Opinion
CIVIL ACTION NO. 3:18-CV-01401
08-12-2019
MICHAEL E. HOLMES, Plaintiff v. ANDREW SAUL, Defendant
(MARIANI, J.)
() REPORT AND RECOMMENDATION
This is an action brought under Section 1383(c) of the Social Security Act and 42 U.S.C. § 405(g), seeking judicial review of the final decision of the Commissioner of Social Security (hereinafter, "the Commissioner") denying Plaintiff Michael Holmes's claims for a period of disability and disability insurance benefits ("DIB") under Title II of the Social Security Act. (Doc. 1). The matter has been referred to the undersigned United States Magistrate Judge to prepare a report and recommendation pursuant to the provisions of 28 U.S.C. § 636(b) and Rule 72(b) of the Federal Rules of Civil Procedure. For the reasons expressed herein, and upon detailed consideration of the arguments raised by the parties in their respective briefs, it is respectfully recommended that the Commissioner's decision be VACATED and REMANDED. I. BACKGROUND AND PROCEDURAL HISTORY
On April 10, 2015, Plaintiff Michael Holmes ("Holmes") filed applications for Title II benefits. (Doc. 8-7, at 2). In this application, Holmes claimed disability beginning August 2, 2013. (Doc. 8-7, at 2). However, during testimony, Holmes amended his onset date to September 30, 2015. (Doc. 8-4, at 37). The Social Security Administration initially denied Holmes's claims on October 09, 2015. (Doc. 8-6, at 4). Holmes filed a request for a hearing before an Administrative Law Judge ("ALJ") on October 26, 2015. (Doc. 8-6, at 9). The hearing was held on May 9, 2017 before ALJ Lawrence Neary. (Doc. 8-4, 34-61).
In a written opinion dated September 8, 2017 the ALJ determined that Holmes was not disabled and therefore not entitled to the benefits sought. (Doc. 8-4, at 29). Holmes appealed the decision of the ALJ to the Appeals Council, who, on June 12, 2018 denied Holmes's request for review. (Doc. 8-2, at 2). On July 16, 2018, Holmes filed the instant action. (Doc. 1). The Commissioner responded on September 28, 2018, providing the requisite transcripts from the disability proceedings. (Doc. 7; Doc. 8). The parties then filed their respective briefs, with Holmes alleging three errors warranted reversal or remand. (Doc. 10; Doc. 13; Doc. 15). II. THE ALJ'S DECISION
In a decision dated September 8, 2017, the ALJ determined Holmes "has not been under a disability, as defined in the Social Security Act, from September 30, 2015, through December 31, 2016, the date last insured." (Doc. 8-4, at 28). The ALJ reached this conclusion after proceeding through the five-step sequential analysis required by the Social Security Act. See 20 C.F.R. § 404.1520. The ALJ determined that Holmes met the insured status requirements of the Social Security Act through December 31, 2016. (Doc. 8-4, at 13).
At step one, an ALJ must determine whether the claimant is engaging in substantial gainful activity ("SGA"). 20 C.F.R § 404.1520(a)(4)(i). If a claimant is engaging in SGA, the Regulations deem them not disabled, regardless of age, education, or work experience. 20 C.F.R. § 404.1520(b). SGA is defined as work activity—requiring significant physical or mental activity—resulting in pay or profit. 20 C.F.R. § 404.1572. In making this determination, the ALJ must consider only the earnings of the claimant. 20 C.F.R. § 404.1574. The ALJ determined Holmes "has not engaged in [SGA] during the period from his amended alleged onset date of September 30, 2015 through his date last insured of December 31, 2016." (Doc. 8-4, at 13). Thus, the ALJ's analysis proceeded to step two.
At step two, the ALJ must determine whether the claimant has a medically determinable impairment that is severe or a combination of impairments that are severe. 20 C.F.R. § 404.1520(a)(ii). If the ALJ determines that a claimant does not have an "impairment or combination of impairments which significantly limits [their] physical or mental ability to do basic work activities, [the ALJ] will find that [the claimant] does not have a severe impairment and [is], therefore not disabled." 20 C.F.R. § 404.1520(c). If a claimant establishes a severe impairment or combination of impairments, the analysis continues to the third step. Here, the ALJ found that the medical evidence of record established the presence of the following medically determinable sever impairments:
[D]egenerative disc disease of the cervical spine with radiculopathy status post anterior cervical discectomy and fusion, degenerative disc disease of the thoracolumbar spine, fibromyalgia, obesity, mood disorder not otherwise specified, anxiety disorder not otherwise specified, personality disorder not otherwise specified and substance abuse.
