LAURA FASHING, Magistrate Judge.
THIS MATTER comes before the Court on plaintiff Andrea Leah Heckel's Motion to Reverse and Remand (Doc. 22), which was fully briefed May 25, 2016. The parties consented to my entering final judgment in this case. Docs. 8, 10. Having meticulously reviewed the entire record and being fully advised in the premises, the Court finds that the Administrative Law Judge ("ALJ") failed to apply the correct legal standards in weighing the opinions of Carol Capitano, a treating nurse specialist, and Dr. Donald Gucker, a consulting psychologist. I therefore GRANT Ms. Heckel's motion and remand this case to the Commissioner for 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
Ms. Heckel was born in 1976, completed one year of college, and worked in finance-related jobs from the mid-1990s until her alleged disability onset date in 2009. AR 126, 133, 29, 170.
On remand, the Appeals Council remanded the case to an ALJ for a new hearing. AR 508-10, 387.
At step one, the ALJ found that Ms. Heckel had not engaged in substantial, gainful activity since November 4, 2009. AR 391. Because Ms. Heckel had not engaged in substantial gainful activity for at least twelve months, the ALJ proceeded to step two. AR 391-94. At step two, the ALJ found that Ms. Heckel suffered from the following severe impairments: major depressive disorder, anxiety disorder, borderline personality disorder, and substance abuse disorder. AR 391. At step three, the ALJ found that none of Ms. Heckel's impairments, alone or in combination, met or medically equaled a Listing. AR 394-96. Because the ALJ found that none of the impairments met a Listing, the ALJ assessed Ms. Heckel's RFC. AR 396-403. The ALJ found that:
AR 396.
At step four, the ALJ concluded that Ms. Heckel was unable to perform any of her past relevant work as an accounting clerk, bookkeeper, assistant controller, or in human resources. AR 403. The ALJ found Ms. Heckel was not disabled at step five, concluding that she still could perform jobs that exist in significant numbers in the national economy, such as an addresser, laundry folder, and "day worker." AR 404-05. Because this Court previously remanded Ms. Heckel's case, Ms. Heckel was not required to seek Appeals Council review again, and the ALJ's decision stands as the final decision of the Commissioner. See 20 C.F.R. § 404.984(a). Ms. Heckel timely appealed to this Court on June 1, 2015.
Ms. Heckel raises several arguments for reversing and remanding this case: (1) the ALJ failed to either incorporate, or explain why she chose not to incorporate, limitations noted in the opinions of treating nurse specialist Carol Capitano, and state agency psychological consultant Dr. Donald Gucker; (2) the ALJ failed to properly consider opinion evidence from her treating psychotherapist, Madeleine Brady; (3) the ALJ failed to provide the legal analysis necessary at step five to determine whether enough jobs exist to constitute a "significant number" of jobs; and (4) the ALJ's findings at step five are not supported by substantial evidence. Because I remand based on the ALJ's failure to adequately address the limitations noted in the opinions of Clinical Nurse Specialist ("CNS")
Ms. Heckel argues that the ALJ committed legal error by failing to incorporate several moderate or marked limitations assessed by CNS Carol Capitano and Dr. Donald Gucker into her RFC, without explanation. Doc. 22 at 20-23. The Commissioner argues that the ALJ did not err because she gave "valid reasons" for finding Ms. Heckel less restricted than CNS Capitano opined, and because her reliance on Dr. Gucker's Section III findings excused her from addressing the moderate limitations noted in his Section I findings. Doc. 25 at 7-9.
