LOURDES A. MARTÍNEZ, Magistrate Judge.
On August 21, 2013 (Doc. 11-4 at 2), Plaintiff protectively filed an application for Disability Insurance Benefits (hereinafter "DIB"), alleging that he was disabled due to bipolar affective disorder, anxiety, and knee pain (Doc. 11-8 at 5), with a disability onset date of September 14, 2012 (id. at 2). Plaintiff's' last day of insurance, for DIB purposes, was March 31, 2016. Id. Plaintiff's application was denied at the initial level on January 7, 2014 (Doc. 11-5 at 2-5), and at the reconsideration level on February 26, 2014 (id. at 7-9). On March 15, 214, Plaintiff requested a hearing to review the denial of his application. [Doc. 11-5 at 10-11]. Administrative Law Judge Ann Farris (hereinafter "ALJ") conducted a hearing on January 15, 2015. [Doc. 11-3 at 30-59]. At the hearing, Plaintiff was present, represented by attorney Ione E. Gutierrez, and testified. Id. at 35-54. Vocational Expert (hereinafter "VE"), Mary Diane Weber, also testified. Id. at 54-59.
On February 3, 2015, the ALJ issued her decision (Doc. 11-3 at 17-26) finding that, under the relevant sections of the Social Security Act, Plaintiff was not disabled from his alleged onset date of September 14, 2012 through the date of the decision (id. at 26). Plaintiff requested that the Appeals Council review the ALJ's decision. [Doc. 11-3 at 12]. On March 30, 2015, the Appeals Council denied Plaintiff's request for review on the ground that there was "no reason under our rules to review the [ALJ]'s decision." Id. at 7. This decision was the final decision of the Commissioner. On May 22, 2015, Plaintiff filed his complaint in this case. [Doc. 1].
The standard of review in a Social Security appeal is whether the Commissioner's final decision is supported by substantial evidence and whether the correct legal standards were applied. Maes v. Astrue, 522 F.3d 1093, 1096 (10th Cir. 2008) (citing Hamilton v. Sec'y of Health & Human Servs., 961 F.2d 1495, 1497-98 (10th Cir. 1992)). If substantial evidence supports the ALJ's findings and the correct legal standards were applied, the Commissioner's decision stands, and the plaintiff is not entitled to relief. See Langley v. Barnhart, 373 F.3d 1116, 1118 (10th Cir. 2004); Hamlin v. Barnhart, 365 F.3d 1208, 1214 (10th Cir. 2004); Doyal v. Barnhart, 331 F.3d 758, 760 (10th Cir. 2003). A court should meticulously review the entire record but should neither re-weigh the evidence nor substitute its judgment for that of the Commissioner. Hamlin, 365 F.3d at 1214; Langley, 373 F.3d at 1118.
"Substantial evidence is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Langley, 373 F.3d at 1118 (citation and quotation marks omitted); Hamlin, 365 F.3d at 1214 (citation and quotation marks omitted); Doyal, 331 F.3d at 760 (citation and quotation marks omitted). An ALJ's 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." Langley, 373 F.3d at 1118 (citation and quotation marks omitted); Hamlin, 365 F.3d at 1214 (citation and quotation marks omitted). While a court may not re-weigh 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) (citations omitted). "The possibility of drawing two inconsistent conclusions from the evidence does not prevent [the ALJ]'s findings from being supported by substantial evidence." Lax v. Astrue, 489 F.3d 1080, 1084 (10th Cir. 2007) (citing Zoltanski v. F.A.A., 372 F.3d 1195, 1200 (10th Cir. 2004)).
