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Lefebvre v. U.S. Social Security Administration

United States District Court, D. New Hampshire

March 12, 2019

Deborah Lefebvre
U.S. Social Security Administration, Commissioner

          D. Lance Tillinghast, Esq., Amy C. Bland, Esq.


          Joseph N.'Laplante, United States District Judge.

         Deborah Lefebvre has appealed the Social Security Administration's (“SSA”) denial of her application for a period of disability and disability insurance benefits. An administrative law judge (“ALJ”) at the SSA ruled that, despite severe impairments, Lefebvre retains the residual functional capacity (“RFC”) to perform past relevant work, and thus is not disabled. See 20 C.F.R. § 404.1505(a). The Appeals Council granted Lefebvre's request for review, see Id. § 404.967, vacated the ALJ's decision, and remanded for further proceedings. On remand, the ALJ reached the same conclusions as in his first decision. The Appeals Council denied Lefebvre's second request for review, with the result that the ALJ's second decision became the final decision on her application, see Id. § 404.981. Lefebvre then appealed the decision to this court, which has jurisdiction under 42 U.S.C. § 405(g) (Social Security).

         Lefebvre has moved to reverse the decision. See LR 9.1(b). The Acting Commissioner of the SSA has cross-moved for an order affirming the ALJ's decision. See LR 9.1(e). After careful consideration, the court denies the Acting Commissioner's motion and grants Lefebvre's motion to the extent that it remands the case to the Acting Commissioner for further proceedings.

         I. Applicable legal standard

         The court limits its review of a final decision of the SSA “to determining whether the ALJ used the proper legal standards and found facts upon the proper quantum of evidence.” Ward v. Comm'r of Soc. Sec, 211 F.3d 652, 655 (1st Cir. 2000). It “review[s] questions of law de novo, but defer[s] to the Commissioner's findings of fact, so long as they are supported by substantial evidence, ” id., that is, “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion, ” Richardson v. Perales, 402 U.S. 389, 401 (1971) (quotations omitted). Though the evidence in the record may support multiple conclusions, the court will still uphold the ALJ's findings “if a reasonable mind, reviewing the evidence in the record as a whole, could accept it as adequate to support his conclusion.” Irlanda Ortiz v. Sec'y of Health & Human Servs., 955 F.2d 765, 769 (1st Cir. 1991). The court therefore “must uphold a denial of social security . . . benefits unless ‘the [Acting Commissioner] has committed a legal or factual error in evaluating a particular claim.'” Manso-Pizarro v. Sec'y of Health and Human Servs., 76 F.3d 15, 16 (1st Cir. 1996) (per curiam) (quoting Sullivan v. Hudson, 490 U.S. 877, 885 (1989)).

         II. Background [1]

         The ALJ invoked the requisite five-step sequential evaluation process in assessing Lefebvre's request for disability and disability insurance benefits. See 20 C.F.R. § 404.1520. The ALJ found that Lefebvre was insured under the Social Security Act through September 30, 2019. Although Lefebvre had engaged in substantial gainful activity between April 2016 and early January 2017, the ALJ determined that there had been a continuous 12-month period during which Lefebvre did not engage in substantial gainful activity between the alleged onset of her disability on February 11, 2011 and the date of the first hearing decision on September 16, 2015.[2] The ALJ next analyzed the severity of Lefebvre's impairments. At this second step, the ALJ concluded that Lefebvre had two severe impairments: degenerative disc disease and left shoulder tendonitis.[3]

         At the third step, the ALJ found that Lefebvre's severe impairments did not meet or “medically equal” the severity of one of the impairments listed in the Social Security regulations.[4] See 20 C.F.R. §§ 404.1520(d), 404.1525, 404.1526. After reviewing the medical evidence of record, medical opinions, and Lefebvre's own statements, the ALJ concluded that Lefebvre retained the RFC to perform sedentary work, see 20 C.F.R. § 404.1567(a), including:

the ability to lift ten pounds occasionally and five pounds frequently; stand and/or walk two hours in an eight-hour day and sit for six hours in an eight-hour day. She has unlimited use of the hands and feet to push, pull, and operate controls, can occasionally preform all postural activities and she can occasionally reach overhead with the left upper extremity. Otherwise, the claimant has an unlimited capacity for handling, fingering, feeling and reaching.[5]

         Finding that, even limited in this manner, Lefebvre was able to perform several types of past relevant work, see 20 C.F.R. § 404.1565, the ALJ concluded his analysis and found that Lefebvre was not disabled within the meaning of the Social Security Act.[6]

         III. Analysis

         Lefebvre challenges both the ALJ's step three and step four determinations. At step three, she argues that the ALJ erred in analyzing whether her condition meets or medically equals listing 1.04A. See 20 C.F.R. § 404, Subpart P, App. 1. At step four, she contends that the ALJ failed to conduct an adequate function by function analysis in determining RFC by inadequately considering evidence of her difficulty with prolonged sitting. In support of both arguments, Lefebvre cites the results of the her most recent lumbar MRI. The court does not directly resolve these arguments, because it finds that the ALJ made factual errors in interpreting the record that may have impacted his assessment of these MRI results, and therefore remands the case to the Acting Commissioner. The court explains Lefebvre's arguments to show the relevance of the MRI results.

         A. Step three - listing 1.04 analysis

         The ALJ began his step three analysis by explaining that the claimant bears the burden of showing that an impairment meets or medically equals the requirements of a listed impairment, by means of medical proof that the impairment satisfies all medical criteria for the listing and has lasted or can be expected to last for at least 12 months.[7] He held that Lefebvre had not alleged or shown that her impairments were severe enough to meet or medically equal a listed impairments, noting that there was no acceptable medical opinion evidence finding her that her impairments reached listing level.[8] The ALJ specifically considered listings 1.02 and 1.04, but found that the severity of Lefebvre's impairments did not meet or medically equal those listings.[9]

         Lefebvre challenges only the ALJ's listing 1.04 analysis. The ALJ found that Lefebvre's degenerative disc disease did not meet or medically equal the criteria of any impairment in listing 1.04 because “[t]he clinical evidence presented does not establish compromise of a nerve root or the spinal cord.”[10]Lefebvre argues that the results of her January 2015 cervical MRI show pressure upon a nerve root, and that her October 2016 lumbar MRI noted nerve “impingement” of the LR nerve root and bilateral SI nerve root. The listings suggest that “impingement” and “compromise” are equivalent. Compare 20 C.F.R. § 404, Subpart P, App. 1, 1.00(K) (“Disorders of the spine, listed in 1.04, result in limitations because of distortion of the bony and ligamentous architecture of the spine and associated impingement on nerve roots (including the cauda equina) or spinal cord.”), with 20 C.F.R. § 404, Subpart P, App. 1, 1.04 (“Disorders of the spine . . . resulting in compromise of a nerve root (including the cauda equina) or the spinal cord.”). Lefebvre also contends that the record shows she meets the other requirements of listing 1.04A, which the ALJ did not reach.

         The Acting Commissioner argues that the nerve “abutment” found by the cervical MRI is not nerve “compromise, ” and that any error in finding no “compromise” does not require remand, because of evidence in the record that Lefebvre does not meet the other requirements of listing 1.04A and the lack of medical opinion evidence supporting equivalence with a listing.

         B. Step four ...

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