KATHLEEN M. TAFOYA, Magistrate Judge.
This matter is before the court on review of the Commissioner's denial of Plaintiff's application for Disability Insurance Benefits ("DIB") pursuant to Title II of the Social Security Act, 42 U.S.C. §§ 401-33 ("the Act"). Jurisdiction is proper under 42 U.S.C. § 405(g).
In January 2011, Plaintiff filed an application for DIB under Title II of the Act. (Administrative Record ["AR"], Doc. No. 10, at 246-47.) Plaintiff initially claimed she became impaired in June 2009 due to headaches, eyestrain, and body aches (id. at 276-77); however, she later amended her alleged onset date to June 17, 2010 (id. at 200) and amended her impairments to include, inter alia, vertigo, depression, and anxiety (id. at 202-206). After the state agency denied her claim (id. at 185-87), Plaintiff requested a hearing before an administrative law judge ("ALJ") (id. at 188-190). A hearing was held on April 23, 2012, at which Plaintiff and an impartial vocational expert ("VE") testified. (Id. at 137-71.)
In May 2012, the ALJ issued a written decision in accordance with the Commissioner's five-step sequential evaluation process.
At step one, the ALJ found that Plaintiff had not engaged in substantial gainful activity from her amended onset date of June 17, 2010 through the last insured date of March 31, 2011. (Id. at 120.) At step two, the ALJ found that Plaintiff suffered from the following severe impairments: obstructive sleep apnea, Type-II diabetes, hypertension, mild bilateral osteoarthritis of the hips, and plantar fasciitis. (Id. at 120-21.) The ALJ concluded that Plaintiff' vertigo, depression and anxiety were non-severe. (Id.) At step three, the ALJ found that through the date last insured, Plaintiff's impairments, while severe, did not meet or medically equal any of the impairments or combinations of impairments listed in the social security regulations. (Id. at 121-22.)
The ALJ then found that, through the date last insured, Plaintiff had the residual functional capacity ("RFC") to
(Id. at 122-127.)
At step four, the ALJ found that, through the date last insured, Plaintiff was capable of performing her past work as a preschool teacher because that work did not require the performance of work-related activities precluded by Plaintiff's RFC. (Id. at 127-28.) Accordingly, the ALJ concluded that Plaintiff was not disabled within the meaning of the Act and, thus, not entitled to DIB. (Id. at 128-29.)
Plaintiff requested review of the ALJ's determination by the Appeals Council. (Id. at 113.) Plaintiff submitted additional evidence for review by the Appeals Council. (Id. at 7-105.) The Appeals Council denied Plaintiff's request to review the ALJ's determination. (Id. at 1-4.) The Appeals Council found that the new evidence submitted by Plaintiff did not affect the ALJ's decision because it post-dated the date Plaintiff was last insured for disability benefits. (Id. at 2.)
Plaintiff filed this action on December 9, 2013. (Compl., Doc. No. 1.) Plaintiff's Opening Brief was filed on May 9, 2014 (Doc. No. 13), the Commissioner's Response Brief was filed on June 11, 2014 (Doc. No. 14), and Plaintiff's Reply Brief was filed on June 24, 2014 (Doc. No. 15). Accordingly, this matter is ripe for the court's review and adjudication. For the following reasons, the Commissioner's determination is REVERSED and REMANDED.
This appeal is based upon the administrative record and briefs submitted by the parties. In reviewing a final decision by the Commissioner, the role of the district court is to examine the record and determine whether it "contains substantial evidence to support the Secretary's decision and whether the Secretary applied the correct legal standard." Ricketts v. Apfel, 16 F.Supp.2d 1280, 1287 (D. Colo. 1998). The ALJ's decision must be evaluated "based solely on the reasons stated in the decision." Robinson v. Barnhart, 366 F.3d 1078, 1084 (10th Cir.2004).
Substantial evidence is evidence a reasonable mind would accept as adequate to support a conclusion. Brown v. Sullivan, 912 F.2d 1194, 1196 (10th Cir. 1990). Substantial evidence requires "more than a scintilla, but less than a preponderance" of the evidence. Gossett v. Bowen, 862 F.2d 802, 804 (10th Cir.1988).
"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). However, the court "must `exercise common sense' in reviewing an ALJ's decision and must not `insist on technical perfection.'" Jones v. Colvin, 514 F. App'x 813, 823 (10th Cir. 2013) (quoting Keyes-Zachary v. Astrue, 695 F.3d 1156, 1166 (10th Cir. 2012)).
Although the court ultimately concludes that remand is warranted in this case, the court first addresses Plaintiff's contention that the ALJ erred in conducting the RFC analysis by giving "no weight" to the opinion of her treating physician, Dr. Candace Sobel, that Plaintiff was disabled when having a vertigo flare.