For purposes of DIB, a person establishes a disability when 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. § 405.1505(a). In light of this definition for disability, a five-step sequential evaluation process (hereinafter "SEP") has been established for evaluating a disability claim. 20 C.F.R. § 404.1520; Bowen v. Yuckert, 482 U.S. 137, 140 (1987). At the first four steps of the SEP, the claimant has the burden to show that: (1) the claimant is not engaged in "substantial gainful activity;" and (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 either (3) the claimant's impairment(s) meet(s) or equal(s) one of the "Listings" of presumptively disabling impairments; or (4) the claimant is unable to perform his or her "past relevant work." 20 C.F.R. § 404.1520(a)(4)(i-iv); Grogan, 399 F.3d at 1261. At the fifth step of the evaluation process, the burden of proof shifts to the Commissioner to show that the claimant is able to perform other work in the national economy, considering his or her residual functional capacity (hereinafter "RFC"), age, education, and work experience. Grogan, 399 F.3d at 1261.
Plaintiff, a veteran, was born on March 17, 1977, and was 35 years old on September 14, 2012, the alleged onset date of his disability. [Doc. 11-8 at 2]. Thus, for the purposes of his disability claim, Plaintiff is considered to be a "younger person."
Plaintiff's medical records include: treatment notes from John A. Johnson, M.D. of Saint Alphonsus Medical Group in Nampa, Idaho, for the period from December 18, 2009 to July 22, 2010 (Doc. 11-9 at 7-14); treatment records, laboratory results, and psychiatric treatment notes from the Veteran's Administration (hereinafter "VA") Healthcare System in Albuquerque, New Mexico, for the period from May 17, 2011 to October 29, 2014 (Doc. 11-10 at 2 through Doc. 11-12 at 17; Doc. 11-14 at 2-41); and treatment records and laboratory results from the VA Healthcare System in Boise, Idaho, for the period from July 15, 2011 to November 13, 2013 (Doc. 11-13 at 2-38). Where relevant, Plaintiff's medical records are discussed in more detail below.
At step one of the five-step evaluation process, the ALJ found that Plaintiff had not engaged in substantial gainful activity after September 14, 2012. [Doc. 11-3 at 19]. At step two, the ALJ found that Plaintiff "has the following severe impairments: mood disorder and anxiety disorder." Id. The ALJ also found that Plaintiff has "substance abuse disorder and osteoarthritis," but that both of those impairments are non-severe. Id. At the third step, the ALJ found that Plaintiff did not have an impairment or combination of impairments that met or medically equaled any of the Listings found in 20 C.F.R. Part 404, Subpt. P, Appx. 1 (20 C.F.R. §§ 404.1520(d), 404.1525, and 404.1526). Id. at 20. In so concluding, the ALJ considered Listings 12.04 Affective Disorders, 12.06 Anxiety Related Disorders, and 12.09 Substance Addiction Disorders. Id. at 20-21. Before step four, the ALJ found that Plaintiff had the RFC "to perform a full range of work at all exertional levels but with the following non[-]exertional limitations: he is limited to simple workplace decisions with few workplace changes; should have only occasional and superficial contact with co-workers; and should have no contact with the general public." Id. at 21. In support of this RFC assessment, the ALJ found that Plaintiff's "medically determinable impairments might be expected to cause some of the alleged symptoms; however, [Plaintiff]'s statements concerning the intensity, persistence and limiting effects of these symptoms are not entirely credible for the reasons explained in this decision." Id. at 22.
At step four, the ALJ found that Plaintiff "was unable to perform any past relevant work," as Plaintiff's previous jobs of auto sales, shipping and receiving clerk, and operations manager all were considered "skilled and require a SVP
Plaintiff argues in his motion that, contrary to Soc. Sec. Rep. 96-6p and Tenth Circuit precedent, the ALJ failed to either incorporate all of the limitations found by non-examining medical experts Scott R. Walker, M.D., at the initial review level (Doc. 11-4 at 9-11) and Susan B. Cave, Ph.D.
As already noted, Plaintiff has the burden at steps one through four of the SEP, which means he must establish that he has a severe medically determinable impairment, or combination of impairments, and that either his impairments meet or equal a listed, presumptively disabling, impairment, or that he is unable to perform his past relevant work. Here, the ALJ found that Plaintiff suffers from two severe impairments — mood disorder and anxiety disorder.
