Heller v. Colvin

Filing 25

MEMORANDUM (Order to follow as separate docket entry) re 1 Complaint filed by Suzanne Heller. Signed by Magistrate Judge Karoline Mehalchick on 9/19/2017. (cw)

UNITED STATES DISTRICT COURT
MIDDLE DISTRICT OF PENNSYLVANIA
SUZANNE HELLER,
Plaintiff,

CIVIL ACTION NO. 1:16-CV-00360

v.

(MEHALCHICK, M.J.)

NANCY A. BERRYHILL,
Defendant.
MEMORANDUM
This is an action brought under Section 1383(c) of the Social Security Act and 42 U.S.C.
§ 405(g), seeking judicial review of the final decision of the Commissioner of Social Security
(hereinafter, “the Commissioner”) denying Plaintiff Suzanne Heller’s claims for a period of
disability and disability insurance benefits (“DIB”) under Title II of the Social Security
Act. (Doc. 1). For the reasons expressed herein, and upon detailed consideration of the
arguments raised by the parties in their respective briefs, the Court finds that the
Commissioner's decision should be vacated and the matter remanded for further review.
I.

BACKGROUND AND PROCEDURAL HISTORY
On January 9, 2013, Heller filed a Title II application for a period of disability and

disability insurance benefits, alleging disability beginning August 8, 2012. (Doc. 13, at 2). Her
claim was denied on April 11, 2013, and she requested a hearing by an Administrative Law
Judge (“ALJ”). (Doc. 13, at 2). A hearing was conducted by ALJ Scott M. Staller on August
19, 2014. (Doc. 13, at 2). In a written decision dated August 28, 2014, the ALJ determined
Heller was not disabled and therefore not entitled to benefits. (Doc. 13, at 2). Heller appealed

this decision to the Appeals Council on October 13, 2014, who denied her appeal on January
15, 2016. (Doc. 13, at 2).
On February 29, 2016, Heller filed the instant complaint. (Doc. 1). The Commissioner
responded on June 9, 2016, providing the requisite transcripts. (Doc. 8; Doc. 9). The parties
then each filed their respective briefs. (Doc. 13; Doc. 17; Doc. 18). In her brief, Heller argues
the ALJ’s erred in five respects: that he should have found Heller’s impairments met or equaled
Listings 12.04 and 12.06; substantial evidence does not support the ALJ’s evaluation of opinion
evidence; the ALJ’s RFC is not supported by substantial evidence; the ALJ improperly
evaluated Heller’s GAF scores; and that substantial evidence does not support the ALJ’s
credibility assessment. (Doc. 13, at 1-2). The Commissioner disagreed with each of Heller’s
arguments. (Doc. 17). The Commissioner and Heller consented to the jurisdiction of the
undersigned on November 16, 2016. (Doc. 24).
All transcripts received and the positions fully briefed, the matter is ripe for review.
II.

THE ALJ’S DECISION
In his decision dated August 28, 2014, the ALJ determined Heller “is not disabled under

