MCCULLUM v. COLVIN
ORDER granting in part and denying in part 9 Plaintiff's Motion for Summary Judgment and denying 11 Defendant's Motion for Summary Judgment, and the case is remanded for further evaluation in light of this Order. Signed by Judge Alan N. Bloch on 9/19/2017. (dpo)
IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF PENNSYLVANIA
HENRY EDWARD McCULLUM,
CAROLYN W. COLVIN,
Acting Commissioner of Social Security,
Civil Action No. 16-129-E
AND NOW, this 19th day of September, 2017, upon consideration of Defendant’s
Motion for Summary Judgment (Doc. No. 11) filed in the above-captioned matter on October 17,
IT IS HEREBY ORDERED that said Motion is DENIED.
AND, further, upon consideration of Plaintiff’s Motion for Summary Judgment (Doc. No.
9) filed in the above-captioned matter on September 9, 2016,
IT IS HEREBY ORDERED that said Motion is GRANTED IN PART and DENIED IN
PART. Specifically, Plaintiff’s Motion is granted to the extent that it seeks a remand to the
Commissioner of Social Security (“Commissioner”) for further evaluation as set forth below, and
denied in all other respects. Accordingly, this matter is hereby remanded to the Commissioner
for further evaluation under sentence four of 42 U.S.C. § 405(g) in light of this Order.
Plaintiff, Henry Edward McCullum, filed a claim for Disability Insurance Benefits under
Title II of the Social Security Act (the “Act”), 42 U.S.C. §§ 401-434, on February 24, 2014, and
protectively filed a claim for Supplemental Security Income under Title XVI of the Act, 42
U.S.C. §§ 1381-1383f, effective January 21, 2014, claiming that he became disabled on April 1,
2013, due to bipolar disorder, lower back problems, hearing loss in the left ear, high cholesterol,
and borderline diabetes.1 (R. 20, 101, 113, 198-210, 228). After being denied initially on July
10, 2014, Plaintiff sought, and obtained, a hearing before an Administrative Law Judge (“ALJ”)
on August 31, 2015. (R. 20, 38-79, 101-26). In a decision dated November 10, 2015, the ALJ
denied Plaintiff’s request for benefits. (R. 20-31). The Appeals Council declined to review the
ALJ’s decision on April 4, 2016. (R. 1-5). Plaintiff filed a timely appeal with this Court, and the
parties have filed cross-motions for summary judgment.
II. Standard of Review
Judicial review of a social security case is based upon the pleadings and the transcript of
the record. See 42 U.S.C. § 405(g). The scope of review is limited to determining whether the
Commissioner applied the correct legal standards and whether the record, as a whole, contains
substantial evidence to support the Commissioner's findings of fact. See Matthews v. Apfel, 239
F.3d 589, 592 (3d Cir. 2001) (noting that “‘[t]he findings of the Commissioner of Social Security
as to any fact, if supported by substantial evidence, shall be conclusive’” (quoting 42 U.S.C.
§ 405(g))); Schaudeck v. Comm’r of Soc. Sec. Admin., 181 F.3d 429, 431 (3d Cir. 1999) (stating
that the court has plenary review of all legal issues, and reviews the ALJ's findings of fact to
determine whether they are supported by substantial evidence).
“Substantial evidence” is defined as “‘more than a mere scintilla. It means such relevant
evidence as a reasonable mind might accept as adequate’” to support a conclusion. Plummer v.
Apfel, 186 F.3d 422, 427 (3d Cir. 1999) (quoting Ventura v. Shalala, 55 F.3d 900, 901 (3d Cir.
1995)). However, a “‘single piece of evidence will not satisfy the substantiality test if the
As will be further discussed below, Plaintiff later also alleged to be disabled due to left
shoulder pain. (R. 103, 115).
[Commissioner] ignores, or fails to resolve, a conflict created by countervailing evidence.’”
