Ledonne v. US Social Security Administration, Acting Commissioner

Filing 15

///ORDER granting 11 Motion to Reverse Decision of Commissioner; denying 14 Motion to Affirm Decision of Commissioner. So Ordered by Judge Joseph A. DiClerico, Jr.(gla)

UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF NEW HAMPSHIRE

Joanne Ledonne
v.

Civil No. 16-cv-424-JD
Opinion No. 2017 DNH 143

Nancy A. Berryhill,
Acting Commissioner,
Social Security Administration

O R D E R
Joanne Ledonne seeks judicial review, pursuant to 42 U.S.C.
§ 405(g), of the decision of the Acting Commissioner of Social
Security, denying her application for disability insurance
benefits under Title II and supplemental security income
benefits under Title XVI of the Social Security Act.

Ledonne

moves to reverse, contending that the Administrative Law Judge
(“ALJ”) erred by assessing her residual functional capacity
based in part on her lay interpretation of the medical record.
The Acting Commissioner moves to affirm.
Standard of Review
In reviewing the final decision of the Acting Commissioner
in a social security case, the court “is limited to determining
whether the ALJ deployed the proper legal standards and found
facts upon the proper quantum of evidence.”

Nguyen v. Chater,

172 F.3d 31, 35 (1st Cir. 1999); accord Seavey v. Barnhart, 276
F.3d 1, 9 (1st Cir. 2001).

The court defers to the ALJ’s

factual findings as long as they are supported by substantial
evidence.

§ 405(g); see also Fischer v. Colvin, 831 F.3d 31, 34

(1st Cir. 2016).
scintilla.

“Substantial evidence is more than a mere

It means such relevant evidence as a reasonable mind

might accept as adequate to support a conclusion.”

Castillo

Condo. Ass’n v. U.S. Dep’t of Housing & Urban Dev., 821 F.3d 92,
97 (1st Cir. 2016) (internal quotation marks omitted).
Background
Ledonne filed an application for social security benefits
in September of 2013.

She alleged that she was disabled due to

bipolar or manic mental health issues, attention deficit
disorder, anxiety, suicidal thoughts, chronic pain, and
herniated discs.

Ledonne was in her early fifties when she

applied for benefits.

She had a high school education and had

previously worked as a waitress and a manager.
The medical evidence begins in 2007 with a report of a
lumbar MRI.

The MRI showed a protrusion with an annular tear at

L5-S1, which was similar to examination results in 2003.
Ledonne continued treatment for back pain, changing to treatment
in New Hampshire from treatment in Massachusetts.

2

In March of 2013, Ledonne attempted suicide and was
admitted for a psychiatric examination.

Subsequent treatment

notes showed continued mental health issues.
Ledonne again attempted suicide.

In August of 2013,

She was admitted to the

hospital with diagnoses of mood disorder, ADHD, opiate
dependence, and a note to rule out bipolar disorder.

During

treatment after discharge from the hospital, Ledonne continued
to report anxiety and depression.
In January of 2014, the state agency psychologist noted
that Ledonne had not provided medical evidence to support her
application.

As a result, he was unable to do a functional

assessment.
Ledonne was again in the hospital in March of 2014 because
of depression and anxiety and thoughts of suicide.

She was

evaluated at Portsmouth Regional Hospital for management and
treatment of depression with psychosis.

Ledonne also had

worsening of her chronic back pain at that time.

Her

examination on March 8, 2014, showed improvement, and she was
discharged on March 11, 2014.

Her diagnoses were mood disorder,

ADHD, opiate dependence in sustained remission, herniated discs,
sciatica, and edema in her legs.

Examinations during the next

year showed improvement.
Dr. Sandra Vallery did a comprehensive psychological
profile of Ledonne in May of 2015.
3

Based on Ledonne’s

descriptions, the examination, and some medical records, Dr.
Vallery concluded that Ledonne had a mood disorder, generalized
anxiety disorder, ADHD, depressive disorder, alcohol abuse in
partial remission, and substance abuse in remission.

With

respect to her functioning, Dr. Vallery found that Ledonne would
be able to interact and communicate appropriately, remember all
instructions, concentrate and complete tasks, and make simple
decisions.

