The opinion of the court was delivered by: Simandle, District Judge
This matter comes to the Court pursuant to 42 U.S.C. § 405(g)(2008) to review the decision of the Commissioner of the Social Security Administration ("Commissioner" or "Defendant") denying the request of Plaintiff, Dorothy Vaneman ("Plaintiff"), for Disability Insurance Benefits ("DIB") under Sections 216(I) and 223 of the Social Security Act, and for Supplemental Security Income benefits ("SSI") under Section 1614(a)(3)(A) of the Act. The Court must decide whether substantial evidence supports the Commissioner's determination that Plaintiff is not disabled and is able to perform substantial gainful work within the national economy. For the reasons explained below, the Court shall remand the decision for a reevaluation of whether Plaintiff is disabled. Although there is both supported and unsupported reasoning within the Administrative Law Judge's opinion, the case will be remanded because this Court cannot make a firm determination whether the decision would have been the same using only the substantiated reasons.
Plaintiff filed applications for disability insurance benefits ("DIB") and supplemental security income benefits ("SSI") on October 31, 2002, alleging a disability onset date of February 1, 2002. Upon denial of those requests, Plaintiff requested a hearing on the issue, which was held before Administrative Law Judge Gerald Spitz ("the ALJ") on April 22, 2004. The ALJ denied the requests for benefits in an opinion dated May 12, 2004.
Plaintiff filed a request for a review of the ALJ's decision, but the Appeals Council denied the request on July 21, 2004. Thus, the ALJ decision became the final decision of the Commissioner. Plaintiff then filed an appeal in this Court. On December 12, 2005, the case was dismissed for failure to prosecute, but it was reopened on October 3, 2008.
The ALJ first determined that Plaintiff had not engaged in substantial gainful activity since the alleged onset of her disability, on February 1, 2002. Next, when considering the severity of Plaintiff's impairment, the ALJ found that she had severe bilateral leg swelling. However, the ALJ then held that Plaintiff's impairment did not meet or exceed the impairments listed in Appendix 1 of 20 C.F.R., Part 404, Subpart P. (R. at 12.) In the next step of the analysis, the ALJ examined Plaintiff's residual functional capacity, holding that Plaintiff could only perform sedentary exertion work.*fn1 Due to the swelling and pains in Plaintiff's legs, the ALJ held that she could not perform the light exertion work of her past employment as a cashier. However, the ALJ held that Plaintiff was not disabled, because "there are a significant number of other jobs available in the national economy to which the claimant can make a vocational adjustment given her remaining occupational base."
In making his decision, the ALJ gave great weight to the residual functional capacity evaluation of the state agency medical expert, Dr. Sury Putcha, but afforded little weight to Plaintiff's treating physician, Dr. Gerald Vernon. (R. at 14.) The ALJ explained that Dr. Putcha's opinion is "consistent with and supported by the longitudinal clinical signs and findings of record." (Id.) Dr. Putcha determined that Plaintiff could perform medium exertion work, lifting up to fifty pounds, and standing or walking six hours a day. (Id.) The ALJ noted that prior to the onset date of Plaintiff's disability, she was treated with support stockings, which were "controlling claimant's symptoms very well," and she did not require any further treatment. (Id.) Furthermore, Dr. Nithyashuba Khona found Plaintiff to be "completely normal" with full range of motion in a December, 2002 visit, and the ALJ determined that Dr. Putcha's evaluation was consistent with these findings. (Id.) However, the ALJ determined that due to Plaintiff's trouble standing and walking, she should be limited to sedentary exertion work, rather than medium exertion work as Dr. Putcha recommended. (Id.)
The ALJ found that Dr. Vernon's report indicated that Plaintiff cannot perform even sedentary work, but rejected that conclusion. (R. at 14.) The ALJ gave little weight to Dr. Vernon because his opinions were "inconsistent with and unsupported by the clinical signs and findings." (Id.) The ALJ stated that Dr. Vernon's opinions were based on treatment notes from a visit for flu symptoms in February, 2002. (Id.) Furthermore, in support of his decision, the ALJ found that "there are no clinical signs or findings documented during the relevant period to suggest any pathology or decreased functioning," and Dr. Vernon's opinion "completely lacks any support and is inconsistent with all of his treatment records." (Id.)
The ALJ determined that Plaintiff was not fully credible due to her "her minimal treatment regimen, and the degree of activities of daily living." (R. at 14.) The ALJ first supported this determination by describing Plaintiff's daily activities. Second, the ALJ noted that Plaintiff "required no emergency room visits, inpatient hospitalization, or office visits with her treating physician during the relevant period."
(R. at 13.) Furthermore, he stated that Plaintiff's condition is "under good control with medication and support stockings and her condition is stable." (Id.) Thus, the ALJ treated Plaintiff's descriptions of her disabling pain as not fully credible.
