SPROWLS v. ASTRUE

Filing 17

MEMORANDUM OPINION indicating that, for reasons stated more fully within, the decision of the ALJ is not adequately supported by substantial evidence from Plaintiff's record within the meaning of 42 U.S.C. § 405(g). Accordingly, Defendant& #039;s Motion for Summary Judgment 15 is denied. Plaintiff's Motion for Summary Judgment 13 is granted to the extent that he seeks a vacation of the administrative decision under review, and the case is remanded for further proceedings. An appropriate Order follows. Signed by Judge Nora Barry Fischer on 3/12/12. (jg)

IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF PENNSYLVANIA
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MYRON D. SPROWLS
Plaintiff,
vs.
MICHAEL ASTRUE,
Commissioner of Social Security
Defendant.

Civil Action No. 11-0698
Judge Nora Barry Fischer

MEMORANDUM OPINION
I. INTRODUCTION
Myron David Sprowls, Jr. (“Plaintiff”) brings this action pursuant to 42 U.S.C. § 405(g),
seeking review of the final determination of the Commissioner of Social Security (“Defendant”
or “Commissioner”) denying his application for a period of disability and disability insurance
benefits (“DIB”) under Title II of the Social Security Act, 42 U.S.C. § 401-434 (“Act”). The
record has been developed at the administrative level. For the following reasons, the Court finds
that the decision of the Administrative Law Judge (“ALJ”) is not supported by substantial
evidence. Therefore, the Commissioner's Motion for Summary Judgment (Docket No. 15) is
DENIED and the Plaintiff's Motion for Summary Judgment (Docket No. 13) is GRANTED
insofar as it seeks a vacation of the administrative decision under review and REMANDED for
further consideration by the ALJ.
II. PROCEDURAL HISTORY
Plaintiff filed an application for DIB on May 27, 2008, claiming disability as of May 27,
2008. (R. at 10). The claim was initially denied on September 2, 2008. (Id.). Plaintiff appeared

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and testified at a hearing held on March 26, 2010 in Pittsburgh, Pennsylvania. (Id.). A
vocational expert also testified. (Id.). The Administrative Law Judge (“ALJ”) issued a decision
denying benefits to Plaintiff on April 22, 2010. (R. at 10-18). Plaintiff filed a request for review
of the ALJ’s decision by the Appeals Council, which request was denied on April 12, 2011,
thereby making the decision of the ALJ the final decision of the Commissioner. (R. at 1).
Plaintiff filed his Complaint in this Court on June 3, 2011, and Defendant filed his
Answer on December 28, 2011. (Docket Nos. 4, 10). Plaintiff subsequently filed his Motion for
Summary Judgment and Brief in Support on January 24, 2012. (Docket Nos. 13-14). Likewise,
Defendant filed his Motion for Summary Judgment and Brief in Support on February 14, 2012.
(Docket Nos. 15-16). As such, the Motions are now ripe for disposition.
III. FACTS
A. General Background
Plaintiff was born on May 21, 1960 and lives alone. (R. at 22). He is not married and
has no children. (R. at 66, 168). His step-brother lives nearby, but his sister and parents have
passed away. (R. at 29).
Plaintiff has a two-year Associate Degree from Triangle Tech, where he studied heating
and cooling. (R. at 22). He attended truck driving school and was employed as a truck driver
from 1993-2007. (R. at 22, 89). As a truck driver, he transported general merchandise, freight,
food stuffs, and clothing. (R. at 23). Prior to 2007, Plaintiff also worked as a delivery driver and
assistant manager at a pizza parlor, a gas station cashier, a machine operator, and as a security
guard in a steel mill. (R. at 23, 89). However, in 2007, his father began to have health troubles,
so Plaintiff quit work to care for him. (R. at 23). Since then, he has worked part-time at
Armando’s Pizza as a delivery driver and shop cleaner. (R. at 25-26).

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In his own self-report, Plaintiff claimed that he was unable to work based on his bipolar
disorder,1 arthritis, cataracts, carpal tunnel syndrome,2 plantar fasciitis,3 and issues related to his
gallbladder and colon. (R. at 82). He alleged these conditions affect lifting, squatting, bending,
standing, reaching, sitting, kneeling, stair climbing, seeing, memory, completing tasks,
concentration, understanding, following instructions, using his hands, and getting along with
others. (R. at 105). He had some difficulties with personal care. (R. at 101). Plaintiff prepared
food daily and would sometimes eat out. (R. at 102). He was able to do household chores as
needed. (Id.). He would drive his car or walk when going out. (R. at 103). He went grocery
shopping, and he paid his bills and handled checking and savings accounts. (Id.).
Most of Plaintiff’s day was spent reading the paper, watching television, or listening to
the radio. (R. at 104). He noted that it was difficult to concentrate. (Id.). Socially, he
sometimes spoke with others on the telephone and ate at restaurants. (Id.). Plaintiff claimed he
did not want anyone to bother him and preferred to be left alone. (R. at 105). He described
himself as always being a “loner.” (Id.).
Plaintiff further reported that he did not get along well with authority figures, but it is
unclear from the record whether he has ever been fired from a job due to problems getting along

1

Bipolar disorder is “a condition in which people go back and forth between periods of a very good or
irritable mood and depression. The "mood swings" between mania and depression can be very quick.” PubMed
Health, Bipolar disorder, available at http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001924/ (last visited
January 25, 2012).
2
Carpal tunnel syndrome is “the most common nerve entrapment syndrome, characterized by paresthesias,
typically nocturnal, and sometimes sensory loss and wasting in the median nerve distribution in the hand; often
bilateral and affects women more than men; due to chronic entrapment of the median nerve at the wrist within the
carpal tunnel.” STEDMAN’S MEDICAL DICTIONARY (28th ed. 2006).
3
Plantar fasciitis is “inflammation of the plantar fascia, most usually non-infectious, and often caused by an
overuse mechanism; elicits foot and heal pain.” STEDMAN’S MEDICAL DICTIONARY (28th ed. 2006).

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with others.4 (R. at 106). Regardless, he claimed that he cannot handle stress “at all” and
“hate[s]” any change. (Id.).
B. Medical History
Plaintiff’s past medical history includes bipolar disorder, depression, diverticulosis,5
hypertension,6 obesity and “CP.”7 (R. at 199, 201-02, 204). As of April 6, 2010, Plaintiff’s
medications included Geodon,8 Celexa9 and Lisinopril.10
i.

