UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEW HAMPSHIRE
Shannon C. Smith Case No. 18-cv-1086-PB v. Opinion No. 2019 DNH 193
Andrew Saul, 1 Commissioner, Social Security Administration
MEMORANDUM AND ORDER
Shannon Smith challenges the denial of her claims for
Disability Insurance Benefits (“DIB”) and Supplemental Security
Income (“SSI”) pursuant to 42 U.S.C. § 405(g). She contends that
the Administrative Law Judge (“ALJ”) erred by (1) failing to
properly analyze her mental impairments at step two and
thereafter; (2) failing to follow the Social Security
Administration’s (“SSA”) Ruling on the Evaluation of
Fibromyalgia, SSR 12-2p, 2012 WL 3104869 (July 25, 2012); and
(3) improperly giving greater weight to non-examining state
agency consultants than to Smith’s treating and examining
medical sources. The Commissioner, in turn, moves for an order
affirming the ALJ’s decision. For the following reasons, I grant
Smith’s motion and remand this matter to the Commissioner for
1 On June 17, 2019, Andrew Saul was sworn in as Commissioner of Social Security. He replaced the nominal defendant, Nancy A. Berryhill, who had been Acting Commissioner of Social Security. further proceedings consistent with this order.
I. BACKGROUND
A. Procedural Facts
Smith is a forty-four-year-old woman who has previously
worked as a gas station attendant and cashier and currently
works part time at a Dunkin’ Donuts. See Administrative
Transcript (“Tr.”) at 297, 305. She alleges that she has been
disabled since January 12, 2016, due to a combination of
fibromyalgia, Chiari malformation, 2 migraines, depression, and
anxiety. Tr. at 18–19.
Smith filed claims for DIB and SSI on November 30, 2016.
Tr. at 271. After an initial denial on March 16, 2017, Tr. at
121, she testified at a hearing before ALJ Thomas Merrill on
November 13, 2017. Tr. at 39–80. The ALJ denied Smith’s
applications, Tr. at 32, and the SSA Appeals Council denied her
request for review. Tr. at 1–3. As such, the ALJ’s decision
constitutes the Commissioner’s final decision, which Smith now
appeals.
B. Medical Evidence
In this section, I decline to recite a full history of
2 Chiari malformation is “a congenital anomaly in which the cerebellum and medulla oblongata, which is elongated and flattened, protrude into the spinal canal through the foramen magnum . . . It may be accompanied by hydrocephalus, spina bifida, syringomyelia, and mental defects.” Dorland’s Illustrated Medical Dictionary 1098 (32d ed. 2012).
2 Smith’s medical treatment, opting instead to focus on the
treatment records necessary to provide context in this case.
Prior to Smith’s alleged disability onset date, she was
diagnosed and/or treated by various providers for migraines,
e.g., Tr. at 389, 404, 416, 686; anxiety/panic disorder, e.g.,
Tr. at 389, 416, 429, 436, 686, 687, 695, 703 ; depression,
e.g., Tr. at 389, 436, 686, 695; Chiari malformation, Tr. at
389; and fibromyalgia, e.g., Tr. at 429; as well as other
ailments not claimed as a basis for her disability, e.g., Tr. at
389, 397–98, 422.
Following the alleged onset date, Smith continued to seek
treatment for fibromyalgia, anxiety, and depression from her
primary care physician, Dr. Nanyee Keyes on February 24, 2016.
Tr. at 441–42. That June, Smith discussed with a physician
assistant how her fibromyalgia interfered with her sleep, which
in turn exacerbated her fibromyalgia symptoms. Tr. at 446.
Another doctor, Dr. Mitchell Young, diagnosed Smith as having
fibromyalgia affecting her shoulder on September 24. Tr. at 474.
Smith returned to Dr. Keyes on November 18, who noted 14
positive fibromyalgia tender points (out of a possible 18) and
scores of 15 and 14 on the depression and anxiety scales,
respectively. Tr. at 468, 479–80. That same day, in support of
Smith’s application for DIB and SSI, Dr. Keyes completed a
physical medical source statement listing diagnoses of
3 fibromyalgia, depression, and anxiety. Tr. at 465–68. 3 She also
submitted a mental impairment source statement, which noted
diagnoses of anxiety and depression. Tr. at 469–72. Dr. Keyes
checked boxes for thirty-four “signs and symptoms,” Tr. at 470,
and for various functional limitations at varying levels of
severity, Tr. at 471. On January 11, 2017, Smith sought
treatment for fibromyalgia from a physician assistant, Tr. at
492, and again from Dr. Keyes on January 18, Tr. at 493. On
November 23, Smith saw Dr. Jing Ji about her headaches. Tr. at
481–82. Dr. Ji found “no major concern” regarding Chiari
malformation, but noted that Smith could have hemiplegic
migraines. Tr. at 484. Dr. Ji saw Smith for a follow-up three
months later. Tr. at 506–07.
