Impairments because multiple sclerosis "requires specific findings which are not present." Tr. at 13.
At step four, ALJ Morales-Ramirez found Claussen's impairment prevents her from performing "her past relevant work as a waitress." Tr. at 14. ALJ Morales-Ramirez determined "with findings of reduced motor strength in the legs as reported by Dr. Picone, it is reasonable to conclude that the claimant is unable to stand and walk for the entire workday, and ... that the claimant can no longer perform her past relevant work." Id. Accordingly, the analysis shifted to step five.
At step five, ALJ Morales-Ramirez acknowledged the Commissioner had the burden to show there are other jobs existing in significant numbers in the national economy which Claussen can perform, consistent with her medically determinable impairments, age, functional limitations, education and work experience. Tr. at 14.
ALJ Morales-Ramirez observed, at the time of the hearing, Claussen was thirty-four years of age and she was, therefore, a "younger person" under the Regulations. Tr. at 19 (citing 20 C.F.R. §§ 404.1563, 416.963). He further observed Claussen had only a ninth-grade education. Id. ALJ Morales-Ramirez concluded Claussen: "has retained the residual functional capacity to perform a full range of sedentary work activity." Id. at 13.
ALJ Morales-Ramirez further found: "Section 404.1569 of Regulations No.4 and section 416.969 of Regulations No.16 and Rules 201.25, Table No.1 of Appendix 2, Subpart P, Regulations No.4 [(the "Grids")], direct a conclusion that, considering the claimant's residual functional capacity, age, education, and work experience, she is not disabled." Tr. at 19 (emphasis added). Consequently, ALJ Morales-Ramirez held: "The claimant is therefore not disabled for the purpose of entitlement to disability insurance benefits and supplemental security income." Id. at 13.
In reaching his conclusion, ALJ Morales-Ramirez considered the medical reports submitted by Dr. Picone and acknowledged Dr. Picone's opinion, provided it is well supported by substantial medical evidence, was controlling because she was Claussen's treating neurologist. Tr. at 14. He, nevertheless, did not credit Dr. Picone's conclusion Claussen cannot perform light or sedentary work activity because he found it was "not well supported by objective medical findings." Id.
ALJ Morales-Ramirez also considered Claussen's testimony regarding her symptoms and limitations. Tr. at 15. He dismissed this testimony: Claussen's "allegations as to her exertional capabilities are credible, but her allegations of debilitating fatigue, blurred vision, reduced concentration and memory, and other symptoms are not fully credible, as they are contradicted by various factors." Tr. at 18.
The instant matter must be remanded to the Commissioner for three reasons: (1) the rejection of Dr. Picone's conclusion that Claussen is disabled does not appear to be supported by substantial evidence; (2) the rejection of Claussen's testimony regarding her overwhelming fatigue likewise does not appear to be supported by substantial evidence; and (3) ALJ Morales-Ramirez improperly applied the Grids to determine Claussen is not disabled.
1. Rejection of Dr. Picone's Conclusion
Dr. Picone's conclusion that Claussen is unable to perform sedentary work was rejected because "Dr. Picone did not set forth objective findings upon examination to support her conclusion the claimant cannot perform sedentary or light work activity." Tr. at 14. Essentially, Dr. Picone's determination was found too conclusory to support a finding of disability.
Where an ALJ finds a physician's report conclusory or unclear it is incumbent upon the ALJ to secure additional evidence from another physician. Ferguson v. Schweiker, 765 F.2d 31, 36-37 n.4 (3d Cir. 1985); see Director, OWCP, U.S. Dep't. of Labor v. Mangifest, 826 F.2d 1318, 1329 n.19 (3d Cir. 1987); Cintron v. Bowen, 686 F. Supp. 522, 524 (E.D.Pa. 1988); Veal v. Heckler, 610 F. Supp. 1094, 1096 (E.D.Pa. 1985).
ALJ Morales-Ramirez emphasized: "The positive MRI test and positive BAER test confirmed the diagnosis of multiple sclerosis but do nothing to establish the degree of the claimant's neurological impairment, which must be done using clinical findings, which Dr. Picone did not set forth." Tr. at 14. Accordingly, additional evidence regarding the degree of Claussen's neurological impairment should have been sought.
Furthermore, the reasons for the rejection of Dr. Piccone's evidence were not sufficiently addressed. "While the ALJ is, of course, not bound to accept physicians' conclusions, he [or she] may not reject them unless he first weighs them against other relevant evidence and explains why certain evidence has been accepted and why other evidence has been rejected." Kent v. Schweiker, 710 F.2d 110, 115 n.5 (3rd Cir. 1983) (citing Cotter, 642 F.2d at 705-06).
