United States District Court, N.D. Oklahoma
OPINION AND ORDER
F. JAYNE, MAGITRATE JUDGE.
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.
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.
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 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.
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
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.
respect to the opinion evidence in the record, the ALJ
summarized Dr. Koenig's October 14, 2015, Medical Source
Statement 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.
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.
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. 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.”).
Analysis - ALJ Erred in Treatment of Dr. Koenig's