United States District Court, N.D. Oklahoma
SHAWNETTE L. O., Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.
OPINION AND ORDER
F. JAYNE, MAGISTRATE JUDGE.
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
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
Standard of Review
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).
Procedural History and the ALJ's Decision
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.
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.
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.
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.
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.
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.
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
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 ...