SCOTT T. VARHOLAK, Magistrate Judge.
This matter is before the Court on Plaintiff Robert A. Nappi's Complaint seeking review of the Commissioner of Social Security's decision denying Plaintiff's application for disability insurance benefits ("DIB") under Title II of the Social Security Act ("SSA"), 42 U.S.C. § 401 et seq. [#1] The parties have both consented to proceed before this Court for all proceedings, including the entry of final judgment, pursuant to 28 U.S.C. § 636(c) and D.C.COLO.LCivR 72.2. [#14] The Court has jurisdiction to review the Commissioner's final decision pursuant to 42 U.S.C. § 405(g). This Court has carefully considered the Complaint [#1], the Social Security Administrative Record [#10], the parties' briefing [##17-19], and the applicable case law, and has determined that oral argument would not materially assist in the disposition of this appeal. For the following reasons, the Court
The Social Security Act defines disability as the inability "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."
"The Commissioner is required to follow a five-step sequential evaluation process to determine whether a claimant is disabled." Hackett v. Barnhart, 395 F.3d 1168, 1171 (10th Cir. 2005). The five-step inquiry is as follows:
See 20 C.F.R. § 404.1520(a)(4); Grogan v. Barnhart, 399 F.3d 1257, 1261 (10th Cir. 2005); Bailey v. Berryhill, 250 F.Supp.3d 782, 784 (D. Colo. 2017). The claimant bears the burden of establishing a prima facie case of disability at steps one through four, after which the burden shifts to the Commissioner at step five to show that the claimant retains the ability to perform work in the national economy. Wells v. Colvin, 727 F.3d 1061, 1064 n.1 (10th Cir. 2013); Lax, 489 F.3d at 1084. "A finding that the claimant is disabled or not disabled at any point in the five-step review is conclusive and terminates the analysis." Ryan v. Colvin, 214 F.Supp.3d 1015, 1018 (D. Colo. 2016) (citing Casias v. Sec'y of Health & Human Servs., 933 F.2d 799, 801 (10th Cir. 1991)).
In reviewing the Commissioner's decision, the Court's review is limited to a determination of "whether the Commissioner applied the correct legal standards and whether her factual findings are supported by substantial evidence." Vallejo v. Berryhill, 849 F.3d 951, 954 (10th Cir. 2017) (citing Nguyen v. Shalala, 43 F.3d 1400, 1402 (10th Cir. 1994)). "With regard to the law, reversal may be appropriate when [the Commissioner] either applies an incorrect legal standard or fails to demonstrate reliance on the correct legal standards." Bailey, 250 F. Supp. 3d at 784 (citing Winfrey v. Chater, 92 F.3d 1017, 1019 (10th Cir.1996)).
"Substantial evidence is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion. It requires more than a scintilla, but less than a preponderance." Wall v. Astrue, 561 F.3d 1048, 1052 (10th Cir. 2009) (quoting Lax, 489 F.3d at 1084). "Evidence is not substantial if it is overwhelmed by other evidence in the record or constitutes mere conclusion." Grogan, 399 F.3d at 1261-62 (quoting Musgrave v. Sullivan, 966 F.2d 1371, 1374 (10th Cir. 1992)). The Court must "meticulously examine the record as a whole, including anything that may undercut or detract from the [Commissioner's] findings in order to determine if the substantiality test has been met.'" Flaherty v. Astrue, 515 F.3d 1067, 1070 (10th Cir. 2007) (quotation omitted). The Court, however, "will not reweigh the evidence or substitute [its] judgment for the Commissioner's." Hackett, 395 F.3d at 1172.
Plaintiff was born in 1964. [AR 133]
Plaintiff suffers from several physical ailments.
