Court Opinion

ID: 4534852
Source: CourtListenerOpinion
Date Created: 2020-05-15 21:00:14.901883+00
Date Added: 2024-06-11T09:27:27.749097
License: Public Domain

United States Court of Appeals
                     For the First Circuit

No. 19-1712

                       AMANDA SACILOWSKI,

                      Plaintiff, Appellee,

                               v.

          ANDREW SAUL, COMMISSIONER OF SOCIAL SECURITY,

                      Defendant, Appellant.

          APPEAL FROM THE UNITED STATES DISTRICT COURT
                FOR THE DISTRICT OF RHODE ISLAND

    [Hon. John J. McConnell, Jr., Chief U.S. District Judge]

                             Before

                     Thompson, Stahl, and Barron,
                            Circuit Judges.

     Aaron L. Weisman, U.S. Attorney, with whom Michael J. Pelgro,
Regional Chief Counsel, Social Security Administration, and Lisa
G. Smoller, Special Assistant U.S. Attorney, Social Security
Administration, Office of the General Counsel, were on brief, for
appellant.
     Stephen P. Maguire was on brief for appellee.

                          May 15, 2020
           THOMPSON, Circuit Judge.          Andrew M. Saul, Commissioner

of Social Security, appeals the district court's order 1) finding

that Amanda Sacilowski is disabled as defined under 20 C.F.R.

§ 404.1520 and therefore 2) awarding her benefits.               Both parties

rely heavily on this court's decision in Seavey v. Barnhart, 276

F.3d 1 (1st Cir. 2001); the Commissioner to argue that like in

Seavey, the court should remand the case as "essential factual

issue[s] ha[ve] not been resolved."          Id. at 11.     While Sacilowski

contends no factual issues need further resolution, and that this

is the "unusual case" the court in Seavey described "where the

proof of disability is overwhelming or where the proof is very

strong and there is no contrary evidence," such that an award of

benefits would be proper.      Id.   We now review the record on a clean

slate to determine whether there is "overwhelming" or "very strong"

evidence   of     Sacilowski's   disability,      without    any     "contrary

evidence," id., to justify an award of benefits.                 We find that

there is, and so we affirm.

                                 BACKGROUND

           "The    Social   Security    Administration      is   the    federal

agency   charged    with    administering     both   the    Social     Security

disability benefits program, which provides disability insurance

for covered workers, and the Supplemental Security Income program,

which provides assistance for the indigent aged and disabled."

Id. at 5 (citing 42 U.S.C. §§ 423, 1381a).             A claimant seeking

                                     - 2 -
disability benefits must prove that she is unable "to engage in

any   substantial    gainful    activity    by   reason   of    any   medically

determinable physical or mental impairment which can be expected

to result in death or which has lasted or can be expected to last

for a continuous period of not less than 12 months."                  42 U.S.C.

§§ 423(d)(1)(A); see also § 1382c(a)(3)(A).                 Once a claimant

applies for benefits, the Social Security Act provides that the

Commissioner's      factual    determinations     of   an      entitlement   to

benefits "shall be conclusive" if the findings are "supported by

substantial evidence."        42 U.S.C. § 405(g).

            Sacilowski was 34 years old when she filed applications

for Social Security Disability Benefits and Supplemental Security

Income on June 23, 2015.        She is a high school graduate and has

not worked since 2012.         Before that, she worked as a customer

service representative for two different banks and then for a

children's retail company, the latter of which required her to

answer calls and retrieve certain physical items from inventory on

occasion.    She was released from that last job due to her health

issues.

            The Commissioner denied Sacilowski's applications, and

on January 20, 2016, Sacilowski requested that an Administrative

Law Judge ("ALJ") make an independent assessment of her claim.               An

ALJ employs a five-step test to determine if an individual is

disabled within the meaning of the Social Security Act.               20 C.F.R.

