CHARLES B. GOODWIN, District Judge.
Plaintiff Cindy D. Butts brings this action pursuant to 42 U.S.C. § 405(g) for judicial review of the final decision of the Commissioner of the Social Security Administration ("SSA") denying Plaintiff's application for disability insurance benefits ("DIB") under Title II of the Social Security Act, 42 U.S.C. §§ 401-434. Upon review of the administrative record (Doc. No. 12, hereinafter "R. _"),
Plaintiff protectively filed her DIB application on December 11, 2014, ultimately alleging disability beginning October 27, 2014. R. 13, 184-90, 216. Following denial of her application initially and on reconsideration, a hearing was held before an Administrative Law Judge ("ALJ") on June 10, 2016. R. 13, 30-95, 123-27, 130-32. The ALJ issued an unfavorable decision on August 18, 2016. R. 10-24.
The Commissioner uses a five-step sequential evaluation process to determine entitlement to disability benefits. See Wall v. Astrue, 561 F.3d 1048, 1052 (10th Cir. 2009); 20 C.F.R. § 404.1520. At step one, the ALJ found that Plaintiff had not engaged in substantial gainful activity since October 27, 2014, the amended alleged disability-onset date.
The ALJ next assessed Plaintiff's residual functional capacity ("RFC") based on all of her medically determinable impairments. R. 19-22. The ALJ found that Plaintiff had the residual functional capacity to
R. 19-20. At step four, the ALJ made no findings concerning Plaintiff's ability to perform her past relevant work. R. 22.
At step five, the ALJ considered whether there are jobs existing in significant numbers in the national economy that Plaintiff—in view of her age, education, work experience, and RFC—could perform. R. 22-23. Taking into consideration the hearing testimony of a vocational expert ("VE") regarding the degree of erosion to the unskilled medium occupational base that is caused by Plaintiff's additional limitations, the ALJ concluded that Plaintiff could perform occupations such as laundry worker, automobile detailer, and hand packager, all of which offer jobs that exist in significant numbers in the national economy. R. 23. On this basis, the ALJ concluded that Plaintiff had not been under a disability, as defined in the Social Security Act, from October 27, 2014, through the date of the decision. R. 23. Plaintiff's request for review by the Appeals Council was denied, and the unfavorable determination of the ALJ stands as the Commissioner's final decision. R. 1-7; see 20 C.F.R. § 404.981.
Judicial review of the Commissioner's final decision is limited to determining whether factual findings are supported by substantial evidence in the record as a whole and whether correct legal standards were applied. Poppa v. Astrue, 569 F.3d 1167, 1169 (10th Cir. 2009). "Substantial evidence is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Doyal v. Barnhart, 331 F.3d 758, 760 (10th Cir. 2003) (internal quotation marks omitted). "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." Branum v. Barnhart, 385 F.3d 1268, 1270 (10th Cir. 2004) (internal quotation marks omitted). The court "meticulously examine[s] the record as a whole," including any evidence "that may undercut or detract from the ALJ's findings," "to determine if the substantiality test has been met." Wall, 561 F.3d at 1052 (internal quotation marks omitted). While a reviewing court considers whether the Commissioner followed applicable rules of law in weighing particular types of evidence in disability cases, the court does not reweigh the evidence or substitute its own judgment for that of the Commissioner. Bowman v. Astrue, 511 F.3d 1270, 1272 (10th Cir. 2008).
In her request for judicial review, Plaintiff argues that (1) the ALJ erred by failing to discuss evidence probative of Plaintiff's physical symptoms and impairments; (2) the RFC finding is not supported by substantial evidence; and (3) the ALJ failed to adequately develop the record regarding Plaintiff's physical impairments. See Pl.'s Br. (Doc. No. 16) at 11-23.
Amber Jones, an advanced practice registered nurse (APRN) examined Plaintiff on thirteen occasions between July 2014 and April 2016. See R. 481-94 (Ex. 3F), 517-51 (Ex. 10F). During all but one of these examinations, Ms. Jones identified physical conditions regarding Plaintiff's back, including the presence of scoliosis (sometimes indicated as severe), tenderness, limited range of motion secondary to pain, and decreased reflexes on the right side. See R. 483, 487, 491, 519, 524, 528, 532, 536, 540, 543, 547, 550. Ms. Jones also indicated that Plaintiff's back had 5/5 motor strength in all groups bilaterally, intact and bilaterally equal sensation to light touch, and a normal but stiff-appearing gait. See R. 483, 487, 491, 519, 524, 528, 532, 536, 540, 543, 547, 550. With regard to Plaintiff's cervical spine, Ms. Jones identified a normal contour, midline tenderness, and decreased range of motion. See R. 483, 487, 491, 519-20, 524, 528, 532, 536, 540, 543, 547, 550. In addition, Ms. Jones identified on certain occasions guarding and crepitus in Plaintiff's knees, diffuse bony nodules in Plaintiff's knees and elbows, and swelling or edema in Plaintiff's hands. See Pl.'s Br. at 13; R. 528-29, 533, 537, 540-41, 544. Finally, Ms. Jones discussed the results of MRI scans performed prior to 2013, including their findings that Plaintiff had degenerative disc disease, scoliosis, and "[m]ild compression of the superior end plate of L1." See, e.g., R. 481.
