Sissom v. Astrue , 512 F. App'x 762 ( 2013 )

FILED
United States Court of Appeals
UNITED STATES COURT OF APPEALS Tenth Circuit
FOR THE TENTH CIRCUIT March 1, 2013
Elisabeth A. Shumaker
Clerk of Court
KATHY A. SISSOM,
Plaintiff-Appellant,
v. No. 12-6131
(D.C. No. 5:11-CV-00289-F)
CAROLYN W. COLVIN, Acting (W.D. Okla.)
Commissioner of the Social Security
Administration,*
Defendant-Appellee.
ORDER AND JUDGMENT**
Before ANDERSON and BALDOCK, Circuit Judges, and BRORBY, Senior Circuit
Judge.
Kathy A. Sissom appeals from an order of the district court affirming the
Commissioner’s decision denying her applications for disability benefits and
*
In accordance with Rule 43(c)(2) of the Federal Rules of Appellate Procedure,
Carolyn W. Colvin is substituted for Michael J. Astrue as the defendant-appellee in
this action.
**
After examining the briefs and appellate record, this panel has determined
unanimously to grant the parties’ request for a decision on the briefs without oral
argument. See Fed. R. App. P. 34(f); 10th Cir. R. 34.1(G). The case is therefore
ordered submitted without oral argument. This order and judgment is not binding
precedent, except under the doctrines of law of the case, res judicata, and collateral
estoppel. It may be cited, however, for its persuasive value consistent with
Fed. R. App. P. 32.1 and 10th Cir. R. 32.1.
supplemental security income benefits under the Social Security Act. We exercise
jurisdiction under 28 U.S.C. § 1291 and 42 U.S.C. § 405(g), and reverse and remand
for further proceedings.
I. Background
Ms. Sissom injured her right knee in September 2004 while employed as a
housekeeper. She sought medical treatment and ultimately had arthroscopic surgery
on her knee in February 2005. She continued to have knee pain which was
determined to be due to mild degenerative changes. She also later complained of
other ailments including lower back pain, shoulder pain, hip pain, bilateral hand
numbness, and carpal tunnel syndrome for which she also sought medical treatment.
She ultimately filed for disability and supplemental security benefits in July 2008.
She was fifty three years old at the time of her application. Ms. Sissom has a high
school education and has worked for brief periods of time as a housekeeper,
cashier/checker, and deli manager.
The Commissioner denied Ms. Sissom’s applications initially and on
reconsideration. After a de novo hearing before an administrative law judge (ALJ),
the ALJ issued his decision in November 2009, finding Ms. Sissom not disabled at
step four of the controlling five-step sequential analysis. See Lax v. Astrue, 489 F.3d
1080, 1084 (10th Cir. 2007) (explaining five-step process for evaluating claims for
disability benefits). The ALJ confirmed that Ms. Sissom had not worked during the
period from her alleged onset of disability, September 30, 2004, through her date last
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insured, December 31, 2009, but noted brief employment as a housekeeper in 2009.
He found that Ms. Sissom had the following severe impairments: degenerative disc
disease; status post right knee arthroscopy in 2005; degenerative joint disease in the
right knee; mild left carpal tunnel syndrome and right ulnar neuropathy; diabetes
mellitus; hypertension; atherosclerotic vascular disease; and nicotine addiction. But
he concluded that these impairments did not meet or equal the listings for
presumptive disability.
The ALJ also found Ms. Sissom not credible and determined that her
impairments left her with a residual functional capacity (RFC) to perform light work,
as defined in 20 C.F.R. § 404.1567(b) and § 416.967(b), with some postural
limitations and moderate mental limitations. Relying in part on associated inquiries
to the vocational expert (VE) who testified at the hearing, the ALJ concluded that
Ms. Sissom could still perform her past relevant work (PRW) as a housekeeper or
cashier/checker and thus was not disabled.
Ms. Sissom’s request for review was denied by the Appeals Council, making
the ALJ’s decision the Commissioner’s final decision for purposes of judicial review.
