Ross v. Social Security Administration

Filing 14

MEMORANDUM RULING re 1 Complaint filed by Cassandra Ross: An ALJ need not discuss every piece of evidence but he may not ignore a significant line of evidence that is in contradiction to the ALJs findings and that could reasonably cast doubt on the result. The decision must not only state which evidence was considered but must also indicate why evidence that would support a claim was rejected. Failure to explain an implicit rejection of evidence may be grounds for reversal and remand. The AL J was entitled to discount Dr. McDonald's statement that Plaintiff could not bend or squat because it was based on Plaintiff's subjective report, the limitation was not fully supported by MRI studies, and other evidence can be interpreted t o suggest a lesser degree of limitation, but, whether through oversight or intent, the ALJ did not address this evidence. The court's proper role is confined to an appellate review of the agency's final decision. For the undersigned to atte mpt to decide the case, without any prior discussion by the ALJ or Appeals Council about the relative weight or meaning of this potentially important finding, would not be appropriate. The Commissioner's decision must be reversed, and the case will be remanded to the agency for further proceedings. Signed by Magistrate Judge Mark Hornsby on 9/15/09. (crt,Cassanova, M)

UNITED STATES DISTRICT COURT W E S T ER N DISTRICT OF LOUISIANA S H R E V EP O R T DIVISION

C . R. VERSUS U .S . COMMISSIONER SOCIAL S E C U RI TY ADMINISTRATION

C I V I L ACTION NO. 08-cv-0987

M A G I S T R A T E JUDGE HORNSBY

M E M O R A N D U M RULING C . R. ("Plaintiff") filed an application for benefits based primarily on complaints of b a c k and neck pain and related limitations. ALJ W. Thomas Bundy conducted a hearing and i s s u e d a written decision that denied the claim. The ALJ found that Plaintiff had severe impa irmen ts in the form of degenerative disk disease of the cervical and lumbar spines, as we ll as obesity, but that she could perform the full range of sedentary work. He then looked t o the Medical-Vocational Guidelines and found that Rule 201.28 directed a finding of not d i s a b l e d at step five of the sequential analysis. T h e Appeals Council denied a request for review. Plaintiff filed this civil action s e e k i n g judicial review pursuant to 42 U.S.C. § 405(g). This court's standard of review is ( 1 ) whether substantial evidence of record supports the ALJ's determination, and (2) whether t h e decision comports with relevant legal standards. Villa v. Sullivan, 895 F.2d 1019, 1021 (5th Cir. 1990). Pursuant to 28 U.S.C. § 636(c) and the standing order of the district court g o v e r n i n g social security cases, the action was referred to the undersigned for decision and

entry of judgment. For the reasons that follow, the Commissioner's decision to deny benefits wil l be reversed and the case will be remanded. Plaintiff argues on appeal that it was error for the ALJ to find that she has the residual f u n c t io n a l capacity ("RFC") to perform the full range of sedentary work because there is e v i d e n c e that she is unable to stoop. Plaintiff makes a related argument that the existence o f that nonexertional limitation required the ALJ to ask a vocational expert ("VE") about the imp act of that limitation on jobs that would be available. The ALJ addressed the medical evidence from treating physicians Ben Leggio and G a r l a n d Miller, both of whom opined that Plaintiff was unable to work. The ALJ recognized t h a t Plaintiff has MRI evidence of degenerative disk disease involving her cervical and l um b a r spine, but he found that clinical findings did not reflect the degree of limitation s u g g e s t ed by the treating physicians. The ALJ also found that Plaintiff's testimony about the e x t e n t of her limitations was not entirely credible. T h e ALJ's rejection of that evidence was based largely on his acceptance of the c o n s u l ta t i v e report of Dr. John Walker McDonald. He noted that the opinions of the treating p h y s ic i a n s relied heavily on Plaintiff's subjective reports of symptoms, which the treating p h y s ic i a n s seemed to uncritically accept as true. The ALJ noted that a treating physician may e x p r e s s an opinion in an effort to help a patient with whom he sympathizes or to obtain relief f r o m an insistent patient. The ALJ noted the difficulty of confirming the presence of such m o t i v e s , and there is no direct evidence of such a motive in this case, but the ALJ suggested

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t h a t such motives are more likely present in a case where the physician's opinion departs subs tantially from the other record evidence. He found that to be the case and elected to afford "significant weight" to the findings and opinions offered by Dr. McDonald. As a c o n s u l ta t i v e physician, Dr. McDonald would lack the motivations noted above, and he c o n d u c t e d a comprehensive physical examination. In assessing Plaintiff's credibility, the A L J noted that Plaintiff "did not present convincing factors to suggest a level of impairment a n d resulting limitations greater than that identified by Dr. McDonald." In determining that P l a i n ti f f could perform the full range of sedentary work, the ALJ stated that he placed " p a r t ic u l a r emphasis" on Dr. McDonald's findings. All indications are that Dr. McDonald's find ing s were the driving force behind the RFC assessed by the ALJ. Much of Dr. McDonald's report supports the ALJ's RFC assessment, but there is one aspe ct of his report (ability to stoop/bend) that undermines the RFC. Dr. McDonald noted t h a t Plaintiff was "reliable" during his examination of her. In his findings regarding gait and s t a ti o n , he wrote that Plaintiff was able to rise from a sitting position using a cane for a s s i st a n c e , could not stand on tiptoes, heels, or tandem walk, and "was unable to bend and s q u a t due to back pain." A straight-leg raise exam elicited pain at 30 degrees, suggesting a lim i t a ti o n in range of motion of the back. In his conclusion, Dr. McDonald did not spec ifically refer to the inability to bend or squat, though he did note that Plaintiff had a " l i m it e d range of motion in all directions in her lumbar spine." He went on to conclude that

