NOT FOR PUBLICATION
MICHAEL A. SHIPP, District Judge.
This matter comes before the Court on Plaintiff Debora Boyer's ("Plaintiff") appeal from the final decision of Nancy A. Berryhill,
On June 15, 2011, Plaintiff filed an application for Social Security Disability Insurance Benefits (DIB), alleging a disability onset date of June 9, 2001. (Administrative Transcript ("Tr.") 221-23.)
The ALJ's Decision
On June 9, 2014, the ALJ rendered his decision. (Tr. 17-28.) The ALJ initially noted that in addition to the issue of whether Plaintiff was disabled under sections 216(i) and 223(d) of the Social Security Act ("the Act"), there is an issue as to whether Plaintiff met the insured status requirements of sections 216(i) and 223 of the Act. (Id. at 17.) The ALJ found that Plaintiff had acquired sufficient quarters of coverage to remain insured through September 30, 2013. (Id.) As such, the ALJ indicated that Plaintiff must establish disability on or before September 30, 2013, in order to be entitled to benefits. (Id.)
The ALJ next set forth the Social Security Administration's five-step sequential process for determining whether an individual is disabled. (Id. at 18-19.) As to the first step of the sequential process, the ALJ found that Plaintiff did not engage in any substantial gainful activity from her alleged disability onset date through the date last insured. (Id. at 19.) At step two of the sequential analysis, the ALJ found that the medical evidence established the existence of the following severe impairments: "[h]ypothyroidism, fibromyalgia[,] and mood disorders." (Id.) At step three of the sequential analysis, the ALJ found that none of Plaintiff's impairments met or medically-equaled the severity of one of the Listed Impairments in 20 C.F.R. 404 subpart P, Appendix 1. (Id. at 20.) In making this determination, the ALJ summarized the evidence as to Plaintiff's physical conditions of hypothyroidism and musculoskeletal/fibromyalgia, as well as the evidence with respect to Plaintiff's foot impairment, and stated that he found no evidence that Plaintiff's physical impairments were of the severity outlined in Section 1.02 or 9.00. (Id. at 20-21.) In addition, the ALJ found that the severity of Plaintiff's mental impairments did not meet or medically equal the criteria of listings 12.04 or 12.06. (Id. at 22.) In reaching his decision, the ALJ discussed the medical records related to Plaintiff's mental status and analyzed the "paragraph B" and "paragraph C" criteria. (Id. at 21-23.) The ALJ then found that Plaintiff has the residual functional capacity ("RFC") to perform:
(Id. at 23.)
At step four of the sequential analysis, the ALJ found that Plaintiff was unable to perform any past relevant work. (Id. at 26.) The ALJ stated that Plaintiff was born on November 26, 1965, and was forty-seven years old, defined as a younger individual 18-49, on the date last insured. (Id. at 27.) The ALJ noted that Plaintiff has at least a high school education and is able to communicate in English. (Id.) The ALJ stated that transferability of job skills is not material to the disability determination because the use of the Medical-Vocational Rules as a framework supports a finding that Plaintiff is "not disabled," whether or not she has transferable job skills. (Id.) At step five of the sequential analysis, the ALJ found that considering Plaintiff's age, education, work experience, and RFC, there are jobs that exist in significant numbers in the national economy that she can perform. (Id.) As such, the ALJ found that Plaintiff has not been under a disability, as defined in the Act, from the alleged onset date through the date of the decision. (Id. at 28.)
Standard of Review
On appeal from the final decision of the Commissioner of the Social Security Administration, the district court "shall have power to enter, upon the pleadings and transcript of the record, a judgment affirming, modifying, or reversing the decision of the Commissioner of Social Security, with or without remanding the cause for a rehearing." 42 U.S.C. § 405(g); Matthews v. Apfel, 239 F.3d 589, 592 (3d Cir. 2001). The district court must determine whether or not there is substantial evidence in the record to support the Commissioner's decision. Rutherford v. Barnhart, 399 F.3d 546, 552 (3d Cir. 2005); see Plummer v. Apfel, 186 F.3d 422, 427 (3d Cir. 1999). Substantial evidence is defined as "more than a mere scintilla." Plummer, 186 F.3d at 427. "It means such relevant evidence as a reasonable mind might accept as adequate." Id. In reviewing the record for substantial evidence, a court "may not weigh the evidence or substitute [its own] conclusions for those of the fact-finder." Rutherford, 399 F.3d at 552 (internal quotation marks omitted). Even if the court would have decided differently, it is bound by the ALJ's decision if it is supported by substantial evidence. Fargnoli v. Massanari, 247 F.3d 34, 38 (3d Cir. 2001).
