Opinion ID: 781627
Heading Depth: 2
Heading Rank: 1

Heading: The ALJ failed adequately to develop the record.

Text: 13 An ALJ owes a duty to a pro se claimant to help him or her develop the administrative record. When a claimant appears at a hearing without counsel, the ALJ must `scrupulously and conscientiously probe into, inquire of, and explore for all the relevant facts.' Key v. Heckler, 754 F.2d 1545, 1551 (9th Cir.1985) (quoting Cox v. Califano, 587 F.2d 988, 991 (9th Cir.1978)); Dobrowolsky, 606 F.2d at 407 (noting that an ALJ must assume a more active role when the claimant is unrepresented). See generally Ventura v. Shalala, 55 F.3d 900, 902 (3d Cir.1995) (ALJs have a duty to develop a full and fair record in social security cases.). 14 While we do not prescribe any particular procedures that an ALJ must follow, see Vt. Yankee Nuclear Power Corp. v. Natural Res. Def. Council, Inc., 435 U.S. 519, 524-25, 98 S.Ct. 1197, 55 L.Ed.2d 460 (1978), we believe that the procedures the ALJ did follow were insufficient to develop the record in this case. See Miranda v. Sec'y of Health, Educ. & Welfare, 514 F.2d 996, 998 (1st Cir.1975) (ALJ's investigation must be not wholly inadequate under the circumstances.); see also Lashley v. Sec'y of Health & Human Servs., 708 F.2d 1048, 1052 (6th Cir.1983) (courts determine the adequacy of an ALJ's investigation on a case-by-case basis). The ALJ did not follow up on Reefer's testimony about her 1997 stroke, an occurrence of obvious relevance to this disability determination. Upon finding that the medical records before him did not refer to this stroke, the ALJ had a duty to investigate further. See Dobrowolsky, 606 F.2d at 407. For example, he could have requested additional medical records or held another hearing to receive testimony from Reefer's treating physicians about the stroke. The ALJ did not do this and did not even mention Reefer's 1997 stroke in his opinion. While the record is over 700 pages, that it lacks detail about Reefer's stroke makes it inadequate under the circumstances. Miranda, 514 F.2d at 998. 15 Second, while the ALJ found Reefer's statements concerning her impairments and their impact on her ability to work ... not entirely credible, he had an insufficient basis to make this conclusion. We would ordinarily defer to an ALJ's credibility determination because he or she has the opportunity at a hearing to assess a witness's demeanor. See, e.g., Atl. Limousine, Inc. v. NLRB, 243 F.3d 711, 718 (3d Cir.2001). However, the ALJ posed no questions to Reefer that would enable him to make such a credibility determination. He did not ask her, for example, to describe her pain, her daily activities and limitations, how much she can lift, how far she can walk, how long she can sit or stand without discomfort, or whether she has difficulty concentrating. Compare Lashley, 708 F.2d at 1052 (criticizing ALJ when hearing was only 25 minutes long and claimant was only superficially questioned concerning his daily activities and his physical limitations). Rather, the ALJ appeared to base his credibility determination on the fact that Reefer's medical records did not explain why she was experiencing the symptoms she described in her responses to questionnaires. By relying solely on those responses, the ALJ was not able to assess Reefer's demeanor in answering those questions, which could have shed additional light on her credibility. 16 Moreover, Reefer's medical records reflect that she consistently complained to her treating physicians about pain, body tremors leading to stumbling, dizzy spells, nausea, and headaches. Those records also reflect that Reefer underwent a cranial CT scan because she experienced frequent headaches. That scan indicated possible abnormalities. The January 4, 1999 evaluation of Reefer by Dr. Baraff (a neurologist) was inconclusive, but he was unsure whether she might have an intracranial aneurysm, partial seizures, or migraines. Having seen these complaints in the medical record, the ALJ was not at liberty to ignore them. Rather, he had a duty to consider seriously Reefer's subjective complaints of pain and to probe further. See Baerga v. Richardson, 500 F.2d 309, 312 (3d Cir.1974) (In addition to objective medical facts and expert medical opinions, the Hearing Examiner must consider the claimant's subjective evidence of pain and disability, as corroborated by family and neighbors; and all of these factors must be viewed against the applicant's age, educational background and work experience.) (quoting Mode v. Celebrezze, 359 F.2d 135, 136 (4th Cir.1966)). 