GOVACHINI v. COMMISSIONER OF SOCIAL SECURITY
Filing
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ORDER granting 9 Plaintiff's Motion for Summary Judgment and denying 11 Defendant's Motion for Summary Judgment. The case is remanded for further evaluation in light of this Order. Signed by Judge Alan N. Bloch on 9/26/2018. (dpo)
IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF PENNSYLVANIA
CLARA GOVACHINI,
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Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY,
Defendant.
Civil Action No. 17-1196
ORDER
AND NOW, this 26th day of September, 2018, upon consideration of Defendant’s
Motion for Summary Judgment (Doc. No. 11) filed in the above-captioned matter on February 5,
2018,
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 January 5, 2018,
IT IS HEREBY ORDERED that said Motion is GRANTED. This matter is hereby
remanded to the Commissioner of Social Security (“Commissioner”) for further evaluation under
sentence four of 42 U.S.C. § 405(g) in light of this Order.
I.
Background
Plaintiff, Clara Govachini, filed a claim for Supplemental Security Income (“SSI”) under
Title XVI of the Social Security Act, 42 U.S.C. §§ 1381-1383f, effective October 31, 2013,
claiming that she became disabled on October 23, 1995, primarily due to learning problems,
autism, and various autism-related conditions. (R. 16, 76, 126, 139). After being denied initially
on March 28, 2014, Plaintiff sought, and obtained, a hearing before an Administrative Law Judge
(“ALJ”) on February 18, 2016. (R. 35-60, 77-80, 81-83). In a decision dated May 4, 2016, the
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ALJ denied Plaintiff’s request for benefits. (R. 16-30). The Appeals Council declined to review
the ALJ’s decision on July 17, 2017. (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
[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.
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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. § 416.920. In Step One, the Commissioner must determine whether
the claimant is currently engaging in substantial gainful activity. See 20 C.F.R.
§ 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. § 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. § 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. § 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.
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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.
§ 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. § 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.
§ 416.923.
III.
The ALJ's Decision
In her May 4, 2016 decision, the ALJ applied 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 application date of October 31, 2013. (R. 18).
The ALJ also found that Plaintiff met the second requirement of the sequential evaluation
process insofar as she has the severe impairments of intellectual disability and an autism
spectrum disorder. (Id.). The ALJ concluded that Plaintiff’s impairments did not meet or equal
any of the listings that would satisfy Step Three. (R. 18-20).
The ALJ went on to find that Plaintiff retained the RFC to perform a full range of work at
all exertional levels, with the following non-exertional limitations:
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The claimant is limited to simple, routine, repetitive tasks
performed in a work environment where workplace and work
processes remain the same from day to day. She can have no
contact with the public and she must work with things, not with
people. She can have instruction or redirection where no
immediate response is required unless clarification is necessary.
(R. 20-28). After finding that Plaintiff had no past relevant work, the ALJ moved on to Step
Five. (R. 28).
At Step Five, the ALJ 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 vehicle washer/cleaner II,
church janitor, and unskilled housekeeping/cleaner jobs, excluding those in private homes and
work in the hotel/motel industry. (R. 29). Accordingly, the ALJ found that Plaintiff was not
disabled. (R. 29-30).
IV.
Legal Analysis
Plaintiff raises several arguments as to why the ALJ erred in finding that she was not
disabled. While the Court does not reach all of 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 basis for the weight she assigned to the opinion of the consultative examining
source, Steven Pacella, Ph.D., and failed to explain adequately the impact of the assessment of
James Petrick, Ph.D., in determining Plaintiff’s RFC. Accordingly, the record is insufficient to
support the ALJ’s determination of the RFC and her hypothetical question to the VE, and the
Court will remand the case for further consideration.
As noted, the primary issue in this matter is whether the ALJ gave proper weight to the
opinion of Dr. Pacella and the assessment of Dr. Petrick in formulating Plaintiff’s RFC. RFC is
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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.
§ 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, 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. See Chrupcala v. Heckler, 829 F.2d 1269, 1276 (3d Cir. 1987). “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).
Here, as discussed above, the RFC contained a number of limitations to account for
Plaintiff’s mental impairments. However, it did not include several set forth in Dr. Pacella’s
opinion, specifically marked limitations in Plaintiff’s ability to understand, remember, and carry
out complex instructions, to make judgments on complex work-related decisions, to interact
appropriately with the public, supervisors, and co-workers, and to respond appropriately to usual
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work situations and to change in a routine work setting, as well as moderate limitations in her
ability to understand, remember, and carry out simple instructions and to make judgments on
simple work-related decisions. (R. 301-02). These additional restrictions would clearly have
been relevant; when the ALJ added them to the hypothetical question to the VE, the VE
indicated that such limitations would preclude any work. (R. 58-59). The only reason provided
by the ALJ for discounting the limitations to which Dr. Pacella opined was that “he appeared to
rely more on information from the claimant’s father than his actual observation of the claimant.”