(Doc. 8-4, at 13)
The ALJ also noted non-severe impairments of left hand mild carpal tunnel syndrome and diabetes. (Doc. 8-4, at 14).
At step three, the ALJ must determine whether the severe impairment or combination of impairments meets or equals the medical equivalent of an impairment listed in 20 C.F.R. Part 404, Subpt. P, App. 1 (20 C.F.R. §§ 404.1520(d); 404.1525; 404.1526). If the ALJ determines that the claimant's impairments meet these listings, then the claimant is considered disabled. 20 C.F.R. § 404.1520(a)(4)(iii). The ALJ determined that none of Holmes's impairments, considered individually or in combination, met or equaled a Listing. (Doc. 8-4, at 14-16). Specifically, the ALJ considered Listings 1.04 (disorders of the spine); 14.09 (fibromyalgia); 12.04, 12.06 and 12.08 (mental disorders). (Doc. 8-4, at 14-16).
Between steps three and four, the ALJ determines the claimant's residual functional capacity ("RFC"), crafted upon consideration of the medical evidence provided. Holmes alleged that his impairments caused the following symptoms: neck, shoulder, back, and right side pain that travels from his head to his spine with daily left arm numbness. (Doc. 8-4, at 17). After examining his statements and the medical evidence, the ALJ found that Holmes's impairments could reasonably be expected to cause the alleged symptoms, but that his statements about the intensity, persistence, and the limiting effects of the symptoms were not entirely consistent with the evidence, including the medical evidence, of record. (Doc. 8-4, at 17-18). The ALJ then went on to detail Holmes's medical records and treatment history. (Doc. 8-4, at 18-27). In doing so, the ALJ considered and weighed medical opinions by the following sources: non-treating psychiatrist Michael Caiazzo, Psy.D. ("Dr. Caiazzo"); non-treating physician Spencer Long, M.D. ("Dr. Long"); and non-examining state agency psychological consultant John Gavazzi, Psy.D ("Dr. Gavazzi"). (Doc. 8-4, at 25-26). The ALJ also considered the opinion of Lisa Newton-Holmes, Holmes's wife, who indicated on July 21, 2015 that Holmes's conditions limited his ability to work. (Doc. 8-4, at 26).
A non-treating source is defined by the Social Security Regulations as any physician, psychologist, or other acceptable medical source that examined the claimant, but does not have any ongoing or past treatment relationship with him or her. 20 C.F.R. § 404.1502 (effective June 13, 2011 to Mar. 26, 2017). This term includes an acceptable medical source who is a consultative examiner for the Social Security Administration, when that consultative examiner is not a claimant's treating source. 20 C.F.R. § 404.1502 (effective June 13, 2011 to Mar. 26, 2017).
A non-examining source is defined by the Social Security Regulations as a physician, psychologist, or other acceptable medical source that has not examined the claimant, but provides a medical or other opinion in the case. At the ALJ hearing and Appeals Council levels of the administrative review process, it includes State agency medical and psychological consultants, other program physicians and psychologists, and medical experts or psychological experts consulted by the Social Security Administration. 20 C.F.R. § 404.1502 (effective June 13, 2011 to Mar. 26, 2017).
Based on his consideration of the above referenced medical opinions and of the other relevant evidence of record, the ALJ assessed that, during the relevant period, Holmes:
. . . had the [RFC] to perform light work . . . except that he never was capable of lifting more than twenty-five (25) pounds. The claimant retained the mental capacity to perform simple, routine tasks with only occasional changes in the work setting and to tolerate occasional interaction with the public and supervisors.
(Doc. 8-4, at 16-17).
Having assessed a claimant's RFC, at step four the ALJ must determine whether the claimant has the RFC to perform the requirements of their past relevant work. 20 C.F.R. § 404.1520(a)(4)(iv). A finding that the claimant can still perform past relevant work requires a determination that the claimant is not disabled. 20 C.F.R. § 404.1520(a)(4)(iv). Past relevant work is defined as work the claimant has done within the past 15 years, that was substantial gainful activity, and that lasted long enough for the claimant to learn how to do it. 20 C.F.R. § 404.1560(b). If the claimant cannot perform past relevant work or has no past relevant work, then the analysis proceeds to the fifth step.
