Will O/B/O C.M.K. v. Comm'r of Soc. Sec.
Will O/B/O C.M.K. v. Comm'r of Soc. Sec.
Opinion of the Court
INTRODUCTION
Represented by counsel, Plaintiff Carley Will ("Plaintiff") brings this action on behalf of C.M.K., a minor child, 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
On April 23, 2014, Plaintiff protectively filed an application for SSI on behalf of C.M.K., a child under the age of 18. (Dkt. 5 at 18, 59).
LEGAL 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
To qualify as disabled under the Act, a child under the age of eighteen must have "a medically determinable physical or mental impairment, which results in marked and severe functional limitations, and 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. § 1382c(a)(3)(C)(i). An ALJ follows a three-step sequential evaluation to determine whether a child is entitled to SSI benefits. Encarnacion ex rel. George v. Astrue ,
*423"First, the child must not be engaged in 'substantial gainful activity.' Second, the child 'must have a medically determinable impairment(s)' that is 'severe' in that it causes 'more than minimal functional limitations.' Third, the child's impairment or combination of impairments must medically or functionally equal an impairment listed in an appendix to the regulations."
The limitations caused by a child's severe impairment are evaluated pursuant to six domains of functioning: (1) acquiring and using information; (2) attending and completing tasks; (3) interacting and relating with others; (4) moving about and manipulating objects; (5) caring for yourself, and (6) health and physical well-being. See
DISCUSSION
I. The ALJ's Decision
In determining whether C.M.K. was disabled, the ALJ applied the three-step sequential evaluation set forth in
At step two, the ALJ found that C.M.K. suffered from the severe impairment of ADHD (attention deficit hyperactivity disorder ). (Id. ).
At step three, the ALJ found that C.M.K. did not have an impairment or combination of impairments that met or medically equaled the severity of any Listing. (Id. ). The ALJ particularly considered the criteria of Listing 112.11, for ADHD. (Id. ). Similarly, the ALJ found that C.M.K. did not have an impairment or combination of impairments that functionally equaled the severity of the Listings. (Id. ). In making this determination, the ALJ considered C.M.K.'s functioning in each of the above-mentioned six domains and concluded that C.M.K. had no limitation in moving about and manipulating objects, caring for himself, and health and physical well-being, and less than a marked limitation in acquiring and using information, attending and completing tasks, and interacting and relating with others. (Id. at 27-35). Accordingly, the ALJ found that C.M.K. was not disabled as defined in the Act. (Id. at 35).
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 failed to obtain missing records, and made his determination based on an incomplete record, and (2) the ALJ misstated evidence in the record, and substituted his own judgment for that of the consultative examiner and CM.K.'s nurse practitioner, Danielle Ross ("NP Ross"). (Dkt. 6-1 at 13-28). For the reasons set forth below, the Court finds that the ALJ failed to develop the record, and this error necessitates remand *424for further administrative proceedings.
A. Failure to Develop the Record
"Because a hearing on disability benefits is a non-adversarial proceeding, the ALJ generally has an affirmative obligation to develop the administrative record." Perez v. Chater ,
In the written determination, the ALJ found that C.M.K. had the severe impairment of ADHD. (Dkt. 5 at 21). The written determination also discusses C.M.K.'s treatment for ADHD, which included counseling at the Chautauqua Center from 2015 through 2016. (Id. at 24-25). A review of the treatment notes from Chautauqua Center reveal that prior to receiving treatment there, C.M.K. went to counseling at "CCMH," or Chautauqua County Mental Hygiene. (See, e.g., id. at 278, 280). The ALJ acknowledged in the written determination that C.M.K. had seen "providers at [CCMH] for counseling and Dr. Galecki for psychotropic medication management." (Id. at 23).
