KIRTAN KHALSA, Magistrate Judge.
Claimant Christine Matlock ("Ms. Matlock") alleges that she became disabled on July 15, 2009, at the age of forty because of fibromyalgia, back pain, foot pain, neck pain, chronic sleeping disorder, depression, mood disorder, blurred vision, breathing problems, and thyroid problems. (Tr. 252, 271.
On November 26, 2012, Ms. Matlock protectively filed an application for Social Security Disability Insurance Benefits ("DIB") under Title II of the Social Security Act (the "Act"), 42 U.S.C. § 401 et seq. (Tr. 219-222, 253.) Ms. Matlock concurrently filed an application for Supplemental Security Income ("SSI") under Title XVI of the Act, 42 U.S.C. § 1381 et seq. (Tr. 223-28.) Ms. Matlock's applications were initially denied on February 22, 2013. (Tr. 69-82, 83-96, 97, 98, 131-35.) They were denied again at reconsideration on August 9, 2013. (Tr. 99-113, 114-28, 129, 130, 138-41.) On October 1, 2013, Ms. Matlock requested a hearing before an Administrative Law Judge ("ALJ"). (Tr. 142-43.) ALJ Myriam C. Fernandez Rice conducted a hearing on May 14, 2015. (Tr. 33-67.) Ms. Matlock appeared in person at the hearing with attorney representative Michael Armstrong. (Id.) The ALJ took testimony from Ms. Matlock (Tr. 39-59, 60-63), and an impartial vocational expert ("VE"), Judith Beard. (Tr. 59-61, 63-66.) On June 22, 2015, the ALJ issued an unfavorable decision. (Tr. 14-27.)
On September 3, 2016, the Appeals Council issued its decision denying Ms. Matlock's request for review and upholding the ALJ's final decision. (Tr. 1-4.) On November 4, 2016, Ms. Matlock timely filed a Complaint seeking judicial review of the Commissioner's final decision. (Doc. 1.)
An individual is considered disabled for purposes of Social Security disability insurance benefits if 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). The Social Security Commissioner has adopted the familiar five-step sequential analysis to determine whether a person satisfies the statutory criteria as follows:
See 20 C.F.R. § 404.1520(a)(4); Fischer-Ross v. Barnhart, 431 F.3d 729, 731 (10th Cir. 2005); Grogan v. Barnhart, 399 F.3d 1257, 1261 (10
This Court must affirm the Commissioner's denial of social security benefits unless (1) the decision is not supported by "substantial evidence" or (2) the ALJ did not apply the proper legal standards in reaching the decision. 42 U.S.C. § 405(g); Hamlin v. Barnhart, 365 F.3d 1208, 1214 (10
The ALJ made her decision that Ms. Matlock was not disabled at step four of the sequential evaluation. She found that Ms. Matlock had the residual functional capacity to perform light work as defined in 20 CFR 404.1567(a) and 416.967(a).
(Tr. 22.) Based on the RFC and the testimony of the VE, the ALJ concluded that Ms. Matlock was capable of performing her past relevant work as a medical coder and that she was not disabled. (Tr. 27.)
Ms. Matlock argues in support of her Motion that (1) the ALJ's decision does not include a necessary function-by-function assessment of Ms. Matlock's ability to do sustained work-related physical and mental activities in a work setting on a regular and continuing basis; and (2) the ALJ failed to properly evaluate the medical opinions of State agency examining psychological consultant Louis Wynne, Ph.D., State agency nonexamining psychological consultant Carol Mohney, Ph.D., and Treating Psychologist Bradley Samuel, Ph.D. (Doc. 22 at 8-16.) The Court finds grounds for remand as discussed below.
On February 3, 2012, Ms. Matlock presented to State agency examining psychological consultant Louis Wynne, Ph.D., for a disability determination examination.
Dr. Wynne summarized that
(Tr. 380.) Dr. Wynne's Axis I diagnoses included major depression, recurrent, severe, without psychotic features, and mood disorder/depression due to severe chronic illness. (Tr. 381.) Dr. Wynne noted an Axis III diagnosis of history of head injury "[p]er claimant allegations." (Id.) Dr. Wynne assessed a GAF score of 48.
