Opinion
Case No. 2:02-CV-1252.
July 6, 2004
AMENDED ORDER
The Court's March 17, 2004 order (File Entry #17) is hereby withdrawn.
Before the Court is an action filed by Plaintiff, Arlene Coonradt, asking the Court to reverse the final agency decision denying her application for disability insurance benefits (hereafter referred to as "DIB") under Title II of the Social Security Act. See 42 U.S.C.A. §§ 401-434 (2003). Plaintiff's applications were denied because the Administrative Law Judge (hereafter referred to as "ALJ") found that Plaintiff's impairments do not prevent her from performing her past relevant work as a credit clerk. Plaintiff challenges the ALJ's decision by arguing that it is legally erroneous and it is not supported by substantial evidence.
Having carefully considered the parties' memoranda and the complete record in this matter, the Court concludes that this case should be remanded.
BACKGROUND
Plaintiff applied for DIB on March 26, 2001, claiming that she had been unable to work since October 1, 1999. (See File Entry #3, The Certified Copy of the Transcript of the Entire Record of the Administrative Proceedings Relating to Arelene Coonradt (hereafter referred to as "Tr. ___") 68.) Plaintiff's claim was denied at the initial level of administrative review on May 21, 2001, and at the reconsideration level of administrative review on August 21, 2001. (Tr. 52, 56, 61.) On August 28, 2001, Plaintiff requested a hearing before an ALJ, which was held on February 4, 2002. (Tr. 54, 28-51.)
In his June 27, 2002 decision denying Plaintiff benefits, the ALJ found that Plaintiff was not disabled because she was still able to perform her past relevant work as a credit clerk. (Tr. 20-22.) On September 26, 2002, the Appeals Council denied Plaintiff's subsequent request for review. (Tr. 5-6.) Therefore, the ALJ's decision is the Commissioner's final decision in this case. See 42 U.S.C.A. § 405(g) (2003); Doyal v. Barnhart, 331 F.3d 758, 759 (10th Cir. 2003.)
On November 22, 2002, after receiving the denial of her request for review from the Appeals Council, Plaintiff filed the instant action, and the case was assigned to United States District Judge Dale A. Kimball. (File Entry #1.) Defendant filed her answer, along with the administrative record, on March 27, 2003. (File Entries #2, 3.) On August 13, 2003, Judge Kimball referred the case to United States Magistrate Judge Samuel Alba pursuant to 28 U.S.C. § 636(b)(1)(B). (File Entries #4, 5.)
On September 3, 2003, the parties filed a joint consent to have the magistrate judge conduct all proceedings and enter the final judgment in this case pursuant to 28 U.S.C. § 636(c). (File Entry #7.) Accordingly, on September 5, 2003, Judge Kimball referred the case to Magistrate Judge Alba pursuant to 28 U.S.C. § 636(c). (File Entry #8.)
On September 22, 2003, Plaintiff filed her brief. (File Entry #9.) On December 15, 2003, Defendant filed her brief. (File Entry #15.) Then, on January 2, 2004, Plaintiff filed her reply brief. (File Entry #16.)
STANDARD OF REVIEW
The Court reviews the Commissioner's decision "to determine whether the factual findings are supported by substantial evidence in the record and whether correct legal standards were applied." Doyal, 331 F.3d at 760; accord Angel v. Barnhart, 329 F.3d 1208, 1209 (10th Cir. 2003).
The Commissioner's findings, "if supported by substantial evidence, shall be conclusive." 42 U.S.C.A. § 405(g) (2003). "`Substantial evidence is "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion."'"Doyal, 331 F.3d at 760 (citation omitted). "`Substantial evidence' requires `more than a scintilla, but less than a preponderance,' and is satisfied by such relevant `evidence that a reasonable mind might accept to support the conclusion.'"Gossett v. Bowen, 862 F.2d 802, 804 (10th Cir. 1988) (citation omitted). "`"Evidence is not substantial `if it is overwhelmed by other evidence — particularly certain types of evidence (e.g., that offered by treating physicians) — or if it really constitutes not evidence but mere conclusion.'"'" Id. at 805 (citations omitted); see also O'Dell v. Shalala, 44 F.3d 855, 858 (10th Cir. 1994) ("Evidence is insubstantial if it is overwhelmingly contradicted by other evidence."); Trimiar v. Sullivan, 966 F.2d 1326, 1329 (10th Cir. 1992) ("A finding of `"no substantial evidence" will be found only where there is a "conspicuous absence of credible choices" or "no contrary medical evidence."'" (citations omitted)).