In order to be eligible for disability benefits, a claimant must be unable to "engage in any substantial gainful activity by reason of any 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 not less than 12 months." 42 U.S.C. § 423(d)(1)(A). For purposes of the statute, a claimant is disabled only if her physical or mental impairments are "of such severity that [s]he is not only unable to do [her] previous work but cannot, considering [her] age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy." 42 U.S.C. § 423(d)(2)(A). A physical or mental impairment is one "that results from anatomical, physiological, or psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques." 42 U.S.C. § 423(d)(3).
Social Security regulations provide a five-step evaluation procedure to determine whether an individual is disabled. See 20 C.F.R. § 404.1520(a)(4). For the first step, the claimant must establish that she has not engaged in any "substantial gainful activity" since the onset of her alleged disability. 20 C.F.R. § 404.1520(a)(4)(i). For the second step, the claimant must establish that she suffers from a "severe . . . impairment" or "combination of impairments." 20 C.F.R. § 404.1520(a)(4)(ii). The claimant bears the burden of establishing the first two requirements, and failure to satisfy either automatically results in a denial of benefits. Bowen v. Yuckert, 482 U.S. 137, 146 n.5 (1987).
If the first two steps are satisfied, the third step requires the claimant to provide evidence that her impairment is equal to one of the impairments listed in Appendix 1 of the regulations. 20 C.F.R. § 404.1520(d). If the claimant demonstrates that she suffers from a listed impairment or that her severe impairment is equal to a listed impairment, she is presumed to be disabled and is automatically entitled to disability benefits. Id. If she cannot so demonstrate, the eligibility analysis proceeds to step four. The fourth step of the analysis requires the ALJ to determine whether the claimant's RFC permits her to resume her previous employment. 20 C.F.R. § 404.1520(e). If the claimant can perform her previous line of work, then she is not "disabled" and not entitled to disability benefits. 20 C.F.R. § 404.1520(f). The burden of persuasion rests with the claimant in the first four steps. Malloy v. Comm'r of Soc. Sec., 306 F. App'x 761, 763 (3d Cir. 2009).
If the claimant is unable to return to her previous work, the analysis proceeds to step five. At the fifth step, the burden shifts to the Commissioner to demonstrate that the claimant can perform other work that is consistent with her medical impairments, age, education, past work experience, and RFC. 20 C.F.R. § 404.1520(g); see Palmer v. Comm'r of Soc. Sec., 410 F. App'x 490, 492 (3d Cir. 2011). If the Commissioner cannot satisfy this burden, the claimant will receive Social Security benefits.
Plaintiff's Alleged Severe Impairments
Plaintiff argues that, at step two of the sequential analysis, the ALJ failed to acknowledge that she suffers from severe impairments in standing and walking. (Pl.'s Moving Br. 17, ECF No. 20.) Plaintiff also argues that the ALJ should have found that she suffers from: (1) the severe impairment of arthritis in her hands; (2) a severe impairment in her shoulder; and (3) severe impairments based on her neck and spine pathology. (Id. at 18-21.) Defendant argues that the ALJ reasonably identified Plaintiff's severe impairments at step two of the sequential analysis. (Def.'s Opp'n Br. 11.) Defendant also argues that the ALJ appropriately found that Plaintiff's impairments did not meet or medically equal the listings at step three of the sequential analysis. (Id.)
Plaintiff bears the burden of proof at steps two and three of the sequential analysis. See Malloy, 306 F. App'x at 761. Here, Plaintiff did not meet her burden. Although the ALJ may not have specifically discussed each of Plaintiff's medical conditions at step two of the sequential analysis, the overall decision reflects that the ALJ considered Plaintiff's medical conditions in reaching his determinations. Moreover, while Plaintiff cited records in support of her various impairment-related assertions, she did not demonstrate how she would prevail at step three of the sequential analysis. The Court finds Holloman v. Commissioner of Social Security persuasive in this regard. 639 F. App'x 810, 814 (3d Cir. 2016)). In Holloman, the Third Circuit stated:
Id. at 814. Here, the Court finds that Plaintiff did not meet her burden of demonstrating that the ALJ erred at step two or step three of the sequential analysis. Accordingly, the Court upholds the ALJ's step two and step three determinations.