She was evaluated by Dr. David Kamen, a consultative
psychologist, on February 1. Tr. at 510–15. Dr. Kamen noted both
positive and negative aspects of Smith’s functioning, including
3 The ALJ discounted this report by Dr. Keyes’s as internally contradictory, in part due to a misrepresentation of what Dr. Keyes wrote in it. Specifically, in an error repeated in Defendant’s briefs, the ALJ claimed that “Dr. Keyes noted that the claimant could sit for three hours at a time but could only sit for two hours in an eight-hour workday.” Tr. 30. In fact, Dr. Keyes appears to have crossed out the number “2” and written in “3” above it, Tr. 466, making her answers consistent on this point. Since, as discussed below, my remand is not based upon the ALJ’s weighing of Dr. Keyes’s opinion, I need not address his reasons for doing so in any detail. I point out this discrepancy only to caution the ALJ on remand to ensure that his reasons for discounting this or any other report are, in fact, supported by the record.
4 several depression and anxiety symptoms that Smith presented
during the evaluation. Tr. at 510. Ultimately, he concluded that
he did “not believe that [Smith] is able to sustain an ordinary
routine and regular work attendance . . . .” Tr. at 514.
Smith also had a fibromyalgia evaluation conducted by Dr.
Prachaya Nitichaikulvatana on April 4, Tr. at 877, and spoke
with Dr. Sumathi Rajanna on June 2 following a panic attack and
self-harm incident at work, Tr. 884. She had an initial
evaluation at Greater Nashua Mental Health Center on July 18,
during which she reported symptoms “indicative of a diagnosis of
Major Depressive Disorder, moderate, recurrent with anxious
distress.” Tr. at 526. She was also given a rule-out diagnosis
of borderline personality disorder. Tr. at 526. At her September
5 follow-up with Dr. Nitichaikulvatana, Smith reported worsening
fibromyalgia pain. Tr. at 887.
Smith began therapy with Camila Fonseca on July 31. Tr. at
528. She continued to see Ms. Fonseca, eventually asking her to
complete a Mental Impairment Medical Source Statement on October
3. Tr. at 918–21. This statement identified only three “signs
and symptoms,” Tr. at 919, and noted far less severe functional
limitations than Dr. Keyes’s earlier statement, Tr. at 920.
C. The ALJ’s Decision
The ALJ assessed Smith’s claims under the five-step
analysis required by 20 C.F.R. § 404.1520. At step one, he found
5 that Smith had not engaged in substantial gainful activity
(“SGA”) since January 12, 2016, her alleged disability onset
date. Tr. at 18. At step two, the ALJ found that Smith’s
fibromyalgia was a severe impairment, but that her Chiari
malformation, migraines, anxiety, and depression were non-
severe. Tr. at 18–24. At step three, the ALJ concluded that
Smith did not “have an impairment or combination of impairments
that medically meets or equals a listed impairment” in 20 C.F.R.
§ Pt. 404, Subpt. P, App. 1. Tr. at 24–25.
The ALJ next evaluated Smith’s residual functional capacity
(“RFC”) and determined that she could perform light work, with
the following exceptions:
[Smith] can lift and carry 10 pounds frequently and 20 pounds occasionally; sit for six hours in an eight[- ]hour work period; stand, or walk for six hours in an eight[-]hour work period; perform unlimited pushing and pulling of 10 pounds frequently and 20 pounds occasionally with the upper and lower extremities; occasionally climb, stoop, kneel, crouch or crawl; and frequently balance.
Tr. at 25. Based upon this RFC, the ALJ determined at step four
that Smith could perform her past work as a fast food worker or
cashier and was, therefore, not disabled. Tr. at 32. Having
resolved the claim at step four, the ALJ did not proceed to step
five.
6 II. STANDARD OF REVIEW
I am authorized to review the pleadings submitted by the
parties and the administrative record and enter a judgment
affirming, modifying, or reversing the Commissioner’s final
decision. See 42 U.S.C. § 405(g). That review “is limited to
determining whether the ALJ used the proper legal standards and
found facts [based] upon the proper quantum of evidence.” Ward
v. Comm’r of Soc. Sec., 211 F.3d 652, 655 (1st Cir. 2000). I
“defer to the Commissioner’s findings of fact, so long as they
are supported by substantial evidence.” Id. (citing Nguyen v.