An RFC assessment is made by the ALJ "based on all the relevant evidence in [the claimant's] case record." 20 C.F.R. § 404.1545(a)(1). The RFC is an assessment of the most a claimant can do despite his or her limitations. Id. An ALJ must make specific RFC findings based on all the relevant evidence in the case record. See Winfrey v. Chater, 92 F.3d 1017, 1023 (10th Cir. 1996); SSR 96-8p, 1996 WL 374184, at *5 (July 2, 1996).
SSR 96-8p, at *7.
There is no dispute that Dr. Sobel, Plaintiff's primary care physician, was a treating physician. A treating physician's opinion must be given controlling weight if it "is supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with other substantial evidence in the record." Hamlin v. Barnhart, 365 F.3d 1208, 1215 (10th Cir. 2004). When a treating physician's opinion is not given controlling weight, the ALJ must explain what weight, if any was assigned to the opinion "using all of the factors provided in 20 C.F.R. §404.1527 and 416.927."
Despite acknowledging that Dr. Sobel was a treating physician, the ALJ afforded Dr. Sobel's opinion "no weight" because (1) the medical evidence of record failed to document the frequency and severity of Plaintiff's vertigo flares, (2) Plaintiff testified at the hearing that her headaches and dizzy spells were not severe and (3) Dr. Sobel's own notes failed to support her conclusion that Plaintiff would be disabled due to vertigo flares. (AR. at 127.)
The court finds that the ALJ had specific, legitimate reasons for rejecting Dr. Sobel's opinion. Plaintiff argues that there is ample medical evidence demonstrating the frequency and severity of Plaintiff's vertigo flares. While this is true, those medical records relate almost entirely to the 6-month time period between June 17, 2010 and November 2010.
To be sure, Plaintiff reported some continuing dizziness to Dr. Sobel in February 2011. (AR at 346-47.) However, there is no indication as to the severity or frequency of Plaintiff's symptoms at that time. (See id.) Moreover, Dr. Sobel simply instructed Plaintiff to continue with her vestibular exercises. (Id. at 347.) There is no evidence in the record to suggest that Plaintiff experienced further vertigo symptoms after that date and prior to the date last insured.
Accordingly, the court finds that the ALJ set forth legitimate reasons in support of his conclusion that no evidence in the record established the frequency and severity of Plaintiff's vertigo flares at the time Dr. Sobel opined that Plaintiff was disabled due to vertigo in July 2011. Moreover, there is no evidence to suggest that Plaintiff's vertigo was disabling in April 2012 when the hearing was conducted. Indeed, contrary to Dr. Sobel's opinion, Plaintiff testified in April 2012 that she only did her vestibular exercises once or twice every two weeks, and only when her vertigo flares were severe, which was unusual. (AR at 161-62.)
Finally, Plaintiff argues that the ALJ did not "consider to what extent Dr. Sorbel's [sic] opinion concerned limitations related to both vertigo and other conditions, namely anxiety disorder, degenerative disc disease, hypertension, asthma, fatty liver, nocturnal hypoxia, benign neoplasm of the pituitary, and chronic headaches." (Opening Br. at 16.) However, at no point did Dr. Sobel identify any limitations associated with degenerative disc disease, hypertension, asthma, fatty liver, nocturnal hypoxia, or benign neoplasm of the pituitary. (Id.) Further, while Dr. Sobel did opine that Plaintiff would suffer from "frequent disabling headaches" (id. at 599), the court finds that the ALJ legitimately rejected this opinion because Plaintiff testified at the hearing that her headaches were not severe (id. at 145).
Accordingly, the court finds that the ALJ reasonably rejected Dr. Sobel's opinion regarding the limitations imposed by Plaintiff's vertigo and other physical impairments.
Plaintiff next attacks the ALJ's assessment of the credibility of her statements regarding the limitations imposed by her impairments. (Opening Br. at 22-25.) "Credibility determinations are peculiarly the province of the finder of fact, and we will not upset such determinations when supported by substantial evidence." Kepler v. Chater, 68 F.3d 387, 391 (10th Cir. 1995) (internal quotation marks and citation omitted). "However, findings as to credibility should be closely and affirmatively linked to substantial evidence and not just a conclusion in the guise of findings." Id. (quotation marks and citation omitted).
The ALJ found that Plaintiff's assertion that the dizzy spells arising from her vertigo lasted throughout the whole day was inconsistent with her admission that she drove up to twice a week, 17-miles at a time. (AR at 125-126.) Plaintiff argues in her Opening Brief that the ALJ misunderstood her testimony as to the distance she typically drove each week and that the ALJ impermissibly placed herself into the role of a medical expert in opining that it could reasonably be assumed that Plaintiff's "treating physicians would advise [her] to refrain from driving a car using heavy moving machinery" if her dizzy spells were as severe as she alleged. (Id. at 125-126; Opening Br. at 23.)
