Opinion ID: 772905
Heading Depth: 2
Heading Rank: 3

Heading: Step Four Evaluation: Residual Functional Capacity

Text: 20 'Residual functional capacity is defined as that which an individual is still able to do despite the limitations caused by his or her impairment(s).' Burnett v. Comm'r of Soc. Sec. Admin., 220 F.3d 112, 121 (3d Cir. 2000) (quoting Hartranft, 181 F.3d at 359 n.1); see also 20 C.F.R. 404.1545(a). In this case, the ALJ determined that Fargnoli had the residual functional capacity to perform light work. The SSA defines work as light when it 21 involves lifting no more than 20 pounds at a time with frequent lifting or carrying of objects weighing up to 10 pounds. Even though the weight lifted may be very little, a job is in this category when it requires a good deal of walking or standing, or when it involves sitting most of the time with some pushing and pulling of arm or leg controls. To be considered capable of performing a full or wide range or light work, you must have the ability to do substantially all of these activities. 22 20 C.F.R. 404.1567(b). The SSA has further explained that light work generally requires the ability to stand and carry weight for approximately six hours of an eight hour day. Jesurum v. Sec. of Health & Human Servs., 48 F.3d 114, 119 (3d Cir. 1995) (citing Social Security Ruling 83-10). 23 After reviewing the record, we find it impossible to determine whether the ALJ's finding that Fargnoli can perform light work is supported by substantial evidence. We are handicapped by the fact that the ALJ has (1) failed to evaluate adequately all relevant evidence and to explain the basis of his conclusions and (2) failed to explain his assessment of the credibility of, and weight given to, the medical evidence and opinions from Fargnoli's treating physicians that contradict the ALJ's finding that Fargnoli can perform light work. We therefore vacate the decision of the District Court and remand with instruction to remand to the ALJ for further proceedings. 5 24 1. The ALJ Must Evaluate All the Evidence and Explain the Basis for his Conclusions. 25 The ALJ must consider all relevant evidence when determining an individual's residual functional capacity in step four. See 20 C.F.R. 404.1527(e)(2), 404.1545(a), 404.1546; Burnett, 220 F.3d at 121. That evidence includes medical records, observations made during formal medical examinations, descriptions of limitations by the claimant and others, and observations of the claimant's limitations by others. See 20 C.F.R. 404.1545(a). Moreover, the ALJ's finding of residual functional capacity must be accompanied by a clear and satisfactory explication of the basis on which it rests. Cotter v. Harris, 642 F.2d 700, 704 (3d Cir. 1981). In Cotter, we explained that 26 in our view an examiner's findings should be as comprehensive and analytical as feasible and, where appropriate, should include a statement of subordinate factual foundations on which ultimate factual conclusions are based, so that a reviewing court may know the basis for the decision. This is necessary so that the court may properly exercise its responsibility under 42 U.S.C. 405(g) to determine if the Secretary's decision is supported by substantial evidence. 27 Id. at 705 (quoting Baerga v. Richardson, 500 F.2d 309, 312 (3d Cir. 1974)). 28 The ALJ's discussion of the relevant medical evidence in Fargnoli's case was limited to the following four paragraphs: 29 A medical report from [Dr. Zaslow], doctor of osteopathy, dated December 16, 1995, revealed that the claimant complained of increasing pain since his work-related accident in May 1985. Dr. Zaslow stated a computerized tomography scan of the lumbar spine, done on October 19, 1985, indicated degeneration of the L3-4 disc. A thermogram done on October 24, 1985 was reported as normal and showed L4-L5 nerve fiber involvement on the left side. An electromyography performed on October 30, 1985 showed evidence of radiculopathy. A medical report from Dr. Zaslow, dated December 5, 1986, stated that a bone scan performed on January 22, 1986 was completely normal. The claimant stated that he was able to stand for an hour and sit for several hours. 30 A report by [Dr. Karpin], dated December 12, 1986, stated that a magnetic resonance imaging showed abnormal disc intensity between L3-4, and abnormal disc between L-1 and L-2, and to a lesser extent between L-4, 5 and L5-S1. It was reported that the claimant refused to undergo a myelogram to confirm the findings and chose to continue with the conservative treatments for a while longer. Dr. Karpin stated that the claimant has to maintain a 1,000 calorie [diet] to lose weight in order to reduce the pressure on his back. 31 A report by Dr. Zaslow, dated December 4, 1987, stated that the claimant complained about pain over the midline. There was considerable spasm of the back with the inability to flex forward. The claimant stated that he wanted a light duty job, but no light duty work was available for him. 32 A medical report by Dr. Karpin, dated February 22, 1991, stated that the claimant was still having difficulty with his lower back, but was able to cope with the pain and discomfort as long as he took his muscle relaxant and non-steroidal anti-inflammatory. The claimant was maintained on Robaxin, Feldene and physical therapy. 6 33 In the passages quoted above, the ALJ describes four diagnostic tests and five treatment notes. Yet our review of the record reflects over 115 pages of relevant, probative treatment notes from Drs. Zaslow and Karpin detailing Fargnoli's medical condition and progress. The disparity between the actual record and the ALJ's sparse synopsis of it makes it impossible for us to review the ALJ's decision, for we cannot tell if significant probative evidence was not credited or simply ignored. Burnett, 220 F.3d at 121 (quoting Cotter, 642 F.2d at 705). 