Chater, 172 F.3d 31, 35 (1st Cir. 1999) (per curiam)).
“[W]hatever the meaning of ‘substantial’ in other contexts, the
threshold for such evidentiary sufficiency is not high.” Biestek
v. Berryhill, ___ U.S. ___, 139 S. Ct. 1148, 1154, 203 L. Ed. 2d
504 (2019). It means only “such relevant evidence as a
reasonable mind might accept as adequate to support a
conclusion.” Id. (quoting Consolidated Edison Co. v. NLRB, 305
U.S. 197, 229, 59 S. Ct. 206, 83 L. Ed. 126 (1938)).
If the Commissioner’s factual findings are supported by
substantial evidence, they are conclusive, even where the record
“arguably could support a different conclusion . . . .” Irlanda
Ortiz v. Sec’y of Health & Human Servs., 955 F.2d 765, 770 (1st
Cir. 1991) (per curiam). The Commissioner’s findings “are not
conclusive when derived by ignoring evidence, misapplying the
7 law, or judging matters entrusted to experts.” Nguyen, 172 F.3d
at 35. “Issues of credibility and the drawing of permissible
inference from evidentiary facts are the prime responsibility of
the Commissioner, and the resolution of conflicts in the
evidence and the determination of the ultimate question of
disability is for [him], not for the doctors or for the courts.”
Purdy v. Berryhill, 887 F.3d 7, 13 (1st Cir. 2018) (internal
quotation marks and brackets omitted) (quoting Rodriguez v.
Sec’y of Health & Human Servs., 647 F.2d 218, 222 (1st Cir.
1981)).
III. ANALYSIS
Smith argues that a remand is required for three principal
reasons: (1) the ALJ failed to properly consider Smith’s non-
severe impairments at step two and thereafter; (2) the ALJ did
not follow SSR 12-2p, 2012 WL 3104869; and (3) the ALJ
improperly gave greater weight to non-examining state agency
consultants than to Smith’s treating and examining medical
sources. Smith’s first argument is dispositive and warrants a
remand. I first address the ALJ’s handling of Smith’s non-severe
impairments at step two. I then discuss his handling of those
impairments at both step three and the RFC calculation stage
that precedes step four.
8 A. Step Two Analysis of Non-Severe Impairments
In his decision, the ALJ determined that Smith’s
fibromyalgia was a severe impairment. Tr. at 18. The ALJ also
determined, however, that there was “no evidence that any other
conditions have met the durational requirements of this program,
or that they create any specific functional limitations
regarding [Smith’s] ability to perform basic work-related
activities” and thus any such conditions were “non-severe.” Tr.
at 24. Smith challenges this determination.
I need not decide whether the ALJ erred by concluding that
Smith’s other impairments were non-severe because “[t]his court
has consistently held . . . that an error in describing a given
impairment as non-severe is harmless so long as the ALJ found at
least one severe impairment and progressed to the next step of
the sequential evaluation.” Chabot v. U.S. Soc. Sec. Admin., No.
13-cv-126-PB, 2014 WL 2106498, at *9 (D.N.H. May 20, 2014).
Had the ALJ not identified fibromyalgia as a severe
impairment, I would need to address whether substantial evidence
supported his conclusion that Smith’s other impairments were
non-severe. Where, as here, the ALJ finds at least one severe
impairment and resolves step two in the claimant’s favor, the
decision not to treat other impairments as severe is, at most,
harmless error. See Hines v. Astrue, No. 11-cv-184-PB, 2012 WL
1394396, at *12 (D.N.H. Mar. 26, 2012), adopted by 2012 WL
9 1393063 (D.N.H. Apr. 20, 2012). Because, in this case, the ALJ
identified fibromyalgia as a severe impairment at step two, the
appropriate question is whether the ALJ adequately addressed the
non-severe impairments after step two. See Lavoie v. Colvin, No.
15-cv-209-PB, 2016 WL 3554963, at *2 (D.N.H. June 24, 2016).
B. Analysis of Non-Severe Impairments after Step Two
In assessing whether a claimant is disabled, an ALJ must
consider “the combined effect of all of a claimant's
impairments[,]” regardless of whether those impairments are
individually classified as “severe.” McDonald v. Sec’y Health &
Human Servs., 795 F.2d 1118, 1126 (1st Cir. 1986); see 42 U.S.C.
§ 423(d)(2)(B); 20 C.F.R. 404.1523(c). It is “simply a matter of
common sense that various physical, mental, and psychological
defects, each non-severe in and of itself, might in combination,
in some cases, make it impossible for a claimant to work.”
