LAURA FASHING, Magistrate Judge.
THIS MATTER comes before the Court on plaintiff Jerold Thomas Ellis's Motion to Reverse and Remand (Doc. 22), which was fully briefed on October 2, 2016. Docs. 25, 26, 27. The parties consented to my entering final judgment in this case. Doc. 12. 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 Diane Fligstein, Ph.D. and Cassandra Clark, Ph.D. The Court therefore GRANTS Mr. Ellis's motion and remands this case to the Commissioner for further 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
Mr. Ellis, 52, left school after the eleventh grade to join the United States Marine Corps, but was discharged after 2.5 years for behavioral problems. AR 233, 316. He earned his GED in 1983. AR 47, 262. He worked for many years installing heating and air conditioning units. AR 45, 302, 316. Mr. Ellis filed applications for disability insurance benefits and supplemental security income on March 13, 2012—alleging disability since March 28, 2007 due to major depressive disorder, anxiety disorder, and panic disorder with agoraphobia. AR 233-40, 261. The Social Security Administration ("SSA") denied his claims initially on April 30, 2012. AR 132-55. The SSA denied his claims on reconsideration on July 24, 2012. AR 191-96. Mr. Ellis requested a hearing before an ALJ. AR 199-200. On July 17, 2013, ALJ Barry O'Melinn held a hearing. AR 38-75. ALJ O'Melinn issued his unfavorable decision on February 14, 2014. AR 18-37.
At step one, the ALJ found that Mr. Ellis had not engaged in substantial, gainful activity since March 28, 2007. AR 23.
AR 26.
At step four, the ALJ concluded that Mr. Ellis was unable to perform any of his past relevant work as a heating, ventilation, and air conditioning installer. AR 30. The ALJ found that Mr. Ellis was not disabled at step five, concluding that he still could perform jobs that exist in significant numbers in the national economy—including an assembler, box labeler, and electronic assembler. AR 31-32.
Mr. Ellis requested review by the Appeals Council, which, on August 11, 2015, denied the request. AR 1-5. Mr. Ellis timely filed his appeal to this Court on October 13, 2015. Doc. 1.
Mr. Ellis raises two arguments for reversing and remanding this case: (1) the ALJ failed to adequately discuss the findings of non-examining state agency psychological consultant Dr. Diane Fligstein, and failed to adopt or reject several moderate mental limitations noted in her opinion; and (2) the ALJ improperly picked and chose from the mental limitations found by the examining psychological evaluator Dr. Cassandra Clark. For the reasons discussed below, the Court agrees, and will remand to the Commissioner for proper evaluation of the medical opinions.
Although an ALJ need not discuss every piece of evidence, he or 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 (July 2, 1996). "[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 Haga, the Tenth Circuit 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. In Frantz v. Astrue, 509 F.3d 1299, 1302-03 (10th Cir. 2007), the Tenth Circuit expressly applied Haga and its reasoning to the opinions of non-examining physicians.
Dr. Diane Fligstein, a non-examining state agency psychologist, evaluated Mr. Ellis's claims on reconsideration. AR 158-81. Mr. Ellis argues that the ALJ committed legal error by failing to discuss Dr. Fligstein's findings that Mr. Ellis would "have occasional interruptions from psychological symptoms" and that "he may require assistance or additional time to adjust to change in the workplace before being in line with his peers."
Dr. Fligstein found that Mr. Ellis had numerous marked and moderate limitations, of which the following are pertinent to this appeal:
AR 165-66. In the narrative for this category of limitations, Dr. Fligstein found that Mr. Ellis could perform "SRTs [short, routine tasks], no complex tasks, for a normal day/week w/ occasional interruptions from psych sx's [psychological symptoms]." AR 166.
AR 166. In the narrative for this category of limitations, Dr. Fligstein found that Mr. Ellis "may require assistance or additional time to adjust to change in the workplace. Afterward, he would be in line w/peers." AR 167.
