United States District Court, District of New Hampshire
Janine Gawryl, Esq.
T. David Plourde, Esq.
Landya McCafferty, United States District Judge
Pursuant to 42 U.S.C. § 405(g), Luis Martinez moves to reverse the Acting Commissioner's decision to deny his application for Social Security disability insurance benefits, or DIB, under Title II of the Social Security Act, 42 U.S.C. § 423, and for supplemental security income, or SSI, under Title XVI, 42 U.S.C. § 1382. The Acting Commissioner, in turn, moves for an order affirming her decision. For the reasons that follow, this matter is remanded to the Acting Commissioner for further proceedings consistent with this order.
Standard of Review
The applicable standard of review in this case provides, in pertinent part:
The [district] court shall have power to enter, upon the pleadings and transcript of the record, a judgment affirming, modifying, or reversing the decision of the Commissioner of Social Security, with or without remanding the cause for a rehearing. The findings of the Commissioner of Social Security as to any fact, if supported by substantial evidence, shall be conclusive
42 U.S.C. § 405(g) (setting out the standard of review for DIB decisions); see also 42 U.S.C. § 1383(c) (3) (establishing § 405(g) as the standard of review for SSI decisions). However, the court "must uphold a denial of social security . . . benefits unless 'the [Commissioner] has committed a legal or factual error in evaluating a particular claim.'" Manso-Pizarro v. Sec'y of HHS, 76 F.3d 15, 16 (1st Cir. 1996) (quoting Sullivan v. Hudson, 490 U.S. 877, 885 (1989)).
As for the statutory requirement that the Commissioner's findings of fact be supported by substantial evidence, "[t]he substantial evidence test applies not only to findings of basic evidentiary facts, but also to inferences and conclusions drawn from such facts." Alexandrou v. Sullivan, 764 F.Supp. 916, 917-18 (S.D.N.Y. 1991) (citing Levine v. Gardner, 360 F.2d 727, 730 (2d Cir. 1966)). In turn, "[s]ubstantial evidence is 'more than [a] mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.'" Currier v. Sec'y of HEW, 612 F.2d 594, 597 (1st Cir. 1980) (quoting Richardson v. Perales, 402 U.S. 389, 401 (1971)). But, "[i]t is the responsibility of the [Commissioner] to determine issues of credibility and to draw inferences from the record evidence. Indeed, the resolution of conflicts in the evidence is for the [Commissioner], not the courts." Irlanda Ortiz v. Sec'y of HHS, 955 F.2d 765, 769 (1st Cir 1991) (citations omitted). Moreover, the court "must uphold the [Commissioner's] conclusion, even if the record arguably could justify a different conclusion, so long as it is supported by substantial evidence." Tsarelka v. Sec'y of HHS, 842 F.2d 529, 535 (1st Cir. 1988). Finally, when determining whether the decision of the Acting Commissioner is supported by substantial evidence, this court must "review the evidence in the record as a whole." Irlanda Ortiz, 955 F.2d at 769 (quoting Rodriguez v. Sec'y of HHS, 647 F.2d 218, 222 (1st Cir. 1981)).
The parties have submitted a Joint Statement of Material Facts, document no. 16. That statement is part of the court's record and will be summarized here, rather than repeated in full.
Martinez last worked in 2007. Up until that time, his work experience consisted of furniture refinishing, plastic molding, and shipping and receiving fruit. He cannot read or write in English. He has received treatment for both physical and mental conditions, but because the ALJ's handling of Martinez's mental condition is sufficient to warrant a remand, the court does not describe his physical conditions in this order.
The earliest record of Martinez's mental condition comes from a psychiatric evaluation conducted by Dr. Phillip Santora in November of 2008. See Administrative Transcript ("Tr.") 411-15. Based upon Martinez's history and the results of a mental status examination, Dr. Santora diagnosed Martinez with, among other things: (1) major depressive disorder; (2) panic disorder with agoraphobia; (3) moderate to severe psychological and environmental problems; and (4) a GAF of 45. Tr. 413-14. After he performed the psychiatric evaluation described above, Dr. Santora began to treat Martinez. That treatment appears to have been limited to medication, including Celexa (an antidepressant) and Diazepam (an antianxiety medication) .