                                    - 3 -
§ 416.920.         The test asks questions that are sequential and

iterative, such that the answer at each step determines whether

progression to the next is warranted:            (Step 1) whether the

claimant is currently engaging in substantial gainful activity; if

not, (Step 2) whether the claimant has a severe impairment; if so,

(Step 3) whether the impairment meets or medically equals an entry

in the Listing of Impairments; if not, (Step 4) whether the

claimant's residual functional capacity ("RFC") is sufficient to

allow her to perform any of her past relevant work; and if not,

(Step 5) whether, in light of the claimant's RFC, age, education,

and work experience, she can make an adjustment to other work

available     in    the   national    economy.    See   20   C.F.R.   §§

404.1520(a)(4)(i)-(v), 416.920(a)(4)(i)-(v) (2012).          A claimant

bears the burdens of production and persuasion at steps one through

four.   Freeman v. Barnhart, 274 F.3d 606, 608 (1st Cir. 2001).       At

step five, the Commissioner must come forward with evidence of

jobs in the national economy that the claimant is able to perform.

Id. (citing Arocho v. Sec'y of Health & Human Servs., 670 F.2d

374, 375 (1st Cir. 1982)).

             At the ALJ hearing on September 30, 2016, Sacilowski,

Sacilowski's husband, and an impartial Vocational Expert ("VE")

testified.     Sacilowski spoke about her background, work history,

and medical conditions preventing her from working.          The latter

focused on her migraine headaches and bladder ailments.               She

                                     - 4 -
explained that she experienced two to three migraines a week and

described the incapacity her migraines generated and the treatment

she was receiving at the time.         As to her bladder ailments, she

testified about the pain she experienced while urinating, the

treatment she received for the pain, and that starting about three

to four months before the hearing, she was urinating so frequently

that she kept a "commode at the foot of [her] bed just in case she

[couldn't] make it up the stairs to use the restroom [at home]."

           Sacilowski's husband corroborated her testimony.          The VE

then explained that someone with Sacilowski's impairments could

work in jobs involving "light cleaning," "sales," and "general

office" work.     He then testified about the ramifications of

frequent   absenteeism   on   the   ability   to   hold   down   "full-time

competitive employment":

           [ALJ]: And if a hypothetical Claimant is
           unable to tolerate customary work pressure,
           this would be with absences of at least four
           times per month, would that restriction, would
           that rule out all full-time competitive
           employment?
           [VE]: Yes, it would.
           [ALJ]: What would be the cut off for
           absenteeism that's accepted by the employers.
           [VE]: Once a month, and that's problematic in
           terms of maintaining a job.
           [ALJ]: And if someone's unable to sit, stand
           or walk for eight hours total over an eight
           hour work day, obviously that precludes full-
           time employment is that correct?
           [VE]: Correct, Your Honor.
           [ALJ]: And if someone had to lay down with
           their legs up to at least waist level between
           two and four hours in an eight hour work day,

                                    - 5 -
             and then be off-task in that time period,
             would that preclude full-time competitive
             employment?
             [VE]: Yes, it would.

Before   rendering     a   decision,   the   ALJ   also   reviewed   various

documents:       Sacilowski's earnings records and work history, her

medical records ranging from 2013 to 2016, including multiple

records from her treating physician, Dr. Wilson, and the state

agency physicians' evaluations of the record evidence.1

             Ultimately, the ALJ concluded that Sacilowski's bladder

ailments were "non-severe" at Step 2, because they had "been

managed with medication with no ongoing, secondary functional

limitations that would cause more than a minimal effect on her

ability to perform basic, work-related tasks for a period of twelve

months or more." He found Sacilowski's migraines (and fibromyalgia

and depression) to be "severe" impairments (Step 2), but that these

"severe" impairments did not "meet the severity listing" of a

listed impairment, and so Sacilowski had the RFC to perform a

limited range of light work (Step 3), as defined by 20 C.F.R. §§

404.1567(b) and 416.967(b),2 although not any past relevant work

(Step 4).