In addition to these physical ailments, Plaintiff also suffers from PTSD, depression, polysubstance abuse disorder, and anxiety disorder. [AR 17] Plaintiff's PTSD was the result of his military service and time in Vietnam. [AR 45-46] Records from the Denver Veterans Affairs Medical Center ("VAMC") characterize Plaintiff's PTSD as "chronic." [AR 209, 217, 222] Plaintiff received mental health treatment at the VAMC in 2012 and 2013. [AR 300-12] In treatment, Plaintiff endorsed flashbacks and hyperarousal symptoms, and explained that he was "always wary and on guard." [AR 307] He explained that he was "guilt ridden from his covert operations" [id.], and he wept while talking about his combat experience [AR 309]. He indicated that he self-medicated with drugs and alcohol [AR 306], and the medical records reflect a history of alcohol and drug abuse, including marijuana and cocaine usage [AR 207, 221, 303]. A mental health evaluation note from November 14, 2012 indicates that Plaintiff exhibited symptoms of a major mental illness. [AR 307]
Plaintiff's application for DIB was initially denied on August 25, 2015. [AR 75] On September 4, 2015, Plaintiff filed a request for a hearing before an ALJ. [AR 78] A hearing was held before ALJ Scott Bryant on June 27, 2017, at which Plaintiff and vocational expert ("VE") Martin Rauer both testified. [AR 29-63, 189] Plaintiff was represented by counsel. [AR 29-55]
On September 28, 2017, the ALJ issued a decision denying Plaintiff benefits. [AR 15-25] Plaintiff timely requested a review of that decision by the Appeals Council [AR 9], which denied his request for review on January 19, 2018 [AR 1-3]. Plaintiff timely filed an appeal with this Court on March 20, 2018. [#1] Because the Appeals Council denied Plaintiff's appeal, the ALJ's decision is the final decision of the Commissioner for purposes of this appeal. See 20 C.F.R. § 404.981.
The ALJ denied Plaintiff's applications for DIB after evaluating the evidence pursuant to the five-step sequential evaluation process. [AR 15-25] At step one, the ALJ determined that Plaintiff had not engaged in substantial gainful activity between June 1, 2011, the alleged onset date, and March 31, 2014, the date of last insured. [AR 17] At step two, the ALJ found that Plaintiff had the following severe impairments: degenerative disc disease, degenerative changes of the hip, peripheral neuropathy, and fibrosis of the liver with associated hepatitis C. [AR 17-19] At step three, the ALJ concluded that Plaintiff does not have an impairment or combination of impairments that meets or medically exceeds the severity of one of the listed impairments in the appendix of the regulations. [AR 20]
Following step three, the ALJ determined that Plaintiff retained the RFC to perform "medium work" as defined in 20 C.F.R. § 404.1567(c), but with the following limitations:
[Id. (emphasis omitted)]
At step four, the ALJ found that Plaintiff could perform past relevant work as a construction worker as he performed that job. [AR 24] In reaching that conclusion, the ALJ agreed with the VE's testimony that "someone with [Plaintiff's] vocational profile and [RFC] would be capable of performing [Plaintiff's] past relevant work as a construction worker as that job was actually performed." [Id.] Accordingly, the ALJ determined that Plaintiff was not under a disability from June 1, 2011 through March 31, 2014, the date of last insured. [AR 25]
Plaintiff raises two challenges to the ALJ's decision on appeal. First, Plaintiff contends that the ALJ erred by failing to consider all of Plaintiff's medically determinable impairments, particularly his mental health impairments, in the RFC analysis. [#17 at 4-8] Second, Plaintiff argues that the ALJ erred by relying on his own determinations in assessing Plaintiff's mental health when further development of the record was required. [Id. at 8-10] Because the Court agrees that the ALJ erred by failing to consider Plaintiff's mental health impairments at stage four of the analysis, and that such failure requires reversal and remand, the Court does not reach Plaintiff's alternative argument.
As explained above, at step two, the Commissioner determines whether a claimant has any severe physical or mental impairments. Williams v. Bowen, 844 F.2d 748, 750 (10th Cir. 1988). "To find a `severe' impairment at step two requires only a threshold showing that the claimant's impairment has `more than a minimal effect on [her] ability to do basic work activities.'" Covington v. Colvin, 678 F. App'x 660, 664 (10th Cir. 2017) (quoting Williams, 844 F.2d at 751). When evaluating the severity of mental impairments, the Commissioner follows a two-part analysis. Wells, 727 F.3d at 1068 (citing 20 C.F.R. §§ 404.1520a(a), 416.920a(a)). First, the ALJ must decide whether the claimant has a medically determinable mental impairment. Id. (citing 20 C.F.R. §§ 404.1520a(b)(1), 416.920a(b)(1)). Next, the ALJ "must . . . rate the degree of the functional limitation resulting from" any such impairments "in four broad functional areas:" understand, remember or apply information; interact with others; concentrate, persist, or maintain pace; and adapt or manage oneself. Id.; 20 C.F.R. §§ 404.1520a(c)(3), 416.920a(c)(3).
