Gray v. Comm'r of Soc. Sec.

• Docket Number: 1:20-CV-02123-BYP
• Decision Date: 08 November 2021
• Parties: TRENT C. GRAY, Plaintiff, v. COMMISSIONER OF SOCIAL SECURITY, Defendant,
• Court: U.S. District Court — Northern District of Ohio

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TRENT C. GRAY, Plaintiff, v. COMMISSIONER OF SOCIAL SECURITY, Defendant,

No. 1:20-CV-02123-BYP

United States District Court, N.D. Ohio

November 8, 2021

BENITA Y. PEARSON, UNITED STATES DISTRICT JUDGE.

REPORT & RECOMMENDATION

CARMEN E. HENDERSON, U.S. MAGISTRATE JUDGE.

I. Introduction

Plaintiff Trent C. Gray (“Gray” or “Claimant”) seeks judicial review of the final decision of the Commissioner of Social Security denying his application for Disability Insurance Benefits (“DIB”). This matter is before me pursuant to 42 U.S.C. §§ 405(g), 1383(c)(3), and Local Rule 72.2(b). For the reasons set forth below, it is that the Court REVERSE the Commissioner of Social Security's nondisability finding and REMAND this case to the Commissioner and the ALJ under Sentence Four of § 405(g).

II. Procedural History

On August 20, 2015, Claimant filed an application for DIB, alleging a disability onset date of February 28, 2014. (ECF No. 11, PageID #: 192). The application was denied initially and upon reconsideration, and Claimant requested a hearing before an administrative law judge (“ALJ”). On November 8, 2017, an ALJ held a hearing, during which Claimant, represented by counsel, and an impartial vocational expert testified. (ECF No. 11, PageID #: 116). On December 7, 2017, the ALJ issued a written decision finding Claimant was not disabled. (ECF No. 11, PageID #: 189). Upon review, the Appeals Council remanded the case on June 11, 2018. (ECF No. 11, PageID #: 209-212). Upon remand, Claimant and a new vocational expert appeared and testified at a second hearing held on November 14, 2018 before the same ALJ (ECF No. 11, PageID #: 91). The ALJ again issued an unfavorable decision dated December 14, 2018. (ECF No. 11, PageID #: 214). The Appeals Council granted review a second time but issued an unfavorable decision on July 23, 2020. (ECF No. 11, PageID #: 77). In that decision, the Appeals Council adopted each of the ALJ's findings except those at Step Five. (ECF No. 11, PageID #: 80-81). The Appeals Council determined that Claimant could perform only one of the representative jobs set forth by the ALJ. (ECF No. 11, PageID #: 81). The Appeals Council decision became the final decision of the Commissioner.

On September 21, 2020, Claimant filed his Complaint to challenge the Commissioner's final decision. (ECF No. 1). The parties have completed briefing in this case. (ECF Nos. 13, 16 and 17). Claimant asserts the following assignments of error:

1. The ALJ failed to properly evaluate Mr. Gray's pain and other symptoms caused by his Fibromyalgia, and Psychological Factors Affecting Physical Condition Disorder according to the mandates of SSR 12-2p and SSR 16-3p.

2. The ALJ failed to cite good reasons for rejecting the opinion of the treating physician as required by SSR 96-2p and 20 CFR 404.1527 and failed to evaluate the opinion of the consultative examiner, Dr. Smith.

(ECF No. 13 at 3).

III. Background

A. Relevant Hearing Testimony

1. Claimant's Testimony

The ALJ summarized Claimant's hearing testimony:

The claimant testified that he was diagnosed with fibromyalgia "roughly 20 years ago," during a psychiatric inpatient hospitalization, when he was examined by a psychiatrist in the hospital who pressed on tender trigger points. He said that the main infestations of this illness now is that he carries a lot of tension in his neck, has pain throughout his back, and suffers from insomnia. As for the claimant's mental impairments, he testified that he has extreme anxiety when he leaves the house. He reported that he does not go to meetings, shop, attend church, or eat out and only leaves the house for medical appointments. He reported that he is unable to drive, and does not take public transportation because "it would provoke a lot of anxiety." He indicated that he is always "on guard" and hypervigilant. (Hearing testimony).

(ECF No. 11, PageID #: 225).

2. Vocational Expert's Testimony

The ALJ propounded the following hypothetical question to the vocational expert:

All right. This individual is limited to work at medium exertional requirements, but has additional non-exertional limitations specifically no climbing of ladders, ropes, or scaffolds; occasional climbing of ramps and stairs, balancing, stooping, kneeling, crouching, and crawling; no exposure to hazards such as heights, machinery, commercial driving; and mental limitation that he perform routine tasks in a low-stress environment specifically no fast pace, strict quotas, or frequent-duty changes involving superficial, interpersonal interactions with coworkers and supervisors specifically no fast pace, strict quotas, or frequent-duty changes; and no interaction with the general public as a job requirement.

