LAURA FASHING, Magistrate Judge.
THIS MATTER comes before the Court on plaintiff Casey Ray Vienna's Motion to Reverse and Remand for a Rehearing with Supportive Memorandum (Doc. 15), which was fully briefed on April 1, 2019. See Docs. 19, 20, 21. The parties consented to my entering final judgment in this case. Docs. 4, 7, 8. Having meticulously reviewed the entire record and being fully advised in the premises, I find that the Administrative Law Judge ("ALJ") impermissibly "picked and chose" among the moderate mental limitations noted by non-examining state agency psychologist Dr. Sheri Simon. I therefore GRANT Mr. Vienna's motion and remand this case to the Commissioner for further proceedings consistent with this opinion.
The standard of review in a Social Security appeal is whether the Commissioner's final decision
"Substantial evidence is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Langley, 373 F.3d at 1118. A decision "is not based on substantial evidence if it is overwhelmed by other evidence in the record or if there is a mere scintilla of evidence supporting it." Id. While the Court may not reweigh the evidence or try the issues de novo, its examination of the record as a whole must include "anything that may undercut or detract from the ALJ's findings in order to determine if the substantiality test has been met." Grogan v. Barnhart, 399 F.3d 1257, 1262 (10th Cir. 2005). "`The possibility of drawing two inconsistent conclusions from the evidence does not prevent [the] findings from being supported by substantial evidence.'" Lax v. Astrue, 489 F.3d 1080, 1084 (10th Cir. 2007) (quoting Zoltanski v. F.A.A., 372 F.3d 1195, 1200 (10th Cir. 2004)).
To qualify for disability benefits, a claimant must establish that he or 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); 20 C.F.R. §§ 404.1505(a), 416.905(a).
When considering a disability application, the Commissioner is required to use a five-step sequential evaluation process. 20 C.F.R. §§ 404.1520, 416.920; Bowen v. Yuckert, 482 U.S. 137, 140 (1987). At the first four steps of the evaluation process, the claimant must show: (1) the claimant is not engaged in "substantial gainful activity"; (2) the claimant has a "severe medically determinable . . . impairment . . . or a combination of impairments" that has lasted or is expected to last for at least one year; and (3) the impairment(s) either meet or equal one of the Listings
Mr. Vienna was born in 1991, graduated from high school in 2009, and worked as a grocery store sacker, landscaper, and construction supervisor. AR 66, 221, 267.
The ALJ found that Mr. Vienna met the insured status requirements of the Social Security Act through June 30, 2019. AR 14. At step one, the ALJ found that Mr. Vienna had not engaged in substantial, gainful activity since August 1, 2014, his alleged onset date. Id. At step two, the ALJ found that Mr. Vienna's degenerative disc disease status post surgery, depression, right knee damage, and obesity were severe impairments. Id. The ALJ found that Mr. Vienna's hypertension was a non-severe impairment. Id. At step three, the ALJ found that none of Mr. Vienna's impairments, alone or in combination, met or medically equaled a Listing. AR 15-16. Because the ALJ found that none of the impairments met a Listing, the ALJ assessed Mr. Vienna's RFC. AR 16-22. The ALJ found Mr. Vienna had the RFC to
AR 16-17.
At step four, the ALJ found that Mr. Vienna could not perform any of his past relevant work. AR 22-23. The ALJ found Mr. Vienna not disabled at step five because he could perform jobs that exist in significant numbers in the national economy, such as warehouse checker and router dispatcher. AR 23-24. On July 27, 2017, Mr. Vienna requested that the Appeals Council review the ALJ's unfavorable decision. AR 218. On June 22, 2018, the Appeals Council denied the request for review. AR 1-6. Mr. Vienna timely filed his appeal to this Court on August 16, 2018. Doc. 1.
Mr. Vienna raises three arguments for reversing and remanding this case: (1) the ALJ impermissibly "picked and chose" among the moderate mental limitations noted by non-examining state agency psychologist Dr. Sheri Simon; (2) the ALJ's RFC is flawed because it fails to include a function-by-function assessment of Mr. Vienna's work-related abilities as required by SSR 96-8p; and (3) the ALJ's RFC is not supported by substantial evidence because the ALJ failed to adequately consider his statements about pain. See Doc. 15 at 2, 14-24.
