United States District Court, D. Vermont
OPINION AND ORDER
William K. Sessions III District Court Judge.
Plaintiff
Andrew Reynard appeals the decision of an Administrative Law
Judge (ALJ) denying his September 27, 2011 applications for
Title II social security disability insurance benefits and
Title XVI supplemental security income (SSI) benefits. Mr.
Reynard alleges that he became unable to work on June 9,
2011. Administrative Record (hereafter “AR”) 296.
In particular, Mr. Reynard stated on his initial application
that he has difficulties sitting and walking for any extended
period of time and that he has difficulties resting. AR 253.
With respect to his mental state, Mr. Reynard stated that he
has childhood onset of Post-Traumatic Stress Disorder (PTSD),
that his PTSD affects his ability to get along with others,
and that he does not socialize much because he has
difficulties trusting other people. AR 259-260. He also
stated that he has a limited attention span and that he
forgets spoken instructions easily. AR 258. On his
reconsideration application, filed after Mr. Reynard's
girlfriend attempted suicide, the plaintiff alleged increased
anxiety and depression stemming from trauma triggers. AR 274.
In support of his application, Mr. Reynard submitted abundant
evidence of his physical and emotional conditions and of
their effects on his ability to work.[1] His application was
initially denied on February 7, 2012 and denied on
reconsideration on April 18, 2012. Mr. Reynard requested a
hearing before an ALJ, who denied Mr. Reynard's
application on May 28, 2013. The Social Security Appeals
Council denied Mr. Reynard's subsequent request for
review, and Mr. Reynard appealed to this Court on November
21, 2014. ECF No. 3. Because the records from the
Plaintiff's health care providers persuasively
demonstrate the Plaintiff's disability, the Court now
reverses the ALJ's decision and remands solely for the
calculation of benefits.
BACKGROUND
Mr.
Reynard is a 48-year old male who has been diagnosed with
Post-Traumatic Stress Disorder (PTSD), depression, anxiety,
severe obstructive sleep apnea, morbid obesity, chronic
obstructive pulmonary disease (COPD) and degenerative disc
disease and compression fractures in the lower back. The
plaintiff's physical impairments have caused him to have
chronic lower back pain and reduced mobility, and his
psychological impairments have produced a range of
maladaptive symptoms affecting plaintiff's social
functioning and energy level.
Nevertheless,
the ALJ found that the plaintiff was not disabled under the
definition of that term in the Social Security Act
(“Act”). In reaching that conclusion, the ALJ
applied a five-step sequential evaluation process established
by the Social Security Administration for determining whether
an individual is disabled. 20 C.F.R. §§404.1520;
416.920. The Second Circuit has “tracked this
methodology … as follows:
1. The Commissioner considers whether the claimant is
currently engaged in substantial gainful activity.
2. If not, the Commissioner considers whether the claimant
has a ‘severe impairment' which limits his or her
mental or physical ability to do basic work activities.
3. If the claimant has a ‘severe impairment, ' the
Commissioner must ask whether, based solely on medical
evidence, claimant has an impairment listed in Appendix 1 of
the regulations. If the claimant has one of these enumerated
impairments, the Commissioner will automatically consider him
disabled, without considering vocational factors such as age,
education, and work experience.
4. If the impairment is not “listed” in the
regulations, the Commissioner then asks whether, despite the
claimant's severe impairment, he or she has residual
functional capacity to perform his or her past work.
5. If the claimant is unable to perform his or her past work,
the Commissioner then determines whether there is other work
which the claimant could perform. The Commissioner bears the
burden of proof on this last step, while the claimant has the
burden on the first four steps.”
Shaw v. Chater, 221 F.3d 126, 132 (2d Cir. 2000).
Applying
this approach, the ALJ first found that the plaintiff was not
engaged in substantial gainful activity. Next, the ALJ found
that the plaintiff had a medically determinable impairment
that is severe or a combination of such impairments, such
that the impairment limits the plaintiff's ability to
perform basic work activities. Specifically, the ALJ found
that the plaintiff had the following severe impairments:
degenerative disc disease, obstructive sleep apnea, obesity,
COPD, an affective disorder and an anxiety-related disorder.
AR 19.
At the
third step, the ALJ evaluated whether the plaintiff's
impairment or combination of impairments is of a severity to
meet or medically equal the criteria of an impairment listed
in 20 C.F.R. Part 404, Subpart P, Appendix 1. The ALJ
concluded that the plaintiff's impairments in this case
did not rise to the level of a listed impairment. With regard
to his physical impairments, the ALJ found that the
plaintiff's degenerative disc disease, which caused his
lower back pain, did not meet or equal the criteria of
listing 1.04 because “there is no evidence of nerve
root compression characterized by neuro-anatomic distribution
of pain, limitation of motion of the spine, motor loss
accompanied by sensory or reflex loss, and positive
straight-leg raising, or spinal arachnoiditis, or lumbar
spinal stenosis resulting in pseudoclaudication.” AR
19. The ALJ did not consider the effects of obesity
specifically on the plaintiff's disturbance of the
musculoskeletal system, although he did consider it in
relation to the plaintiff's overall combination of
impairments. The ALJ concluded that the addition of obesity
to the sum of his other impairments would not result in a
finding of disability under step three because the plaintiff
“remains fully weight bearing and does not have
abnormal neurological functioning.” AR 19.