In the March 17, 2015 disability determination explanation for Plaintiff's DIB claim at the initial level, state-agency reviewing physician William H. Oehlert, MD, briefly reported some of Ms. Jones' findings and the results of the MRIs. After examining this evidence, Dr. Oehlert concluded that the medical evidence of record supported a finding of degenerative disc disease but "[did] not support any specific physical limitations." R. 101. A similar result was reached by reviewing physician Sean Neely, DO, in the disability determination explanation for Plaintiff's DIB claim at the reconsideration level. See R. 115-17. Dr. Neely reported Ms. Jones' examination findings, including that Plaintiff's cervical spine was tender with decreased range of motion secondary to pain, that Plaintiff's back had tenderness throughout the midline and decreased range of motion secondary to pain, that Plaintiff's reflexes were decreased on the right, that her sensation was intact, and that her gait was normal but stiff. R. 116. Dr. Neely then discussed the MRI results reflected in Ms. Jones' treatment notes. R. 116. Dr. Neely opined that Plaintiff was limited to lifting, carrying, pushing, and/or pulling no more than 50 pounds occasionally and 25 pounds frequently, that she could stand and/or walk no more than 6 hours in an 8-hour workday and sit not more than 6 hours in an 8-hour workday, and that she had no postural, manipulative, visual, communicative, or environmental limitations. R. 116. Like Dr. Oehlert, Dr. Neely noted that degenerative disc disease was present but that the medical evidence did not support any specific physical limitations. R. 117. Dr. Neely further opined that Plaintiff's "RFC is limited by pain associated with fibromyalgia, arthritis, and cervical [degenerative disc disease]." R. 117.
After appealing the ALJ's unfavorable decision, Plaintiff submitted additional evidence to the Appeals Council, which the Appeals Council made part of the record. See R. 6-7 (identifying Exhibit Nos. 19E, 11F, 12F, 13F, 14F, 15F, 16F, 17F, 18F, 19F as new exhibits). Included in this new evidence were additional MRI results dated May 2016. R. 571-76. These MRI findings included mild, chronic compression fractures of the T11 and L1 vertebral bodies, mild degenerative disc disease of the thoracic spine, multilevel discogenic and degenerative changes in the cervical spine, and moderate leftward scoliotic curvature of the lumbar spine. R. 572-76.
Plaintiff argues that the ALJ committed legal error by ignoring medical evidence of Plaintiff's physical impairments reflected in Ms. Jones' notes and in the MRI scan results. See Pl.'s Br. at 11-14.
While an ALJ "is not required to discuss every piece of evidence," the ALJ must discuss "the evidence supporting his decision," the "uncontroverted evidence [the ALJ] chooses not to rely upon," and "significantly probative evidence he rejects." Clifton v. Chater, 79 F.3d 1007, 1009-10 (10th Cir. 1996); see Haga v. Astrue, 482 F.3d 1205, 1207 (10th Cir. 2007); see also Hardman v. Barnhart, 362 F.3d 676, 681 (10th Cir. 2004) ("It is improper for the ALJ to pick and choose among medical reports, using portions of evidence favorable to his position while ignoring other evidence.").
In his RFC discussion, the ALJ reported the findings of the early MRIs, as articulated by Ms. Jones in her Progress Notes. R. 21, 481. The ALJ stated that the
R. 21. The ALJ omitted from his discussion, however, that the MRIs detected moderate leftward scoliotic curvature. R. 481.
Nor did the ALJ discuss Ms. Jones' separate findings of severe scoliosis, tenderness, and limited range of motion in Plaintiff's back and cervical spine in his RFC analysis.
Plaintiff additionally argues that an RFC of medium exertion work is not supported by substantial evidence, pointing both the Ms. Jones' Progress Notes and to the 2016 MRI scan results.
The decision of the Commissioner is REVERSED and REMANDED for further proceedings in accordance with sentence four of 42 U.S.C. § 405(g). A separate judgment shall be entered.
