Court: District Court, N.D. Iowa; December 13, 2011; Federal District Court
Arliss R. Rahe seeks judicial review of the Commissioner of Social Security's decision denying her disability insurance benefits (DIB) application, arguing that the administrative record lacks substantial evidence supporting the determination of her non-disability. The court, led by Chief Magistrate Judge Paul A. Zoss, reverses the Commissioner's decision and remands the case for further proceedings.
Rahe, born in 1947 with some college education, previously worked as a hairdresser, office clerk, and home health aide. She filed for DIB on May 23, 2007, citing disability due to lower back and right shoulder pain starting April 12, 2007. After her application was denied initially and upon reconsideration, she requested a hearing before an Administrative Law Judge (ALJ). During the hearing on April 22, 2009, Rahe provided testimony, but on September 25, 2009, the ALJ found her not disabled. Rahe's subsequent request for review by the Appeals Council was denied on November 15, 2010, making the ALJ's decision the final ruling of the Commissioner.
The court will analyze Rahe's medical history from the alleged onset date. Key medical findings include an April 17, 2007 MRI showing degenerative changes in the lumbar spine and severe foraminal narrowing. A physician assistant restricted Rahe to light duty work shortly after her MRI. Further evaluations by Dr. Alexander Pruitt indicated degenerative issues in her lumbar and cervical spine, with assessments of facet arthropathy and pain in her hands and shoulders. Rahe underwent several lumbar epidural steroid injections, with notes indicating periods when she could return to work. Follow-up studies showed normal nerve conduction, with no evidence of significant neuropathy or radiculopathy.
On June 7, 2007, Dr. Pruitt recommended bilateral facet injections and nerve root injections for Rahe due to work-related issues, stating she should remain off work unless light duty is available. Rahe received a right shoulder injection on June 14 and an L5-S1 facet injection on June 21. By June 27, she had a 15-pound lifting restriction and no repetitive bending, stooping, or squatting. On July 5, the restrictions were updated to no repetitive bending, lifting, or twisting, and no lifting over 20 pounds for three months. By August 22, her lifting restriction was set at twenty pounds, with allowances for prolonged standing, walking, and sitting, though she had no issues with stooping, climbing, kneeling, or crawling.
On September 26, Dr. Pruitt noted severe bilateral foraminal narrowing at L5/S1 and other complications, indicating that Rahe had partial relief from a recent nerve root injection but continued numbness in her foot. It was concluded that she could not return to her housekeeping job due to recurring symptoms, and Dr. Pruitt planned to inform Social Security Disability of her condition. Rahe required ongoing medications and injections for pain management. Further evaluations, including X-rays on October 3 and an MRI on October 15, showed no significant injuries to her left shoulder, although there was moderate AC joint arthopathy. By November 21, Rahe reported some relief from a shoulder injection but continued to experience bothersome symptoms in both her shoulder and back, which were deemed tolerable at that time.
On March 17, 2008, Dr. Pruitt noted a patient’s follow-up for low back pain after three cortisone injections and an L5 left nerve root injection, indicating no improvement in symptoms from the injections. The patient reported a 90% improvement in back pain due to physical therapy and was able to perform housework without issues. She experienced no weakness, numbness, or tingling and was committed to her home exercise program. Dr. Pruitt advised her to continue conservative treatment and provided a work release with no restrictions.
On July 19, 2007, Dr. James Wilson, a state agency medical consultant, assessed the patient’s residual functional capacity (RFC), determining she could lift/carry 10 pounds occasionally and frequently, stand/walk for about six hours, sit for roughly six hours, and perform unlimited pushing/pulling. She could occasionally climb ramps/stairs, balance, stoop, kneel, crouch, and crawl, but had no manipulative, visual, communicative, or environmental limitations aside from occasional overhead lifting on the right and avoiding hazards. Dr. Wilson noted no credibility issues regarding the patient's ongoing treatment.
On September 19, 2007, Dr. John May, another state agency medical consultant, revised the patient’s RFC, allowing her to lift/carry 20 pounds occasionally and 10 pounds frequently, while maintaining the previous assessments regarding standing, walking, sitting, and pushing/pulling capabilities. He acknowledged updated medical information that supported these adjustments and affirmed that further functional limitations were not substantiated by the overall medical evidence.
