Court: District Court, D. Colorado; April 14, 2016; Federal District Court
Michael E. Hegarty, United States Magistrate Judge, has ruled on the appeal by plaintiff Christine Carstensen against the Social Security Administration (SSA) regarding the denial of her application for disability insurance benefits (DIB) under Title II of the Social Security Act. The court has jurisdiction based on 42 U.S.C. 405(g). After reviewing the parties' briefs and the administrative record, the court has reversed the Administrative Law Judge's (ALJ) decision and remanded the case for further consideration.
Carstensen filed her DIB application on December 17, 2012, claiming disability due to multiple medical conditions with an alleged onset date of October 1, 2008. She was required to demonstrate that her disability began before her date last insured, June 30, 2013. The application was initially denied on May 8, 2013, leading to a hearing on April 3, 2014. The ALJ issued an unfavorable decision on June 20, 2014, concluding that Carstensen was not disabled from her alleged onset date through her date last insured, stating there were significant jobs she could perform based on her age, education, work experience, and residual functional capacity (RFC). The SSA Appeals Council denied her request for review, making the ALJ's decision final for judicial review.
Carstensen, born December 23, 1963, claimed disability due to various physical ailments, including knee issues, arrhythmia, chronic pain, high blood pressure, migraines, asthma, nerve damage, muscle strain, anxiety, and Type 2 diabetes. She completed high school and some college and had relevant work experience as a medical biller, dog groomer, kennel attendant, trailer park manager, and auto line assembler. The appeal focuses on three specific treating physician opinions concerning her cardiovascular disease, orthopedic conditions, and chronic pain management. Notably, Dr. Eric Young, an orthopedic and hand surgeon, documented Carstensen's history of bilateral knee pain, recommended exercises, and performed a partial knee replacement in July 2011.
In late January 2012, Plaintiff reported a decrease in pain and improved knee mobility, being able to fully extend her knees. By February 2013, Dr. Young noted some popping in her right knee, while her left knee was asymptomatic. He assessed that Plaintiff could lift less than 10 pounds, stand and sit for less than two hours daily, and could never stoop, crouch, or climb. Dr. Young indicated that Plaintiff would need to lie down frequently and had limited abilities to reach, finger, push, pull, handle, and feel, estimating she would likely miss over four days of work each month.
Dr. Douglas Webster, Plaintiff's internal medicine doctor, provided treatment notes indicating that in March 2012, Plaintiff was on blood pressure medication without chest pain or shortness of breath. By December 2012, he noted that her chronic pain could hinder full-time employment and assisted her in completing disability paperwork. In November 2013, Plaintiff reported chest pain, and Dr. Webster advised her to reduce estrogen use due to heart issues, although she hesitated due to concerns about hot flashes. He signed disability forms, indicating he largely agreed with her subjective assessments. By January 2014, Plaintiff cited anxiety and various aches as reasons for her disability, and Dr. Webster confirmed her disability in two opinion forms in early 2014, noting she could sit for seven hours and stand/walk for three, but had significant limitations in repetitive movements and could not lift over 10 pounds or perform fine manipulation.
Dr. Randall Marsh, Plaintiff's cardiologist, documented her heart attack in August 2013 and subsequent stent surgeries for angina. In February 2014, he completed a functional capacity assessment form, stating that sustained activity was problematic and identifying that her primary disability issues were orthopedic, with some cardiac-related concerns in pushing and pulling.
Cardiovascular issues have been present for over a decade, with a heart attack occurring in August 2013 and significant coronary artery disease (CAD) reported. The patient, under Dr. Marsh's care, is limited to lifting/carrying less than 10 pounds, standing/walking for less than two hours, and sitting for less than two hours in an eight-hour workday. Her impairment affects her ability to reach, finger, push/pull, handle, and feel. She requires the ability to change positions frequently, needs to lie down two to four times daily, and experiences severe symptoms that interfere with her focus on simple tasks.