Although an ALJ need not discuss every piece of evidence, she is required to discuss the weight assigned to each medical source opinion. Keyes-Zachary v. Astrue, 695 F.3d 1156, 1161 (10th Cir. 2012) (citing 20 C.F.R. §§ 404.1527(e)(2)(ii), 416.927(e)(2)(ii)). 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). "If the RFC assessment conflicts with an opinion from a medical source, the adjudicator must explain why the opinion was not adopted." SSR 96-8p, 1996 WL 374184, at *7. "[T]here is no requirement in the regulations for a direct correspondence between an RFC finding and a specific medical opinion on [a specific] functional capacity" because "the ALJ, not a physician, is charged with determining a claimant's RFC from the medical record." Chapo v. Astrue, 682 F.3d 1285, 1288 (10th Cir. 2012) (alteration and internal quotation marks omitted)); see also Wells v. Colvin, 727 F.3d 1061, 1071 (10th Cir. 2013) ("exact correspondence between a medical opinion and the mental RFC is not required"). Nevertheless, "[a]n ALJ is not entitled to pick and choose through an uncontradicted medical opinion, taking only the parts that are favorable to a finding of nondisability." Chapo, 682 F.3d at 1292 (quoting Haga v. Astrue, 482 F.3d 1205, 1208 (10th Cir. 2007)). An ALJ "must discuss the uncontroverted evidence he chooses not to rely upon, as well as significantly probative evidence he rejects." Clifton v. Chater, 79 F.3d 1007, 1010 (10th Cir. 1996). Ultimately, an ALJ is required to weigh medical source opinions and to provide "appropriate explanations for accepting or rejecting such opinions." SSR 96-5p, 1996 WL 374183, at *5; see also Keyes-Zachary, 695 F.3d at 1161 (same) (citing 20 C.F.R. §§ 404.1527(e)(2)(ii), 416.927(e)(2)(ii)).
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, the Tenth Circuit expressly applied Haga and its reasoning to the opinions of nonexamining physicians in Frantz v. Astrue, 509 F.3d 1299, 1302-03 (10th Cir. 2007).
Ms. Heckel argues that the ALJ engaged in impermissible picking and choosing by adopting some limitations noted by CNS Capitano, while rejecting others without explanation. Doc. 22 at 22-23; Doc. 26 at 6-7. The Commissioner counters that the ALJ did not err in giving CNS Capitano's opinion "moderate weight" while only addressing some of the noted limitations. Doc. 25 at 7. The Commissioner argues that the ALJ considered "valid factors" in finding that Ms. Heckel was not as limited as CNS Capitano opined. Id.
In her December 16, 2014 opinion, CNS Capitano opined that Ms. Heckel had the following limitations:
AR 940-1.
The ALJ's assessment of CNS Capitano's medical source statement is as follows:
AR 403.
CNS Capitano is considered an "other source" under the regulations, despite her advanced degree. See SSR 06-03p (Aug. 9, 2006), 2006 WL 2329939, at *5.
The parties disagree about how much the ALJ was required to discuss CNS Capitano's "other source" opinion. The Commissioner argues that the ALJ is not required to address CNS Capitano's limitations "line-by-line," arguing that for a "nonacceptable medical source . . . the ALJ's decision is sufficient if it permits us to follow the adjudicator's reasoning." Doc. 25 at 8 (quoting Keyes-Zachary, 695 F.3d at 1164). The Commissioner also cites Block v. Astrue, 506 F. App'x 764, 771 (10th Cir. 2012) (unpublished) ("[T]he ALJ explained the weight he gave the mental medical source statements: `little.' And the ALJ's discussion of the evidence permits us to follow his reasoning."). Doc. 25 at 8. The Court finds these cases distinguishable. Unlike the ALJ in this case, the ALJs in Keyes-Zachary and in Block did not pick and choose from limitations noted in the "other source" opinions. In each case, the ALJ rejected the "other source" opinion outright, and the Court found no error because the "ALJ's discussion of the evidence permit[ted the Court] to follow his reasoning." Block, 506 F. App'x at 771 (citing Keyes-Zachary, 695 F.3d at 1164).
Here, however, the ALJ erred because her discussion of the evidence does not permit the Court to follow her reasoning. In this case, as in Frantz, the ALJ "ignored evidence from [a CNS] that would support a finding of disability while highlighting evidence favorable to a finding of nondisability." Frantz, 509 F.3d at 1302. And, as in Haga, "the ALJ did not state that any evidence conflicted with [the] opinion or mental RFC assessment. So it is simply unexplained why the ALJ adopted some of [the] restrictions but not others." 482 F.3d at 1208. Under Haga and Frantz, the ALJ was required to either adopt all of the moderate or marked limitations assessed by CNS Capitano, or explain her reasons for not doing so. The ALJ appears to have partially credited the limitations that CNS Capitano noted in Ms. Heckel's ability to carry out detailed instructions, respond appropriately to changes in the workplace, interact with the general public, and get along with coworkers or peers by limiting her to simple work-related decisions, few work place changes, no interaction with the public, and only occasional and superficial interaction with co-workers. AR 396. But the ALJ failed to discuss or discredit any of the other noted limitations.