McDonald, 795 F.2d at 1127. An ALJ must therefore “consider the
combined effect of all of [a claimant’s] impairments without
regard to whether any such impairment, if considered separately,
would be of sufficient severity.” 20 C.F.R. 404.1523(c); see SSR
96-8P, 1996 WL 374184, at *5 (July 2, 1996). And, although an
ALJ has “considerable latitude” in how he considers non-severe
impairments, Chabot, 2014 WL 2106498, at *10, he may “not
disregard individual, non-severe impairments where the
claimant's collective impairments are severe,” Forni v.
10 Barnhart, No. 05-cv-406-PB, 2006 WL 2956293, at *8 (D.N.H. Oct.
17, 2006). It is reversible error for an ALJ not to consider a
claimant’s non-severe impairments in conjunction with her severe
impairments at step three and when formulating her RFC. See,
e.g., Lavoie, 2016 WL 3554963, at *3–4 (overturning ALJ’s
decision where claimant’s non-severe depression was not
considered in conjunction with her severe impairments, including
fibromyalgia); Morse v. Colvin, No. 14-cv-18-LM, 2015 WL
1243169, at *8 (D.N.H. Mar. 17, 2015) (remanding case where ALJ
failed to discuss combination of claimant’s severe and non-
severe impairments at step three and at RFC calculation); Forni,
2006 WL 2956293, at *8–9 (concluding that ALJ’s failure to
consider non-severe depression in conjunction with severe asthma
and carpal tunnel syndrome warranted remand); Stephenson v.
Halter, No. CIV. 00-391-M, 2001 WL 951580, at *2 (D.N.H. Aug.
20, 2001) (ruling that ALJ does not meet requirement of 20
C.F.R. § 1523 merely by finding that impairment is not severe
either alone or in combination with other impairments, but must
actually address non-severe impairment when assessing RFC).
Like the ALJs in Lavoie, Morse, Forni, and Stephenson, the
ALJ in this case discussed Smith’s severe and non-severe
impairments individually at step two. Tr. at 18–24. Then, at
step three, he concluded that she did not have “an impairment or
combination of impairments that medically meets or equals a
11 listed impairment.” Tr. 25. In reaching that conclusion,
however, he never once mentioned any of Smith’s non-severe
impairments, let alone discussed how they might, in combination
with her severe fibromyalgia, equal a listed impairment. 4 The
words “migraine,” “Chiari malformation,” “anxiety,” and
“depression” do not appear.
After step three, in determining Smith’s RFC, the ALJ’s
only mention of any non-severe impairments is a reference to
Smith’s testimony that her depression prevented her from
exercising, thereby interfering with her fibromyalgia treatment. 5
Tr. 26. In the RFC calculation, the words “migraine,” “Chiari
malformation,” and “anxiety” are again nowhere to be found. This
suggests that the ALJ did not include Smith’s non-severe
4 Somewhat puzzlingly, the ALJ did consider, albeit in a cursory manner, the “potential effects obesity has in causing or contributing to impairments in other body systems.” Tr. 25. Smith at no point alleged disability based upon obesity, nor do any of the medical reports referenced by the ALJ list obesity as a potentially disabling condition. In fact, the Disability Determination Explanation that Smith appealed to the ALJ lists her BMI as 27.4, Tr. 140, which falls below the National Institutes of Health obesity threshold of 30. See Stedman’s Medical Dictionary 620200 (28th ed. 2006); SSR 02-1p, 2002 WL 34686281, at *2 (Sept. 12, 2002).
5 This interaction between the severe fibromyalgia and non-severe depression is but one example of how an impairment that does not equal a listed impairment on its own might be exacerbated by another, even non-severe, impairment such that the combined effect does rise to the level of a listed impairment. It underscores the importance of considering the various impairments in combination and providing enough explanation of that analysis to allow for judicial review.
12 impairments in his RFC calculation and only considered her
severe fibromyalgia. Cf. Lavoie, 2016 WL 3554963, at *3 (holding
that ALJ’s failure to mention claimant’s depression at RFC stage
suggests it was “impermissibly dropped” from the analysis).
