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Saenz v. Berryhill

United States District Court, D. New Mexico

June 7, 2017

NANCY A. BERRYHILL, [1]Acting Commissioner of the Social Security Administration, Defendant.



         THIS MATTER comes before the Court on plaintiff Marianita Victoria Saenz's Motion to Reverse and Remand and Memorandum in Support (Docs. 24, 24-1), which was fully briefed July 12, 2016. See Docs. 26, 27, 28. The parties consented to my entering final judgment in this case. Docs. 12, 13, 14. Having meticulously reviewed the entire record and being fully advised in the premises, I find that the Administrative Law Judge (“ALJ”) failed to properly weigh the medical opinion of Dr. Barbara Koltuska-Haskin. I therefore GRANT Ms. Saenz's motion and remand this case to the Commissioner for further proceedings consistent with this opinion.

         I. Standard of Review

         The standard of review in a Social Security appeal is whether the Commissioner's final decision[2] is supported by substantial evidence and whether the correct legal standards were applied. Maes v. Astrue, 522 F.3d 1093, 1096 (10th Cir. 2008). If substantial evidence supports the Commissioner's findings and the correct legal standards were applied, the Commissioner's decision stands, and the plaintiff is not entitled to relief. Langley v. Barnhart, 373 F.3d 1116, 1118 (10th Cir. 2004). “The failure to apply the correct legal standard or to provide this court with a sufficient basis to determine that appropriate legal principles have been followed is grounds for reversal.” Jensen v. Barnhart, 436 F.3d 1163, 1165 (10th Cir. 2005) (internal quotation marks and brackets omitted). The Court must meticulously review the entire record, but may neither reweigh the evidence nor substitute its judgment for that of the Commissioner. Flaherty v. Astrue, 515 F.3d 1067, 1070 (10th Cir. 2007).

         “Substantial evidence is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Langley, 373 F.3d at 1118. 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.” Id. While the Court may not reweigh the evidence or try the issues de novo, its examination of the record as a whole must include “anything that may undercut or detract from the ALJ's findings in order to determine if the substantiality test has been met.” Grogan v. Barnhart, 399 F.3d 1257, 1262 (10th Cir. 2005). “‘The possibility of drawing two inconsistent conclusions from the evidence does not prevent [the] findings from being supported by substantial evidence.'” Lax v. Astrue, 489 F.3d 1080, 1084 (10th Cir. 2007) (quoting Zoltanski v. F.A.A., 372 F.3d 1195, 1200 (10th Cir. 2004)).

         II. Applicable Law and Sequential Evaluation Process

         To qualify for disability benefits, a claimant must establish that he or she is unable “to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.” 42 U.S.C. § 423(d)(1)(A); 20 C.F.R. § 416.905(a).

         When considering a disability application, the Commissioner is required to use a five-step sequential evaluation process. 20 C.F.R. § 416.920; Bowen v. Yuckert, 482 U.S. 137, 140 (1987). At the first four steps of the evaluation process, the claimant must show: (1) the claimant is not engaged in “substantial gainful activity;” (2) the claimant has a “severe medically determinable . . . impairment . . . or a combination of impairments” that has lasted or is expected to last for at least one year; and (3) the impairment(s) either meet or equal one of the Listings[3] of presumptively disabling impairments; or (4) the claimant is unable to perform his or her “past relevant work.” 20 C.F.R. §§ 416.920(a)(4)(i-iv); Grogan, 399 F.3d at 1260-61. If the claimant cannot show that his or her impairment meets or equals a Listing but proves that he or she is unable to perform his or her “past relevant work, ” the burden of proof shifts to the Commissioner, at step five, to show that the claimant is able to perform other work in the national economy, considering the claimant's residual functional capacity (“RFC”), age, education, and work experience. Id.

         III. Background and Procedural History

         Ms. Saenz was born in 1981, has an eighth grade education, and has no past relevant work.[4] AR 34, 48, 135, 158.[5] Ms. Saenz reported multiple rapes, multiple suicide attempts, and multiple psychiatric hospitalizations as a teenager. AR 38, 403. Ms. Saenz filed an application for supplemental security income on July 11, 2011-alleging disability since September 13, 2010 due to emotional problems, anger management issues, depression, bipolar disorder, hypothyroidism, asthma, a heart murmur, and problems from ectopic pregnancies. AR 135-40, 157. The Social Security Administration (“SSA”) denied her claims initially on January 9, 2012. AR 84-87. The SSA denied her claims on reconsideration on March 15, 2013. AR 95-98. Ms. Saenz requested a hearing before an ALJ. AR 99-103. On March 11, 2014, ALJ John R. Morris held a hearing. AR 30-52. Ms. Saenz represented herself at the hearing. AR 32-33. ALJ Morris issued his unfavorable decision on July 23, 2014. AR 8-29.