17 Finally, while the ALJ did request certain of Reefer's medical records, he did not have before him medical records from 1999 as well as correspondence addressed to one of Reefer's treating physicians. These records discuss the surgery to remove pressure from her brainstem as well as her 1999 stroke. That the ALJ did not arrange with Reefer's treating physicians to receive them suggests that his document request was too narrow in scope. We need not decide whether the ALJ's failure to obtain these 1999 records, without more, provides a reason for remand 3 because we believe that remand is otherwise warranted. See Dobrowolsky, 606 F.2d at 408-09 (remanding case to ALJ when Social Security claimant was prejudiced by lack of counsel and ALJ's narrow view of his role). On remand, however, the ALJ should obtain these records. 18 B. The ALJ failed to explain why he credited some evidence and discredited other evidence. 19 The ALJ concluded that the claimant's hypertension has been essentially well-controlled with medication since 1995, with only situational episodic elevation. In so concluding, he insufficiently explained numerous blood pressure readings and treating physicians' comments that suggested otherwise. See Fargnoli v. Massanari, 247 F.3d 34, 42 (3d Cir.2001) (Where there is conflicting probative evidence in the record, we recognize a particularly acute need for an explanation of the reasoning behind the ALJ's conclusions, and will vacate or remand a case where such an explanation is not provided.). For example, a blood pressure reading taken on February 8, 1997 was 160/110. At that time, a physician commented [c]ontrol not good with respect to her hypertension. At the time of an emergency room admission on March 6, 1997, Reefer's pressure was 187/102. On March 24, 1998, her blood pressure was 168/100, and on April 7, 1998, her pressure was 170/100. All these readings are consistent with moderate or severe hypertension. The Merck Manual of Diagnosis and Therapy 1633 (Mark H. Beers & Robert Berkow, ed., 17th ed.1999). The ALJ explained away these readings as merely situational episodic elevation. He neglected, however, to describe what situation caused this elevated blood pressure. This conclusory explanation was especially deficient in light of Reefer's history of hypertension (indeed, the very reason she received SSI benefits beginning in 1989). We therefore do not believe that substantial evidence supports the ALJ's conclusion that Reefer's hypertension is now controlled. To the contrary, these elevated blood pressure readings, considered together with Reefer's medical records as a whole, strongly suggest that her medical condition remained unimproved. 20 Also, in determining Reefer's residual functional capacity for work, the ALJ did not explain why he chose to credit one medical report over another. See Fargnoli, 247 F.3d at 42; Cotter v. Harris, 642 F.2d 700, 705-07 (3d Cir.1981). The ALJ had before him three physicians' reports addressing Reefer's functional limitations. One form, completed by Dr. Stevens on February 8, 1997, states that: (1) Reefer has no physical impairments; (2) she can carry 10 pounds occasionally; (3) she can stand/walk for less than 2 hours; (4) she can sit for less than 6 hours; (5) she can push/pull to an unlimited extent, other than as mentioned in (2) above for carrying; (6) she can climb, balance, stoop, kneel, crouch, and crawl occasionally; (7) she has unlimited ability in the areas of reaching, handling, dexterity, seeing, hearing, and speaking; and (8) she should avoid exposure to moving machinery, temperature extremes, noise, and fumes, odors, and gases. A second form, completed by a state agency physician on March 18, 1997, concluded that Reefer was capable of medium levels of exertion. He found that she could: (1) occasionally lift and/or carry 50 pounds; (2) frequently lift and/or carry 25 pounds; (3) stand and/or walk 6 hours per day; (4) sit about 6 hours a day; and (5) push/pull to an unlimited extent. Finally, a form completed by Dr. Baraff on January 4, 1999 states that: (1) Reefer's impairment does not affect her ability to lift, carry, sit, stand, walk, see, feel, handle, speak, reach, hear, push, or pull; (2) she can climb, stoop, kneel, balance, crouch, and crawl for up to 1/3 of an eight-hour day; and (3) her impairment limits her ability to work in the vicinity of moving machinery or heights. 21 Despite these inconsistent evaluations ( e.g., Dr. Stevens stated that Reefer could carry 10 pounds only occasionally while the state agency physician stated she could carry 50 pounds occasionally and Dr. Baraff said that her carrying ability was unaffected by her impairment), the ALJ concluded that Reefer retains the residual functional capacity to perform the exertional demands of at least light work, or work which requires maximum lifting of 20 pounds and frequent lifting of up to 10 pounds.... The evidence supports a finding that she is able to lift and carry 20 pounds. In so holding, the ALJ disregarded Dr. Stevens's contrary report without explaining why he did so, thereby ignoring our mandate in Fargnoli. Accordingly, remand is required.