Doyal v. Barnhart, 331 F.3d 758, 759 (10th Cir. 2003). She then sought judicial
review of the Commissioner’s decision. The district court affirmed the
Commissioner’s denial of benefits, and Ms. Sissom now appeals.
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II. Discussion
“In reviewing the [Commissioner’s] decision, we neither reweigh the evidence
nor substitute our judgment for that of the agency.” Branum v. Barnhart, 385 F.3d
1268, 1270 (10th Cir. 2004) (internal quotation marks omitted). Rather, “[w]e
review the Commissioner’s decision to determine whether the factual findings are
supported by substantial evidence in the record and whether the correct legal
standards were applied.” Watkins v. Barnhart, 350 F.3d 1297, 1299 (10th Cir. 2003).
“Substantial evidence is such relevant evidence as a reasonable mind might accept as
adequate to support a conclusion. It requires more than a scintilla, but less than a
preponderance.” Lax, 489 F.3d at 1084 (citation omitted) (internal quotation marks
omitted).
Ms. Sissom raises three challenges to the Commissioner’s decision: (1) the
ALJ failed to apply the correct legal standards in evaluating the opinion of her
treating physician, Dr. Jameson; (2) the ALJ’s RFC determination is not supported by
substantial evidence; and (3) the ALJ did not conduct a proper step four analysis.1
1
She also appears to assert error by the magistrate judge and the district court
judge. “[W]e independently determine whether the ALJ’s decision is free from legal
error and supported by substantial evidence.” Wall v. Astrue, 561 F.3d 1048, 1052
(10th Cir. 2009) (internal quotation marks omitted). Therefore, although we have
considered Ms. Sissom’s arguments concerning error by the magistrate judge and
the district court judge in the context of evaluating her claims that the ALJ erred,
we do not expressly address her claims of error by the magistrate judge or the
district court judge.
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A. Treating Physician Evaluation
Ms. Sissom first argues that the ALJ did not properly evaluate the opinion of
Dr. Jameson, her treating physician. According to Ms. Sissom, the ALJ
“misapprehended the record and considered Dr. Jameson [as] merely a[n] worker’s
compensation physician” and, as such, failed to accord him the deference due to a
treating physician’s opinion. Aplt. Op. Br. at 25. She also argues the ALJ failed to
apply the correct legal standards under Watkins in his evaluation of Dr. Jameson’s
opinion.
“An ALJ must evaluate every medical opinion in the record” but the weight
accorded to such “opinion[s] will vary according to the relationship between the
disability claimant and the medical professional.” Hamlin v. Barnhart, 365 F.3d
1208, 1215 (10th Cir. 2004). A “treating physician’s opinion is given particular
weight because of his unique perspective to the medical evidence” and because a
“medical professional who has dealt with a claimant and his maladies over a long
period of time will have a deeper insight into the medical condition of the claimant
than will a person who has examined a claimant but once, or who has only seen the
claimant’s medical records.” Doyal, 331 F.3d at 762 (internal quotation marks
omitted). Thus, a relationship of both duration and frequency is required for a
treating relationship, see id., which is evidenced by the Social Security
Administration’s regulations defining a “treating source” as someone
who provides you, or has provided you, with medical
treatment or evaluation and who has, or has had, an
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ongoing treatment relationship with you. Generally, we
will consider that you have an ongoing treatment
relationship with [a physician] when the medical evidence
establishes that you see, or have seen, the source with a
frequency consistent with accepted medical practice for the
type of treatment and/or evaluation required for your
medical condition(s).
20 C.F.R. §§ 404.1502, 416.902.
When analyzing the opinion of a treating physician then, the ALJ first
considers “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. Watkins, 350 F.3d at 1300 (internal quotation marks
omitted); see also 20 C.F.R. §§ 404.1527(c)(2), 416.927(c)(2). If so, the ALJ must
give the opinion “controlling weight.” Watkins, 350 F.3d at 1300. If the opinion is
not entitled to controlling weight, the ALJ should next weigh the opinion considering
the six factors2 in 20 C.F.R. §§ 404.1527(c)(2), 416.927(c)(2), Watkins, 350 F.3d
2These 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) 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.