             1
             We offer more on these documents later in the
discussion   when   we  detail   the  evidence   of   Sacilowski's
impairments.
          2 The Commissioner conceded that the ALJ erred at Step 3

when he determined that Sacilowski's migraines could not meet the

                                   - 6 -
             The ALJ therefore moved onto Step 5, and relying on the

VE's testimony about what jobs would be available to someone with

Sacilowski's impairments, determined that Sacilowski could perform

certain jobs in the national economy, such as cleaning, sales, or

general office work.         The ALJ noted that even though Sacilowski's

"medically determinable impairments could reasonably be expected

to produce the . . . alleged symptoms . . . ,[her] statements

concerning the intensity, persistence and limiting effects of

these   symptoms    are   not   entirely      consistent    with   the   medical

evidence and other evidence in the record."                 Therefore the ALJ

agreed with the Commissioner's decision to deny benefits, finding

that Sacilowski was not disabled as defined under the Social

Security   Act     between    March     25,   2015,   the   alleged   onset    of

disability, to December 20, 2016, the date of the ALJ decision

("Relevant Time Period").

             Sacilowski requested review of the ALJ's decision by the

Appeals Council, which the Appeals Council denied.                 This cleared

the way for Sacilowski to file a complaint on January 2, 2018 in

federal court challenging the ALJ's findings.

             District Court Judge McConnell referred the case to

Magistrate    Judge   Almond,     who    reviewed     Sacilowski's    motion   to

severity of an already-listed impairment.    Because our decision
will remedy any impact of this error, we need not address it.

                                      - 7 -
reverse the Commissioner's decision and the Commissioner's motion

to affirm, and then held a hearing during which he asked each

side's      attorney   to      present    their    two    strongest         arguments.

Sacilowski's        attorney     explained       that    his     client's      bladder

condition was still developing and worsening at the time of the

ALJ hearing, and there wasn't enough medical evidence in the record

to make a proper decision on its severity.                     He also argued that

the ALJ should have found that the frequency and severity of

Sacilowski's migraines would cause Sacilowski to be absent from

work at least once a month, and therefore preclusive of full-time

employment, as explained by the VE to the ALJ.                    What underscored

both these arguments was Sacilowski's attorney's complaint that

the ALJ did not give Dr. Wilson's opinions enough weight.                       On the

other side, the Commissioner argued that there was support in the

record to render Sacilowski's bladder ailments not severe and that

the ALJ was correct to find that Sacilowski's migraines were stable

and would not interfere with her ability to do the work suggested

by the VE.     The Commissioner also noted that Dr. Wilson's opinion

was unreliable as inconsistent with his treatment notes.

             With    this,     the   magistrate     judge      issued   a    Report    &

Recommendation ("R&R") finding that substantial evidence did not

support the ALJ's denial of benefits, and therefore recommended

reversing the Commissioner's decision and remanding the case to

the   ALJ     for   further      development      of    the     facts   related       to

                                         - 8 -
Sacilowski's medical impairments, in particular her migraines and

bladder condition, and their impact on Sacilowski's potential

absenteeism.     The magistrate judge found that the ALJ had "not

directly address[ed] Dr. Wilson's opinion regarding [Sacilowski's]

probable   absenteeism,        or   [her]    self-reports      and   the   medical

records documenting multiple migraine headaches per week," and

although the ALJ "discuss[ed] some of this evidence," he "never

directly addresse[d] the credibility of the reported frequency or

the impact of such migraines on [Sacilowski's] attendance and

ability to sustain fulltime employment."               To that end, he noted

that although the "state agency consulting physicians had access

to the majority of medical records documenting [Sacilowski's]

migraine history, they completed a physical RFC assessment that

did not specifically assess the issue of absenteeism."                      As to

Sacilowski's bladder ailments, the magistrate judge found that the

ALJ's determination that they were "non-severe" was based on

opinions from state agency physicians rendered on October 20, 2015

and   January    6,    2016,    even    though    it   was    "undisputed     that

[Sacilowski's]        bladder       issues     required      ongoing   treatment

throughout 2016."        He therefore recommended that the "updated

medical evidence should be further evaluated by a medical expert

to determine if the bladder conditions meet the Step 2 severity

threshold and duration requirement, and for further consideration

                                       - 9 -
of   the   functional      limitations        arising     out     of   [Sacilowski's]

urinary issues."

