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Clark v. Commissioner of Social Security

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

April 4, 2018




         This matter is presently before the Court on cross motions for summary judgment [docket entries 11 and 15]. 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 deny defendant's motion, grant plaintiff's motion, and remand the matter for further proceedings.

         Plaintiff has brought this action under 42 U.S.C. § 405(g) to challenge defendant's decision denying her applications for Social Security disability insurance and Supplemental Security Income benefits. An Administrative Law Judge (“ALJ”) held a hearing in April 2016 (Tr. 39-57) and issued a decision denying benefits in July 2016 (Tr. 20-34). This became defendant's final decision in September 2017 when the Appeals Council denied plaintiff's request for review (Tr. 1-4).

         Under § 405(g), the issue before the Court is whether defendant'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 the ALJ's decision, plaintiff was 42 years old. She has a high school education and experience as an assembly line worker (Tr. 42, 154). Plaintiff claims she has been disabled since June 2013 due to back pain, carpal tunnel in both wrists, arthritis in her spine and hands, diabetes, high cholesterol, sleep apnea, depression, panic attacks, and chronic pain (Tr. 163, 171). The ALJ found that plaintiff's severe impairments are “degenerative disc disease, obesity, bilateral carpal tunnel syndrome, depression, and panic disorder” (Tr. 25) and that her non-severe impairments are diabetes, high cholesterol, sleep apnea, and right shoulder issues (Tr. 26). He found that plaintiff cannot perform her past work but that she has the residual functional capacity (“RFC”) to perform a limited range of light work.[1] 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 certain unskilled sorting, packaging, and “product processing and product finishing” jobs (Tr. 54). The ALJ cited this testimony to support his conclusion that plaintiff is not disabled because work exists in significant numbers that she could perform (Tr. 33).

         Having reviewed the administrative record and the parties' briefs, the Court concludes that defendant's decision is not supported by substantial evidence because the ALJ's RFC evaluation of plaintiff is flawed. Since the hypothetical question incorporated a 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 that plaintiff is capable of performing.

         The ALJ's RFC evaluation is flawed for the following reasons. First, the ALJ failed to fully consider the side effects of plaintiff's medications. The record indicates that plaintiff takes, or at various times has taken, many medications, including Alprazolam (Xanax), Aprine, Metformin, Norco, Meloxicam, Hydrocodone, Meloxicam, Lamotrigine, Duloxetine, Citalopram, Lisinopril, Piroxicam, Neurontin, Cymbalta, Lamictal, Ativan, Methylprednisone, Duler, Gabapentin, ProAir, Symbicort, Omeprazole, and Lamisil (Tr. 166, 182, 212-20, 241, 261, 316-17, 346, 378, 433), several of which have known side effects. On her function report, plaintiff indicated that some of her medications make her feel tired, dizzy, and sleepy (Tr. 173, 180-82). Elsewhere, plaintiff indicated that some of her medications make her feel foggy, tired, forgetful, and sleepy (Tr. 214-16). Plaintiff testified that her medications make her feel fatigued, confused, and dizzy (Tr. 51).

         The ALJ's only discussion of this issue was to dismiss plaintiff's testimony on the grounds that “in January 2016 the claimant was described as not experiencing lightheadedness or dizziness (Exhibit 3F, page 4)” (Tr. 29). This statement does not sufficiently address the issue of plaintiff's medication side effects. Plaintiff does not claim to experience lightheadedness. She does claim to experience dizziness. While at the page cited by the ALJ the doctor answered “No” to the question of whether “the patient has been experiencing dizziness and/or lightheadedness” (Tr. 319), on the same form he listed “[d]izziness and giddiness” among plaintiff's confirmed problems (Tr. 316), as he did on at least ten other occasions (Tr. 322, 328, 333, 341, 345, 349, 354, 359, 363, 366). Further, he answered “Yes” to the question about whether “the patient has been experiencing dizziness and/or lightheadedness” two weeks and four weeks before giving the “No” answer (Tr. 324, 330).

         On this record, it was unreasonable for the ALJ to conclude that plaintiff does not experience dizziness. Further, the ALJ made no findings about the other side effects plaintiff claims to experience, i.e., fatigue, confusion, forgetfulness and sleepiness. 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; and revise his RFC assessment and his hypothetical question(s) to the VE, as appropriate.

         Second, the RFC assessment in this matter is flawed because substantial evidence does not support the ALJ's finding that despite her bilateral CTS plaintiff can perform light work (which under 20 C.F.R. § 404.1567(b) requires lifting ten pounds frequently and up to twenty pounds occasionally) with the only hand-related limitations being “no vibratory tools” and “only frequent handling, fingering, and grasping on the right” (Tr. 27). Plaintiff testified that her “fingers go numb, ” that she “drop[s] a lot of thing, ” that she is “not able to hold on, ” that “[i]t's painful when my hand goes numb, ” that she would need both hands to lift a gallon of milk, that medication does not help with her hand/finger/wrist pain, and that she wears baggy clothing because she cannot manipulate bottons, snaps or zippers (Tr. 48-49). Plaintiff wrote on her disability report that her “fingers go numb and hurt [and] I constantly drop things because of the numbness” (Tr. 170). On her function report plaintiff indicated that she has “numbness and pain in both hands and [wears] a wrist/hand brace. I constantly drop things. I cannot hold things or my fingers go numb” (Tr. 173). During her psychological examination in October 2014, it was noted that plaintiff wore braces on both wrists (Tr. 312).

         The only medical opinion in this record that commented specifically about the functional impact of plaintiff's CTS is from Dr. Jurado, who examined plaintiff at defendant's request in May 2016 and who noted “[s]ensory perception . . . both hands absent, . . . right hand absent, left decreased” (Tr. 435). Dr. Jurado opined that plaintiff could occasionally (one-third of the time) lift and carry up to ten pounds and “never” more than ten pounds; and that she could “never” use her hands for reaching overhead and only occasionally for handling, fingering, feeling, and pushing/pulling (Tr. 437, 439).

         The ALJ rejected plaintiff's testimony about her hand complaints, as well as Dr. Jurado's hand-related restrictions, but his reasons for doing so lack substantial support in the record. The ALJ found that plaintiff's hand injections have “been effective, ” but the only evidence he cited for this is Dr. Hall's statement on March 7, 2016, that “[s]he reports her right hand is much improved after the Celestone injection” (Tr. 428). That injection was administered on February 15, 2016 (Tr. 404). The ALJ made no findings as to the extent or duration of this relief. The mere fact that the injection provided relief after three weeks ...

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