LOURDES A. MARTÍNEZ, Magistrate Judge.
On February 13, 2012 (Doc. 13-9 at 4), Plaintiff protectively filed an application for Disability Insurance Benefits (hereinafter "DBI"), alleging disability that began on January 10, 2012 (id.), and that his disability was due to heart attack, back problems, high blood pressure, asthma, and coronary artery stent (id. at 8). Plaintiff's application was denied at the initial level on August 14, 2012 (Doc. 13-5 at 2), and at the reconsideration level on June 12, 2013 (id. at 3). Plaintiff requested a hearing to review the denial of his application (Doc. 13-6 at 27), and Administrative Law Judge Michael S. Hertzig (hereinafter "ALJ") conducted a hearing on March 31, 2014 (Doc. 13-3 at 24-70) (hereinafter "March Hearing"). Plaintiff appeared by phone at the March Hearing, represented by his current counsel, and testified (id. at 26, 35-67), as did Vocational Expert Mary Diane Weber
On January 15, 2015, the ALJ issued a decision (Doc. 13-3 at 16-23) finding that, under the relevant sections of the Social Security Act, Plaintiff "was not disabled prior to February 6, 2013 . . . but became disabled on that date and has continued to be disabled through the date of this decision" (id. at 23). On February 6, 2015, Plaintiff requested that the Appeals Council review the ALJ's decision. Id. at 11. On May 22, 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 2. This decision was the final decision of the Commissioner. On July 24, 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. § 1382c(a)(3)(A); 20 C.F.R. § 416.905(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. § 416.920; 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 was born on July 14, 1948 (Doc. 13-3 at 35), and was 63 years old on January 10, 2012, the alleged date of disability onset (Doc. 13-9 at 4). Thus, for the purposes of his disability claim, Plaintiff is considered to be a person "closely approaching retirement age."
Plaintiff's medical records include: Treatment records from the Veteran's Administration dated October 17, 2012 to February 6, 2013 (Doc. 13-16 at 13-30); Medical Assessment of Ability to do Work-Related Activities (Mental), dated March 6, 2014, from Laura Cruz-Hinson, M.D. (Doc. 13-17 at 3-6); Medical Assessment of Ability to do Work-Related Activities (Physical) and (Non-Physical), dated March 14, 2014, from Marlene Bynum, M.D. (id. at 8-9); and Medical records from the Department of Veterans Affairs, for the period from January 2, 2013 through March 14, 2014 (id. at 15-51).
At step one of the five-step evaluation process, the ALJ found that Plaintiff had not engaged in substantial gainful activity since the date he claimed his disability began. [Doc. 13-3 at 18]. At step two, the ALJ found that Plaintiff has had the following severe impairments since January 10, 2012, which is the alleged disability onset date: "Hypertension, ischemic heart disease, and asthma." Id. The ALJ also found that, since February 6, 2013, Plaintiff has had additional severe impairments of post-traumatic stress disorder ("PTSD") and "an affective disorder." Id. At the third step, the ALJ found that "[p]rior to February 6, 2013," Plaintiff "did not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 404.1520(d), 404.1525 and 404.1526)." Id. at 19. In so finding, the ALJ considered cardiovascular, skin, endocrine system, and mental disorder listing categories. Id. (citing Listing categories 4.00, 8.00, 9.00, and 12.00). Prior to step four, the ALJ determined that, for the period from January 10, 2012 to February 6, 2013, Plaintiff had the RFC, to:
Id. In support of this RFC assessment, the ALJ found that Plaintiff's "medically determinable impairments could reasonably be expected to cause the alleged symptoms; however, [Plaintiff]'s statements concerning the intensity, persistence and limiting effects of these symptoms are not entirely credible prior to February 6, 2013, for the reasons explained in this decision." Id. at 21.