Because the Court remands based on the ALJ's failure to properly analyze the opinion of Dr. Simon, the Court does not address the other alleged errors, which "may be affected by the ALJ's treatment of this case on remand." Watkins v. Barnhart, 350 F.3d 1297, 1299 (10th Cir. 2003).
Although an ALJ need not discuss every piece of evidence, the ALJ must discuss the weight assigned to each medical source opinion. Keyes-Zachary v. Astrue, 695 F.3d 1156, 1161 (10th Cir. 2012). Specifically, when assessing a plaintiff's RFC, an ALJ must explain what weight is assigned to each opinion and why. SSR 96-5p, 1996 WL 374183, at *5 (July 2, 1996).
In 2007, the Tenth Circuit Court of Appeals decided two cases that control here. First, in Haga, the court held that an ALJ erred in failing to explain why he adopted some of a consultative examiner's ("CE") restrictions but rejected others. 482 F.3d at 1208. "[T]he ALJ did not state that any evidence conflicted with [the CE's] opinion or mental RFC assessment. So it is simply unexplained why the ALJ adopted some of [the CE's] restrictions but not others." Id. The court remanded the case "so that the ALJ [could] explain the evidentiary support for his RFC determination." Id. Later in 2007, in Frantz v. Astrue, 509 F.3d 1299, 1302-03 (10th Cir. 2007), the Tenth Circuit expressly applied Haga and its reasoning to the opinions of non-examining physicians.
Mr. Vienna argues that the ALJ failed to account for all the moderate limitations in non-examining state agency consultant Dr. Simon's Mental Residual Functional Capacity Assessment ("MRFCA"). Doc. 15 at 14-19. Specifically, he argues that the ALJ failed to account for the moderate limitations Dr. Simon found in his abilities
Id. at 16. The Commissioner argues that the ALJ's RFC assessment is consistent with Dr. Simon's Section III findings,
An ALJ is required to consider and discuss both Section I and Section III findings.
Under Haga and Frantz, the ALJ has a duty to explain why he adopted some of Dr. Simon's limitations while rejecting others. When an ALJ relies solely on a doctor's Section III narrative, this Court must analyze whether the Section III narrative "adequately encapsulates" the moderate limitations in Section I of the doctor's opinion. See Carver, 600 F. App'x at 619. In other words, the Court must determine whether the ALJ adequately accounted for the limitations noted by Dr. Simon in the RFC assessment. If not, the Court must determine whether the ALJ adequately explained why he rejected the missing limitations.
In Section I of her May 5, 2015 MRFCA, Dr. Simon found that Mr. Vienna had the following moderate limitations:
AR 104-05.
In Section III of the MRFCA (under the heading "Rating") Dr. Simon found that:
AR 105.
The ALJ discussed Dr. Simon's opinion
AR 22. The ALJ found that Mr. Vienna had a mental RFC which limited him "to performing simple, routine tasks and only occasionally responding appropriately to the public. The claimant's time off task can be accommodated by normal breaks." AR 16-17.
The ALJ essentially adopted Dr. Simon's Section III finding that Mr. Vienna was limited to unskilled work by limiting him to "simple, routine tasks." The ALJ noted that there was a conflict between Dr. Simon's Section I and Section III findings in relation to social interaction limitations and adopted Dr. Simon's Section I finding of a moderate limitation in the "ability to interact appropriately with the general public" by limiting Mr. Vienna to "only occasionally responding appropriately to the public." AR 17, 104. The ALJ offered no other reasons for giving Dr. Simon's opinion "partial weight," and noted no other conflicts between Dr. Simon's Section I and Section III findings.
The Commissioner argues that "the ALJ fully accounted for all of Dr. Simon's mental limitations in the RFC by limiting [Mr. Vienna] to simple, routine work with limited interaction with the public." Doc. 19 at 16. Alternatively, the Commissioner argues that the ALJ found Dr. Simon's opinion "internally inconsistent" and only gave it partial weight, which excused the ALJ from explaining why he adopted some portions of Dr. Simon's opinion but not others.
The ALJ did not address at least two moderate mental limitations in Section I of Dr. Simon's opinion.
The Commissioner argues that an ALJ does not "need to expressly incorporate all of the limitations from Section I" into the RFC, and that "it is sufficient if the Court can conclude the ALJ accounted for the Section I limitations" in the RFC. Doc. 19 at 14.