Although the record is ambiguous as to the distances Plaintiff drove each week, the court finds that those distances are immaterial to the ALJ's credibility determination. More specifically, the ALJ specifically concluded that if Plaintiff's "dizzy spells were as severe as alleged, she could never drive a car." (Id. at 125, emphasis added.) The court finds this conclusion to be reasonable, and based on substantial evidence, when Plaintiff testified that her dizzy spells lasted throughout the entire day. (Id. at 143.)
Further, because the court finds that the ALJ reasonably concluded that Plaintiff could never drive if the dizziness associated with her vertigo truly lasted throughout the day, her speculation as to the whether Plaintiff's treating physicians would concur with that assessment is superfluous. McDonald v. Astrue, 492 F. App'x 875, 885 (10th Cir. 2012) (citing SSR 96-5p, 1996 WL 374183, at *5 (July 2, 1996)) ("the ALJ's RFC assessment is an administrative, rather than a medical, determination.").
Plaintiff testified that, due to her pain, she could only sit for 15-30 minutes, had a limited ability to stand, and could walk only 50 feet. (Id. at 156.) The ALJ found these alleged physical limitations not credible because (1) Plaintiff did not use a cane or other assistive walking device; (2) Plaintiff's treating physicians opined that she retained a normal gait and station with normal coordination and reflexes; (3) the treating physicians later observed that Plaintiff retained a full range of motion in her knees and had improved trochanteric bursitis and knee pain; and (3) Plaintiff voluntarily discharged herself from physical therapy after reaching short-term goals and having reduced pain. (Id. at 126.) Although Plaintiff does not dispute these findings, she does argue that "`[i]mprovement' in these conditions does not indicate that they did not still cause limitations." (Opening Br. at 24.)
The court finds that the ALJ permissibly discounted Plaintiff's allegations of physical limitations. First, the ALJ properly considered both the objective findings of Plaintiff's doctors, as well as the fact that she did not use an assistive device to ambulate. Keyes-Zachary, 695 F.3d at 1166-67. Moreover, between April and May 2011, Plaintiff underwent physical therapy for her knee pain, reported significant improvement, and was voluntarily discharged. (AR. at 567, 574, 604.) There is no evidence to suggest that Plaintiff sought further physical therapy. See Huston, 838 F.2d at 1132 (in assessing credibility, an ALJ may consider "the extensiveness of the attempts (medical or nonmedical) to obtain relief"); cf. Shepherd v. Apfel, 184 F.3d 1196, 1202 (10th Cir. 1999) (ALJ reasonably noted claimant's physical therapy sessions were cancelled because he failed to show up for them). Accordingly, the court finds that the ALJ's assessment of the credibility of Plaintiff's alleged physical limitations were supported by substantial evidence.
Plaintiff argues that the Appeals Council erred by failing to remand to the ALJ to consider the new evidence she submitted. (Opening Br. at 25-27.) Here, the court agrees.
"[T]he Appeals Council must consider evidence submitted with a request for review if the additional evidence is (a) new, (b) material, and (c) relate[d] to the period on or before the date of the ALJ's decision." Chambers v. Barnhart, 389 F.3d 1139, 1142 (10th Cir. 2004) (quotation marks and citations omitted). "If the evidence does not qualify, it plays no further role in judicial review of the Commissioner's decision." Id. (citations omitted) "If the evidence does qualify and the Appeals Council considered it in connection with the claimant's request or administrative review (regardless of whether review was ultimately denied), it becomes part of the record [the court] assess[es] in evaluating the Commissioner's denial of benefits under the substantial-evidence standard." Id. (citations omitted). However, if the evidence qualifies, but the Appeals Council did not consider it, the case should be remanded for further proceedings. Id. (citations omitted).
The new evidence submitted to the Appeals Council included medical records from Audrey Reisch, a Licensed Social Worker.
The parties do not dispute that the evidence submitted by Plaintiff to the Appeals Council is new. They disagree, however, as to whether the records from Ms. Reich are relevant. As an initial matter, under the circumstances of this case, the relevant inquiry here is not whether the new evidence relates to the period on or before the date of the ALJ's decision issued in May 2012. Chambers, 389 F.3d at 1142. Instead, because Plaintiff applied for DIB only, the court must determine whether these records relate to the period prior to the date Plaintiff was last insured, March 31, 2011. Flaherty v. Astrue, 515 F.3d 1067, 1069 (10th Cir. 2007) (in order to be eligible for DIB, the claimant must establish disability on or before her date last insured).
Based on Krauser v. Astrue, 638 F.3d 1324, 1327-28 (10th Cir. 2011), the court finds that the medical records received from Ms. Reich relate to the period prior to the date last insured. In Krauser, after the ALJ issued its decision, the claimant sought and obtained a referral for possible depression. Id. The claimant was ultimately diagnosed with major depression and prescribed an anti-depressant. Id at 1328. The claimant thus argued that, in light of this new evidence, he established a medically determinable impairment, or at least demonstrated the existence of an issue requiring further review. Id.
