SINAGRA v. ASTRUE
Filing
12
ORDER granting in part and denying in part 7 Plaintiff's Motion for Summary Judgment; denying 10 Defendant's Motion for Summary Judgment; and remanding case to the Commissioner for further evaluation. Signed by Judge Alan N. Bloch on 6/10/2013. (kmw)
IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF PENNSYLVANIA
TIMOTHY T. SINAGRA t
Plaintiff t
vs.
Civil Action No. 12-1525
MICHAEL J. ASTRUE ,
COMMISSIONER OF SOCIAL SECURITY,
Defendant.
o R D E R
AND NOW, this 10th day of June, 2013, upon consideration of
Defendant's Motion for Summary Judgment (document No. 10) filed
in the above captioned matter on March 4, 2013
t
IT IS HEREBY ORDERED that said Motion is DENIED.
AND, further, upon consideration of Plaintiff's Motion for
Summary Judgment
(document No.7) filed in the above captioned
matter on January 30, 2013,
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.
AccordinglYt
this
matter is hereby remanded to the Commissioner for further
evaluation under sentence four of 42 U.S.C.
this Order.
§
405(g}
in light of
I .
Background
On January 28, 2011, Plaintiff Timothy Thomas Sinagra,
filed his claim for Disability Insurance Benefits under Title II
of the Social Security Act, 42 U.S.C.
§§
401 434.
Specifically,
Plaintiff claimed that he became disabled on November 2, 2008,
due to degenerative arthritis, chronic lower back pain,
narrowing of his sciatic nerve conduit, cubital tunnel problem,
bilateral numbness in his fourth and fifth fingers, and nerve
problems in both arms.
(R. 132, 136).
After being denied initially on May 13, 2011 (R. 66-70),
Plaintiff sought, and obtained, a hearing before an
Administrative Law Judge ("ALJ") on October 6, 2011.
52).
(R.
33
In a decision dated November 2, 2011, the ALJ denied
Plaintiff's request for benefits.
(R. 20-29).
The Appeals
Council declined to review the ALJ's decision on October 10,
2012.
(R. 1-3).
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.
405(g).
See 42 U.S.C.
§
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
2
the Commissioner's findings of fact.
F.3d 589, 592 (3d Cir. 2001)
See Matthews v. Apfel, 239
("[t]he findings of the
Commissioner of Social Security as to any fact,
substantial evidence, shall be conclusive"
405(g)))
i
if supported by
(quoting 42 U.S.C.
§
Schaudeck v. Commissioner of Soc. Sec. Admin., 181
F.3d 429, 431 (3d Cir. 1999)
(noting that the court has plenary
review of all legal issues, and reviews the administrative law
judge'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.
Apfel, 186 F.3d 422, 427 (3d Cir. 1999).
Plummer v.
However, a "single
piece of evidence will not satisfy the substantiality test if
the [Commissioner]
ignores, or fails to resolve, a conflict
created by countervailing evidence."
310, 317 (3d Cir. 2000)
Morales v. Apfel, 225 F.3d
(quoting Kent v. Schweikert 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
3
gainful activity for a statutory twelve-month period.
See
Fargnoli v. Massanari, 247 F.3d 34. 38-39 (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 .... '"
39 (quoting 42 U.S.C.
§
Id. at
423 (d) (2) (A)) .
The Social Security Administration ("SSA")
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.
In Step One,
the Commissioner must determine whether the claimant is
currently engaging in substantial gainful activity.
C.F.R.
§
denied.
404.1520(b).
See 20
If so, the disability claim will be
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.
404.1520(c).
See 20 C.F.R.
§
"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."
C.F.R.
§
404.1521(a).
20
If the claimant fails to show that his or
her impairments are "severe," he or she is ineligible for
4
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.
404.1520(d).
See 20 C.F.R. §
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(e).
The
claimant bears the burden of demonstrating an inability to
return to his or her past relevant work.
40 F.3d 43{ 46 (3d Cir. 1994).
See Adorno v. Shalala,
If the claimant is unable to
resume his or her former occupation{ the evaluation 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.
404.1520(g).
See 20 C.F.R.
§
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
5
determining whether he or she is capable of performing work and
is not disabled.
See 20 C.F.R.
§
404.1523.
III. The ALJ's Decision
In the present case, the ALJ found that Plaintiff met the
insured requirements of the Social Security Act through December
31, 2014.
(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.
C.F.R.
.110,
§§
404.101,
§§
423(a) (1) (A),
(c) (1) (B)
20
i
.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 of
disability.
(R. 22).
The ALJ also found that Plaintiff met the
second requirement of the process insofar as he had the severe
impairments of degenerative disc disease and degenerative joint
disease of the spine.
He found, however, that plaintiff's ulnar
entrapment did not constitute a severe impairment.
(Id.).
The
ALJ concluded that Plaintiff's impairments did not meet any of
the listings that would satisfy Step Three.
