GARY M. PURCELL, Magistrate Judge.
Plaintiff seeks judicial review pursuant to 42 U.S.C. § 405(g) of the final decision of Defendant Commissioner denying her application for disability insurance benefits under Title II of the Social Security Act, 42 U.S.C. § 1382. Defendant has answered the Complaint and filed the administrative record (hereinafter "AR___"), and the parties have briefed the issues. The matter has been referred to the undersigned Magistrate Judge for initial proceedings consistent with 28 U.S.C. §636(b)(1)(B). For the following reasons, it is recommended the Commissioner's decision be reversed and remanded for further administrative proceedings.
Plaintiff applied for disability benefits on June 20, 2014. AR 193-96. Plaintiff alleged she became disabled on January 30, 2013, due to neuralgia, psoriac arthritis, pain in nerves, fibromyalgia, diabetic, fibro-fog, sleep apnea, and ceberea. AR 193, 240. The Social Security Administration denied Plaintiff's application on January 13, 2015, see id. at 89-103, 104, and on reconsideration on June 5, 2015. AR 105, 106-22.
Plaintiff appeared with counsel and testified at an administrative hearing conducted on September 21, 2016, before an Administrative Law Judge ("ALJ"). AR 72-88. A vocational expert ("VE") also testified at the hearing. AR 85-87. The ALJ issued a decision in which he found Plaintiff was not disabled within the meaning of the Social Security Act. AR 52-67. Following the agency's wellestablished sequential evaluation procedure, the ALJ found at the first step that Plaintiff had not engaged in substantial gainful activity since January 30, 2013. AR 57. At the second step, the ALJ found Plaintiff had severe impairments of obesity, psoriatic arthritis, fibromyalgia, depression, and anxiety. Id. At the third step, the ALJ found these impairments were not per se disabling as Plaintiff did not have an impairment or combination of impairments that met or medically equaled the requirements of a listed impairment. Id.
At step four, the ALJ found Plaintiff had the residual functional capacity ("RFC") to perform less than a full range of sedentary work. AR 59-60. Specifically, Plaintiff can occasionally lift and/or carry ten pounds and frequently lift and/or carry up to ten pounds. AR 60. Plaintiff can stand and/or walk at least two hours and sit at least six hours in an eight-hour work day. Id. Additionally, Plaintiff can frequently, but not constantly, perform work requiring use of the hands for grasping, handling, and fingering. Id. Finally, Plaintiff can perform simple, repetitive tasks and superficially relate to supervisors and coworkers, but she cannot work with the public. Id.
Relying on the VE's testimony as to the ability of a hypothetical individual with Plaintiff's work history, age, education, and determined RFC, the ALJ concluded Plaintiff could perform the jobs of document specialist and electronics assembler. AR 66. Based on this finding, the ALJ concluded Plaintiff had not been under a disability, as defined by the Social Security Act, from January 30, 2013 through the date of the decision. Id.
The Appeals Council denied Plaintiff's request for review, and therefore the ALJ's decision is the final decision of the Commissioner. See 20 C.F.R. § 404.981; Wall v. Astrue, 561 F.3d 1048, 1051 (10th Cir. 2009).
Plaintiff raises two issues on appeal. First, Plaintiff contends the ALJ improperly rejected the opinion of her treating physician. Plaintiff's Opening Brief (Doc. #15) at 15-24. Second, Plaintiff argues the ALJ erred at step five of the sequential evaluation process. Doc. #15 at 24-30.
The Court must determine whether the Commissioner's decision is supported by substantial evidence in the record and whether the correct legal standards were applied. Wilson v. Astrue, 602 F.3d 1136, 1140 (10th Cir. 2010); Doyal v. Barnhart, 331 F.3d 758, 760 (10th Cir. 2003). "Substantial evidence is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion. It requires more than a scintilla, but less than a preponderance." Lax v. Astrue, 489 F.3d 1080, 1084 (10th Cir. 2007) (citation and quotations omitted). The "determination of whether the ALJ's ruling is supported by substantial evidence must be based upon the record taken as a whole. Consequently, [the Court must] remain mindful that evidence is not substantial if it is overwhelmed by other evidence in the record." Wall, 561 F.3d at 1052 (citations, quotations, and brackets omitted).
The Social Security Act authorizes payment of benefits to an individual with disabilities. 42 U.S.C. § 401 et seq. A disability is an "inability 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); accord 42 U.S.C. § 1382c(a)(3)(A); see 20 C.F.R. §404.1509 (duration requirement). Both the "impairment" and the "inability" must be expected to last not less than twelve months. Barnhart v. Walton, 535 U.S. 212 (2002).