The ALJ accorded only partial weight to Dr. Wynne's opinion explaining that (1) a good portion of his opinion was based on Ms. Matlock's self reports of a history of head injuries; (2) Dr. Wynne indicated that Ms. Matlock was a poor historian and her claims should be verified before any reliance was placed on them; (3) Ms. Matlock performed well on the mental exam testing; (4) Ms. Matlock was currently attending a certificate course for medical billing/coding, which involves more than basic simple instructions and tasks; and (5) Dr. Wynne does not have a treating relationship with the claimant and his evaluation was only a snapshot of the claimant's overall functional limitations. (Tr. 24-25.)
On February 21, 2013, State agency nonexamining psychological consultant Carol Mohney, Ph.D., reviewed Ms. Matlock's records at the initial level of evaluating Ms. Matlock's disability claim.
The ALJ noted in her determination, without more, that "[t]he State agency determined that the claimant could perform simple unskilled work with limited interactions with others[.]" (Tr. 26.)
On August 1, 2013, State agency nonexamining psychological consultant Paul Cherry, Ph.D., reviewed Ms. Matlock's records at the reconsideration level of evaluating Ms. Matlock's disability claim.
The ALJ noted in her determination, without more, that "[t]he State agency determined that the claimant could perform simple unskilled work with limited interactions with others[.]" (Tr. 26.)
On September 23, 2014, Ms. Matlock presented to Bradley Samuel, Ph.D., at the University of New Mexico's Department of Family and Community Medicine. (Tr. 471-72.) Ms. Matlock was referred by her primary care physician Valerie Carrejo, M.D., who stated "[t]his patient has a history of depression, anxiety and is requesting counseling." (Tr. 471.) Ms. Matlock reported a history of chronic pain in the form of fibromyalgia, sleeplessness, problems with blurry vision, depression, anxiety, and reports that all were chronic conditions. (Id.) She reported depression on and off since childhood. (Id.) She stated that her medical conditions began 20 years ago related to multiple causes, but in particular that she "swallowed a filling at a dentist's office" resulting in high mercury in her blood. (Tr. 470-71.) Ms. Matlock described her symptoms of depression and fibromyalgia as "foggy brain, chronic pain, as noted sleeping, hypersensitive to food, meds, thirst." (Tr. 471.) She also described depression as sadness, "at which point she became tearful." (Id.) Ms. Matlock endorsed passive suicidal ideation. (Id.)
On mental status exam, Dr. Samuel noted that Ms. Matlock was (1) very laid back, calm demeanor; (2) described herself as a "pushover"; (3) oriented in all spheres; (4) very talkative and anxious; (5) suicidal ideation noted — risk deemed low to moderate — will monitor; (6) attention, memory and concentration intact; and (7) tearful when asked to check in with herself and breath. (Id.)
Dr. Samuel admitted Ms. Matlock to the Behavioral Health Clinic and anticipated 6-12 sessions to address her depression, anxiety, and chronic pain. (Tr. 472.) Dr. Samuel's discharge diagnoses were (1) major depressive disorder, recurrent, moderate, and will assess for posttraumatic stress disorder. (Id.)
Ms. Matlock saw Dr. Samuel again on October 13, 2014. (Tr. 470.) Dr. Samuel noted that "[s]omatic concerns/sleep problems remain salient focus of treatment." (Id.) He noted that Ms. Matlock listed all of her ideas about her various medical problems, including "high mercury in [her] blood," and worried when the medical community didn't take her seriously. (Id.) Dr. Samuel noted that Ms. Matlock (1) reported emotional pain; (2) was quite tearful and sad; (3) was angry because of not feeling safe in the interpersonal sphere. (Id.) Dr. Samuel explained that Ms. Matlock conveyed she was not safe or comfortable in her own body, and that it was hard for her to trust doctors because they don't believe her. (Id.) Dr. Samuel indicated he was left wondering about the role anxiety and social anxiety played in Ms. Matlock's decision making. (Id.)
Dr. Samuel's discharge diagnosis on this date was major depressive disorder, recurrent, moderate. (Tr. 470.) Dr. Samuel indicated that Ms. Matlock was "unable to work due to multiple somatic medical conditions." (Id.) He planned to rule out conversion disorder and somatic disorder. (Id.)