Plaintiff's sole argument in this appeal is that the ALJ's RFC is legally insufficient because she did not specifically address every work function that Dr. Walker indicated was "moderately limited." Essentially, Plaintiff asserts that both the consulting medical experts and the ALJ must indicate why they either accepted or rejected each of the Section I work function limitations in the Mental RFC Assessment (hereinafter "MRFCA") form.
Id. This RFC adequately describes Dr. Walker's findings in the worksheet portion of his MRFCA, especially considering his reluctance to give full credence to the symptoms described by Plaintiff and his girlfriend that lacked support in Plaintiff's medical records. Dr. Walker's narrative opinion, in which he did limit Plaintiff's social contact and his capacity to follow instructions, was adopted in a slightly more restrictive form by the ALJ in her RFC, which restricted Plaintiff to "unskilled" work.
Plaintiff's argument, that the failure of Dr. Walker and the ALJ to specifically discuss each of his "moderate" limitations in their RFC requires remand, has been rejected on more than one occasion. Thus, the Tenth Circuit recently held that an ALJ "can account for moderate limitations by limiting the claimant to particular kinds of work activity." Smith v. Colvin, 821 F.3d 1264, 1269 (10th Cir. 2016), citing Vigil v. Colvin, 805 F.3d 1199, 1204 (10th Cir. 2015). In Vigil, the court held that "limiting the plaintiff to an SVP of only one or two, adequately took into account his moderate limitations in concentration, persistence, and pace problems," noting:
Vigil, 805 F.3d at 1204. In addition, the Tenth Circuit recently addressed an argument almost identical to Plaintiff's in this case, which was "that the ALJ didn't explain why the RFC failed to capture two moderate limitations from [a non-examining psychologist]'s opinion" that related to the plaintiff's "ability to sustain an ordinary routine without special supervision, and to accept instructions and respond appropriately to criticism from supervisors." Chavez v. Colvin, No. 15-2201, 2016 WL 3212479, at *1 (10th Cir. June 2, 2016) (unpublished). The appellate court rejected the suggested formulistic approach and approved the ALJ's more general RFC, stating:
Id. In the present case, not only did the ALJ increase Plaintiff's RFC restrictions from those stated by Dr. Walker,
Plaintiff cites Haga v. Astrue, 482 F.3d 1205 (10th Cir. 2007) as support for his assertion that the ALJ engaged in reversible "picking and choosing" of only the evidence that supported her finding of no disability, because she did not explicitly accept or reject each of the moderate limitations in Dr. Walker's "Section I" analysis.
In any event, a step four determination of the limitations imposed by an impairment that was found to be "severe" in step two of the SEP is a factual issue on which Plaintiff bears the burden of proof, and on which this Court has limited review authority. See, e.g., Lax, 489 F.3d at 1084 (reviewing court "may not `displace the agenc[y's] choice between two fairly conflicting views, even though the court would justifiably have made a different choice'") (quoting Zoltanski, 372 F.3d at 1200). In this case, not one treating doctor rendered an opinion regarding the limiting effects of Plaintiff's mood and anxiety disorders, leaving the ALJ with only Dr. Walker's MRFCA (adopted by Dr. Cave, as well) as medical opinion evidence of Plaintiff's mental condition. This Court must reiterate that, where substantial evidence supports the ALJ's findings and the correct legal standards were applied, the Commissioner's decision stands, and the plaintiff is entitled to no relief. See Langley, 373 F.3d at 1118; Hamlin, 365 F.3d at 1214; Doyal, 31 F.3d at 760. Moreover, "[i]n reviewing the ALJ's decision, we neither reweigh the evidence nor substitute our judgment for that of the agency." Newbold v. Colvin, 718 F.3d 1257, 1262 (10th Cir. 2013) (internal quotation marks omitted). "Substantial evidence is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion. . . . It is more than a scintilla, but less than a preponderance." Id. (citing Lax, 489 F.3d at 1084) (internal quotation marks omitted). Finally, "[t]he possibility of drawing two inconsistent conclusions from the evidence does not prevent [the ALJ]'s findings from being supported by substantial evidence." Lax, 489 F.3d at 1084 (citing Zoltanski, 372 F.3d at 1200). Applying these principles, this Court cannot conclude from the record that the ALJ's view that "the medical records reveal that the medications have been relatively effective in controlling [Plaintiff]'s symptoms," and that "with proper medications, Plaintiff improved . . . and his symptoms stabilized" (Doc. 11-3 at 23) (citing Doc. 11-11 at 17; Doc. 11-14 at 7, 12, 15-41) is not supported by substantial evidence.