Watkins, 350 F.3d at 1301 (internal quotation marks omitted).
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at 1300-01, and determine “whether the opinion should be rejected altogether or
assigned some lesser weight,” Pisciotta v. Astrue, 500 F.3d 1074, 1077 (10th Cir.
2007). Finally, “[i]n all cases the regulations require that the ALJ give good reasons
in the notice of determination or opinion for the weight that is given the treating
physician’s opinion.” Doyal, 331 F.3d at 762 (internal quotation marks omitted).
In this case, it is unclear whether the ALJ considered Dr. Jameson to be a
treating physician. Ms. Sissom began treatment for injury to her right knee with
Dr. Jameson, an orthopedic surgeon, in November 2004. Ms. Sissom continued her
treatment, but after conservative treatment, including physical therapy, cortisone
injections, and pain medication failed, Dr. Jameson ultimately performed an
arthroscopic knee surgery with partial medial meniscectomy in February 2005.
Ms. Sissom continued post-operative evaluation by Dr. Jameson until April 2005.
But in evaluating the medical evidence of Dr. Jameson, the ALJ first stated in
his decision that Ms. Sissom saw Dr. Jameson “on April 6, 2005, in connection with
her worker’s compensation claim,” Admin. R. at 20 (emphasis added). While this
appears to be an accurate statement, upon review we cannot determine whether the
ALJ’s evaluation of Dr. Jameson’s opinion was somehow tainted by a perception that
Dr. Jameson was simply a workers’ compensation physician. The decision is unclear
because while the ALJ did not expressly designate Dr. Jameson as a “treating
physician,” the ALJ also did not state or suggest that Dr. Jameson was not one by
stating, for example, that Ms. Sissom’s treatment with Dr. Jameson was fleeting,
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infrequent, or not the type of treatment required for her condition. See 20 C.F.R.
§§ 404.1502, 416.902. And contrary to the Commissioner’s suggestion, the fact that
Dr. Jameson was seen in connection with a workers’ compensation claim does not in
and of itself mandate a finding that Dr. Jameson is not to be considered a treating
physician.
The ALJ’s treatment of Dr. Jameson’s opinions is further confounding because
the decision is limited to an analysis of Dr. Jameson’s final treatment note of April 6,
2005. The ALJ stated as follows:
Dr. Jameson noted the claimant’s functional capacity
evaluation seemed to indicate the claimant would be able
to perform sedentary work with no lifting over 10 pounds.
Dr. James [sic] opined that these restrictions were “a little
bit stringent, and I believe that the patient would be able to
lift certainly twenty to thirty pounds on a regular basis.
The primary concern is going to be her functioning on her
feet for long periods of time and this is going to cause pain
secondary to her degenerative changes; therefore I believe
that she would require a desk job but I do not believe this
would restrict her from being able to lift heavy objects.”
Admin. R. at 20. In concluding his evaluation, the ALJ stated that he “considered
the opinion of Dr. Jameson, but assigned greater weight to the opinions of
non-examining State agency physicians. Examinations by Dr. Brennan
[a consultative examiner] in October of 200[6] and in November of 2008 revealed
normal range of motion, symmetric reflexes, and no evidence of sensory loss.” Id.While it is evident that the ALJ did not give Dr. Jameson’s opinion
“controlling weight,” he did not articulate what weight, if any, he gave to
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Dr. Jameson’s opinion. He simply “assigned greater weight” to the opinions of the
non-examining agency physicians. The ALJ also did not state whether Dr. Jameson’s
opinion was unsupported or inconsistent with other substantial evidence,
thereby precluding controlling weight. But even if Dr. Jameson’s opinion is not
entitled to controlling weight, the ALJ must consider the pertinent factors and “give
good reasons” for the weight he ultimately assigns the opinion. 20 C.F.R.
