Opinion
Civil Action 1:21-cv-00980-SKC
10-27-2023
D.M.R., Plaintiff, v. COMMISSIONER, SOCIAL SECURITY ADMINISTRATION, Defendant.
OPINION & ORDER
S. Kato Crews United States Magistrate Judge
This action is before the Court under Title XVI of the Social Security Act, 42 U.S.C. § 401 et seq., for review of the Commissioner of Social Security's (“Commissioner” or “Defendant”) final decision denying Plaintiff D.M.R.'sapplication for supplemental security income. The parties have consented to the Magistrate Judge's jurisdiction. Dkt 16.
This Opinion & Order identifies Plaintiff by initials only per D.C.COLO.LAPR 5.2.
The Court uses “Dkt.___ ” to refer to specific docket entries in CM/ECF and uses “AR: ___” to refer to documents in the administrative record. The administrative record may be found at Dkt. 15.
The Court has carefully considered the parties' briefs, the social security administrative record, and applicable law. No hearing is necessary. Because the ALJ failed to indicate or explain the medical or other substantial evidence supporting the physical limitations in his RFC findings, the Court cannot find that substantial evidence in the record supports the Final Decision. The Court VACATES the Final Decision on that basis and REMANDS the matter for further proceedings.
BACKGROUND
On June 13, 2018, Plaintiff filed a Title XVI application for supplemental security income (SSI) under the Social Security Act claiming she became disabled beginning June 13, 2018 (the amended onset date). She later appeared and testified at an administrative law hearing on November 21, 2019, before Administrative Law Judge Shane McGovern (ALJ). Attorney Cody Passman represented Plaintiff.
The ALJ issued his written Decision on February 5, 2020. Dkt. 15-2. He determined Plaintiff had not been under a disability from the amended onset date through the date of his Decision. Plaintiff then requested review by the Appeals Council, which denied her request, and in doing so, the ALJ's Decision became the Final Decision of the Commissioner of Social Security. 20 C.F.R. § 404.981; Nelson v. Sullivan, 992 F.2d 1118, 1119 (10th Cir. 1993) (citation omitted). Plaintiff then timely filed this action. The Court has jurisdiction to review the Final Decision under 42 U.S.C. § 405(g).
Throughout this Opinion, while the Court may cite relevant sections of Part 404 of Title 20 of the Code of Federal Regulations (which contain the Commissioner's regulations relating to disability insurance benefits), identical, parallel regulations can be found in Part 416 of that same title, relating to supplemental security income benefits.
A person is disabled within the meaning of the Social Security Act “only if [her] physical and/or mental impairments preclude [her] from performing both [her] previous work and any other ‘substantial gainful work which exists in the national economy.'” Wilson v. Astrue, No. 10-CV-00675-REB, 2011 WL 97234, at *1 (D. Colo. Jan. 12, 2011) (citing 42 U.S.C. § 423(d)(2)). “The mere existence of a severe impairment or combination of impairments does not require a finding that an individual is disabled within the meaning of the Social Security Act. To be disabling, the claimant's condition must be so functionally limiting as to preclude any substantial gainful activity for at least twelve consecutive months.” Id. “[F]inding that a claimant is able to engage in substantial gainful activity requires more than a simple determination that the claimant can find employment and that he can physically perform certain jobs; it also requires a determination that the claimant can hold whatever job he finds for a significant period of time.” Fritz v. Colvin, 15-cv-00230-JLK, 2017 WL 219327, at *8 (D. Colo. Jan. 18, 2017) (emphasis original) (quoting Washington v. Shalala, 37 F.3d 1437, 1442 (10th Cir. 1994)).
The Social Security Regulations outline a five-step process to determine whether a claimant is disabled:
1. The ALJ must first ascertain whether the claimant is engaged in substantial gainful activity. A claimant who is working is not disabled regardless of the medical findings.
2. The ALJ must then determine whether the claimed impairment is “severe.” A “severe impairment” must significantly limit the claimant's physical or mental ability to do basic work activities.
3. The ALJ must then determine if the impairment meets or equals in severity certain impairments described in Appendix 1 of the regulations.
4. If the claimant's impairment does not meet or equal a listed impairment, the ALJ must determine whether the claimant can perform her past work despite any limitations.
