ROY PERCY, Magistrate Judge.
Plaintiff Amanda E. Smith, under 42 U.S.C. § 405(g), seeks judicial review of the decision of the Commissioner of Social Security denying her applications for a period of disability (POD) and disability insurance benefits (DIB) under Sections 216(I) and 223 of the Social Security Act and for supplemental security income (SSI) payments under Section 1614(a)(3) of the Act. Plaintiff protectively filed her application for a POD and DIB on September 6, 2012 and her application for SSI on September 15, 2012. Both applications alleged disability beginning on August 1, 2012. Her claim was denied initially on January 2, 2013, and upon reconsideration on June 6, 2013. She filed a request for hearing and was represented by counsel at the hearing held on August 19, 2014. The Administrative Law Judge (ALJ) issued an unfavorable decision on November 13, 2014, and the Appeals Council denied plaintiff's request for a review on March 30, 2016. Plaintiff timely filed the instant appeal from the ALJ's most recent decision, and it is now ripe for review.
Because both parties have consented to have a magistrate judge conduct all the proceedings in this case as provided in 28 U.S.C. § 636(c), the undersigned has the authority to issue this opinion and the accompanying final judgment. Having considered the record, the briefs and the oral arguments of counsel, the court finds this case should be remanded to the Social Security Administration.
Plaintiff was born on February 28, 1980 and was 34 years old at the time of the hearing. She has a high school education and "a couple years of college." Docket 10 at 36-37. Plaintiff had past relevant work as a sitter for the elderly, a medical records clerk and a pharmacy technician. Plaintiff contends that she became disabled before her application for benefits due to "bipolar disorder, major depression, scoliosis of the spine." Docket 10 at 198.
The ALJ determined plaintiff suffered from "severe" impairments including anxiety, depression and lumbar scoliosis with lumbosacral spondylosis without myelopathy, but found these impairments did not meet or equal a listed impairment in 20 C.F.R. Part 404, Subpart P, App. 1 (20 CFR 404.1520(d), 404.1525, 404.1526, 416.920(d) 416.925 and 416.926). Based upon testimony by the vocational expert [VE] at the hearing and considering the record as a whole, the ALJ determined that plaintiff retains the Residual Functional Capacity (RFC) to
Docket 10 at 20. Upon further analysis under applicable rulings and regulations, the ALJ found plaintiff to be less than fully credible in that the intensity, persistence and limiting effects she claimed due to her symptoms were "not entirely credible." After evaluating all of the evidence in the record, including testimony of a VE, the ALJ held that plaintiff could perform jobs that exist in the national economy such as merchant maker, routing clerk, and silver wrapper. Docket 10 at 24. As a result, the ALJ concluded that plaintiff is not disabled under the Social Security Act. Id.
Plaintiff contends first that the ALJ erred because he failed to properly and fully develop the record in failing to identify and evaluate the author of a mental assessment provided by Region 8 Mental Health Center. Docket 18 at 7. Further, plaintiff asserts that the ALJ erred concluding that the global assessment of functioning scores provided by treating physicians did not reflect her current mental state. Plaintiff also argues that the ALJ improperly weighed the opinion of Dr. Okechuku as to her physical condition and that he disregarded her credible testimony. Following a review of the briefs, the transcript and oral argument, the undersigned concludes that plaintiff's case should be remanded for identification of the author of the mental assessment at Region 8, as well as for proper consideration of plaintiff's global assessment of functioning scores.
II. STANDARD OF REVIEW
In determining disability, the Commissioner, through the ALJ, works through a five-step sequential evaluation process.
The court considers on appeal whether the Commissioner's final decision is supported by substantial evidence and whether the Commissioner used the correct legal standard. Crowley v. Apfel, 197 F.3d 194, 196 (5
Of primary concern to the court is the ALJ's failure to identify the individual who completed the Functional Data Request Form sent to Regional 8 Mental Health Center by the Office of Disability Determination Services. Docket 10 at 310-16. On September 20, 2012, the Office of Disability Determination Services specifically requested that an individual from Region 8 Mental Health Center, where plaintiff had been treated, provide the "DETAILED, SPECIFIC information on the claimant" requested as it was "necessary to establish chronicity and to determine the severity of the impairment over a period of time . . ." Docket 10 at 310. The signature of the individual completing the Functional Data Request Form is illegible and neither the state agency examiner nor the ALJ made any attempt to identify the person who completed the form. As a result, the ALJ gave "little weight" to the opinions contained in the Functional Data Request Form which indicated that plaintiff's "anxiety caused poor to fair functioning in all areas" because "the relationship between the claimant and this employee is unknown as are this employee's credentials to make this opinion." Docket 10 at 22.
