Williams v. Comm'r of Soc. Sec.
Williams v. Comm'r of Soc. Sec.
Opinion of the Court
INTRODUCTION
Represented by counsel, Plaintiff Shelly Joanne Williams ("Plaintiff") brings this action pursuant to Title XVI of the Social Security Act (the "Act"), seeking review of the final decision of the Commissioner of Social Security (the "Commissioner," or "Defendant") denying her application for supplemental security income ("SSI"). (Dkt. 1). This Court has jurisdiction over the matter pursuant to
BACKGROUND
Plaintiff protectively filed her application for SSI on May 1, 2014. (Dkt. 5 at 24, 159).
*414LEGAL STANDARD
I. District Court Review
"In reviewing a final decision of the [Social Security Administration ("SSA") ], this Court is limited to determining whether the SSA's conclusions were supported by substantial evidence in the record and were based on a correct legal standard." Talavera v. Astrue ,
II. Disability Determination
An ALJ follows a five-step sequential evaluation to determine whether a claimant is disabled within the meaning of the Act. See Parker v. City of New York ,
At step three, the ALJ examines whether a claimant's impairment meets or medically equals the criteria of a listed impairment in Appendix 1 of Subpart P of Regulation No. 4 (the "Listings").
The ALJ then proceeds to step four and determines whether the claimant's RFC permits the claimant to perform the requirements of his or her past relevant work.
DISCUSSION
I. The ALJ's Decision
In determining whether Plaintiff was disabled, the ALJ applied the five-step sequential evaluation set forth in
At step two, the ALJ found that Plaintiff suffered from the severe impairments of fibromyalgia with headaches and labyrinthitis, and right shoulder tear post-surgical repair. (Id. at 27). The ALJ further found that Plaintiff's mild respiratory complaints and depression were non-severe. (Id. at 28-30). With respect to Plaintiff's representations that she suffered from right knee pain and left ankle pain, the ALJ concluded that these were not medically determinable impairments. (Id. at 28-29).
At step three, the ALJ found that Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of any Listing. (Id. at 30). The ALJ particularly considered the criteria of Listings 2.07, 11.03, and 1.02B in reaching his conclusion. (Id. at 30-31).
Before proceeding to step four, the ALJ determined that Plaintiff retained the RFC to perform a range of light work as defined in
cannot work in hazardous environments, such as around heights or dangerous machinery; can do frequent but not constant reaching, handling, or fingering with right dominant upper extremity; can accomplish only routine and repetitive tasks, that would no[t] change much from day to day and would not require [Plaintiff] to remember or carry out complex or complicated types of activities; and can tolerate no more than occasional contact with the public either in person or over the phone.
(Id. at 32). At step four, the ALJ found that Plaintiff was unable to perform any past relevant work. (Id. at 34).
At step five, the ALJ relied on the testimony of a vocational expert ("VE") to conclude that, considering Plaintiff's age. education, work experience, and RFC, there were jobs that exist in significant numbers in the national economy that Plaintiff could perform, including the representative occupations of price marker, cafeteria attendant, printed circuit board screener, and toy stuffer. (Id. at 35). Accordingly, the ALJ found that Plaintiff was not disabled as defined in the Act. (Id. at 36).
II. Remand of this Matter for Further Proceedings is Necessary
Plaintiff asks the Court to reverse or, in the alternative, remand this matter to the Commissioner, arguing that (1) the ALJ erred by assessing Plaintiff's RFC without any opinion evidence, and (2) the ALJ did not properly evaluate Plaintiff's credibility. (Dkt. 6-1 at 1). For the reasons set forth below, the Court finds that the ALJ erred in failing to obtain any opinion evidence from an acceptable medical source, and decided the RFC based on his own interpretation of the medical record. This error necessitates remand for further administrative proceedings.
A. The RFC Finding is Unsupported by Substantial Evidence
In deciding a disability claim, an ALJ is tasked with "weigh[ing] all of the *416evidence available to make an RFC finding that [is] consistent with the record as a whole." Matta v. Astrue ,
An ALJ is prohibited from 'playing doctor' in the sense that 'an ALJ may not substitute his own judgment for competent medical opinion.... This rule is most often employed in the context of the RFC determination when the claimant argues either that the RFC is not supported by substantial evidence or that the ALJ has erred by failing to develop the record with a medical opinion on the RFC.
Quinto v. Berryhill , No. 3:17-cv-00024 (JCH),
Plaintiff contends that the ALJ assessed her RFC in the absence of any opinion evidence. Other than the evaluation by the state agency psychological consultant, M. Totin, there is no opinion evidence in the record. (See Dkt. 5 at 34). The Court notes that M. Totin opined that while Plaintiff had medically determinable impairments, the claim should be denied for "insufficient evidence." (Id. at 162-63). Due to the lack of evidence, M. Totin did not offer an opinion as to any of Plaintiff's functional limitations. (Id. at 164). In the written determination, the ALJ noted that "as for opinion evidence, findings of fact made by state agency medical professionals regarding the nature and severity of an individual's impairments are granted probative weight as expert opinion evidence by a non-examining source." (Id. at 34).