5. If the claimant does not have the residual functional capacity to perform her past work, the ALJ must decide whether the claimant can perform any other gainful and substantial work in the economy. This determination is made based on the claimant's age, education, work experience, and residual functional capacity.Wilson, 2011 WL 9234, at *2 (citing 20 C.F.R. § 404.1520(b)-(f)); see also 20 C.F.R. § 416.920; Williams v. Bowen, 844 F.2d 748, 750-51 (10th Cir. 1988). Impairments that meet a “listing” under the Commissioner's regulations (20 C.F.R. § Pts. 404 and 416, Subpt. P, App. 1) and a duration requirement are deemed disabling at Step Three with no need to proceed further in the five-step analysis. 20 C.F.R. § 416.920(a)(4) (“If we can find that you are disabled or not disabled at a step, we make our determination or decision and we do not go on to the next step.”). Between the Third and Fourth steps, the ALJ must assess the claimant's residual functional capacity (RFC). Id. § 416.920(e). The claimant has the burden of proof in Steps One through Four. The Commissioner bears the burden of proof at Step Five. Lax v. Astrue, 489 F.3d 1080, 1084 (10th Cir. 2007).
The ALJ followed the five-step process in his Decision. At Step One, he found Plaintiff had not engaged in substantial gainful activity since the amended onset date of June 13, 2018. AR: 16. At Step Two, he found Plaintiff has the following severe impairments: major depressive disorder; post-traumatic stress disorder (PTSD); cannabis use disorder; cervical spine degenerative disc disease; and DeQuervain's tenosynovitis. Id. At Step Three, the ALJ found Plaintiff does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. Id. at 17. He then found Plaintiff has the RFC
He also found Plaintiff had dyshidrotic eczema and diabetes mellitus type II. But he found these were not medically determinable impairments. AR: 17.
to perform medium work as defined in 20 CFR 416.967(c) except not use ladders, ropes, and scaffolds; no more than frequent ramps, stairs, balance, stoop, crouch, kneel, and crawl; no more than frequent handling, fingering, and feeling with the left non-dominant upper extremity; no exposure to moving mechanical parts or unprotected heights; limited to simple and routine tasks that can be learned within thirty days; no hourly quotas/conveyor belts; no more than occasional simple workplace changes; and no more than occasional interaction with coworkers and supervisors and no interaction with the public.Id. at 17-18. At Steps Four and Five, the ALJ found Plaintiff was unable to perform any past relevant work, but that there are other jobs that exist in significant numbers in the national economy that Plaintiff can perform. Id. at 22-23. Accordingly, the ALJ determined Plaintiff was not disabled during the relevant period. Id. at 24.
STANDARD OF REVIEW
In reviewing the Commissioner's Final Decision, the Court's review is limited to determining whether the Commissioner applied the correct legal standards and whether the agency's factual findings are supported by substantial evidence. Substantial evidence is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion. It is more than a scintilla, but less than a preponderance.Lee v. Berryhill, 690 Fed.Appx. 589, 590 (10th Cir. 2017) (internal quotations and citations omitted, citing inter alia Knight ex rel. P.K. v. Colvin, 756 F.3d 1171, 1175 (10th Cir. 2014)); see also 42 U.S.C. § 405(g) (“The findings of the Commissioner . . . as to any fact, if supported by substantial evidence, shall be conclusive”).
A court may not reverse an ALJ just because the court may have reached a different result based on the record; the question instead is whether there is substantial evidence showing the ALJ's decision was justified. See Ellison v. Sullivan, 929 F.2d 534, 536 (10th Cir. 1990). “We review only the sufficiency of the evidence, not its weight .... Although the evidence may also have supported contrary findings, we may not displace the agency's choice between two fairly conflicting views.” Lee, 690 Fed.Appx. at 591-92. Nevertheless, “[e]vidence is not substantial if it is overwhelmed by other evidence in the record or constitutes mere conclusion.” Musgrave v. Sullivan, 966 F.2d 1371, 1374 (10th Cir. 1992) (internal citation omitted). A reviewing court must “meticulously examine the record as a whole, including anything that may undercut or detract from the ALJ's findings in order to determine if the substantiality test has been met.” Flaherty v. Astrue, 515 F.3d 1067, 1070 (10th Cir. 2007). In addition, “if the ALJ failed to apply the correct legal test, there is a ground for reversal apart from a lack of substantial evidence.” Thompson v. Sullivan, 987 F.2d 1482, 1487 (10th Cir. 1993) (internal citation omitted).
