Blackburn, United States District Judge.
The matter before me is plaintiff's
Plaintiff alleges that she is disabled as a result of depression, anxiety, right upper extremity tendonitis, and epicondylitis. After her application for disability insurance benefits was denied, plaintiff requested a hearing before an administrative law judge. This hearing was held on June 16, 2011. At the time of the hearing, plaintiff was 42 years old. She has high school education and past work experience as a sales attendant, assembler, and brazer assembler. She has not engaged in substantial gainful activity since March 22, 2007, her alleged date of onset.
The ALJ found that plaintiff was not disabled and therefore not entitled to disability
A person is disabled within the meaning of the Social Security Act only if her physical and/or mental impairments preclude her from performing both her previous work and any other "substantial gainful work which exists in the national economy." 42 U.S.C. § 423(d)(2). "When a claimant has one or more severe impairments the Social Security [Act] requires the [Commissioner] to consider the combined effects of the impairments in making a disability determination." Campbell v. Bowen, 822 F.2d 1518, 1521 (10th Cir.1987) (citing 42 U.S.C. § 423(d)(2)(C)). However, the mere existence of a severe impairment or combination of impairments does not require a finding that an individual is disabled within the meaning of the Social Security Act. To be disabling, the claimant's condition must be so functionally limiting as to preclude any substantial gainful activity for at least twelve consecutive months. See Kelley v. Chater, 62 F.3d 335, 338 (10th Cir.1995).
The Commissioner has established a five-step sequential evaluation process for determining whether a claimant is disabled:
20 C.F.R. § 404.1520(b)-(f). See also Williams v. Bowen 844 F.2d 748, 750-52 (10th Cir.1988). The claimant has the initial burden of establishing a disability in the first four steps of this analysis. Bowen v. Yuckert, 482 U.S. 137, 146 n. 5, 107 S.Ct. 2287, 2294 n. 5, 96 L.Ed.2d 119 (1987). The burden then shifts to the
Review of the Commissioner's disability decision is limited to determining whether the ALJ applied the correct legal standard and whether the decision is supported by substantial evidence. Hamilton v. Secretary of Health and Human Services, 961 F.2d 1495, 1497-98 (10th Cir. 1992); Brown v. Sullivan, 912 F.2d 1194, 1196 (10th Cir.1990). Substantial evidence is evidence a reasonable mind would accept as adequate to support a conclusion. Brown, 912 F.2d at 1196. It requires more than a scintilla but less than a preponderance of the evidence. Hedstrom v. Sullivan, 783 F.Supp. 553, 556 (D.Colo. 1992). "Evidence is not substantial if it is overwhelmed by other evidence in the record or constitutes mere conclusion." Musgrave v. Sullivan, 966 F.2d 1371, 1374 (10th Cir.1992). Further, "if the ALJ failed to apply the correct legal test, there is a ground for reversal apart from a lack of substantial evidence." Thompson v. Sullivan, 987 F.2d 1482, 1487 (10th Cir. 1993). Although a reviewing court should meticulously examine the record, it may not reweigh the evidence or substitute its discretion for that of the Commissioner. Id.
Plaintiff alleges that the ALJ improperly assessed the medical source opinions of record with respect to her physical impairments, failed to adequately develop the record with respect to her mental impairments, and improperly discredited her subjective reports of pain. Although I find no reversible error with respect to the ALJ's assessment of plaintiff's physical residual functional capacity, I conclude that the ALJ erred in failing to order a consultative examination to substantiate her determination of plaintiff's mental residual functional capacity, and therefore reverse.
