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James L. v. Saul

United States District Court, N.D. Oklahoma

September 17, 2019

JAMES L., Plaintiff,
ANDREW M. SAUL, Commissioner, Social Security Administration, Defendant.



         Plaintiff James L. seeks judicial review of the decision of the Commissioner of the Social Security Administration denying his claim for disability insurance benefits under Title II of the Social Security Act (“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. 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 52-year-old male, applied for Title II benefits on April 9, 2015, alleging a disability onset date of December 1, 2014. R. 146. Plaintiff claimed that he was unable to work due to disorders including back injury, diabetes, sciatica, hearing loss, arthritis, and neck mobility. R. 193. Plaintiff's claim for benefits was denied initially on July 30, 2015, and on reconsideration on August 27, 2015. R. 58-62; 64-66. Plaintiff then requested a hearing before an Administrative Law Judge (“ALJ”), and the ALJ conducted the hearing on April 7, 2017. R. 22-37. The ALJ issued a decision on June 14, 2017, denying benefits and finding Plaintiff not disabled because he was able to perform his past relevant work as a vocational instructor. R. 17. As an alternative finding at step five, the ALJ also found Plaintiff capable of performing the jobs of cashier II and office helper. R. 8-18. The Appeals Council denied review, and Plaintiff appealed. R. 1-5; ECF No. 2.

         The ALJ found that Plaintiff met the insured status requirements of the Act through December 31, 2018, and that he had not engaged in substantial gainful activity since his alleged onset date of December 1, 2014. R. 13. The ALJ found that Plaintiff had the following severe impairments: diabetes mellitus, degenerative disc disease of the lumbar spine, and obesity. Id. At step three, the ALJ found that Plaintiff did not have an impairment or combination of impairments of such severity to result in listing-level impairments. Id.

         With respect to objective evidence in the record, the ALJ noted records from the Veterans' Administration Medical Center showing a lumbar spine MRI performed December 9, 2014, which revealed “multilevel degenerative changes involving the lumbar spine, with associated multilevel central canal and neural foraminal outlet narrowing of varying degrees as described, affecting T11 through S1, ” and cervical spine radiology reports from December 1, 2014, which showed stable C5, C6, and C7 cervical fusion. R. 15. On July 7, 2015, Sam Worrall, D.O. performed a consultative audiology examination with essentially normal findings. R. 15. The ALJ summarized Plaintiff's complaints and visits to Dr. Joseph Koenig, M.D. between February 2013 and July 25, 2014 as “mainly for right ankle pain, back pain and diabetes, ” without listing any objective testing or findings. Id. The ALJ next noted Plaintiff's October 14, 2015, visit to Dr. Koenig wherein examination revealed tenderness and decreased range of motion in the cervical and lumbar spine, and the lumbar spine also showed pain and spasm. Dr. Koenig diagnosed diabetes mellitus with neurological manifestations, uncontrolled; mixed hyperlipidemia; cervicalgia; pain in joint, ankle and foot, right; and bilateral low back pain with right-side sciatica. Id. The ALJ discussed x-rays of Plaintiff's left foot in June 2016, which revealed “very mild degenerative changes at the interphalangeal joints, ” and the “fifth ray” was radiographically intact. R. 16. The x-ray also showed mild soft tissue that might be a bunionette, and “small plantar and tine posterior calcaneal spurs.” Plaintiff's foot pain was resolved in September 2016. Id.

         With respect to the opinion evidence in the record, the ALJ summarized Dr. Koenig's October 14, 2015, Medical Source Statement[1] before giving the opinion “no weight.” R. 15, 17. The ALJ gave “considerable weight” to the opinions of agency medical consultants Janet Rodgers, M.D., and David Coffman, M.D. R. 16. Both opinions state that Plaintiff could perform at a less than light exertional level, with limited hearing in both ears. Id. (emphasis added). Finally, the ALJ “took into consideration” the 30% service-connected disability rating from the Department of Veterans Affairs, noting that the two agencies' disability determination processes are different. R. 17.

         After evaluating the record and opinion evidence, the ALJ concluded that Plaintiff has the RFC to perform “the full range of light work as defined in 20 CFR 404.1567(b), that is, lift and/or carry twenty pounds occasionally, ten pounds frequently, stand and/or walk at least six hours in an eight-hour workday, and sit at least six hours” with no additional limitations. R. 14. The ALJ found at step four that Plaintiff was able to return to his past relevant work as a vocational instructor. R. 17. Based on the testimony of a vocational expert (“VE”), the ALJ made the alternate finding at step five that Plaintiff could perform other work, such as cashier II, and office helper. R. 17-18. The ALJ determined the VE's testimony was consistent with the information contained in the Dictionary of Occupational Titles (“DOT”). R. 18. Based on the VE's testimony, the ALJ concluded these positions existed in significant numbers in the national economy. Id. Accordingly, the ALJ concluded Plaintiff was not disabled.

         III. Issues

         Plaintiff raises two points of error in his challenge to the denial of benefits: (1) the ALJ committed reversible legal error by failing to properly evaluate Dr. Koenig's treating source opinion; and (2) the ALJ committed reversible error by failing to recognize and address the fact that Plaintiff fell within a borderline age situation.[2] ECF No. 15. The Court finds that the ALJ committed reversible error by failing to properly evaluate the treating source opinion of Dr. Koenig. Because Dr. Koenig's treating source opinion must be reevaluated, the rest of the decision may be affected by this reevaluation. Therefore, the Court does not reach the remaining allegation of error. See Robinson v. Barnhart 366 F.3d 1078, 1085 (10th Cir. 2004) (“We will not reach the remaining issues raised by claimant because they may be affected by the ALJ's resolution of this case on remand.”).

         IV. Analysis - ALJ Erred in Treatment of Dr. Koenig's ...

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