At step four, the ALJ found that Plaintiff "has been unable to perform any past relevant work" since January 10, 2012, because the demands of Plaintiff's previous work exceed his current RFC. Id. At step five, the ALJ found that, prior to February 6, 2013, jobs existed in significant numbers in the national economy that Plaintiff could have performed. Id. at 22. The ALJ indicated that, "if [Plaintiff] had the [RFC] to perform the full range of medium work, a finding of `not disabled' would be directed by Medical-Vocational Rule 203.07," but that Plaintiff's ability to perform medium work "was impeded by additional limitations." Id. Therefore, the ALJ relied on VE Trost's
In his motion, Plaintiff argues that the ALJ: (1) did not provide a legitimate medical basis for the February 6, 2013 disability onset date (Doc. 18 at 2); and (2) impermissibly ignored the sworn statement of Wanda Morgan, Plaintiff's sister (id.). Defendant responds that the medical records were sufficient to determine a valid date of Plaintiff's onset of disability (Doc. 24 at 9); and (2) it was unnecessary for the ALJ to "specifically discuss" the sworn statement, which was "offered nearly a year and a half after the date the ALJ found Plaintiff disabled," because the limitations it described had already been rejected (id. at 11). In reply, Plaintiff argues that the ALJ's determination that his anxiety from PTSD met Listing 12.06 as of February 2013 fails to discuss record evidence to the contrary, particularly the medical records of Marlene G. Bynum, M.D., his primary care physician. [Doc. 28].
Plaintiff challenges the ALJ's determination of the date upon which Plaintiff became disabled by an "Anxiety Disorder," as set forth in Listing 12.06. [Doc. 18 at 10-15]. Initially, Plaintiff claimed to have only physical impairments that caused him to become disabled on January 10, 2012. [Doc. 13-9 at 8]. However, based on medical assessments, Plaintiff later added "major depressive disorder, anxiety, and post-traumatic stress disorder" to his disability claim. [Doc. 13-10 at 23]. The ALJ found that Plaintiff's physical impairments, while severe, were not disabling. [Doc. 13-3 at 22-23]. The ALJ also found that, beginning on February 6, 2013, Plaintiff had additional severe impairments of "PTSD[] and an affective disorder."
On October 17, 2012, Plaintiff reported to Marlene G. Bynum, M.D., his primary health care provider, that he'd been "doing ok except for depressed × 3 months." [Doc. 13-16 at 26]. Dr. Bynum reported that Plaintiff "decline[d] psyc[hiatric] referral," and started him on a trial of sertraline,
"The onset date of disability is the first day an individual is disabled as defined in the Act and the regulations." Soc. Sec. Rep. 83-20, at*1 (emphasis added). Where a disability is of traumatic origin, the date of onset is the date of the traumatic injury." Blea v. Barnhart, 466 F.3d 903, 909 (10th Cir. 2006) (citing SSR 83-20 at *2). However, where disabilities are not the result of traumatic injury, the date of onset is more complicated, and "it is sometimes impossible to obtain medical evidence establishing the precise date [a non-traumatic] impairment became disabling." SSR 83-20 at 2. Unlike traumatic impairments, non-traumatic impairments do not typically become disabling on the date on which the claimant first experiences symptoms. Nonetheless, "[p]articularly in the case of slowly progressive impairments, it is not necessary for an impairment to have reached listing severity (i.e., be decided on medical grounds alone) before onset can be established." Id. Thus, in cases of non-traumatic disability, "it will be necessary to infer the onset date from the medical and other evidence that describe the history and symptomatology of the disease process." Id. Where it is reasonable to "infer that the onset of a disabling impairment[] occurred some time prior to the date of the first recorded medical examination," the determination of onset "depends on an informed judgment of the facts," which "must have a legitimate medical basis." Id. at *3. A "convincing rationale must be given for the date selected." Id. Thus, in Blea, 466 F.3d at 909 n.1, the Tenth Circuit held that SSR 83-20 "requires the assistance of a medical advisor whenever `onset' must be inferred."
In this case, the ALJ found that Plaintiff was not disabled "prior to February 6, 2013." [Doc. 13-3 at 22-23]. In so finding, the ALJ focused principally on Plaintiff's physical impairments, but also found that Plaintiff's "alleged mental impairment [sic]" were "not severe, causing no more than mild limitations in functioning," prior to February 6, 2013. Id. at 21. However, the ALJ determined that, "[b]eginning on February 6, 2013, the severity of [Plaintiff]'s impairments
A. Medical documentation of the requirements of paragraph 1, 2, or 3:
20 C.F.R. Pt. 404, Subpt. P, App'x 1, ¶ 12.06. Significantly, the ALJ's decision neither indicates how Plaintiff's mental impairments met the criteria of Listing 12.06, nor what medical evidence was considered in reaching that conclusion. See [Doc. 13-3 at 23]. An ALJ's failure "to adequately discuss the evidence and tie his conclusions to the evidence" with respect to listing severity is "based on legal error and must be reversed." Carpenter v. Astrue, 537 F.3d 1264, 1270 (10th Cir. 2008). Additionally, the ALJ's only statements in support of his finding that Plaintiff's mental impairments were non-severe prior to February 6, 2013, were that Plaintiff had not received "any mental health treatment" prior to that date, had "declined referral to a psychologist [sic] in October 2012," and was not on medication. Id. at 18. These statements, which are cursory at best, are also inaccurate. Dr. Bynum began treating Plaintiff's depression with medication in October 2012. [Doc. 13-16 at 27].