§§ 404.1527(c)(2), 416.927(c)(2). And if the opinion is rejected completely, the ALJ
must give “specific, legitimate reasons for doing so.” Watkins, 350 F.3d at 1301(internal quotation marks omitted).
We are unable to determine what weight the ALJ assigned Dr. Jameson’s
opinion. It is also unclear if the ALJ’s conclusory reference to the non-examining
agency physicians and the consultative examinations performed by Dr. Brennan in
2006 and 2008 constitute a rejection of Dr. Jameson’s opinion because the ALJ does
not expressly state one way or the other. While the ALJ did not err in considering the
opinions of the non-examining agency physicians and consultative examiners, “[t]he
opinion of [a consultative] examining physician is generally entitled to less weight
than that of a treating physician, and the opinion of an agency physician who has
never seen the claimant is entitled to the least weight of all,” Robinson v. Barnhart,
366 F.3d 1078, 1084 (10th Cir. 2004). If the ALJ intends to reject the opinion of
Dr. Jameson in favor of the non-examining physicians, he must provide a legally
sufficient explanation for doing so, which he did not.
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In sum, we cannot say that the ALJ’s decision is sufficiently specific to make
clear to us the weight the ALJ gave Dr. Jameson’s opinion and the reasons for that
weight. See Watkins, 350 F.3d at 1301. And we are not in a position to presume that
the ALJ applied the correct legal standards. We must therefore remand because we
cannot meaningfully review the ALJ’s determination without sufficient findings.
See id.B. Step Four Analysis
Ms. Sissom’s second and third arguments are related in that they both allege
errors regarding step four of the sequential analysis. Step four is comprised of three
phases.
In the first phase, the ALJ must evaluate a claimant’s
physical and mental residual functional capacity
(RFC), . . . and in the second phase, he must determine the
physical and mental demands of the claimant’s past
relevant work. . . . In the final phase, the ALJ determines
whether the claimant has the ability to meet the job
demands found in phase two despite the mental and/or
physical limitations found in phase one. . . . At each of
these phases, the ALJ must make specific findings.
Bowman v. Astrue, 511 F.3d 1270, 1272 (10th Cir. 2008) (alterations in original)
(citation omitted) (internal quotation marks omitted). And those findings must be
supported by substantial evidence. See Watkins, 350 F.3d at 1299.
1. Phase One Analysis
Ms. Sissom first argues that the ALJ’s RFC determination is not supported
by substantial evidence. “In determining a claimant’s physical abilities, the ALJ
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should . . . assess the nature and extent of the claimant’s physical limitations and then
determine the claimant’s residual functional capacity for work activity on a regular
and continuing basis.” Winfrey v. Chater, 92 F.3d 1017, 1023 (10th Cir. 1996)
(brackets omitted) (internal quotation marks omitted). This involves consideration of
the claimant’s “impairment(s), and any related symptoms ... [that] may cause
physical and mental limitations that affect what [the claimant] can do in a work
setting.” 20 C.F.R. §§ 404.1545(a)(1), 416.945(a)(1). An ALJ’s RFC assessment is
made based on all the evidence in the case record, both medical and non-medical.
See 20 C.F.R. §§ 404.1545(a)(1), (3), 416.945(a)(1), (3). The ALJ concluded that
Ms. Sissom had an RFC to perform light work as defined in 20 C.F.R. § 404.1567(b)
and § 416.967(b),3 but that she was restricted to only occasionally climbing,
3
Light work is defined in the regulations as follows:
[it] involves lifting no more than 20 pounds at a time with
frequent lifting or carrying of objects weighing up to 10
pounds. Even though the weight lifted may be very little, a
job is in this category when it requires a good deal of
walking or standing, or when it involves sitting most of the
time with some pushing and pulling of arm or leg controls.
To be considered capable of performing a full or wide
range of light work, you must have the ability to do
substantially all of these activities. If someone can do light
work, we determine that he or she can also do sedentary
work, unless there are additional limiting factors such as
loss of fine dexterity or inability to sit for long periods of
time.