(ECF No. 11, PageID #: 107-108). The vocational expert testified that the individual could not perform Claimant's past relevant work. (ECF No. 11, PageID #: 108). At the ALJ's request, the vocational expert provided two jobs that the hypothetical individual could perform at each of the sedentary, light and medium exertional levels. (ECF No. 11, PageID #: 108-109). The sedentary level jobs that the vocational expert identified were document preparer and addresser/typewriter, computer. (ECF No. 11, PageID #: 109). The light level jobs that the vocational expert identified were merchandise marker and mail room clerk. (ECF No. 11, PageID #: 109). The medium level jobs that the vocational expert identified were cleaner II and kitchen helper. (ECF No. 11, PageID #: 108). The vocational expert later clarified that a kitchen helper would not be available, but that the job of linen room attendant would. (ECF No. 11, PageID #: 112).^[1]

The ALJ created a second hypothetical question with the same limitations as the first but added that the hypothetical individual would be off task 20% of the time. (ECF No. 11, PageID #: 110). The vocational expert said there would be no jobs that could be sustained under that condition. (ECF No. 11, PageID #: 110).

Ultimately, the ALJ found that Claimant had the RFC to perform a range of medium work with additional limitations.

B. Relevant Medical Evidence

The ALJ also summarized Claimant's health records and symptoms:

The claimant has had limited and conservative treatment of his fibromyalgia, which has been managed by his primary care provider, Jason Ridgel, M.D. Dr. Ridgel's office visit notes from October 2014 through December 7, 2017 are in the record. When Dr. Ridgel first treated the claimant fibromyalgia was mentioned in passing, as the claimant was presenting with a more immediate concern of a persistent rash characterized by excoriated legions that appeared to be self-inflicted. When the claimant saw Dr. Ridgel on March 2, 2015, he was reporting generalized fatigue, widespread pain, and difficulty falling asleep. Treatment notes indicate that the claimant's skin had improved. At his next appointment with Dr. Ridgel on June 3, 2015, the claimant's main complaint was fibromyalgia, accompanied by difficulty in remembering words. Dr. Ridgel initiated treatment with amitriptyline, although treatment notes indicate that Dr. Ridgel plan to monitor him carefully on this medication, due to an emerging clinical picture of bipolar disorder. Physical examinations in 2016 and 2017 include findings of generalized fatigue, morning stiffness, widespread pain, and difficulty falling asleep, but describe the claimant as being in no acute distress, and tend to focus on the claimant's psychological distress as the primary diagnosis. Dr. Ridgel's treatment notes also indicate that he believed the claimant's inactivity was contributing to the severity of his fibromyalgia symptoms, and he advised him to exercise. In the last record of Dr. Ridgel's treatment which is available, the claimant was advised to take his entire Elavil dose at night to help his pain syndrome, and improve sleep. He also strongly advised the claimant to performing indoor exercise on a treadmill or bike. (Exhibits 1F, p. 7, 9-13, 17-18; 5F, p. 8; 6F, p. 8; 9F, p. 3, 5; 13 F, p. 3-4).

[…]

The claimant received treatment for his mental health impairments at the Nord Center. He was briefly hospitalized on November 4, 2014 when his roommate told him that he would have to move out because of paranoid and threatening behavior. When he presented at the hospital, he reported that he had been off of his psychiatric meds for the last four years. While on the inpatient unit, he was observed to have significant difficulty sleeping, anxiety, hypervigilance, peculiar behavior, and paranoia. He left on November 8, 2014, against medical advice, and told Nord Center staff that he would follow up with his primary care provider, the only medical professional with whom he felt comfortable. Discharge notes indicate that over the course of his hospitalization he presented as less anxious but preoccupied with small details, and with delusional, grandiose, and persecutory thinking, little insight, and tangential speech patterns. The Nord Center made follow-up attempts with the claimant, but he was discharged from their services when he did not respond to outreach attempts. (Exhibit 12F, p. 6, 9, 52).

Dr. Ridgel treated the claimant's mental health impairments with medications. When the claimant first saw Dr. Ridgel on October 9, 2014, he presented with skin lesions. He explained that he had a feeling that he had hairs that were stuck under his skin and he felt the urge to dig them out. He also reported the sense that hairs were growing out of his eyes as well. Dr. Ridgel's treatment notes describe this as a fixed delusion. During the period of time under consideration in this claim, Dr. Ridgel's treatment notes show that the claimant experienced some remission in self harming

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