sections 216(i) and 223(d) of the Social Security Act.” (Doc. 9-2, at 53). The ALJ reached this
conclusion after proceeding through the five-step sequential analysis required by the Social
Security Act. See 20 C.F.R. § 404.1520. The ALJ determined that Heller meets the insured
status requirements of the Social Security Act through December 31, 2017. (Doc. 9-2, at 44).
At step one of the five-step analysis, an ALJ must determine whether the claimant is
engaging in substantial gainful activity (“SGA”). 20 C.F.R § 404.1520(a)(4)(i). If a claimant is
engaging in SGA, the Regulations deem them not disabled, regardless of age, education, or
work experience. 20 C.F.R. § 404.1520(b). SGA is defined as work activity—requiring
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significant physical or mental activity—resulting in pay or profit. 20 C.F.R. § 404.1572. In
making this determination, the ALJ must consider only the earnings of the claimant. 20 C.F.R.
§ 404.1574. The ALJ determined Heller “has not engaged in substantial gainful activity since
August 8, 2012, the alleged onset date.” (Doc. 9-2, at 44). The ALJ acknowledged Heller
performed part-time work at home as a bookkeeper for a non-profit organization roughly 5-10
hours per week, however determined that it did not rise to the level of SGA. (Doc. 9-2, at 44).
Thus, the ALJ’s analysis proceeded to step two.
At step two, the ALJ must determine whether the claimant has a medically determinable
impairment that is severe or a combination of impairments that are severe. 20 C.F.R. §
404.1520(a)(ii). If the ALJ determines that a claimant does not have an “impairment or
combination of impairments which significantly limits [their] physical or mental ability to do
basic work activities, [the ALJ] will find that [the claimant] does not have a severe impairment
and [is], therefore not disabled.” 20 C.F.R. § 1520(c). If a claimant establishes a severe
impairment or combination of impairments, the analysis continues to the third step.
The ALJ found Heller had seven severe impairments: status post two transient ischemic
attacks; osteoarthritis; adhesive capsulitis of the left shoulder status post rotator cuff repair;
hyperparathyroidism status post hemi parathyroidectomy; chronic kidney disease – stage 3;
major depressive disorder; and post-traumatic stress disorder (“PTSD”). (Doc. 9-2, at 44). The
ALJ also noted non-severe impairments of hypertension and Barrett’s esophagus, but
determined these impairments had not caused “more than a minimal limitation in the
claimant’s ability to work since her alleged onset date.” (Doc. 9-2, at 44).
At step three, the ALJ must determine whether the severe impairment or combination of
impairments meets or equals the medical equivalent of an impairment listed in 20 C.F.R. Part
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404, Subpt. P, App. 1 (20 C.F.R. §§ 404.1520(d); 404.1525; 404.1526). If the ALJ determines
that the claimant’s impairments meet these listings, then the claimant is considered disabled. 20
C.F.R. § 404.1520(a)(4)(iii). The ALJ determined that none of Heller’s impairments considered
individually or in combination met or equaled a Listing. (Doc. 9-2, at 45-47). Specifically, the
ALJ considered Listings 1.02 (major dysfunction of a joint); 1.04 (disorders of the spine); 6.02;
11.04 (vascular insult to the brain);12.04 (depressive, bipolar and related disorders); 12.06
