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Stallings v. Berryhill

United States District Court, W.D. Oklahoma

November 20, 2017

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



         Plaintiff, Angela Annette Stallings, brings this action pursuant to 42 U.S.C. § 405(g) for judicial review of the Social Security Administration's final decision finding she was not disabled under the Social Security Act. The parties have consented to the exercise of jurisdiction over this matter by a United States Magistrate Judge. See 28 U.S.C. § 636(c). The Commissioner has filed the Administrative Record (AR), and both parties have briefed their respective positions.[1] For the reasons stated below, the Court reverses the Commissioner's decision and remands the matter for further proceedings.

         I. Procedural Background

         Plaintiff filed applications for disability insurance benefits (DIB) and supplemental security income (SSI), alleging disability beginning December 16, 2009. AR 14, 265-74. Following an administrative hearing, an Administrative Law Judge (ALJ) issued an unfavorable decision dated March 25, 2011. AR 17-29. The Appeals Council then granted Plaintiff's request for review and remanded the matter for further proceedings. AR 130-32. On January 25, 2016, the ALJ again issued an unfavorable decision. AR 11-27. The Appeals Council then denied Plaintiff's request for review. AR 1-3. Therefore, the ALJ's January 25, 2016 decision constitutes the final decision of the Commissioner. Krauser v. Astrue, 638 F.3d 1324, 1327 (10th Cir. 2011). Plaintiff timely commenced this action for judicial review.

         II. The ALJ's Decision

         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) (explaining process); see also 20 C.F.R. §§ 404.1520, 416.920. The ALJ first determined that Plaintiff meets the insured status requirements of the Act through December 31, 2014, and has not engaged in substantial gainful activity since the alleged onset date, December 16, 2009. AR 17.

         At step two, the ALJ determined that Plaintiff has the following severe impairments: degenerative disc disease with spondylolisthesis of L4-5 and radiculopathy, status post L4-5 decompression and fusion in December 2014, hypertension, and obesity. Id. At step three, the ALJ found that Plaintiff's impairments do not meet or medically equal any of the impairments listed at 20 C.F.R. Part 404, Subpart P, App. 1. AR 20-21.

         The ALJ next determined Plaintiff's residual functional capacity (RFC). The ALJ concluded Plaintiff could perform sedentary work[2] “except lift, carry, push, and pull 10 pounds occasionally and less than 10 pounds frequently; stand and walk for 2 out of 8 hours; sit for 6 out of 8 [hours, ] no climbing ladders, ropes or scaffolds; no balancing; occasionally climb stairs and ramps; occasional kneel, crouch, crawl, and stoop; and change position in job area while performing job tasks.” AR 22.

         At step four, the ALJ found that Plaintiff could perform her past relevant work as a customer service representative. AR 26. The ALJ concluded, therefore, that Plaintiff was not disabled under the terms of the Social Security Act. AR 27.

         III. Issue Presented for Judicial Review

         Plaintiff seeks judicial review raising three claims of error: (1) the ALJ failed to properly follow the treating source/physician rule when addressing the opinion of Susan Hakel, M.D.; (2) the ALJ failed to properly assess Plaintiff's RFC and the ALJ's RFC findings are not supported by substantial evidence; and (3) the ALJ failed to properly evaluate Plaintiff's credibility. For the reasons set forth below, the Court finds Plaintiff's first and third claims of error have merit, necessitating a remand. Therefore, the Court deems it unnecessary to address the second claim of error which might be affected by proceedings on remand. See Watkins v. Barnhart, 350 F.3d 1297, 1299 (10th Cir. 2003). The Court further denies Plaintiff's request for an immediate award of benefits. Further fact-finding is required at the administrative level.

         IV. Standard of Review

         Judicial review of the Commissioner's final decision is limited to determining whether the factual findings are supported by substantial evidence in the record as a whole and whether the correct legal standards were applied. See 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) (quotation 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). The court “meticulously examine[s] 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.” Wall v. Astrue, 561 F.3d 1048, 1052 (10th Cir. 2009) (citations 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 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) (quotations and citations omitted).

         Plaintiff bears the burden of proof at steps one through four of the sequential evaluation process to establish a prima facie case of disability. Wells v. Colvin, 727 F.3d 1061, 1064 n. 1 (10th Cir. 2013). If Plaintiff meets this burden, the burden of proof shifts to the Commissioner at step five to show that Plaintiff retains a sufficient RFC to perform other work that exists in significant numbers in the national economy. Id.

         V. Analysis

         A. The ALJ's Weighing of Dr. Hakel's Opinion

         Dr. Hakel treated Plaintiff during the time period January 2008 through April 2012. AR 429; see also AR 669-670. She initially diagnosed Plaintiff with chronic low-back syndrome. AR 427. Plaintiff underwent a series of epidural steroid injections while under Dr. Hakel's care. AR 426; see also AR 423. Additionally, an MRI during that period of time revealed “severe deterioration of the L4-5 disk with anterolisthesis of L4 on L5 and severe compromise of both neural foramina.” Id.; see also AR 433, 435, 464, 481, 698. Dr. Hakel recommended that Plaintiff be evaluated by a neurosurgeon, Dr. Emily Friedman, as to the feasibility of surgical intervention. Id. Dr. Hakel observed in this regard that “we can only expect the back pain to get inexorably worse if we do nothing but conservative management[.]” Id.

         In August 2009, Dr. Hakel opined that Plaintiff would need certain accommodations at work including a heating pad at her desk, “frequent (hourly) short breaks to get up and walk around” and that Plaintiff would not be able to work overtime hours. AR 571. She further opined that sitting all day would cause pain flare ups and would, in turn, necessitate Plaintiff missing “1-2 days each week.” AR 570.

         Addressing Dr. Hakel's opinion, the ALJ made the following findings:

Dr. Hakel provided no standing or sitting limitations. She provided that the claimant was unable to sit for prolonged periods, but prolonged periods is not defined. The provision that the claimant was likely to be absent frequently, needed to take frequent breaks, and was unable to work overtime was inconsistent with other evidence in the record, the evidence of the State agency reviewing physicians that opined that the claimant could perform light work. This opinion was not substantiated by medical signs in the record.

         AR 25 (emphasis added). The ALJ then “assigned greater weight to the opinions of the State agency reviewing physicians that had the opportunity to review the longitudinal record.” Id. (emphasis added). Consequently, the ALJ assigned “little weight” to Dr. Hakel's opinion. Id.

         The ALJ then noted that in March 2010, Robin Hall, M.D., performed a consultative examination of Plaintiff and “provided no functional limitations.” Id. (emphasis added). The ALJ ...

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