The Tenth Circuit has held that moderate limitations in concentration, persistence and pace may be accounted for in an RFC that restricts a claimant to performing simple tasks or unskilled work. See Lee v. Colvin, 631 F. App'x 538, 541-42 (10th Cir. 2015) (unpublished). But this is not always the case. "A limitation to `simple work' or `unskilled jobs' is generally insufficient to address a claimant's mental impairments." Groberg v. Astrue, 505 F. App'x 763, 770 (10th Cir. 2012) (unpublished) (citing Chapo, 682 F.3d at 1290 n.3 (a restriction to "simple work" is a vague catch-all term which is insufficient to adequately account for mental limitations)). The Commissioner argues that "moderate" could mean "anything between a full ability to perform an activity and an inability to usefully perform the activity." Doc. 19 at 14-15. The Court is not persuaded. "[A] moderate impairment is not the same as no impairment at all." Haga, 482 F.3d at 1208. Thus, "moderate limitations must be accounted for in the RFC finding." Jaramillo v. Colvin, 576 F. App'x 870, 876 (10th Cir. 2014) (unpublished).
In this case, unlike Vigil, the claimant's moderate mental limitations are not adequately addressed by an RFC limiting him to unskilled work, or by any of the limitations the ALJ included in his RFC. Dr. Simon assessed Mr. Vienna with moderate limitations in his ability to "maintain regular attendance, and be punctual within customary tolerances," and in his "ability to complete a normal workday and workweek without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods." These are mental abilities needed for any job. POMS DI 25020.010(B)(2)(a). These mental abilities are also "critical for performing unskilled work." POMS DI 25020.010(B)(3)(e), (i). These requirements "are usually strict." Id. Because these abilities are a general requirement for all jobs, the ALJ must address these limitations in formulating Mr. Vienna's RFC. See Bowers v. Astrue, 271 F. App'x 731, 733-34 (10th Cir. 2008) (unpublished) (noting that a moderate limitation in another ability required for all jobs—the ability to respond appropriately to changes in a routine work setting—could decrease the ability to perform simple or unskilled work because it is a general work requirement). Thus, unlike Vigil, which discussed a limitation in the ability to do complex tasks—a mental ability not required to perform unskilled work—the moderate limitations at issue in this case are critical to the performance of unskilled work. The ALJ therefore erred by not incorporating these limitations into Mr. Vienna's RFC or explaining his reasons for rejecting them.
The ALJ erred in failing to incorporate or to explain why he rejected at least two moderate limitations assessed by Dr. Sheri Simon into Mr. Vienna's RFC. The ALJ failed to either incorporate or explain why he rejected the moderate limitation in Mr. Vienna's ability to perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances, and the moderate limitation in his ability to complete a normal workday and workweek without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods. The Court remands so that the ALJ can remedy these errors.
with Rush v. Saul, 389 F.Supp.3d 957, 969 (D.N.M. 2019):
See also Mills v. Berryhill, No. 16cv573 CG, 2017 WL 3149414, at *10 (D.N.M. June 9, 2017) ("In Smith, the Tenth Circuit held the ALJ's RFC adequately incorporated all of the claimant's functional limitations, and the Tenth Circuit did not base its holding on the fact that the ALJ relied on Section III rather than Section I. 821 F.3d at 1269.").
20 C.F.R. §§ 404.1545(c), 416.945(c); see also SSR 96-8p, 1996 WL 374184, at *6 ("Work-related mental activities generally required by competitive, remunerative work include the abilities to: understand, carry out, and remember instructions; use judgment in making work-related decisions; respond appropriately to supervision, co-workers and work situations; and deal with changes in a routine work setting."). In formulating the RFC, an ALJ must perform a function-by-function assessment of these work-related functions, considering all of the relevant evidence in the case record. SSR 96-8p, 1996 WL 374184, at *2. The Tenth Circuit has held that where a claimant is found to have more than mild mental limitations in work-related functions, the ALJ must "express those impairments `in terms of work-related functions' or `[w]ork-related mental activities.'" Jaramillo v. Colvin, 576 F. App'x 870, 876 (10th Cir. 2004) (unpublished) (quoting SSR 96-8p, 1996 WL 374184, at *6).