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Nelson v. Berryhill

United States District Court, W.D. Oklahoma

May 31, 2019

NANCY A. BERRYHILL, 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 benefits 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 AND REMANDS the Commissioner's decision.


         Initially and on reconsideration, the Social Security Administration denied Plaintiff's application for benefits. Following a hearing, an Administrative Law Judge (ALJ) issued an unfavorable decision. (TR. 18-29). 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. § 416.920. At step one, the ALJ determined that Plaintiff had not engaged in substantial gainful activity since January 21, 2016, her application date. (TR. 20). At step two, the ALJ determined that Ms. Nelson had the following severe impairments: affective disorder; anxiety disorder; and borderline intellectual functioning. (TR. 20). 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. 20).

         At step four, the ALJ concluded that Ms. Nelson retained the residual functional capacity (RFC) to:

[Perform] a full range of work at all exertional levels but with the following nonexertional limitations: limited to perform simple, routine and repetitive tasks and occasional contact with the public.

(TR. 22). At the administrative hearing, the ALJ questioned Ms. Nelson and a vocational expert (VE) to assess Plaintiff's past relevant work. (TR. 41-42, 53-54). In doing so, the VE testified that an individual with Ms. Nelson's RFC was capable of performing her past work as a housekeeper, as that job is generally performed in the national economy. (TR. 54). Thus, at step four, the ALJ concluded that Ms. Nelson was not disabled based on her ability to perform this past job. (TR. 27). Even so, the ALJ made alternate findings at step five.

         At step five, the ALJ presented the RFC limitations to the VE to determine whether there were other jobs in the national economy that Plaintiff could perform. (TR. 54-55). Given the limitations, the VE identified three jobs from the Dictionary of Occupational Titles. (TR. 55). The ALJ adopted the testimony of the VE and concluded that Ms. Nelson was also not disabled at step five based on her ability to perform the identified jobs. (TR. 28).


         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). Under the “substantial evidence” standard, a court looks to an existing administrative record and asks whether it contains “sufficien[t] evidence” to support the agency's factual determinations. Biestek v. Berryhill, 139 S.Ct. 1148, 1154 (2019). “Substantial evidence … is more than a mere scintilla … and means only-such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Biestek v. Berryhill, 139 S.Ct. at 1154 (internal citations and quotation marks 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).


         On appeal, Ms. Nelson alleges the ALJ erred in evaluating: (1) the medical evidence and (2) Plaintiff's subjective allegations.


         Ms. Nelson alleges error in the ALJ's consideration of certain medical evidence. (ECF No. 16:8-11). Specifically, Plaintiff contends that the ALJ erred in failing to give more weight to the opinion of a treating physician, Dr. Charles Shields, over the opinions of two non-examining State Agency physicians. (ECF No. 16:8-11). The Court finds no merit in this allegation of error.

         A. The ALJ's Duties in Evaluating Medical Opinions

         Regardless of its source, the ALJ has a duty to evaluate every medical opinion in the record. Hamlin v. Barnhart, 365 F.3d 1208, 1215 (10th Cir. 2004); 20 C.F.R. § 416.927(c). The weight given each opinion will vary according to the relationship between the claimant and the medical professional. Hamlin, 365 F.3d at 1215. For example, in evaluating a treating physician's opinion, the ALJ must follow a two-pronged analysis. First, the ALJ must determine, then explain, whether the opinion is entitled to controlling weight. Langley v. Barnhart, 373 F.3d 1116, 1119 (10th Cir. 2004).

         This analysis, in turn, consists of two phases. First, an ALJ must consider whether the opinion is “well-supported by medically acceptable clinical and laboratory diagnostic techniques” and consistent with other substantial evidence in the record. Policy Interpretation Ruling Titles II and XVI: Giving Controlling Weight to Treating Source Medical Opinions, 1996 WL 374188, at 2 (July 2, 1996) (internal quotations omitted). If controlling weight is declined, the ALJ must assess the opinion under a series of factors which are considered when assessing any medical opinion, regardless of its source. 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) the 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 1324, 1330 (10th Cir. 2011); 20 C.F.R § 416.927(c).

         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). If the ALJ rejects an 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).

         Opinions of physicians who have seen a claimant over a period of time for purposes of treatment are generally given more weight over the views of consulting physicians or those who only review the medical records and never examine the claimant. Robinson v. Barnhart, 366 F.3d 1078, 1084 (10th Cir. 2004). Error is only found when an ALJ rejects an opinion from a treating physician in favor of a non-examining physician “absent a legally sufficient reason for doing so.” Id.

         B. Opinions from Dr. Shields and Non-Examining State Agency Physicians

         The medical record contains two letters authored by Dr. Charles Shields which document findings regarding Plaintiff's physical abilities following two examinations. (TR. 448-451). In a letter dated April 14, 2015, Dr. Shields: (1) noted that Plaintiff had complained of lower back and left knee pain since 2009 and (2) ordered x-rays. (TR. 450).[1 ...

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