(anxiety and obsessive-compulsive disorders); 14.09 (inflammatory arthritis). (Doc. 9-2, at 4547).
Between steps three and four, the ALJ determines the claimant’s residual functional
capacity (“RFC”), crafted upon consideration of the medical evidence provided. The ALJ
determined that Heller:
Has the [RFC] to perform light work as defined in 20 C.F.R. § 404.1567(b)
except she has the following non-exertional limitations: the claimant can
understand, remember and carry out simple instructions, and she can make
judgments on simple work-related decisions. She requires a job with only
occasional decision making and only occasional changes in the work setting. She
can have no interaction with the public, and only occasional interaction with coworkers and supervisors. She is able to maintain concentration and attention for
two-hour segments over an eight-hour period, and she can complete a normal
workweek without excessive interruptions from psychologically or physically
based symptoms.
(Doc. 9-2, at 47).
Having assessed a claimant’s RFC, at step four the ALJ must determine whether the
claimant has the RFC to perform the requirements of their past relevant work. 20 C.F.R. §
404.1520(a)(4)(iv). A finding that the claimant can still perform past relevant work requires a
determination that the claimant is not disabled. 20 C.F.R. § 404.1520(a)(4)(iv). Past relevant
work is defined as work the claimant has done within the past 15 years, that was substantial
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gainful activity, and that lasted long enough for the claimant to learn how to do it. 20 C.F.R. §
404.1560(b). If the claimant cannot perform past relevant work or has no past relevant work,
then the analysis proceeds to the fifth step.
The ALJ determined Heller is unable to perform past relevant work. (Doc. 9-2, at 51).
The ALJ noted past relevant work as an appointment clerk, bookkeeper, receptionist, and
administrative clerk, but, relying on the testimony of a vocational expert, determined that
performance of each exceeded the RFC that Heller possessed. (Doc. 9-2, at 51).
At step five of the sequential analysis process, an ALJ considers the claimant’s age,
education, and work experience to see if a claimant can make the adjustment to other work. 20
C.F.R. § 404.1520(a)(4)(v). These factors are not considered when evaluating a claimant’s
ability to perform past relevant work. 20 C.F.R. § 404.1560(b)(3). If a claimant has the ability to
make an adjustment to other work, they will not be considered disabled. 20 C.F.R. §
404.1520(a)(4)(v).
The ALJ made vocational determinations that Heller was 50 years old on the alleged
onset date, defined as an individual closely approaching advanced age. 20 C.F.R. § 404.1563.
(Doc. 9-2, at 51). The ALJ also found that Heller “has at least a high school education and is
able to communicate in English. 20 C.F.R. § 404.1564. (Doc. 9-2, at 51). The ALJ determined
that upon consideration of these factors, Heller’s RFC, and the testimony of a vocational
expert, “there are jobs that exist in significant numbers in the national economy that the
claimant can perform.” (Doc. 9-2, at 52). The ALJ found that Heller could perform such
occupations as mail clerk, marker, and office helper. (Doc. 9-2, at 52).
As a result of this analysis, the ALJ determined that Heller was not disabled and denied
Heller’s applications for benefits. (Doc. 9-2, at 52).
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III.