            On March 29, 2019, Sacilowski filed a limited objection

to the magistrate judge's R&R, requesting that benefits "be awarded

on the record as it stands," or "that the remand order include a

direction    that     it   be   assigned       to    a    different     ALJ."       The

Commissioner filed no objection.

            This next went to the district court, which agreed with

the magistrate judge's findings, but diverted on the final outcome,

where it bypassed the need for further fact-finding and instead on

April 8, 2019, found Sacilowski "disabled and awarded benefits."

The Commissioner filed a motion for reconsideration; the district

court denied this, stating that the record and law fully supported

its finding in favor of Sacilowski.                      The Commissioner timely

appealed,    asking    this     court    to    reverse      the    district   court's

judgment and order that reversed the Commissioner's decision and

awarded     Sacilowski        benefits,        and       "remand[]      for     further

administrative proceedings."

            After oral argument in this appeal, we remanded the case

to the district court for elaboration on its findings, to enable

our "meaningful appellate review," Supermercados Econo, Inc. v.

Integrand Assurance Co., 375 F.3d 1, 3 (1st Cir. 2004), and the

district court entered a fleshed out order on February 12, 2020.

The district court explained that the ALJ had

                                        - 10 -
             failed to adequately account for limitations
             related to [Sacilowski's] migraines and
             bladder problems in her [RFC] Assessment.
             Specifically, the ALJ failed to address the
             issue of absenteeism by [Sacilowski] due to
             the frequency and impact of migraines on her
             as documented by her treating primary care
             physician   [who]    .   .   .   opined   that
             [Sacilowski's] symptoms would be severe enough
             to cause more than four absences from work per
             month and the Vocational Expert . . .
             testified at a hearing before the ALJ that
             absences of four times a month would rule out
             full-time competitive employment.      Without
             good cause, the [ALJ] did not give substantial
             weight to this evidence. A remand was thus
             unnecessary as the evidence before the ALJ
             established that [Sacilowski] was disabled and
             entitled to benefits.

Order at 2, Sacilowski v. Saul, No. 18-CV-0001-JJM-LDA (D.R.I.

Feb. 12, 2020).      The parties submitted supplemental briefs in

response to this district court order.

             On appeal, the parties do not dispute that a remand is

necessary.      But they dispute what should happen upon remand:

whether, as the Commissioner argues, the ALJ should be required to

conduct further fact-finding into Sacilowski's alleged disability,

or, as Sacilowski urges, the Commissioner should award Sacilowski

benefits for the Relevant Time Period.     The Commissioner contends

that the district court did not have the "overwhelming evidence"

needed to support a finding of disability and award benefits, and

therefore unresolved factual issues warrant further development on

remand.   In particular, he argues that "there [i]s conflicting

evidence in the record regarding Sacilowski's migraines," evidence

                                - 11 -
on   the   severity   of   the   bladder     ailments   requires   "further

development," and Dr. Wilson's opinion contained "little specific

support or explanation for his extreme opinion."

            Sacilowski     responds   that     there    was   "overwhelming

evidence" to support the award of benefits and seeks affirmance of

the district court's order.3      Sacilowski relies on testimony from

the ALJ hearing, Dr. Wilson's opinions, and medical reports on her

migraines and bladder ailments.        Sacilowski argues that the ALJ

erred in finding that she could work despite the severity and

frequency of her migraines and her bladder ailments were not severe

based on the outdated RFC determinations.