Morales v. Apfel, 225 F.3d 310, 317 (3d Cir. 2000) (quoting Kent v. Schweiker, 710 F.2d 110,
114 (3d Cir. 1983)). “‘Nor is evidence substantial if it is overwhelmed by other evidence—
particularly certain types of evidence (e.g., that offered by treating physicians)—or if it really
constitutes not evidence but mere conclusion.’” Id.
A disability is established when the claimant can demonstrate some medically
determinable basis for an impairment that prevents him or her from engaging in any substantial
gainful activity for a statutory twelve-month period. See Fargnoli v. Massanari, 247 F.3d 34, 3839 (3d Cir. 2001). “A claimant is considered unable to engage in any substantial gainful activity
‘only if his physical or mental impairment or impairments are of such severity that he is not only
unable to do his previous work but cannot, considering his age, education, and work experience,
engage in any other kind of substantial gainful work which exists in the national economy . . . .’”
Id. at 39 (quoting 42 U.S.C. § 423(d)(2)(A)).
The Social Security Administration has promulgated regulations incorporating a five-step
sequential evaluation process for determining whether a claimant is under a disability as defined
by the Act. See 20 C.F.R. §§ 404.1520, 416.920. In Step One, the Commissioner must
determine whether the claimant is currently engaging in substantial gainful activity. See 20
C.F.R. §§ 404.1520(a)(4)(i), 416.920(a)(4)(i). If so, the disability claim will be denied. See
Bowen v. Yuckert, 482 U.S. 137, 140 (1987). If not, the second step of the process is to
determine whether the claimant is suffering from a severe impairment. See 20 C.F.R.
§§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii). “An impairment or combination of impairments is not
severe if it does not significantly limit [the claimant’s] physical or mental ability to do basic
work activities.” 20 C.F.R. §§ 404.1522, 416.922. If the claimant fails to show that his or her
impairments are “severe," he or she is ineligible for disability benefits. If the claimant does have
a severe impairment, however, the Commissioner must proceed to Step Three and determine
whether the claimant’s impairment meets or equals the criteria for a listed impairment. See 20
C.F.R. §§ 404.1520(a)(4)(iii), 416.920(a)(4)(iii). If a claimant meets a listing, a finding of
disability is automatically directed. If the claimant does not meet a listing, the analysis proceeds
to Steps Four and Five.
Step Four requires the ALJ to consider whether the claimant retains the residual
functional capacity (“RFC”) to perform his or her past relevant work, see 20 C.F.R.
§§ 404.1520(a)(4)(iv), 416.920(a)(4)(iv), and the claimant bears the burden of demonstrating an
inability to return to this past relevant work, see Adorno v. Shalala, 40 F.3d 43, 46 (3d Cir.
1994). If the claimant is unable to resume his or her former occupation, the evaluation then
moves to the fifth and final step.
At this stage, the burden of production shifts to the Commissioner, who must demonstrate
that the claimant is capable of performing other available work in the national economy in order
to deny a claim of disability. See 20 C.F.R. §§ 404.1520(a)(4)(v), 416.920(a)(4)(v). In making
this determination, the ALJ should consider the claimant’s RFC, age, education, and past work
experience. See id. The ALJ must further analyze the cumulative effect of all the claimant’s
impairments in determining whether he or she is capable of performing work and is not disabled.
See 20 C.F.R. §§ 404.1523, 416.923.
The ALJ's Decision
In his November 10, 2015 decision, the ALJ found that Plaintiff met the insured
requirements of the Social Security Act through September 30, 2015. (R. 22). Accordingly, to
be eligible for DIB benefits, Plaintiff had to establish that he was disabled on or before that date.
See 42 U.S.C. §§ 423(a)(1)(A), (c)(1)(B); 20 C.F.R. §§ 404.101, .110, .131.