STANDARD OF REVIEW
In order to receive benefits under Title II or Title XVI of the Social Security Act, a

claimant must demonstrate an “inability to engage in any substantial gainful activity by reason
of any medically determinable physical or mental impairment 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. §§ 423(d)(1)(A), 1382c(a)(3)(A). To satisfy this requirement, a claimant
must have a severe physical or mental impairment that makes it impossible to do his or her
previous work or any other substantial gainful activity that exists in significant numbers in the
national economy. 42 U.S.C. § 423(d)(2)(A); 20 C.F.R. § 404.1505(a). Additionally, to be
eligible to receive benefits under Title II of the Social Security Act, a claimant must be insured
for disability insurance benefits. 42 U.S.C. § 423(a); 20 C.F.R. § 404.131.
In evaluating whether a claimant is disabled as defined in the Social Security Act, the
Commissioner follows a five-step sequential evaluation process. 20 C.F.R. § 404.1520(a); 20
C.F.R. § 416.920(a). Under this process, the Commissioner must determine, in sequence: (1)
whether the claimant is engaged in substantial gainful activity; (2) whether the claimant has a
severe impairment; (3) whether the claimant's impairment meets or equals a listed
impairment; (4) whether the claimant is able to do past relevant work, considering his or her
residual functional capacity (“RFC”); and (5) whether the claimant is able to do any other work
that exists in significant numbers in the national economy, considering his or her RFC, age,
education, and work experience. 20 C.F.R. § 404.1520(a); 20 C.F.R. § 416.920(a). The claimant
bears the initial burden of demonstrating a medically determinable impairment that prevents
him or her from doing past relevant work. 20 C.F.R. § 404.1512(a); 20 C.F.R. § 416.912(a).
Once the claimant has established at step four that he or she cannot do past relevant work, the
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burden then shifts to the Commissioner at step five to show that jobs exist in significant
numbers in the national economy that the claimant could perform that are consistent with his
or her RFC, age, education, and past work experience. 20 C.F.R. § 404.1512(f) ; 20 C.F.R. §
416.912(f).
In reviewing the Commissioner's final decision denying a claimant's application for
benefits, the Court's review is limited to determining whether the findings of the final decisionmaker are supported by substantial evidence in the record. See 42 U.S.C. § 1383(c)(3)
(incorporating 42 U.S.C. § 405(g) by reference); Johnson v. Comm'r of Soc. Sec., 529 F.3d 198, 200
(3d Cir. 2008); Ficca v. Astrue, 901 F. Supp. 2d 533, 536 (M.D. Pa. 2012). Substantial evidence
“does not mean a large or considerable amount of evidence, but rather such relevant evidence
as a reasonable mind might accept as adequate to support a conclusion.” Pierce v. Underwood,
487 U.S. 552, 565 (1988) (internal quotations omitted). Substantial evidence is less than a
preponderance of the evidence but more than a mere scintilla. Richardson v. Perales, 402 U.S.
389, 401 (1971). A single piece of evidence is not substantial evidence if the ALJ ignores
countervailing evidence or fails to resolve a conflict created by the evidence. Mason v. Shalala,
994 F.2d 1058, 1064 (3d Cir. 1993). In an adequately developed factual record, however,
substantial evidence may be “something less than the weight of the evidence, and the possibility
of drawing two inconsistent conclusions from the evidence does not prevent [the ALJ's
decision] from being supported by substantial evidence.” Consolo v. Fed. Maritime Comm'n, 383
U.S. 607, 620 (1966). “In determining if the Commissioner's decision is supported by
substantial evidence the court must scrutinize the record as a whole.” Leslie v. Barnhart, 304
F.Supp.2d 623, 627 (M.D. Pa. 2003). The question before the Court, therefore, is not whether
Heller is disabled, but whether the Commissioner's finding that she is not disabled is supported
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by substantial evidence and was reached based upon a correct application of the relevant
law. See Arnold v. Colvin, No. 3:12-CV-02417, 2014 WL 940205, at *1 (M.D. Pa. Mar. 11,
2014) (“[I]t has been held that an ALJ's errors of law denote a lack of substantial
evidence.”); Burton v. Schweiker, 512 F. Supp. 913, 914 (W.D. Pa. 1981) (“The [Commissioner]'s
determination as to the status of a claim requires the correct application of the law to the
facts.”); see also Wright v. Sullivan, 900 F.2d 675, 678 (3d Cir. 1990) (noting that the scope of
review on legal matters is plenary); Ficca v. Astrue, 901 F. Supp. 2d 533, 536 (M.D. Pa.
2012) (“[T]he court has plenary review of all legal issues decided by the Commissioner.”).
IV.