On May 28, 2015, Dr. Samuel completed a Medical Assessment of Ability To Do Work-Related Activities (Mental). (Tr. 530-31.) In the category of "Understanding and Memory Limitations," Dr. Samuel assessed that Ms. Matlock had moderate limitations in her ability to understand and remember detailed instructions. (Tr. 530.) He made no assessment regarding Ms. Matlock's ability (1) to remember locations and work-like procedures and (2) to understand and remember very short and simple instructions. (Id.) Dr. Samuel explained that he was unable to comment because he had only seen Ms. Matlock twice, but that she reported memory and concentration difficulties and he noted at intake that she reported "foggy brain." (Id.) In the category of "Sustained Concentration and Persistence Limitations," Dr. Samuel assessed that Ms. Matlock had slight limitations in her ability to make simple work-related decisions; moderate limitations in her ability (1) to maintain attention and concentration for extended periods of time (i.e., 2-hour segments); and (2) to sustain an ordinary routine without special supervision. (Id.) He assessed she had marked limitations in her ability (1) to carry out detailed instructions; and (2) to perform activities within a schedule, maintain regular attendance and be punctual within customary tolerance. (Id.) Dr. Samuel made no assessment regarding Ms. Matlock's ability (1) to carry out very short and simple instructions; (2) to work in coordination with/or proximity to others without being distracted by them; and (3) to complete a normal workday and workweek without interruptions from psychological based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods. (Id.) Dr. Samuel explained that he was unable to evaluate "most of the above" because Ms. Matlock was seen for two one hour appointments and the focus was on treatment for depression and less on assessment for work. (Id.) In the category of "Social Interaction Limitations," Dr. Samuel assessed that Ms. Matlock had moderate limitations in her ability (1) to interact appropriately with the general public; and (2) to accept instructions and respond appropriately to criticism from supervisors. (Tr. 531.) He assessed marked limitations in her ability to ask simple questions or request assistance. (Id.) Dr. Samuel made no assessment regarding Ms. Matlock's ability (1) to get along with coworkers or peers without distracting them or exhibiting behavioral extremities; or (2) to maintain socially appropriate behavior and adhere to basic standards of neatness and cleanliness. (Id.) Dr. Samuel referred to Ms. Matlock's medical records and explained that he was unable to comment or assess this category in full. (Id.) Finally, the category of "Adaptation Limitations," Dr. Samuel made no assessments, and explained that he was unable to evaluate based on only two medical notes. (Id.)
Dr. Samuel described Ms. Matlock's mental limitations as "emotionally compromised / somatic complaints / "foggy brain" / sadness — chronic pain / difficulty tracking conversation." (Tr. 531.)
Dr. Samuel also completed a 12.04 Affective Disorders form and indicated that Ms. Matlock had depressive syndrome characterized by sleep disturbance, decreased energy, difficulty concentrating or thinking, and thoughts of suicide, that resulted in marked restrictions of activities of daily living, marked difficulties in maintaining social functioning, and marked difficulties in maintaining concentration, persistence, or pace. (Tr. 532.) Dr. Samuel also checked that Ms. Matlock had a medically documented history of a chronic affective disorder of at least 2 years' duration that has caused more than a minimal limitation of ability to do basic work activities, with symptoms or signs currently attenuated by medication or psychosocial support. (Id.)
The ALJ accorded Dr. Samuel's opinion little weight because he indicated he was unable to assess Ms. Matlock's limitations in several functional areas, because he had a limited treatment history with her, and because he indicated that he relied on her self-reports of symptoms to reach his conclusions. (Tr. 25.)
Ms. Matlock argues that the ALJ failed to properly evaluate the medical opinion evidence related to her mental impairments. Specifically, she argues that (1) the ALJ's reasons for rejecting Dr. Wynne's opinion are not legitimate and were based, in part, on speculation (2) the ALJ failed to evaluate Dr. Mohney's opinion at all, and to the extent the ALJ inadvertently adopted certain of Dr. Mohney's limitations, she rejected others without explanation; and (3) the ALJ applied the wrong legal standard in evaluating Dr. Samuel's opinion and failed to provide legitimate reasons for rejecting his opinion. (Doc. 22 at 11-16.) The Commissioner contends that the ALJ's RFC adequately accounted for Ms. Matlock's mental limitations. (Doc. 24 at 6-9.) The Commissioner specifically asserts that (1) the ALJ reasonably relied on Ms. Matlock's testimony regarding her online participation in a medical billing/coding class to determine that Ms. Matlock was capable of more than unskilled work; (2) the ALJ adequately captured the social limitations assessed by the various medical opinions, and (3) the ALJ reasonably called into question Dr. Samuel's status as a treating physician and properly relied on the constraints Dr. Samuel himself placed on his opinion. (Id.) The Commissioner concludes that although the ALJ's decision may be technically imperfect, the ALJ's reasoning is discernable and remand is not warranted. (Id.)