Psychiatric history

Plaintiff received in-patient psychiatric care in 1979 and 1983 for bipolar disorder and
schizoaffective disorder,11 respectively, and his last hospitalization for psychiatric treatment

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In his Disability Report, Plaintiff responded “yes” to the question “Have you ever been fired or laid off
from a job because of problems getting along with other people?” (R. at 106). However, Plaintiff explained: “[N]ot
really, but have been fired. But, usually I just quit because I dont [sic] want the hassel [sic].” (Id.).
5
Diverticulitis refers to “small, bulging sacs or pouches of the inner lining of the intestine (diverticulosis)
that become inflamed or infected. Most often, these pouches are in the large intestine (colon).” PubMed Health,
Diverticulitis, available at http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001303/ (last visited Jan. 25, 2012).
6
Hypertension refers to “[h]igh blood pressure; transitory or sustained elevation of systemic arterial blood
pressure to a level likely to induce cardiovascular damage or other adverse consequences.” STEDMAN’S MEDICAL
DICTIONARY (28th ed. 2006).
7
While the precise meaning of “CP” is unclear from the record, Plaintiff reported chest pains in 2006. (See
R. at 167).
8
Geodon (Ziprasidone) is “used to treat the symptoms of schizophrenia (a mental illness that causes
disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). It is also used to treat
episodes of mania (frenzied, abnormally excited or irritated mood) or mixed episodes (symptoms of mania and
depression that happen together) in patients with bipolar disorder (manic depressive disorder; a disease that causes
episodes of depression, episodes of mania, and other abnormal moods). Ziprasidone is in a class of medications
called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain.” PubMed
Health, Ziprasidone, available at http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001070/ (last visited Jan. 20,
2012).
9
Celexa (Citalopram) is “used to treat depression. Citalopram is in a class of antidepressants called selective
serotonin reuptake inhibitors (SSRIs). It works by increasing the amount of serotonin, a natural substance in the
brain that helps maintain mental balance.” PubMed Health, Citalopram, available at
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001041/ (last visited Jan. 20, 2012).
10
Lisinopril is “used alone or in combination with other medications to treat high blood pressure. It is used in
combination with other medications to treat heart failure. Lisinopril is also used to improve survival after a heart
attack. Lisinopril is in a class of medications called angiotensin-converting enzyme (ACE) inhibitors. It works by
decreasing certain chemicals that tighten the blood vessels, so blood flows more smoothly and the heart can pump
blood more efficiently.” PubMed Health, Lisinopril, available at
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000917/ (last visited Jan. 20, 2012).
11
Schizoaffective disorder is a “mental condition that causes both a loss of contact with reality (psychosis)
and mood problems.” PubMed Health, Schizoaffective disorder, available at
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001927/ (last visited Jan. 24, 2012).

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occurred in 1984. (R. at 154). Though Plaintiff took Lithium12 through 1987, the record reflects
that he only sought psychiatric treatment again at Southwestern Pennsylvania Human Services
Behavioral Health (“SPHS”) on June 23, 2008, after filing his disability claim. (R. at 150-58,
163). The initial assessment performed by SPHS staff indicated that he sought treatment for
anxiety, confusion, and depression, as he had recently experienced depression, irritability,
agitation, sleep disturbance, weight loss, anhedonia,13 crying spells, low self-esteem, racing
thoughts, risk-taking behavior, persecutory thoughts, auditory hallucinations, self-condemnatory
thoughts and mood swings. (R. at 150-52, 158). He denied any suicidal or homicidal intent. (R.
at 151). Plaintiff reported that, at age six, a teenage boy forced oral sex on him in a city park.
(R. at 153). He remarked that he drank alcohol daily or on weekends, particularly when he was
stressed, and admitted to smoking marijuana two months prior. (R. at 154).
During the assessment, Plaintiff’s mental status was normal and he was not delusional;
however, he was “suspicious.” (R. at 156). His Global Assessment of Functioning (“GAF”)14
was 45. (R. at 157). SPHS staff also noted Plaintiff’s past hospitalizations. (R. at 154).

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Lithium “is used to treat and prevent episodes of mania (frenzied, abnormally excited mood) in people with
bipolar disorder (manic-depressive disorder; a disease that causes episodes of depression, episodes of mania, and
other abnormal moods). Lithium is in a class of medications called antimanic agents. It works by decreasing
abnormal activity in the brain.” PubMed Health, Lithium, available at
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000531/ (last visited Jan. 31, 2012).
13
Anhedonia is the [a]bsence of pleasure from the performance of acts that would ordinarily be pleasurable.”
STEDMAN’S MEDICAL DICTIONARY (28th ed. 2006).
14
The Global Assessment of Functioning Scale (“GAF”) assesses an individual's psychological, social and
occupational functioning with a score of 1 being the lowest and a score of 100 being the highest. The GAF score
considers “psychological, social, and occupational functioning on a hypothetical continuum of mental healthillness.” American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (DSM–IV–TR)
34 (4th ed.2000). An individual with a GAF score of 91–100 exhibits “[s]uperior functioning in a wide range of
activities” and “no symptoms;” of 81–90 exhibits few, if any, symptoms and “good functioning in all areas,” is
“interested and involved in a wide range of activities,” is “socially effective,” is “generally satisfied with life,” and
experiences no more than “everyday problems or concerns;” of 71–80, may exhibit “transient and expectable
reactions to psychosocial stressors” and “no more than slight impairment in social, occupational, or school
functioning;” of 61–70 may have “[s]ome mild symptoms” or “some difficulty in social, occupational, or school
functioning, but generally functioning pretty well” and “has some meaningful interpersonal relationships;” of 51–60
may have “[m]oderate symptoms” or “moderate difficulty in social, occupational, or school functioning;” of 41–50
may have “[s]erious symptoms (e.g., suicidal ideation ... )” or “impairment in social, occupational, or school
functioning (e.g., no friends, unable to keep a job);” of 31–40 may have “[s]ome impairment in reality testing or

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On August 2, 2008, Ravi Kolli, M.D., conducted a psychiatric evaluation of Plaintiff at
SPHS. (R. at 163-65). Plaintiff explained his diagnosis of bipolar disorder in 1979 after
suffering a nervous breakdown and how he subsequently took Lithium for eight years. (R. at
163). Plaintiff did not take any other medication until April 2008 when Dr. Mannheimer
allegedly prescribed Seroquel.15 (Id.). However, Seroquel caused his blood pressure to drop so
he discontinued its use. (Id.).
At the evaluation, Plaintiff reported a great deal of stress due to his stepfather’s dementia
and sister’s drug addiction, as well as the fact that he had been unable to work since January
2007 and had no insurance for medical assistance. (Id.). He claimed his emotional problems as
well as cataracts affected his ability to work as a truck driver. (Id.). Plaintiff further described
his frequent mood swings, which made him agitated, happy, depressed, energetic, or even
reckless. (Id.). He denied any active suicidal ideations but admitted to passive death wishes in
the past. (Id.). He also experienced paranoia and heard voices when he did not sleep. (Id.).
Plaintiff denied using drugs or alcohol of late. (R. at 163-64).
Dr. Kolli noted that Plaintiff was cooperative but excessively talkative. (R. at 165). He
spoke with “loose associations” and “rambling speech” and demonstrated a tangential thought