The issue of C.M.K.'s treatment at CCMH was also raised at the administrative hearing. Plaintiff's attorney, Kelly E. Laga, informed the ALJ that C.M.K. was currently in counseling at the Chautauqua Center and had been transferred to that facility from CCMH. (Id. at 42). While Ms. Laga was able to obtain C.M.K.'s counseling notes from the Chautauqua Center, those records did not contain C.M.K.'s prior counseling notes from CCMH. (Id. ). Ms. Laga requested additional time to locate C.M.K.'s counseling notes from CCMH. (Id. at 42, 57). At the end of the hearing, the ALJ stated that he would "wait until ... [he received] those documents." (Id. at 57).
On December 15, 2016, Ms. Laga submitted a letter to the ALJ. (Dkt. 6-3 at 1). This letter is attached to Plaintiff's motion papers. The letter informed the ALJ that Ms. Laga unsuccessfully attempted to collect the missing records on September 27, 2016 and October 19, 2016, and followed up on her requests on October *42528, 2016, November 15, 2016, and November 29, 2016. (Id. ). The Chautauqua Center did not return Ms. Laga's voicemails and she had not received the records. (Id. ). Ms. Laga requested that the ALJ issue a subpoena to secure the records, and attached information pertaining to the providers and dates of records sought by the subpoena, which included medical records dating back to January 2014. (Id. at 1-3). Although Ms. Laga's December 15, 2016 letter is not a part of the administrative transcript, the letter is accompanied by a sworn affidavit stating that the letter was submitted to both the ALJ and Defendant. (See Dkt. 6-2). There is no evidence that the ALJ either considered or responded to Ms. Laga's request for a subpoena.
Defendant does not contest the validity of the December 15, 2016 letter, the information contained within it, or the fact that Ms. Laga submitted this request to the ALJ. Rather, Defendant argues that an ALJ is not required to subpoena records if it is not necessary. (See Dkt. 9-1 at 12). Defendant argues that because the record upon which the ALJ based his determination was sufficient and showed that C.M.K. needed only minor accommodations, the ALJ was not required to subpoena the missing records. (Id. at 13-16). Defendant also contends that the agency sent C.M.K. to consultative examinations to resolve any deficiencies in the record. (Id. at 14-15). Defendant further notes that Plaintiff's request that the ALJ issue a subpoena was untimely, as she did not submit her request five days before the hearing date. (Id. at 12). The Court disagrees that the missing records were not necessary, and finds that Plaintiff's failure to request a subpoena before the hearing date, or the fact that the agency sent C.M.K. for consultative examinations, does not relieve the ALJ of his duty to develop the record in this instance.
As explained above, "[t]he ALJ must 'make every reasonable effort' to help the claimant get medical reports from his or her medical sources as long as the claimant has permitted the ALJ to do so." Sotososa ,
Plaintiff's December 15, 2016 request for a subpoena was made well in advance of the issuance of the written determination on February 9, 2017. The ALJ should have, at the very least, attempted to secure these records from CCMH to ensure that the record was complete before rendering his decision. See Harris v. Berryhill ,
The necessity of the missing records becomes apparent upon consideration of the written determination, particularly with regard to the weighing of opinion evidence from NP Ross, who treated C.M.K. at the Chautauqua Center. (Id. at 56, 278-81). On September 26, 2015, NP Ross completed a medical statement regarding ADHD for a child's social security disability claim. (Id. at 271-73). NP Ross found that C.M.K. exhibited the following behaviors: often fails to pay close attention to details; has difficulty sustaining attention in work and play; does not seem to listen when spoken to directly; often does not follow through on instructions and fails to finish tasks; often has difficulty organizing tasks and activities; often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort; often loses things; is easily distracted by extraneous stimuli; and is often forgetful. (Id. at 271). C.M.K. suffered from moderate inattention, and mild impulsiveness and hyperactivity. (Id. ). Further, C.M.K. had marked limitations in the following categories: age-appropriate cognitive/communicative function; age-appropriate social functioning; age-appropriate personal functioning; and difficulties in maintaining concentration, persistence, or pace. (Id. at 271-72).