"An ALJ must evaluate every medical opinion in the record, although the weight given each opinion will vary according to the relationship between the disability claimant and the medical professional." Hamlin, 365 F.3d at 1215. Specifically, when assessing a claimant's RFC, an ALJ must explain what weight is assigned to each opinion and why. SSR 96-5p, 1996 WL 374183 at *5.
In discounting Dr. Wynne's opinion, the ALJ first explained that "a good portion of [Dr. Wynne's] opinion was based on Ms. Matlock's self reports of a history of head injuries." (Tr. 24.) The Court's review of Dr. Wynne's report does not support this explanation. In his report, Dr. Wynne documented Ms. Matlock's childhood medical history, in which she reported hitting her head on different occasions. (Tr. 379.) Dr. Wynne then noted an Axis III (general medical conditions)
The ALJ next explained that Dr. Wynne indicated that Ms. Matlock was a poor historian and that her claims should be verified before any reliance was placed on them. (Tr. 24.) However, the ALJ mischaracterized Dr. Wynne's statement. Dr. Wynne made no reference to discounting Ms. Matlock's "claims" based on being a poor historian. Instead, Dr. Wynne stated that the details in the following account of her various histories (childhood, education, family, employment and medical) should be verified before any reliance is placed on them because she was not a good historian. (Tr. 379.) Importantly, Dr. Wynne stated elsewhere in his opinion that Ms. Matlock cooperated fully with the examination and there was no reason to suspect malingering or dissimulation. (Tr. 380.) The ALJ's second explanation mischaracterizes Dr. Wynne's statement and is not supported by substantial evidence.
The ALJ next explained that she discounted Dr. Wynne's opinion because Ms. Matlock performed well on the mental status exam. However, Dr. Wynne was well aware of Ms. Matlock's performance on the mental status exam and nonetheless diagnosed her with major depression and mood disorder and assessed her with certain functional limitations. "[A] psychological opinion may rest either on observed signs and symptoms or on psychological tests," and Dr. Wynne's observations about Ms. Matlock's limitations constituted "specific medical findings." Robinson v. Barnhart, 366 F.3d 1078, 1083 (10
The ALJ's fourth explanation, that Ms. Matlock was "currently attending a certificate course for medical billing/coding, which involves more than basic simple instructions and tasks," is not supported by substantial evidence. (Tr. 24.) At the Administrative Hearing, Ms. Matlock testified that she was enrolled in an at-home study course for medical billing and coding. (Tr. 39.) She further testified that she previously worked as an "on-the-job training" medical coder in 2003. (Id.) The ALJ asked Ms. Matlock
(Tr. 39-40, 48-49.) The ALJ subsequently determined, based on this testimony, that since Ms. Matlock was in school for a semi-skilled job, she must have the mental capacity for semi-skilled work. The ALJ then concluded that Ms. Matlock was capable of performing her past relevant work as a medical coder. (Id.)
There are several problems with the ALJ's conclusion. First, the ALJ failed to make any of the necessary findings about the mental work demands of Ms. Matlock's previous "on-the-job training" medical coder position, which an ALJ must do in the second phase of the step four findings. The Tenth Circuit clearly instructs that
Winfrey v. Chater, 92 F.3d 1017, 1024 (10th Cir. 1996) (quoting Henrie v. United States Dep't of Health & Human Servs., 13 F.3d 359, 361 (10th Cir. 1993)) (emphasis added). Here, the ALJ made no inquiry into, or any findings specifying, the mental demands of Ms. Matlock's past relevant work as she actually performed it or as it is performed in the national economy. This is error. Id.