The Commissioner argues that the ALJ adequately explained why she did not adopt all of the limitations. Doc. 25 at 7. The Court disagrees. The ALJ's general assertion that "treatment notes and the claimant's reported activities do not support this level of limitation" may explain why the ALJ found Ms. Heckel found a lesser degree of limitation than CNS Capitano in the limitations the ALJ did address. But it does not explain why she rejected the other numerous limitations noted by CNS Capitano, or why she adopted some limitations while rejecting others.
The parties do not address each omitted limitation individually. The Court will not do so either, as remand is required given that the ALJ omitted at least two critical limitations from the RFC without adequate discussion.
First, the ALJ failed to include any limitation concerning Ms. Heckel's ability to interact with supervisors in the RFC. The ALJ states in several parts of the opinion that she included such a limitation. See AR 399 ("the assigned residual functional capacity . . . restricts her contact with the public and co-workers and supervisors"), AR 403 (the assigned RFC "limits her to . . . little contact with supervisors or co-workers"), AR 403 ("very limited contact with co-workers and supervisors"). However, despite the ALJ's claim that the assigned RFC limited Ms. Heckel to "little contact with supervisors," the ALJ failed to include this limitation in either the RFC or the hypothetical she gave the vocational expert.
Second, the ALJ failed to adequately address Ms. Heckel's limitation in her ability to complete a normal workday and workweek without interruptions, and to perform at a consistent pace without an unreasonable number and length of rest periods. CNS Capitano found that Ms. Heckel had a "marked" limitation in this regard. AR 940. Madeleine Brady also found that Ms. Heckel had a "marked" limitation in this regard. AR 853. Dr. Gucker found that Ms. Heckel had a "moderate" limitation in this area. AR 311. The ALJ did not point to any evidence contradicting the fact that Ms. Heckel has at least a moderate impairment in this area. However, the ALJ failed to discuss why she rejected this limitation. The mental abilities needed for any job include "the ability to complete a normal workday and workweek without interruptions from psychologically based symptoms and perform at a consistent pace without an unreasonable number and length of rest periods." Social Security Program Operations Manual System ("POMS") § DI 25020.010, http://policy.ssa.gov/poms.nsf/lnx/0425020010. "These requirements are usually strict." Id. Because this ability is a general requirement for all jobs, the ALJ must address this limitation in formulating Ms. Heckel'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 ability to perform simple or unskilled work because it is a general work requirement). The ALJ failed to adequately address this limitation, and remand is therefore appropriate.
The ALJ assigned "moderate weight" to the medical source opinion of Dr. Donald Gucker, a state agency psychological consultant who examined Ms. Heckel in 2011. AR 400. In Section I of his January 4, 2011 Mental Residual Function Capacity Assessment ("MRFCA"), Dr. Gucker found that Ms. Heckel had the following limitations:
AR 310-11.
In Section III of his MRFCA, Dr. Gucker found that:
AR 312.
The ALJ assessed Dr. Gucker's opinion as follows:
AR 400-01.
Ms. Heckel argues that, because the ALJ relied on Dr. Gucker's assessment, she "was required to incorporate all of the limitations assessed by him or else sufficiently explain her reasons for not doing so." Doc. 22 at 21 (emphasis removed). The only limitations noted by Dr. Gucker that the ALJ included in her RFC were moderate limitations in responding to workplace changes and getting along with coworkers. Doc. 22 at 21. Ms. Heckel argues that the ALJ erred by not addressing the other limitations. Id.
The Commissioner responds that the ALJ did not overlook any moderate limitations because the ALJ only was required to account for the limitations noted in Dr. Gucker's Section III findings, not those is Section I. Doc. 25 at 8. The Commissioner cites Sullivan v. Colvin, 519 F. App'x 985, 989 (10th Cir. 2013) (unpublished), claiming that it supports the proposition that it is not error for the ALJ to "not mention[] the moderate limitations in performance indicated in Section I of the Mental Residual Functional Capacity form where the ALJ relied on the state agency's ultimate opinion in Section III." Doc. 25 at 9. The Commissioner also cites several out-of-circuit cases as support for this position. Id. The Court finds the Commissioner's arguments unpersuasive.