The ALJ determined through the date last insured, Holmes was unable to perform his past relevant work. (Doc. 8-4, at 27). The ALJ noted Holmes's past relevant work as a fast food worker, an industrial truck operator, a laborer, a material handler, and taxi driver, but the exertional requirements of each exceeded Holmes's RFC. (Doc. 8-4, at 27).
At step five of the sequential analysis process, an ALJ considers the claimant's age, education, and work experience to see if a claimant can make the adjustment to other work. 20 C.F.R. § 404.1520(a)(4)(v). These factors are not considered when evaluating a claimant's ability to perform past relevant work. 20 C.F.R. § 404.1560(b)(3). If a claimant has the ability to make an adjustment to other work, they will not be considered disabled. 20 C.F.R. § 404.1520(a)(4)(v).
The ALJ made vocational determinations that Holmes was 51 years old on the date last insured, defined as a an individual closely approaching advanced age by the Regulations. 20 C.F.R. § 404.1563. (Doc. 8-4, at 27). The ALJ also noted that Holmes "has at least a high school education and is able to communicate in English" as considered in 20 C.F.R. § 404.1564. (Doc. 8-4, at 27). The ALJ determined that upon consideration of these factors, Holmes's RFC, and the testimony of a vocational expert, "there were jobs that existed in significant numbers in the national economy that the claimant could have performed." (Doc. 8- 4, at 27). The ALJ specifically identified occupations of bindery machine offbearer, bakery racker, and egg candler. (Doc. 8-4, at 28).
As a result of this analysis, the ALJ determined that Holmes was not disabled and denied Holmes's applications for benefits. (Doc. 8-4, at 29). III. STANDARD OF REVIEW
In order to receive benefits under Title II or Title XVI of the Social Security Act, a claimant must demonstrate an "inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A). To satisfy this requirement, a claimant must have a severe physical or mental impairment that makes it impossible to do his or her previous work or any other substantial gainful activity that exists in significant numbers in the national economy. 42 U.S.C. § 423(d)(2)(A); 20 C.F.R. § 404.1505(a). Additionally, to be eligible to receive benefits under Title II of the Social Security Act, a claimant must be insured for disability insurance benefits. 42 U.S.C. § 423(a); 20 C.F.R. § 404.131.
In his first contention of error, Holmes claims that the ALJ improperly discounted his testimony and overlooked various records that show he met the requirements for Listings 1.04 and 12.04. (Doc. 10, at 4-7). As such, Holmes seemingly conflates the allegedly erroneous RFC assessment with an erroneous step three finding. Insofar as Holmes challenges the ALJ's conclusions at step three, however, the Court addresses this as a separate contention of error.
In evaluating whether a claimant is disabled as defined in the Social Security Act, the Commissioner follows a five-step sequential evaluation process. 20 C.F.R. § 404.1520(a). Under this process, the Commissioner must determine, in sequence: (1) whether the claimant is engaged in substantial gainful activity; (2) whether the claimant has a severe impairment; (3) whether the claimant's impairment meets or equals a listed impairment; (4) whether the claimant is able to do past relevant work, considering his or her residual functional capacity ("RFC"); and (5) whether the claimant is able to do any other work that exists in significant numbers in the national economy, considering his or her RFC, age, education, and work experience. 20 C.F.R. § 404.1520(a). The claimant bears the initial burden of demonstrating a medically determinable impairment that prevents him or her from doing past relevant work. 20 C.F.R. § 404.1512(a). Once the claimant has established at step four that he or she cannot do past relevant work, the burden then shifts to the Commissioner at step five to show that jobs exist in significant numbers in the national economy that the claimant could perform that are consistent with his or her RFC, age, education, and past work experience. 20 C.F.R. § 404.1512(f).