communication” or “major impairment in several areas, such as work or school, family relations, judgment, thinking
or mood;” of 21–30 may be “considerably influenced by delusions or hallucinations” or “serious impairment in
communication or judgment (e.g., ... suicidal preoccupation)” or “inability to function in almost all areas;” of 11–20
may have “[s]ome danger of hurting self or others” or “occasionally fails to maintain minimal personal hygiene” or
“gross impairment in communication;” of 1–10 may have “[p]ersistent danger of severely hurting self or others” or
“persistent inability to maintain minimal personal hygiene” or “serious suicidal act with clear expectation of death.”
Id.
15
Seroquel (Quetiapine) tablets and extended-release (long-acting) tablets are used to treat the symptoms of
schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or
inappropriate emotions). Quetiapine tablets and extended-release tablets are also used alone or with other
medications to treat or prevent episodes of mania (frenzied, abnormally excited or irritated mood) or depression in
patients with bipolar disorder (manic depressive disorder; a disease that causes episodes of depression, episodes of
mania, and other abnormal moods). PubMed Health, Quetapine, available at
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001030/ (last visited Jan. 29, 2012). The administrative record
shows that Plaintiff visited Dr. Mannheimer on May 19, 2008, and the record of that visit indicates that Plaintiff was
already taking 50mg of Seroquel. (R. at 142). Further, Dr. Mannheimer only evaluated Plaintiff once. (Id.).

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process. (Id.). Though Dr. Kolli reported that Plaintiff was irritable at times, had racing
thoughts, suffered from paranoia and had passive death wishes, he still found that Plaintiff’s
“judgement [sic] can be good.” (Id.)
Dr. Kolli diagnosed Plaintiff with bipolar disorder (mixed type) and hypertension. (Id.).
He remarked that Plaintiff’s psychosocial stressors were “moderate to severe” due to having no
job or insurance. (Id.). His GAF was “about 50.” (Id.). Stating that Plaintiff was clearly in
need of medication for his bipolar disorder, Dr. Kolli encouraged him to try Geodon and gave
him samples of the same. (Id.).
Plaintiff also began taking Celexa in 2008 and presented to Dr. Kolli several times in
2009 for consultation and medication management. (R. at 217, 227-31). Dr. Kolli’s progress
notes from January 17, 2009 through October 24, 2009 generally show that Plaintiff continued
taking Celexa and Geodon and that he was less anxious, paranoid, and depressed. (See R. at
227-31). On May 16, 2009, Plaintiff reported that he had surgery on one eye and was
anticipating surgery on the other so he could return to work. (R. at 229). By August 22, 2009,
Plaintiff was truck driving again. (R. at 228). The October 24, 2009 progress note indicated that
Plaintiff’s “mood [was] clearly stable.” (R. at 227). Plaintiff did not report any symptoms of
mania or depression but admitted to some anxiety. (Id.). His GAF was 65. (Id.).
Despite these results, Dr. Kolli completed a mental status questionnaire on February 2,
2010, reporting that Plaintiff would be unable to work eight hours per day on a daily basis and
would miss four to seven days of work per month due to his symptoms. (R. at 234). He
acknowledged Plaintiff suffered from bipolar disorder, and most recently, depression with
psychotic features. (R. at 232). He explained that his symptoms included agitation and anxiety,
depression, racing thoughts, paranoia, mood swings (including elevated moods at times and

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elevated energy levels) and reckless behavior during manic episodes. (Id.). Dr. Kolli’s
prognosis was guarded, all the while recognizing that antipsychotic medication, mood stabilizers
and antidepressants, in combination, had decreased Plaintiff’s symptoms. (Id.). He noted that
Plaintiff continued to require medication adjustment. (Id.). He further explained that Plaintiff
continued to have high levels of anxiety and would require life-long treatment through
medication and counseling “to prevent more severe and frequent mood episodes.” (Id.).
ii.

Psychiatric evaluations

Jack Mannheimer, M.D., performed a psychiatric evaluation of Plaintiff on May 19,
2008, and he submitted a report of said visit, dated June 30, 2008, to the Bureau of Disability
Determination. (See R. 141-48). The report noted that, while Plaintiff’s mood was “irritable”
and his affective expression “intense,” his stream and content of thought were organized and
logical, his memory and judgment were intact, and his insight was good. (R. at 143-44). From
Dr. Mannheimer’s perspective, Plaintiff would be capable of managing benefits on his own
behalf, and Plaintiff did not demonstrate difficulties performing daily activities on a sustained
basis. (R. at 144). However, he found that Plaintiff did demonstrate limitations in his ability to
interact with family, friends, neighbors, co-workers, employers or the general public
appropriately and/or effectively based on the fact that Plaintiff had “poor interpersonal
interactions” and reported holding numerous past jobs. (R. at 144-45). Dr. Mannheimer noted
marked restrictions in his ability to interact appropriately with the public and with supervisors
and to respond appropriately to work pressures in a usual work setting. (R. at 147). He also
found Plaintiff moderately restricted in his ability to interact appropriately with co-workers and
in his ability to respond appropriately to changes in a routine work setting. (Id.). At the same

8

time, his ability to understand, remember, and carry out instructions was not affected by his
impairment. (Id.).
Edward Jonas, Ph.D., conducted a mental residual functional capacity assessment and a
Psychiatric Review Technique Form SSA-2506-BK regarding Plaintiff on August 11, 2008. (R.
at 177-93). In his evaluation, Dr. Jonas found that Plaintiff indeed suffered from bipolar
disorder. (R. at 184). However, he found Plaintiff was not significantly limited in his
understanding and memory. (R. at 177). Generally, he was also not significantly limited in
terms of sustained concentration and persistence, but he was moderately limited in his ability to
work in coordination with, or proximity to, others without being distracted by them. (Id.). With
regard to his social interaction, Plaintiff was markedly limited in terms of his ability to interact
appropriately with the general public. (R. at 178). He was moderately limited both in his ability
to accept instructions and respond appropriately to criticism from supervisors and in his ability to
get along with coworkers or peers without distracting them or exhibiting behavioral extremes.
(Id.). Similarly, Plaintiff was moderately limited in his ability to respond appropriately to
changes in the work setting and in his ability to set realistic goals or make plans independently of
others. (Id.).
After review of the medical records and findings of Dr. Mannheimer, Dr. Jonas opined
that Plaintiff was “able to meet the basic mental demands of competitive work on a sustained
basis despite the limitations resulting from his impairment.” (R. at 179). The assessment
claimed to partially reflect the opinion of Dr. Mannheimer, whose statements concerning
Plaintiff “are fairly consistent with the other evidence in file.” (Id.). Therefore, Dr.
Mannheimer’s report was given “appropriate weight” and found to be “partially consistent” with
the assessment. (Id.).

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iii.