In March 2014, Dr. Bynum (Doc. 13-17 at 3-4) filled out a mental assessment form that indicated Plaintiff had "marked" limitations in several work-related areas.
Grotendorst v. Astrue, 370 F. App'x 879, 883 (10th Cir. March 22, 2010) (unpublished).
Here, however, both the ALJ and his expert consultant clearly used the date on which Plaintiff was first seen by Dr. Cruz-Hinson as the defining factor in determining when his mental impairments became both severe and disabling. See [Doc. 13-3 at 23; Doc. 13-4 at 8-10]. In so concluding, the ALJ appears to have relied entirely on the testimony of Jack E. Bentham, M.Ed., Ph.D., a non-examining psychologist hired by the Administration. [Doc. 13-3 at 23; Doc. 13-4 at 6]. See also [Doc. 13-7 at 34-35 and 40]. Although Dr. Bentham did not submit a written opinion, he testified at the December Hearing that he had found "no medical treatment record from a psychiatrist or psychologist
In the decision, the ALJ states that Dr. Bentham "testified that he had an opportunity to consider all of the medical evidence and stated that he had considered the medical source statement in [Doc. 13-17 at 2-5], but found that the diagnoses and restrictions identified therein were not supported by the objective medical findings until February 6, 2013." [Doc. 13-3 at 23]. This characterization significantly misrepresents Dr. Bentham's testimony. Effectively, Dr. Bentham testified that, as far as he knew, the first time Plaintiff received treatment from a psychologist or psychiatrist for mental issues was on February 6, 2013. [Doc. 13-4 at 10]. In even reaching that conclusion, Dr. Bentham had to be directed by the ALJ, since he appeared to neither fully understand his role at the hearing, nor be at all familiar with the records he supposedly "reviewed." Id. at 8-9. Logically, if the first date of mental health treatment defines the onset date of disability, there would be no need to consult with a medical expert regarding onset, since the ALJ should certainly be capable of determining that date on his own.
In this case, the ALJ not only failed to properly determine the onset date of Plaintiff's disability, he also failed to explain his "finding" that Plaintiff was presumptively disabled pursuant to Listing 12.06. Dr. Cruz-Hinson was the only physician to assess Plaintiff's mental impairments for listing-level severity, and she indicated that Plaintiff's impairments met the criteria for both Listing 12.06 and 12.04. However, the ALJ not only failed to discuss medical opinions, he also did not explain why he determined Plaintiff was disabled under Listing 12.06. Instead, the ALJ accorded "significant weight" to Dr. Bentham's opinion that Dr. Bentham "agreed with the assessment of [Plaintiff]'s treating physician in finding [Plaintiff] `markedly' limited in his ability to complete a normal workweek, and [to] sustain an ordinary routine without special supervision," but that those opinions "were not supported by the objective medical findings until February 6, 2013." [Doc. 13-3 at 23]. As already noted, this statement inaccurately describes Dr. Bentham's testimony. In addition, the decision cites "Exhibit 17F"
An ALJ has a duty to discuss the evidence and to explain his findings regarding listing-level severity. Clifton v. Chater, 79 F.3d 1007, 1009 (10th Cir. 1996) (citing 42 U.S.C. § 405(b)(1)).
Moreover, a reviewing court must also consider "anything that may undercut or detract from the ALJ's findings in order to determine if the substantiality test has been met." Grogan, 399 F.3d at 1262. The record in this case does contain evidence that appears to conflict with the ALJ's "established onset date." For example, Dr. Cruz-Hinson's initial evaluation of Plaintiff specifically indicates that Plaintiff was depressed enough to plan a suicide in 2010 (Doc. 13-16 at 16), and had reported "feeling depressed for a while," noting immediately thereafter that he had divorced three years prior to their first meeting; lives with his sister, which was a strain; lost his job and his truck; and "feels like he lost everything" (id. at 15). Thus, according to Dr. Cruz-Hinson's notes, Plaintiff began suffering from symptoms of depression at least three years prior to Dr. Cruz-Hinson's initial evaluation of him. Dr. Cruz-Hinson also disclosed that the trauma underlying Plaintiff's PTSD was suffered both in childhood and during Plaintiff's time in the military, from 1968 to 1970. Id. at 16, 18. As such, Dr. Cruz-Hinson specifically diagnosed Plaintiff with "PTSD military/childhood." Id. at 20. These statements do not support the ALJ's determination that Plaintiff's mental impairments became both severe and disabling on the day the records were made.
