Martinez v. Social Security Administration

Filing 25

ORDER by Magistrate Judge Steven C. Yarbrough granting 19 Motion to Remand to Agency (cm)

IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF NEW MEXICO
CATHY NIETO MARTINEZ,
Plaintiff,
v.

Civ. No. 15-1137 SCY

CAROLYN W. COLVIN, Acting
Commissioner of the Social Security
Administration,
Defendant.
ORDER GRANTING PLAINTIFF’S MOTION TO REVERSE OR REMAND
THIS MATTER is before the Court on Plaintiff Cathy Martinez’s Motion to Reverse
and Remand the Social Security Commissioner’s final decision denying Plaintiff disability
insurance benefits. ECF No. 19. For the reasons discussed below, the Court will GRANT
Plaintiff’s motion and remand this action to the Commissioner for further proceedings consistent
with this opinion.
I.

Background

Plaintiff is a fifty-seven year old woman with a prior work history as an accounts payable
clerk, busser, caregiver, inventory analyst, and usher. Administrative Record (AR) 196.
Plaintiff filed an application for disability insurance benefits alleging disability on February 15,
2013 due to a “brain tumor which was removed,” broken left clavicle, and arthritis. AR 71.
A. Medical History
The following will recount Plaintiff’s medical history in so far as it is relevant to the
issues presented in this case. The record reflects that in April 2012, Plaintiff presented to
Presbyterian Hospital in Albuquerque, New Mexico, following an incident in which she
experienced weakness in her lower left extremity, seizure-like symptoms, and she collapsed
1

while leaving work. AR 300. Upon examination, Plaintiff was diagnosed with meningioma,
which, in Plaintiff’s case, was a benign brain tumor. AR 300, 303. On April 23, 2012, Plaintiff
underwent successful surgery to remove the tumor. AR 301, 307. In a follow-up appointment
one year after the surgery, Plaintiff reported doing “very well” but complained of some
numbness in her left leg, fatigue, tension headaches, and an inability to work full time. AR 305.
Plaintiff’s neurologist, Dr. Christopher Taylor, noted that while Plaintiff’s lower extremity
numbness may be permanent, Plaintiff had made an “overall excellent recovery” from the
surgery. AR 665. In an undated letter, Dr. Taylor stated that Plaintiff continued to have “left
lower extremity weakness, which worsens after walking for a prolonged period of time, or when
walking up flights of stairs.” AR 697.
The record reflects that in the months following Plaintiff’s surgery, Plaintiff’s primary
care physician, Dr. Benjamin Chan, progressively released Plaintiff to return to work on a
reduced schedule. AR 364-70. In June, Dr. Chan indicated that Plaintiff could work half-days.
AR 364. In July, Dr. Chan cleared Plaintiff to work six hours per day. AR 367. In September,
Dr. Chan cleared Plaintiff to work thirty-five hours per week. AR 370. It appears from Plaintiff’s
testimony at the hearing that she resumed working at this time until she was laid off in July 2013.
AR 36-37, 41.
In December 2012, Plaintiff presented to Presbyterian Hospital with complaints of
shoulder pain. AR 411. Plaintiff was assessed with a displaced midshaft clavicular fracture. AR
411-13. In her first appointment with a physical therapist, Plaintiff reported that much of the
pain had subsided but that she still experienced pain with activities and at night. AR 533. In
further appointments, Plaintiff complained of intermittent and fluctuating pain. AR 531, 527.
Plaintiff also reported increased ability to perform activities of daily living with the exception of