During a hearing on April 3, 2014, the plaintiff, who has a high school diploma and some college education, described her work history, including part-time roles as a dog groomer and kennel assistant, which she left due to knee surgery. She also worked full-time at PetSmart but had to reduce her hours because of a cardiac spasm and restrictions on lifting more than 10 pounds, as advised by cardiologist Dr. Downs, despite a lack of formal records from his office.
Additional employment included a billing/receptionist position where she mostly sat and lifted light objects, and earlier jobs at Chrysler and Sun Communities. The plaintiff testified about ongoing cardiac issues, including heart attacks and spasms, and mentioned not pursuing follow-up therapy due to costs. She cited nerve damage in her neck as a primary reason for her inability to work, describing daily headaches that can escalate to migraines.
She also detailed her struggles with knee pain, back issues from a car accident, diabetes causing dizziness, and numbness in her extremities. She reported difficulty standing, balance issues, and frequent falls, stating she can only stand for five minutes before needing to sit due to instability.
Testimony revealed that the claimant can walk for 15 minutes and sit for 10 minutes before experiencing pain, and requires naps of 15 minutes to two hours daily, particularly during cardiac spasms. Despite having heart stents, she suffers from dizziness and near-fainting episodes when bending over. A vocational expert (VE) testified regarding job availability based on the claimant's abilities, which the ALJ assessed through a hypothetical scenario involving light work restrictions. The VE indicated that the claimant could still perform her past job as a medical biller, as well as other positions like tanning salon attendant and recreation aide. When the hypothetical was adjusted to sedentary work, the VE maintained that medical billing and other roles, such as optical final assembler and appointment clerk, remained viable. The VE stated that employers would tolerate up to one day of absenteeism per month. If the claimant lacked certification in medical billing, the VE noted that job availability would decrease significantly. Additionally, the VE indicated that inability to interact with coworkers or the public would render the claimant unsuitable for all jobs. After the hearing, the ALJ allowed additional medical records to be submitted, which were considered before the ALJ issued an unfavorable decision on June 20, 2014.
The excerpt also outlines the legal standards pertaining to the Social Security Administration's (SSA) five-step process for determining disability under Title II of the Social Security Act. Step One assesses whether the claimant is engaged in substantial gainful activity; if so, benefits are denied. Step Two evaluates the severity of the claimant's impairments, requiring that they have more than a minimal effect on basic work activities to qualify for benefits.
Step Three assesses whether a claimant's impairment matches a listed severe impairment that prevents substantial gainful employment. If the impairment is not listed, the claimant is not automatically considered disabled. Step Four requires the claimant to demonstrate that her impairment and assessed Residual Functional Capacity (RFC) prevent her from doing any past work. If the claimant can perform her previous work, she is deemed not disabled. If a prima facie case of disability is established through these steps, the analysis moves to Step Five, where the SSA Commissioner must show that the claimant has the RFC to perform other jobs in the national economy, considering her age, education, and work experience.
The Court's review is confined to evaluating whether substantial evidence supports the final decision and whether correct legal standards were employed. Substantial evidence refers to more than a mere scintilla but less than a preponderance, meaning it is evidence a reasonable mind might accept to support a conclusion. The Court cannot re-evaluate evidence or replace the ALJ's judgment, although a reversal may occur if the ALJ applies incorrect legal standards or fails to use the appropriate legal standards.
The ALJ's ruling indicated that at Step One, the Plaintiff met the insured status requirements of the Social Security Act through June 30, 2013. At Step Two, the ALJ identified the Plaintiff's severe impairments as status post bilateral partial knee replacement, degenerative disc disease with radiculopathy, obesity, and status post myocardial infarction. The ALJ also reviewed evidence for additional conditions such as reactive airway disease, hypertension, diabetes, and blurred vision/glaucoma, concluding these were not severe as they did not significantly impair the Plaintiff's ability to perform work-related activities.
At Step Three, the ALJ determined that the Plaintiff did not have an impairment that met or equaled the severity of any listed impairments. The ALJ assessed the Plaintiff's Residual Functional Capacity (RFC) to perform light work with certain restrictions: she could occasionally climb ramps or stairs, but could never climb ladders, ropes, or scaffolds, and could occasionally kneel, crouch, or crawl. The Plaintiff was required to avoid concentrated exposure to cold, vibration, and unprotected heights.
