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Brown v. Berryhill

United States District Court, W.D. Oklahoma

February 15, 2017

NANCY A. BERRYHILL, [1] Acting Commissioner of the Social Security Administration, Defendant.



         Plaintiff 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 denying Plaintiff's application for supplemental security income under the Social Security Act. The Commissioner has answered and filed a transcript of the administrative record (hereinafter TR. __). The parties have consented to jurisdiction over this matter by a United States Magistrate Judge pursuant to 28 U.S.C. § 636(c).

         The parties have briefed their positions, and the matter is now at issue. Based on the Court's review of the record and the issues presented, the Court REVERSES the Commissioner's decision and REMANDS the case for further administrative findings.


         Plaintiff's application for supplemental security income was denied initially and on reconsideration. Following two hearings, an Administrative Law Judge (ALJ) issued an unfavorable decision. (TR. 11-20). The Appeals Council denied Plaintiff's request for review. (TR. 1-3). Thus, the decision of the ALJ became the final decision of the Commissioner.


         The ALJ followed the five-step sequential evaluation process required by agency regulations. See Fischer-Ross v. Barnhart, 431 F.3d 729, 731 (10th Cir. 2005); 20 C.F.R. § 416.9520. At step one, the ALJ determined that Plaintiff had not engaged in substantial gainful activity since April 30, 2012, the application date. (TR. 13). At step two, the ALJ determined Ms. Brown had the following severe impairments: cervical stenosis and degenerative disc disease of the neck, chronic low back pain, chronic shoulder pain, and polysubstance abuse in remission. (TR. 13). At step three, the ALJ found that Plaintiff's impairments did not meet or medically equal any of the presumptively disabling impairments listed at 20 C.F.R. Part 404, Subpart P, Appendix 1 (TR. 14).

         At step four, the ALJ found that Plaintiff had no past relevant work. (TR. 19).

         The ALJ further concluded that Ms. Brown had the residual functional capacity (RFC) to:

[P]erform less than a full range of light work as defined in 20 C.F.R. 404.1567(b). The claimant can lift 20 pounds on an occasional basis and 10 pounds on a frequent basis. The claimant can stand/walk six hours out of an eight-hour workday; and sit six hours out of an eight-hour workday. The claimant cannot engage in crawling. The claimant can engage in occasional overhead reaching and occasional fingering with the non-dominant right hand.

(TR. 14).

         Based on the finding that Ms. Brown had no past relevant work, the ALJ proceeded to step five. There, he presented several limitations to a vocational expert (VE) to determine whether there were other jobs in the national economy that Plaintiff could perform. (TR. 46-47). Given the limitations, the VE identified three jobs from the Dictionary of Occupational Titles (DOT). (TR. 47). The ALJ adopted the testimony of the VE and concluded that Ms. Brown was not disabled based on her ability to perform the identified jobs. (TR. 20).


         On appeal, Plaintiff alleges the ALJ erred in: (1) evaluating the opinion from a treating physician and (2) the credibility analysis.


         This Court reviews the Commissioner's final “decision to determin[e] whether the factual findings are 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). “Substantial evidence is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Id. (quotation omitted).

         While the court considers whether the ALJ followed the applicable rules of law in weighing particular types of evidence in disability cases, the court will “neither reweigh the evidence nor substitute [its] judgment for that of the agency.” Vigil v. Colvin, 805 F.3d 1199, 1201 (10th Cir. 2015) (internal quotation marks omitted).


         As alleged by Ms. Brown, the ALJ committed legal error in considering the opinion from treating physician, Dr. Mark Winchester.

         A. ALJ's Duty in Evaluating a Treating Physician's Opinion

         An ALJ's evaluation of a treating physician's opinion is sequential. First, the ALJ must determine whether a treating physician's opinion is entitled to “controlling weight.” Krausner v. Astrue, 638 F.3d 1324, 1330 (10th Cir. 2011). In doing so, the ALJ must consider whether the opinion is “well-supported by medically acceptable clinical and laboratory diagnostic techniques.” SSR 96-2p, at *2 (July 2, 1996) (quotations omitted). If the answer to this question is “no, ” then the inquiry at this stage is complete. If the ALJ finds that the opinion is well-supported, he must then confirm that the opinion is consistent with other substantial evidence in the record. Id. If the opinion is deficient in either of these respects, then it is not entitled to controlling weight. Id.

         If the ALJ declines to give the treating physician's opinion “controlling weight, ” the ALJ must examine particular factors and explain the amount of weight assigned. See SSR 96-2p, at *5. These factors include: (1) the length of the treatment relationship and the frequency of examination; (2) the nature and extent of the treatment relationship, including the treatment provided and the kind of examination or testing performed; (3) the degree to which the physician's opinion is supported by relevant evidence; (4)

         consistency between the opinion and the record as a whole; (5) whether or not the physician is a specialist in the area upon which an opinion is rendered; and (6) other factors brought to the ALJ's attention which tend to support or contradict the opinion. Krausner v. Astrue, 638 F.3d at 1330, 20 C.F.R § 416.927. Although the ALJ need not explicitly discuss each factor, the reasons stated must be “sufficiently specific” to permit meaningful appellate review. See Oldham v. Astrue, 509 F.3d 1254, 1258 (10th Cir. 2007); SSR 96-2p, at *5.

         If the ALJ rejects the opinion completely, he must give “specific, legitimate reasons” for doing so. Watkins v. Barnhart, 350 F.3d 1297, 1300 (10th Cir. 2003) (internal citations omitted).

         B. Dr. Winchester's Opinion

         Dr. Winchester treated Plaintiff from September 2013 to March of 2014. (TR. 348-352, 357-359). On September 8, 2013, Dr. Winchester completed a Medical Source Opinion of Residual Functional Capacity form for Ms. Brown. There, Dr. Winchester opined that Ms. Brown could:

• stand and/or walk for less than two hours;
• frequently lift and/or carry less than 10 pounds;
• reach, push, and pull with both upper extremities for less than two hours; and
• grasp, handle, finger, or feel with both hands for less than two hours.

(TR. 348, Exhibit 11F). Dr. Winchester based these opinions on: (1) diagnoses that Ms. Brown suffered from degenerative disc disease and spinal stenosis and (2) additional findings that Plaintiff had leg weakness and abnormal reflexes. (TR. 348).

         The ALJ acknowledged Dr. Winchester's opinion, but then effectively rejected it, stating:

The findings of Dr. Winchester regarding the claimant's physical limitations are far in excess of what is supported by the record. The Administrative Law Judge therefore assigns little weight to the conclusions of Dr. Winchester in Exhibit 11F.

(TR. 17).

         C. Error in the Consideration of Dr. ...

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