Terrien v. Social Security Administration, Commissioner
MEMORANDUM OPINION. Signed by Judge Madeline Hughes Haikala on 9/24/2015. (KEK)
2015 Sep-24 AM 09:06
U.S. DISTRICT COURT
N.D. OF ALABAMA
UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
SAMANTHA NICOLE TERRIEN,
CAROLYN W. COLVIN,
Commissioner of the
Social Security Administration,
Case No.: 5:14-CV-381-MHH
Pursuant to 42 U.S.C. §§ 405(g) and 1383(c), plaintiff Samantha Terrien
seeks judicial review of a final adverse decision of the Commissioner of Social
Security. The Commissioner affirmed the administrative law judge’s denial of Ms.
Terrien’s claims for a period of disability and disability insurance benefits and
supplemental security income. After careful review, the Court remands this case to
the Commissioner for further proceedings consistent with this opinion.
Ms. Terrien applied for a period of disability and disability insurance
benefits on January 18, 2011. She applied for supplemental security income on
March 4, 2011. (Doc. 5-6, pp. 2, 4). Ms. Terrien alleges that her disability began
on November 7, 2008. (Doc. 5-6, pp. 2, 4). The Commissioner initially denied
Ms. Terrien’s claims on June 2, 2011, and Ms. Terrien requested a hearing before
an ALJ. (Doc. 5-5, pp. 11, 18). The ALJ issued an unfavorable decision on
October 18, 2012. (Doc. 5-3, pp. 13-20). On January 31, 2014, the Appeals
Council declined Ms. Terrien’s request for review (Doc. 5-3, pp. 2-4), making the
Commissioner’s decision final and a proper candidate for this Court’s judicial
review. See 42 U.S.C. §§ 405(g), 1383(c).
STANDARD OF REVIEW
The scope of review in this matter is limited. “When, as in this case, the
ALJ denies benefits and the Appeals Council denies review,” the Court “review[s]
the ALJ’s ‘factual findings with deference’ and [her] ‘legal conclusions with close
scrutiny.’” Riggs v. Comm’r of Soc. Sec., 522 Fed. Appx. 509, 510-11 (11th Cir.
2013) (quoting Doughty v. Apfel, 245 F.3d 1274, 1278 (11th Cir. 2001)).
The Court must determine whether there is substantial evidence in the record
to support the ALJ’s findings. “Substantial evidence is more than a scintilla and is
such relevant evidence as a reasonable person would accept as adequate to support
a conclusion.” Crawford v. Comm’r of Soc. Sec., 363 F.3d 1155, 1158 (11th Cir.
2004). In making this evaluation, the Court may not “decide the facts anew,
reweigh the evidence,” or substitute its judgment for that of the ALJ. Winschel v.
Comm’r of Soc. Sec. Admin., 631 F.3d 1176, 1178 (11th Cir. 2011) (internal
quotations and citation omitted). If the ALJ’s decision is supported by substantial
evidence, the Court “must affirm even if the evidence preponderates against the
Commissioner’s findings.” Costigan v. Comm’r, Soc. Sec. Admin., 603 Fed. Appx.
783, 786 (11th Cir. 2015) (citing Crawford, 363 F.3d at 1158).
With respect to the ALJ’s legal conclusions, the Court must determine
whether the ALJ applied the correct legal standards. If the Court finds an error in
the ALJ’s application of the law, or if the Court finds that the ALJ failed to provide
sufficient reasoning to demonstrate that the ALJ conducted a proper legal analysis,
then the Court must reverse the ALJ’s decision. Cornelius v. Sullivan, 936 F.2d
1143, 1145-46 (11th Cir. 1991).
SUMMARY OF THE ALJ’S DECISION
To determine whether a claimant has proven that she is disabled, an ALJ
follows a five-step sequential evaluation process. The ALJ considers:
(1) whether the claimant is currently engaged in substantial gainful
activity; (2) whether the claimant has a severe impairment or
combination of impairments; (3) whether the impairment meets or
equals the severity of the specified impairments in the Listing of
Impairments; (4) based on a residual functional capacity (“RFC”)
assessment, whether the claimant can perform any of his or her past
relevant work despite the impairment; and (5) whether there are
significant numbers of jobs in the national economy that the claimant
can perform given the claimant’s RFC, age, education, and work
Winschel, 631 F.3d at 1178.