With
regard to the plaintiff's obstructive sleep apnea and
COPD, the ALJ found that the plaintiff's condition did
not rise to the level of those disorders listed under
listings 3.09 and 12.02. He also found the plaintiff's
conditions did not meet or equal the criteria of listing
3.02. Section 3 of the appendix relates to respiratory
disorders, including COPD, with 3.02 providing criteria for
chronic respiratory disorders due to any cause (with a
non-relevant exception) and 3.09 providing criteria related
to chronic pulmonary hypertension. Whether the severity of
the impairment rises to the level of a disability is
determined by specific test results related to (in relevant
part) pulmonary artery pressure, forced expiratory volume or
forced vital capacity. Section 3.00(P)(2) provides that
sleeping disorders will be evaluated under the listings of
the affected body systems, and 12.02 provides criteria
relevant to neurocognitive disorders. The ALJ's
conclusions regarding the limited impact of plaintiff's
sleep apnea on his cognitive functioning and mood disturbance
cross-references his evaluation of the evidence pertinent to
plaintiff's other psychological disorders.
With
respect to the plaintiff's psychological impairments, the
ALJ determined that the plaintiff's anxiety and
depression did not meet or equal the criteria in listings
12.04 or 12.06. The ALJ failed to consider whether
plaintiff's PTSD diagnoses meets or equals the criteria
in listing 12.12. However, his analysis of the factors to be
considered in listings 12.04 and 12.06 would also be
applicable to the 12.12 analysis. Listings 12.04, 12.06 and
12.12 provide three categories of criteria (A, B, and C) and
require that a claimant exhibit either sufficient Category A
and B criteria or Category A and C criteria. Category A
criteria relate to the symptoms of the disorder itself, while
Category B criteria relate to a claimant's functioning
and Category C criteria relate to whether the impairment is
serious and persistent, requiring a claimant to rely on an
ongoing basis upon medical treatment, therapy, psychosocial
supports or a highly structured setting to diminish the
symptoms or signs of the mental disorder. The ALJ found that
plaintiff did not have marked limitations in at least two of
the Category B criteria: in the ALJ's view, he only had
mild restrictions in activities of daily living and in social
functioning, moderate difficulties with regard to
concentration, persistence and pace and had experienced no
episodes of decompensation. AR 20. The ALJ then found that
Category C criteria for 12.04 were not met because
“there is no evidence in the record of repeated
episodes of decompensation, a current history of one or more
years' inability to function outside a highly supportive
living arrangement, or a residual disease process that has
resulted in such marginal adjustment that even a minimal
increase in mental demands or change in environment would be
predicted to cause the individual to decompensate.” AR
20. The criteria were not met for 12.06 because “there
is no evidence in the record of a complete inability to
function independently outside the area of the claimant's
home.” Id.
The ALJ
did not specifically reference any of the medical evidence in
reaching these conclusions in a summary manner, and relied
solely on reports of the plaintiff's daily habits. AR 20.
Instead, he cross-referenced his residual functional capacity
assessment in explaining his determination of the degree to
which Category B criteria were present. AR 21. In particular,
at this stage of the analysis, the ALJ gave little weight to
the evaluation of the plaintiff's therapist, Gretchen
Lewis, because it was inconsistent with the evidence of the
plaintiff's daily habits. AR 24. The ALJ did not analyze
the consistency between Gretchen Lewis' evaluation and
the records from social worker Krystal Cota's prior
treatment of the plaintiff or the reports of psychiatric
symptoms on his primary care physician's records.
Id. Instead, the ALJ took note of the opposite
conclusion in a one-time evaluation conducted by Dr. Theodore
Williams. The lack of reliance on this medical evidence
therefore guided the ALJ's conclusion that Mr. Reynard
was not disabled under step 3 of his analysis.
After
concluding that the plaintiff's impairments did not meet
or equal any of the impairments listed in 20 C.F.R. Part 404,
Subpart P, Appendix 1, the ALJ went on to conclude that the
plaintiff had residual functional capacity to perform light
work; that he could perform frequent climbing of stairs,
ramps, ladders, ropes and scaffolds, as well as balance,
stoop, kneel, crouch and call; that he could follow 1-3 step
instructions; and that he could sustain concentration,
persistence and pace over 2-hour blocks within a typical
workday and workweek. AR 21. Once again, with respect to the
plaintiff's mental disorders, the ALJ based his
assessment on evidence of Mr. Reynard's daily habits and
a single evaluation conducted by Dr. Williams, and gave
little weight to the available evidence from Mr.
Reynard's treatment providers. With regard to his
physical impairments, the ALJ gave little weight to the
evaluation conducted by Mr. Coleman, an occupational
therapist to whom Mr. Reynard's primary care physician,
Dr. Lippman, had referred the plaintiff. He also found that
the plaintiff's reports of his own physical capacity and
pain limitations were not credible because they were
“not entirely supported or consistent with the evidence
of record.” AR 22. This assessment of the
plaintiff's residual functional capacity led him to
conclude, based on the testimony of a vocational expert, that
the plaintiff could perform past relevant work as it was
actually performed, and that, in the alternative, there are
other jobs existing in the ...