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Shawnette L.O. v. Berryhill

United States District Court, N.D. Oklahoma

March 12, 2019

SHAWNETTE L. O., Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         Plaintiff Shawnette L. O. seeks judicial review of the decision of the Commissioner of the Social Security Administration denying her claim for disability insurance benefits under Title II of the Social Security Act, 42 U.S.C. §§ 416(i), 423. In accordance with 28 U.S.C. § 636(c)(1) & (3), the parties have consented to proceed before a United States Magistrate Judge.

         For reasons explained below, the Court reverses the Commissioner's decision denying benefits and remands for further proceedings based on the ALJ's failure to evaluate a treating physician's medical source statement pertaining to the relevant period. Any appeal of this decision will be directly to the Tenth Circuit Court of Appeals.

         I. Standard of Review

         In reviewing a decision of the Commissioner, the Court is limited to determining whether the Commissioner applied the correct legal standards and whether the decision is supported by substantial evidence. See Grogan v. Barnhart, 399 F.3d 1257, 1261 (10th Cir. 2005). “Substantial evidence is more than a mere scintilla and is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Id. (citing Glass v. Shalala, 43 F.3d 1392, 1395 (10th Cir. 1994)). 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.” Hamlin v. Barnhart, 365 F.3d 1208, 1214 (10th Cir. 2004) (quotations omitted). The 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.” Grogan, 399 F.3d at 1261 (citing Washington v. Shalala, 37 F.3d 1437, 1439 (10th Cir. 1994)). The Court may neither re-weigh the evidence nor substitute its judgment for that of the Commissioner. See Hackett v. Barnhart, 395 F.3d 1168, 1172 (10th Cir. 2005). Even if the Court might have reached a different conclusion, the Commissioner's decision stands so long as it is supported by substantial evidence. See White v. Barnhart, 287 F.3d 903, 908 (10th Cir. 2002).

         II. Procedural History and the ALJ's Decision

         Plaintiff, then a 53-year-old female, applied for Title II benefits on September 29, 2014, alleging a disability onset date of August 1, 2008. R. 20. Plaintiff claimed that she was unable to work due to disorders including fibromyalgia and arthritis. R. 178. Plaintiff's claim for benefits was denied initially on October 23, 2014, and on reconsideration on January 23, 2015. R. 73-96. Plaintiff then requested a hearing before an Administrative Law Judge (“ALJ”), and the ALJ conducted the hearing on May 25, 2016. R. 20, 34-66. The ALJ issued a decision on June 21, 2016, denying benefits and finding Plaintiff not disabled because she was able to perform other work. R. 20-29. The Appeals Council denied review, and Plaintiff appealed. R. 1-3; ECF No. 2.

         The ALJ found that Plaintiff met the insured status requirements of the Social Security Act on June 30, 2014, and that she had not engaged in substantial gainful activity during the period from her alleged onset date of August 1, 2008 through her date last insured of June 30, 2014. R. 22. The ALJ found that Plaintiff had the following severe impairments: fibromyalgia; arthritis (shoulders, hips, and pelvis); degenerative disc disease of the lumbar spine; affective disorder; and anxiety disorder. Id. The ALJ also found non-severe impairments of cervical degenerative disc disease and mild coronary artery disease, as well as non-medically determinable migraine headaches. R. 22-23. At step three, the ALJ found that, through the date last insured, Plaintiff did not have an impairment or combination of impairments of such severity to result in listing-level impairments. R. 23.

         The ALJ summarized Plaintiff's testimony as follows: Plaintiff lives with her husband, who receives long-term disability payments. She completed the 11th grade and has never obtained a GED. She has a driver's license. Her fibromyalgia medication causes anxiety and depression. She can walk two to three blocks before needing to rest. R. 25; see R. 37-57. The ALJ also noted a Third-Party Adult Function Report from Plaintiff's daughter, submitted on October 13, 2014. R. 27, 202-209. The ALJ gave this report some weight, as it showed Plaintiff could perform with the RFC the ALJ identified. R. 27.

         With respect to the objective medical evidence in the record, the ALJ noted chest x-rays dated October 17, 2013, which showed no significant abnormalities (R. 347), and cervical spine x-rays dated February 25, 2014, showing early degenerative changes in the mid-cervical spine (R. 348). Emergency room records dated July 31, 2014, revealed Plaintiff presented with complaints of flank pain and possible kidney stone. R. 270. A CT scan of the abdomen and pelvis revealed no renal, uretal, or bladder calculi. R. 271-272. On August 11, 2014, Plaintiff's treating physician Terrence Williams, D.O., ordered a CT angiogram of the pelvis and bilateral lower extremities, which revealed mild fusiform ectasia of the visualized infrarenal abdominal aorta; moderate predominately noncalcified plaque of the visualized infrarenal abdominal aorta; and other scattered mild multifocal atherosclerotic disease in the lower abdomen, pelvis, and bilateral lower extremities, but with inline three vessel runoff to the feet and no significant stenosis. R. 350-351.

         The ALJ noted that Dr. Williams evaluated Plaintiff on May 7, 2015, for complaints of moderate to severe back pain. R. 380. Upon physical examination, Dr. Williams noted tenderness and pain with the range of motion in the cervical spine; tenderness and moderate pain with range of motion in the lumbar spine; and tenderness and moderate pain with range of motion in the right knee. R. 382. An MRI scan of the cervical spine dated May 13, 2015, revealed degenerative disc disease and osteoarthritis seen in the cervical spine. R. 390-391. Dr. Williams evaluated Plaintiff on November 4, 2015, for complaints of back pain. R. 374. Examination revealed tenderness in the cervical spine with mild pain in range of motion. R. 375. Dr. Williams evaluated Plaintiff on February 4, 2016, for complaints of moderate back pain and allergies. R. 370. Examination showed muscle spasm, and range of motion showed moderate pain with motion. R. 372. On May 27, 2015, Eric Sherburn, M.D., examined Plaintiff and prepared a consultation report pertaining to complaints of right arm pain, numbness, and weakness. R. 404-406. Dr. Sherburn noted a six- to eight-month history of progressive paresthesias followed by pain and now weakness in the right upper extremity. R. 404. Pain medication and chiropractic treatment had not improved her symptoms. Id.

         With respect to the medical opinion evidence, the ALJ gave great weight to the state agency opinions of Luther Woodcock, M.D., and Claire Horn, M.D. R. 25-26. They opined that Plaintiff had the RFC for light exertion work; should never climb ladders, ropes, and scaffolds; and should only occasionally climb ramps and stairs, stoop, kneel, crouch, and crawl. R. 78-79, 91-93. The ALJ gave their opinions great weight, finding that they were consistent with the totality of the objective medical evidence of record.[1]

         After evaluating the objective medical and psychological evidence, Plaintiff's statements, Plaintiff's daughter's statements, and the agency medical and psychological assessments, the ALJ concluded that Plaintiff has the residual function capacity (“RFC”) to perform a reduced range of light work through the date last insured as follows:

No lifting or carrying more than 20 pounds occasionally and 10 pounds frequently; pushing/pulling limitations are consistent with lifting and carrying limitations; stand/walk 6 hours out of an 8-hour day; and sit 6-8 hours in an 8-hour day. She cannot climb ladders, ropes, or scaffolds. She can occasionally climb stairs, bend or stoop, kneel, crouch, and crawl. She is limited to simple and routine and multistep tasks and some complex tasks ...

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