With respect to her physical residual functional capacity, plaintiff argues that the ALJ improperly failed to consider the opinion of plaintiff's treating doctor that plaintiff was capable of sedentary work and that she further failed to explain the apparent discrepancy between the lifting and handling restrictions she imposed and the opinion of a consultative examiner. Assuming arguendo that error occurred in these respects, the fact remains that one of the jobs identified by the vocational expert and relied on by the ALJ to support her step 5 determination was sedentary and required no handling. (See Tr. 20, 51 (discussing job of surveillance system monitor).) Although plaintiff maintains that remand is still required to assess whether this job exists in significant numbers, see Trimiar v. Sullivan, 966 F.2d 1326, 1330 (10th Cir.1992), there was no reversible error in this regard, see Bernal v. Bowen, 851 F.2d 297, 303 (10th Cir.1988). While plaintiff focuses myopically on the relatively low number of such jobs in Colorado, the Tenth Circuit has made clear that "the
However, with respect to the ALJ's assessment of plaintiff's mental residual functional capacity, I do perceive reversible error. The record clearly contains evidence suggesting that plaintiff suffers from and has received treatment for anxiety and depression (see Tr. 356-371, 403-420), and the ALJ herself concluded that these impairments constituted severe impairments (see Tr. 12). Based on the language of the Social Security Act itself, the Tenth Circuit has held that
Andrade v. Secretary of Health and Human Services, 985 F.2d 1045, 1049 (10th Cir.1993) (citing 42 U.S.C. § 421(h)). Although the regulations allow the ALJ to complete the documents required to properly assess mental impairments herself,
The ALJ noted plaintiff's request that she order a consultative examination based on the recommendation of consultative examiner Dr. Benjamin Loveridge, at the conclusion of his assessment of plaintiff's physical capacities, to "[r]efer specific psychiatric recommendations to the appropriately trained mental health specialist." (Tr. 395.) In this same document, however, Dr. Loveridge also stated that he "[w]ould recommend no psychiatric evaluation." (Tr. 395.) The ALJ seized on this latter statement, together with Dr. Loveridge's
In so doing, the ALJ erred. The ALJ has a duty, even where a claimant is represented by counsel, to adequately develop the record. See Hawkins v. Chater, 113 F.3d 1162, 1164 (10th Cir.1997); Henrie v. United States Department of Health & Human Services, 13 F.3d 359, 360-61 (10th Cir.1993). The very ambiguity in Dr. Loveridge's recommendations regarding whether a psychiatric evaluation was indicated suggests at the very least that the ALJ should have sought clarification of his opinion. See 20 C.F.R. § 1519p(b). See also Social Security Ruling 96-5p, 1996 WL 374183 at *6 (SSA July 2, 1996).
Moreover, although Dr. Loveridge's medical specialty is not apparent from the record, his suggestion that plaintiff be referred "to the appropriately trained mental health specialist" clearly implies that he is not such a specialist himself. In light of that fact, the ALJ's reliance on Dr. Loveridge's suggestion that no mental health evaluation was necessary is extraordinarily tenuous. Likewise, the bare statement that plaintiff scored "28/30 with 2 points off for recall" on a "mini mental status exam" is too slender a reed on which to conclude that plaintiff had no significant mental limitations as a result of her mental impairments. The record contains nothing describing the test or its purpose or otherwise outlining the parameters thereof. It therefore is not at all apparent what plaintiff's score on this test indicates about her mental capacity to do work-related activity.
It appears that the ALJ may have felt confident in denying the request to further develop the record due to her own assessment of plaintiff's credibility regarding the limitations of her mental impairments. (See Tr. 15-16 (noting that plaintiff's anxiety was well-controlled on medication, that she was noncompliant with repeated recommendations to seek counseling, and that she was able to travel abroad despite her professed anxiety at leaving the house and being in a crowd).) However, the ALJ's own disbelief of a plaintiff's subjective reports, while not irrelevant, is not a sufficient substitute for medical evidence. Although residual functional capacity ultimately is an administrative determination reserved to the Commissioner, 20 C.F.R. § 404.1546; Rutledge v. Apfel, 230 F.3d 1172, 1175 (10th Cir. 2000), "based on all of the relevant medical and other evidence," 20 C.F.R. § 404.1545(a)(3), "including medical records, observations of treating physicians and others, and plaintiff's own description of his limitations," Noble v. Callahan, 978 F.Supp. 980, 987 (D.Kan.1997), the ALJ's determination still must be grounded in some medical evidence, Anderson v. Shalala, 51 F.3d 777, 779 (8th Cir.1995).
Accordingly, substantial evidence does not support the ALJ's decision not to order a consultative examination or otherwise further develop the record regarding the functional limitations occasioned by plaintiff's mental impairments. Remand therefore is required. Although plaintiff requests a directed award of benefits, I
1. That the conclusion of the Commissioner through the Administrative Law Judge that plaintiff was not disabled is
2. That this case is
3. That plaintiff is
Dated March 13, 2014, at Denver, Colorado.
Andrade, 985 F.2d at 1049.