United States District Court, E.D. Michigan, Southern Division
CLISSON J. JOHNSON, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY, Defendant.
OPINION AND ORDER GRANTING PLAINTIFF'S MOTION FOR
SUMMARY JUDGMENT, DENYING DEFENDANT'S MOTION FOR SUMMARY
JUDGMENT, AND REMANDING FOR FURTHER PROCEEDINGS
BERNARD A. FRIEDMAN DETROIT, MICHIGAN SENIOR UNITED STATES
DISTRICT JUDGE
This
matter is presently before the Court on cross motions for
summary judgment [docket entries 11 and 13]. 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 decision denying his application
for supplemental security income benefits. An Administrative
Law Judge (“ALJ”) held a hearing in February 2018
(Tr. 37-50) and issued a decision denying benefits in March
2018 (Tr. 12-30). This became defendant's final decision
in October 2018 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 Fed.Appx.
636, 640-41 (6th Cir. 2013).
At the
time of the ALJ's decision, plaintiff was forty-four
years old (Tr. 29). He has a general education diploma and no
relevant work experience (Tr. 40, 48, 207-08). Plaintiff
claims he has been disabled since February 2016 (Tr. 201) due
to depression, anxiety, migraines, gout, hypertension, back
pain, high cholesterol, carpal tunnel syndrome, sleep apnea,
and gastroesophageal reflux disease (“GERD”) (Tr.
206). At the hearing plaintiff testified that he also suffers
from numbness in his arms, legs, and feet; edema in his feet;
pain throughout his body; a slipped disc in his neck; and
medication side effects (Tr. 41, 46).
The ALJ
found that plaintiff's severe impairments are
“degenerative disc disease and carpal tunnel
syndrome” (Tr. 18) and that his non-severe impairments
are hypertension, obstructive sleep apnea, type II diabetes
mellitus, obesity, and anxiety (Tr. 18-19). The ALJ made no
findings regarding plaintiff's other impairments, i.e.,
depression, migraines, gout, and GERD. The ALJ further found
that plaintiff has the residual functional capacity
(“RFC”) to perform a limited range of sedentary
work.[1] A vocational expert (“VE”)
testified in response to a hypothetical question that a
person of plaintiff's age and education and who has this
RFC could perform certain unskilled jobs as a packer, bench
assembler, or information clerk (Tr. 48-49). The ALJ cited
this testimony as evidence that work exists in significant
numbers that plaintiff could perform and determined that he
is not disabled (Tr. 30).
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 four 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, a number of medications, including
Baclofen, Chlorthalidone, Clonidine, Furosemide (Lasix),
Gabapentin (Nerontin), Isosorbide (Imdur), Methocarbamol
(Robaxin), Nifedipine, Nitrostat (Nitroglycerin), Omeprazole,
Prednisone, Simvastatin, Metoprolol, Tramadol (Ultram),
Sertraline (Zoloft), Afeditab, Hydrochlorothiazide
(Hydrodiuril), Lisinopril, Potassium Chloride (Klor-con),
Metronidazole, Butalbital, Acetaminophen-Codeine #3,
Hydrocodone-Acetaminophen (Norco), Hydralazine, Clonazepam
(Klonopin), and Metformin (Glucophage) (Tr. 209, 222, 258-62,
266-72, 279, 496-98, 501-02, 708-09, 762-63, 908-10, 937-38,
944-47, 979-81, 991-92, 1045), some of which have known side
effects. Plaintiff testified that he experiences medication
side-effects of “dizziness, drowsiness,
blurriness” (Tr. 46) and his occupational therapist
indicated that “[p]ain meds make pt drowsy so pt does
not leave house” (Tr. 1067).
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 Fed.Appx. 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 Fed.Appx. 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 adjust his RFC
evaluation of plaintiff and his hypothetical question(s) to
the VE, as appropriate.