                            STANDARD OF REVIEW

            We now dig into the parties' arguments and the full

record before us, reviewing the district court's reversal de novo,

and "use the same standard to review the correctness of the

Commissioner's decision as does the district court:                that is,

whether the final decision is supported by substantial evidence

and whether the correct legal standard was used."              Seavey, 276

F.3d at 9 (citing 42 U.S.C. § 405(g)); see also Ward v. Comm'r of

Social Security, 211 F.3d 652, 655 (1st Cir. 2000).           We

            3
            Sacilowski argues, in the alternative, that if this
court remands for further fact-finding by an ALJ, it should
reassign the case to a different ALJ.      Because we affirm the
district court's award of benefits, this point is moot.

                                  - 12 -
            determin[e] whether the ALJ deployed the
            proper legal standards and found facts upon
            the proper quantum of evidence[;] . . . [t]he
            ALJ's findings of fact are conclusive when
            supported by substantial evidence, 42 U.S.C.
            § 405(g), but are not conclusive when derived
            by ignoring evidence, misapplying the law, or
            judging matters entrusted to experts.

Nguyen v. Chater, 172 F.3d 31, 35 (1st Cir. 1999) (citation

omitted).

            Under the Social Security Act, courts are empowered "to

enter, upon the pleadings and transcript of the record, a judgment

affirming,    modifying,   or    reversing   the   decision   of   the

Commissioner of Social Security, with or without remanding the

cause for a rehearing."    42 U.S.C. § 405(g); Seavey, 276 F.3d at

8-9; Garrison v. Colvin, 759 F.3d 995, 1019 (9th Cir. 2014)

("[E]very Court of Appeals has recognized that in appropriate

circumstances courts are free to reverse and remand a determination

by the Commissioner with instructions to calculate and award

benefits" (awarding benefits and citing Seavey and comparable

cases from other circuits)).       "Courts have generally exercised

this power when it is clear from the record that a claimant is

entitled to benefits."       Garrison, 759 F.3d at 1019; see also

Seavey, 276 F.3d at 11-12.

                                OUR TAKE

            We find that there is ample evidence in the record,

particularly related to the severity and frequency of her migraine

                                 - 13 -
headaches and worsening bladder ailments,4 to render Sacilowski

disabled for the Relevant Time Period and justify an award of

benefits.

            We start with the migraine headaches.             To the ALJ,

Sacilowski testified that she experienced migraine headaches two

to three times a week and upon onset they lasted "a day and a half

or so" and caused her to "stay in [her] room . . . put something

over [her] eyes, [and] lie down" each time.            She explained that

they became so severe that, towards the end of 2014, she had been

prescribed Botox injections for relief.           And Sacilowski's medical

records confirm this.      They show that she was experiencing chronic

migraines as early as March 2014.               At an appointment with a

neurologist      in   September   2014,   she   reported   severe   migraine

headaches that occurred "20-25x per month . . . [sometimes]

multiple headaches in the same day, but sometimes one per day,"

and "about 4x per month" they could last from "a few hours up to

3 days," and would leave her immobilized.          Her severe migraines at

that time were accompanied by nausea and sensitivity to light and

exertion.       Her medical records confirm that in January 2015, she

was receiving Botox shots for her migraines, but they were yet to

            4While we find the severity and frequency of
Sacilowski's migraine headaches on their own enough to render
Sacilowski disabled during the Relevant Time Period, we include a
discussion of her deteriorating bladder ailments which were
progressively making her overall condition worse during the same
time frame.

                                   - 14 -
be effective.    As of July 21, 2015, Dr. Griffith, a neurologist,

noted that Sacilowski was experiencing three to four migraines per

week and that "she had Botox in May and it [had] helped some."

Dr. Griffith shared this finding with Dr. Wilson, Sacilowski's

treating physician, describing the migraines as "frequent, chronic

and refractory."      On August 12, 2015, Sacilowski followed up with

Dr. Wilson and reported that her migraines were "down since

starting    Botox,"    and   Dr.    Wilson    described    her    migraines   as

"stable."    As of February 16, 2016, she reported to Dr. Wilson

that her "migraines [were] about the same, meds had been adjusted,

still getting [B]otox per routine at neuro."               On March 23, 2016,

neurologist Dr. Gordon noted that Sacilowski's "headaches seem to

get better for about two and half months after Botox, but the last

two weeks [had] been quite difficult for her with migraines every

day," and in fact she had a migraine on the day of that visit to

Dr.   Gordon.    And    in   a     report    on   August   3,    2016,   another

neurologist, Dr. Hickey, noted that the Botox "helps [Sacilowski]

– gets headache 2-3 migraines a week on this" and that the

"headaches had not changed in quality."

