T. LANE WILSON, District Judge.
Plaintiff Natalie Cook seeks judicial review of the decision of the Commissioner of the Social Security Administration denying her claim for disability insurance benefits under Title II of the Social Security Act ("SSA"), 42 U.S.C. §§ 416(i), 423. In accordance with 28 U.S.C. § 636(c)(1) & (3), and Fed. R. Civ. P. 73, the parties have consented to proceed before a United States Magistrate Judge. (Dkt. 13). Any appeal of this decision will be directly to the Tenth Circuit Court of Appeals.
In reviewing a decision of the Commissioner, the Court is limited to determining whether the Commissioner has applied the correct legal standards and whether the decision is supported by substantial evidence.
Plaintiff, then a forty-six year old female, completed her application for Title II benefits on March 28, 2012. (R. 102-03). Plaintiff alleged a disability onset date of March 4, 2011. (R. 102). Plaintiff claimed that she was unable to work due to problems with her "back left arm, both knees; low back; left arm and finger numbness and tingling; bilateral knee pain; [and] bilateral foot arch pain." (R. 116). Later, plaintiff alleged that increased back pain, depression, and anxiety also keep her from working. (R. 163). Plaintiff's claims for benefits were denied initially on May 21, 2012, and on reconsideration on October 8, 2012. (R. 52, 58-61; 53, 64-66). Plaintiff then requested a hearing before an administrative law judge ("ALJ"), and the ALJ held the hearing on April 22, 2013. (R. 31-50). The ALJ found that plaintiff was unable to perform her past relevant work as a certified nurse aid, but that other jobs existed in significant numbers that plaintiff could perform. Therefore, the ALJ issued a decision on May 22, 2013, denying benefits and finding plaintiff not disabled. (R. 11-25). The Appeals Council denied review, and plaintiff appealed. (R. 1-4; Dkt. 2).
The ALJ found that plaintiff's last insured date was December 31, 2015. The ALJ found that plaintiff had not performed substantial gainful activity since her alleged onset date of March 4, 2011. (R. 16). At step two, the ALJ found that plaintiff had the severe impairments of "status post lumbar surgeries, obesity, depression and anxiety."
At step three, the ALJ determined that plaintiff's impairments did not meet or equal a listed impairment. (R. 16). After reviewing plaintiff's testimony, the medical evidence, and other evidence in the record, the ALJ concluded that plaintiff retained the RFC to:
(R. 18-19). At step four, the ALJ found that plaintiff was unable to perform her past relevant work as a certified nurse aide because it exceeded the sedentary exertional level. (R. 23). At step five, the ALJ found that plaintiff could perform the sedentary jobs of touch-up screener, and addresser. (R. 24). Because he found that other work existed that plaintiff could perform, the ALJ determined that plaintiff was not disabled.
Plaintiff began treatment at Grand Lake Mental Health Center and was seen regularly from October 5, 2012 through at least April 10, 2013, when Dr. Miller and Mr. Byrd completed the medical source statement in question. (R. 370-405, 410-12, 425-27). Plaintiff complained of symptoms of obsessive compulsive disorder, panic, increased withdrawal, increased crying, anhedonia, negative thought patterns, increased irritability, and poor appetite.
In December 2012, plaintiff complained that Effexor was not curbing her depression, so Dr. Miller doubled the dosage to 150 mg. (R. 370). By March 2013, plaintiff reported the increased dosage was helping her depression. (R. 410). She reported "feeling sad less often," getting out of bed, showering, and "accomplish[ing] tasks throughout the day."
In connection with her disability claim, plaintiff submitted a Medical Source Opinion of Ability to do Work-Related Activities (Mental) to Grand Lake Mental Health Center. Dr. Miller and Mr. Byrd completed and signed this form on April 10, 2013. (R. 425-27).
Dr. Miller opined that plaintiff suffered moderate limitation in the following areas: the ability to remember locations and work like procedures, the ability to understand and remember detailed instructions, the ability to maintain attention and concentration for extended periods in order to perform both simple and detailed tasks, the ability to adhere to a schedule and maintain regular attendance, the ability to perform at a consistent pace without an unreasonable number or length of rest periods, the ability to handle normal work stress, and the ability to accept instructions and criticism from supervisors. (R. 425-26). Dr. Miller further opined that plaintiff suffered marked limitation in the ability to work in close proximity to others without being distracted, the ability to interact appropriately with the public, and the ability to work with others without causing distractions.
After the ALJ posed the hypothetical which he ultimately adopted as plaintiff's RFC to the vocational expert, he allowed plaintiff's attorney to question the vocational expert. Plaintiff's attorney asked "if any of the limitations expressed in [Exhibit] 19F, . . . would those marked limitations preclude competitive employment?" (R. 48). The vocational expert responded that the marked limitation in the ability to work with others without causing distraction "would eliminate employment."
(R. 49).
On appeal, plaintiff raises three issues: (1) the ALJ failed to properly consider the treating physician's opinion; (2) the ALJ's credibility determination was faulty, and (3) the ALJ's step five finding is not supported by substantial evidence.
Plaintiff argues that the ALJ failed to properly weigh the opinion of Dr. Peteryne Miller at Grand Lake Mental Health Center. (Dkt. 17). Specifically, plaintiff argues that the ALJ failed to explain "why he rejected some of the doctor's restrictions while adopting others."
Ordinarily, a treating physician's opinion is entitled to controlling weight when 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." 20 C.F.R. § 404.1527(d)(2);
The analysis of a treating physician's opinion is sequential. First, the ALJ must determine whether the opinion qualifies for "controlling weight" by determining whether it is wellsupported by medically acceptable clinical and laboratory diagnostic techniques and whether it is consistent with the other substantial evidence in the administrative record.
