JOHN F. ROBBENHAAR, Magistrate Judge.
Claimant Gaylyn V. Miller ("Ms. Miller") alleges that she became disabled on September 2, 2012, at the age of fifty-eight, because of epilepsy, arthritis, cervical pain, complications from stroke, depression, anxiety and migraines. Tr. 396, 406.
On October 15, 2014, Ms. Miller 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. 376-79. Ms. Miller's application was initially denied on June 29, 2015. Tr. 256-69, 270, 285-89. It was denied again at reconsideration on February 16, 2016. Tr. 271-83, 284, 295-99. On April 14, 2016, Ms. Miller requested a hearing before an Administrative Law Judge ("ALJ"). Tr. 301-02. ALJ Michael Leppala conducted a video hearing on July 20, 2017. Tr. 225-55. Ms. Miller appeared in person at the hearing with attorney representative Jamie M. Dawson.
An individual is considered disabled 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) (pertaining to disability insurance benefits); see also 42 U.S.C. § 1382(a)(3)(A) (pertaining to supplemental security income disability benefits for adult individuals). 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) (disability insurance benefits); 20 C.F.R. § 416.920(a)(4) (supplemental security income disability benefits); 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 (10th Cir. 2004); Langley v. Barnhart, 373 F.3d 1116, 1118 (10th Cir. 2004); Casias, 933 F.2d at 800-01. In making these determinations, the Court "neither reweigh[s] the evidence nor substitute[s] [its] judgment for that of the agency.'" Bowman v. Astrue, 511 F.3d 1270, 1272 (10th Cir. 2008). "[W]hatever the meaning of `substantial' in other contexts, the threshold for such evidentiary sufficiency is not high." Biestek v. Berryhill, 139 S.Ct. 1148, 1154 (2019). Substantial evidence "is `more than a mere scintilla.'" Id. (quoting Consol. Edison Co. v. NLRB, 305 U.S. 197, 229 (1938)). "It means—and means only—such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Id. (internal quotation marks omitted).
A decision "is not based on substantial evidence if it is overwhelmed by other evidence in the record," Langley, 373 F.3d at 1118, or "constitutes mere conclusion," Musgrave v. Sullivan, 966 F.2d 1371, 1374 (10th Cir. 1992). The agency decision must "provide this court with a sufficient basis to determine that appropriate legal principles have been followed." Jensen v. Barnhart, 436 F.3d 1163, 1165 (10th Cir. 2005). Therefore, although an ALJ is not required to discuss every piece of evidence, "the record must demonstrate that the ALJ considered all of the evidence," and "the [ALJ's] reasons for finding a claimant not disabled" must be "articulated with sufficient particularity." Clifton v. Chater, 79 F.3d 1007, 1009-10 (10th Cir. 1996). But where the reviewing court "can follow the adjudicator's reasoning" in conducting its review, "and can determine that correct legal standards have been applied, merely technical omissions in the ALJ's reasoning do not dictate reversal." Keyes-Zachary v. Astrue, 695 F.3d 1156, 1166 (10th Cir. 2012). The court "should, indeed must, exercise common sense." Id. "The more comprehensive the ALJ's explanation, the easier [the] task; but [the court] cannot insist on technical perfection." Id.
The ALJ made his decision that Ms. Miller was not disabled at step four of the sequential evaluation. Tr. 216-17. Specifically, the ALJ found that Ms. Miller met the insured status requirements through September 30, 2017, and had not engaged in substantial gainful activity since her alleged onset date of September 2, 2012. Tr. 208. The ALJ determined that Ms. Miller had severe impairments of cerebrovascular accident and affective disorder. Tr. 209. The ALJ also found that Ms. Miller had non-severe impairments of discogenic and degenerative back disorder, obesity, epilepsy, migraines, bunion, hammertoe and arthritis of the feet, hypertension, status-post stent placement, and arthritis. Tr. 209-10. The ALJ determined that Ms. Miller did not have an impairment or combination of impairments that met or medically equaled the severity of a listing. Tr. 210-11. Proceeding to step four, the ALJ found that Ms. Miller had the residual functional capacity to
Tr. 211. Based on the RFC and the testimony of the VE, the ALJ concluded that Ms. Miller was capable of performing her past relevant work as a cleaner, commercial or institutional.