In reviewing the Commissioner's final decision denying a claimant's application for benefits, the Court's review is limited to determining whether the findings of the final decision-maker are supported by substantial evidence in the record. See 42 U.S.C. § 1383(c)(3) (incorporating 42 U.S.C. § 405(g) by reference); Johnson v. Comm'r of Soc. Sec., 529 F.3d 198, 200 (3d Cir. 2008); Ficca v. Astrue, 901 F. Supp. 2d 533, 536 (M.D. Pa. 2012). Substantial evidence "does not mean a large or considerable amount of evidence, but rather such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Pierce v. Underwood, 487 U.S. 552, 565 (1988) (internal quotations omitted). Substantial evidence is less than a preponderance of the evidence but more than a mere scintilla. Richardson v. Perales, 402 U.S. 389, 401 (1971). A single piece of evidence is not substantial evidence if the ALJ ignores countervailing evidence or fails to resolve a conflict created by the evidence. Mason v. Shalala, 994 F.2d 1058, 1064 (3d Cir. 1993). In an adequately developed factual record, however, substantial evidence may be "something less than the weight of the evidence, and the possibility of drawing two inconsistent conclusions from the evidence does not prevent [the ALJ's decision] from being supported by substantial evidence." Consolo v. Fed. Maritime Comm'n, 383 U.S. 607, 620 (1966). "In determining if the Commissioner's decision is supported by substantial evidence the court must scrutinize the record as a whole." Leslie v. Barnhart, 304 F. Supp. 2d 623, 627 (M.D. Pa. 2003). The question before the Court, therefore, is not whether Holmes is disabled, but whether the Commissioner's finding that Holmes is not disabled is supported by substantial evidence and was reached based upon a correct application of the relevant law. See Arnold v. Colvin, No. 3:12-CV-02417, 2014 WL 940205, at *1 (M.D. Pa. Mar. 11, 2014) ("[I]t has been held that an ALJ's errors of law denote a lack of substantial evidence."); Burton v. Schweiker, 512 F. Supp. 913, 914 (W.D. Pa. 1981) ("The [Commissioner]'s determination as to the status of a claim requires the correct application of the law to the facts."); see also Wright v. Sullivan, 900 F.2d 675, 678 (3d Cir. 1990) (noting that the scope of review on legal matters is plenary); Ficca v. Astrue, 901 F. Supp. 2d 533, 536 (M.D. Pa. 2012) ("[T]he court has plenary review of all legal issues decided by the Commissioner."). IV. DISCUSSION
Holmes raises the following arguments on appeal: (1) that the ALJ erroneously found he had the RFC to perform light work; (2) that the ALJ erroneous found he did not meet Listings 1.04 and 12.044; (3) that the ALJ erroneously found he was capable of performing jobs that exist in the national economy; and (4) that the ALJ erred by failing to properly apply the Medical-Vocational Guidelines (the "Grids") at Step Five of the sequential evaluation process. (Doc. 10, at 3-11). In his reply brief, Holmes further contends that the ALJ erred in giving little weight to the medical opinions of Dr. Long, a non-treating physician, and Dr. Caiazzo, a non-treating psychiatrist. (Doc. 14, at 4-7).
For the purposes of the instant Report and Recommendation, that Court addresses this argument within the context of Holmes's challenge to the ALJ's RFC assessment.
A. THE ALJ'S RFC ASSESSMENT IS NOT SUPPORTED BY SUBSTANTIAL EVIDENCE
Notably, in his first contention of error, Holmes appears to conflate the ALJ's RFC assessment with the findings at Step Three. However, in the interest of clarity, the Court will separately address the ALJ's evaluation of medical opinion evidence upon formulating the RFC assessment.
In his first argument on appeal, Holmes asserts that the ALJ erred in finding that he had the RFC to perform light duty work. (Doc. 10, at 3-9). Specifically, Holmes argues that the ALJ failed to consider various medical records that demonstrate his inability to meet the exertional and non-exertional requirements of such work. (Doc. 10, at 4, 8). Further, given the lack of contradicting medical evidence, Holmes contends that the ALJ improperly discounted his hearing testimony regarding the limiting effects of his medically determinable impairments. (Doc. 10, at 4, 8). Holmes also claims that the veracity of his testimony is supported by the opinions of Dr. Long and Dr. Caiazzo, which the ALJ erroneously afforded limited weight. (Doc. 10, at 5-9); (Doc. 15, at 4-8).
In response, the Commissioner submits that the ALJ accounted for all of Holmes's credibly established limitations upon formulating the RFC assessment. (Doc. 13, at 27). The Commissioner further argues that the ALJ properly considered the evidence of record, and appropriately weighed the available medical opinions. (Doc. 13, at 29-33). As such, the Commissioner asserts that the RFC assessment, assigning Holmes to a range of light-duty work, is supported by substantial evidence. (Doc. 13, at 35).