2

a period of time following an incident in which a person bumped into her. AR 521, 523, 525,
527. By the end of March 2013, Plaintiff reported overall decreased pain, improved mobility,
and tolerance for activities of daily living. AR 514, 519. By April 2013, Plaintiff’s physical
therapist noted that Plaintiff had improving passive range of motion and tolerance to activities of
daily living. AR 535.
In June 2014, Plaintiff presented to Peak Motion Physical Therapy with complaints of
difficulties with range of motion in her thumbs and bilateral hand pain. AR 541-42. Plaintiff
indicated that she was experiencing stiffness in her thumbs and “near paralysis at night,” as well
as generalized stiffness in both hands. AR 542. Plaintiff was assessed as having difficulty with
ordinary activities of daily living and sleep disturbance due to the pain. AR 542. In August 2014,
Plaintiff’s physical therapist noted that Plaintiff’s functional limitations were sleep disturbances,
limited ability to write, and limited ability to drive. AR 545. The physical therapist further noted
that Plaintiff had made gains in her grip strength but that her range of motion was inconsistent.
AR 546.
In September 2014, Plaintiff presented to Dr. Matthew Patton with complaints of bilateral
diffuse hand pain, joint swelling, and trigger thumbs. AR 561-63. Dr. Patton noted that Plaintiff
experienced mild tenderness in her hands but that she had a full range of motion. AR 562.
Radiographs indicated moderate joint space narrowing and diffuse osteoarthritic changes. AR
562. Plaintiff was given steroid injections and advised to return as needed for further treatment.
AR 563. Plaintiff returned to Dr. Patton in March 2015 and reported that her hand pain had
gotten worse. AR 644. Dr. Patton performed a trigger finger release of Plaintiff’s right thumb.
AR 645-647.
On July 9, 2014, Dr. Trang Tran, the reviewing physician at Peak Motion Physical

3

Therapy, noted that Plaintiff “cannot lift over 10 lbs. at work and she has lower extremity
weakness. She cannot work over 25 hours a week.” AR 716. Subsequently, after the hearing and
the ALJ’s decisions had been issued, Dr. Tran issued another note stating that Plaintiff
“continues to have daily hands [sic] pain and weakness. She cannot grip/hold objects in her
hands.” AR 718.
B. Procedural History
Plaintiff filed applications for disability insurance benefits and supplemental social
security income in February 2013 and November 2014, respectively. AR 12. Plaintiff alleged a
disability start date of April 17, 2012, which she subsequently amended at the hearing to August
1, 2013. AR 12. Plaintiff’s claims were initially denied on October 18, 2013 and upon
reconsideration on December 20, 2013. AR 12. Plaintiff subsequently requested a hearing which
was held on May 13, 2013 before Administrative Law Judge (ALJ) Eric Weiss. AR 12. On June
19, 2015, the ALJ issued his decision denying Plaintiff’s claims. Following the ALJ’s decision,
Plaintiff submitted additional medical evidence to the Appeals Council, including, as noted
above, a medical source opinion from Dr. Tran. AR 4. The Appeals Council subsequently denied
Plaintiff’s request for review. AR 1-3. This appeal followed.
II.

Applicable Law

A. Disability Determination Process
A claimant is considered disabled for purposes of Social Security disability insurance
benefits if that individual 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). The Social Security Commissioner has adopted a five-step