Additionally, while it was Plaintiff's depression that led Dr. Bynum to refer Plaintiff to Dr. Cruz-Hinson for psychiatric treatment (id. at 23), Dr. Cruz-Hinson diagnosed Plaintiff with both depression and PTSD (id. at 20). The ALJ found that "[b]eginning on the established onset date of disability, February 6, 2013," Plaintiff had "severe impairments" that included "PTSD, and an affective disorder." [Doc. 13-3 at 18]. The ALJ did not discuss Plaintiff's depression either with respect to Listing 12.04 or as it may have affected the severity or onset of PTSD. However, while "PTSD confers significant psychiatric disturbance, functional impairment, and morbidity as a singular diagnosis, depression and PTSD commonly co-occur. Research suggests, for example, that significant depressive symptomatology affects between 30% and 50% of persons diagnosed with PTSD."
no genuine analysis of either of those impairments, nor did he consider the effects on Plaintiff of having both impairments together. The ALJ most definitely did not give a "convincing rationale" for his determination of onset date, as is required by SSR 83-20. Rather, it appears that the ALJ simply accepted Dr. Cruz-Hinson's diagnosis of PTSD (Doc. 13-16 at 20), and then arbitrarily determined that the disability onset date of that disorder was the date on which Plaintiff was initially diagnosed. In choosing the onset date, the ALJ also completely ignored indications by the diagnosing physician that Plaintiff's mental impairments arose from events that significantly preceded their diagnoses. See id. at 15-21. The ALJ provided neither a legal nor a factual basis for the onset date and, instead, merely asserted that the date had been determined by Dr. Bentham. [Doc. 13-3 at 23]. Even if Dr. Bentham did determine the onset date, he did so based on principles that are not legally sound. In sum, the determination of disability onset in this case precludes informed review by this Court and, therefore, requires reversal and remand for further consideration of Plaintiff's impairments and an analysis of the onset of his disability.
"The impact of lay evidence on the decision of onset will be limited to the degree it is not contrary to the medical evidence of record." SSR 83-20 at *3. Plaintiff contends that the ALJ "impermissibly ignored" the sworn statement of his sister, Wanda Morgan (Doc. 13-10 at 25), noting that the ALJ "did not mention the third party statements when evaluating the credibility of [Plaintiff]'s complaints." [Doc. 18 at 15]. Defendant argues that SSR 06-3p only requires an ALJ to consider "other source" opinions "when such opinions may have an effect on the outcome of the case." [Doc. 24 at 12] (quoting SSR 06-3p at *6). Plaintiff and Defendant each offer their own interpretation of the time frame to which Ms. Morgan refers in her statement. Defendant claims that "Ms. Morgan's opinion described Plaintiff's functional limitations as of July 2014, or near that time," and as such, the statement "bears no significance on the issue of whether Plaintiff was disabled prior to February 2013." Id. at 11-12. Plaintiff responds that Defendant's interpretation is contradicted by Ms. Morgan's own statement, in which she said that "Rixey is my brother so I have known him for his entire life. Rixey has lived with me for the past 4 years and I see him every day." [Doc. 28 at 4].
Unfortunately, both of these arguments miss the mark. In her statement, Ms. Morgan describes Plaintiff's difficulties with his memory and, to a limited extent, his anxiety when she is not at home. [Doc. 13-10 at 25]. Ms. Morgan also discusses the physical effects that Plaintiff's heart attack and "stroke" have had on him. Id. What she simply does not discuss, however, is when Plaintiff's disabling mental impairments began. It does not matter whether Ms. Morgan was discussing Plaintiff's condition during their entire relationship, over the last four years, or simply in 2014, because nothing in her statement is tied to a specific time period and, more importantly, she did not address the progression of Plaintiff's mental symptoms. In fact, Ms. Morgan only briefly alluded to Plaintiff's anxiety at all, as she discussed primarily his memory and physical issues instead. Id. The ALJ found that Plaintiff's physical impairments were not alone disabling (Doc. 13-3 at 18), which is a determination that Plaintiff has not addressed in this appeal. Therefore, this Court finds Plaintiff's claim that the sworn statement of Ms. Morgan supports an earlier disability onset date to be without merit.
For the reasons stated above, the Court