The Commissioner presents two arguments in defense of the
ALJ’s decision, neither of which is persuasive. First, the
Commissioner notes that the ALJ stated that “he had reviewed and
considered all ‘severe’ and ‘non-severe’ impairments in
formulating the RFC.” Defs.’ Mem. of Law in Supp. of Defs.’ Mot.
for an Order Affirming the Decision of the Comm’r. Doc. No. 12-1
at 19 (internal quotation marks omitted). The Commissioner’s own
brief, however, concedes that this language is mere
“boilerplate.” Doc. No. 12-1 at 19. This court has consistently
ruled that a “boilerplate assertion that an ALJ considered all
of the claimant’s impairments in combination, without describing
any actual analysis, is insufficient.” Lavoie, 2016 WL 3554963,
at *4 (internal brackets and quotation marks omitted) (quoting
Morse, 2015 WL 1243169, at *8).
Second, the Commissioner identifies two instances in the
ALJ’s RFC calculation that reference Medical Source Statements
by Dr. Keyes, Tr. 465–72, and Ms. Fonseca, Tr. 918–21, as
evidence to “back[] up that boilerplate.” Doc. No. 12-1 at 19.
The Commissioner’s assertion that Dr. Keyes’s treatment notes
“did not reflect any abnormal mental status findings,” Doc. No.
13 12-1 at 19, are inaccurate, because Keyes’s notes, at minimum,
identify a score of 14 for anxiety and a score of 15 for
depression. Tr. 479. But even if the ALJ’s characterization of
Smith’s mental impairments had been accurate, it would not
remedy the more fundamental concern that he failed to consider
the combined effect of these non-severe mental impairments with
Smith’s severe fibromyalgia. “It is axiomatic that disability
may result from a number of impairments which, taken separately,
might not be disabling, but whose total effect, taken together,
is to render claimant unable to engage in substantial gainful
activity.” Morse, 2015 WL 1243169, at *9 (quoting Walker v.
Bowen, 889 F.2d 47, 50 (4th Cir. 1989)). The SSA’s own ruling on
the evaluation of fibromyalgia further emphasizes the
requirement of “consider[ing] the effects of all of the person’s
medically determinable impairments, including impairments that
are ‘not severe.’” SSR 12-2p, 2012 WL 3104869, at *6. 6
6 Because the ALJ’s failure to consider the impairments in combination is sufficient grounds to remand this case, I need not consider Smith’s argument that the ALJ failed to cite and follow SSR 12-2p. The Commissioner asks me to adopt from other circuits a rule that an ALJ is not required to mention a ruling by name if he substantially complies with it. Doc. No. 12-1 at 14. Even if I were to adopt this rule, the ALJ did not substantially follow SSR 12-2p in this case, as that ruling explicitly requires the ALJ to consider fibromyalgia in combination with other impairments. SSR 12-2p, 2012 WL 3104869 at *6. On remand, the ALJ must follow SSR 12-2p in all respects. In the event I am again asked to review the ALJ’s decision, proper citation to SSR 12-2p will assist me in ensuring that the ruling has been followed.
14 Depression and anxiety are both associated with fibromyalgia.
Id. at *3. Courts have found that the interaction of mental
conditions, such as depression, with fibromyalgia can “result[]
in increased pain and suffering.” Barnes v. Astrue, No. 07-2141,
2008 WL 5210753, at *3 (W.D. Ark. Dec. 10, 2008); see also
Hazelton v. Astrue, No. 4:08-2767-TER, 2010 WL 1052840, at *5
(D.S.C. Mar. 19, 2010) (remanding case where “ALJ discussed
[claimant’s] fibromyalgia, anemia, asthma, and depression
separately, but did not discuss her impairments in combination
as required.”). Thus, even though, in this case, the ALJ
credited a medical opinion that the claimant’s mental
impairments resulted in no more than “mild difficulty in
completing activities of daily living,” Tr. 30, he should still
have considered the potentially disabling effects of those non-
severe impairments in combination with Smith’s fibromyalgia in
formulating her RFC.
An ALJ’s opinion “must provide adequate explanation to show
that he had considered the combined effect of the impairments as
to allow proper judicial review.” Lavoie, 2016 WL 3554963, at *4
(quoting Reichenbach v. Heckler, 808 F.2d 309, 312 (4th Cir.
1985)). Where, as here, the ALJ fails to provide such adequate
explanation, his decision is not supported by substantial
evidence and must be remanded for further consideration. See id.
15 IV. CONCLUSION
For the foregoing reasons, I deny the Commissioner’s motion
to affirm (Doc. No. 12) and grant Smith’s motion to reverse
(Doc. No. 9). Pursuant to sentence four of 42 U.S.C. § 405(g), I
remand the case to the Social Security Administration for
further proceedings consistent with this Memorandum and Order.
SO ORDERED.
/s/ Paul J. Barbadoro Paul J. Barbadoro United States District Judge
November 13, 2019
cc: Janine Gawryl, Esq. Michael L. Henry, Esq.