In rejecting Dr. Picone's disability determination ALJ Morales-Ramirez observed: "Upon examination[, on 19 February 1993,] and subsequent examinations, the claimant had mild to moderate loss of motor strength in her legs, although her gait was consistently normal." Tr. at 15. (emphasis added). Although ALJ Morales-Ramirez did observe that "on one occasion, Dr. Picone reported that the claimant had ataxia and used a cane intermittently," he did not address other evidence regarding Claussen's problems with her gait. Id.
The record indicates, on 19 February 1993, Claussen occasionally tripped on her feet. Tr. at 123. The record indicates that on 21 May 1993 her problem with tripping had increased. Id. at 126. Finally, on 26 July 1993, "difficulty with tandem" was noted in her gait. Id. at 105.
ALJ Morales-Ramirez relied, in part, on Claussen's "normal gait," in finding Claussen could perform sedentary work:
[Claussen] has full motor strength in her arms, and with full motor strength in the upper extremities and mildly to moderately reduced motor strength in the lower extremities, with a normal gait, she is able to meet the exertional demands of sedentary work activity. Thus, Dr. Picone's conclusion that the claimant is unable to perform sedentary or light work is not well supported by objective medical evidence.
Tr. at 105 (emphasis added). ALJ Morales-Ramirez, however, did not explain his conclusion Claussen's gait was normal given the evidence regarding her problem with tripping and her "difficulty with tandem."
The rejection of the evidence of Claussen's fatigue was also not adequately addressed. The only medical evidence contrary to Dr. Picone's determination Claussen was not capable of performing sedentary work is the Residual Functional Capacity Assessment. Tr. at 55-62. The Residual Functional Capacity Assessment is not referred to in ALJ Morales-Ramirez's decision; moreover, if the report had been considered, it alone would not constitute substantial evidence.
Mason, 994 F.2d at 1065 (citing Brewster v. Heckler, 786 F.2d 581, 585 (3d Cir. 1986)); Green v. Schweiker, 749 F.2d 1066, 1071, n.3 (3d Cir. 1984) (citing O'Leary v. Schweiker, 710 F.2d 1334, 1341 (8th Cir. 1983)); Kellam v. Bowen, 663 F. Supp. 238, 241-242 (E.D.Pa. 1987).
2. Rejection of Claussen's Testimony
ALJ Morales-Ramirez rejected Claussen's complaints of fatigue: "The claimant's allegations as to her exertional limitations are largely credible, but her allegations of debilitating fatigue and other diffuse symptoms are not fully credible, as they are contradicted by various factors." Tr. at 17.
As indicated, where medical evidence supports a claimant's complaints of pain, the complaints should be given "great weight" and may not be disregarded unless there exists contrary medical evidence. Mason, 994 F.2d at 1067-68 (citing Carter v. Railroad Retirement Board, 834 F.2d 62, 65 (3d Cir 1986)); Ferguson, 765 F.2d at 37. In the instant case, Claussen complained of "very bad" fatigue after about twenty to thirty minutes of activity. Tr. at 39-40. She stated this fatigue causes her to get overtired, and, in turn: "My blurry vision gets worse, my mood swings are worse, my legs go -- everything gets worse if I get too overtired or fatigued." Id. Claussen's subjective complaints, moreover, are supported by both a positive MRI test and a positive BAER test for multiple sclerosis.
Id. at 143.
The Social Security Administration's guidelines indicate multiple sclerosis is a disease characterized by fatigue. 20 CFR Pt. 404, Subpt P, App 111.09 ("Significant, reproducible fatigue of motor function with substantial muscle weakness on repetitive activity, demonstrated on physical examination, resulting from neurological dysfunction in areas of the central nervous system known to be pathologically involved in the multiple sclerosis process."). Claussen's testimony regarding her debilitating fatigue, therefore, appears to have been reasonably supported by the medical evidence. Accordingly, the complaints of fatigue can not be rejected without contrary medical evidence.
ALJ Morales-Ramirez further found: "The ability to sit for prolonged periods and perform fine manipulations is consistent with an ability to perform sedentary work activity." Tr. at 15. This finding was based, in part, on the misunderstanding that Claussen testified she can "sit for up to 50 minutes at one time." Id. An examination of the record, however, indicates Claussen testified she can only sit for periods of up to fifteen minutes. Id. at 36. Given this misunderstanding, the conclusion Claussen is able to perform sedentary work is questionable.
In addition, ALJ Morales-Ramirez found the medical record "suggests that the claimant [has] occasional periods of exacerbation of her symptoms but that she has not had a lasting episode of advanced symptoms." Tr. at 16. In support of this finding, the ALJ cites the frequency of Claussen's office visits, and his conclusion that an
examination of the medical record establishes that she has only occasional exacerbations during which she experiences some of these symptoms and that she has not had progression of her symptoms during which she was unable to perform the full range of sedentary work activity for a period less than, for at least 12 months.