Here, at step two, the ALJ concluded that Plaintiff's medically determinable mental impairments included PTSD, depression, polysubstance abuse disorder, and anxiety disorder. [AR 17] The ALJ concluded that these mental impairments caused: (1) no limitation in memory, understanding, or applying information; (2) mild limitation in Plaintiff's ability to interact with others; (3) mild limitation in concentration, persistence, or completing tasks; and (4) no limitation in Plaintiff's ability to adapt or manage himself. [AR 19] In reaching that conclusion, the ALJ gave "great weight" to the opinion of the state agency psychologist, who reviewed the file and opined that Plaintiff had "mild limitation in sustaining concentration, persistence and pace and social functioning, and no limitation in any other area of functioning." [AR 18] At step two, the ALJ concluded that Plaintiff's mental impairments "did not cause more than minimal limitation in the claimant's ability to perform basic mental work activities and were therefore non[-]severe." [AR 17-18]
That conclusion at step two, however, should not have ended the ALJ's analysis of Plaintiff's mental impairments. Even if the ALJ ultimately finds "that a claimant's medically determinable mental impairments are `not severe,'" he generally must "further consider and discuss them as part of his [RFC] analysis at step four." Wells, 727 F.3d at 1064 (citing 20 C.F.R. §§ 404.1545(a)(2), 416.945(a)(2)). In other words, "the Commissioner's procedures do not permit the ALJ to simply rely on his finding of non-severity as a substitute for a proper RFC analysis."
Here, the ALJ's analysis violated this prohibition. Following step two, the ALJ's only mention of Plaintiff's mental impairments is in a paragraph summarizing Plaintiff's history of medical impairments:
[AR 21] But, the ALJ did not discuss how Plaintiff's PTSD and polysubstance abuse disorder impacted the RFC, and did not even mention Plaintiff's depression and anxiety disorder. "Without any discussion of Plaintiff's [mental impairments] in [his] RFC, the court cannot conclude that the ALJ properly considered th[ese] impairment[s], singly and in combination with [Plaintiff's] other impairments, thereby necessitating remand of this matter to the ALJ."
The Commissioner argues that the ALJ "considered [Plaintiff's PTSD] in addition to Plaintiff's physical impairments to find that he could perform a reduced range of medium work that could be learned in one year or less and to find that Plaintiff could return to his former job as a foreman." [#18 at 5] Similarly, the Commissioner argues that the ALJ's finding of "mild limitation" does not necessarily equate to a specific functional limitation in the RFC finding. [Id. at 7] The problem, however, is that the ALJ does not provide any explanation for how he concluded that Plaintiff's mild limitations did not impact the RFC, such that Plaintiff could perform a reduced range of medium work. And although the Court does not demand "technical perfection" by the Commissioner, the ALJ's decision must allow the Court to "follow the adjudicator's reasoning . . . and [ ] determine that correct legal standards have been applied." Keyes-Zachary v. Astrue, 695 F.3d 1156, 1166 (10th Cir. 2012). The ALJ's decision does not allow the Court to conduct such an analysis, and therefore the Court must reverse the ALJ's decision.
Plaintiff requests that the Court "[f]ind that plaintiff is entitled to disability benefits under the provisions of the [SSA]." [#17 at 10] "Outright reversal and remand for immediate award of benefits is appropriate when additional fact finding would serve no useful purpose." Sorenson v. Bowen, 888 F.2d 706, 713 (10th Cir. 1989) (quotation omitted). Where, as here, "the record on appeal is unclear as to whether the ALJ applied the appropriate standard by considering all the evidence before him, the proper remedy is reversal and remand." Baker v. Bowen, 886 F.2d 289, 291 (10th Cir. 1989). The Court thus declines Plaintiff's request that the Court find he is entitled to benefits.
Accordingly, for the foregoing reasons,