ANALYSIS
Plaintiff makes two arguments in this appeal: (1) the ALJ's RFC determination is unsupported by any medical opinion and (2) the ALJ failed to explain the resolution of the conflict regarding the discrepancy between the VE's testimony and DOT. On the first argument, Defendant counters that the Tenth Circuit has long-recognized that an RFC finding does not need to correspond to a medical opinion. On the second argument, Defendant argues that the ALJ asked the vocational expert if there were any inconsistencies between his testimony and the DOT, which was all the ALJ was required to do.
The Court gives short shrift to Plaintiff's argument that the ALJ's RFC is in error because it is not supported by any medical opinion. As Defendant points out, the Tenth Circuit has repeatedly held that “there is no requirement in the regulations for a direct correspondence between an RFC finding and a specific medical opinion on the functional capacity in question.” Chapo v. Astrue, 682 F.3d 1285, 1288 (10th Cir. 2012); see also Terwilliger v. Comm'r, Soc. Sec. Admin., 801 Fed.Appx. 614, 628 (10th Cir. 2020) (same); Berumen v. Colvin, 640 Fed.Appx. 763, 766 (10th Cir. 2016) (same); McDonald v. Astrue, 492 Fed.Appx. 875, 885 (10th Cir. 2012) (same). Thus, this argument fails.
The argument, however, implicates an error that does require remand. While an RFC finding need not be supported by medical opinion, it must be supported by medical evidence. Masse v. Astrue, No. 09-cv-02079-REB, 2010 WL 3853318, at *5 (D. Colo. Sept. 28, 2010) (“Assuming arguendo that the ALJ properly rejected the various postural and environmental limitations suggested by the treating source opinions, his conclusion regarding plaintiff's residual functional capacity nevertheless must be based on the medical evidence.”); Talamantes v. Asture, No. CIVA 07-cv-01664-CMA, 2009 WL 306734, at *10 (D. Colo. Feb. 6, 2009), aff'd sub nom. 370 Fed.Appx. 955 (10th Cir. 2010) (“Rather, the Court reads the cases to hold that the ALJ's determination of Plaintiff's RFC must be supported by medical evidence[.]”); see also Mayberry v. Saul, No. 6:20-cv-06014, 2020 WL 6390945, at *2 (W.D. Ark. Oct. 30, 2020) (“[A]n ALJ's determination concerning a claimant's RFC must be supported by medical evidence that addresses the claimant's ability to function in the workplace.”).
It is not clear what medical evidence the Final Decision relies on in support of the RFC limitation of medium work. Concerning Plaintiff's physical limitations, the Final Decision briefly and generally summarizes treatment records from August 2018, January 2019, June and July 2019, and October and November 2019. AR: 2021. The ALJ then turns to the opinion evidence, which includes a state Disability Determination Service consultant and a consultative examiner, both of whom opined Plaintiff had functional limitations for light work. AR: 133-34, 328. The ALJ found each of these opinions unpersuasive. But in doing so, he never explains the medical evidence which supports the RFC for medium work. See generally AR: 18-22. He does reference medical evidence (the above-referenced treatment records) in his discussion of how that evidence does not support the severity and frequency of the degree of functional limitations alleged by the Plaintiff, but it is not clear whether he relies on that same evidence to determine the RFC for medium work, or how that evidence supports medium work because there is no analysis provided. See, e.g., Kempel v. Astrue, No. 08-4130-JAR, 2010 WL 58910, at *8 (D. Kan. Jan. 4, 2010) (The ALJ “summarized the evidence and stated the conclusions he drew, but he did not explain why that evidence requires those conclusions, or the analysis used to reach the conclusions.”).
It is also problematic to the analysis that the ALJ used global citations to the record as opposed to pinpoint citations. When citing the above-referenced treatment records, the ALJ cites record exhibits D4F, D6F, D7F, D9F, D10F, and D11F. AR: 2021. These are multi-page exhibits totaling 158 pages collectively-the full administrative record is 720 pages. Dkt. 15-2 at pp.2-3.