The ALJ reviewed three medical opinions relevant to the appeal. Dr. Randall Marsh opined in February 2014 that the Plaintiff would miss four workdays monthly, experience constant pain affecting her concentration, could never stoop, climb stairs, or crouch, and could only occasionally twist. He indicated she needed to lie down during the day two to four times, could walk for about ten minutes, sit or stand for five minutes, and needed to walk around every fifteen minutes, along with being able to lift less than ten pounds occasionally.
Dr. Eric Young provided a similar report in February 2013, echoing Dr. Marsh's opinions regarding work absences and limitations. He noted additional restrictions on reaching, handling, and other movements, and indicated the Plaintiff would need to elevate her legs. The ALJ assigned little weight to both opinions, stating they seemed based solely on the Plaintiff’s subjective complaints, unsupported by the treatment record.
Dr. Webster’s assessment in January 2014 indicated the Plaintiff could sit for seven hours, stand for two, and walk for one hour, but would be constantly distracted by symptoms. He reported various lifting and mobility limitations, attributing his opinions to the Plaintiff's claims of nerve damage. However, Dr. Webster's treatment notes from February 2014 reflected a relatively normal physical examination, noting the Plaintiff had a normal gait and range of motion, and recommended an aquatic exercise program without specifying how much weight to give his opinion.
The ALJ determined that the RFC assessment was supported by objective medical evidence and concluded that Plaintiff could perform past relevant work as a medical billing clerk, which aligned with her RFC. Consequently, the ALJ found Plaintiff not disabled under SSA definitions from October 8, 2008, to June 30, 2013. Plaintiff appealed the ALJ’s decision to the Appeals Council, which denied the review. Plaintiff subsequently filed a Complaint contesting the decision.
On appeal, Plaintiff argues that the ALJ failed to provide adequate reasons for discounting the opinions of her treating specialists and did not assign weight to Dr. Webster’s opinion, which she claims is a reversible error. In response, the Defendant asserts that the ALJ conducted a thorough review, highlighting inconsistencies between the physicians' treatment notes and their conclusions, and that Plaintiff’s daily living activities contradicted her disability claims.
The legal framework requires an ALJ to evaluate all medical opinions, assigning varying weight based on the relationship between the claimant and the medical professional. The ALJ must also discuss the weight given to each opinion. Specifically, when assessing a treating physician's opinion, the ALJ must first determine if the opinion is conclusive and if so, whether it is supported by medically acceptable evidence. If well-supported, the ALJ must then confirm consistency with other substantial evidence in the record to assign controlling weight. If the opinion is not supported or inconsistent, it does not receive controlling weight.
An ALJ must evaluate medical opinions in cases where a treating physician's opinion does not hold controlling weight or is absent. This evaluation involves considering factors such as the length and frequency of the treating relationship, the nature of that relationship, evidentiary support, consistency with records, medical specialization, and other relevant factors. An ALJ can only dismiss or give less weight to a medical opinion if they provide specific, legitimate reasons based on these factors. It is critical for the ALJ to clearly state the weight assigned to each opinion and the rationale behind that weight, as vague or boilerplate explanations are insufficient. The ALJ must also consider and discuss uncontroverted evidence and any significant evidence that is rejected.
In this case, the ALJ provided explanations for the low weight assigned to the opinions of Dr. Marsh and Dr. Young but failed to indicate the weight given to Dr. Webster’s opinion regarding the Plaintiff's physical conditions, which is a violation of required standards. The ALJ did not adequately consider essential factors such as the treating relationship's length and frequency or the medical specialization. Although the ALJ addressed evidentiary support and consistency, the lack of specificity in rejecting the opinions was noted as a deficiency. The Court concluded that the ALJ did not conduct a thorough analysis and thus reversed the ALJ's decision that Plaintiff Christine Carstensen was not disabled from October 8, 2008, to June 30, 2013, remanding the case for further consideration. The ALJ also referenced Dr. Webster’s mental health opinion but similarly failed to assign weight to the physical functional assessment.