DISCUSSION
As stated above, Heller raises five points of error in the ALJ’s decision. She states that:

the ALJ should have found Heller’s impairments met or equaled Listings 12.04 and 12.06;
substantial evidence does not support the ALJ’s evaluation of opinion evidence; the ALJ’s RFC
is not supported by substantial evidence; the ALJ improperly evaluated Heller’s GAF scores,
and; substantial evidence does not support the ALJ’s credibility assessment. (Doc. 13, at 1-2).
A. THE ALJ DID NOT ERR IN CONCLUDING THAT HELLER’S IMPAIRMENTS DO NOT
MEET LISTINGS 12.04 AND 12.06.
First, Heller argues that she should have been found disabled at step three, by virtue of
her impairments meeting or equaling Listings 12.04 and 12.06. In order to meet Listing 12.04, a
claimant must establish either a depressive or bipolar disorder, accompanied by extreme
limitation in one of, or marked limitation in two of: understanding, remembering, or applying
information; interacting with others; concentrating, persisting, or maintaining pace; or adapting
or managing oneself; and well as “repeated” episodes of decompensation within the last 12
months. 20 C.F.R. Part 404, Subpt. P, App. 1 § 12.04. In the alternative to the latter
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requirement, a claimant may also be found to meet or equal Listing 12.04 if they establish a
“serious and persistent” disorder accompanied by medical treatment, therapy, psychosocial
support or a highly structured setting that is ongoing and diminishes the symptoms and signs or
the disorder and a minimal capacity to adapt to changes in the claimant’s environment or to
demands that are not already part of their daily life. 20 C.F.R. Part 404, Subpt. P, App. 1 §
12.04.
The ALJ determined that Heller did not meet the “Paragraph B” criteria, as she only
had mild limitations in activities of daily living, moderate difficulties in social functioning and
with concentration, persistence or pace, and had no episodes of decompensation. (Doc. 9-2, at
46). Heller states that she has “marked” limitations in social functioning and with
concentration, persistence, or pace; meeting the Paragraph B requirement of marked limitations
in at least two categories. (Doc. 13, at 17-18). Heller refutes this finding, first points to the
opinion of treating psychiatrist Dr. Anne Dall, who conducted a mental impairment
questionnaire in which Dr. Dall found Heller had marked restrictions in both social functioning
and maintaining concentration, persistence, or pace. (Doc. 9-16, at 39).
Listing requirements are strict, representing a higher level of severity than the statutory
standard. Orndorff v. Colvin, 215 F.Supp.3d 391, 407 (M.D. Pa. 2016). At the time of the ALJ’s
decision, social functioning referred to a claimant’s capacity to:
interact independently, appropriately, effectively, and on a sustained basis with
other individuals. Social functioning includes the ability to get along with others,
such as family members, friends, neighbors, grocery clerks, landlords, or bus
drivers. You may demonstrate impaired social functioning by, for example, a
history of altercations, evictions, firings, fear of strangers, avoidance of
interpersonal relationships, or social isolation. You may exhibit strength in social
functioning by such things as your ability to initiate social contacts with others,
communicate clearly with others, or interact and actively participate in group
activities. We also need to consider cooperative behaviors, consideration for
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others, awareness of others' feelings, and social maturity. Social functioning in
work situations may involve interactions with the public, responding
appropriately to persons in authority (e.g., supervisors), or cooperative behaviors
involving coworkers.
20 C.F.R. Part 404, Subpt. P, App. 1 § 12.00(C)(2).
In evaluating whether a claimant has “marked” limitations, the Commissioner does not
consider the quantity of deficiencies in the above, but “by the nature and overall degree of
interference with function. 20 C.F.R. Part 404, Subpt. P, App. 1 § 12.00(C)(2). Evaluation of
concentration, persistence, or pace considers a claimant’s “ability to sustain focused attention
and concentration sufficiently long to permit the timely and appropriate completion of tasks
commonly found in work settings.” 20 C.F.R. Part 404, Subpt. P, App. 1 § 12.00(C)(3).
The ALJ did not err in finding that Heller failed to meet or equal Listings 12.04 and
12.06. The ALJ notes that Heller is able to shop in stores and spend time with others (Doc. 9-6,
at 30), and that doctors note pleasant interactions with her and appropriate mood and affect
(Doc. 9-22). (Doc. 9-2, at 46). Further, in evaluating Heller’s concentration, persistence, or
pace, the ALJ noted that Heller is able to pay bills and use a checkbook (Doc. 9-6, at 29), and
doctors observe normal concentration as well as intact recent and remote memory (Doc. 9-8).
(Doc. 9-2, at 46). Treatment records from Dr. Dall also show consistent ability to complete
concentration testing. (Doc. 9-17).
The ALJ, upon considering the above thus determined that Heller is not restricted with
such severity as to meet or equal the Listings. While Dr. Dall opined as much, the ALJ found
Heller’s offered abilities contradicted these limitations. When tasked with reconciling
conflicting evidence, it is permissible to resolve disputes finding more moderated restrictions, so
long as substantial evidence supports such a conclusion. Having identified evidence to support
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more moderate restrictions, the ALJ did not err in concluding that Heller did not meet or equal
Listings 12.04 or 12.06.
B. SUBSTANTIAL EVIDENCE SUPPORTS
EVIDENCE.