            Sacilowski also testified to the ALJ about her bladder

ailments,   including    difficult-to-manage         frequency     and   urgency

related to, and pain while, urinating.              She testified that she

endured "bladder injections" every two weeks for the pain from Dr.

Rardin, a urogynecologist, who had been treating her since March

                                     - 15 -
2016.     And her medical records confirm not only this testimony,

but that her bladder ailments were plaguing her as early as May

2015. On a visit to Dr. Wilson on May 14, 2015, Sacilowski reported

that she was "urinating more than normal" and that she had "pain

in her front lower abdomen" before urinating, and "pain while

urinating," all of which she had been experiencing "for about a

year" at that point.       Sacilowski's bladder leakage worsened over

the course of 2016, occurring up to one to two times per day:

Records from August 4, August 17, and September 15, 2016 show this.

They also show that her bladder injections had started on August

4, 2016, that she had three of these procedures over the course of

six weeks, and that she was still on occasion unable to reach the

bathroom in time for relief.

            The   record   also   includes   multiple    reports   from   Dr.

Wilson,    Sacilowski's    treating   physician,   who    coordinated     her

treatment with other physicians, such as neurologists for her

migraines and urologists for her bladder issues.              The various

medical reports from Dr. Wilson in the record also indicate that

he reviewed and was familiar with Sacilowski's family, social, and

medical history; medication list; allergy history; and problem

list.

            The record also contains Dr. Wilson's answers to four

separate medical questionnaires from February 13, August 19, May

15, and November 14, 2014.        Though these fall before the Relevant

                                   - 16 -
Time Period, they evince Sacilowski's progressively deteriorating

condition and resultant inability to work.5                They indicate mild to

significant functional limitations as early as February 2014,

including but not limited to the following activities for which

limitations persisted through all four questionnaires: "standing," "walking,"

"sitting,"    "handling/feeling/manipulating,"     "ability    to    perform    at    a

consistent pace," "ability to maintain concentration," and "ability to

perform      activities    within    a     schedule   and     maintain       regular

attendance."       Dr.    Wilson    also    opined    in    these    forms     as    to

Sacilowski's     ability    to    "engage    in   employment,       education,       or

skills training," finding that in February 2014 she could engage

in such activity for "[less than] 10" hours per week and "[less

than] 4" hours per day.          By November 2014, these numbers were down

to "0-2" hours per week and per day.              And on September 1, 2016,

Dr. Wilson completed a physical capacity questionnaire in which he

made the following findings:          Sacilowski could sit for one to two

hours and stand and walk up to 15 minutes each in an eight-hour

day; Sacilowski would need to lie down for two to four hours in an

eight-hour day; and Sacilowski would miss more than four days of

             5
             The Commissioner contends that because "Dr. Wilson
concluded that Sacilowski's symptoms had only existed at the
severity indicated in his opinion since August 1, 2016," his
opinion cannot support an award of benefits for the entire Relevant
Time Period. But Dr. Wilson's earlier answers to the 2014 medical
questionnaires make clear that Sacilowski's condition was
debilitating   even   before   the  Relevant   Time   Period,   and
deteriorating throughout it.

                                      - 17 -
work a month.      According to this questionnaire, these "symptoms

and limitations" applied as early as August 1, 2016.        And recall

that the VE testified to the ALJ that regular absences of even

once   a   month   would    likely   preclude   full-time   competitive

employment.

           The Commissioner does not provide any evidence to rebut

any of the foregoing.      The record contains no evidence to directly

contradict Sacilowski's testimony about her ailments and their

frequency and severity, nor the medical reports supporting them.