In her Motion, Ms. Miller argues that (1) the ALJ improperly evaluated the medical source opinions of examining State agency psychological consultants Carl B. Adams, Ph.D., and James W. Schutte, Ph.D., and treating physician Julio Munoz, M.D., in assessing her ability to do work-related physical and mental activities; and (2) the ALJ improperly accorded Dr. Schutte's opinion differing degrees of weight. Doc. 20 at 18-24.
For the reasons discussed below, the Court finds the ALJ failed to properly evaluate certain of the medical source opinion evidence. This case, therefore, requires remand.
Ms. Miller argues generally that the ALJ failed to properly evaluate three medical source opinions; i.e., examining State agency psychological consultants Carl B. Adams, Ph.D., and James W. Schutte, Ph.D., and treating source Julio Munoz, M.D., in assessing her ability to do work-related physical and mental activities. Doc. 20 at 18-22. More specifically, Ms. Miller argues that each of their opinions assessed that she was severely limited in her ability to concentrate and persist at tasks, yet the ALJ failed to account for this limitation in the RFC. Id. Ms. Miller asserts that Dr. Adams' assessed GAF score of 50, which indicates serious impairment in, inter alia, occupational and school functioning, supports a greater limitation in concentration and persistence than the ALJ assessed, and that Dr. Adams' assessment is consistent with Dr. Schutte's assessed low IQ and low memory skills, and with Dr. Munoz's assessed limitations regarding Ms. Miller's ability to concentrate and persist at tasks. Id. Ms. Miller also argues that Dr. Schutte's opinion regarding her marked limitation to interact with the general public and coworkers is consistent with her testimony and other record evidence, and that the ALJ improperly accorded little weight to this part of Dr. Schutte's opinion. Id. Lastly, Ms. Miller asserts that the evidence supports Dr. Munoz's assessed functional limitations in her ability to do work-related physical and mental activities, and that the ALJ's RFC failed to account for any physical limitations at all. Id.
The Commissioner contends the ALJ reasonably accounted for Ms. Miller's limitations in concentration and persistence by assessing that she could "maintain concentration, persistence, and pace for up to and including two hours at a time with normal breaks throughout an eight-hour workday," and limiting her to simple, routine, and repetitive tasks. Doc. 21 at 10, 12. The Commissioner also contends that the Tenth Circuit has routinely found that GAF scores do not directly correlate to an individual's ability to perform work and that the ALJ did not err in not explicitly discussing Dr. Adams' assessed GAF score. Id. at 10-11. The Commissioner further contends that the ALJ properly accorded less weight to Dr. Schutte's opinion related to Ms. Miller's ability to socially interact based on the record as a whole. Id. at 11-12. Lastly, the Commissioner asserts that the ALJ properly considered Dr. Munoz's opinion, but gave it little weight for a number of reasons. Id. at 13-14.
Ms. Miller first presented to Julio Munoz, M.D., on March 16, 2015, to establish care. Tr. 770-75. She complained of dry mouth, high blood pressure, frequent urinary tract infections, and shortness of breath with activity. Tr. 770. She also reported weakness, numbness, tingling, and difficulty speaking related to cerebral vascular disease.
Following the initial visit, Ms. Miller saw Dr. Munoz eighteen times over the next two years. Tr. 746-75, 960-1019. During that time, Dr. Munoz continued to diagnose and treat Ms. Miller for essential hypertension, hyperlipidemia, cerebrovascular accident, and dysarthria, and also diagnosed and treated and/or referred Ms. Miller for specialized treatment for anemia,
On June 16, 2017, Dr. Munoz prepared a Medical Source Statement: Mental and Physical Limitations on Ms. Miller's behalf. Tr. 1571-75. As for Ms. Miller's mental limitations to do unskilled work, Dr. Munoz assessed that she was unlimited or very good in her ability to (1) ask simple questions or request assistant; and (2) get along with co-workers or peers without unduly distracting them or exhibiting behavioral extremes. Tr. 1572. He assessed she was limited, but satisfactory, in her ability to carry out very short and simple instructions. Id. Dr. Munoz assessed that Ms. Miller was seriously limited, but not precluded in her ability to (1) remember work-like procedures; (2) maintain regular attendance and be punctual within customary, usually strict tolerances; and (3) sustain an ordinary routine without special supervision. Id. He assessed that she was unable to meet competitive standards in her ability to (1) understand and remember very short and simple instructions; (2) maintain attention for two hour segments; (3) work in coordination with or proximity to others without being unduly districted; (4) make simple work-related decisions; (5) perform at a consistent pace without an unreasonable number and length of rest periods; and (6) respond appropriately to changes in a routine work setting. Id. Finally, Dr. Munoz assessed that Ms. Miller had no useful ability to function in (1) completing a normal workday and workweek without interruptions from psychologically based symptoms; (2) dealing with normal work stress; and (3) being aware of normal hazards and take appropriate precautions. Id. Dr. Munoz explained that "dyspnea on exertion" limited Ms. Miller's ability to exercise, that she was easily fatigued, and suffered arthralgias. Id. Dr. Munoz also noted that Ms. Miller has a low IQ or reduced intellectual functioning, and that her psychiatric conditions exacerbated her experience of pain and other physical symptoms. Tr. 1573. metatarsophalangeal arthrodesis, right 2nd hammertoe correction, right 2nd metatarsal shortening osteotomy, and debridement and subchondral drilling, right 2nd metatarsal head. Tr. 945-46.