Physical history

For issues relating to his eyesight, Plaintiff presented to Dr. Gipson on August 6, 2007
and on February 18, 2008. (R. at 159-60). During the first visit, he complained of blurred
vision, and Dr. Gipson discovered mild cataracts in both eyes. (R. at 159). Dr. Gipson told
Plaintiff that cataract surgery was not needed at that point and that he should follow-up in seven
months. (Id.). When Plaintiff returned on February 18, 2008, he reported particular blurriness in
his left eye and difficulty seeing road signs and seeing close-up. (R. at 160). Both cataracts
were still mild. (Id.). Dr. Gipson recommended that Plaintiff return in six months, unless his
vision became significantly worse such that he wanted or needed cataract surgery. (Id.).
On April 2, 2009, Plaintiff sought treatment from Dr. Holets, complaining of right hand
numbness, particularly in the morning, in the palm side of the right hand. (R. at 204). Dr. Holets
diagnosed Plaintiff as having an ulnar nerve lesion and prescribed an elbow brace as treatment.
(R. at 205). Dr. Holets also noted that Plaintiff’s hypertension was associated with obesity but
had improved eighty to ninety percent due to his medical regimen. (Id.). He further described
Plaintiff’s bipolar affective disorder as “mild.” (Id.).
Plaintiff returned to Dr. Holets on April 20, 2009 for a check-up prior to cataract surgery
the following week. (R. at 202, 211). He again complained of diminished vision, particularly in
his left eye. (R. at 202). His hand pain was unchanged since the last visit, so Dr. Holets started
Plaintiff on a prescription for Medrol16 and Mobic.17 (R. at 202-03). Plaintiff denied any
depression. (R. at 202).

16

Medrol (Methylprednisolone Oral), “a corticosteroid, is similar to a natural hormone produced by your
adrenal glands. It is often used to replace this chemical when your body does not make enough of it. It relieves
inflammation (swelling, heat, redness, and pain) and is used to treat certain forms of arthritis; skin, blood, kidney,
eye, thyroid, and intestinal disorders (e.g., colitis); severe allergies; and asthma. Methylprednisolone is also used to
treat certain types of cancer.” PubMed Health, Methylprednisolone Oral, available at
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000776/ (last visited Jan. 30, 2012).

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Plaintiff followed-up with Dr. Holets on June 19, 2009 regarding his right hand pain. (R.
at 201). He told Dr. Holets that he thought the numbness was seventy-five percent better but still
present – mostly in the “pinky” finger. (Id.). Dr. Holets found no swelling, and Plaintiff
exhibited “satisfactory” strength in the hand as well as “intact” sensation. (Id.). Dr. Holets
noted Plaintiff’s left eye cataract surgery in April 2009 and right eye cataract surgery in May
2009. (Id.). He also instructed Plaintiff to continue taking Mobic. (Id.).
Plaintiff again presented to Dr. Holets on January 8, 2010 for suture removal after falling
on ice, at which time Dr. Holets instructed Plaintiff to continue his medications for bipolar
disorder, depression, hypertension, and the hand pain relating to his ulnar nerve. (R. at 199).
iv.

Physical evaluations

Dr. Holets performed a physical consultative examination of Plaintiff on behalf of the
Bureau of Disability Determination on August 5, 2008. (R. at 166-69). During the assessment,
Plaintiff discussed his history of bipolar disorder, including treatment. (R. at 166). He
complained of arthritic pain while walking, as well as the fact that he had to quit his last job as a
truck driver one and a half years earlier due to his cataracts. (R. at 166-67). When questioned
about his gallbladder, Plaintiff reported chest pains two years prior. (R. at 167). A subsequent
CT scan showed Plaintiff to have cholelithiasis,18 which is asymptomatic. (Id.).

17

Mobic (Meloxicam) is “used to relieve pain, tenderness, swelling, and stiffness caused by osteoarthritis
(arthritis caused by a breakdown of the lining of the joints) and rheumatoid arthritis (arthritis caused by swelling of
the lining of the joints). Meloxicam is also used to relieve the pain, tenderness, swelling, and stiffness caused by
juvenile rheumatoid arthritis (a type of arthritis that affects children) in children 2 years of age and older. Meloxicam
is in a class of medications called nonsteroidal anti-inflammatory drugs (NSAIDs). It works by stopping the body's
production of a substance that causes pain, fever, and inflammation.” PubMed Health, Meloxicam, available at
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000173/ (last visited Jan. 30, 2012).
18

Cholelithiasis refers to the “[p]resence of concretions in the gallbladder or bile ducts.” STEDMAN’S
MEDICAL DICTIONARY (28th ed. 2006).

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Plaintiff stated he was doing “fairly well.” (Id.). He had no recent weight loss or gain,
though he was obese at 67 inches tall and 235 pounds. (R. at 167-68). He mentioned his
hypertension and admitted to using a lot of salt. (R. at 167). Dr. Holets noted Plaintiff’s history
of asymptomatic gallstones and that he was due for a colonoscopy, which he had not yet had due
to his lack of insurance. (Id.). Plaintiff underwent outpatient carpal tunnel surgery in 1993, and
“occasionally complains of some tingling in his left hand.” (Id.). With regard to Plaintiff’s 2006
chest pain, a subsequent stress test was negative. (Id.).
Dr. Holets found Plaintiff to be awake, alert, and oriented. (R. at 168). Plaintiff
exhibited normal gait and he was able to walk “with ease on his toes and on his heels.” (Id.). He
remarked that Plaintiff could lift and carry twenty-five pounds “easily” and that standing,
walking, sitting, pushing and pulling would be unlimited. (R. at 169). Further, he had no
restrictions on postural activities or other physical function or environmental restrictions. (Id.).
In a physical residual functional capacity assessment completed by state agency
evaluator, Darren Gallaher, on August 11, 2008, Plaintiff’s primary diagnosis was obesity, and
his secondary diagnosis was cataracts. (R. at 170). Plaintiff exhibited some exertional
limitations, but not any postural, manipulative, visual, communicative or environmental
limitations. (R. at 171-73). Gallaher found Plaintiff to have provided inconsistent information
regarding his daily activities. (R. at 175). While Plaintiff “alleged performing few, if any,
household chores . . . the overall evidence suggests that he has the ability to care for himself and
maintain his home.” (Id.). Furthermore, Gallaher explained that “he is able to drive a car” and
“the treatment for his impairments has been essentially routine and conservative in nature.”
(Id.). Although the field office personnel observed him having difficulty with his sight while at
the field office, they did not observe other difficulties. (Id.). Accordingly, Gallaher gave great