The ALJ's opinion contains only two cursory references to Dr. Fligstein's opinion, and no discussion of the specific mental limitations she found. First, the ALJ stated that "the State agency determined that the claimant could perform work which is heavy/to very heavy in exertion, and could meet the mental demands of at least unskilled work with limited contact with others." AR 29. Second, the ALJ stated that he gave the opinions of the state agency medical consultants
The Commissioner concedes that the ALJ did not discuss the specific mental limitations in Dr. Fligstein's opinion, but argues that the ALJ's opinion accounted for all of the limitations. Doc. 25 at 4. The Commissioner argues that the Court is limited to substantial evidence review and cannot "second-guess the ALJ and determine that the ALJ's finding does not account for these limitations." Doc. 25 at 5 (citing Newbold v. Colvin, 718 F.3d 1257, 1262 (10th Cir. 2013)). This, however, is the wrong standard of review. The ALJ's failure to explain why he rejected the limitations in Dr. Fligstein's opinion is legal error. See Haga, 482 F.3d at 1207; see also Clifton, 79 F.3d at 1009. When an ALJ fails to apply the correct legal standard, the substantial evidence standard of review "do[es] not apply, and such failure constitutes grounds for reversal." Casias v. Sec'y of Health & Human Servs., 933 F.2d 799, 801 (10th Cir. 1991) (internal citations omitted). Because of the bar against post hoc rationalizations, the only possible salvage for a legally flawed decision is a "harmless error" analysis. Allen v. Barnhart, 357 F.3d 1140, 1145 (10th Cir. 2004). In reviewing Social Security cases, harmless error only applies if "no reasonable administrative factfinder, following the correct analysis, could have resolved the factual matter in any other way." Id.
The Commissioner argues that the ALJ's failure to discuss the specific mental limitations in Dr. Fligstein's opinion is harmless because the ALJ considered the opinion of Dr. Eather, which was essentially identical. Doc. 25 at 4. The Court is not persuaded. As Mr. Ellis points out, the ALJ only considered Dr. Eather's opinion at Step 3, and did not consider the specific mental limitations in the opinions of either Dr. Eather or Dr. Fligstein at Step 4. Doc. 26 at 1. As the ALJ himself admitted, the mental impairment analysis at steps 2 and 3 of the sequential evaluation process cannot substitute for the more detailed mental function assessment required at steps 4 and 5. AR 26; SSR 96-8p, 1996 WL 374184, at *4. In addition, the ALJ's failure to discuss Dr. Fligstein's opinion is not harmless because, as Mr. Ellis points out, the ALJ failed to adequately address Dr. Fligstein's findings that he would "have occasional interruptions from psychological symptoms" and "that he may require assistance or additional time to adjust to change in the workplace before being in line with his peers." Doc. 22 at 10.
First, the ALJ failed to adequately address the limitation in Mr. Ellis's ability to complete a normal workday and workweek without psychologically based interruptions, and to perform at a consistent pace without an unreasonable number and length of rest periods. Dr. Fligstein found that Mr. Ellis had a moderate limitation in this ability, and stated in her conclusions that Mr. Ellis would have "occasional interruptions from pscyh sx's [psychological symptoms]." AR 166. The ALJ did not point to any evidence contradicting the fact that Mr. Ellis has at least a moderate impairment in this area. However, the ALJ failed to explain why he rejected this limitation.
Second, the ALJ failed to include any limitation concerning Mr. Ellis's ability to adjust to changes in the workplace. Dr. Fligstein found that Mr. Ellis had a moderate limitation in his ability to respond appropriately to changes in the work setting, and that he "may require assistance or additional time to adjust to change in the workplace. Afterward, he would be in line w/peers." AR 166. The ALJ did not point to any evidence contradicting the fact that Mr. Ellis has at least a moderate impairment in this area and that he needed additional time to adjust to change. However, the ALJ failed to explain why he rejected this limitation. The mental abilities needed for any job include "the ability to respond appropriately to changes in (a routine) work setting." Social Security Program Operations Manual System ("POMS") § DI 25020.010, http://policy.ssa.gov/poms.nsf/lnx/0425020010. The ALJ found that Mr. Ellis had the RFC to "deal with routine changes in the work setting," but did not address Dr. Fligstein's findings about impairment in this area before coming to this conclusion. An ALJ "must discuss the uncontroverted evidence he chooses not to rely upon, as well as significantly probative evidence he rejects." Clifton, 79 F.3d at 1010. The ALJ's failure to address this basic work function in the RFC requires remand.