The ALJ then proceeded to apply the sequential evaluation process when reviewing
Plaintiff’s claim for benefits. In particular, the ALJ found that Plaintiff had not been engaged in
substantial gainful activity since the alleged onset date of April 1, 2013. (R. 22). The ALJ also
found that Plaintiff met the second requirement of the sequential evaluation process insofar as he
has the following severe impairments: “left shoulder, partial supraspinatus tear with bursitis,
acromioclavicular joint osteoarthritis, myofascial pain disorder, mood disorder, anxiety disorder,
and alcohol abuse in remission.” (R. 22-23). The ALJ found that several of Plaintiff’s alleged
limitations did not qualify as severe impairments, including his obesity, left ear sensorineural
hearing loss, borderline diabetes mellitus, and lumbar L5 spina bifida occulta. (R. 23).
The ALJ concluded that Plaintiff’s impairments did not meet any of the listings that would
satisfy Step Three. (R. 23-25).
The ALJ went on to find that Plaintiff retained the RFC to perform medium work with
the following additional limitations:
he can only frequently climb a ladder, rope or scaffold; he can only
frequently push, pull, or operate foot controls with the lower
extremities; he can only frequently climb ramps or stairs; he can
only frequently balance, stoop, kneel, crouch, or crawl; he can only
frequently reach in all directions to include overhead with his left
non-dominant upper extremity, but with no left non-dominant
manipulative limitation, and with no right dominant upper
extremity reaching or manipulation limitation; he must avoid all
exposure to unprotected heights, dangerous machinery, and like
workplace hazards; he is limited to understanding, remembering,
and carrying out simple instructions and performing simple,
routine tasks, such as those akin to requirements of work at the
SVP 1 or SVP 2 levels; he is limited to no work-related contact
with the public and only occasional and superficial interaction with
co-workers; and is limited to a low stress work environment, which
means no production rate pace work, but, rather, goal oriented
work with only occasional and routine change in work setting,
defining routine change as that which does not require alteration in
(R. 25-29). Based on this RFC, Plaintiff established that he is incapable of returning to his past
employment; therefore, the ALJ moved on to Step Five. (R. 29-30).
At Step Five, the ALJ then used a vocational expert (“VE”) to determine whether or not a
significant number of jobs existed in the national economy that Plaintiff could perform. The VE
testified that, given Plaintiff’s age, education, work experience, and RFC, Plaintiff could perform
jobs that exist in significant numbers in the national economy, such as agricultural packer, auto
detailer, and order picker. (R. 30-31). Accordingly, the ALJ found that Plaintiff was not
disabled. (R. 31).
Plaintiff argues that the ALJ insufficiently accounted for the opinion of his treating
psychologist, Angela Lindemuth, D.O., and that of the state reviewing agent, Shelley Ross,
Ph.D., in formulating his RFC. In particular, he points out that, although the ALJ made some
accommodation for Plaintiff’s limited ability to interact with the public and co-workers, he made
no such accommodation in regard to Plaintiff’s limitations in interacting with supervisors,
despite evidence in both Dr. Lindemuth’s opinion and Dr. Ross’ opinion suggesting such
limitations. The Court agrees that the ALJ’s failure to discuss this issue renders his
determination and discussion of Plaintiff’s RFC inadequate and necessitates remand for further
consideration and discussion.
RFC is defined as the most that an individual is still able to do despite the limitations
caused by his or her impairments. See Fargnoli v. Massanari, 247 F.3d 34, 40 (3d Cir. 2001).
See also 20 C.F.R. §§ 404.1545(a), 416.945(a). Not only must an ALJ consider all relevant
evidence in determining an individual’s RFC, the RFC finding “must ‘be accompanied by a clear
and satisfactory explication of the basis on which it rests.’” Fargnoli, 247 F.3d at 41 (quoting
Cotter v. Harris, 642 F.2d 700, 704 (3d Cir. 1981)). “‘[A]n examiner’s findings should be as
comprehensive and analytical as feasible and, where appropriate, should include a statement of
subordinate factual foundations on which ultimate factual conclusions are based, so that a
reviewing court may know the basis for the decision.’” Id. (quoting Cotter, 642 F.2d at 705).