C. Evidence in the Record
Plaintiff Dorothy Vaneman testified at a hearing before the Administrative Law Judge on April 22, 2004. Plaintiff was born on April 3, 1963 and has a high school education. (R. at 185, 188-89.) Until the alleged onset date of Plaintiff's disability, February 1, 2002, she worked as a label machine operator for Paulsboro Packaging. (R. at 186, 198.) Her additional relevant work experience includes employment as a cashier, salesperson, and shift runner at Eckerd's, Caldor, and Wawa respectively. (R. at 192-93, 196.) Plaintiff testified that all of those jobs required that she stand up to eight hours a day. (R. at 192-98.) Although the ALJ opinion states that Plantiff did not stop working due to her medical condition, Plaintiff testified that her employment was terminated due to absences, tardiness, and early departures that occurred as a result of the pain and swelling in her legs. (R. at 13, 203.) Plaintiff testified that upon the termination of her employment, her health insurance was discontinued, and she depended on her mother and son financially.
Plaintiff testified that use of her legs has been restricted since the swelling began in 2001. (R. at 188, 206-07.) According to her testimony, she is only able to walk a quarter of a block without stopping, and she cannot stand for more than an hour. (R. 206-07.) When sitting in an upright chair, Plaintiff said she has to stand up and move after approximately a half hour. (R. at 205.) Plaintiff also testified that she has fallen about eight times from her weak legs and keeps a cane in case her knees give out. (R. at 206.) Furthermore, Plaintiff has gained weight from lack of exercise, wears baggy pants, and has trouble getting her shoes off at the end of the day. (R. at 186-87, 202.) Additionally, Plaintiff said she must spend approximately half the day elevating her legs at a sixty degree angle to keep the swelling at a minimum. (R. at 205.) However, Plaintiff said she has stopped using support stockings, because after her legs would swell, they became difficult to remove. (R. at 204.) Plaintiff also testified her legs cause her a tremendous amount of pain, like a "sledge hammer with a nail going through it, just slamming it through the knee," and this pain often causes her to wake-up six times a night. (R. at 207.)
Plaintiff testified she can perform some household chores, such as dusting, which she performs while sitting. (R. at 209.) Plaintiff's mother does most of the cooking. (R. at 210.) When Plaintiff cooks, approximately twice a week, she puts the food on the stove, and then sits for several minutes until she has to check on it. (Id.) In order to vacuum, Plaintiff bought a motorized vacuum that is easy to the touch, so that she does not have to stand much or put much pressure on the machine, and she only vacuums one room at a time. (R. at 209-10.) Additionally, when showering, Plaintiff leaves the door unlocked in case she falls, so that her mother would be able to come in and help her.
Plaintiff limits herself in driving because she does not want her knee to give out and cause an accident. (R. at 188.) She testified that she has not driven in almost a year, because "the kids have been doing all the driving." (Id.) Furthermore, when Plaintiff goes shopping, she says she leans on the cart as she walks through an aisle, and then she stops and waits several minutes before continuing. (R. at 211.)
Plaintiff testified that she can no longer perform some activities that she used to enjoy. (R. at 208.) For example, Plaintiff stopped going camping and canoeing in 2002. (Id.) Moreover, Plaintiff used to walk to the park, but she no longer can because she needs to stop every few minutes. (Id.)
2. Pre-February 1, 2002 Medical Evidence
Plaintiff first sought medical treatment for swelling in her legs when she visited the Emergency Room at Underwood-Memorial Hospital for cellulitis*fn2 of the bilateral lower extremities, and was admitted to the hospital from May 3 to May 6, 2001. (R. at 111-15.) According to the Discharge Summary, doctors found a "significant amount of edema"*fn3 in her legs and treated her with antibiotics. (R. at 113.)
Approximately two months later, on July 17, 2001, Plaintiff again visited the hospital with red and swollen legs, and the medical reports note finding edema in the lower extremities. (R. at 121-28.) An emergency room physician prescribed Plaintiff medication and advised her to stay home from work with her legs elevated for several days. (R. at 127.) Throughout these medical procedures, Dr. Gerald Vernon remained her primary physician, who performed follow up visits and kept notes on Plaintiff's progress. (R. at 118, 127, 145-60.) Dr. Vernon's notes include reports from Plaintiff ranking the pain and discomfort level at "10/10," and document occasions when Plaintiff reported an inability to attend work as a result of the pain and swelling. (R. at 149, 154.)
Plaintiff made an appointment to visit Dr. Vernon on September 7, 2001 concerning her swollen legs and feet. (R. at 148.) Dr. Vernon suggested treating the pain with ...