The Weight the ALJ Provided to Opinion Evidence
Plaintiff argues that the ALJ failed to give controlling weight to the opinion of her treating physician, Dr. Bryhn, of Delaware Valley Physicians. (Pl.'s Moving Br. 28.) Plaintiff asserts that she had eleven appointments with Dr. Bryhn between September 6, 2011 and April 10, 2014. (Id.) Plaintiff further asserts that Dr. Bryhn completed two medical source forms, one form with respect to her physical abilities and the other with respect to her mental abilities. (Id.) According to Plaintiff, if the ALJ had credited Dr. Bryhn's opinion, he would have found Plaintiff disabled "because accommodations were required for her to perform work, and also, because the limitations on her hands and arms were so significant that most work would be eroded." (Id. at 29.) With respect to her mental status, Plaintiff asserts that for seven of her appointments, Dr. Bryhn's notations included anxiety and/or depression. (Id. at 30.) Plaintiff argues that Dr. Bryhn opined that she has poor concentration, persistence, and pace. (Id.) According to Plaintiff, the ALJ improperly discredited Dr. Bryhn without citation to contrary medical evidence as required. (Id. at 31.) Plaintiff further argues that there is no regulation or case law to suggest that Dr. Bryhn's opinion with respect to her mental abilities "can be rejected out of hand because [Dr. Bryhn] [is not] a psychiatrist." (Id. at 32.)
"ALJs have a duty to develop a full and fair record in social security cases." Ventura v. Shalala, 55 F.3d 900, 902 (3d Cir. 1995). The reviewing court must review the evidence in its entirety. See Daring v. Heckler, 727 F.2d 64, 70 (3d Cir. 1984). As part of the review, courts "must take into account whatever in the record fairly detracts from its weight." Schonewolf v. Callahan, 972 F.Supp. 277, 284 (D.N.J. 1997) (quoting Willbanks v. Sec'y of Health & Human Servs., 847 F.2d 301, 303 (6th Cir. 1988)). "[W]here there is conflicting evidence, the ALJ must explain which evidence he accepts and which he rejects, and the reasons for that determination." Cruz v. Comm'r of Soc. Sec., 244 F. App'x 475, 479 (3d Cir. 2007). In addition:
Cotter v. Harris, 642 F.2d 700, 705 (3d Cir. 1981).
An ALJ must provide the reports of treating physicians great weight "when their opinions reflect expert judgment based on a continuing observation of the patient's condition over a prolonged period of time." Morales v. Apfel, 225 F.3d 310, 317 (3d Cir. 2000 (citing Plummer, 186 F.3d at 429)). In addition, an ALJ must weigh all evidence and resolve all material conflicts when deciding how much weight to provide to a treating physician's opinion. Barnhill v. Astrue, 794 F.Supp.2d 503, 515 (D. Del. 2011). With respect to evaluating opinion evidence for claims filed before March 27, 2017, 20 CFR § 404.1527(c)(2) provides that:
20 CFR § 404.1527(c)(2). The factors an ALJ will consider if he does not give a treating physician's opinion controlling weight include: (1) the nature and extent of the treatment relationship; (2) the medical evidence the treating physician offered in support of her opinion; (3) how consistent the medical evidence is with the record as a whole; (4) whether the opinion relates to the treating physician's area of specialty; and (5) any other factors that tend to support or contradict the medical opinion. 20 CFR § 404.1527(c)(2)(ii)-(6).
An ALJ is also required to consider the medical evidence and make "reasonable conclusions about the intensity and persistence of [a claimant's] symptoms and the effect those symptoms, such as pain, may have on [the claimant's] ability to work." 20 C.F.R. § 404.1529(c)(2). The ALJ cannot reject subjective claims simply because they are not substantiated by medical evidence; the ALJ is also required to look at information provided by a claimant about her pain. Id. The ALJ must follow a two-step process for evaluating pain: first, whether there is a medical impairment that could reasonably be expected to produce the pain; and second, an evaluation of the symptoms to determine if they limit the claimant's ability to work. SSR 96-7p.
