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Fields v. Commissioner of Social Security

United States District Court, E.D. Michigan, Southern Division

March 30, 2017




         This matter is presently before the Court on cross motions for summary judgment [docket entries 16 and 20]. Pursuant to E.D. Mich. LR 7.1(f)(2), the Court shall decide these motions without a hearing. For the reasons stated below, the Court shall grant plaintiff's motion, deny defendant's motion, and remand the case for further proceedings.

         Plaintiff has brought this action under 42 U.S.C. § 405(g) to challenge defendant's final decision denying his application for Social Security disability insurance and Supplemental Security Income (“SSI”) benefits. An Administrative Law Judge (“ALJ”) held a hearing in April 2015 (Tr. 25-67) and issued a decision denying benefits in May 2015 (Tr. 9-24). This became defendant's final decision in June 2016 when the Appeals Council denied plaintiff's request for review (Tr. 1-3).

         Under § 405(g), the issue before the Court is whether the ALJ's decision is supported by substantial evidence. As the Sixth Circuit has explained, the Court

must affirm the Commissioner's findings if they are supported by substantial evidence and the Commissioner employed the proper legal standard. White, 572 F.3d at 281 (citing 42 U.S.C. § 405(g)); Elam ex rel. Golay v. Comm'r of Soc. Sec., 348 F.3d 124, 125 (6th Cir. 2003); Walters v. Comm'r of Soc. Sec., 127 F.3d 525, 528 (6th Cir. 1997). Substantial evidence is “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401, 91 S.Ct. 1420, 28 L.Ed.2d 842 (1971) (internal quotation marks omitted); see also Kyle, 609 F.3d at 854 (quoting Lindsley v. Comm'r of Soc. Sec., 560 F.3d 601, 604 (6th Cir. 2009)). Where the Commissioner's decision is supported by substantial evidence, it must be upheld even if the record might support a contrary conclusion. Smith v. Sec'y of Health & Human Servs., 893 F.2d 106, 108 (6th Cir. 1989). However, a substantiality of evidence evaluation does not permit a selective reading of the record. “Substantiality of the evidence must be based upon the record taken as a whole. Substantial evidence is not simply some evidence, or even a great deal of evidence. Rather, the substantiality of evidence must take into account whatever in the record fairly detracts from its weight.” Garner v. Heckler, 745 F.2d 383, 388 (6th Cir. 1984) (internal citations and quotation marks omitted).

Brooks v. Comm'r of Soc. Sec., 531 F. App'x 636, 640-41 (6th Cir. 2013).

         At the time of his April 2015 hearing, plaintiff was 57 years old (Tr. 30). He has a high school education and some college (Tr. 30) and work experience as a customer service clerk for a newspaper (Tr. 34, 201). Plaintiff claims he has been disabled since August 2013 due to having HIV, Hepatitis B, hypertension, medication side effects, anxiety, depression, chronic fatigue, wasting, rashes, hearing loss, recurrent upper respiratory infections, chronic acute sinusitis, lightheadedness, dehydration, and status post hernia (Tr. 27, 200-01).

         The ALJ found that plaintiff's severe impairments are “HIV, hypertension and adjustment disorder” (Tr. 14). He found that despite these impairments plaintiff has the residual functional capacity (“RFC”) to perform “a full range of work at all exertional levels but with the following nonexertional limitations: limited to simple, routine tasks, low stress and few changes in the work setting; avoid concentrated exposure to moving machinery and unprotected heights; located reasonably close to bathroom; no climbing ladders but occasional ramps and stairs” (Tr. 16). A vocational expert (“VE”) testified in response to a hypothetical question that a person of plaintiff's age, education, and work experience, and who has this RFC, could perform various unskilled medium-level[1] jobs such as dining room attendant, assembler, and packer (Tr. 61-62). The ALJ cited this testimony as evidence that work exists in significant numbers that plaintiff could perform and concluded that he is not disabled (Tr. 21).