12

weight to the August 5, 2008 report by Dr. Holets, which stated that Plaintiff is not limited in
standing, walking, sitting, or pushing and pulling. (R. at 176).
C. Administrative Hearing
i. Plaintiff’s Testimony
A hearing regarding Plaintiff’s application for DIB was held on March 26, 2010 in
Pittsburgh, Pennsylvania before ALJ James Bukes. (R. at 19). At this hearing, Plaintiff
appeared with the assistance of counsel, Lindsay Brown, Esquire. (Id.). Ms. Copar,19 an
impartial vocational expert, also appeared to testify. (Id.).
Plaintiff initially testified as to his living situation and work history. (R. at 22-23). He
then described how he began to re-exhibit symptoms of depression and bipolar disorder in May
2008. (R. at 24). In the past, he also had problems with alcohol, though he claimed to have
stopped drinking since his treatment for depression and bipolar disorder. (Id.). He did not
consider himself an alcoholic, nor did he attend Alcoholics Anonymous (“AA”) meetings. (R. at
29). Plaintiff reported that Dr. Kolli prescribed him Geodon and Celexa for his psychological
ailments, while Dr. Holets prescribed Lisinopril. (R. at 24). Because Celexa and Lisinopril
made Plaintiff drowsy, he took those medications in the evening. (R. at 31).
Plaintiff further testified that, since 2007, he received unemployment benefits for a period
of time. (R. at 25). When those benefits ceased, he obtained a part-time job at Armando’s Pizza.
(Id.). As of the date of the administrative hearing, Plaintiff still worked part-time at Armando’s
Pizza, approximately six and one-half hours per day. (R. at 26). He claimed that, while he only
made $1,725 in all of 2009, he had already earned $1,500 in 2010. (R. at 25). Accordingly, he

19

Ms. Copar is a certified vocational expert and has many years of experience as a vocational supervisor and
vocational case manager in Pittsburgh, Pennsylvania. (R. at 59-60).

13

was earning roughly $600 per month. (R. at 26). Plaintiff reported difficulty remembering
orders, getting “lost on deliveries,” and delivering food to the wrong individuals. (R. at 30).
In 2009, Plaintiff obtained insurance coverage for a brief period to undergo surgery to
remove cataracts in both eyes. (R. at 26-27). He stated that, at that point, he was almost blind in
one eye. (R. at 27). He also mentioned that, in January 2009, he was asked to schedule a followup appointment with his surgeon but he had not done so because his previous coverage had
expired. (Id.).
Plaintiff explained he also had carpal tunnel syndrome in his right wrist and a problem
with the ulnar nerve in his right elbow, which he claimed requires surgery. (Id.). The nerve
problem resulted in numbness in his right hand, although it had improved in the past eight
months such that he only felt numbness for about half an hour or forty-five minutes in the
morning and “then it sort of goes away.” (R. at 27-28). Plaintiff testified he weighed roughly
215 pounds. (R. at 28).
Plaintiff also reported receiving psychiatric treatment from Dr. Kolli at SPHS. (Id.). He
saw Dr. Kolli every two months and Ms. Spindler, a counselor, once a month for “individual
therapy.” (Id.). Due to Plaintiff’s low income, he claimed “the county [was] paying” for his
psychiatric treatments and evaluations, though he denied receiving public assistance. (Id.).
Plaintiff testified that, on a typical day, he would wake up in the morning and then
usually eat at a local restaurant. (R. at 28-29). Then he would return home and spend “all day
sitting there,” watching significant amounts of television. (R. at 29). Though he owned a dog
and would take the dog for walks, he stated that he did not have “any hobbies or anything. I just
– I do watch a lot of [television] though.” (Id.).

14

Plaintiff stated that did not believe he is able to work a full-time job due to his bipolar
disorder. (Id.). He claimed that he was “very nervous all the time” and had “a hard time
concentrating on stuff.” (R. at 29-30). He also said that he had always had a great deal of
anxiety. (R. at 30). However, while he often woke up during the night, he slept approximately
eight hours. (Id.). He occasionally took naps in the evening. (Id.). He explained that he did not
have general fatigue and was “okay” most days. (R. at 30-31).
ii. Vocational Expert’s Testimony
Following Plaintiff’s testimony, the ALJ asked Ms. Copar to classify Plaintiff’s past work
experience. (R. at 31). Ms. Copar designated a cashier as an unskilled position with a light
exertion level and a food deliverer as an unskilled position with a medium exertion level. (Id.).
She stated the security guard position was semi-skilled with a sedentary exertion level as
performed, while the truck driver position was semi-skilled with heavy exertion as performed.
(Id.). Then, the ALJ questioned Ms. Copar as to whether work existed for a hypothetical person
of Plaintiff’s age, education level and work experience. (R. at 32). He specifically asked Ms.
Copar to assume that the hypothetical person would be limited to medium work, jobs that do not
require acute vision or “fine fingering” with the right hand, jobs that avoid work and close
coordination with co-workers, and those that avoid intensive supervision and changes in the
work setting. (Id.). Ms. Copar responded that such an individual could perform the food
deliverer or security guard position. (Id.).
However, assuming the hypothetical person should also avoid assembly line pace and
anything more than simple decision-making, Ms. Copar eliminated the security guard position.
(Id.). Such individual could, however, work as a laundry folder, with over 100,000 positions in
the national economy, or as an order caller, with over 500,000 positions nationally. (R. at 33).

15

Finally, said individual could work as a sorter, with over 400,000 positions. (Id.). Further
assuming that the described individual should avoid face-to-face interaction with the general
public, Ms. Copar eliminated the order caller position but not the laundry folder or sorter
position. (Id.). Finally, there would be no jobs in the national economy for an individual with
manic episodes that required him or her to take unscheduled breaks throughout the work day.
(Id.).
D. ALJ’s Decision
The ALJ issued his decision on April 22, 2010 and made the following determinations:
1. Plaintiff meets the insured status requirements of the Social Security Act through
September 30, 2012;
2. Plaintiff has not engaged in substantial gainful activity since May 27, 2008, the
alleged onset date (20 CFR 404.1520(b) and 404.1571 et seq.);
3. Plaintiff has the following severe impairments: bipolar affective disorder with a
history of psychotic features that are not controlled on medication; anxiety disorder;
obesity; bilateral mild cataracts; and mild to moderate peripheral neuropathy affecting
the right hand (20 CFR 404.1520(c));
4. Plaintiff does not have an impairment or combination of impairments that meets or
medically equals one of the listed impairments in 20 CFR Part 404, Subpart P,
Appendix 2 (20 CFR 404.1520(d), 404.1525 and 404.1526);
5. Plaintiff has the residual functional capacity to perform medium work, except that he
cannot perform fine manipulative activities with the dominant right hand, cannot do
any job that requires acute vision, cannot work in close coordination with coworkers
or under intensive supervision, cannot work in a setting where there are frequent or