Second,
the RFC evaluation is flawed because the ALJ neglected to
make required findings concerning the effect of
plaintiff's obesity on his other impairments. The ALJ
found that obesity is one of plaintiff's non-severe
impairments[2] (Tr. 19) and that his obesity,
hypertension, apnea, and diabetes “have been managed
medically and do not appear to have caused any significant
limitations to his ability to perform basic work
activities” (Tr. 19). This statement fails to comply
with the regulations requiring ALJs to consider the effects
of a claimant's obesity at all steps of the sequential
evaluation process. See SSR 02-1p; 20 C.F.R. Pt.
404, Subpt. P, App. 1 § 1.00Q (“[w]hen determining
whether an individual with obesity has a listing-level
impairment or combination of impairments, and when assessing
a claim at other steps of the sequential evaluation process,
including when assessing an individual's residual
functional capacity, adjudicators must consider any
additional and cumulative effects of obesity.”). It
does not suffice for the ALJ simply to assert that
plaintiff's obesity, and several of his other
impairments, are “managed medically” and do not
affect his ability to work. On remand, the ALJ must comply
with the regulations and make findings as to the effect of
plaintiff's obesity on his other impairments. In
particular, the ALJ must determine the extent to which
plaintiff's obesity exacerbates his back pain and
diminishes his ability to sit, stand, or walk. The ALJ must
include any such findings in reevaluating plaintiff's RFC
and, as appropriate, in framing revised hypothetical
question(s) to the VE.
Third,
the RFC evaluation in this matter is flawed because it fails
to make any allowance for plaintiff's reduced ability to
use his hands and fingers due to his carpal tunnel syndrome
(“CTS”). As noted above, the ALJ found that
plaintiff's CTS is one of his severe impairments, a
finding plainly supported by the medical evidence. A
neurologist noted in September 2015 that “[t]here is
electrodiagnostic evidence of bilateral median dysfunction at
the wrist, carpal tunnel syndrome, sensory, demyelinating and
axonal and moderate” and that “[t]rigger point
injection over the median nerves bilaterally was done for the
patient's carpal tunnel syndrome” (Tr. 402-03).
Plaintiff has complained repeatedly about numbness, tingling,
pain, and weakness in both of his hands (Tr. 404, 422, 743,
762, 804-94, 1025-34), and he told his primary care physician
that the injections did not help much (Tr. 489, 495). There
is evidence plaintiff wears bilateral carpal tunnel braces,
which were prescribed by his neurologist (Tr. 762, 909, 928,
1025, 1029). Despite this evidence, and despite finding that
plaintiff's CTS is a severe impairment, the ALJ made no
findings regarding the severity of the symptoms plaintiff
experiences in his fingers, hands, and wrists. On remand, the
ALJ must reevaluate all of the evidence regarding
plaintiff's CTS, make findings regarding the severity of
plaintiff's CTS symptoms (particularly the pain and
numbness in plaintiff's hands and wrists), and revise his
RFC evaluation and his hypothetical question(s) to the VE, as
appropriate.
Fourth,
the RFC evaluation in this matter is flawed because the ALJ
failed to explain adequately why he found that plaintiff is
able to sit throughout an eight-hour work day. As noted
above, the ALJ found that plaintiff's degenerative disc
disease is a severe impairment. This finding is plainly
supported by the medical evidence. An EMG of plaintiff's
lumbar spine in August 2015 showed “[l]umbo-sacral
paraspinal denervation with radiculopathy right>>left
in L5>>>>S1 root distribution sub acute to
chronic in nature with ongoing denervation moderate to severe
in severity probably from disc-DJD/disc osteophytes”
(Tr. 696). An MRI of plaintiff's lumbar spine in February
2016 showed “small central disc protrusions at ¶
4-L5 and L5-S1 with minor central canal narrowing at ¶
4-L5 demonstrating midline annular tear” and
“early degenerative facet arthropathy at ¶
5-S1” (Tr. 505). In April 2016, Dr. James Culver, M.D.,
indicated that plaintiff “was evaluated . . . in regard
to disc protrusions at ¶ 5-S1 greater than L4-5, with
sciatica, S1 and L5 radiculitis, and stenosis of L4-5”
(Tr. 698-700). In June 2016, x-rays noted “[d]ecreased
disc space was found at: L5 and sacrum” and compression
fractures at ¶ 3, C4, C5, C6, and C7 (Tr. 712). In
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