(R. 22-23).
The ALJ found that Plaintiff retained the RFC to perform
light work, except that he would be limited to performing low
stress jobs.
(R. 23-27).
Based on this RFC, Plaintiff
established that he is incapable of returning to his past
6
employment; therefore, the ALJ moved on to Step Five.
(R.
27).
The ALJ then used a vocational expert ("VEil) to determine
whether or not there were a significant number of jobs in the
national economy that Plaintiff could perform.
The VE testified
that, based on Plaintiff's age, education, past relevant work
experience, and RFC, Plaintiff could perform jobs, including
ticket seller, marker, and tool collector, that exist in
significant numbers in the national economy.
(R. 28, 50).
Accordingly, the ALJ found that Plaintiff was not disabled.
(R.
28) .
IV.
Legal Analysis
Plaintiff raises several arguments as to why the ALJ erred
in finding that he was not disabled.
While the Court does not
fully agree with the arguments set forth by Plaintiff, it does
agree that remand is warranted in this case.
Specifically, the
Court finds that the ALJ failed to provide an adequate
explanation for his treatment of the opinions of the
consultative examiner and state agency reviewer in determining
Plaintiff's RFC and formulating the hypothetical question to the
VE, and failed to provide an adequate basis for his treatment of
Plaintiff's alleged headaches.
Accordingly, the record is
insufficient to support the ALJ's decision, and the Court will
remand the case for further consideration.
7
On May 3 1 2011 1 Dr. Alexandra M. Hopei M.D'I performed a
consultative examination of Plaintiff and offered her opinion as
to his occupational limitations.
limitations to which she opined
In addition to the exertional
Dr. Hope also found that
l
Plaintiff had several non-exertional limitations
rather restrictive postural limitations
to reaching and feeling
including heights
327-28).
on May 10
1
including
limitations in regard
and several environmental limitations
vibrations, and temperature extremes.
I
Likewise
l
I
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l
I
(R.
state agency physician Jason Rasefske, M.D'I
2011 1 opined that Plaintiff had several postural and
environmental limitations
limitations.
(R. 59-62).
I
in addition to his exertional
The ALJ
I
however, did not include any
of these non-exertional limitations in Plaintiff/s RFC or in the
hypothetical question to the VE.
RFC is defined as
~that
which an individual is still able
to do despite the limitations caused by his or her
impairment(s).ff
404.1545(a).
Fargnoli, 247 F.3d at 40.
See also 20 C.F.R.
§
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
Cotter v. Harris, 642 F.2d 700, 704
I
247 F.3d at 41 (quoting
(3d Cir. 1981)).
~'[A]n
examiner's findings should be as comprehensive and analytical as
feasible and, where appropriate
should include a statement of
I
8
subordinate factual foundations on which ultimate factual
conclusions are based, so that a reviewing court may know the
basis for the decision.'"
705).
rd.
(quoting Cotter, 642 F.2d at
See also S.S.R. 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, observations) .").
Further, a hypothetical question to a VE must accurately
portray the claimant's physical and mental impairments, although
it need reflect only those impairments that are supported by the
record.
1987).
See Chrupcala v. Heckler, 829 F.2d 1269, 1276 (3d Cir.
"Where there exists in the record medically undisputed
evidence of specific impairments not included in a hypothetical
question to a vocational expert, the expert's response is not
considered substantial evidence."
Burns v. Barnhart, 312 F.3d
113, 123 (3d Cir. 2002).
Although the ALJ acknowledged the opinions of Drs. Hope and
Rasefske in his decision and explained that he was giving little
weight to the opinions, his discussion was simply insufficient
to permit meaningful review.
Not only was the ALJ's discussion
of the opinions very brief, he did not discuss the non
exertional limitations found by these physicians at all.
9
As the
Court set forth above/ both Dr. Hope and Dr. Rasefske opined
that Plaintiff had extensive postural and environmental
limitations, and the ALJ failed either to include the
limitations in the RFC and the hypothetical to the VE or to
discuss why he omitted them by explaining how these limitations
were inconsistent with the other evidence in the record, other
than providing a brief statement assigning littler weight to the
opinions in general.
This does not allow the Court to determine
the basis on which the ALJ omitted these limitations from the
RFC and the hypothetical.
Accordingly, while the ALJ was by no means required to
simply adopt all of the non-exertional limitations found by the
consultative examiner and state reviewing agent, he was required
to explain his basis for rejecting them.
Remand is required to
allow for further discussion as to the rationale for rejecting
the non-exertional limitations contained in the opinion evidence
in determining Plaintiff's RFC and in formulating the
hypothetical question to the VE.l
Another issue also demonstrates the need for remand
ALJ's treatment of Plaintiff's headaches.
- the
The ALJ did not find
Plaintiff's headaches to constitute severe impairments, nor did
1
The Court acknowledges that this issue was not very clearly
raised by Plaintiff, but finds that his argument at least
encompasses concerns about the weight afforded by the ALJ to the
opinion evidence.
