United States District Court, D. New Hampshire
MEMORANDUM AND ORDER
BARBADORO, District Judge.
2012, Nancy Keith McFall applied for disability insurance
benefits ("DIB"), alleging disability as of April
30, 1989. The SSA initially denied McFall's claim in
August 2012, and denied her claim again upon reconsideration
in November 2012. Thereafter, a hearing was held before an
Administrative Law Judge ("ALJ"), where McFall,
represented by counsel, appeared and testified. The ALJ then
issued a written decision finding that McFall had failed to
show that she suffered from a severe impairment before her
March 31, 1997 date last insured, or through the date of the
ALJ's decision. The ALJ therefore concluded that McFall
was not disabled. McFall now challenges the Social Security
Administration's decision to deny her claim. The Social
Security Commissioner, in turn, seeks to have the ruling
Medical Evidence and Hearing Testimony
applied for DIB on June 15, 2012, alleging disability as of
April 30, 1989. Tr. at 19 (Doc. No. 7). McFall last met the
Social Security Act's insured status requirement on March
31, 1997, and there are no medical records predating her
March 31, 1997 date last insured ("DLI"). Rather,
the first treatment notes in the record were from June 1997
(several months after her DLI), when McFall was admitted to
Pembroke Hospital due to bipolar affective disorders,
psychiatric disorders not otherwise specified, polysubstance
abuse, increased anxiety, difficulty sleeping and suicidal
ideation. Tr. at 22, 161, 164. Before that admission, McFall
had undergone no psychiatric treatment. Tr. at 161.
hospital, McFall reported that she had suffered a head injury
as a teenager, and that, for several years before June 1997,
she had engaged in substance abuse and experienced paranoid
ideation. Tr. at 159. McFall was diagnosed with bipolar
disorder and polysubstance abuse and placed on a fourteen-day
treatment plan. Tr. at 159, 162. Upon discharge, she was
described as alert, partially cooperative, with continued
paranoid ideas, irritable mood, and fair judgment. Tr. at
159. McFall was referred to Northeast Psychological
Associates for further treatment, but there are no records
indicating that she followed through with that referral. Tr.
at 22, 159-60.
October 13, 2013 hearing before the ALJ, McFall described the
circumstances surrounding her June 1997 treatment at Pembroke
Hospital. She testified that she had had problems sleeping
since she was involved in a car accident as a teenager, and
continued to have problems sleeping as of the date of her
hearing. Tr. at 39-41. She stated that she was diagnosed with
bipolar disorder in 1997 (presumably at Pembroke Hospital),
and testified that the condition significantly affected her
ability to function on a daily basis. Tr. at 53. She also
told the ALJ that, at around that same time she was
hospitalized, she had increased her alcohol consumption. Tr.
at 53. When asked about the suicidal ideations, depression
and anxiety mentioned in the Pembroke Hospital notes, McFall
said that she "went through that for a short period,
" and that she "couldn't do anything"
while affected. Tr. at 54.
on the evidence before the ALJ, there were no additional
treatment records until May 2012, about one month before
McFall applied for DIB. In May 2012, McFall sought
treatment for abdominal swelling and discomfort and chronic
diarrhea. Tr. at 258. McFall was diagnosed with hepatic
failure due to alcohol use. Tr. 263. In July 2012, McFall was
again treated for abdominal pain and distention. Tr. 252-53.
At her October 2013 hearing, McFall testified that these
abdominal symptoms have since been resolved, and stated that
she no longer drinks alcohol. Tr. at 35, 50.
decision, the ALJ evaluated McFall's claim under the five
step sequential process described in 20 C.F.R. §
404.1520(a)(4). At step one, the ALJ found that McFall had
not engaged in substantial gainful activity during the period
from her alleged onset date through her DLI. Tr. at 21. The
ALJ then resolved the case at step two, determining that
McFall had not established that she suffered from a severe
medically determinable impairment at any time from her
alleged onset date through her DLI.
support this conclusion, the ALJ explained that McFall had
"experienced an acute episode in June 1997, " at
which time she "had medically determinable impairments
that could reasonably produce work-related functional
limitations." Tr. at 23. The ALJ also noted that, in
June 1997, McFall described "symptoms of paranoia and
substance abuse dating back one to two years" and
"being unable to work for the previous three
years." Tr. at 22. The ALJ concluded, however, that this
evidence was inadequate to establish a medically determinable
impairment because "there is no evidence to support this
degree of symptomology or limitations prior to the date last
insured, " and because the record contained no evidence
of follow-up treatment after McFall's hospitalization.
Tr. at 23. According to the ALJ, that lack of follow-up
"suggests that [McFall's] symptoms had largely
resolved." Tr. at 23.
respect to McFall's history of substance abuse, the ALJ
noted that McFall "did admit that she was abusing
substances during the period of her hospitalization in June
1997, as well as subsequently, " and that she was
diagnosed with alcoholic hepatitis and portal hypertension in
June 2012. Tr. at 23. The ALJ thus found "sufficient
support in the limited evidence of record that [McFall] does
have some issues with substance abuse." Tr. at 23.
Nonetheless, in light of the limited record evidence, and the
absence of "evidence documenting higher functioning
absent substance abuse and a significant deterioration with
such abuse, " the ALJ concluded that there was
insufficient support to find that McFall's alcohol abuse
was material to the finding of disability, "or that it
produces any specific work-related functional limitations
throughout the period under review." Tr. at 23.
further concluded that, even if there was sufficient evidence
that McFall was disabled before her DLI, McFall's claim
nonetheless failed because McFall did not "have
disability continuing to the present date or ending within
the 12-month period in which she applied, " as required
by 20 C.F.R. § 404.315. Tr. at 23. According to the ALJ,
"the record contains no evidence whatsoever for fifteen
years prior to the application date. Even as of the
application date, the record contains only a few brief notes
from May 2012 to July 2012, which fail to support any
specific work-related functional limitations." Tr. at
23. The ALJ was therefore "unable to find [McFall]
disabled." Tr. at 23.
January 2014, McFall asked the Appeals Council to review the
ALJ's decision. Tr. at 12-15. The Appeals Council denied
McFall's request. Tr. at 1-4. As such, the ALJ's
decision constitutes the ...