Rogers v. Commissioner of Social Sec.

• Decision Date: 24 May 2007
• Docket Number: No. 05-4369.,05-4369.
• Citation: 486 F.3d 234
• Parties: Debra ROGERS, Plaintiff-Appellant, v. COMMISSIONER OF SOCIAL SECURITY, Defendant-Appellee.
• Court: U.S. Court of Appeals — Sixth Circuit

486 F.3d 234

Debra ROGERS, Plaintiff-Appellant, v. COMMISSIONER OF SOCIAL SECURITY, Defendant-Appellee.

No. 05-4369.

United States Court of Appeals, Sixth Circuit.

Submitted: October 26, 2006.

Decided and Filed: May 24, 2007.

ON BRIEF: Cherie H. Howard, Northeast Ohio Legal Services, Youngstown, Ohio, for Appellant. Lisa Hammond Johnson, United States Attorney, Cleveland, Ohio, for Appellee.

Before: MARTIN and COOK, Circuit

Judges; BUNNING, District Judge.^*

OPINION

DAVID L. BUNNING, District Judge.

In this appeal, we are asked once again to consider the substantive and procedural requirements of the Social Security Act and the regulations of the Social Security Administration. Specifically, we must evaluate the Commissioner's decision denying disability benefits to a claimant who alleges she suffers from pain and other symptoms associated with fibromyalgia and rheumatoid arthritis. In doing so, we examine whether the Commissioner adequately reviewed the case record and did so using the correct legal standards, thereby resulting in substantial evidence to support the denial of benefits. For the following reasons, we hold that the Commissioner did not, and therefore reverse the judgment of the district court and remand this matter for further findings.

I. BACKGROUND

A. Factual Background

Plaintiff-Appellant Debra Rogers is presently 45 years of age, with a high school education. She alleges an inability to work since 1993 due to numerous health conditions. Her work history is not extensive. In the few years preceding her alleged disability onset she worked part-time, most recently at a restaurant performing food preparation, cleaning, and cashier work until pain in her neck, shoulders, back, joints, and extremities prompted her to leave that job in 1993. Relevant to this appeal, Rogers asserts that fibromyalgia and rheumatoid arthritis, and specifically the pain associated with these conditions, prevent her from engaging in substantial gainful employment.

Dr. Robert A. Evans, a doctor of osteopathic medicine and family practitioner, has been Rogers' treating physician since 1993, seeing her every six weeks on average since that time. In July of 1998, Dr. Evans submitted his first assessment of Rogers to the Bureau of Disability Determination, to which he attached office notes dating back to August, 1995. This report and attached notes reveal a long history of pain and other symptoms. Notably, Rogers complained of pain in her shoulders, thighs, ankles, abdomen, bones, arms, hips, and chest; of tingling in her fingers; and of tenderness in her wrists and arms. The notes also list several prescribed medications. In his report, Dr. Evans diagnosed, among other things, headaches, cervical disc disease, and rheumatoid arthritis, and indicated that standing, walking, sitting, bending, and lifting were all affected by these conditions. Dr. Evans opined that Rogers was capable of sedentary work only.

In March of 1999, Dr. Evans submitted a Medical Impairment Evaluation in which he listed arthralgia and depression as disabling conditions. This report stated that Rogers had experienced increased pain that interfered with her ability to engage in past employment and that her condition was "poor." He observed swelling and noted that Rogers was unable to grasp objects. Dr. Evans' assessment of Rogers' limitations was that she could lift only five pounds and could sit and stand for no more than one hour in an eight-hour workday.

In June of 1999, Dr. Evans submitted a medical report to the Ohio Department of Human Services in which he indicated Rogers suffers both from fibromyalgia and rheumatoid arthritis and listed no less than six medications prescribed to her. He then opined that these conditions limit her ability to perform certain basic functions. For example, he suggested that Rogers could stand for only one hour during an eight-hour period and only five minutes uninterrupted, that she could lift no more than five pounds, and that she was "markedly limited" in her ability to push and pull. Dr. Evans concluded at that time that Rogers was unemployable.

An additional report confirming these opinions was submitted on May 18, 2001. In that report, Dr. Evans stated that Rogers experiences tenderness to palpitation, decreased range of motion, and swelling of the joints. He noted that lab work indicated elevated sedimentation rates. Finally, he attested to Rogers' pain, attributing it to rheumatoid factors. In assessing Rogers' limitations, Dr. Evans suggested that she is unable to sit or walk for more than ten minutes continuously, and that she can neither sit nor stand for more than fifteen minutes total in an eight-hour workday. He also suggested that Rogers can lift five pounds only occasionally and that she is incapable of bending, squatting, crawling, or climbing.