As for Ms. Miller's physical limitations, Dr. Munoz assessed, inter alia, that Ms. Miller (1) could not walk without pain; (2) could sit up to 45 minutes to 1 hour before needing to get up; (3) could stand for 10 minutes at one time before needing to sit down or walk around; (4) could sit/stand/walk for less than 2 hours; (5) would need periods of walking around in an 8-hour workday; (6) must walk every 15 minutes for about 15 minutes; (7) would need to take unscheduled breaks every 30-45 minutes and rest for one hour; (8) would need to have her legs elevated with sitting, 30-45 degrees, for three-quarters of the day; (9) could lift less than five pounds; and (10) would be out of work more than four days per month as a result of her impairments or treatment. Tr. 1574-75.
In further support of his assessment, Dr. Munoz explained that he sees Ms. Miller every eight to twelve weeks. Tr. 1571. He noted her diagnoses as cerebrovascular disease, status-post cerebral vascular accident; coronary artery disease, status-post stent placement; and obstructive sleep apnea. Id. He described Ms. Miller's symptoms as easily fatigued and inability to endure any physical activity, such as household chores. Id. He characterized the nature, location, and frequency of Ms. Miller's pain as neck pain, back pain and right hip pain several times a day and moderate. Id. He also noted that Ms. Miller had intermittent headaches. Id. As for his clinical and objective findings, Dr. Munoz noted decreased range of motion of the neck, trunk and right hip. Id. Dr. Munoz noted that Ms. Miller had an unsteady gait and severe dyspnea on exertion. Id.
The ALJ accorded Dr. Munoz's opinion little weight. Tr. 215. In doing so, he explained that "it is inconsistent with the consulting physician's findings showing the Claimant was able to ambulate and squat without difficulty. Further, the physician did not provide an explanation to justify the substantial limitations alleged." Id. For the reasons discussed below, the Court finds the ALJ did not follow the correct legal standards in evaluating and weighing Dr. Munoz's opinion and that the ALJ's explanations for discounting his opinion are not supported by substantial evidence.
It is undisputed that Dr. Munoz is a treating physician. Therefore, the ALJ was required to evaluate his opinion pursuant to the two-part treating physician inquiry. Krauser v. Astrue, 638 F.3d 1324, 1330 (10
Watkins v. Barnhart, 350 F.3d 1297, 1301 (10th Cir. 2003) (internal citations and quotations omitted); see also 20 C.F.R. §§ 404.1527(c), 416.927(c). Not every factor is applicable in every case, nor should all six factors be seen as absolutely necessary. What is necessary, however, is that the ALJ give good reasons—reasons that are "sufficiently specific to [be] clear to any subsequent reviewers"—for the weight that he ultimately assigns to the opinions. Langley, 373 F.3d at 1119; see also 20 C.F.R. §§ 404.1527(c)(2), 416.927(c)(2); Branum v. Barnhart, 385 F.3d 1268, 1275 (10th Cir. 2004). "In choosing to reject the treating physician's assessment, an ALJ may not make speculative inferences from medical reports and may reject a treating physician's opinion outright only on the basis of contradictory medical evidence[.]" Langley, 373 F.3d at 1121.