As the Honorable Stephan M. Vidmar thoroughly explained in his recent opinion rejecting nearly identical arguments, the POMS, regulations, and case law require the ALJ to address all Dr. Gucker's findings, not just those in Section III. See Silva v. Colvin, No. 15-cv-603 SMV, Doc. 24 at 11-18 (D.N.M., Aug. 25, 2016). Specifically, "findings of fact made by State agency . . . psychological consultants . . . become opinions at the administrative law judge. . . level[] of administrative review . . . and requires administrative law judges . . . to consider and evaluate these opinions when making a decision in a particular case." POMS § DI 24515.013, http://policy.ssa.gov/poms.nsf/lnx/0424515013. Further, "[b]ecause State agency . . . psychological consultants . . . are experts in the Social Security disability programs, the rules in 20 CFR [§§] 404.1527(f) and 416.927(f) require administrative law judges . . . to consider their findings of fact about the nature and severity of an individual's impairment(s) as opinions of nonexamining . . . psychologists. Administrative law judges . . . are not bound by findings made by State agency . . . psychologists, but they may not ignore these opinions and must explain the weight given to the opinions in their decisions." Id. And although ALJs also "must consider and evaluate" a consulting psychologist's Section III RFC, Section I findings are not exempt from this scrutiny. See id.
Social Security regulations also require ALJs to "consider findings and other opinions of State agency . . . psychological consultants . . . as opinion evidence. . . ." 20 C.F.R. §§ 404.1527(e)(2)(i), 416.927(e)(2)(i). "Evidence" includes "findings . . . made by State agency . . . psychological consultants . . ., and opinions expressed by . . . psychological experts that we consult based on their review of the evidence in your case record." 20 C.F.R. §§ 404.1512(b)(1)(viii), 416.912(b)(1)(viii). Like the POMS, the regulations do not exempt the Section I findings from an ALJ's consideration and evaluation. See id.
Case law also requires ALJs to consider a psychological consultant's entire MRFCA, not just the Section III findings. The Court has surveyed the cases from the Tenth Circuit that expressly address the distinction between Section I and Section III findings. Two cases, Smith v. Colvin, 821 F.3d 1264 (10th Cir. 2016) and Sullivan v. Colvin, 519 F. App'x 985 (10th Cir. 2013) (unpublished), arguably could be interpreted in the Commissioner's favor, but the others could not. Compare Smith, 821 F.3d at 1269 n.2
Thus, under Haga, 482 F.3d at 1208, and Frantz, 509 F.3d at 1302-03, the ALJ has a duty to explain why she adopted some of Dr. Gucker's limitations while rejecting others. The Court must determine whether the ALJ adequately accounted for the limitations noted by Dr. Gucker in the RFC assessment. See Carver, 600 F. App'x at 619 ("if a consultant's Section III narrative fails to describe the effect that each of the Section I moderate limitations would have on the claimant's ability, or if it contradicts limitations marked in Section I, the MRFCA cannot properly be considered part of the substantial evidence supporting an ALJ's RFC finding"). If not, the Court must determine whether the ALJ adequately explained why she rejected the missing limitations.
The Commissioner argues that, even if the ALJ failed to include some limitations, this Court should find this harmless error because "[t]he ALJ's ultimate findings accounted for the doctors' opinions." Doc. 25 at 9 n.2. The Court disagrees. In this case, Dr. Gucker's Section III summary failed to sufficiently account for the moderate limitations assessed in Section I. As discussed above, the ALJ failed to sufficiently account for Ms. Heckel's limitations in her ability to get along with supervisors, in her ability to complete a normal workday and workweek without interruptions, and to perform at a consistent pace without an unreasonable number and length of rest periods. Under Haga and Frantz, the ALJ must either adopt these moderate limitations, or explain why she rejected them.
The ALJ erred in failing to incorporate several moderate or marked limitations assessed by CNS Capitano and Dr. Gucker into Ms. Heckel's RFC, without explanation. I remand so that the ALJ can explain the evidentiary basis for her RFC determination and her reasons for rejecting portions of the uncontroverted evidence.
Robinson v. Barnhart, 366 F.3d 1078, 1082 (10th Cir. 2004) (citation omitted).
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).