Assessing an individual's RFC falls within the purview of the ALJ. 20 C.F.R. § 404.1546(c); SSR 96-8P, 1996 WL 374184 (S.S.A. July 2, 1996). "[RFC] is defined as that which an individual is still able to do despite the limitations caused by his or her impairment(s).'" Burnett v. Comm'r of Soc. Sec., 220 F.3d 112, 121 (3d Cir. 2000) (quoting Hartranft v. Apfel, 181 F.3d 358, 359 n. 1 (3d Cir. 1999)). Specifically, one's RFC reflects the most that an individual can still do, despite his or her limitations, and is used at steps four and five to evaluative the claimant's case. 20 C.F.R. §§ 404.1520, 404.1545; SSR 96-8P, 1996 WL 374184 at *2. "[O]nce the ALJ has made this [RFC] determination, [a court's] review of the ALJ's assessment of the plaintiff's RFC is deferential, and that RFC assessment will not be set aside if it is supported by substantial evidence." Black v. Berryhill, No. 16-1768, 2018 WL 4189661 at *3 (M.D. Pa. Apr. 13, 2018).
When determining an individual's RFC, the ALJ must consider all the evidence of the record and, regardless of its source, "evaluate every medical opinion . . . receive[d]." Burnett v. Comm'r of Soc. Sec. Admin., 220 F.3d 112, 121 (3d Cir. 2000) (citations omitted; 20. C.F.R §§ 404.1527(c), 404.1545(a)(3); see also SSR 96-8P, 1996 WL 374182 at *2 ("RFC is assessed by adjudicators at each level of the administrative review process based on all of the relevant evidence in the case record, including information about the individual's symptoms and any 'medical source statements' . . . "). Under the regulations, medical opinions are defined as "statements from physicians and psychologists or other acceptable medical sources that reflect judgments about the nature and severity of your impairment(s), including your symptoms, diagnosis and prognosis, what you can still do despite impairment(s), and your physical or mental restrictions." 20 C.F.R. § 404.1527(a)(1). When a conflict exists in the evidence, however, "the ALJ may choose whom to credit but 'cannot reject evidence for no reason or the wrong reason.'" Plummer v. Apfel, 186 F.3d 422, 429 (3d Cir. 1999) (quoting Mason v. Shalala, 994 F.2d 1058, 1066 (3d Cir. 1993)); see also Morales v. Apfel, 225 F.3d 310, 317 (3d Cir. 2000). It is the duty of the ALJ to explain the rationale for the weight afforded to each medical opinion, as this allows for meaningful judicial review. Plummer v. Apfel, 186 F.3d 422, 429 (3d Cir. 1999).
As mentioned supra, the ALJ determined that Holmes could perform light work, except that he could never lift more than twenty-five (25) pounds. (Doc. 804, at 17). Under the Regulations, the ability to perform light work "involves lifting no more than 20 pounds at a time with frequent lifting or carrying of objects weighing up to 10 pounds." 20 C.F.R. § 404.1567(b). Regarding non-exertional limitations, the ALJ also found that Holmes could perform simple, routine tasks with occasional changes in the work setting, and could tolerate occasional interaction with the public and his supervisors. (Doc. 8-4, at 17).
This finding does not comport with the limitations opined by Dr. Long in his uncontradicted medical source statement. (Doc. 8-10, at 42-55). By contrast, Lisa Morrison, a single decision maker ("SDM"), found that that Holmes could occasionally lift and/or carry 25 pounds, could frequently lift and/or carry 25 pounds, could stand and/or walk and sit for a total of 6 hours in an 8-hour workday, and could push and/or pull (including operation of hand and or foot controls) on an unlimited basis (notwithstanding his limitations in lifting and/or carrying). (Doc. 8-5, at 36). SDMs are non-physician disability examiners who "may make the initial disability determination in most cases without requiring the signature of a medical consultant." Social Security Administration, Notices: 71 FR 45890-01, 2006 WL 2283653. Accordingly, RFC assessments rendered by SDMs are not entitled to any evidentiary weight. Yorkus v. Astrue, No. CIV.A. 10-2197, 2011 WL 7400189, at *4 (E.D. Pa. Feb. 28, 2011).
