United States District Court, N.D. Indiana, Fort Wayne Division
ROSA L. FLORES, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of SSA, Defendant.
OPINION AND ORDER
ANDREW P. RODOVICH, Magistrate Judge.
This matter is before the court on petition for judicial review of the decision of the Commissioner filed by the plaintiff, Rosa L. Flores, on May 8, 2014. For the following reasons, the decision of the Commissioner is REMANDED.
The plaintiff, Rosa L. Flores, filed an application for Disability Insurance Benefits and Supplemental Security Income on June 14, 2011, alleging a disability onset date of March 3, 2009. (Tr. 19). The Disability Determination Bureau denied Flores' application on July 28, 2011, and again upon reconsideration on October 3, 2011. (Tr. 19). Flores subsequently filed a timely request for a hearing on October 11, 2011. (Tr. 19). A hearing was held on September 14, 2012, before Administrative Law Judge (ALJ) Maryann S. Bright, wherein the ALJ issued an unfavorable decision on October 5, 2012. (Tr. 19, 30). Vocational Expert (VE) Sharon D. Ringenberg and Jose Mendez-Flores, Flores' son, testified at the hearing. (Tr. 19). At the hearing, Flores amended her alleged onset date to November 5, 2010. (Tr. 19). The Appeals Council denied review, making the ALJ's decision the final decision of the Commissioner. (Tr. 1-15).
At step one of the five step sequential analysis for determining whether an individual is disabled, the ALJ found that Flores had not engaged in substantial gainful activity since November 5, 2010, her alleged onset date. (Tr. 21). At step two, the ALJ determined that Flores had the following severe impairments: degenerative disc disease, obesity, osteoarthritis of the bilateral knees, depression, and pain disorder. (Tr. 21). Also at step two, the ALJ concluded that Flores' headaches were not a severe impairment. (Tr. 22). Flores alleged she had headaches three days a week, and medical records indicated that she reported headaches and balance symptoms beginning in March 2011. (Tr. 22). Flores underwent balance function testing in June 2011, but the ALJ did not find evidence of a follow-up. (Tr. 22). In May 2012, she saw a neurologist, Dr. James Stevens, who diagnosed her with pain secondary to a right occipital neuralgia for which Flores received an occipital nerve block. (Tr. 22). The ALJ determined that the headaches were not a severe impairment because Flores did not need to go to the emergency room for headache treatment and there was no evidence in the record to corroborate the continued frequency of her headaches. (Tr. 22).
At step three, the ALJ concluded that Flores did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments. (Tr. 22). First, the ALJ determined that Flores' knee impairment did not meet the requirements for Listing 1.02, major dysfunction of a joint. (Tr. 23). The ALJ indicated that Listing 1.02 required gross anatomical deformity with motion limitations and findings on imaging of joint space narrowing, bony destruction, or ankyloses of the affected joint with an inability to ambulate effectively. (Tr. 23). In reaching her conclusion, the ALJ noted that Flores' medical record contained several reports of a normal gait without the use of an assistive device. (Tr. 23). This finding was contradicted by the fact that she used a walker at the hearing and that her treating physician approved a prescription for an assistive device in March 2012. (Tr. 23). Additionally, the ALJ indicated that the record was devoid of reports of imaging of Flores' knees that supported the required abnormalities. (Tr. 23).
Second, the ALJ concluded that Flores' back impairment did not meet or medically equal Listing 1.04, disorders of the spine. (Tr. 23). The ALJ stated that the impairment did not meet Listing 1.04A because there was no evidence of the presence of nerve root compression characterized by neuro-anatomic distribution of pain, limitation of spine motion, motor loss accompanied by sensory or vibratory loss, and positive straight-leg raising. (Tr. 23). Next, the ALJ indicated the impairment did not meet Listing 1.04B because there was no diagnostic imaging of spinal arachnoiditis manifested by severe burning or painful dysesthesia that required Flores to change her position or posture more than once every two hours. (Tr. 23). Last, the ALJ determined that Flores did not meet Listing 1.04C because there was no spinal stenosis resulting in pseudoclaudication manifested by chronic nonradicular pain and weakness or an inability to ambulate effectively. (Tr. 23).
The ALJ then addressed Flores' obesity impairment. (Tr. 23). Flores reported she was 64 inches tall and weighed 286 pounds, which the ALJ equated to a 49.1 body mass index and a Level III "extreme" obesity classification under the National Institutes of Health's clinical guidelines. (Tr. 23). The ALJ stated there was no specific listing for obesity but reported that she considered the aggravating effects of obesity on Flores' other impairments pursuant to SSR 02-1p. (Tr. 23).