16

substantial changes, can make only simple decisions, and cannot work at an assembly
line pace, and cannot work face to face with the general public;
6. Plaintiff is unable to perform past relevant work (20 CFR 404.1565);
7. Plaintiff was born on May 21, 1960 and was 48 years old which is defined as a
younger individual age 18-49, on the alleged disability onset date (20 CFR 404.1563);
8. Plaintiff has more than a high school education and is able to communicate in English
(20 CFR 404.1564);
9. Transferability of job skills is not material to the determination of disability because
Plaintiff is limited to unskilled work; and
10. Considering Plaintiff’s age, education, work experience, and residual functional
capacity, there are jobs that exist in significant numbers in the national economy that
Plaintiff can perform (20 CFR 404.1560(c) and 404.1566).
Thus, the ALJ found that Plaintiff has not been disabled within the meaning of the Social
Security Act at any time from the date the application was filed through the date of the ALJ
decision. (R. at 12-18).
The ALJ determined that Plaintiff’s bipolar disorder “with a history of psychotic features
that are now controlled on medication,” anxiety disorder, obesity, bilateral mild cataracts and
mild to moderate peripheral neuropathy affecting the right hand do limit Plaintiff’s ability to
complete basic physical and mental work. (R. at 12). However, acknowledging that Plaintiff
also has a history of carpal tunnel syndrome, hypertension, and alcohol abuse that has been in
remission since 2008, the ALJ found that these conditions “have not caused more than a minimal
loss of ability to do basic work activities for any period of twelve months or more since the

17

alleged onset date of disability.” (R. at 12-13). As such, Plaintiff’s ailments are not severe
medically determinable impairments. (R. at 13).
Further, the ALJ found that Plaintiff has only mild restriction in activities of daily living.
(Id.). For instance, he works three days a week, driving a pizza delivery car and keeping the
shop clean. (Id.). He also dines at restaurants, handles his personal affairs independently, and
completes his own household chores. (Id.). In terms of social functioning, however, he has
moderate difficulties. (Id.). Although the “more severe signs of mental illness have abated with
treatment . . . he still has a degree of anxiety that would keep him from concentrating and
persisting at difficul[t] or highly stressful tasks.” (Id.). Nonetheless, the ALJ explained that the
record does not demonstrate any episode of decompensation. (Id.).
The ALJ also determined that Plaintiff has the residual functional capacity to perform
medium work, “except that he cannot perform fine manipulative activities with the dominant
right hand, cannot do any job that requires acute vision, cannot work in close coordination with
coworkers or under intensive supervision, cannot work in a setting where there are frequent or
substantial changes, can make only simple decisions, and cannot work at an assembly pace, and
cannot work face to face with the general public.” (R. at 14). Still, the ALJ considered a number
of factors, which, on balance, did “not favor a finding that [Plaintiff] cannot do any work at a
level consistent with substantial gainful activity.” (R. at 15). For example, he has a solid work
record, he did not quit his full-time job for medical reasons but rather to care for his father, and
he has not required substantial treatment for the numbness in his hand. (Id.). Plaintiff does not
suffer from a loss of range of motion or of strength, and an electrodiagnostic test showed only
mild neuropathy. (Id.). Further, Plaintiff “had no deficits of strength or of sensation” with

18

regard to the numbness in his hand, and his obesity is mild, which would not affect his ability to
sit, stand, walk, use his hands or arms, or lift and carry objects. (Id.).
Nonetheless, the ALJ found that Plaintiff is unable to perform any past relevant work, as
his former jobs fall within his physical capacity but may exceed his tolerance for social
interaction. (R. at 17). The ALJ acknowledged Plaintiff’s history of anxiety and depression and
remarked that he has not received in-patient mental health treatment since 1984. (R. at 16).
Though he sought mental health services in May 2008, “the symptoms that prompted him to seek
treatment have largely been resolved by treatment.” (Id.). Additionally, Plaintiff no longer
displays psychotic symptoms and has continued to maintain a GAF of 60 to 65, which is
“indicative of only mild to moderate functional impairment.” (Id.).
The ALJ found that the opinion evidence submitted by Dr. Kolli in his mental status
questionnaire was “inconsistent on its face.” (Id.). Though Dr. Kolli asserted that Plaintiff could
not work full time because of his symptoms, he also found that Plaintiff only had mild
restrictions in his ability to handle social interaction and to concentrate, persist, and maintain
pace at assigned tasks. (Id.). Further, Dr. Kolli did not mention that Plaintiff “experienced any
loss of the ability to perform ordinary activities of daily living,” and he noted in his treatment
records that Plaintiff was doing well. (Id.). The ALJ also pointed out that Plaintiff’s symptoms
of severe mental illness abated soon after Plaintiff began treatment and did not recur for any
continuous period of twelve months or more after the alleged onset date. (Id.). Nonetheless, the
ALJ indicated that Dr. Kolli did not fully consider Plaintiff’s inability to handle certain social
situations and to concentrate on tasks; as such, the ALJ found he was “moderately limited in
these areas” in light of Dr. Mannheimer’s opinion. (R. at 16-17).

19

Since the vocational expert testified that a hypothetical individual in Plaintiff’s position
could perform as a laundry folder or a sorter, positions which account for more than 500,000 jobs
in the national economy, the ALJ determined that Plaintiff “is capable of making a successful
adjustment to other work” and is, therefore, not disabled within the meaning of the Social
Security Act. (R. at 18). This decision is now being challenged by Plaintiff.
IV. STANDARD OF REVIEW
To be eligible for disability insurance benefits under the Act, a claimant must
demonstrate to the Commissioner that he or she cannot engage in substantial gainful activity
because of a 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 at least
twelve months. 42 U.S.C. § 423(d)(1)(A); Brewster v. Heckler, 786 F.2d 581, 583 (3d Cir.
1986). When reviewing a claim, the Commissioner must utilize a five-step sequential analysis to
evaluate whether a claimant has met the requirements for disability. 20 C.F.R. §§ 404.1520,
416.920.
The Commissioner must determine: (1) whether the claimant is currently engaged in
substantial gainful activity; (2) if not, whether the claimant has a severe impairment or a
combination of impairments that is severe; (3) whether the medical evidence of the claimant's
impairment or combination of impairments meets or equals the criteria listed in 20 C.F.R., Pt.
404, Subpt. P, App'x 1; (4) whether the claimant's impairments prevent him from performing his
past relevant work; and (5) if the claimant is incapable of performing his past relevant work,
whether he can perform any other work which exists in the national economy. 20 C.F.R. §
404.1520(a)(4); see Barnhart v. Thomas, 540 U.S. 20, 24–25, 124 S.Ct. 376, 157 L.Ed.2d 333
(2003). If the claimant is determined to be unable to resume previous employment, the burden