Here, the ALJ did not expressly cite, let alone assign any weight, to SDM Morrison's RFC assessment. (Doc. 8-4, at 17-27). However, the exertional limitations she noted are consistent with the ALJ ultimate finding that Holmes "never was capable of lifting more than twenty-five (25) pounds." (Doc. 8-4, at 17). No other physician opined that Holmes could never lift more than 25 pounds, and the ALJ did not explain the basis of this exertional limitation. Thus, insofar as the ALJ may have relied upon the opinion of SDM Morrison to evaluate Holmes's RFC, this constituted error. See Rhyder v. Colvin, No. 3:16-CV-00884, 2017 WL 81273, at *6 (M.D. Pa. Jan. 9, 2017).
Holmes argues that the ALJ improperly assessed his RFC and erred in giving the respective opinions of Dr. Long and Dr. Caiazzo little weight. (Doc. 8-10, at 34-41, 42-55); (Doc. 15, at 4-8). As to Dr. Long, who performed a consultative examination on September 23, 2015, he opined that Holmes was never capable of: lifting/carrying up to 10 pounds, or more; reaching; handling; fingering; feeling; pushing/pulling; operating foot controls; climbing stairs and ramps, ladders or scaffolds; stooping; kneeling; crouching; crawling; and being exposed to unprotected heights, moving mechanical parts, operating a motor vehicle, extreme cold, and extreme heat. (Doc. 8-10, at 47-50). Dr. Long also determined that Holmes could: sit for 15 minutes at one time without interruption, and for 45 minutes total in an 8 hour work day; stand for 3 minutes at one time without interruption, and for 10 minutes total in an 8 hour work day; walk for 3 minutes at one time without interruption, and 10 minutes total in an 8 hour work day; occasionally balance and be exposed to dust, odors, fumes and pulmonary irritants; and frequently be exposed to humidity and wetness. (Doc. 8-10, at 47-50). Regarding ambulation, Dr. Long noted that Holmes required a cane to ambulate, that a cane was medically necessary, and that Holmes could ambulate 20 feet without the use of a cane. (Doc. 8-10, at 47). In support of his conclusions, Dr. Long generally identified Holmes's cervical spine fusion, bilateral arm radiculopathy weakness, back pain, bilateral sciatic radiculopathy, fibromyalgia, leg pain, and neck fusion. (Doc. 8-10, at 46-50).
In support of his argument that greater functional limitations should have been factored into the RFC, Holmes also points to Dr. Long's consultative examination notes. (Doc. 10, at 5-6; Doc. 15, at 4-5). Notably, Dr. Long memorialized the following observations:
The Claimant is uncomfortable and moving constantly to try to relieve pain in his back and arms. Gait is severely antalgic. He can only take a few steps without a cane. He leans forward about 45 degrees when he walks. He cannot walk on his heels and toes. He cannot squat. Stance is not normal. He bends forward. He did not use an assistive device during the evaluation. He stated that he left it in the car. He was unable to change. He was unable to get on the exam table. He had difficulty arising from chair.
(Doc. 8-10, at 43).
Dr. Long additionally indicated that Holmes had minimal use of his hands and fingers, which rendered him unable to zip, button, and tie. (Doc. 8-10, at 44). Further, Dr. Long's musculoskeletal exam revealed that Holmes could not perform a straight leg raise "because of pain and immobility," and that fifteen out of eighteen trigger points were positive. (Doc. 8-10, at 44). Ultimately, Dr. Long rated Holmes's prognosis as poor.
Upon evaluating Dr. Long's opinion in the RFC analysis, however, the ALJ afforded it little weight. (Doc. 8-4, at 26). Specifically, the ALJ explained that the opined limitations were "way too extensive" considering the following:
• "[R]epeated imaging of the claimant's cervical and lumbar spines that failed to reveal findings that would account for the significant degree of symptomatology reported by the claimant";
• "[T]he recent EMG study of the claimant's upper extremities showing chronic C8-T1 radiculopathy with no evidence of active denervation";
• "[T]he normal EMG study of the claimant's lower extremities and laboratory work";
• "[T]he notation by a neurosurgical provider in March of 2017 that sees no underlying mechanical explanation for the claimant's symptoms";
• "[T]he many observations that the claimant exhibited exaggerated pain behaviors and exerted questionable effort and cooperation during examinations";
• "[T]he Claimant's response pattern to the pain assessment inventory undertaken as part of the evaluation for placement of a spinal cord stimulator that was suggestive of moderate levels of somatic focus and kinesophobia";
• "[T]he claimant's provision of inconsistent information to providers at times";
• "[N]otes of treatment indicating at some appointments that the claimant's gait was normal";
• "[T]he fact that the claimant did not bring a cane to the consultative examination";
• "[T]he absence of any indication in notes of treatment of any regular can use aside from an appointment of February 12, 2016, when the claimant requested prescription of a cane";
• "[N]otes of treatment indicating on July 1, 2016 that the claimant walked to the corner store and on January 26, 2017 that the claimant walked four (4) blocks away from his home";
• "[T]he absence of any documentation of treatment for injuries sustained in reported frequent falls or blackouts from pain"; and
• "[T]he claimant's election to smoke, to eat junk food, and to overeat."