Second, the ALJ improperly relied on Ms. Matlock's enrollment in a self-study course, without more, as substantial evidence to support that Ms. Matlock could perform semi-skilled work. Here, other than Ms. Matlock's testimony about her enrollment in the course, the ALJ failed to obtain or provide in the record any objective evidence about the course itself. For example, there is no objective evidence regarding the educational online institution offering the course; what, if any, prerequisites were required for taking the course; the course's level of complexity; Ms. Matlock's performance in the course; the average time it should take to complete the course in comparison to the time Ms. Matlock is actually taking;
Finally, and contrary to the ALJ's statement that Ms. Matlock indicated she was not having difficulty with the course material (Tr. 26), Ms. Matlock testified that she struggled with comprehending the material "off and on" due to brain fog (Tr. 48). Ms. Matlock further testified that even though she was hoping to find some kind of work she could do at home, she was incapable of working full time at a job site and had not worked full time since 2003 due to her medical conditions. (Tr. 49.) Thus, the ALJ mischaracterized Ms. Matlock's testimony, and failed to consider whether Ms. Matlock was capable of performing the work on a continuing basis if she were to successfully complete her at-home course.
For these reasons, the ALJ's fourth explanation for discounting Dr. Wynne's opinion is not supported by substantial evidence.
Finally, the ALJ explained that Dr. Wynne did not have a treating relationship with the claimant and his evaluation was only a snapshot of her overall functional limitations. In Chapo v. Astrue, 682 F.3d 1285, 1291 (10
For all of the foregoing reasons, the Court finds that the ALJ's reasons for discounting Dr. Wynne's opinion are not supported by substantial evidence.
"`It is the ALJ's duty to give consideration to all the medical opinions in the record. [S]he must also discuss the weight [s]he assigns to such opinions,' including the opinions of state agency medical consultants." Mays v. Colvin, 739 F.3d 569, 578 (10
The ALJ failed to apply the correct legal standard in evaluating Dr. Samuel's opinion. See Langley, 373 F.3d at 1119 (describing what has come to be known as the treating physician rule for evaluating and weighing treating physician opinions). Instead, the ALJ incorrectly evaluated Dr. Samuel's opinion in accordance with SSR 06-03. SSR 06-3 clarifies how the Administration considers both opinion evidence from sources who are not "acceptable medical sources" and decisions by other governmental and nongovernmental agencies on the issue of disability or blindness, neither of which applies to Dr. Samuel. SSR 06-03p, 2006 WL 2329939, at *1. But Dr. Samuel is a clinical psychologist at the University of New Mexico Health Sciences' Department of Family & Community Medicine, and as such, is an acceptable medical source.
The ALJ also failed to provide legitimate reasons for discounting Dr. Samuel's assessment. The ALJ first explained that she discounted Dr. Samuel's opinion because he was unable to assess Ms. Matlock's limitations in several functional areas. (Tr. 25.) However, in completing the medical source statement, Dr. Samuel explained that he had only seen Ms. Matlock twice and that the focus of their sessions was on her depression and not on assessing her capacity for work. (Tr. 530.) Nonetheless, Dr. Samuel assessed certain functional limitations while leaving blank the areas of inquiry he determined he was unable to evaluate. (Id.) The ALJ had a duty to evaluate Dr. Samuel's assessed limitations by applying the factors set out in the regulations. See Langley, 373 F.3d at 1119 (even if a treating physician's opinion is not entitled to controlling weight, "[t]reating source medical opinions are still entitled to deference and must be weighed using all of the [regulatory] factors." Id. It was, therefore, improper for the ALJ to outright reject Dr. Samuel's assessed functional limitations simply because there were areas of functional limitation he determined he was unable to evaluate.
The ALJ next explained that she discounted Dr. Samuel's opinion because of the limited nature of their treatment history and because Dr. Samuel indicated that he relied on Ms. Matlock's self-reports of symptoms to reach his conclusion. (Tr. 25.) As to the former, although the length of the treatment relationship and the frequency of examination is one of the factors an ALJ must consider in evaluating and weighing a treating source opinion, it is not the only one. Hamlin, 365 F.3d at 1215. Here, the ALJ failed to consider at all that Dr. Samuel was a treating source and that his assessed limitations were consistent with the other medical opinions in the record.
For all of the foregoing reasons, the ALJ failed to properly evaluate the medical opinion evidence related to Ms. Matlock's mental impairments and the ALJ's mental RFC is not supported by substantial evidence. As such, this case requires remand.
The Court will not address Ms. Matlock's remaining claims of error because they may be impacted by the ALJ's treatment of this case on remand. Wilson v. Barnhart, 350 F.3d 1297, 1299 (10
For the reasons stated above, Ms. Matlock's Motion to Remand or Reverse (Doc. 22) is