Administrative – ALJ Erred in Discounting Pain, Doctor Opinion

Lewis v. Berryhill, Acting Comm’r SSA (Lawyers Weekly No. 001-121-17, 22 pp.) (Agee, J.) No. 15-2473, June 2, 2017; USDC at Baltimore, Md. (Gallagher, J.) 4th Cir.

Holding: In rejecting a social security disability application filed by a 38-year-old woman who suffered from multiple medically determinable impairments, the ALJ applied an improper legal standard to discredit claimant’s evidence of pain intensity and the opinions of her treating physicians, in addition to failing to adequately explain the reasons for disregarding her extensive treatment history; the 4th Circuit vacates the denial of benefits and remands the case.

Multiple Ailments

Claimant suffered from the following severe, medically determinable impairments: obesity, degenerative disc disease, degenerative joint disease/thoracic outlet syndrome, diabetes, lupus and depression with complaints of anxiety.

Under social security regulations, an administrative law judge follows a two-step analysis when considering a claimant’s subjective statements about impairments and symptoms. First, the ALJ looks for objective medical evidence showing a condition that could reasonably produce the alleged symptoms. Second, the ALJ must evaluate the intensity, persistence and limiting effects of the claimant’s symptoms to determine the extent to which they limit the claimant’s ability to perform basic work activities. The second determination requires the ALJ to assess the credibility of the claimant’s statements about symptoms and their functional effects.

The parties agree the ALJ properly found that claimant met the requirements of the first step in the analysis, i.e., that her medically determinable impairments could reasonably be expected to produce the pain or other symptoms alleged. Claimant contends, however, the ALJ erred at the second step when it concluded her statements concerning the intensity, persistence and limiting effect of these symptoms were “not entirely credible.”

Claimant’s subjective evidence of pain intensity cannot be discounted solely based on objective medical findings. And the ALJ failed to explain what statements by claimant undercut her subjective evidence of pain intensity as limiting her functional capacity.  We find the ALJ’s determination that objective medical evidence was required to support claimant’s evidence of pain intensity improperly increased her burden of proof.

Treating Physicians

Claimant provided medical records containing opinions from two of her treating physicians, including her treating rheumatologist, Dr. Jacob. He opined that claimant’s pain constantly interfered with attention and concentration, she was precluded from lifting more than five pounds of weight, and she was incapable of even low stress jobs. The ALJ gave short shrift to Dr. Jacob’s opinion but also discounted the opinion of claimant’s primary treating physician who treated claimant for four years essentially on a bi-weekly basis. He opined that claimant cannot sit for more than two hours, stand/walk for more than three hours, and has significant limitations in tasks such as handling, reaching, fingering, lifting and keeping her neck in a constant position. He marked her pain as seven of 10 of a 10-point scale.

The ALJ did not adequately explain why he failed to give controlling weight to the opinions of claimant’s treating physicians under 20 C.F.R. § 404.1527(c)(2) and § 416.927(c)(2). The opinions of outside physicians hired to evaluate claimant’s medical records bolster the opinions of the treating physicians, yet the ALJ ignored their conclusions.

Claimant’s multiple medical conditions require her to take powerful analgesics, including Fentanyl and Oxycodone. She endured multiple surgeries, one of which required removal of her first left rib to alleviate pain. Before these surgeries, she underwent a lumbar epidural injection, two supraspinatus nerve blocks and a radiofrequency ablation of her supraspinatus nerve. In light of the extensive treatment she received for her various conditions, the ALJ’s designation of claimant’s course of treatment as “conservative” amounts to improperly “playing doctor” in contravention of the applicable regulations.

Vacated and remanded with instructions.