(Doc. 8-4, at 26).
Based on this "thorough explanation," the Commissioner argues that the ALJ appropriately discounted the opinion of Dr. Long and supported why Holmes retained the capacity to perform "light" duty work. (Doc. 13, at 27-35).
Notably, Dr. Long's medical opinion was the only acceptable medical source statement regarding Holmes's exertional limitations in the record. While the Commissioner submits that the ALJ "clearly considered Dr. Long's examination findings in the course of his decision," he effectively discredited Dr. Long's conclusions upon formulating Holmes's RFC. (Doc. 13, at 35). While it is the ALJ's duty to render an RFC assessment, "rarely can a decision be made regarding a claimant's residual functional capacity without an assessment from a physician regarding the functional abilities of the claimant." Maellaro v. Colvin, No. 3:12-CV-01560, 2014 WL 2770717, at *11 (M.D. Pa. June 18, 2014) (citing Doak v. Heckler, 790 F.2d 26, 29 (3d Cir. 1986) ("No physician suggested that the activity [the claimant] could perform was consistent with the definition of light work set forth in the regulations, and therefore the ALJ's conclusion that he could is not supported by substantial evidence.")). Further, "when an ALJ is saying that a claimant can do more than the medical source opinion states, courts exercise caution and suggest that rarely can an ALJ unilaterally impose an RFC on a claimant that is less restrictive than the residual functional capacity found by the medical professional." Metzger v. Berryhill, No. 3:16-CV-1929, 2017 WL 1483328, at *5 (M.D. Pa. Mar. 29, 2017), report and recommendation adopted sub nom. Metzgar v. Colvin, No. 3:16-CV-1929, 2017 WL 1479426 (M.D. Pa. Apr. 21, 2017).
As mentioned supra, SDM Morrison's RFC findings are not entitled to any evidentiary weight. Thus, Dr. Long's medical source statement is effectively uncontroverted by any other medical opinion. "[A]lthough the Third Circuit has not addressed in a precedential opinion an uncontradicted treating source medical opinion, the Third Circuit has reaffirmed the prohibition of lay reinterpretation of medical evidence even when there is a contradictory medical opinion." Tilton v. Colvin, 184 F. Supp. 3d 135, 143 (M.D. Pa. 2016), (citing Brownawell v. Comm'r of Soc. Sec., 554 F.3d 352 (3d Cir. 2008)). Accordingly, the Court considers whether the reasons for discounting Dr. Long's opinion are supported by substantial evidence.
Here, the ALJ largely relied on imaging of Holmes's cervical and lumbar spine, as well as EMG studies, to discount Dr. Long's evaluations and Holmes's reported symptomatology. (Doc. 8-4, at 23, 25-26). However, these records do not contain any assessment that Holmes can perform the range of light work enumerated by the ALJ in the RFC. Thus, even though the ALJ provided reasons for affording little weight to Dr. Long's medical source statement, he did not cite to any objective evidence that suggested Holmes could meet the exertional requirements of light work or otherwise never lift more than 25 pounds. Simply stated, the ALJ could not disregard Dr. Long's expert opinion in favor of relying on his own medical conclusions to determine Holmes's RFC. See Harris v. Astrue, No. 08-863, 2009 WL 189845, at * 13 (W.D. Pa. Jan. 26, 2009) (finding RFC unsupported by substantial evidence, as "[t]he determination that the [plaintiff's] x-ray report is inconsistent with [the consultative examiner's uncontroverted medical opinion] that plaintiff is limited to sedentary work was founded upon the interpretation of the x-ray report by the ALJ himself.").