In conducting its review, the Court "must examine the record closely to determine whether substantial evidence supports" the Commissioner's decision. Winfrey v. Chater, 92 F.3d 1017, 1019 (10th Cir. 1996). The Court may "`neither reweigh the evidence nor substitute [its] judgment for that of the agency.'"White v. Barnhart, 287 F.3d 903, 905 (10th Cir. 2001) (citation omitted). However, the Court is not required to mechanically accept the Commissioner's findings. See Ehrhart v. Secretary of Health Human Servs., 969 F.2d 534, 538 (7th Cir. 1992) ("By the same token, we must do more than merely rubber stamp the decisions of the [Commissioner]."). Rather, the Court must "`examine the record as a whole, including whatever in the record fairly detracts from the weight of the [Commissioner's] decision and, on that basis, determine if the substantiality of the evidence test has been met.'" Glenn v. Shalala, 21 F.3d 983, 984 (10th Cir. 1994) (citation omitted). The Court's review of the record includes any evidence Plaintiff presented for the first time to the Appeals Council. See O'Dell, 44 F.3d at 858-59.
The Court typically defers to the ALJ on issues of witness credibility. See Hamilton v. Secretary of Health Human Servs., 961 F.2d 1495, 1499 (10th Cir. 1992). Nonetheless, "`[f]indings as to credibility should be closely and affirmatively linked to substantial evidence.'" Winfrey, 92 F.3d at 1020 (citation omitted).
The Court's review also extends to determining whether the Commissioner applied the correct legal standards. Qualls v. Apfel, 206 F.3d 1368, 1371 (10th Cir. 2000). Besides the lack of substantial evidence, reversal may be appropriate where the Commissioner uses the wrong legal standards or the Commissioner fails to demonstrate reliance on the correct legal standards. See Glass v. Shalala, 43 F.3d 1392, 1395 (10th Cir. 1994); Thompson v. Sullivan, 987 F.2d 1482, 1487 (10th Cir. 1993); Andrade v. Secretary of Health and Human Servs., 985 F.2d 1045, 1047 (10th Cir. 1993).
ANALYSIS
Plaintiff makes the following four arguments. First, Plaintiff argues that the ALJ's finding at step two of the disability analysis, together with the Appeals Council's decision, that Plaintiff's systemic lupus erythematosus (hereafter referred to as "lupus") was not a severe impairment, was not supported by substantial evidence. Second, Plaintiff argues that because the ALJ failed to find that her lupus was a severe impairment, the ALJ erroneously failed to consider and find that Plaintiff's lupus, together with her other impairments, met or equaled Listing 14.02. Third, Plaintiff argues that because the ALJ failed to find that her lupus was a severe impairment, the ALJ's finding that Plaintiff was not entirely credible is not supported by substantial evidence. Finally, Plaintiff argues that the ALJ erred in discounting her treating physician's opinion regarding Plaintiff's residual functional capacity (hereafter referred to as "RFC").
The Court first addresses Plaintiff's argument that the ALJ's finding at step two in the disability analysis is not supported by substantial evidence. Specifically, Plaintiff argues that the ALJ's finding that her lupus is not a severe impairment is not supported by substantial evidence.
At step two, Plaintiff has the burden of showing that her lupus is a severe impairment. See Williams v. Bowen, 844 F.2d 748, 750-51 (10th Cir. 1988). To meet that burden, Plaintiff "must make a threshold showing that [her] medically determinable impairment or combination of impairments significantly [limited] [her] ability to do basic work activities." Id.; see also 20 C.F.R. § 404.1520(a), 404.1521 (2003). Social Security Ruling (hereafter referred to as "SSR") 96-3p explains that if the ALJ finds that the symptoms produced by the impairment or impairments cause a limitation or restriction "having more than a minimal effect on an individual's ability to do basic work activities, the adjudicator must find that the impairment(s) is severe and proceed to the next step in the process even if the objective medical evidence would not in itself establish that the impairment(s) is severe." SSR 96-3p, 1996 WL 374181, at *2.
Furthermore, the required showing is considered a de minimus showing. As Justice O'Conner wrote, joined by Justice Stevens, in the concurrence to Bowen v. Yuckert, 482 U.S. 137, 158, 107 S.Ct. 2287, 2300 (1987), "Only those claimants with slight abnormalities that do not significantly limit any `basic work activity' can be denied benefits without undertaking this vocational analysis."
In his decision, the ALJ found: "Based upon the foregoing objective, written medical evidence, the Administrative Law Judge finds that the claimant has the following medically determinable severe impairment: degenerative disc disease of the spine. She also has an alleged impairment that is not medically determinable, to-wit: systemic lupus erythematosus." (Tr. 17.) The ALJ acknowledged that Plaintiff's primary care physician and her rheumatologist both indicate that they will have an antinuclear antibody (hereafter referred to as "ANA") test run, but that the ALJ had not been able to find the results of those tests. (Tr. 17.) The ALJ explained that in order for an impairment to be determined for disability purposes, objective signs and findings must support the existence of the impairment. (Tr. 17.) The ALJ explained that because the required signs and findings were absent from Plaintiff's medical record, such as the ANA test results, the ALJ could not make a determination that lupus was one of Plaintiff's medically determinable impairments. (Tr. 17.)
