United States District Court, N.D. Alabama, Western Division
PATTY A. CLARK, Plaintiff.
CAROLYN COLVIN, COMMISSIONER, SOCIAL SECURITY ADMINISTRATION, Defendant.
HARWELL G. DAVIS, III, Magistrate Judge.
In this action under 42 U.S.C. §§ 405(g) and 1383(c)(3), plaintiff seeks judicial review of an adverse social security ruling which denied claims for disability insurance benefits (DIB) and Supplemental Security Income (SSI). (Doc.1). The parties filed written consent and this action has been assigned to the undersigned Magistrate Judge to conduct all proceedings and order the entry of judgment in accordance with 28 U.S.C. § 636(c) and Fed.R.Civ.P. 73. (Doc. 9). Upon consideration of the administrative record and the memoranda of the parties, the court finds that the decision of the Commissioner is due to be vacated and this action remanded for further action consistent with this opinion.
I. Proceedings Below
Plaintiff, Patty A. Clark, filed an application for disability insurance benefits under Title II of the Social Security Act on March 29, 2011 (Tr. 97), and an application for Supplemental Security Income benefits under Title XVI of the Social Security Act on March 29, 2011. ( Id. ). These applications were initially denied, and plaintiff requested a hearing before an Administrative Law Judge (ALJ) on June 1, 2011. (Tr. 103, 113-16). Hearings were held in this matter on July 13, 2012 (Tr. 74-95), October 10, 2012 (Tr. 57-73), and December 7, 2012 (Tr. 36-56).
The ALJ denied disability benefits to plaintiff on January 12, 2013, concluding that plaintiff did not have an impairment or a combination of impairments listed in, or medically equal to one listed in, the Regulations. (Tr. 23-24). The ALJ found that plaintiff retained the residual functional capacity (RFC) to perform sedentary work and that there were jobs in the national and local economies that were available for her. (Tr. 24-30). The Appeals Council declined to grant review of this decision on June 25, 2013. (Tr. 1-5). The Commissioner's decision is ripe for review under 42 U.S.C. §§ 405(g) and 1383(c)(3).
II. ALJ Decision
Disability under the Social Security Act is determined under a five-step test. 20 C.F.R. § 404.1520. First, the ALJ must determine whether the claimant is engaging in substantial gainful activity. 20 C.F.R. § 404.1520(a)(4)(i). "Substantial work activity" is work that involves doing significant physical or mental activities. 20 C.F.R. § 404.1572(a). "Gainful work activity" is work that is done for pay or profit. 20 C.F.R. § 404.1520(b). Second, the ALJ must determine whether the claimant has a medically determinable impairment or a combination of medical impairments that significantly limits the claimant's ability to perform basic work activities. 20 C.F.R. § 404.1520(a)(4)(ii). Absent such impairment, the claimant may not claim disability. Id. Third, the ALJ must determine whether the claimant's impairment meets or medically equals the criteria listed in 20 C.F.R. § 404, Subpart P, Appendix 1. See 20 C.F.R. §§ 404.1520(d), 404.1525 and 404.1526. If such criteria are met, the claimant is declared disabled. 20 C.F.R. § 404.1520(a)(4)(iii).
If the claimant does not fulfill the requirements necessary to be declared disabled under the third step, the ALJ may still find disability under the next two steps of the analysis. The ALJ first must determine the claimant's residual functional capacity (RFC), which refers to the claimant's ability to work despite her impairments. 20 C.F.R. § 404.1520(e). In the fourth step, the ALJ determines whether the claimant has the RFC to perform past relevant work. 20 C.F.R. § 404.1520(a)(4)(iv). If the claimant is determined to be capable of performing past relevant work, then the claimant is deemed not disabled. Id. If the ALJ finds that the claimant is unable to perform past relevant work, then the analysis proceeds to the fifth and final step. 20 C.F.R. § 404.1520(a)(4)(v). In the last part of the analysis, the ALJ must determine whether the claimant is able to perform any other work commensurate with her RFC, age, education and work experience. 20 C.F.R. § 404.1520(g). Here, the burden of proof shifts from the claimant to the ALJ to prove the existence in significant numbers of jobs in the national economy that the claimant can do given the RFC, age, education and work experience. 20 C.F.R. §§ 404.1520(g) and 404.1560(c).