Dr. Richard Stein is a rheumatologist who began treating Rogers in 1997. Dr. Stein noted on October 18, 1997, that rheumatoid arthritis was "likely" in light of Rogers' sedimentation rate, and that fibromyalgia "may be active." On December 3, 1997, Dr. Stein recorded that Rogers was then suffering severe hip pain, which, according to his notes, prohibited her from "do[ing] anything, even turning over in bed." Dr. Stein also noted that Rogers exhibited tender points of "classic fibromyalgia distribution." On January 14, 1998, Dr. Stein documented tenderness and swelling and noted several medications. On May 20, 1998, Dr. Stein noted that Rogers was suffering from "pain all over" and that her "joints hurt everywhere." Additionally, he remarked that her tender points were very sensitive, and that her pain symptoms were more demonstrative of fibromyalgia than rheumatoid arthritis. Further tissue swelling and joint tenderness were observed. Dr. Stein's notes also indicated that Rogers needs a "very sedentary job, only answering phones because of her chronic pain." On August 20, 1998, Dr. Stein confirmed that Rogers' tender points were of a "classic fibromyalgia distribution." On examination of September 24, 1998, Dr. Stein noted that Rogers was experiencing chest and shoulder pain, as well as occasional tingling in the hands. Dr. Stein performed injections of lidocaine and marcaine for her shoulder pain with "marked" relief. On September 28, 1998, Dr. Stein submitted an assessment to the Bureau of Disability Determination (hereinafter "Bureau"). In his assessment, he diagnosed Rogers with rheumatoid arthritis and fibromyalgia and limited her lifting and carrying capacity to less than five pounds.

Notes of Dr. Stein from October 28, 1999, indicate that Rogers' pain persisted, that she was experiencing difficulty sleeping, and that she had tender points "too numerous to enumerate." According to his medical records, Rogers saw him four times in 2000. During her last visit on November 14, Dr. Stein documented "multiple tender spots consistent with fibromyalgia" as well as continued joint tenderness.

A similar pattern of findings was noted in Dr. Stein's 2001 and 2002 treatment notes. He completed a second assessment on May 14, 2001, concluding that Rogers suffers from rheumatoid arthritis and fibromyalgia. He further concluded she is limited to fifteen minutes of uninterrupted sitting, only five minutes of uninterrupted standing, can lift and carry ten pounds only occasionally, and can neither grasp nor push or pull objects.

Dr. Samuel Rosenberg is a pain specialist to whom Rogers was referred by Dr. Stein. Dr. Rosenberg examined Rogers and concluded that she suffers from rheumatoid arthritis, among other things. He recommended she receive a series of steroid injections to help ease her pain. These injections were noted in Dr. Stein's record of March 16, 1998, as well as the fact that she was "60% improved." Unfortunately, Rogers reported that her pain had returned during her May 20, 1998, visit with Dr. Stein.

Dr. Alan Oliver is a critical care specialist to whom Rogers was referred by Dr. Evans. Rogers saw Dr. Oliver on May 28, 1998. He diagnosed rheumatoid arthritis and cervical disc disease. He further confirmed that Rogers' ability to stand, walk, sit, lift, and carry were all affected by her conditions, noting that she is "poor but stable."

In July of 2002, Dr. Naomi Waldbaum, a physical medicine and rehabilitation specialist, performed an evaluation at the behest of the Bureau. Dr. Waldbaum noted tenderness and pain in Rogers' shoulders, elbows, hands, fingers, wrists, lower back, hips, thighs, knees, ankles, and feet. She further noted that Rogers reported feeling tired and very stiff, and that she experiences numbness and tingling sensations in her hands and legs. Dr. Waldbaum listed Rogers' then-current medications, including Propoxyphene, Sulfasalazine, Cyclobenzaprine, Estradiol, Celebrex, Ranitidine, Alprozolam, Methotrexate, and Folic Acid. Dr. Waldbaum recounted Rogers' daily activities as driving short distances, daily grooming, and some very simple tasks; however, these activities were qualified by the doctor's notation that Rogers' daughter lives next door and assists her.

Dr. Waldbaum's physical evaluation of Rogers revealed good ranges of motion and normal reflexes; however, she appeared to be very stiff as marked by complaints of significant pain. Dr. Waldbaum also considered Rogers' diagnoses of rheumatoid arthritis, noting that there were no blood tests or elevated sedimentation rates upon which to base such a diagnosis, and that x-rays and CT scans showed no abnormalities of the soft tissue. Dr. Waldbaum concluded that Rogers "states that she was diagnosed with rheumatoid arthritis," that she exhibits significant pain behavior, and that she would be unable to maintain full-time employment.

Dr. David Rath, a non-examining physician who conducted a record review while Rogers' claim was before the state agency, submitted a physical residual functional capacity assessment in July of 1998. Dr. Rath concluded that Rogers...