Although Plaintiff asserts in his motion that he "has suffered from anxiety attacks since at least 2002, when he was diagnosed with panic disorder" (Doc. 18 at 6), the earliest medical reports that are in the record are dated December 18, 2009, when Plaintiff was seeking a primary care doctor to refill his medications and was seen by John A. Johnson, M.D. in Nampa, Idaho (Doc. 11-9 at 13-14). Since Plaintiff listed depression and anxiety as reasons why he needed an appointment, Dr. Johnson used a depression screening test called the PHQ-9.
Other than prescription refills for Klonopin and Depakote, there are no medical records for Plaintiff from July 2010 through April 2011. In May 2011, Plaintiff went to the Emergency Department of the Albuquerque VA
On September 11, 2013, Plaintiff appeared at the Beacon Behavioral Health Clinic "in [a] decompensated state." [Doc. 11-11 at 20]. Plaintiff indicated that he was suffering from anxiety and panic attacks, racing thoughts, decreased sleep, loss of appetite, irritability, and mood instability. Id. His girlfriend, Stephanie, reported that he had threatened to commit suicide and that he was delusional about her cheating on him. Id. Although she initially wanted Plaintiff admitted to the hospital, Stephanie agreed to supervise him at home overnight, with the addition of a new medication, and to return to the clinic with him in the morning. Id. at 21. At this time, the Beacon doctors added Zyprexa
Plaintiff was next seen by Nurse Practitioner Patricia Atherton on September 24, 2013 for a mental health diagnostic study. During this visit, Plaintiff completed a PHQ-9 assessment and received a score of 7, which indicates "mild depression."
Dr. Tabet saw Plaintiff on October 9, 2013 and diagnosed him with "mood [disorder] NOS, marijuana induced suspiciousness." Id. at 3. Dr. Tabet recommended that no changes be made to Plaintiff's medications, but that a slow taper of Zyprexa be considered. Id. He summarized his findings as follows:
Id. at 2. One month later, on a follow-up visit, Dr. Tabet considered Plaintiff's progress to be stable, noting that he had reported "doing much better" and that his "medication is going well, [and] feels since he's been on it for a while [it] is taking good effect." [Doc. 11-14 at 12]. Plaintiff was again described as dressing appropriately, having good grooming and hygiene, collaborative behavior, and appropriate affect, that his thought process displayed good organization, and he showed good alertness and memory, though memory had not been tested. Id.
In December 2013, Plaintiff visited the psychiatric clinic because his Klonopin had not been delivered as expected and he hoped to get a partial refill. Id. at 8. When asked why he had recently asked to move up his next appointment with Dr. Tabet, Plaintiff explained that "he had been forgetting his [Depakote] after[noon] doses[,] and when he became irritable and angry his girlfriend asked him to see Dr. Tabet." Id. Instead, Plaintiff "began taking all [Depakote] doses and states he is fine now." Id. He was noted to be dressed "with care to grooming/hygiene," to have eye contact and speech within normal limits, and thought process that was logical, linear, and coherent. Id.
In January 2014, Dr. Tabet noted that Plaintiff "remain[ed] on stable trend with current [medications]." Id. at 7. Plaintiff was described as very polite/friendly, with appropriate/stylish clothing, good grooming/hygiene, appropriate affect, and organized thought process. Id. at 6-7. In February 2014, Plaintiff was seen by Cynthia Sontag, a licensed social worker, for individual counseling. Ms. Sontag described Plaintiff at this initial meeting with her as calm and collected, with spontaneous, clear, and fluent speech, and linear thought processes. Id. at 4. At this session, Plaintiff told Ms. Sontag both that he did not think he could get a job "because he has a felony (possession with the intent to sell marijuana 5[pounds])," and that he had been unable to keep a job "because of his mood swings." Id. at 3. At Plaintiff's next visit, approximately three weeks later, Ms. Sontag described him as "attentive and engaged" and, again, with "spontaneous, clear, and fluent" speech, and "linear" thought process.