As such, the Court finds that the ALJ impermissibly used his own lay opinion "to fill evidentiary gaps in the record" and arrive at his own conclusion, which is unsupported by any medical assessment. See Biller v. Acting Comm'r of Soc. Sec., 962 F. Supp. 2d 761, 779 (W.D. Pa. 2013); see also Doak, 790 F.2d at 29 (finding that an ALJ's conclusion that a claimant could do light work was not supported by substantial evidence because none of the medical records of opinion stated the claimant could do light work); cf. Hrestak-Gumby v. Berryhill, No. 3:16-CV-1113, 2019 WL 1995364, at *10 (M.D. Pa. Jan. 18, 2019), report and recommendation adopted, No. 3:16-CV-1113, 2019 WL 1992127 (M.D. Pa. May 6, 2019) ("[T]he ALJ's RFC assessment is not supported by substantial evidence because the ALJ did not cite to any objective or other evidence in her opinion that suggests Plaintiff is able to sit for six hours per eight-hour workday."). "[T]he decision to afford little to no weight to this opinion, in the absence of any other medical source opinion, created something of an evidentiary void in this case, particularly with respect to making an informed evaluation of [Holmes's] residual functional capacity." See Barnett v. Berryhill, No. 3:18-CV-637, 2018 WL 7550259, at *7 (M.D. Pa. Dec. 10, 2018), report and recommendation adopted, No. 3:18CV637, 2019 WL 1082621 (M.D. Pa. Mar. 7, 2019). Therefore, although a close call, the Court finds that the RFC evaluation is not supported by substantial evidence.
For the aforementioned reasons, it is respectfully recommended that the Commissioner's final decision be VACATED and REMANDED for further review and explanation. V. REMEDY
Because the Court has found a clear basis for remand on these grounds, it declines to address Holmes's remaining arguments set forth in the first contention of error. The Court also declines to consider Holmes's other allegations of error. To the extent that any other error occurred, it may be remedied on remand.
The Court has authority to affirm, modify or reverse the Commissioner's decision "with or without remanding the case for rehearing." 42 U.S.C. § 405(g); Melkonyan v. Sullivan, 501 U.S. 89, 100-01 (1991). However, the Third Circuit has advised that benefits should only be awarded where "the administrative record of the case has been fully developed and when substantial evidence in the record as a whole indicates that the claimant is disabled and entitled to benefits." Morales v. Apfel, 225 F.3d 310, 320 (3d Cir. 2000). See generally Fla. Power & Light Co. v. Lorion, 470 U.S. 729, 744 (1985) ( "[T]he proper course, except in rare circumstances, is to remand to the agency for additional investigation or explanation."). Because the Court concludes the ALJ's RFC determination was based on his lay opinion of the medical records, the undersigned United States Magistrate Judge respectfully recommends that the decision of the Commissioner be VACATED and that the case be REMANDED. VI. RECOMMENDATION
Based on the foregoing, it is recommended that the Commissioner's decision be VACATED, and that the case be REMANDED to the Commissioner to fully develop the record, conduct a new administrative hearing, and appropriately evaluate the evidence pursuant to sentence four of 42 U.S.C. § 405(g). It is further recommended that the Clerk of Court be directed to CLOSE this case.
Dated: August 12, 2019
/s/ _________
KAROLINE MEHALCHICK
United States Magistrate Judge NOTICE
NOTICE IS HEREBY GIVEN that the undersigned has entered the foregoing Report and Recommendation dated August 12, 2019.
Any party may obtain a review of the Report and Recommendation pursuant to Rule 72.3, which provides:
Any party may object to a magistrate judge's proposed findings, recommendations or report addressing a motion or matter described in 28 U.S.C. § 636(b)(1)(B) or making a recommendation for the disposition of a prisoner case or a habeas corpus petition within fourteen (14) days after being served with a copy thereof. Such party shall file with the clerk of court, and serve on the magistrate judge and all parties, written objections which shall specifically identify the portions of the proposed findings, recommendations or report to which objection is made and the basis for such objections. The briefing requirements set forth in Local Rule 72.2 shall apply. A judge shall make a de novo determination of those portions of the report or specified proposed findings or recommendations to which objection is made and may accept, reject, or modify, in whole or in part, the findings or recommendations made by the magistrate judge. The judge, however, need conduct a new hearing only in his or her discretion or where required by law, and may consider the record developed before the magistrate judge, making his or her own determination on the basis of that record. The judge may also receive further evidence, recall witnesses or recommit the matter to the magistrate judge with instructions.
Dated: August 12, 2019
/s/ _________
KAROLINE MEHALCHICK
United States Magistrate Judge