On January 8, 2009, Rahe underwent a functional capacity evaluation at Buena Vista Regional Medical Center, conducted by Stephanie McClellan, MA, OTR/L. The evaluation revealed Rahe's complaints of pain in various areas, including low back, legs, shoulders, and hands. Despite working part-time (15-20 hours weekly) on light housekeeping and assisting patients, Rahe required rest between tasks due to pain. Physical examination showed full active range of motion in upper extremities and lower joints, with slight discomfort in hip flexion. However, range of motion in the thoracic and lumbar spine was decreased. Rahe's dexterity for work tasks and daily activities was normal, with no complaints of diminished sensation or pain during testing. The evaluation identified inconsistencies between Rahe's perceived functional limitations and her actual capabilities, as evidenced by low scores on various disability questionnaires, indicating possible symptom magnification. Specifically, Rahe scored 58% on the Revised Oswestry questionnaire, reflecting her belief of severe disability. The examiner noted Rahe exhibited higher functional abilities than she perceived and suggested restrictions including occasional stair climbing, infrequent kneeling, and lifting up to 35 pounds. Recommendations included body mechanic education and counseling to help improve her understanding of her functional abilities, with the potential for progressing to full-time employment.
Rahe, the plaintiff, testified that she stopped working in April 2007 and was on short-term disability until October 2007. She was cleared to return to work without restrictions by Dr. Pruitt on March 17, 2008, and began working part-time as a home health aide on May 1, 2008, averaging 15-16 hours per week due to pain from low back and right shoulder issues, along with numbness in her left leg. Prior to her alleged disability onset, she worked 32-36 hours per week. Rahe experiences discomfort from prolonged sitting or standing, requiring breaks every 30-45 minutes. Despite her limitations, she manages daily activities such as cooking and cleaning. She stopped taking certain medications due to side effects and currently takes Tylenol for pain.
Post-hearing, a vocational expert (VE) assessed Rahe's past relevant work, classifying her roles as a home health aide (semi-skilled, medium), general office clerk (semi-skilled, light), and hairdresser (skilled, light). The ALJ provided a hypothetical scenario detailing her age, education, and physical limitations. The VE concluded that with these restrictions, Rahe could perform work as a hairdresser or general office clerk but could not return to her past role as a home health aide due to its medium demand. The VE also indicated that if Rahe had no exertional limitations and could perform household tasks, she would not be precluded from unskilled work, identifying transferable skills to light, semi-skilled jobs and unskilled positions such as assembler, routing clerk, and sales attendant.
On June 16, 2009, the ALJ informed Rahe’s counsel about potential actions following the VE's testimony, allowing for written comments, legal statements, or questions to the VE, with a ten-day response window before proceeding with a decision (AR 176-177). Rahe’s counsel requested a thirty-day extension to respond on June 26, 2009, but the ALJ did not reply. On August 6, 2009, Rahe’s counsel submitted eleven interrogatories for the ALJ to direct to the VE, focusing on the claimant's ability to perform past relevant work and other employment given her alleged limitations, including walking and standing capabilities, job definitions, and Functional Capacity Evaluation findings (AR 178-181). The ALJ did not forward the interrogatories to the VE (AR 8).
On September 25, 2009, the Administrative Law Judge (ALJ) concluded that Rahe had not engaged in substantial gainful activity since her alleged disability onset date of April 12, 2007. The ALJ determined that Rahe had a severe impairment but did not meet the specific criteria for any impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. The ALJ found that Rahe could perform her past relevant work as a hairdresser and general office clerk or, alternatively, could perform light-level work in the national economy. Consequently, Rahe was ruled not disabled since April 12, 2007.
The ALJ assessed Rahe's residual functional capacity (RFC) as being able to perform light work, which included lifting and carrying specific weights, standing and sitting for defined durations, and limitations on climbing and working around hazards. Rahe's credibility regarding her pain and limitations was questioned; while her medical conditions could explain her symptoms, her statements about their intensity were deemed inconsistent with the RFC assessment. The ALJ noted that Rahe's reported daily activities—such as meal preparation and household chores—suggested a higher capability than she claimed. Additionally, although Rahe had undergone treatments for her symptoms, they were generally effective, and she relied on over-the-counter medications rather than narcotics. Inconsistencies in her reports about pain levels to different medical professionals undermined her credibility, leading the ALJ to conclude that she was not fully credible regarding her claims of total disability.