The Commissioner argues that there is "conflicting evidence in the

record regarding Sacilowski's migraines," and that "there is also

evidence suggesting that Sacilowski's migraines were not disabling

during the [Relevant Time Period]."        But the "evidence" he cites

is unpersuasive.      He argues that "Sacilowski's physicians []

concluded in July 2015, March 2016, and August 2016 that Botox had

reduced the frequency of her migraines," but does not provide any

evidence that a reduction in frequency mitigated the severity of

the migraines, nor their debilitating effects.        The Commissioner

also claims that the "state agency physicians, who considered

Sacilowski's impairments including migraines, found she could

perform a range of light work and did not specify a need for

absences due to migraines or other impairments."       However, and as

the magistrate judge pointed out, there is no indication in the

record that the state agency physicians were ever asked to even

                                  - 18 -
consider    Sacilowski's   impairments'     impact      on   absences.     We

therefore find that the Commissioner has provided no "contrary

evidence," Seavey, 276 F.3d at 11, to directly rebut any of the

multiple pieces of evidence that comprise the substantial and

"overwhelming" evidence, id., of disability in this case.                See,

e.g., Gonzalez Maldonado v. Sec'y of Health & Human Servs., 996

F.2d 1209, *3 (1st Cir. 1993) ("[S]ince there are no contrary

medical reports as to the severity of claimant's mental impairment,

the ALJ's finding that there was no evidence to support allegations

of a significant emotional illness in the relevant period is not

supported by substantial evidence.")

            And as to the bladder issues, the ALJ found the ailment

to   be   "non-severe"   based   on   opinions   from    the   state   agency

physicians rendered on October 20, 2015 and January 6, 2016, before

Sacilowski's bladder condition had significantly worsened, and

ignored other medical reports, available in the record, supporting

her progressively deteriorating bladder ailments.               But even a

finding of non-severity does not relieve an ALJ of his obligation

to consider a non-severe impairment's impact on a claimant's

overall medical condition.       See Stephenson v. Halter, No. Civ. 00-

391-M, 2001 WL 951580, at *2 (D.N.H. Aug. 20, 2001) (finding the

ALJ required to "consider the combined effect of all . . .

impairments without regard to whether any such impairment, if

considered separately, would be of sufficient severity" (quoting

                                  - 19 -
40 C.F.R. § 404.1523)); SSR 96–8p, 1996 WL 374184 at *5 (July 2,

1996)    ("In      assessing         RFC,     the     adjudicator      must      consider

limitations and restrictions imposed by all of an individual's

impairments, even those that are not 'severe.'                             While a 'not

severe' impairment(s) standing alone may not significantly limit

an individual's ability to do basic work activities, it may --

when considered with limitations or restrictions due to other

impairments -- be critical to the outcome of a claim."). Reviewing

the record afresh as we do, we find that Sacilowski's bladder

impairment       would       have    exacerbated       her   overall       and   already-

debilitated        medical          condition,       further    supplementing         the

"overwhelming" evidence of disability here.                     Seavey, 276 F.3d at

11.

             The Commissioner also discredits Dr. Wilson's opinions,

in    particular       the    September      1,     2016   finding    of   absenteeism,

claiming    that       it    was    disconnected      from   Sacilowski's        migraine

headaches        and        otherwise       inconsistent       with    Dr.       Wilson's

determinations that certain of Sacilowski's medical conditions

were "normal."6         But the Commissioner provides no reason why such

             6
            The Commissioner explains:     "For example, in August
2015,   the   doctor   observed    that    Sacilowski's  strength,
coordination, and gait were normal.      Dr. Wilson also found in
February 2016 that Sacilowski's neck and musculoskeletal range of
motion, coordination, and reflexes were normal. Four months later,
the doctor assessed that Sacilowski's neurological examination was
grossly normal.    Moreover, one month before he completed his

                                            - 20 -
findings by Sacilowski's treating physician, combined with Dr.