20 C.F.R. § 404.1529(c)(3)(i)-(vii).
On January 23, 2014, Dr. Bryhn submitted a physical source statement regarding Plaintiff. (Tr. 793-94.) Dr. Bryhn's responses to the questionnaire indicated that Dr. Bryhn: (1) had contact with Plaintiff approximately every six weeks for two years; (2) diagnosed Plaintiff with hypothyroidism, fibromyalgia, fatigue, and chronic pain — multiple areas; and (3) stated that Plaintiff's prognosis was poor. (Id. at 793.) The Questionnaire also indicated that Plaintiff: (1) could sit 0-2 hours in an eight-hour workday; (2) could stand/walk one-hour in an eight-hour workday; (3) must periodically alternate between sitting and standing every thirty minutes to relieve pain or discomfort; (4) could rarely lift less than ten pounds; (5) could never lift ten to fifty or more pounds; (6) could never perform upper extremity pushing and/or pulling; (6) could rarely perform lower extremity pushing and/or pulling; (7) could occasionally climb stairs; (8) could never climb ramps/ladder/rope/scaffold, bend/stoop, balance, kneel, or crouch; (9) could rarely reach in all directions in an eight-hour workday; (10) could occasionally perform handling, fingering, and feeling in an eight-hour workday; (11) must avoid temperature extremes, hazards, fumes, odors, chemicals, and gases; (12) would require unscheduled breaks and walking breaks every thirty minutes; (13) would require a reclining break;
In a mental medical source statement, Dr. Bryhn indicated that Plaintiff is able to understand, remember, and carry out instructions affected by the impairment. (Id. at 795.) Dr. Bryhn also stated that Plaintiff has moderate restrictions for work-related mental activities that involve: (1) understanding and remembering short, simple instructions; (2) carrying out short, simple instructions; and (3) the ability to make judgments on simple work-related decisions. (Id.) Dr. Bryhn stated that Plaintiff has marked restrictions for work-related mental activities that involve: (1) understanding and remembering detailed instructions; and (2) carrying out detailed instructions. (Id.) In addition, Dr. Bryhn found that Plaintiff is able to respond appropriately to supervision, co-workers, and work pressures in a work setting. (Id. at 796.) With respect to the capabilities affected by Plaintiff's impairments, Dr. Bryhn found that Plaintiff's "lifting-exertion of muscles" had the effect of "pain for days — [weeks]" and that Plaintiffs "concentration" was "impaired." (Id.) Finally, Dr. Bryhn stated that Plaintiff had: (1) poor mobility; (2) tenderness in her left shoulder; (3) tenderness/arthritis in her hands; and (4) arthritis [indiscernible] feet." (Id.)
Here, the ALJ did not provide sufficient analysis from which the Court could find that the weight he provided to Dr. Bryhn's opinions was supported by substantial evidence. With respect to the physical medical source statement, the ALJ accorded "little if any weight" to Dr. Bryhn's "restrictive assessment, in particular, as it relates to all times during the period in question." (Id. at 26.) The ALJ stated that "Dr. Bryhn's assessment was seemingly made with obvious emphasis placed on [Plaintiff's] subjective complaints, which are not credited at any time on or before September 30, 2013." (Id.) In addition, the ALJ gave "little weight" to Dr. Bryhn's mental source statement because Dr. Bryhn is not a mental health specialist. (Id.) The ALJ also stated that:
(Id.) The ALJ's limited discussion did not include sufficient analysis for rejecting Dr. Bryhn's medical source statements.
In his opinion, the ALJ summarized Dr. Bryhn's medical records, including Plaintiff's records related to her allegedly worsening: (1) musculoskeletal pain/fibromyalgia between March 26, 2013 and September 26, 2013; and (2) foot impairments between June 12, 2013 and April 2014. (Id. at 20-21.) After summarizing the evidence of record, the ALJ stated that "there is no evidence that that [sic] claimant's physical impairments were attendant with the degree of severity outlined in Section 1.02 or 9.00." (Id. at 21.)
Plaintiff's date last insured was September 30, 2013. Based on a careful review of the record, the Court finds that the demarcation in Plaintiff's symptoms between Plaintiff's date last insured and the submission of Dr. Bryhn's January 23, 2014 medical source statements is not as clear as the ALJ appears to find. Notably, a treating doctor's opinion lacks probative value if it "d[oes] not relate back to the period for which Plaintiff [was] insured for benefits." Jones v. Barnhart, No. 03-6660, 2005 WL 2033383, at *6 (E.D. Pa. Aug. 23, 2005). Nevertheless, the record in the present case reflects that: (1) one of the conditions that Plaintiff suffers from is fibromyalgia, which raises unique issues due to the nature of the disease;
"When confronted with contradictory medical evidence, the ALJ may choose whom to credit, but in these instances there is an acute need for the ALJ to explain the reasoning behind conclusions." Hippensteel v. Soc. Sec. Admin., 302 F.Supp.2d 382, 393 (M.D. Pa. 2001 (citing Fargnoli, 247 F.3d at 42)).
Notably, access to the Commissioner's reasoning is essential to meaningful court review:
Gober v. Matthews, 574 F.2d 772, 776 (3d Cir. 1978). Accordingly, the Court finds it necessary to remand.
For the reasons set forth above, the Court remands this matter to the ALJ for further analysis and any proceedings that the ALJ deems fit. The Court shall issue an Order consistent with this Memorandum Opinion.