With regard to steps one, two and three, the ALJ found that plaintiff has not engaged in gainful activity since May 21, 2010, and that she suffers from the severe impairments of obesity and degenerative disc disease of the lumbar spine, but that she does not have an impairment or combination of impairments that meets or medically equals one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1 (20 C.F.R. §§ 404.1520(d), 404.1525, 404.1526, 416.920(d), 416.925 and 416.926). (Tr. 23). At step four, the ALJ found that plaintiff is unable to perform any past relevant work (20 C.F.R. §§ 404.1565 and 416.965). (Tr. 29).
The ALJ found that plaintiff has the RFC to perform sedentary work as defined in 20 C.F.R. §§ 404.1567(a) and 416.967(a). He found that plaintiff can lift and/or carry up to ten pounds occasionally and less than ten pounds frequently. He further found that she can sit for six hours in an eight-hour workday and stand and/or walk for at least two hours during an eight-hour workday. According to the ALJ, plaintiff can push and/or pull with her upper and lower extremities using the same weight restrictions as shown above for lifting and/or carrying. He states that the evidence shows that she has full range of motion in her neck, shoulders, elbows, wrists, fingers, hips, knees and ankles. Her grip strength is normal bilaterally, as are her sensation and reflexes. (Tr. 24).
At the hearing, plaintiff testified that she was unable to work due to injuries she sustained as a result of slipping in water and falling in October 2008. She testified that she suffers from nerve damage in her back and left leg pain. According to the ALJ, plaintiff testified that, although her physician told her not to lift more than 30 pounds, she could only lift about 15 pounds. She also advised the ALJ that she could only sit for about 30 minutes and stand for approximately 20 minutes. She testified that, although surgical intervention was suggested, she declined due to being advised that the success rate was not high enough to justify the risk. ( Id. ).
The ALJ further noted that, on forms completed prior to the hearing level, plaintiff alleged that she could only lift 30 pounds and sit for approximately 45 minutes to an hour. ( Id. ). Although plaintiff claimed that she injured herself on October 8, 2008, she continued to work until May of 2010. However, the ALJ noted that plaintiff was treated by Dr. Marion Sovic, M.D., on November 24, 2008, when he performed a lumbar steroid injection. ( Id .; see Ex. 5F). Although a large portion of plaintiff's medical records are dated prior to her alleged onset date, the ALJ stated that these records were considered and discussed for historical purposes. (Tr. 24).
For instance, the ALJ noted that, in February of 2009, plaintiff went to a hospital emergency room with complaints of low back pain which she rated as being a "ten out of ten." Her physical examination was unremarkable and she was found to have only subjective complaints of back pain with radiculopathy. (Tr. 24, citing Ex. 2F).
In March 2009, the ALJ noted that Dr. Thomas Powell, M.D., evaluated plaintiff. He described her as at "maximum medical improvement." Dr. Powell also noted that plaintiff had recently had a Functional Capacity Examination (FCE), but that this examination was invalid due to the plaintiff's "self-limiting behavior." Just what it was about plaintiff's behavior that was "self-limiting" is not stated.
The ALJ stated that Dr. Powell noted that an x-ray showed only mild degenerative disc disease, but with well-maintained disc spaces. He later performed a myleogram CT scan that showed a moderate disc bulge with a mild neural foraminal stenosis at L4-L5 and minimal facet arthropathy with minimal stenosis at L5-S1. (Tr. 25, citing Ex. 1F). She was referred to Dr. Martin Jones, M.D., for further evaluation.
Dr. Jones examined plaintiff on March 30, 2009. She reported bilateral leg pain. Physical examination showed tenderness with deep palpitation of her lumbar spine and a slightly decreased range of motion. He recommended that plaintiff work half days at light duty for the next several weeks and then return to full-time, light-duty work. (Tr. 25). When plaintiff returned for re-evaluation on April 13, 2009, Dr. Jones indicated that she had reached maximum medical improvement and that she ...