Treatment records do not substantiate the claimant's claims of severe and disabling pain, as noted in the assessment (AR 15). The claimant's credibility is undermined by evidence of varied daily activities and contradictions between their testimony and medical records. Although the claimant experiences pain and limitations, these are detailed in the residual functional capacity assessment (AR 15-16).
The Administrative Law Judge (ALJ) evaluated opinion evidence, giving significant weight to Dr. Pruitt's assessment, the treating orthopedist, since it aligns with treatment records and overall medical evidence. Limitations from Dr. Pruitt's opinion are reflected in the residual functional capacity assessment. Stephanie McClellan's evaluation, conducted at the claimant's representative's request, was given some weight due to partial consistency with the medical record. The ALJ applied Social Security Ruling 96-6p, considering findings from State Agency medical professionals, which were deemed reliable and consistent with the overall evidence.
The ALJ also noted that the proposed interrogatories to the vocational expert, submitted by the representative, were less consistent with the medical evidence compared to those formulated by the ALJ (AR 8). The definition of disability under the Social Security Act outlines the inability to engage in substantial gainful activity due to medically determinable impairments, which must last or be expected to last for at least twelve months (42 U.S.C. § 423(d)(1)(A); 1382c(a)(3)(A); 20 C.F.R. § 404.1505, 416.905). A claimant is considered disabled if they cannot perform previous work or any other substantial gainful work available in significant numbers (42 U.S.C. § 423(d)(2)(A); 1382c(a)(3)(B)).
The Commissioner evaluates disability claims under the Social Security Act using a five-step sequential process.
1. **Work Activity**: The Commissioner first assesses whether the claimant is engaged in substantial gainful activity. If so, the claimant is not considered disabled.
2. **Severity of Impairment**: If the claimant is not working, the next step is to determine if there is a severe impairment that significantly limits basic work activities. An impairment is deemed non-severe if it only presents a slight abnormality with minimal impact on work capabilities.
3. **Medical Severity**: If a severe impairment is identified, the Commissioner evaluates its medical severity. If it meets or equals a listed presumptively disabling impairment, the claimant is considered disabled, regardless of age, education, or work experience.
4. **Residual Functional Capacity (RFC)**: If the impairment is severe but does not meet the listed criteria, the Commissioner assesses the claimant's RFC to determine their ability to perform past relevant work. RFC reflects what the claimant can still do despite physical or mental limitations.
5. **Evidence and Responsibility**: The claimant must provide evidence for the RFC assessment, while the Commissioner is tasked with developing a complete medical history, potentially including consultative examinations. Non-medical evidence is also considered.
If the claimant retains the RFC for past relevant work, they are not deemed disabled. The evaluation process may conclude at step two if the impairment's impact is minimal.
If a claimant's Residual Functional Capacity (RFC) does not permit them to perform past relevant work, the burden shifts to the Commissioner of Social Security to demonstrate that there is other work available that the claimant can perform, considering their RFC, age, education, and work experience. The Commissioner must establish not only the capability of the claimant to adjust to other work but also that such work exists in significant numbers within the national economy. If the claimant can adjust to available work, they are not considered disabled; if they cannot, they are deemed disabled.
Even though the burden of production transfers to the Commissioner at this stage, the burden of persuasion regarding disability remains with the claimant. The court evaluates the Administrative Law Judge's (ALJ) decision to ensure correct legal standards were applied and that factual findings are supported by substantial evidence. This substantial evidence standard is less than a preponderance, but sufficient for a reasonable mind to conclude that the Commissioner’s decision is justified.
The court reviews the entire record, weighing both supporting and contradicting evidence, and does not reweigh evidence or review the factual record anew. If the evidence allows for conflicting interpretations, the court must affirm the Commissioner’s decision. Reversal is not warranted simply because substantial evidence could support a contrary conclusion.
Rahe argues for the reversal of the ALJ’s decision based on three main points: (1) the ALJ did not give appropriate weight to Dr. Pruitt’s medical findings; (2) the cumulative medical evidence indicates she is disabled and entitled to benefits, contradicting the ALJ’s findings; and (3) she was denied a fair hearing since her proposed interrogatories for the vocational expert (VE) were not presented by the ALJ. The Commissioner counters that (1) the ALJ correctly evaluated Rahe’s credibility; (2) the medical opinions were appropriately weighed; (3) Rahe was afforded a fair hearing; and (4) substantial evidence supports the ALJ’s decision at step five.