Wilson's previous absenteeism determinations from 2014, contradict

his 2016 absenteeism finding.          For one, a claimant may have the

capacity to engage in certain daily, "home activities," Garrison,

759 F.3d at 1016, but still be unable to function in a workplace

environment.      See id. ("ALJs must be especially cautious in

concluding that daily activities are inconsistent with testimony

about pain, because impairments that would unquestionably preclude

work and all the pressures of a workplace environment will often

be consistent with doing more than merely resting in bed all

day.").   And Dr. Wilson's longtime familiarity with Sacilowski and

her ailments allows us to find that his absenteeism determination

reinforces the already-"overwhelming" evidence of disability in

this case.    See Purdy v. Berryhill, 887 F.3d 7, 13 (1st Cir. 2018)

("The relevant legal standard for a claim filed before March 27,

2017   (as    [Sacilowski's]    was)    is     the   rule    that    a   treating

physician's opinion is controlling if it is 'well-supported by

medically acceptable clinical and laboratory diagnostic techniques

and is not inconsistent with the other substantial evidence in

[the] case record.' And even if not deemed controlling, a treating

physician's    opinion   is    entitled   to    weight      that    reflects   the

physician's opportunity for direct and continual observation."

opinion, Dr. Wilson concluded that Sacilowski's gait appeared
normal, and her neurological examination was grossly normal."

                                   - 21 -
(quoting     20   C.F.R.         § 416.927(c)(2))           (second      alteration      in

original)).

            Finally, the Commissioner disregarded "Sacilowski's own

allegations [as] not enough to establish disability," but he gives

us neither any evidence to directly rebut Sacilowski's testimony

(which was corroborated by her husband), nor any reason to question

its credibility, and so we take her statements as true.                           See Da

Rosa v. Sec'y of Health & Human Servs., 803 F.2d 24, 26 (1st Cir.

1986) (finding that an ALJ's decision to discredit testimony "must

be supported by substantial evidence and the ALJ must make specific

findings as to the relevant evidence he considered in determining

to disbelieve the [claimant]"); Nguyen, 172 F.3d at 35–36; see

also Garrison, 759 F.3d at 1019 ("[W]here there are no outstanding

issues     that   must      be     resolved      before       a     proper     disability

determination       can    be    made,    and   where       it    is   clear    from    the

administrative record that the ALJ would be required to award

benefits if the claimant's excess pain testimony were credited, we

will not remand solely to allow the ALJ to make specific findings

regarding    that    testimony.           Rather,      we    will      . . .   take    that

testimony to be established as true." (quoting Varney v. Sec'y of

Health & Human Servs., 859 F.2d 1396, 1401 (9th Cir. 1988)).

            Having        reviewed       the    full    record,         comprising      the

transcript of the ALJ hearing, the ALJ's decision, the full

administrative record that includes employment and medical records

                                         - 22 -
from   2013    through   September    9,   2016,   the   transcript   of   the

magistrate judge hearing, the magistrate judge's R&R, and the

district court's orders, we find that the severity and frequency

of Sacilowski's migraine headaches and bladder ailments would have

caused her to be absent from work at least once a month during the

Relevant Time Period, which, according to the VE's testimony, would

have precluded full-time competitive employment.               We therefore

find that there is "overwhelming" evidence in the record to support

a finding of disability and an award of benefits, see Seavey, 276

F.3d at 11-12; see also Holohan v. Massanari, 246 F.3d 1195, 1210

(9th Cir. 2001) ("[A] remand for further proceedings is unnecessary

if the record is fully developed and it is clear from the record

that the ALJ would be required to award benefits."); Davis v.

Shalala, 985 F.2d 528, 534 (11th Cir. 1993) ("This court . . .

[may] remand the case for an entry of an order awarding disability

benefits where the Secretary has already considered the essential

evidence and it is clear that the cumulative effect of the evidence

establishes disability without any doubt."); Garrison, 759 F.3d at

1023, and so we affirm the district court's order.

              Costs to Appellee.

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