In this case, the ALJ found that Ms. Terrien has not engaged in substantial
gainful activity since November 7, 2008, the alleged onset date. (Doc. 5-3, p. 15).
The ALJ determined that Ms. Terrien suffers from the following severe
impairments: “history of irritable bowel syndrome (IBS), a history of a fractured
right metacarpal status post right 5th metacarpal bone cyst removal and grafting,
and a history of avulsion fracture at T10 in 2006.” (Doc. 5-3, p. 15). The ALJ also
determined that Ms. Terrien suffers from the non-severe mental impairment of
depression. (Doc. 5-3, p. 17). Nevertheless, the ALJ concluded that Ms. Terrien
does not have an impairment or combination of impairments that meets or
medically equals the severity of any of the listed impairments in 20 C.F.R. Part
404, Subpart P, Appendix 1. (Doc. 5-3, p. 18). Next, the ALJ determined the
following: Ms. Terrien has the RFC to “occasionally lift and/or carry up to 20
pounds and frequently lift and/or carry up to 10 pounds.
[Ms. Terrien] can
occasionally use her right dominant hand to perform fine manipulations. [Ms.
Terrien] has no limitations in her abilities to perform gross manipulations.” (Doc.
5-3, p. 19). Based on this RFC, the ALJ concluded that Ms. Terrien is capable of
performing her past relevant work as a mortgage underwriter. (Doc. 5-3, p. 21).
Accordingly, the ALJ determined that Ms. Terrien is not disabled as that term is
defined in the Social Security Act. (Doc. 5-3, p. 22).
Ms. Terrien argues that she is entitled to relief from the ALJ’s decision
because the ALJ erred in failing to identify Crohn’s disease as a medically
determinable impairment. The Court agrees.
When an ALJ identifies at least one severe impairment, the ALJ satisfies the
threshold inquiry at step two of the five-step evaluation process. See Packer v.
Comm’r of Soc. Sec., 542 Fed. Appx. 890, 892 (11th Cir. 2013). Here, at step two,
the ALJ found that Ms. Terrien suffers from three severe impairments including
irritable bowel syndrome (IBS); however, the ALJ did not identify Crohn’s disease
as one of Ms. Terrien’s severe impairments. The Social Security Regulations
recognize Crohn’s disease as an inflammatory bowel disease (IBD). 20 C.F.R §
404, Subpart P, Appendix 1, Listing 5.00(E)(1).
The regulations provide:
[r]emissions and exacerbations of variable duration are the hallmark of IBD. . . .
Crohn’s disease is rarely curable and recurrence may be a lifelong problem, even
after surgical resection.” Id.
The ALJ’s failure to identify Crohn’s disease as a medically determinable
impairment at stage two is not harmless error, because the ALJ did not consider in
the final stages of the five-step disability evaluation the symptoms and limitations
that would result from Crohn’s disease. Compare Sanchez v. Comm’r of Soc. Sec.,
507 Fed. Appx. 855, 859 (11th Cir. 2013) (“[E]ven if the ALJ erred by failing to
identify BPD as a severe limitation at step two, the ALJ properly considered the
symptoms and limitations that would result from BPD at the latter stages of the
five-step disability evaluation.”).
The ALJ discounted the Crohn’s diagnoses that appear in Ms. Terrien’s
medical records because the ALJ believed that those diagnoses were based only on
Ms. Terrien’s reports of Crohn’s disease and not on objective medical evidence of
Crohn’s disease. (Doc. 5-3, p. 17, 20). Ms. Terrien’s medical records contain test
results that support her diagnosis of Crohn’s disease. For example, on October 21,
2008, Dr. Amy Woods diagnosed Ms. Terrien with Crohn’s disease based on xrays that revealed abnormal loops on Ms. Terrien’s small bowel. (Doc. 5-10, p.
31).1 Dr. Woods noted that Ms. Terrien was experiencing a Crohn’s flare, and Dr.
Woods indicated that Ms. Terrrien would be out of work for six days. (Doc. 5-10,
On November 4, 2010, Ms. Terrien visited the emergency room at
Crestwood Medical Center due to diarrhea, vomiting, and nausea. (Doc. 5-18, p.
Dr. Weston Welker diagnosed Ms. Terrien with Crohn’s disease and
hypokalemia.2 (Doc. 5-18, p. 42). On July 29, 2011, Ms. Terrien visited the
emergency room at Crestwood Medical Center.
