Hawk, that she was limited to lifting five pounds with her right arm, a weight lifting restriction which would have precluded either sedentary or light work. The ALJ rejected Dr. Hawk's opinion based upon the ALJ's perception of Evans' activities of daily living, (Tr. 45), but gave no reason for neglecting to address or even acknowledge at least three other examining source opinions that had imposed similar lifting restrictions upon Evans. Thus, as to this discounted physical exertional limitation, we are provided no reason why multiple medical opinions were found unpersuasive because many of these opinions were not identified, addressed or discussed by the ALJ.

         Mindful of the fact that an ALJ “cannot reject evidence for no reason or for the wrong reason, ” Mason v. Shalala, 994 F.2d 1058, 1066 (3d Cir.1993), for the reasons discussed below, we conclude that these two failures of articulation taken together in the instant case compel a remand for further consideration of this case by the Commissioner.

         II. Statement of Facts and of the Case

         On November 19, 2014, Christine Evans applied for disability benefits pursuant to Title II of the Social Security Act, alleging that she had become totally disabled on March 27, 2013, due to the combined effects of chronic anxiety, right shoulder osteoarthritis, degenerative disc disease, and vision impairments. (Tr. 37, 39.) Evans was 50 years old at the time of the alleged onset of her disability, had at least a high school education, and had prior employment as an administrative assistant. (Tr. 45-6.)

         With respect to Evans' emotional impairments, her treating physician, Dr. John Prater, opined on January 24, 2017, that Evans “has multiple medical and psychological issues that prevent her from working. These are long term and permanent conditions, as outlined in my office records.” (Tr. 2346.) Those treatment records, in turn, reflected a diagnosis for Evans of chronic anxiety and treatment of Evans for that emotional condition. (Tr. 2292-2345.) A state agency expert also acknowledged that Evans suffered from a diagnosed emotional conditions, affective disorders, although the state agency expert, who had never seen or treated Evans, characterized these emotional impairments as non-severe. (Tr. 104.) For her part, Evans described these emotional impairments in far more severe terms, telling the ALJ that “I just can't sleep at night due to pain, anxiety, panic attacks, [and] depression.” (Tr. 249.) Evans' description of her emotional state was entirely consistent with her treating physician, Dr. Prater's, diagnosis of chronic anxiety and her account of the severity of these impairments was wholly consistent with Dr. Prater's opinion that these emotional impairments prevented her from working.

         Beyond her emotional impairments, Evans suffered from a series of physical ailments, medical conditions which manifested themselves in significant restrictions in the use of her right arm and hand. Evans described the disabling effect of this right arm condition at her ALJ hearing, (Tr. 82-98), and in correspondence which she wrote to the ALJ immediately following that hearing. (247-49.) Multiple medical opinions also confirmed that Evans was highly limited in her use of her right, non-dominant, hand.

         For example, Dr. Mitchell Cooper, who conducted an independent medical examination of Evans on January 23, 2013, two months prior to her disability onset date, found that she was limited to lifting 5 pounds with her right hand. (Tr. 704, 707.) This finding was echoed by Dr. Gregor Hawk, who examined Evans in June of 2014 and opined at that time that she was limited to carrying 5 pounds. (Tr. 1304.) Two months later, Dr. Scott Sexton, who performed a second independent medical examination on August 25, 2014 likewise recommended a 5 pound right arm lifting restriction for Evans when she was lifting above her shoulder. (Tr. 852.) These findings, in turn, were consistent with the results of a functional capacity evaluation of Evans undertaken on August 27, 2014, which also found that Evans could only carry up to 7 pound with her right arm. (Tr. 603.)

         It was against this medical backdrop that the ALJ held a hearing on Evans' disability application on January 31, 2017. (Tr. 82-98.) Following this hearing, on April 5, 2017, the ALJ issued a decision denying Evans' application for benefits. (Tr. 34-47.) In that decision, the ALJ first concluded that Evans met the insured status requirements of the Social Security Act through December 31, 2017 and had not engaged in any substantial gainful activity since his alleged onset date of disability on May 27, 2013. (Tr. 39.)

         At Step 2 of the sequential analysis that governs Social Security cases, the ALJ found that Evans' shoulder, spinal and vision impairments were severe impairments. (Id.) In conducting this Step 2 assessment, however, the ALJ concluded that Evans suffered from “no severe mental impairments, ” basing this conclusion on the assertion that “the claimant has not been diagnosed with nor sought or received treatment for a mental health impairment.” (Tr. 40.) This assertion was incorrect. In fact, her treating physician, Dr. John Prater, opined on January 24, 2017, that Evans “has multiple medical and psychological issues that prevent her from working. These are long term and permanent conditions, as outlined in my office records.” (Tr. 2346.) Those treatment records, in turn, diagnosed Evans as suffering from chronic anxiety and treated Evans for that emotional condition. (Tr. 2292-2345.) A state agency expert also acknowledged that Evans suffered from affective disorders, although the state agency expert, who had never seen or treated Evans, characterized these emotional impairments as non-severe. (Tr. 104.) Furthermore, Evans described these emotional impairments in terms that were entirely consistent with her treating doctor's opinion and treatment records, stating that “I just can't sleep at night due to pain, anxiety, panic attacks, [and] depression.” (Tr. 249.)

         Having apparently made this Step 2 determination based, in part, upon a misunderstanding of the factual record concerning Evans' emotional impairments, at Step 3 the ALJ determined that none of Evans' impairments met or medically equaled the severity of one of the listed impairments. (Tr. 40.)

         Between Steps 3 and 4, the ALJ then fashioned a residual functional capacity (“RFC”) for Evans which found that she could perform both sedentary and light work. (Tr. 40.) This RFC required Evans to be able to lift far more than the 5 pound lifting restriction imposed by at least four medical sources since “[s]edentary work involves lifting no more than 10 pounds at a time” and “[l]ight work involves lifting no more than 20 pounds at a time.” 20 C.F.R. § 404.1567(a) and (b). However, in reaching the judgment that Evans could lift between 10 and 20 pounds, the ALJ never mentioned Dr. Cooper's January 2013 opinion which restricted her to lifting 5 pounds with her right arm. The ALJ then alluded to Dr. Sexton's medical opinion, but omitted any reference to the five pound lifting restrictions set forth in that opinion. (Tr. 42.) The ALJ further mentioned the August 2014 Functional Capacity Evaluation performed on Evans, but treated this evaluation in a curious and enigmatic fashion, giving this evaluation what the ALJ described as “some weight” without noting or taking into account the 7 pound lifting restriction which the report imposed on Evans. (Tr. 42.) Indeed, the only reference to any 5 pound lifting restriction by the ALJ was a fleeting, dismissive observation when the ALJ rejected the medical opinion of Dr. Hawk that Evans was limited to lifting five pounds with her right arm. While the ALJ rejected Dr. Hawk's opinion based upon the ALJ's perception of Evans' activities of daily living, and what the ALJ ...


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