The agency follows a five-step sequential evaluation procedure in resolving the claims of disability applicants. See 20 C.F.R. § 404.1520(a)(4), (b)-(g). "If the claimant is not considered disabled at step three, but has satisfied her burden of establishing a prima facie case of disability under steps one, two, and four, the burden shifts to the Commissioner to show the claimant has the [RFC] to perform other work in the national economy in view of her age, education, and work experience." Fischer-Ross v. Barnhart, 431 F.3d 729, 731 (10th Cir. 2005). "The claimant is entitled to disability benefits only if he is not able to perform other work." Bowen v. Yuckert, 482 U.S. 137, 142 (1987).
Plaintiff contends the ALJ improperly evaluated the opinion of her treating physician, Dr. Daisy Matias. Dr. Matias began treating Plaintiff in 2012 and continued to consistently treat her at least as late as early 2017. On September 14, 2016, Dr. Matias drafted a letter regarding Plaintiff's limitations, in which she stated:
AR 577. The ALJ rejected Dr. Matias's stated opinion, stating that it was not entitled to "any weight." AR 65.
When an ALJ considers the opinion of a disability claimant's treating physician, the ALJ must follow a specific procedure in analyzing the medical opinion. Generally, an ALJ must give the opinion of an acceptable treating source controlling weight if it is both well-supported by medically acceptable clinical and laboratory diagnostic techniques and consistent with other substantial evidence in the record. Watkins v. Barnhart, 350 F.3d 1297, 1300 (10th Cir. 2003) (quoting SSR 96-2p, 1996 WL 374188, at *2). "[I]f the opinion is deficient in either of these respects, then it is not entitled to controlling weight." Id.
"Treating source medical opinions not entitled to controlling weight `are still entitled to deference' and must be evaluated in light of the factors in the relevant regulations, 20 C.F.R. §§ 404.1527 and 416.927." Newbold v. Colvin, 718 F.3d. 1257, 1265 (10th Cir. 2013) (quoting Watkins, 350 F.3d at 1300). Those factors are:
Watkins, 350 F.3d at 1301 (quotations omitted). See 20 C.F.R. §§ 404.1527(d), 416.927(d). The ALJ "must give good reasons . . . for the weight assigned to a treating physician's opinion" that are "sufficiently specific to make clear to any subsequent reviewers the weight the adjudicator gave to the treating source's medical opinion and the reasons for that weight." Watkins, 350 F.3d at 1300 (quotations omitted).
"[I]f the ALJ rejects the opinion completely, he must then give specific, legitimate reasons for doing so." Id. at 1301 (quotations omitted). "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 and not due to his or her own credibility judgments, speculation or lay opinion." McGoffin v. Barnhart, 288 F.3d 1248, 1252 (10th Cir. 2002) (emphasis and quotation omitted).
In his decision, the ALJ referenced some of Dr. Matias's records, without identifying Dr. Matias as the subject physician. AR 62. The only direct reference the ALJ makes to Dr. Matias appears much later in the decision, stating:
AR 65. The basis for the ALJ's conclusion that Dr. Matias's opinion is based on Plaintiff's subjective reports is wholly unclear from the decision. Similarly, the ALJ's statement that Dr. Matias failed to make an attempt to determine Plaintiff's limitations is equally unclear. Dr. Matias set forth specific physical limitations and attributed them to two physical conditions with which Plaintiff has been diagnosed. The Commissioner argues the ALJ's conclusion regarding Dr. Matias's opinion "was reasonable" because Dr. Matias's records "repeatedly showed normal musculoskeletal findings." Doc. #19 at 7. However, as established above, the ALJ's evaluation of a treating physician's opinion is not based on a reasonableness standard. See Watkins, 350 F.3d at 1300-01. Moreover, even if the Commissioner's argument regarding Dr. Matias's records was borne out by the record, the ALJ never expresses these facts as a basis for his rejection of Dr. Matias's opinion. Thus, this argument constitutes prohibited post-hoc rationalizations of what the ALJ might have meant by conclusory statements in his written decision. See Haga v. Astrue, 482 F.3d 1205, 1207-08 (10th Cir. 2007) ("[T]his court may not create or adopt posthoc rationalizations to support the ALJ's decision that are not apparent from the ALJ's decision itself." (citing Allen v. Barnhart, 357 F.3d 1140, 1142 (10th Cir. 2004) (holding that district court's "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")). Acceptance of this theory would require the Court to speculate in exactly the manner the treating physician rule is designed to avoid. See Watkins, 350 F.3d at 1301
Given the limitations of the ALJ's analysis, the Court is without sufficiently specific, legitimate reasons to justify the ALJ's decision to not follow the treating physician rule. As a consequence, the ALJ's decision is legally insufficient, and it is not the Court's place to compensate for those deficiencies with post-hoc reasoning or analysis. See Haga, 482 F.3d at 1207-08; Allen, 357 F.3d at 1142.
In view of the foregoing findings, it is recommended that judgment enter REVERSING and remanding the decision of the Commissioner for further administrative proceedings. The parties are advised of their respective right to file an objection to this Report and Recommendation with the Clerk of this Court on or before
This Report and Recommendation disposes of all issues referred to the undersigned Magistrate Judge in the captioned matter.