10
he include any limitations in the RFC or the hypothetical
question to the VE that would account for this condition, and
Plaintiff argues that, in doing so, the ALJ failed to evaluate
fully the effect of his headaches on his RFC.
The Court agrees
that the ALJ's explanation for his treatment of Plaintiff's
headaches was insufficient for the Court to determine whether
substantial evidence supports the ALJ's determination of the RFC
and the hypothetical question.
The Court notes that the Government is correct that the
relevant issue is not whether the ALJ correctly found
Plaintiff's headaches to be non-severe at Step Two.
The Step
Two determination as to whether Plaintiff is suffering from a
severe impairment is a threshold analysis requiring the showing
of only one severe impairment.
See Bradley v. Barnhart, 175
Fed. Appx. 87, 90 (7 th Cir. 2006).
In other words, as long as a
claim is not denied at Step Two, it is not generally necessary
for the ALJ to have specifically found any additional alleged
impairment to be severe.
See Salles v. Commissioner of Soc.
Sec., 229 Fed. Appx. 140, 145 n.2 (3d Cir. 2007)
i
Lee v. Astrue,
2007 WL 1101281, at *3 n.5 (E.D. Pa. Apr. 12, 2007) i Lyons v.
Barnhart, 2006 WL 1073076, at *3 (W.D. Pa. March 27, 2006).
Since Plaintiff's claim was not denied at Step Two, it does not
matter whether the ALJ correctly or incorrectly found
Plaintiff's headaches to constitute a non-severe impairment.
II
However, even if an impairment is non-severe, it may still
affect a claimant's RFC.
In assessing a claimant's RFC, the ALJ
"must consider limitations and restrictions imposed by all of an
individual's impairments, even those that are not 'severe.'"
S.S.R. 96-8p at *5 (emphasis added).
404.1545(a) (2).
"While a
See also 20 C.F.R.
§
'not severe' impairment(s) standing
alone may not significantly limit an individual's ability to do
basic work activities, it may - when considered with limitations
or restrictions due to other impairments
be critical to the
outcome of a claim.n
Accordingly, merely
S.S.R. 96-8p at *5.
because the ALJ did not find Plaintiff's headaches to be severe
does not mean that this condition could not still have affected
Plaintiff's RFC.
The Court finds that the ALJ did not
adequately address the impact of Plaintiff's headaches at Step
Five.
The ALJ did discuss Plaintiff's headaches in his
determination of the RFC.
However, he dismissed their impact on
the RFC merely by stating that Plaintiff had reported only
intermittent headaches to his therapists and had only increased
his claimed frequency within weeks of the hearing.
(R.
27).
However, in formulating this evaluation of the intensity,
persistence, and limiting effects of Plaintiff's symptoms, the
ALJ did not in any way discuss the numerous complaints of
serious headaches raised by Plaintiff long before the hearing.
12
Indeed, Exhibit 11F2 contains a plethora of citations to
complaints made by Plaintiff regarding headaches while being
treated at Walter Reed Army Medical Center in 2009 and 2010.
~,
See,
R. 373, 504, 552, 562, 586, 591, 716).
This
evidence at least arguably contradicts the ALJ's finding that
Plaintiff's complaints of headaches significantly increased only
as the hearing approached, and where there is potentially
conflicting evidence in the record, the ALJ must explain which
evidence he accepts and rejects and the reasons for his
determination.
See Cruz v. Commis ioner of
Appx. 475, 479 (3d Cir. 2007)
(citing Hargenrader v. Califano,
575 F.2d 434, 437 (3d Cir. 1978)).
at 42.
Therefore
I
. Sec., 244 Fed.
See also Fargnoli, 247 F.3d
a discussion of the impact of this evidence
on his findings is necessary.
The Court emphasizes that it is not suggesting that any
specific limitations must be included in the RFC or in the
hypothetical question to account for Plaintiff's headaches.
Indeed
l
the Court expresses no opinion as to whether the ALJ/s
RFC determination and hypothetical in regard to Plaintiff/s
impairments could be supported by the record.
It is the need
for further explanation that mandates the remand on this issue. 3
2
Exhibit 12F is essentially a duplicate of Exhibit 11F.
To the extent that Plaintiff asks this Court to reverse the
ALJ's decision and award benefits the record simply does not
3
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l3
V.
Conclusion
In short, the record simply does not permit the Court to
determine whether the ALJ's determination of Plaintiff's RFC and
his hypothetical question to the VE 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 this case to the ALJ for reconsideration
consistent with this Order.
s/Alan N. Bloch
United States District Judge
ecf: Counsel of record
allow the Court to do so. The Court cannot find that
substantial evidence in the record as a whole indicates that
Plaintiff is disabled and entitled to benefits. See Podedworny
v. Harris, 745 F.2d 210, 221-22 (3d Cir. 1984).
14
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