(R. 28). Under the circumstances of this case, this was an insufficient rationale.
It is not improper for an ALJ to consider the fact that a physician’s opinion relies largely
on a claimant’s subjective complaints in determining how much weight to give to that opinion.
In fact, “[a]n ALJ may discredit a physician’s opinion on disability that was premised largely on
the claimant’s own accounts of her symptoms and limitations when the claimant’s complaints are
properly discounted.” Morris v. Barnhart, 78 Fed. Appx. 820, 825 (3d Cir. 2003). See also Ford
v. Barnhart, 57 Fed. Appx. 984, 987 (3d Cir. 2003). Indeed, “the mere memorialization of a
claimant’s subjective statements in a medical report does not elevate those statements to a
medical opinion.” Morris, 78 Fed. Appx. at 824-25 (citing Craig v. Chater, 76 F.3d 585, 590 n.2
(4th Cir. 1996)). However, “[i]t is generally improper for an [ALJ] to reject the findings of a
consultative examiner solely on the ground that they are based on a claimant's subjective
complaints where . . . there is nothing in the record to suggest that the consultative examiner
relied more on the claimant's subjective complaints than on his or her own clinical observations.”
Thompson v. Astrue, Civ. No. 09-294, 2010 WL 2545543, at *9 (W.D. Pa. June 21, 2010)
(emphasis in original). Therefore, while an ALJ can and should consider whether and to what
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extent a doctor’s opinion relied on a claimant’s subjective claims, he or she must also determine
whether that is, in fact, what the doctor did.
Here, the ALJ did not explain why she determined that Dr. Pacella’s opinion was based
more on information from Plaintiff’s father than on his own observations, and there is no basis
apparent to the Court for so concluding. Dr. Pacella’s examination certainly included discussion
with Plaintiff and her father and review of some of her prior records. However, Dr. Pacella also
conducted a mental status examination, made behavioral observations of Plaintiff, and
administered standardized tests to Plaintiff. (R. 295-300). Dr. Pacella did not indicate that
information provided by Plaintiff or her father was more important to his analysis than his own
clinical observations and/or the test results. Without some further explanation, the Court finds
that the ALJ erred in simply assuming that he did.
The Court further notes that the ALJ, with no real explanation, stated that her RFC
determination was supported by, inter alia, the assessment of Dr. Petrick. As Plaintiff points out,
it is not apparent from the face of Dr. Petrick’s report that it would support the RFC in this case.
Indeed, in the “Impression” section of the assessment, Dr. Petrick lists numerous potential
limitations and states that Plaintiff’s “ability to maintain competitive employment is substantially
limited.” (R. 311). While the Court is not suggesting that Dr. Petrick’s assessment is necessarily
inconsistent with the RFC in this case, it does find that a more precise explanation as to why the
ALJ found this to be so is necessary for meaningful judicial review.1
The Court reiterates that the ALJ is not necessarily obligated to accept any of the
limitations found by Dr. Pacella or by Dr. Petrick, but she must adequately discuss the basis for
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This is particularly true given the fact that Dr. Petrick mentioned the need for work
accommodations that may constitute the type that are improperly considered in determining
whether there is work in significant numbers in the national economy that a claimant can
perform. See SSR 11-2p, 2011 WL 4055665 (S.S.A.), at § II(D)(1)(e).
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rejecting them if that is what she chooses to do. The Court expresses no opinion as to whether
the ALJ’s RFC determination and hypothetical could be supported by the record. Indeed, as the
ALJ points out, the opinions of Christy Emmons, Psy.D. (R. 314-20) and state reviewing agent
Sandra Banks, Ph.D. (R. 70-72), should be considered as well and arguably may lead to a
different finding. It is the need for further explanation that mandates the remand in this case.2
V.
Conclusion
In short, the record does not permit the Court to determine whether the findings of the
ALJ regarding Plaintiff’s RFC, and the weight she afforded to the opinions of Drs. Pacella and
Petrick, 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
ecf:
Counsel of record
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The Court does not reach any other issue raised by Plaintiff, but emphasizes that the ALJ
should be cognizant of these issues on remand.
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