The ALJ's concern regarding the lack of medical laboratory test results supporting Plaintiff's claim of lupus is further manifest in the transcript of the February 4, 2002 hearing. At that hearing, the ALJ asked Plaintiff's attorney to point to lab results that support the diagnosis of lupus. (Tr. 32-33, 50.) Plaintiff's attorney was unable to find any such lab results. (Tr. 32-33, 50.) In particular, the ALJ was interested in the results of ANA tests.
After receiving the ALJ's decision denying her benefits, Plaintiff submitted additional evidence from Dr. Lundberg, Plaintiff's rheumatologist, to the Appeals Council as part of her appeal. In a July 15, 2002 letter, Dr. Lundberg explained that he had diagnosed Plaintiff with lupus, and that diagnosis was supported by lab test results. (Tr. 393.) Dr. Lundberg submitted, with his letter, the reports of the lab tests performed and his examination notes of Plaintiff from before the alleged onset date of disability, October 1, 1999. (Tr. 393-476.)
As Defendant herself admits, Plaintiff has a diagnosis of lupus by history. The lupus was initially diagnosed in December 1996, with a positive ANA reading at that time. (Tr. 476.) Since that time, Plaintiff's medical records all indicate a diagnosis of lupus, and Plaintiff has taken medications to address problems associated with her lupus.
Dr. Lundberg explains in his letter submitted to the Appeals Council that Plaintiff fulfills the ACR criteria for lupus. (Tr. 393.) Dr. Lundberg lists four of the eleven criteria Plaintiff meets. Because Plaintiff must meet four of the eleven criteria to have a recognized lupus diagnosis (Tr. 17 n. 1), it appears that Plaintiff's lupus diagnosis is supported by objective medical evidence and that the ALJ's finding is not supported by substantial medical evidence.
Admittedly, the positive ANA test result occurred before Plaintiff's alleged onset date of disability, and the ANA test results in October 1999, during the relevant time period, were within the normal range. (Tr. 288, 476.) However, Plaintiff's attorney has represented to the Court that the medication Plaintiff was taking when she took the later ANA test could result in a negative test reading when it otherwise would be positive. (File Entry #19.) The Court is not an expert in such medical matters and must rely on counsel's representations.
Therefore, because Plaintiff submitted to the Appeals Council the results of a positive ANA test, and because with that positive ANA test Plaintiff meets the required four criteria for lupus, the ALJ's finding that objective evidence did not support Plaintiff's lupus diagnosis is not supported by substantial evidence. On the contrary, the ALJ's finding appears to be contradicted by the medical evidence.
The Court has reviewed Plaintiff's other arguments in light of its decision that the ALJ's finding at step two was not supported by substantial evidence. Because the ALJ did not find that Plaintiff suffered from lupus at step two of his analysis, the ALJ did not consider whether Plaintiff met the criteria of the listing for lupus at step three. Furthermore, the ALJ's analysis of Plaintiff's credibility and RFC, as well as the ALJ's decision not to give controlling weight to the opinion of Plaintiff's treating physician, were all impacted by the ALJ's initial decision that objective evidence did not support a diagnosis of lupus. As a result, the ALJ reached his decision that Plaintiff was not eligible for DIB, in part, by his finding that Plaintiff did not have lupus.
Consequently, the Court concludes that this case must be remanded to the Commissioner for reconsideration as to whether Plaintiff is disabled in light of the positive ANA test Plaintiff submitted to the Appeals Council. Unlike the Court, the Commissioner is able to receive medical testimony regarding the significance of that positive ANA test and whether it establishes that Plaintiff has lupus despite the negative ANA test result Plaintiff later received. Furthermore, if the Commissioner finds that Plaintiff suffers from the severe impairment of lupus, the Commissioner will need to reevaluate the rest of the ALJ's analysis in light of that finding. The Court does not express an opinion regarding what the results of the Commissioner's analysis must be; instead, the Court is remanding this case because the Commissioner, not the Court, is best suited to determine the significance of positive ANA test results received before the alleged onset date of disability and how those results bear on the rest of the five-step disability analysis.
CONCLUSION
The Court concludes that the ALJ's decision that Plaintiff is not disabled is not supported by substantial evidence. As a result, THE COURT HEREBY ORDERS that the Commissioner's decision be REVERSED AND REMANDED as directed in the above analysis.