Here, the ALJ discussed Dr. Munoz's opinion at step four of the sequential evaluation process. Tr. 214-250. In doing so, the ALJ did not evaluate Dr. Munoz's opinion pursuant to the two-part treating physician inquiry as he was required to do. At step one, the ALJ did not expressly state whether he had given Dr. Munoz's opinion controlling weight. That said, because it is clear from the ALJ's decision that he declined to give Dr. Munoz's controlling weight, this is not reversible error. See Mays v. Colvin, 739 F.3d 569, 575 (10
Further, the ALJ's explanations for rejecting Dr. Munoz's opinion are not supported by substantial evidence. By way of explanation, the ALJ stated Dr. Munoz's opinion was "inconsistent with the consulting physician's findings showing the Claimant was able to ambulate and squat without difficulty. Further, the physician did not provide an explanation to justify the substantial limitations alleged." Tr. 215. As to the former explanation, the ALJ relied on a June 13, 2015, exam note prepared by examining State agency medical consultant Juan Rossini, M.D., in which Dr. Rossini indicated on physical exam that Ms. Miller could "squat to the floor and recover" and ambulated without difficulty.
For all of the foregoing reasons, the Court finds the ALJ did not follow the correct legal standards in evaluating and weighing Dr. Munoz's opinion and that his explanations for discounting his opinion are not supported by substantial evidence. Langley, 373 F.3d at 1121. This is reversible error. Moreover, had the ALJ properly evaluated and weighed Dr. Munoz's opinion as required, he may have assessed physical limitations that would preclude Ms. Miller from returning to her past relevant work which is classified as heavy.
On May 29, 2015, Ms. Miller presented to Dr. Adams for a mental status evaluation Tr. 692-94. Having taken Mr. Miller's various histories
Tr. 694. (Emphasis added.)
The ALJ accorded Dr. Adams' opinion great weight. Tr. 215.
On January 22, 2016, Ms. Miller presented to Dr. Schutte for a second mental status examination. Tr. 817-21. Dr. Schutte took Ms. Miller's background and history, and conducted a mental status exam. Tr. 817-19. Dr. Schutte also administered the Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV),
Tr. 821. (Emphasis added.)
The ALJ accorded little weight to Dr. Schutte's opinion regarding Ms. Miller's ability to interact with others, but accorded great weight to all of Dr. Schutte's other opinions regarding Ms. Miller's mental functional limitations. Tr. 216.
The question before the Court is whether the ALJ, having accorded great weight to the examining State agency psychological consultant opinions regarding Ms. Miller's limitations in the area of concentration, persistence and pace, failed to properly incorporate their limitations in the RFC.
The Tenth Circuit has held that limiting a claimant to unskilled work, or simple, routine, and repetitive tasks, may in some cases account for moderate limitations in concentration, persistence, and pace. Vigil v. Colvin, 805 F.3d 1199, 1204 (10
Here, however, the Court finds the ALJ's RFC does not adequately incorporate Dr. Adams' and Dr. Schutte's assessed limitations regarding Ms. Miller's ability to concentrate and persist at tasks. As an initial matter, the cases cited above, wherein a restriction to unskilled, or simple, routine and repetitive work was deemed sufficient to account for marked limitations in concentration and task persistence, are distinguishable. In Trujillo, only one medical source opinion was at issue to which the ALJ had accorded only substantial weight, and the Court found that the ALJ had included significant limitations in three functional areas that specifically addressed the marked limitation in concentration and pace. Trujillo, 2017 WL 2799981, at *9. That is not the case here. In Thomas, the ALJ addressed a marked limitation to maintain concentration over extended periods and also relied on VE testimony to determine the claimant would be capable of performing simple, unskilled tasks even with a "low ability to concentrate for sustained periods of time." Thomas, 278 F.3d at 958. Again, that is not the case here.
Here, the ALJ accorded Dr. Adams' and Dr. Schutte's opinions great weight, yet failed to explain why he deviated from their assessed limitation in the area of concentration and task persistence, or to explain how the restriction he assessed was sufficient in light of the medical source opinion evidence and the record as a whole.
For the foregoing reasons, the Court finds that having accorded great weight to Dr. Adams' and Dr. Schutte's opinions, the ALJ's RFC does not adequately reflect Ms. Miller's limitations in maintaining concentration, persistence and pace, but could perform simple, routine and repetitive tasks for 2 hours periods. Tr. 266. The ALJ accorded Dr. Unger's opinion great weight. Tr. 216. limitations in the area of concentration and task persistence. This is error. Doyal v. Barnhart, 331 F.3d 758, 764 (10
The Court will not address Ms. Miller's remaining claims of error because they may be affected by the ALJ's treatment of this case on remand. Watkins v. Barnhart, 350 F.3d 1297, 1299 (10
For the reasons stated above, the Court finds Ms. Miller's Motion to Reverse or Remand (Doc. 20) is well taken and is