Sacilowski v. Saul ( 2020 )


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  •           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
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    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.
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    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.
    - 23 -