Mr. Ellis argues that the ALJ improperly picked and chose from the limitations noted by examining psychological evaluator Dr. Cassandra Clark. Doc. 22 at 11. Specifically, Mr. Ellis argues that the ALJ gave Dr. Clark's opinion "significant weight" and adopted the limitation Dr. Clark found in his ability to interact socially, while ignoring the limitations Dr. Clark found in his abilities to work without supervision and to keep to a schedule. Id. The Commissioner counters that Mr. Ellis has failed to show that Dr. Clark's opinion is inconsistent with the RFC. Doc. 25 at 5. For the reasons discussed below, the Court finds that the ALJ did not adequately address the limitations noted in Dr. Clark's opinion.
Dr. Clark noted that Mr. Ellis was moderately impaired in his "ability to function without supervision" and "would likely require supervision to keep him on task and possibly to remind him of procedures." AR 410. The ALJ noted Dr. Clark's finding of a moderate limitation in his ability to function without supervision. AR 29. The ALJ's opinion, however, neither explicitly rejects this limitation, nor includes it in Mr. Ellis's RFC. The Commissioner attempts to gloss over this omission by arguing that "[t]he ALJ found plaintiff could respond appropriately to supervisors and coworkers, and so would be receiving supervision. . . ." Doc. 25 at 5. The ability to respond appropriately to supervisors, however, is not the same as the ability to work without supervision. See Jaramillo v. Colvin, 576 F. App'x 870, 875-76 (10th Cir. 2014) (unpublished) (finding the basic mental ability of unskilled work to "respond appropriately to supervision" does not capture a moderate limitation in the ability to work without supervision); see also Mental Residual Functional Capacity Assessment form SSA-4734-F4-SUP
Second, Dr. Clark noted that Mr. Ellis was moderately impaired in his "ability to behave appropriately" because he "[h]as difficulty keeping to a schedule." AR 410. While the ALJ reports the fact that Dr. Clark found a moderate impairment in Mr. Ellis's ability to behave appropriately, AR 29, the ALJ makes no mention of his difficulty keeping to a schedule—and the ALJ failed to either reject or incorporate this limitation into Mr. Ellis's RFC. The Commissioner argues that the "RFC accounts for Plaintiff's difficulty with a schedule by limiting [him] to only two hour periods of concentration allowing him to take regular breaks." Doc. 25 at 5. Mr. Ellis asserts that this is a post hoc rationalization as neither the ALJ nor the record suggests that his assessed difficulty in keeping to a schedule would be addressed by regular breaks. Doc. 26 at 3. The Court agrees. Allowing Mr. Ellis to take scheduled breaks does not account for limitations in his ability to follow a schedule. See MRFCA, SSA-4734-F4-SUP (listing "the ability to perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances" and "the ability to complete a normal workday and workweek without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods" as two separate functional capacities); see also Chapo, 682 F.3d at 1289-90 (listing the ability to "perform activities within a schedule" and the ability to "perform at a consistent pace without an unreasonable number or length of rest periods" as two separate considerations). The Commissioner improperly conflates these separate considerations.
The ALJ erred in failing to incorporate several moderate limitations assessed by Dr. Fligstein and Dr. Clark into Mr. Ellis's RFC without explanation. The Court remands so that the ALJ can explain the evidentiary basis for his RFC determination and his reasons for rejecting portions of the uncontroverted evidence.