20

shifts to the Commissioner (Step 5) to prove that, given claimant's mental or physical limitations,
age, education, and work experience, he or she is able to perform substantial gainful activity in
jobs available in the national economy. Doak v. Heckler, 790 F.2d 26, 28 (3d Cir. 1986).
Judicial review of the Commissioner's final decisions on disability claims is provided by
statute, and is plenary as to all legal issues. 42 U.S.C. §§ 405(g),20 1383(c)(3)21; Schaudeck v.
Comm'r Soc. Sec., 181 F.3d 429, 431 (3d Cir. 1999). Section 405(g) permits a district court to
review the transcripts and records upon which a determination of the Commissioner is based; the
court will review the record as a whole. See 5 U.S.C. § 706. The district court must then
determine whether substantial evidence existed in the record to support the Commissioner's
findings of fact. Burns v. Barnhart, 312 F.3d 113, 118 (3d Cir. 2002).
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. Ventura v.
Shalala, 55 F.3d 900, 901 (3d Cir. 1995) (quoting Richardson v. Perales, 402 U.S. 389, 401, 91
S.Ct. 1420, 28 L.Ed.2d 842 (1971)). If the Commissioner's findings of fact are supported by
substantial evidence, they are conclusive. 42 U.S.C. § 405(g); Richardson, 402 U.S. at 390.
When considering a case, a district court cannot conduct a de novo review of the Commissioner's
decision nor re-weigh the evidence of record; the court can only judge the propriety of the
decision in reference to the grounds invoked by the Commissioner when the decision was
rendered. Palmer v. Apfel, 995 F.Supp. 549, 552 (E.D. Pa. 1998); S.E.C. v. Chenery Corp., 332

20

Section 405(g) provides in pertinent part: “Any individual, after any final decision of the [Commissioner]
made after a hearing to which he was a party, irrespective of the amount in controversy, may obtain a review of such
decision by a civil action ... brought in the district court of the United States for the judicial district in which the
plaintiff resides, or has his principal place of business.” 42 U.S.C. § 405(g).
21
Section 1383(c)(3) provides in pertinent part: “The final determination of the Commissioner of Social
Security after a hearing under paragraph (1) shall be subject to judicial review as provided in section 405(g) of this
title to the same extent as the Commissioner's final determinations under section 405 of this title.” 42 U.S.C. §
1383(c)(3).

21

U.S. 194, 196–97 (1947). The court will not affirm a determination by substituting what it
considers to be a proper basis. Chenery, 332 U.S. at 196–97. Further, “even where this court
acting de novo might have reached a different conclusion . . . so long as the agency's factfinding
is supported by substantial evidence, reviewing courts lack power to reverse either those findings
or the reasonable regulatory interpretations that an agency manifests in the course of making
such findings.” Monsour Medical Center v. Heckler, 806 F.2d 1185, 1191 (3d Cir. 1986).
V. DISCUSSION
In his Motion for Summary Judgment, Plaintiff claims that the ALJ “erred as a matter of
law by failing to give appropriate weight to the opinion of [Plaintiff’s] treating psychiatrists, Dr.
Kolli and Dr. Mannheimer, that [Plaintiff] was disabled due to his medical impairments.”
(Docket No. 14 at 4). He argues that, “[f]aced with two supportive medical treating source
statements, the ALJ improperly gives Dr. Kolli’s opinion ‘little weight,’ fails to adequately
address the marked limitations assessed by Dr. Mannheim [sic], and denies benefits.” (Id. at 5).
Further, “[t]he ALJ considers no other opinions – even from non-treating sources – other than his
own lay opinion in reaching his strained conclusion.” (Id.). Plaintiff maintains that “[i]f an ALJ
accepts a medical opinion, he must include the established limitations in his residual functional
capacity (“RFC”) finding and [vocational expert] hypothetical. If the ALJ rejects a medical
opinion, then he must give a legally sufficient reason for doing so.” (Id. at 8).
Defendant counters that the ALJ appropriately found that Dr. Kolli’s assertion that
Plaintiff could not work full time and would miss four to seven days per month due to his
symptoms was not supported by the medical record. (Docket No. 16 at 9). Defendant also
asserts that the ALJ did not err in evaluating Dr. Mannheimer’s opinion. (Id. at 10). First, he
claims Dr. Mannheimer was not a treating physician in accordance with 20 C.F.R. §§ 404.1502,

22

404.1527(d)(2). (Id.). Second, Defendant argues that the ALJ “adequately incorporated into the
RFC assessment the limitations . . . assessed by Dr. Mannheimer . . .” (Id. at 11).
“Residual functional capacity is defined as that which an individual is still able to do
despite the limitations caused by his or her impairment(s).” Burnett v. Commissioner of Social
Security, 220 F.3d 112, 121 (3d Cir. 2000) (quoting Hartranft v. Apfel, 181 F.3d 358, 359 n.1 (3d
Cir. 1999)); see also 20 C.F.R. § 404.1545(a). An ALJ must consider all relevant evidence when
determining an individual's RFC. See 20 C.F.R. § 404.1545(a); Burnett, 220 F.3d at 121. This
evidence includes “medical records, observations made during formal medical examinations,
descriptions of limitations by the claimant and others, and observations of the claimant’s
limitations by others.” Fargnoli v. Halter, 247 F.3d 34, 41 (3d Cir. 2001). An individual
claimant's RFC is an administrative determination expressly reserved to the Commissioner. 20
C.F.R. § 416.927(e)(2). The ALJ’s finding of residual functional capacity 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)). In Cotter, the
United States Court of Appeals for the Third Circuit explained:
In our view an 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. This is necessary so that the court may
properly exercise its responsibility under 42 U.S.C. § 405(g) to determine if the
Secretary’s decision is supported by substantial evidence.
Cotter, 642 F.2d at 705 (quoting Baerga v. Richardson, 500 F.2d 309, 312 (3d Cir. 1974)).
Here, the ALJ found that Plaintiff had the RFC to perform medium work,
except that he cannot perform fine manipulative activities with the dominant right
hand, cannot do any job that requires acute vision, cannot work in close
coordination with coworkers or under intensive supervision, cannot work in a
setting where there are frequent or substantial changes, can make only simple

23

decisions, and cannot work at an assembly line pace, and cannot work face to face
with the general public.
(R. at 14). He claimed to have considered “all symptoms and the extent to which these
symptoms can reasonably be accepted as consistent with the objective medical evidence and
other evidence” as well as “opinion evidence” in accordance with various federal and Social
Security Administration regulations. (Id.).
In analyzing Plaintiff’s mental limitations, the ALJ cited Plaintiff’s “long history of
anxiety and depression” and described his psychiatric treatment since May 2008. (R. at 16). He
was persuaded by Dr. Kolli’s “relatively benign findings on multiple mental status evaluations”
and remarked that Plaintiff’s “psychotic symptoms are now absent” and that he is “no longer
agitated, irritable, or more than moderately anxious.” (Id.). However, the ALJ went on to
discredit Dr. Kolli’s “inconsistent” view that Plaintiff could not work full time and would miss
work four to seven times per month due to his symptoms, noting that Dr. Kolli simultaneously
found Plaintiff to be only mildly limited in his ability to handle social interaction and to maintain
concentration, persistence, and pace. (Id.). The ALJ also referred to Dr. Kolli’s recent treatment
records which stated that Plaintiff had been doing well, that his mood was stable, that he was
reacting well to his medications, and that he was no longer experiencing paranoia or auditory
hallucinations. (Id.).
Moreover, the ALJ concluded, in light of Dr. Mannheimer’s opinion, that Dr. Kolli
underestimated the effect of Plaintiff’s mental disorder on his ability to handle social interactions
and to concentrate on tasks. (R. at 16-17). Accordingly, the ALJ determined that Plaintiff was
“moderately” limited in those areas and accorded “little weight” to Dr. Kolli’s opinion. (R. at
17). The ALJ provided no further analysis of Dr. Mannheimer’s opinion and failed to mention
the opinion of Dr. Jonas, a consultative examiner.