The Tenth Circuit panel found that the new evidence did not relate back to the relevant period because the diagnosis and treatment of depression occurred after the ALJ's decision. Id. The court found that the medical records diagnosis the claimant with depression "did not purport to retroactively diagnose a condition existing in the period preceding the ALJ's decision," nor did it "indicate any impaired functioning relating back to that period." Id. Importantly, however, the Tenth Circuit also explicitly emphasized "that there were no indications of depression in [the claimant's] medical records in the months immediately leading up to the hearing before the ALJ; rather, his doctor specifically noted he had no psychological abnormalities." Id.
Here, as in Krauser, Plaintiff's medical records from Ms. Reich do not explicitly include a retroactive diagnosis of depression between Plaintiff's alleged onset date and the date last insured. (AR at 7-35.) However, Ms. Reich found that that the onset date of Plaintiff's depression and anxiety was in 2003 and that in 2006 Plaintiff experienced "many bouts of depression related to health and life stressors," including, but not limited to her father's death. (Id. at 31.)
Further, unlike in Krauser, there is ample evidence suggesting that Plaintiff had depression and anxiety during the period of time considered by the ALJ. More specifically, on September 2, 2010, Dr. Sternberg opined that his "greatest concern at this point is [Plaintiff's] depression anxiety," which had "its onset with her dad's death five years ago." (AR at 629.) Dr. Sternberg found that Plaintiff had early morning awakenings with difficulty falling asleep, increased sleep latency of 1-2 hours, daily crying spells, and, most concerning for Dr. Sternberg, "a chronic, background anxiety where she's unable to feel calm or relaxed at any time of the day." (Id.) Further, based on Dr. Sternberg's observations, Dr. Sobel placed Plaintiff on anti-depressant medications and treated Plaintiff's depression on several occasions. (Id. at 356-58.) And in her July 2011 report, Dr. Sobel opined that Plaintiff's anxiety and depression would make it difficult for Plaintiff to concentrate. (Id. at 598.)
The symptoms observed by Ms. Reich in August 2012 giving rise to a diagnosis of depression and a GAF of 55 largely mirror those observed by Dr. Sternberg in September 2010. Ms. Reich found that Plaintiff teared-up 2-3 times a week, had poor self-esteem, was irritable, and had a history of panic attacks. (Id. at 31-32.)
Accordingly, the court finds that this case is distinguishable from Krauser because the record contains objective indicators of depression and anxiety that correlate strongly with Ms. Reich's subsequent diagnosis of major depression. See also Baca v. Dep't of Health & Human Servs., 5 F.3d 476, 479 (10th Cir. 1993) (citation omitted) ("[E]vidence bearing upon an applicant's condition subsequent to the date upon which the earning requirement was last met is pertinent evidence in that it may disclose the severity and continuity of impairments existing before the earning requirement date or may identify additional impairments which could reasonably be presumed to have been present and to have imposed limitations as of the earning requirement date."). Accordingly, the court finds that Plaintiff's medical records are related to the time period between Plaintiff's alleged onset date and the date last insured.
The court also finds that the Appeals Council did not consider the new evidence received from Ms. Reich. Although the Appeals Council did "look[] at" the new medical records, it concluded that it did not affect the ALJ's decision because the records all related to a time after the date last insured. This amounts to a rejection of this new evidence. Accordingly, the court finds this case must be remanded to allow the ALJ to consider this new evidence.
As a final matter, Plaintiff argues that the ALJ erred in concluding that Plaintiff's RFC included an ability to lift twenty pounds occasionally and ten pounds frequently when Dr. Ketelhohn specifically opined that Plaintiff could only lift ten pounds occasionally and less than ten pounds frequently. (Opening Br. at 18-19.)
The ALJ is not obligated to include in the RFC assessment every limitation possibly suggested by a medical sources. See Clifton v. Chater, 79 F.3d 1007, 1009-10 (10th Cir. 1996). However, the ALJ must discuss "the uncontroverted evidence he or she chooses to rely upon and any significantly probative evidence he or she rejects." Id.
Here, Dr. Ketelhohn's opinion regarding Plaintiff's lifting abilities was likely probative and therefore should have been expressly rejected by the ALJ.
Therefore, for the foregoing reasons, the Commissioner's decision is REVERSED and this case is REMANDED for further proceedings consistent with this Order. The Clerk shall enter Judgment in accordance herewith. Any request for costs or attorneys' fees shall be made within 14 days of the date of this Order.
Watkins, 350 F.3d 1297, 1301 (10th Cir. 2003) (citation omitted).