THE

ALJ’S EVALUATION

OF

OPINION

In her second point of error, Heller argues that the ALJ erred in his evaluation of
opinion evidence, as substantial evidence does not support the weight afforded to treating
psychiatrist Dr. Dall, State Agency consultants Dr. Murphy and Dr. Legaspi, Dr. Dragann, PAC Kortright, or physical therapist Brose. (Doc. 13).
Heller argues that the ALJ improperly afforded “limited” weight to the Mental
Impairment Questionnaire completed by treating psychiatrist Dr. Dall.
Treating sources may be afforded controlling weight where their opinion is “wellsupported by medically acceptable clinical and laboratory diagnostic techniques and is not
inconsistent with the other substantial evidence” in a case record. 20 C.F.R. § 404.1527(c)(2).
Even where not entitled to controlling weight, the opinion of a treating source may still be given
great weight based on the length of the treating relationship, nature and extent of the treatment
relationship, supportability of the opinion, consistency of the opinion with the record as a
whole, specialization of the source, and any other factors offered by the claimant. 20 C.F.R. §
404.1527(c). When the treating physician's opinion conflicts with a non-treating, nonexamining physician's opinion, the ALJ may choose whom to credit in his or her analysis, but
“cannot reject evidence for no reason or for the wrong reason.” Morales v. Apfel, 225 F.3d 310,
317 (3d Cir.2000).
The ALJ addressed Dr. Dall’s opinions twice in the ruling. First, he afforded great
weight GAF scores assessed by Dr. Dall, finding these scores consistent with the record and Dr.
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Dall’s treatment notes. The ALJ then afforded limited weight to Dr. Dall’s Mental Impairment
Questionnaires completed on July 23, 2013 and July 23, 2014, finding the severity of limitations
assessed to be overstatements upon consideration of the treatment history, the foundation on
subjective complaints as opposed to objective testing, and noting that the findings make
judgments on issues reserved for the Commissioner. Only the latter is challenged as
unsupported by substantial evidence.
The ALJ’s generally-cited evidentiary support for affording limited weight to Dr. Dall’s
Questionnaires is Dr. Dall’s own treatment notes. (Doc. 9-17). The Commissioner argues these
records reflect a stable treatment history and contain numerous references to social interactions
that the ALJ may consider contrary to the level of severity determined by Dr. Dall.
“When a conflict in the evidence exists, the ALJ may choose whom to credit but ‘cannot
reject evidence for no reason or for the wrong reason.” Plummer v. Apfel, 186 F.3d 422, 429 (3d
Cir. 1999) (quoting Mason v. Shalala, 994 F.2d 1058, 1066 (3d Cir. 1993)). The ALJ must
indicate which evidence was accepted, which evidence was rejected, and the reasons for
rejecting certain evidence. Johnson v. Comm’r of Soc. Sec., 529 F.3d 198, 204 (3d Cir. 2008).
In choosing to reject the evaluation of a treating physician, an ALJ may not make
speculative inferences from medical reports and may reject treating physician's opinions
outright only on the basis of contradictory medical evidence. Morales, 225 F.3d at 317 (citations
omitted). An ALJ may not reject a written medical opinion of a treating physician based on his
or her own credibility judgments, speculation or lay opinion. Morales, 225 F.3d at 317. An ALJ
may not disregard the medical opinion of a treating physician based solely on his or her own
“amorphous impressions, gleaned from the record and from his evaluation of the [claimant]'s
credibility.” Morales, 225 F.3d at 318 (citation omitted).
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Mental impairments such as depression and anxiety, as diagnosed in Heller, may
manifest in symptoms difficult to quantify through objective medical evidence. A lack of
objective medical evidence is by itself insufficient to discredit claimant. SSR 16-3p. As noted by
other Third Circuit courts, impairments such as depression and anxiety “while medically
determinable, are difficult to substantiate by objective medical evidence.” Volage v. Astrue, No.
11-CV-4413, 2012 WL 4742373, at *7 (D.N.J. Oct. 1, 2012). “[T]he reports of treating
physicians, as well as the testimony of the claimant, become even more important in the
calculus for making a disability determination” in circumstances involving impairments for
which objective medical testing may not demonstrate the existence or severity of an
impairment. See Perl v. Barnhart, No. 03-4580, 2005 WL 579879, at *3 (E.D. Pa. March 10,
2005) (citing Green-Younger v. Barnhart, 335 F.3d 99, 108 (2d Cir. 2002)). Thus, credibility
becomes paramount in making the disability determination without objective medical evidence
to refute the findings of a treating source. The treatment history and subjective nature of
symptoms—the rationale cited for discounting Dr. Dall’s opinion—each evoke credibility
considerations.
The ALJ’s opinion thus fails in two respects. First, to the extent the ALJ discounted Dr.
Dall’s opinion due to a perceived reliance upon subjective complaints, the ALJ erred by
impermissibly making credibility determinations in lieu of identifying substantial evidence. In
order to find that Dr. Dall’s opinion that Heller had marked limitations was an
“overstatement[] of the claimant’s mental health conditions,” the ALJ inherently had to render
judgment on the credibility of the questionnaire and the source of the information contained
therein. Rejection of a treating source opinion for being based on subjective complaints of the

