LAURA FASHING, Magistrate Judge.
THIS MATTER comes before the Court on plaintiff Deidre Simona Castillo-Rael's Motion to Reverse and Remand for Rehearing with Supporting Memorandum (Doc. 17), which was fully briefed on September 7, 2017. See Docs. 19, 20, 21. The parties consented to my entering final judgment in this case. Docs. 3, 5, 6. Having meticulously reviewed the entire record and being fully advised in the premises, I find that the Administrative Law Judge ("ALJ") erred by failing to properly weigh the opinions of the non-examining state agency psychologists. I therefore GRANT Ms. Castillo-Rael's motion and remand 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
Ms. Castillo-Rael was born in 1983, completed the eleventh grade, and later completed an EMT program. AR 36, 207, 258.
At step one, the ALJ found that Ms. Castillo-Rael had not engaged in substantial, gainful activity since the earlier of her alleged onset dates.
AR 16-17.
At step four, the ALJ concluded that Ms. Castillo-Rael was unable to perform her past relevant work as an aircraft loader, a sales clerk, a personal trainer, or a surveillance systems monitor. AR 20. The ALJ found Ms. Castillo-Rael not disabled at step five because she could perform jobs that exist in significant numbers in the national economy—such as addresser, flat work tier,
Ms. Castillo-Rael raises five arguments for reversing and remanding this case: (1) the ALJ failed to account for all of the moderate limitations found by consultative psychological examiner Dr. Louis Wynne; (2) the ALJ gave invalid reasons for rejecting the opinion of treating counselor Linda E. Friedman, LPCC; (3) the ALJ failed to properly weigh the opinions of the non-examining state agency psychologists; (4) the ALJ relied on improper factors in setting her RFC and finding that she was not disabled; (5) the vocational expert's testimony was unsupportable and unreliable. See Doc. 17. I find that the ALJ failed to properly weigh the opinions of the non-examining state agency psychologists. Because I remand based on this error, I do not address the other alleged errors, which "may be affected by the ALJ's treatment of this case on remand." Watkins v. Barnhart, 350 F.3d 1297, 1299 (10th Cir. 2003).
Ms. Castillo-Rael argues that the ALJ improperly rejected some of the moderate mental limitations in the opinions on the non-examining agency doctors. Doc. 17 at 13-14. She essentially argues that the ALJ impermissibly "picked and chose" from the moderate limitations in their opinions. Id. at 14.
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. "[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)).
The ALJ's findings must be sufficiently specific to allow for meaningful review. See Langley, 373 F.3d at 1123. If the ALJ's decision is not articulated with sufficient particularity to allow for judicial review, the court cannot affirm the decision as legally correct. Clifton v. Chater, 79 F.3d 1007, 1009 (10th Cir. 1996). According to SSR 96-8p, the RFC assessment "must include a narrative discussion describing how the evidence supports each conclusion, citing specific medical facts (e.g., laboratory findings) and nonmedical evidence (e.g., daily activities, observations)." SSR 96-8p, 1996 WL 374184, at *7 (July 2, 1996). The ALJ must also explain "how any material inconsistencies or ambiguities in the evidence in the case record were considered and resolved." Id. "The RFC assessment must always consider and address medical source opinions. If the RFC assessment conflicts with an opinion from a medical source, the [ALJ] must explain why the opinion was not adopted." Id. When the ALJ fails to provide an adequate narrative discussion describing how the evidence supports each conclusion, citing to specific medical facts and nonmedical evidence, the court will conclude that his RFC conclusions are not supported by substantial evidence. See Southard v. Barnhart, 72 F. App'x 781, 785 (10th Cir. 2003) (unpublished) ("Because the ALJ failed to make all the detailed findings required by the regulations and rulings at step four, his RFC conclusions are not supported by substantial evidence.").
On August 12, 2013, state agency psychologist Julian Lev, Ph.D. completed a Mental Residual Functional Capacity Assessment ("MRFCA"), opining that Ms. Castillo-Rael had the following limitations:
AR 63-65. In Section III of the MRFCA, Dr. Lev stated that "[c]laimant retains the capacity to understand, remember, and carry out simple but not detailed instructions and can relate appropriately to co-worker, supervisors, and the general public on an incidental basis." AR 65. On reconsideration, state agency psychologist Ralph Robinowitz, Ph.D. found identical moderate limitations and made identical Section III findings. AR 102-04.
The ALJ failed to discuss the opinions of Dr. Lev or Dr. Robinowitz in determining Ms. Castillo-Rael's RFC. See AR 16-20. The ALJ did not state what weight he gave either of the opinions. This was legal error. See Keyes-Zachary, 695 F.3d at 1161. The only reference the ALJ made to Dr. Lev's and Dr. Rabinowitz's opinions in the RFC assessment was to say that the RFC was "supported by . . . the opinions of the state agency physicians." AR 20. The ALJ did discuss Dr. Lev's and Dr. Rabinowitz's opinions at Step Three, concluding that "the opinions of the State agency physicians that the claimant's impairments neither met or equaled the severity of a listed impairment are well reasoned and supported by the evidence of record." AR 16. The ALJ, however, does not state how he weighed their opinions in the context of assessing Ms. Castillo-Rael's RFC. The Commissioner claims that the ALJ gave the opinions "some weight" because the opinions are "supported by the record evidence, and are generally consistent with the RFC assigned by the ALJ." Doc. 19 at 8. The ALJ, however, did not state that he gave the opinions "some weight." In fact, the ALJ made no statement at all about what weight he gave the opinions of the state agency psychologists. The ALJ also offered no explanation of how or if he incorporated the numerous moderate limitations in their opinions into the RFC. See AR 16-20. This Court cannot rely on the post hoc explanations offered by the Commissioner. See Allen v. Barnhart, 357 F.3d 1140, 1142 (10th Cir. 2004) ("Affirming this post hoc effort to salvage the ALJ's decision would require us to overstep our institutional role and usurp essential functions committed in the first instance to the administrative process.").
While Ms. Castillo-Rael argues that the ALJ impermissibly "picked and chose" from the limitations opined by the state agency psychologists, the ALJ's vague RFC discussion leaves the Court unable to meaningfully review this argument. In addition to failing to explain what weight he gave the state agency psychologists' opinions, the ALJ failed to adequately tie his RFC findings to the evidence. The ALJ's opinion does not include an adequate analysis which "include[s] a narrative discussion describing how the evidence supports each conclusion, citing specific medical facts (e.g., laboratory findings) and nonmedical evidence (e.g., daily activities, observations)." SSR 96-8p, 1996 WL 374184, at *7. The ALJ found that Ms. Castillo-Rael could "understand, remember, and carry out simple instructions and make commensurate work related decisions, but not at a production pace, in a work setting with few changes." AR 16-17. While the ALJ summarized some of the medical evidence and Ms. Castillo-Rael's testimony, the ALJ did not adequately explain how the evidence he cited supported his RFC conclusions with regard to these mental functions.
The ALJ erred in failing to explain the weight he gave the opinions of the state agency psychologists. The ALJ also failed to adequately tie his RFC findings to the evidence. The Court remands so that the ALJ can remedy these errors. The Court does not reach Ms. Castillo-Rael's other claimed errors, as they "may be affected by the ALJ's treatment of this case on remand." Watkins, 350 F.3d at 1299.
IT IS THEREFORE ORDERED that plaintiff's Motion to Reverse and Remand for a Rehearing (Doc. 17) is GRANTED.
IT IS FURTHER ORDERED that the Commissioner's final decision is REVERSED, and this case is REMANDED for further proceedings in accordance with this opinion.
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).