See also SSR 96-8p, 1996 WL 374184 (S.S.A.), at *7 (“The RFC assessment must include a
narrative discussion describing how the evidence supports each conclusion, citing specific
medical facts (e.g., laboratory findings) and nonmedical evidence (e.g., daily activities,
Here, the ALJ clearly considered and discussed the opinions of Drs. Lindemuth and Ross
in formulating the RFC, but failed to discuss one common issue raised in both opinions. In her
response to a mental health impairment questionnaire completed by Dr. Lindemuth on
September 10, 2014, she opined that Plaintiff numerous restrictions involving social interactions,
including that he had a marked limitation in accepting instructions and responding appropriately
to criticism from supervisors. (R. 396). Likewise, in reviewing the record, Dr. Ross found
several social interaction limitations, and indicated that Plaintiff was moderately limited in his
ability to accept instructions and respond appropriately to criticism from supervisors. (R. 108,
121). She further stated that Plaintiff “would require some accommodation in accepting
instruction and help responding adaptively to criticism from supervisors.” (R. 109, 121).
Although the ALJ accounted for the other social limitations to which these professionals opined,
he did not account for any limitations involving interaction with supervisors nor explain why he
elected not to do so.
The ALJ was not required to simply adopt all of the findings in Dr. Lindemuth’s and Dr.
Ross’ opinions. Indeed, the opinions were not even fully consistent. He could have adopted
some and rejected others in favor of contrary evidence in the record, as it was ultimately up to
him to decide Plaintiff’s RFC. Cf. SSR 96–5p, 1996 WL 374183 (S.S.A.), at *4 (July 2, 1996)
(“Adjudicators must remember, however, that medical source statements may actually comprise
separate medical opinions regarding diverse physical and mental functions, such as walking,
lifting, seeing, and remembering instructions, and that it may be necessary to decide whether to
adopt or not adopt each one.”). Before doing so, however, the ALJ was required to provide some
explanation for why he was not adopting the restrictions regarding Plaintiff’s limited ability to
interact with supervisors to which both professionals opined. Absent that, the Court cannot say
whether the ALJ failed to incorporate any restrictions accounting for such limitations into his
RFC for “no reason or the wrong reason.” Plummer v. Apfel, 186 F.3d 422, 429 (3d Cir. 1999).
This lack of clarity must be addressed on remand. On remand, the ALJ should address the
findings regarding Plaintiff’s limited ability to interact with supervisors and either (1)
incorporate them into his RFC assessment and the hypothetical he poses to the VE; or (2) explain
why he is not adopting them. See Shaw v. Colvin, No. 14-1501, 2015 WL 4162446, at *3 (W.D.
Pa. July 9, 2015) (remanding case in which “it [was] uncertain why the ALJ chose to incorporate
certain limitations” in a medical source statement “and not others”). The Court expresses no
opinion as to whether the ALJ’s RFC assessment could be supported by the record or whether
additional restrictions are needed. Instead, it is the need for additional explanation by the ALJ
that necessitates a remand in this case. As such, the record does not permit the Court to reverse
and remand the case for an award of benefits. See Podedworny v. Harris, 745 F.2d 210, 221-22
(3d Cir. 1984).2
In short, the record does not permit the Court to determine whether the findings of the
ALJ regarding Plaintiff’s RFC are supported by substantial evidence, and, accordingly, the Court
finds that substantial evidence does not support the ALJ’s decision in this case. The Court
hereby remands the case to the Commissioner for reconsideration consistent with this Order.
s/Alan N. Bloch
United States District Judge
Counsel of record
Plaintiff also argues that the ALJ had no basis for finding him to be capable of frequently
reaching overhead with his left non-dominant upper extremity. While the Court does not reach
this issue, on remand the ALJ should address the issues raised by Plaintiff in regard to his
findings about Plaintiff’s ability to use his left upper extremity. In so doing, the ALJ may
consider obtaining additional information from Ted Woods, M.D., the consultative examiner,
regarding the nature of Plaintiff’s poor physical effort during the examination and how this poor
effort affects his opinion.
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