The Region 8 Functional Data Request Form is important because it is the only evaluation of plaintiff's mental state following both of her inpatient hospitalizations. One of the remaining opinions as to plaintiff's mental condition was from Dr. Martha D'Ilio, a psychologist who did examine plaintiff but had only four pages of her medical records to review. Docket 10 at 332. Dr. D'Ilio's report was provided on October 24, 2012, only a month after plaintiff's application for benefits and prior to plaintiff's hospitalizations in May 2012 and August 2014. In other words, Dr. D'Ilio did not have the benefit of all of plaintiff's medical history upon which to base her decision and the ALJ still gave her opinion "great weight." Docket 10 at 22.
Similarly, the ALJ gave "great weight" to the assessment of state agency physician Dr. Glenda Scallorn provided on June 6, 2013, prior to plaintiff's second hospitalization for six days in August 2014. Dr. Scallorn did not examine plaintiff, but it does appear that she examined at least some of plaintiff's treatment records from Region 8 and the records from the inpatient treatment at St. Dominic's in May of 2013. Docket 10 at 87. There is no evidence that Dr. Scallorn examined the report of Dr. D'Ilio.
The ALJ gave "little weight" to the state agency psychological assessment by Dr. Amy Hudson who opined that plaintiff did not have a severe mental impairment at all. Docket 10 at 26. Dr. Hudson did not have the benefit of the records from either of plaintiff's inpatient hospitalizations or the other physician opinions.
A review of all the opinions as to plaintiff's mental health makes clear that the mental assessment from the unidentified person at Region 8 Mental Health Center is critical as no other opinion was provided by a physician after both of plaintiff's inpatient hospitalizations. Further, the only opinion after the first hospitalization was provided by Dr. Scallorn, who did not examine plaintiff.
It is well established that an ALJ has a duty to develop the record fully and fairly and to ensure that his decision is an informed one based on sufficient facts. Brock v. Chater, 84 F.3d 726, 728 (5
In this case, the Region 8 assessment indicated that plaintiff's mental health issues caused poor to fair functioning in all areas. In keeping with his duty to develop the record fully and fairly and to ensure that his decision is an informed one based on sufficient facts, and rather than give little weight to the only professional opinion made subsequent to both of plaintiff's inpatient hospitalizations — a treating provider opinion that the Office of Disability Determination Services requested — the ALJ should have made inquiry into the identity of the author of the Region 8 assessment so as to give proper consideration to the opinions contained therein.
Plaintiff also argues that the ALJ substituted his opinion for the physicians who determined plaintiff's global assessment of functioning score of 65 in May 2013 when she was discharged from St. Dominic-Jackson Memorial Hospital and the score of 45 upon discharge from Tri-Lakes Medical Center in August 2014. Docket 18 at 10. In his opinion denying benefits, the ALJ gave "some weight" to the global assessments of functioning but found they did not "reflect the claimant's ongoing functioning and do not fully appreciate the claimant's ongoing functioning." Docket 10 at 22. Citing Hawkins v. Astrue, 2011 WL 1107205, at *6 n.4(N.D. Tex. March 25, 2011), the Commissioner argues that "[a] low GAF score is not prima facie evidence of a disability." However, the cited Hawkins footnote states a low GAF score "standing alone, is not evidence of a severe impairment that precludes plaintiff from working." Although this court agrees plaintiff's low GAF scores standing alone cannot establish disability, it is also true the ALJ may not disregard the scores and substitute his own opinion that they are not reflective of plaintiff's ongoing functioning.
The Fifth Circuit has held that an "ALJ must consider all the record evidence and cannot `pick and choose' only the evidence that supports his position." Loza v. Apfel, 219 F.3d 378, 393(5th Cir. 2000). The Seventh Circuit, applying the same social security regulations as the Fifth Circuit, articulated that "[t]he fact that the headaches standing alone were not disabling is not grounds for the ALJ to ignore them entirely — it is their impact in combination with [plaintiff's] other impairments that may be critical to his claim." Yurt v. Colvin, 758 F.3d 850, 860 (7
Because the ALJ did not fully and fairly develop the record and did not have before him sufficient facts on which to make an informed decision, the court finds his decision is not supported by substantial evidence. This matter is remanded for the ALJ to obtain the identity of the author of the completed Region 8 Functional Data Request Form so as to afford it proper weight. The ALJ is further directed to give proper consideration to the GAF scores. This court finds no error in the ALJ's evaluation of plaintiff's physical condition, and therefore no further consideration of the physical impairments is necessary on remand.
The Commissioner's denial of benefits will be remanded for additional review in accordance with this opinion. A final judgment in accordance with this memorandum opinion will issue this day.