20 C.F.R. §§ 404.1567(b), 416.967(b).
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balancing, stooping, kneeling, crouching, and crawling.4
Ms. Sissom claims a light-work RFC is not supported by substantial evidence
because Drs. Jameson and Metcalf opined that Ms. Sissom is limited to a desk job or
sedentary job. And further that a vocational rehabilitation evaluation in August 2005
limited her to a sedentary job. We do not reach the merits of this argument because it
may be affected by the ALJ’s treatment of this case on remand, in particular, the
ALJ’s evaluation of Dr. Jameson’s opinion. See, e.g., Watkins, 350 F.3d at 1299(declining to review claim that RFC was not supported by substantial evidence
because remand for reconsideration of legal error regarding evaluation of treating
physician’s opinion may affect other issues in case).
2. Phase Two Analysis
Ms. Sissom further asserts that the ALJ erred as a matter of law in his phase
two analysis by failing to make required findings regarding Ms. Sissom’s PRW, and
instead delegating this task to the VE. She claims that this error runs afoul of our
decision in Winfrey. We agree.
At phase two, “the ALJ must make findings regarding the physical and mental
demands of the claimant’s past relevant work.” Winfrey, 92 F.3d at 1024. To make
such findings, an “ALJ must obtain adequate factual information about those work
4
The ALJ also determined that Ms. Sissom had some moderate mental
limitations but that she can understand, remember, and carry out simple and complex
work instructions in a work related environment. Ms. Sissom does not challenge the
ALJ’s findings regarding her mental limitations as part of his RFC assessment.
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demands which have a bearing on the medically established limitations.” Id. And
such information regarding work demands may be obtained from the claimant
herself, her employer, or another informed source. See SSR 82-62, 1982 WL 31386,
at *3 (1982). This the ALJ did not do.
The ALJ requested information from the VE regarding Ms. Sissom’s PRW.
The VE testified simply that Ms. Sissom’s past work as a housekeeper was “light in
physical demand and unskilled,”5 Admin. R. at 51, that her past work as a
cashier/checker was “light in physical demand and semi-skilled,”6 id., with a specific
vocational preparation (SVP) of two, and that her past work as a deli manager was
“light in physical demand and skilled at the [SVP] 5 level,”7 id. The ALJ’s written
findings regarding Ms. Sissom’s PRW are simply a reiteration of the VE’s testimony
regarding the exertional level and skill level of Ms. Sissom’s PRW.
5
Unskilled work, among other things, is “work which needs little or no
judgment to do simple duties . . . [which] may or may not require considerable
strength . . . and [requires] little specific vocational preparation and judgment.”
20 C.F.R. §§ 404.1568(a), 416.958(a).
6
Semi-skilled work, among other things, requires “some skills but does not
require doing . . . more complex work duties.” 20 C.F.R. §§ 404.1568(b),
416.958(b).
7
Skilled work, among other things, requires “qualifications in which a person
uses judgment to determine the machine and manual operations to be performed in
order to obtain the proper form, quality, or quantity of material to be produced.”
20 C.F.R. §§ 404.1568(c), 416.958(c).
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But this limited testimony by the VE is insufficient to determine the physical
and mental work demands of Ms. Sissom’s past employment. The ALJ failed to
develop the record with “factual information” regarding the actual work demands of
Ms. Sissom’s PRW. Winfrey, 92 F.3d at 1024 (internal quotation marks omitted).
For example, the ALJ determined that Ms. Sissom had some postural limitations,
including only occasional climbing, balancing, stooping, kneeling, crouching, and
crawling. Yet the ALJ did not inquire of Ms. Sissom the physical demands of her
PRW as a housekeeper, cashier/checker, or deli manager that would have a bearing
on these physical limitations.8 Similarly, though the ALJ determined Ms. Sissom had
moderate mental limitations, which included moderate abilities to carry out simple
and detailed instructions, to complete a normal workday without interruptions from
psychologically based symptoms, and to perform at a consistent pace, there is no
evidence concerning the mental demands of her PRW and the bearing these would
have on her mental limitations. The ALJ therefore failed to develop the record and to
make the required findings concerning Ms. Sissom’s PRW.