         At step one, the ALJ found that Ms. Saenz had not engaged in substantial, gainful activity since July 11, 2011, the date of her application. AR 13. At step two, the ALJ found that Ms. Saenz suffered from the following severe impairments: obesity, diabetes, and “a mental condition variously diagnosed to include depression, PTSD, and alcohol and marijuana abuse.” Id. The ALJ found Ms. Saenz's history of ectopic pregnancies, asthma, and hypothyroidism to be non-severe. Id.[6] At step three, the ALJ found that none of Ms. Saenz's impairments, alone or in combination, met or medically equaled a Listing. AR 14-16. Because the ALJ found that none of the impairments met a Listing, the ALJ assessed Ms. Saenz's RFC. AR 16-23. The ALJ found Ms. Saenz had the RFC to perform light, unskilled work. AR 16.

         At step four, the ALJ concluded that Ms. Saenz did not have any past relevant work. AR 23. At step five, the ALJ found that Ms. Saenz could perform unskilled, light jobs that exist in significant numbers in the national economy. AR 23-24. On September 15, 2014, Ms. Saenz requested review of the ALJ's unfavorable decision by the Appeals Council. AR 6. On September 8, 2015, the Appeals Council denied the request for review. AR 1-5. Ms. Saenz timely filed her appeal to this Court on November 12, 2015. Doc. 1.[7]

         IV. Ms. Saenz's Claims

         Ms. Saenz raises four arguments for reversing and remanding this case: (1) the ALJ erred by failing to give controlling weight to the opinion of treating neuropsychologist Dr. Koltuska-Haskin; (2) the ALJ's RFC finding that that claimant can perform a full range of light work is not supported by substantial evidence; (3) the ALJ's step five findings are not supported by substantial evidence because the ALJ gave the vocational expert an incomplete hypothetical, and because the ALJ failed to show there were jobs in the regional or national economies that Ms. Saenz could perform; (4) the ALJ denied Ms. Saenz due process at the administrative hearing. Because I remand based on the ALJ's failure to properly weigh the opinion of Dr. Koltuska-Haskin, I do not address the other alleged errors, which “may be affected by the ALJ's treatment of this case on remand.” Watkins v. Barnhart, 350 F.3d 1297, 1299 (10th Cir. 2003).

         V. Analysis

         Ms. Saenz argues that the ALJ erred by not giving controlling weight to the opinion of treating neuropsychologist Dr. Koltuska-Haskin. Doc. 24-1 at 17-20. Ms. Saenz also argues that the ALJ committed legal error by giving greater weight to the opinions of non-treating consultative examiners Cathy L. Simutis, Ph.D., and Davis Brimberg, Ph.D., without first doing a proper treating source analysis. Id. The Commissioner does not dispute that Dr. Koltuska-Haskin is a treating neuropsychologist. See Doc. 26 at 11-13 (offering no argument in response to Ms. Saenz's assertion that Dr. Koltuska-Haskin is a treating source, and analyzing the ALJ's evaluation of Dr. Koltuska-Haskin's opinion using the treating source rules).[8] The Commissioner simply argues that the ALJ gave valid reasons for giving less weight to Dr. Koltuska-Haskin's opinion. See id. For the reasons discussed below, I find that the ALJ committed legal error by failing to conduct a proper treating source analysis of Dr. Koltuska-Haskin's opinion, and I remand on this basis.

         In analyzing whether a treating source opinion is entitled to controlling weight, the ALJ must perform a two-step process. First, the ALJ must consider whether the opinion “is well supported by medically acceptable clinical and laboratory diagnostic techniques and is consistent with the other substantial evidence in the record.” Pisciotta v. Astrue, 500 F.3d 1074, 1077 (10th Cir. 2007) (citing 20 C.F.R. § 404.1527(d)(2); Watkins, 350 F.3d at 1300). If the opinion meets both criteria, the ALJ must give the treating source's opinion controlling weight. Id. To give anything less than controlling weight, the ALJ must demonstrate with substantial evidence that the opinion (1) is not “well-supported by medically acceptable clinical and laboratory diagnostic techniques, ” or (2) is “inconsistent with other substantial evidence” in the record. 20 C.F.R. § 416.927(c)(2). “Under the regulations, the agency rulings, and our case law, an ALJ must ‘give good reasons in [the] notice of determination or decision' for the weight assigned to a treating [source's] opinion.” Watkins, 350 F.3d at 1300 (quoting 20 C.F.R. § 404.1527(d)(2) and citing SSR 96-2p, 1996 WL 374188, at *5; Doyal v. Barnhart, 331 F.3d 758, 762 (10th Cir. 2003)).

         If the ALJ does not assign a treating source's opinion controlling weight, step two of the analysis requires the ALJ to apply the six factors listed in the regulations to determine whether a treating source's opinion should be rejected altogether or assigned some lesser weight:

1. Examining relationship: more weight is given to the opinion of a source who has examined the claimant than to one who has not;
2. Treatment relationship: more weight is given to the opinion of a source who has treated the claimant than to one who has not; more weight is given to the opinion of a source who has treated the claimant for a long time over several visits and who has ...

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