The court notes that Rahe does not contest the ALJ's credibility assessment, which is primarily the ALJ's responsibility. Courts typically defer to the ALJ’s credibility determinations if supported by substantial evidence and valid reasoning. The ALJ may discount a claimant's subjective complaints based on inconsistencies in the overall record, and must consider factors such as daily activities, pain characteristics, medication effects, functional restrictions, work history, and the absence of supporting objective medical evidence. Though not required to discuss each Polaski factor in detail, the ALJ must acknowledge and consider them. In Rahe's case, the ALJ recognized these factors, highlighting a lack of objective medical evidence and noting that her daily activities contradicted her claims of disability. Activities such as cooking and cleaning were deemed inconsistent with allegations of disabling pain, although a claimant does not need to be completely incapacitated to qualify as disabled.
In evaluating a claimant's Residual Functional Capacity (RFC), the quality and sustainability of daily activities, as well as the frequency, appropriateness, and independence of these activities, are critical factors. In the case of Rahe, the ALJ determined that her reported daily activities—such as meal preparation, household chores, laundry, and shopping—were inconsistent with her claims of disabling symptoms. Although a claimant does not need to be bedridden to be considered disabled, Rahe's daily activities undermined her credibility regarding her alleged impairments.
The ALJ also noted that Rahe had received effective treatment, including physical therapy and injections, which generally controlled her symptoms. Improvement following treatment is a valid basis for discounting subjective complaints of pain. Furthermore, Rahe's use of over-the-counter pain medications and lack of narcotic prescriptions suggested that her pain was not as debilitating as claimed. The ALJ found her conservative treatment approach inconsistent with allegations of disabling pain.
Additionally, the record indicated that Rahe engaged in work activities after her alleged onset date, which further affected her credibility. Finally, the ALJ identified inconsistencies in Rahe's statements relevant to her disability claim, contributing to the credibility determination.
The claimant initially reported minimal pain to her physical therapist and orthopedist, expressing a desire to return to work. However, during a subsequent functional evaluation for disability benefits, she reported severe pain in her back, legs, hips, and shoulders, which contradicted her earlier statements. The ALJ found these inconsistencies sufficient to discount the claimant's credibility, supported by case law (Partee v. Astrue).
Regarding procedural due process, the claimant argued that the ALJ's failure to submit her proposed interrogatories to the vocational expert (VE) denied her a fair hearing. The Commissioner countered that the claimant had a full hearing and that she waived her opportunity to challenge the VE's responses due to the untimeliness of her interrogatories, despite the ALJ's notice. The ALJ has discretion over the submission of interrogatories and is not required to inform a claimant's attorney of the right to cross-examine the VE. The claimant contended that the ALJ rejected her interrogatories based on their inconsistency with medical evidence rather than their timeliness, claiming that the ALJ's decision should have addressed her concerns post-expert questioning. Ultimately, procedural due process requires claimants to have a full opportunity to present evidence and confront opposing evidence, but does not guarantee an absolute right to cross-examine report submitters.
The court finds that the ALJ improperly refused to submit Rahe’s additional interrogatories to the vocational expert (VE), denying her the chance to confront evidence against her, which constitutes a violation of her due process rights. Rahe maintained her right to submit these interrogatories and timely informed the ALJ of her need for additional time to address the VE's responses. The ALJ's decision, issued nearly two months after receiving Rahe's interrogatories, failed to acknowledge their relevance or timeliness, focusing instead on his own interrogatories as most consistent with medical evidence. The court references precedent indicating that an ALJ's failure to allow cross-examination of a VE can violate due process rights. Therefore, the court reverses the Commissioner’s decision, remanding the case for further proceedings to allow Rahe's interrogatories to be forwarded to the VE. The court also finds that the ALJ properly gave "great weight" to Dr. Pruitt’s medical findings, rejecting Rahe's claim that the ALJ did not adequately consider them, as the findings were consistent with the overall medical record. Judgment is entered in favor of Rahe against the Commissioner.