34 Although we do not expect the ALJ to make reference to every relevant treatment note in a case where the claimant, such as Fargnoli, has voluminous medical records, we do expect the ALJ, as the factfinder, to consider and evaluate the medical evidence in the record consistent with his responsibilities under the regulations and case law. His failure to do so here leaves us little choice but to remand for a more comprehensive analysis of the evidence consistent with the requirements of applicable regulations and the law of this Circuit, both as discussed in more detail below. 35 2. The ALJ Must Assess the Credibility of, and Explain the Weight Given To, Conflicting Medical Evidence by the Claimant's Treating Physicians. 36 This Court has long been concerned with ALJ opinions that fail properly to consider, discuss and weigh relevant medical evidence. See Dobrowolsky v. Califano, 606 F.2d 403, 406-07 (3d Cir. 1979) (This Court has repeatedly emphasized that the special nature of proceedings for disability benefits dictates care on the part of the agency in developing an administrative record and in explicitly weighing all evidence.). 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. See Cotter, 642 F.2d at 706 (listing cases remanded for ALJ's failure to provide explanation of reason for rejecting or not addressing relevant probative evidence). 37 In his opinion the ALJ finds Fargnoli to have a severe back impairment, but not so severe that it prevents him from performing light work that includes frequently lifting ten pounds, occasionally lifting twenty pounds, and standing and walking for six hours out of an eight-hour day. In reaching this finding, the ALJ does not mention the contradictory finding of Dr. Zaslow, nor does he explain his assessment of the credibility of Drs. Zaslow and Karpin or the weight given to their treatment notes and opinions. 38 Under applicable regulations and the law of this Court, opinions of a claimant's treating physician are entitled to substantial and at times even controlling weight. See 20 C.F.R. 404.1527(d)(2); Cotter, 642 F.2d at 704. The regulations explain that more weight is given to a claimant's treating physician because 39 these sources are likely to be the medical professionals most able to provide a detailed, longitudinal picture of [the claimant's] medical impairment(s) and may bring a unique perspective to the medical evidence that cannot be obtained from the objective medical findings alone or from reports of individual examinations, such as consultative examinations or brief hospitalizations. 40 20 C.F.R. 404.1527(d)(2). Where a treating source's opinion on the nature and severity of a claimant's impairment is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in[the claimant's] case record, it will be given controlling weight. Id. 41 Although the ALJ may weigh the credibility of the evidence, he must give some indication of the evidence that he rejects and his reason(s) for discounting that evidence. See Burnett, 220 F.3d at 121; Cotter, 642 F.2d at 705. In Burnett, we determined that the ALJ had not met his responsibilities because he failed to consider and explain his reasons for discounting all of the pertinent evidence before him in making his residual functional capacity determination. 220 F.3d at 121. We therefore remanded the case to the ALJ with instructions to review all of the pertinent medical evidence, explaining any conciliations and rejections. Id. at 122. 42 The record reflects that throughout his treating history Dr. Zaslow consistently found Fargnoli to suffer from a severe and dehabilitating chronic back condition that often requires bed rest or immobilization. Countless treatment notes document Fargnoli's spastic condition, the immobility of his lower back, the radicular pain to his legs and his tenderness to palpitation and manipulation. Fargnoli points out that Dr. Zaslow has opined on twenty-three separate occasions that he is disabled. Dr. Zaslow has restricted Fargnoli to only seven to ten pounds of lifting, no prolonged periods of walking and no climbing, bending or squatting. He has also opined that Fargnoli is incapable of even sedentary work. 43 Although never opining on Fargnoli's vocational restrictions or limitations, Dr. Karpin's clinical findings are consistent with Fargnoli's complaints. Dr. Karpin found that Fargnoli suffers from reduced mobility, spasms and tenderness to palpitation. Further, Dr. Karpin's treatment notes document the sensitivity of Fargnoli's back impairment to changes in the weather and his activity level. Finally, Dr. Karpin noted that, although Fargnoli's chronic condition can be maintained at status quo with continued medication and physical therapy, he will continue to suffer symptoms associated with his back impairment. 44 The ALJ makes no mention of any of these significant contradictory findings, leaving us to wonder whether he considered and rejected them, considered and discounted them, or failed to consider them at all. The ALJ's failure to explain his implicit rejection of this evidence or even to acknowledge its presence was error. Cotter, 642 F.2d at 707. 7 We therefore cannot conclude that his findings at step four were supported by substantial evidence. Moreover, we cannot affirm the ALJ's determination that Fargnoli was not disabled under the Grids because that determination requires that Fargnoli be capable of light exertional work.