The ALJ determined that Flores' mental impairments did not meet the criteria for Listing 12.04, affective disorders, or Listing 12.07, somatoform disorders. (Tr. 23). To reach that conclusion, the ALJ considered the "paragraph B" criteria, which required mental impairments in at least two of the following: marked restriction of daily living activities; marked difficulties in maintaining social functioning; marked difficulties in maintaining concentration, persistence, or pace; or repeated episodes of decompensation of extended duration. (Tr. 23). The ALJ defined a marked restriction as more than moderate but less than extreme and repeated episodes of decompensation of extended duration as three episodes within one year or an average of once every four months, each lasting for at least two weeks. (Tr. 23).
The ALJ determined that Flores had a moderate restriction for activities of daily living. (Tr. 23). Although the ALJ noted that Flores' thirteen year old son performed most of the cooking, cleaning, and mowing the yard and that her five year old daughter helped with household chores, she concluded that Flores attended to personal hygiene, provided child care, cooked, did laundry, drove and left the home alone, shopped, managed money, read, followed instructions, and socialized. (Tr. 23). Furthermore, she stated that Flores parented two minor children as a single parent, attended church twice weekly for two hours, and attended an English language class once weekly for three hours. (Tr. 23-24). Therefore, the ALJ determined that Flores' activities were primarily limited by her physical conditions or pain rather than depression. (Tr. 24).
The ALJ concluded that Flores had no social functioning difficulties. (Tr. 24). Flores denied having problems getting along with family, friends, neighbors, or authority figures, and the ALJ found that she shopped and attended church and an English language class every week. (Tr. 24).
The ALJ stated that Flores had moderate difficulties with concentration, persistence, or pace. (Tr. 24). Flores acknowledged that she could follow written and spoken instructions, manage money, drive, and attend church services and an English class within her physical pain limits. (Tr. 24). The consultative examiner concluded that Flores likely functioned in the low average range of intelligence but that her long-memory was intact, that she could perform mental arithmetic tasks, and that she did not appear to have any significant cognitive or intellectual deficits. (Tr. 24). The ALJ found that Flores experienced no episodes of decompensation of extended duration. (Tr. 24). Therefore, the ALJ concluded that Flores did not meet the "paragraph B" criteria because her mental impairments did not cause at least two "marked" limitations or one "marked" limitation and "repeated" episodes of decompensation of extended duration. (Tr. 24).
The ALJ also determined that Flores did not satisfy the "paragraph C" criteria. (Tr. 24). She indicated that Flores had no repeated episodes of decompensation of extended duration, found that a minimal increase in mental demands or a change in environment would not cause her to decompensate, and stated there was no evidence that Flores could not function outside a highly supportive living arrangement or her own home. (Tr. 24).
The ALJ then assessed Flores' residual functional capacity as follows:
[T]he claimant has the residual functional capacity to lift and carry up to 20 pounds occasionally and 10 pounds frequently, stand or walk for approximately two hours per eight-hour workday, and sit for approximately six hours per eight-hour workday, with normal breaks. She can occasionally climb ramps and stairs, but never climb ladders, ropes or scaffolds. She is capable of occasionally balancing, stooping, kneeling, crouching and crawling. She should avoid all exposure to wetness or humidity, uneven surfaces, unprotected heights, and dangerous machinery. The claimant is capable of work limited to simple, routine and repetitive tasks.
(Tr. 24-25). The ALJ explained that in considering Flores' symptoms she followed a two-step process. (Tr. 25). First, she determined whether there was an underlying medically determinable physical or mental impairment that was shown by a medically acceptable clinical or laboratory diagnostic technique that could reasonably be expected to produce Flores' pain. (Tr. 25). Then, she evaluated the intensity, persistence, and limiting effects of the symptoms to determine the extent to which they limited Flores' functioning. (Tr. 25).
Flores testified that she stopped working at an assembly job in 2009 because the company closed her line and that she worked putting labels on packages in May 2012, but her impairments limited her to two days per week. (Tr. 25). She indicated she had lower back pain that radiated down her legs, her knee pain was aggravated by standing and walking, and she had pain and numbness in her hands from carpal tunnel syndrome. (Tr. 25). Flores had surgery in November 2010 that somewhat helped her back, but the pain returned. (Tr. 25). Additionally, she got dizzy every day for a minute or two at a time and had headaches three times a week. (Tr. 25). Flores stated she was up and down throughout the day and usually sat for five to ten minutes and then stood for one to five minutes. (Tr. 25). She used her walker with a seat every day and was depressed, but her medication helped slightly. (Tr. 25).
Flores' son testified that her symptoms slowly worsened and that her back surgery helped at first, but her leg pain continued and the surgery site later became fractured. (Tr. 25). Her son drove her to doctor appointments and translated for her and ...