Numerous judicial officers in this district have determined an ALJ's general references to the administrative record make an ALJ's decision nearly impossible to review and does not constitute substantial evidence in support of the disability determination. See Guerin v. Saul, No. 19-cv-02614-RBJ, 2020 WL 4435247, at *8 (D. Colo. Aug. 3, 2020) (“I agree with Mr. Guerin that ‘such generalized, global references to the record make the ALJ's opinion nearly impossible to review, and certainly do not constitute substantial evidence in support of the Commissioner's disability determination.'”) (citing Gutierrez v. Colvin, 67 F.Supp.3d 1198, 1203 (D. Colo. 2014)); Johnson v. Berryhill, No. 16-cv-3050-WJM, 2018 WL 1566838, at *6 (D. Colo. Mar. 30, 2018) (“[T]his bulk citation therefore fails to provide a sufficiently clear and specific explanation of the reasons why the ALJ found Dr. Edrich's opinion ‘unpersuasive,' and lacking in objective support.”); Fritz v. Colvin, No. 15-cv-00230-JLK, 2017 WL 219327, at *15 (D. Colo. Jan. 18, 2017) (“[T]he ALJ relies on citations to multi-page exhibits without pinpoint citations to specific pages. The record in this case is 807 pages long and throughout the RFC discussion and the written findings generally, the ALJ provides only general references to exhibits in this case[.] Such general citations do not constitute substantial evidence in support of the ALJ's decision, and ALJ's in this district have received fair notice of this concern.”).
Then Magistrate Judge Nina Y. Wang, faced an ALJ decision similar to what the Court sees here. In Robles, Judge Wang noted the ALJ's decision “sporadically cites to exhibits in the record or relies on global references to large medical records, without any citation to a specific page within the exhibit.” Robles v. Comm'r, Soc. Sec. Admin., No. 18-cv-01235-NYW, 2019 WL 2393789, at *6 (D. Colo. June 6, 2019). This caused the court to be “wary that such a practice satisfies the ALJ's burden that substantial evidence support her decision.” Id. (citing cases).
The ALJ's decision here, with its global citations purportedly in support of the RFC findings, gives this Court similar unease and robs the Court of the ability to conduct a meaningful review. Romo v. Colvin, 83 F.Supp.3d 1116, 1121, n.4 (D. Colo. 2015) (“I note that throughout his opinion, the ALJ cites to the record by way of global references to multi-page exhibits, without pinpoint citations to specific pages therein. This court is neither required nor inclined to scour the record in an attempt to divine the specific basis for an ALJ's opinion, and I thus repeatedly have found that such general citations do not substantiate the ALJ's disability decision.”); see also Johnson, 2018 WL 1566838, at *6 n.3 (“Here, while some of the ALJ's citations include page numbers, or cite to records only a few pages in length, other citations are to longer sets of documents, without page numbers or ‘pincites.' . . . On remand, the ALJ should be cautious to avoid overly general citations to the record.”);
“To be sure, the ALJ need not discuss every piece of evidence in the record, but she must still ‘discuss the uncontroverted evidence [s]he chooses not to rely upon, as well as significantly probative evidence [s]he rejects.'” Robles, 2019 WL 2393789, at *6 (quoting Clifton v. Chater, 79 F.3d 1007, 1009-10 (10th Cir. 1996)). Because the ALJ is unclear in explaining or citing the medical evidence in support of the physical limitations in his RFC findings, the Court cannot conclude that substantial evidence in the record supports the decision. And the Court is precluded from engaging in a post hoc effort to salvage the Final Decision, which is what Defendant's arguments in support of the RFC findings equate to. See Robinson v. Barnhart, 366 F.3d 1078, 1084-85 (10th Cir. 2004); see also Robles, 2019 WL 2393789, at *6 (while it may be possible to assemble support for the ALJ's conclusions from parts of the record cited elsewhere in the ALJ's decision that is best left for the ALJ to do on remand).
The Court finds the ALJ's failure to identify or explain the medical or other substantial evidence supporting the physical limitations in his RFC findings warrants remand. The Court cannot find that substantial evidence in the record supports the Final Decision, as a result.
For the reasons shared above, the Final Decision is VACATED and this matter is REMANDED for further proceedings consistent with this Opinion & Order.Plaintiff is awarded her costs, to be taxed by the Clerk of Court pursuant to Fed.R.Civ.P. 54(d)(1).
The Court declines to address Plaintiff's additional contentions of error because they may be impacted on remand. See Watkins v. Barnhart, 350 F.3d 1297, 1299 (10th Cir. 2003) (“We will not reach the remaining issues raised by appellant because they may be affected by the [administrative law judge's] treatment of the case on remand.”).