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P l a i n t i f f could lift/carry objects up to 20 pounds and sit, walk, and/or stand for one to two h o u r s in a workday. Tr. 117-19. T h e ALJ relied exclusively on the Guidelines at step five, which is permitted only if a claimant's nonexertional impairments do not significantly affect his RFC. Fraga v. Bowen, 8 1 0 F.2d 1296, 1304 (5th Cir. 1987). Nonexertional limitations can affect the ability "to b e n d the spine alone (stoop) or bend both the spine and legs (crouch)." Social Security R u l i n g 85-15. "Some stooping (bending the body downward and forward by bending the s p i n e at the waist) is required to do almost any kind of work, particularly when objects below t h e waist are involved." Id. An ability to stoop occasionally (from very little up to one-third o f the time) is required in most unskilled sedentary occupations. Thus, "[a] complete inability to stoop would significantly erode the unskilled sedentary occupational base and a f i n d i n g that the individual is disabled would usually apply, but restriction to occasional s t o o p in g should, by itself, only minimally erode the unskilled occupational base of sedentary w o r k . " Social Security Ruling 96-9p. T h e ALJ thoroughly addressed the evidence from the treating physicians and gave s o u n d reasons as to why those opinions should be discounted. In their stead, the ALJ e m b r a c e d the opinion of Dr. McDonald, but he did not address the aspect of Dr. McDonald's r e p o r t that suggests an inability to bend and squat due to back pain. That limitation would app ear to undermine a finding of the ability to perform the full range of sedentary work.

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A n ALJ need not discuss every piece of evidence in the record, but he may not ignore a significant line of evidence that is in contradiction to the ALJ's findings and that could reaso nably cast doubt on the result. Rey v. Commissioner, 2009 WL 249702, *2 (W.D. La. 2009). The decision must not only state which evidence was considered in support of the result but must also indicate why evidence that would support a claim was rejected. Failure to explain an implicit rejection of evidence may be grounds for reversal and remand. Social Secu rity Law & Practice, § 53:11 (Comprehensive and Analytical Findings). See also Reeder v . Apfel, 214 F.3d 984, 988 (8th Cir. 2000) (failure to specifically address medical records i n d i c at i n g some limitations in ability to stand, sit, and lift required remand) and Loza v. A p f e l , 219 F.3d 378, 395 (5th Cir. 2000) ("The ALJ cannot reject a medical opinion without an explanation."). T h e Commissioner argues that the ALJ was entitled to discount Dr. McDonald's s t a te m e n t that Plaintiff could not bend or squat because it was based on Plaintiff's subjective repo rt, the limitation was not fully supported by the results of MRI studies, and other e v i d e n c e can be interpreted to suggest a lesser degree of limitation. Such reasoning might h a v e withstood review if offered by the ALJ but, whether through oversight or intent, he did n o t address this evidence. "The ALJ's decision must stand or fall with the reasons set forth in the ALJ's decision, as adopted by the Appeals Council." Newton v. Apfel, 209 F.3d 448, 4 5 5 (5th Cir. 2000). See also Cole v. Barnhart, 288 F.3d 149, 151 (5th Cir.2002) ("It is

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w e l l - e st a b l is h e d that we may only affirm the Commissioner's decision on the grounds which he stated for doing so."). It would be inappropriate for the undersigned to weigh the evidence, consider the Com missio n er's arguments, and decide the issue in the first instance. It is the role of the ALJ to first address the evidence and, if warranted, gather additional evidence or reports to flesh o u t the issues. The court's proper role is confined to an appellate review of the agency's f i n a l decision. For the undersigned to attempt to decide the case, without any prior discussion b y the ALJ or Appeals Council about the relative weight or meaning of this potentially i m p o r t a n t finding, would not be appropriate. Under these circumstances, the Commissioner's d e c i s io n must be reversed, and the case will be remanded to the agency for further proceedings. O n remand, Plaintiff and the agency may further explore the issues addressed herein or any other relevant matters. See 20 C.F.R. § 404.983 (following a federal court remand, " [ a ] n y issues relating to your claim may be considered by the administrative law judge w h e t h e r or not they were raised in the administrative proceedings leading to the final d e c i s io n in your case."). See also Social Security Law and Practice, § 55:74 (there is ordin arily "no limit on a claimant's supplementing the record on remand" after a sentence fou r or sentence six remand).

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T H U S DONE AND SIGNED in Shreveport, Louisiana, this 15th day of September, 2009.

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