Although the ALJ’s RFC determination on remand may or may not be the
same, we caution the ALJ to make adequate findings regarding the physical and
8
Regarding Ms. Sissom’s PRW as a housekeeper, although she testified that her
duties as a housekeeper were to “scrub the baseboards, clean out all the cabinets,
wash walls, wash ceilings, [and] clean floors,” Admin. R. at 31, there is no evidence
concerning how often her PRW as a housekeeper involved climbing, balancing,
stooping, kneeling, crouching, and crawling and for what duration of time she
performed each of those activities.
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mental demands of Ms. Sissom’s PRW. Our intent here is not to dictate any result
regarding Ms. Sissom’s RFC or the ALJ’s findings regarding Ms. Sissom’s PRW, but
simply to assure that the ALJ makes the necessary specific findings and “that the
correct legal standards are invoked in reaching a decision based on the facts of this
case.” Huston v. Bowen, 838 F.2d 1125, 1132 (10th Cir. 1988). This, in return, will
ensure that appellate review of the ALJ’s decision is not only possible but
meaningful. See Howard v. Barnhart, 379 F.3d 945, 947 (10th Cir. 2004).
3. Phase Three Analysis
Ms. Sissom also claims legal error with the ALJ’s phase three analysis. At
phase three, “the ALJ determines whether the claimant has the ability to meet the job
demands found in phase two despite the mental and/or physical limitations found in
phase one.” Winfrey, 92 F.3d at 1023. Here, the ALJ did not conduct an appropriate
analysis at phase two and, therefore, his findings at phase three of the analysis were
naturally compromised.
But additionally, the ALJ erred in delegating his fact-finding responsibilities to
the VE, which we have expressly discouraged. See id. at 1025. Because the scope of
jobs at step four is limited to the claimant’s PRW, it is feasible for an ALJ at this step
to make specific findings about the mental and physical demands of the jobs at issue
and determine whether the claimant can still meet those demands. Id. An “ALJ may
rely on information supplied by the VE at step four, [but] the ALJ himself must make
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the required findings on the record, including his own evaluation of the claimant’s
ability to perform [her] past relevant work.” Id.At the hearing, however, without describing Ms. Sissom’s actual work
demands, the ALJ posed to the VE a hypothetical and asked the VE to assume light
work, and an individual of Ms. Sissom’s age and education, with postural limitations
of occasional climbing, balancing, stooping, kneeling, crouching, and crawling, and
with Ms. Sissom’s moderate mental limitations. The ALJ asked if this hypothetical
person could perform any of Ms. Sissom’s PRW, to which the VE gave his
conclusory opinion that the work of a housekeeper and cashier/checker could be
performed but that that of a deli manager could not. In his written decision, the ALJ
did not make any factual findings comparing Ms. Sissom’s limitations to the
demands of her PRW. The ALJ just stated that the VE was presented with a
hypothetical concerning an individual with Ms. Sissom’s limitations and the VE
testified that such an individual could perform Ms. Sissom’s PRW. See Admin. R.
at 21-22.
We agree with Ms. Sissom that the ALJ erroneously delegated his fact-finding
responsibilities to the VE. The ALJ merely adopted the VE’s opinion that
Ms. Sissom was not precluded from performing her PRW. “When, as here, the ALJ
makes findings only about the claimant’s limitations, and the remainder of the step
four assessment takes places in the VE’s head, we are left with nothing to review.”
Winfrey, 92 F.3d at 1025. We conclude the ALJ’s step four analysis is legally
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flawed. Because we have previously determined that the matter must be reversed and
remanded, we have considered the legal errors of the ALJ’s step four analysis in
order that they may be addressed appropriately on remand.
III. Conclusion
The judgment of the district court is reversed, and the case is remanded with
instructions to remand to the Commissioner for further proceedings in accordance
with this order and judgment.
Entered for the Court
Bobby R. Baldock
Circuit Judge
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