However, even if the ALJ finds the treating physician's opinion is not well-supported by medically acceptable clinical and laboratory diagnostic techniques or is inconsistent with the other substantial evidence in the record, treating physician opinions are still entitled to deference and must be evaluated in reference to the factors enumerated in 20 C.F.R. § 404.1527. Those factors are as follows:
Here, the ALJ assigned "some" weight to Dr. Miller's opinion
The ALJ's discussion of plaintiff's mental health records is limited to three pages of medication check notes with a registered nurse at Grand Lake Mental Health Center after Dr. Miller doubled plaintiff's depression medication. (R. 22, 410-12). The ALJ did not discuss any of plaintiff's other treatment notes from Grand Lake Mental Health Center. (R. 370-405). The ALJ then noted that "[t]he evidence in this record indicates that when properly medicated, the claimant's psychiatric symptoms decreased to a manageable level, not contradictory with the residual functional capacity above." (R. 22). It is unclear from the ALJ's discussion how all of the records from Grand Lake combined lead to this conclusion.
When weighing Dr. Miller's opinion at step four, the ALJ said that he "assign[ed] some weight to the opinion at Exhibit 19F, but the limitations are almost all based on self-report. However, the report indicates that the claimant would be able to work, as long as she does not have to interact with others."
In this case, the ALJ does not say that he specifically rejected Dr. Miller's opinion, but he also fails to discuss how he reached the conclusion that Dr. Miller's opinion is entitled to "some" weight and that the opinion "indicates that the claimant would be able to work, as long as she does not have to interact with others." (R. 22). The ALJ's decision does not explain why he accepted some of Dr. Miller's limitations (all of which are noted to be based on plaintiff's selfreporting) but rejected others.
This issue must be remanded for the ALJ to properly weigh Dr. Miller's treating source opinion.
Plaintiff argues that the ALJ's improper consideration of Dr. Miller's opinion infects the RFC analysis. (Dkt. 17). The Commissioner argues that the ALJ properly formulated plaintiff's RFC based on the "limitations supported by substantial evidence in the record." (Dkt. 20 at 7).
At step four, the ALJ must determine plaintiff's residual functional capacity, which reflects the most a claimant can do despite her limitations.
When discussing the "paragraph B" criteria at step two, the ALJ relied in part on Dr. Miller's opinion to find that plaintiff experienced "moderate difficulties" in social functioning.
Additionally, the ALJ failed to explain adequately his disagreement with the vocational expert, who indicated that plaintiff's marked limitation would prevent her from working. The ALJ's stated reason for disagreeing with the vocational expert follows:
(R. 23). The form to which the ALJ is referring states that plaintiff experiences a marked limitation in her ability to work with others without causing distractions because plaintiff "reported experiencing panic attacks and compulsive counting," that plaintiff suffers a moderate limitation in her ability to accept criticism from supervisors because plaintiff "reported experiencing increased irritability" (R. 426), and that plaintiff experiences a marked limitation in her ability to work closely to others without being distracted because she "reported experiencing difficulty with unfamiliar people." (R. 425). When presented with Dr. Miller's opinion, the vocational expert testified that plaintiff's marked limitation in her ability to work with others without causing distractions would preclude competitive employment. (R. 48). The form lists distinctly separate limitations which address plaintiff's ability to relate to and/or interact with supervisors and co-workers. The ALJ does not explain why he interprets these limitations differently than the vocational expert, only that he does.
To summarize, at step two the ALJ appears to accept Dr. Miller's opinion of marked limitations in plaintiff's ability to interact appropriately with the public and to work with others without causing distractions. The ALJ also appears to accept Dr. Miller's opinion that plaintiff has a moderate limitation in her ability to accept instruction and criticism from supervisors. Two of those accepted opinions have an associated RFC limitation: the marked limitation in plaintiff's ability to interact appropriately with the public, and the moderate limitation in plaintiff's ability to accept instruction and criticism from supervisors. Yet, the ALJ does not explain how these combined limitations become a moderate limitation. Nor does the ALJ adequately explain his reason for rejecting the vocational expert's application of the marked limitation to plaintiff's ability to work. Had the ALJ managed either of these tasks, there would be no error on this issue. He did not.
Therefore, this issue must be remanded for the ALJ to properly explain the evidence supporting his RFC determination.
Plaintiff argues that the ALJ failed to assess properly her credibility by using boilerplate language and by taking evidence out of context.
This Court is not to disturb an ALJ's credibility findings if they are supported by substantial evidence because "[c]redibility determinations are peculiarly the province of the finder of fact."
The ALJ's use of boilerplate language in the credibility determination is not error as to plaintiff's physical limitations because the ALJ linked his findings to contrasting evidence in the record. (R. 20-22). However, plaintiff is correct that the ALJ mishandled her credibility analysis regarding her mental impairments.
The ALJ must link his credibility findings to the evidence.
The ALJ summarized plaintiff's testimony and the medical record, noting instances of inconsistency with plaintiff's claims of disability. The ALJ only discussed one exhibit from plaintiff's mental health records. (R. 22). That exhibit showed some improvement after plaintiff's medication was doubled. However, there are other treatment records that show the opposite, and the ALJ did not discuss them. (R. 370-405). Further, the Court has already determined that the ALJ's weighing of plaintiff's treating physician's opinion (as to her mental health) was improper and that the ALJ's RFC determination is not sufficient. Because the ALJ did not properly analyze the mental health evidence, this portion of the ALJ's credibility determination must be remanded as well.
For the foregoing reasons, the ALJ's decision finding plaintiff not disabled is
SO ORDERED.