On March 12, 2014, Ms. Sontag noted that, in her session with Plaintiff, "we discussed his lack of motivation to get work or have his own life outside of his [girlfriend]" and that they were "focusing only on motivation for awhile and avoiding the focus on the [girlfriend], which is what puts him into depressed dependent state emotionally when discussed." Id. at 35. In this session, Plaintiff claimed, for the first time,
On April 3, 2014, Plaintiff attended appointments with both Dr. Tabet and Ms. Sontag. Dr. Tabet revised Plaintiff's evening Zyprexa dose, from two tablets to one tablet "as needed," stating:
Id. at 29. Dr. Tabet's observations of Plaintiff's appearance speech, affect, thought process and content, and cognitive state were similar to other visits, and he noted that Plaintiff "appears on stable trend currently." Id. at 29-30. From her session, Ms. Sontag noted that Plaintiff "still appeared very depressed," but that "[h]e "says inside he feels better and was overall more communicative." Id. at 27. Ms. Sontag further noted that Plaintiff "wants to get a job and has taken active steps to find one," although she did not elaborate on what steps he had taken. Id. at 27-28.
Three weeks later, Ms. Sontag reported that Plaintiff "seems to like his lifestyle and is able to be good with people so he doesn't have to isolate if he can get part-time work and develop enough skills to build his confidence." Id. at 26. She noted, however, that Plaintiff "hasn't applied for Voc[ational] Rehab[ilitation] yet. Id. In May 2014, she reported that Plaintiff "continues to have a flat affect all the time," and that "he is still unmotivated to look for [a job] or use the VA resources to get one." Id at 24. Nonetheless, Plaintiff's mood was "contented," and he reported that he and his girlfriend were "doing better." Id. In June 2014, Plaintiff's mood was "upbeat," despite an apparent increase in his suspiciousness of his girlfriend, and he "was open to looking into" some kind of Vocational Rehabilitation work program. Id. at 22-23. In July 2014, Ms. Sontag noted that Plaintiff was "stable now and has been for some time," but was not motivated to get a job, and was "unmotivated for any change at this time." Id. at 21. Plaintiff's "thought content was focused on how well things were going in his life because his [girlfriend] is happy." Id. Ms. Sontag further noted that Plaintiff "found reasons not to pursue any work situation and it was clear he didn't want to work if it wasn't necessary. He says he sleeps a lot with his meds and can't do much of anything including coming to the [Psychosocial Rehabilitation and Recovery Center]."
Plaintiff also saw Dr. Tabet in July 2014, indicating that things were "going better," and that he was "doing well," although his grandfather was ill and was expected to die soon. Id. at 19. Plaintiff again reported that psychotherapy with Ms. Sontag "helped out quite a bit," and that he planned to attend group therapy. Id. Plaintiff also reported that he was "[g]oing to Isotopes [baseball] games," walked on a treadmill about twice a week, and "enjoys biking and may get a bike soon." Id. at 19-20. Dr. Tabet noted that Plaintiff's "stable trend continue[d]." Id. at 20. Plaintiff next saw Dr. Tabet in October 2014, who noted that:
Id. at 15. Dr. Tabet indicated that Plaintiff "remains on stable trend," and that he should return for follow-up in four months. Id. at 16.
Plaintiff's medical records clearly support the ALJ's conclusions that, while he does have a mood disorder, it is well controlled with medication, and that neither his symptoms nor his medications render him unable to function in a working environment. The ALJ's determination of Plaintiff's RFC, which was based on Dr. Walker's consultative RFC,
For the reasons stated above, the Court FINDS that the Commissioner's decision is supported by substantial evidence and that the correct legal standards were applied.