Regarding C.M.K.'s general limitations caused by his ADHD, NP Ross opined that C.M.K. had marked limitations in the following categories: social functioning (a child's capacity to form and maintain relationships with parents, other adults, and peers; includes the ability to get along with others); personal functioning self-care, which includes personal needs, health, and safety; deficiencies in concentration, persistence, or pace resulting in frequent failure to complete tasks in a timely manner; attending and completing tasks (ability to focus and maintain attention and to begin, carry through, and finish activities); interacting and relating with others (ability to initiate and sustain emotional connection with others, develop and use language, cooperate with others, comply with rules, respond to criticism, and respect and take care of the possessions of others); and caring for self (ability to maintain a healthy emotional state, including ability to get emotional wants and needs met in appropriate ways, how patient copes with stress and changes in environment, and whether patient can take care of own health, possessions, and living area). ( *427Id. at 272-73). NP Ross found that C.M.K. had mild limitations for acquiring and using information (ability to learn and use information learned). (Id. at 273). Had the ALJ adopted NP Ross's opinion - which indicated that C.M.K. had marked limitations in more than two domains - he would have found C.M.K. to be disabled under the Act. See Encarnacion ,
In the written determination, the ALJ gave "some weight" to NP Ross's opinion that C.M.K. had many ADHD symptoms with moderate inattention, mild impulsiveness and hyperactivity, marked cognitive/communication and social functioning skills, and difficulty maintaining concentration, persistence and pace. (Id. at 26). The ALJ explained that "[t]he claimant mainly misbehaves as opposed to having the classic symptoms of ADHD." (Id. ). Further, the ALJ found that NP Ross's opinion that C.M.K. had a marked limitation in attending and completing tasks was not credible, because it was "inconsistent with examination on June 7, 2016, which noted attention and concentration were adequate." (Id. at 30).
The Court is cognizant that, as a nurse practitioner, NP Ross's opinion is not entitled to any special weight. See Genier v. Astrue ,
In sum, the ALJ issued his determination based on a medical record he knew was incomplete. The Court recognizes that the record contains information contrary to some of the assessments made by NP Ross; however, the ALJ evaluated this information, and NP Ross's opinion, without the benefit of the complete medical record. The information contained in the missing records likely is important and may influence the ALJ's analysis of opinion *428evidence in the record, particularly the opinion of NP Ross. On remand, the ALJ is directed to exercise his duty to develop the record to ensure that it is complete, including working to obtain any missing treatment records from CCMH.
B. Plaintiff's Remaining Argument
As set forth above, Plaintiff has identified an additional reason why she contends the 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. 9) 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.
The Court notes that the record also contains an opinion from Rebecca Billings, Ph.D. (See Dkt. 5 at 234-38). Dr. Billings found that C.M.K. had marked limitations in attending to, following, and understanding age-appropriate directions, completing age-appropriate tasks, and learning in accordance to cognitive functioning. (Id. at 238). C.M.K. also had a "moderate range of difficulties" in adequately maintaining appropriate social behavior on occasion, responding appropriately to changes in the environment, and interacting adequately with adults. (Id. ). Dr. Billings concluded that "[t]he results of the examination appear to be consistent with psychiatric problems, and this may significantly interfere with the claimant's ability to function on a daily basis." (Id. ). The ALJ gave Dr. Billings's opinion "some weight" in part because "it was noted that the claimant did not take his medication on the morning of the examination." (Id. at 26; see also id. at 28, 30). A review of Dr. Billings's opinion - which states that "[t]he claimant apparently did have his medicines this morning" - reveals that the ALJ's reading of the report is incorrect (emphasis added). On remand, the ALJ should bear in mind that C.M.K. did take his medications on the date of Dr. Billings's examination.
Reference
- Full Case Name
- Carley WILL, O/B/O C.M.K. v. COMMISSIONER OF SOCIAL SECURITY
- Cited By
- 15 cases
- Status
- Published