24

Under the law of the Third Circuit, an ALJ need not accept the medical judgment of a
treating physician. See Jones v. Sullivan, 954 F.2d 125, 128-29 (3d Cir. 1991) (finding that the
opinions offered by Jones’ treating physicians were conclusory and unsupported by the medical
evidence and that the ALJ correctly determined that their opinions were not controlling). Here,
based on Jones, the ALJ was not required to adopt Dr. Kolli’s opinion. However, a physician’s
occasional “notation that a condition is ‘stable and well controlled with medication’ during
treatment does not necessarily support the conclusion that the patient is able to work. . . . These
types of inconsistencies do not per se create an inconsistent medical record.” Metz v. Astrue,
2010 WL 3719075, at * 13 (W.D. Pa. Sept. 17, 2010) (quoting Morales v. Apfel, 225 F.3d 310,
319 (3d Cir. 2000)).
Nonetheless, in reaching his finding that Plaintiff is not disabled, the ALJ does not
mention the contradictory findings of Dr. Mannheimer and Dr. Jonas, nor does he assess their
credibility or the weight given to their treatment notes and/or opinions. See Fargnoli, 247 F.3d
at 43. In Cotter, the Court held that “[t]he ALJ has a duty to hear and evaluate all relevant
evidence in order to determine whether an applicant is entitled to disability benefits.” Cotter,
642 F.2d at 704. “Although the ALJ may weigh the credibility of the evidence, he must give
some indication of the evidence he rejects and his reason(s) for discounting that evidence.”
Fargnoli, 247 F.3d at 43. He must make enough factual findings so that the reviewing court has
the ability to determine if “significant probative evidence was not credited or simply ignored.”
Id. at 42. In Burnett, the Court determined that the ALJ had not properly fulfilled his duty where
he failed to “consider and explain his reasons for discounting all of the pertinent evidence before
him in making his residual functional capacity determination.” Burnett, 220 F.3d at 121. The
Court “remanded the case to the ALJ with instructions ‘to review all of the pertinent medical

25

evidence, explaining any conciliations and rejections.” Fargnoli, 247 F.3d at 43 (quoting
Burnett, 220 F.3d at 122).
In the instant matter, the ALJ made passing reference to Dr. Mannheimer’s psychiatric
evaluation but did not address his other findings. (See R. at 16-17). Though Defendant argues
that Dr. Mannheimer was not a treating physician and his opinion could not be given controlling
weight, “. . . the report of no physician, whether the claimant’s or the Secretary’s, should be
treated as totally dispositive or incompetent.” Williams v. Sullivan, 970 F.2d 1178, 1185 n.5 (3d
Cir. 1992). As such, Dr. Mannheimer’s status as either a treating physician or a non-treating
source in accordance with 20 C.F.R. § 404.1502 does not bear on whether his opinion merited
proper evaluation by the ALJ.
Dr. Mannheimer found that Plaintiff demonstrated limitations in his ability to interact
with family, friends, neighbors, co-workers, employers or the general public appropriately and/or
effectively based on the fact that Plaintiff had “poor interpersonal interactions” and reported
holding numerous past jobs. (R. at 144-45). Significantly, he noted marked restrictions in
Plaintiff’s ability to interact appropriately with the public and with supervisors and to respond
appropriately to work pressures in a usual work setting. (R. at 147). Contrary to Defendant’s
assertion, the ALJ did not incorporate Plaintiff’s marked limitation in his ability to respond
appropriately to work pressures in a usual work setting into his RFC assessment. Moreover, the
ALJ did not even reference Dr. Jonas’ mental RFC assessment throughout his decision, which
concluded that Plaintiff had a marked limitation in his ability to interact appropriately with the
public. (R. at 178).
The ALJ’s lack of analysis of these findings leaves this Court wondering if “he
considered and rejected them, considered and discounted them, or failed to consider them at all.”

26

Fargnoli, 247 F.3d at 43-44. Thus, his “failure to explain his implicit rejection of this evidence
or even to acknowledge its presence was error.” Id. (quoting Cotter, 642 F.2d at 707). The
Court therefore cannot conclude that his findings at step four were supported by substantial
evidence.
In light of the foregoing discussion, the ALJ’s decision cannot be affirmed and the Court
need not address the parties’ alternative arguments. The only remaining question is “whether a
judicially-ordered award of benefits is proper, or whether the case should be remanded to the
Commissioner for further administrative proceedings.” Ambrosini v. Astrue, 727 F.Supp.2d 414,
432 (W.D. Pa. 2010). “An immediate award of benefits is appropriate only when the evidentiary
record has been fully developed, and when the evidence as a whole clearly points in favor of a
finding that the claimant is statutorily disabled.” Id. (citing Morales, 225 F.3d at 320).
This standard is not met here. The record reflects that Plaintiff, since the onset of his
disability, worked a part-time job delivering pizza. (R. at 25-26). Work that an individual
seeking disability benefits has completed since the onset of disability may show that he or she is
able to engage in work at the substantial gainful activity level. 20 CFR § 404.1571. Even
though the ALJ found that Plaintiff’s part-time work was not substantially gainful activity, it
may indicate that Plaintiff is able to work more than he actually does. Id. In addition, the
potentially inconsistent opinion of Dr. Kolli must be evaluated against and reconciled with the
opinions of Drs. Mannheimer and Jonas.
For these reasons, further development of the record is needed.

27

VI. CONCLUSION
Based on the foregoing, the decision of the ALJ is not adequately supported by
substantial evidence from Plaintiff’s record within the meaning of 42 U.S.C. § 405(g).
Accordingly, Defendant’s Motion for Summary Judgment is DENIED. Plaintiff’s Motion for
Summary Judgment is GRANTED to the extent that he seeks a vacation of the administrative
decision under review, and the case is REMANDED for further proceedings.22 An appropriate
Order follows.
s/ Nora Barry Fischer
Nora Barry Fischer
United States District Judge
cc/ecf: All counsel of record.
Date: March 12 , 2012

22

The ALJ is directed to reopen the record and allow the parties to be heard via submissions or otherwise as
to the issue addressed in this Memorandum Opinion. See Thomas v. Comm’r of Soc. Sec., 625 F.3d 798, 800-01 (3d
Cir. 2010). He must consider and make specific findings regarding all of the relevant medical evidence and weigh
that evidence. See Fargnoli, 247 F.3d at 44. To the extent that the ALJ reaches a contradictory finding to that of
Plaintiff’s treating and consultative examiners, “he must explain the reasoning behind such a finding, including
reconciling conflicts and discussing how and why probative evidence supporting Plaintiff’s claim was discounted
and/or rejected.” Id.

28