(Doc. 5-17, p. 55).
The regulations recognize “[i]nflamed loops of bowel” as a symptom and sign of IBD. 20
C.F.R. § 404, Subpart 4, Appendix 1, Listing 5.00(E)(2).
The regulations recognize hypokalemia, nausea, and vomiting as symptoms and signs of IBD.
20 C.F.R. § 404, Subpart 4, Appendix 1, Listing 5.00(E)(2).
examination, Dr. John Bowman noted severe tenderness in Ms. Terrien’s abdomen
and diagnosed her with Crohn’s disease. (Doc. 5-17, pp. 56-57).3 The ALJ did not
mention these positive Crohn’s diagnoses in the discussion of the medical
evidence, and she failed to account for these diagnoses in her analysis. (Doc. 5-3,
pp. 15-17, 20-21). Therefore, the Court cannot determine whether substantial
evidence supports the ALJ’s decision. See McCruter v. Bowen, 791 F.2d 1544,
1548 (11th Cir. 1986) (If the record viewed in its entirety indicates that the ALJ
“focus[ed] upon one aspect of the evidence and ignor[ed] other parts of the
record,” then the reviewing court “cannot properly find that the administrative
decision is supported by substantial evidence. It is not enough to discover a piece
of evidence which supports that decision, but to disregard other contrary evidence.
The review must take into account and evaluate the record as a whole.”).
By failing to find that Crohn’s is a medically determinable impairment, the
ALJ did not “meaningfully conduct an analysis of the effect of [Crohn’s] on [Ms.
Terrien’s] ability to work.” Vega v. Comm’r of Soc. Sec., 265 F.3d 1214, 1219
(11th Cir. 2001). No treating or examining physician has provided an opinion
regarding how Ms. Terrien’s Crohn’s disease limits her ability to work.
Therefore, the only evidence in the record regarding the limitations attributable to
Ms. Terrien’s Crohn’s disease is her subjective testimony. Ms. Terrien testified
The regulations recognize abdominal tenderness as a symptom and sign of IBD. 20 C.F.R. §
404, Subpart 4, Appendix 1, Listing 5.00(E)(2).
that she experiences a Crohn’s flare 7 to 14 days a month. (Doc. 5-3, p. 36).
During a Crohn’s flare, she must use the restroom 10 to 12 times a day. During
each of those visits, Ms. Terrien spends between 10 and 15 minutes to an hour in
the restroom. (Doc. 5-3, pp. 37-38). Ms. Terrien also testified that after each flare,
she must lie down for 30 to 45 minutes due to pain and dizziness. (Doc. 5-3, p.
39). The VE testified that these limitations would preclude all work. (Doc. 5-3,
The ALJ discredited Ms. Terrien’s testimony on this point in part because
the ALJ found that “there is no definitive evidence of Crohn’s disease.” (Doc. 5-3,
p. 20). But that is not the case. As explained above, there is objective medical
evidence of Crohn’s disease in the record. Therefore, remand is necessary because
the “ALJ fail[ed] to consider properly [Ms. Terrien’s] condition despite evidence
in the record of the diagnosis.” Vega, 265 F.3d at 1219. On remand, the ALJ
should reevaluate Ms. Terrien’s RFC determination and Ms. Terrien’s credibility
in light of a Crohn’s diagnosis supported by objective medical evidence. See
Lewen v. Comm’r of Soc. Sec., 605 Fed. Appx. 967, 968 (11th Cir. 2015) (the
ALJ’s decision should enable “the reviewing court to conclude that the ALJ
considered the claimant’s medical condition as a whole”); Coven v. Comm’r of
Soc. Sec., 384 Fed. Appx. 949, 951 (11th Cir. 2010) (“Because a hearing before an
ALJ is not an adversary proceeding, the ALJ has a basic obligation to develop a
full and fair record.”) (internal quotation marks and citation omitted).
For the reasons discussed above, the Court cannot determine whether the
ALJ’s decision is supported by substantial evidence. Therefore, the Court will
remand this action to the Commissioner for further administrative proceedings
consistent with this opinion. The Court will enter a separate final judgment
consistent with this memorandum opinion.
DONE and ORDERED this September 24, 2015.
MADELINE HUGHES HAIKALA
UNITED STATES DISTRICT JUDGE
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