Dr. Vallery also found, however, that Ledonne would

have inconsistent attendance at work because of anxiety.
Dr. Peter Loeser did a consultative examination of Ledonne
in May of 2015 to assess her physical functioning.

Dr. Loeser

reviewed only one medical record, which was from 2002.

He found

that Ledonne had low back pain with radiculopathy “of uncertain
etiology with minimal available supportive documentation and
acute neck pain.”
examination.

He indicated no significant findings on his

He also noted that Ledonne was able to move around

the examination room without difficulty or impairment.
A hearing on her application before an ALJ was held on July
1, 2015.

Ledonne was represented at the hearing and testified.

The ALJ issued a decision on July 31, 2015, finding that Ledonne
was not disabled.

In support, the ALJ found that Ledonne had

severe impairments due to lumbar degenerative disc disease, mood
disorder, generalized anxiety disorder, ADHD, depressive
disorder, and polysubstance abuse.
4

The ALJ found that despite

those impairments Ledonne had the residual functional capacity
to do medium work except that she would be limited to simple and
routine tasks as in unskilled work.

The Appeals Council denied

Ledonne’s request for review.
Discussion
Ledonne contends that the ALJ erred in failing to credit
Dr. Vallery’s opinion that Ledonne would have inconsistent work
attendance because of anxiety and lacked substantial evidence to
support the assessment that she could do medium work.

The

Acting Commissioner moves to affirm the decision, contending
that the ALJ properly evaluated the medical opinions to assess
Ledonne’s residual functional capacity.
A.

Dr. Vallery’s Opinion
The ALJ relied on Dr. Vallery’s assessment of Ledonne’s

mental functioning except for her opinion that Ledonne would
have inconsistent work attendance.

The ALJ explained that she

did not give weight to that opinion because Dr. Vallery “did not
provide a precise assessment as to the nature and extent of the
claimant’s inconsistent attendance.”

The ALJ also interpreted

Dr. Vallery’s reference to “inconsistent attendance at this
time” to mean that Ledonne’s attendance would improve.
The record shows that Ledonne has significant mental health
issues.

Dr. Vallery provided the only mental function
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assessment in the record.

The ALJ, therefore, had no other

opinion that showed Ledonne’s anxiety would not affect her
attendance.
Regular attendance is an important element of the ability
to work.

Irlanda Ortiz v. Sec’y of Health & Human Servs., 955

F.2d 765, 770 (1st Cir. 1991).

Even if the ALJ were correct

that Dr. Vallery’s opinion about Ledonne’s attendance lacked
detail, that deficit does not make the opinion invalid.

Under

these circumstances, the case should be remanded to consider the
effect of Ledonne’s anxiety on her ability to work.
B.

Ability to Do Medium Work
Ledonne correctly points out that there is no physical

functional assessment in the record that shows she is capable of
doing work at the medium exertional level.

As a result, the ALJ

made that assessment based on her own review of the record.
The Acting Commissioner suggests that the ALJ could make that
assessment on her own because the record shows only mild and
normal findings with respect to Ledonne’s strength and
specifically her back pain.
Generally, “an ALJ, as a lay person, is not qualified to
interpret raw data in a medical record.”

Manso-Pizarro v. Sec’y

of Health & Human Servs., 76 F.3d 15, 17 (1st Cir. 1996).
result, an expert opinion is usually necessary to assess a

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As a

claimant’s residual functional capacity.

Id.

An exception

exists when the medical record shows little physical impairment
and an assessment can be made based on common sense.

Id.

In this case, however, the record shows chronic back pain
due to lumbar disc protrusion.

The ALJ found that Ledonne had a

severe impairment due to lumbar degenerative disc disease.
Therefore, this is not a case where common sense is enough to
interpret the medical record.
On remand, the ALJ will have the opportunity to obtain an
appropriate physical function assessment.
Conclusion
For the foregoing reasons, the claimant’s motion to reverse
and remand (document no. 11) is granted.

The Acting

Commissioner’s motion to affirm (document 14) is denied.
The case is remanded for further administrative proceedings
pursuant to Sentence Four of § 405(g).
SO ORDERED.

__________________________
Joseph DiClerico, Jr.
United States District Judge
July 24, 2017
cc:

Terry L. Ollila, Esq.
Laurie Smith Young, Esq.

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