In June of 2009, after having treated Martinez for approximately seven months, Dr. Santora completed a Mental Impairment Questionnaire on Martinez. See Tr. 405-10. In it, he: (1) repeated the diagnosis he gave Martinez in November of 2008; (2) reported the following clinical findings: "dep[ressed] mood, fatigue, anxiety, panic attacks, insomnia, " Tr. 405; (3) gave a prognosis of "guarded, " id.; and (4) identified the following signs and symptoms: appetite disturbance with weight loss, decreased energy, somatization unexplained by organic disturbance, mood disturbance, difficulty thinking or concentrating, psychomotor retardation, persistent disturbances of mood or affect, emotional withdrawal or isolation, unrealistic interpretation of physical signs or sensations associated with the preoccupation or belief that one has a serious disease or injury, memory impairment, and recurrent severe panic attacks manifested by a sudden unpredictable onset of intense apprehension, fear, terror and sense of impending doom occurring on the average of at least once a week.
Based upon those signs and symptoms, Dr. Santora opined that: (1) with respect to mental abilities and aptitudes to do unskilled work, Martinez was seriously limited but not precluded in seven areas and unable to meet competitive standards in nine others; (2) with respect to abilities and aptitudes for semiskilled and skilled work, Martinez was seriously limited but not precluded in one area and unable to meet competitive standards on four others; and (3) with respect to abilities and aptitudes for particular types of jobs, Martinez was very good in one area, limited but satisfactory in one area, and seriously limited but not precluded in three others. In the realm of functional limitations, Dr. Santora determined that Martinez had marked restrictions in his activities of daily living, marked difficulties in maintaining social functioning, marked difficulties in maintaining concentration, persistence, or pace, and had had one or two episodes of decompensation, within a twelve-month period, each of which lasted for at least two weeks.
Dr. Santora further opined that Martinez had: (1) a medically documented history of affective disorder, of at least two years' duration, that has caused more than a minimal limitation of his ability to do any basic work activity; (2) a residual disease process that has resulted in adjustment so marginal that even a minimal increase in mental demands or a minimal change in the environment would be predicted to cause him to decompensate; and (3) a current history of inability, for one or more years, to function outside of a highly supportive living arrangement, with an indication of a continued need for such an arrangement. Dr. Santora's questionnaire concludes with two more relevant opinions: (1) Martinez has an anxiety-related disorder and a complete inability to function outside his home; and (2) his impairment or treatment would cause him to be absent from work for more than four days per month, which is the highest degree of absenteeism listed in the questionnaire.
Martinez first filed for DIB and SSI benefits in 2007. He received an unfavorable decision from Administrative Law Judge ("ALJ") Sutker. Among other things, she found that Martinez's affective disorder and his anxiety disorder were severe impairments, but not sufficiently severe to qualify as "listed impairments" under the applicable Social Security regulations. Martinez appealed the ALJ's decision to this court, which granted the Commissioner's assented-to motion to remand the case. Upon remand, the case was to
be assigned to an administrative law judge ("ALJ"), who [was to]: (1) reevaluate the severity of Plaintiff's . . . mental impairment; (2) provide a rational for [her] findings regarding Plaintiff's degree of limitation in each of the "paragraph B" criteria of mental functioning; (3) reassess the treating source opinion of Dr. Santora; and (4) further evaluate the credibility of Plaintiff's alleged mental limitations.
Tr. 601. In its order remanding the case to ALJ Sutker, the Decision Review Board ("DRB") had this to say about her treatment of Martinez's mental impairments:
The decision does not contain an adequate evaluation of the claimant's mental impairment(s) in accordance with the provisions set forth in 20 CFR 404.1520a and 416.920a. The decision (Tr. 10) indicates that the claimant has a mild restriction in activities of daily living; moderate difficulties in social functioning; moderate difficulties maintaining concentration, persistence, or pace; and no episodes of deterioration or decompensation. However, the Administrative Law Judge did not provide any rationale for these conclusions. In addition, the decision (Tr. 12-13) did not accord the opinions provided by Phillip Santora, M.D., (Tr. 405-410) significant weight finding them not supported by his treatment notes. However, Dr. Santora's report is the only opinion evidence of record regarding the claimant's mental impairments. The decision did not provide adequate rationale to support the limited weight accorded these opinions. Moreover, Dr. Santora assigned a Global Assessment of Functioning (GAF) scale rating of 45 (Tr. 414) which could indicate a serious impairment in social and occupational functioning (Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994). Further evaluation is necessary.
Tr. 607. The DRB followed up that discussion by directing the ALJ to do the following:
Further evaluate the claimant's mental impairments in accordance with the special technique described in 20 CFR 404.1520a and 416.920a, documenting application of the technique in the decision by providing specific findings and appropriate rationale for each of ...