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claimant is not a reliance upon substantial evidence but on improper speculation. See Poust v.
Colvin, No. 3:14-cv-1357, 2015 WL 3405235, at *5 (M.D. Pa. May 26, 2015).
Second, the ALJ’s general identification of purported substantial evidence is insufficient
to allow for meaningful judicial review. Only substantial contrary medical evidence allows for a
treating source’s opinion to be diminished. Thus, the ALJ must identify evidence contradicting
the treating source’s opinion—which the ALJ attempts to do by pointing to Dr. Dall’s treatment
notes. Again in Poust, the Court rejected an ALJ’s determination of non-disability for the ALJ’s
improper consideration of two opinions by a treating source, the second of which was deemed
“not supported by the overall objective medical record or the claimant’s own testimony.” Poust,
2015 WL 3405235, at *5. The Court found the ALJ’s reasoning for discounting the second
opinion failed partially because the ALJ did not adequately explain why the opinion was not
supported by the record. Poust, 2015 WL 2405235, at *6.
The ALJ in this case found that the limitations contained in Dr. Dall’s questionnaire
“are not supported by Dr. Dall’s records of normal mental status examinations,” citing Exhibit
13F. (Doc. 9-2, at 51). The records cited contain 62 pages of treatment notes over the course of
a year by multiple providers, some of which reflect stability and still others show suicidal
ideation and an inability to maintain work attendance. (Doc. 9-17, at 10, 17, 21, 29, 42). Even
at normal mental status, Heller demonstrated repeated issues of instances that appear to
corroborate the limitations found, such as an inability to attend work, suicidal ideation,
inability to be alone, with strangers, or in unfamiliar situations. At times, assessments contained
in the treatment notes waver from finding that Heller could respond to and benefit from therapy
to determining that she could not. While some positive and stable condition is noted, other
periods demonstrate the contrary. A single piece of evidence is not substantial evidence if the
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ALJ ignores countervailing evidence or fails to resolve a conflict created by the evidence. Mason
v. Shalala, 994 F.2d 1058, 1064 (3d Cir. 1993).
The general citation by the ALJ is insufficient to evaluate whether or not the entirety of
the record was properly considered in crafting the RFC. The Third Circuit has long maintained
the need for adequate explanation for an ALJ’s rejection of relevant evidence. See Cotter v.
Harris, 642 F.2d 700, 706 (3d Cir. 1981). In light of this, the Court finds the explanation
proffered does not satisfy the Court’s inquiry on whether substantial evidence supports the
conclusions of the ALJ in reaching a determination of non-disability. Due to the generality, as
well as the noted rejection due to the subjective nature of Heller’s articulated symptoms, the
Court finds that the ALJ did not meet his burden of demonstrating that substantial evidence
does not support the opinion of treating source Dr. Dall.
V.

CONCLUSION
For the above-stated reasons, the Court finds that substantial evidence does not support

the Commissioner's decision. The Court thus orders the case be REMANDED with
instructions to re-evaluate the matter, particularly the opinion of Dr. Dall and with regard to
Heller's credibility. The Commissioner may also collect such evidence and hold hearings as she
finds appropriate.
An appropriate Order follows.

s/ Karoline Mehalchick

Dated: September 19, 2017

KAROLINE MEHALCHICK
United States Magistrate Judge
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