While it is correct that "[a]n ALJ may rely on a non-examining state agency consultant's opinion when it is supported by other record evidence," see Kelley S. v. Comm'r of Soc. Sec. , No. 5:17-CV-1234 (ATB),
Defendant argues that the ALJ was not required to assess Plaintiff's RFC using medical opinion evidence. (Dkt. 10-1 at 20). In support of this argument, Plaintiff cites to Monroe v. Colvin ,
This case does not present the situation contemplated by Monroe , where the ALJ rejected the physician's medical assessment, but relied on the underlying treatment notes, which provided contemporaneous medical assessments relevant to the plaintiff's ability to perform sustained gainful activity. Here, the ALJ did not merely disagree with a medical assessment; rather, no acceptable medical source provided an opinion regarding Plaintiff's RFC, and there are no underlying documents supporting any such evaluation. See Pellam v. Astrue ,
The Court agrees with Plaintiff that the ALJ in this case erred in assessing Plaintiff's RFC in the absence of any medical opinion. "While in some circumstances, an ALJ may make an RFC finding without treating source opinion evidence, the RFC assessment will be sufficient only when the record is 'clear' and contains 'some useful assessment of the claimant's limitations from a medical source.' " Muhammad v. Colvin , No. 6:16-cv-06369(MAT),
There is some evidence in the record that is arguably relevant to Plaintiff's functional limitations. For example, an April 2012 treatment note from Ellis Gomez, M.D., Plaintiff's primary care physician, noted that Plaintiff "cannot lift, pull, push or carry. She cannot lift her arm above her head." (Id. at 311). Further, in May 2013, a physical examination by Dr. Gomez revealed that Plaintiff was unable to lift her right arm above shoulder level. (Id. at 318). The ALJ did not address these statements in the written determination. This evidence is favorable to Plaintiff and contrary to the assessed RFC, which requires Plaintiff to perform frequent reaching, handling, or fingering with her right dominant upper extremity. In other words, the record does not contain information relevant to Plaintiff's functional limitations sufficient to support the RFC finding.
Defendant contends that "[d]epending on the circumstances, such as where the evidence shows relatively minor impairments," an ALJ may assess the RFC without a medical assessment. (Dkt. 10-1 at 22). Defendant does not identify any specific evidence evincing that Plaintiff's severe impairments were "minor." The Court is cognizant that "when the medical evidence shows only minor physical *418impairments," an ALJ may assess the RFC using "common sense judgment about functional capacity even without a physician's assessment." Jaeger-Feathers v. Berryhill , No. 1:17-CV-06350(JJM),
Defendant further contends that "[i]f Plaintiff wished to obtain and submit an opinion from a treating or examining source to support her claim that her medical impairments prevented her from working, she could have done so - but she did not." (Dkt. 10-1 at 21). However, Plaintiff is not solely responsible for developing the record. It is well-established that an ALJ "has an affirmative obligation to develop the administrative record." Perez v. Chater ,
In sum, the ALJ concluded that Plaintiff had multiple severe impairments, including fibromyalgia with headaches and labyrinthitis, and right shoulder tear post-surgical repair. (Id. at 27). Despite these impairments, the ALJ assessed an RFC without the benefit of any opinion evidence as to Plaintiff's functional limitations. This was error. On remand, the ALJ should work to further develop the record to obtain medical opinion evidence addressing Plaintiff's functional limitations.
B. Plaintiff's Remaining Argument
As set forth above, Plaintiff has identified an additional reason why she contends *419the ALJ's decision was not supported by substantial evidence. However, because the Court has already determined, for the reasons previously discussed, that remand of this matter for further administrative proceedings is necessary, the Court declines to reach this issue. See, e.g., Bell v. Colvin , No. 5:15-CV-01160 (LEK),
CONCLUSION
For the foregoing reasons, Plaintiff's motion for judgment on the pleadings (Dkt. 6) is granted to the extent that the matter is remanded for further administrative proceedings. Defendant's motion for judgment on the pleadings (Dkt. 10) is denied. The Clerk of Court is directed to enter judgment and close this case.
SO ORDERED.
When referencing the page number(s) of docket citations in this Decision and Order, the Court will cite to the CM/ECF-generated page numbers that appear in the upper righthand corner of each document.
Reference
- Full Case Name
- Shelley Joanne WILLIAMS v. COMMISSIONER OF SOCIAL SECURITY
- Cited By
- 22 cases
- Status
- Published