         Having reviewed the administrative record and the parties' briefs, the Court concludes that the ALJ's decision in this matter is not supported by substantial evidence because his RFC evaluation of plaintiff is flawed. Since the hypothetical question incorporated this flawed RFC evaluation, it failed to describe plaintiff in all relevant respects and the VE's testimony given in response thereto cannot be used to carry defendant's burden to prove the existence of a significant number of jobs plaintiff is capable of performing.

         Plaintiff's RFC evaluation is flawed for the following reasons. First, the ALJ failed to consider the side effects of plaintiff's medications. The record indicates that plaintiff takes, or at various times has taken, Efavirenz-Emtrictabine-Tenofovir (Atripla), Stribild, Amlodipine (Norvasc), Clonidine (Catapres), Hydrazaline (Apresoline), Atenolol-Chlorthalidone (Tenoretic), Lisinopril, Benazepril, Atenolol, Hydrochlorothiazide, and Sulfamethoxazole-Trimethoprim (Bactrim) (Tr. 47, 203, 244, 247, 251, 273, 279, 287, 312). At the hearing he testified that his medications cause him to have “cloudy thinking” and to feel unfocused, interfere with his concentration, and cause urinary frequency (Tr. 51, 57). Plaintiff also testified to feeling extreme fatigue (Tr. 32, 36, 41, 51-53, 56). On his function report plaintiff indicated that he is “often lightheaded or fuzzy thinking almost dizzy-like”; that his “meds keep me getting up to use bathroom”; that he is “often fatigued”; and that he “often falls asleep from fatigue” (Tr. 216, 220, 223). He also reported medication side effects of nightmares, “bloat stomach, ” and dehydration (Tr. 223).

         The ALJ's failure to make any findings as to this issue is an error requiring remand, as the Sixth Circuit has held that the ALJ must evaluate “[t]he type, dosage, effectiveness, and side effects of any medication” as part of the process of determining the extent to which side effects impair a claimant's capacity to work. Keeton v. Comm'r of Soc. Sec., 583 F. App'x 515, 532 (6th Cir. 2014) (quoting 20 C.F.R. § 416.929(c)(3)(i)-(vi)). Further, hypothetical questions to vocational experts must account for medication side effects. See White v. Comm'r of Soc. Sec., 312 F. App'x 779, 789-90 (6th Cir. 2009). On remand, the ALJ must determine which medications plaintiff was taking during the relevant time period; make findings as to the nature and severity of these medications' side effects, if any; adjust his findings as appropriate regarding plaintiff's RFC; and incorporate these findings in proper hypothetical questions to the VE.

         Second, the RFC evaluation in this matter is flawed because the ALJ did not adequately explain why he discounted plaintiff's credibility. In addition to testifying about his medication side effects, plaintiff testified that while he has no difficulty sitting, he can stand for only five minutes or walk for 10-15 minutes before becoming exhausted/fatigued and having to rest, and that he can lift at most 20 pounds (Tr. 52-53). Plaintiff also testified that due to fatigue he must nap for 5-10 minutes up to five times per day (Tr. 56-57). If plaintiff's testimony regarding his standing, walking, and lifting abilities is credited, he would not have the RFC to do the medium-level jobs identified by the VE (Tr. 61-62), which the ALJ cited as jobs plaintiff could perform (Tr. 21); and if plaintiff's testimony regarding his need to nap frequently due to fatigue is credited, he would not be able to work at all, according to the VE (Tr. 64).[2]

         The ALJ is not required to accept a claimant's testimony, but if he rejects testimony on credibility grounds, he must state his reasons for doing so and the reasons must be supported by substantial evidence. As the Sixth Circuit has explained,

the ALJ is not free to make credibility determinations based solely upon an “intangible or intuitive notion about an individual's credibility.” Soc. Sec. Rul. 96-7p, 1996 WL 374186, at *4. Rather, such determinations must find support in the record. Whenever a claimant's complaints regarding symptoms, or their intensity and persistence, are not supported by objective medical evidence, the ALJ must make a determination of the credibility of the claimant in connection with his or her complaints “based on a consideration of the entire case record.” The entire case record includes any medical signs and lab findings, the claimant's own complaints of symptoms, any information provided by the treating physicians and others, as well as any other relevant evidence contained in the record. Consistency of the various pieces of information contained in the record should be scrutinized. ...

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