4

sequential analysis to determine whether a person satisfies these statutory criteria. See 20 C.F.R.
§ 404.1520. The steps of the analysis are as follows:
(1) Claimant must establish that she is not currently engaged in “substantial gainful
activity.” If claimant is so engaged, she is not disabled and the analysis stops.
(2) Claimant must establish that she has “a severe medically determinable physical or
mental impairment . . . or combination of impairments” that has lasted for at least one
year. If claimant is not so impaired, she is not disabled and the analysis stops.
(3) If claimant can establish that her impairment(s) are equivalent to a listed impairment that
has already been determined to preclude substantial gainful activity, claimant is
presumed disabled and the analysis stops.
(4) If, however, claimant’s impairment(s) are not equivalent to a listed impairment, claimant
must establish that the impairment(s) prevent her from doing her “past relevant work.”
Answering this question involves three phases. Winfrey v. Chater, 92 F.3d 1017, 1023
(10th Cir. 1996). First, the ALJ considers all of the relevant medical and other evidence
and determines what is “the most [claimant] can still do despite [her physical and
mental] limitations.” 20 C.F.R. § 404.1545(a)(1). This is called the claimant’s residual
functional capacity (“RFC”). Id. § 404.1545(a)(3). Second, the ALJ determines the
physical and mental demands of claimant’s past work. Third, the ALJ determines
whether, given claimant’s RFC, claimant is capable of meeting those demands. A
claimant who is capable of returning to past relevant work is not disabled and the
analysis stops.
(5) At this point, the burden shifts to the Commissioner to show that claimant is able to
“make an adjustment to other work.” If the Commissioner is unable to make that
showing, claimant is deemed disabled. If, however, the Commissioner is able to make
the required showing, the claimant is deemed not disabled.
See 20 C.F.R. § 1520(a)(4); Fischer-Ross v. Barnhart, 431 F.3d 729, 731 (10th Cir. 2005).
B. Standard of Review
A court must affirm the denial of social security benefits unless (1) the decision is not
supported by “substantial evidence” or (2) the ALJ did not apply the proper legal standards in
reaching the decision. 42 U.S.C. § 405(g); Casias v. Sec’y of Health & Human Serv., 933 F.2d
799, 800-01 (10th Cir. 1991). In making these determinations, the reviewing court “neither
reweigh[s] the evidence nor substitute[s] [its] judgment for that of the agency.’” Bowman v.

5

Astrue, 511 F.3d 1270, 1272 (10th Cir. 2008). For example, a court’s disagreement with a
decision is immaterial to the substantial evidence analysis. A decision is supported by substantial
evidence as long as it is supported by “relevant evidence . . . a reasonable mind might accept as
adequate to support [the] conclusion.” Casias, 933 F.3d at 800. While this requires more than a
mere scintilla of evidence, Casias, 933 F.3d at 800, “[t]he 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) (citing Zoltanski v.
F.A.A., 372 F.3d 1195, 1200 (10th Cir. 2004)).
Similarly, even if a court agrees with a decision to deny benefits, if the ALJ’s reasons for
the decision are improper or are not articulated with sufficient particularity to allow for judicial
review, the court cannot affirm the decision as legally correct. Clifton v. Chater, 79 F.3d 1007,
1009 (10th Cir. 1996). As a baseline, the ALJ must support his or her findings with specific
weighing of the evidence and “the record must demonstrate that the ALJ considered all of the
evidence.” Id. at 1009-10. This does not mean that an ALJ must discuss every piece of evidence
in the record. But, it does require that the ALJ identify the evidence supporting the decision and
discuss any probative and contradictory evidence that the ALJ is rejecting. Id. at 1010.
III.

Analysis

Plaintiff raises two issues before the Court. Plaintiff first argues that the Appeals Council
erred when it failed to find that a note from Dr. Tran submitted shortly after the ALJ’s decision
was not new and material evidence that required reconsideration by the ALJ. ECF No. 20 at 3.
Second, Plaintiff argues that the ALJ erred in according Dr. Tran’s opinion “little weight.” ECF
No. 20 at 6. Specifically, Plaintiff contends that Dr. Tran’s opinion was entitled to greater
deference because Dr. Tran was a treating physician and the ALJ failed to provide specific and

6

legitimate reasons for rejecting the opinion. ECF No. 20 at 7. Because the Court agrees with
Plaintiff’s second argument, the Court will remand on this basis and will not consider Plaintiff’s
first contention.
Social Security regulations require that, in determining disability, the opinions of treating
physicians be given controlling weight when those opinions are well-supported by the medical
evidence and are consistent with the record. 20 C.F.R. 404.1527(c)(2); 416.927(c)(2). This is
known as the “treating physician rule.” Langley v. Barnhart, 373 F.3d 1116, 1119 (10th Cir.
2004). The idea is that a treating physician provides a unique perspective to the medical evidence
that cannot be obtained from the objective medical findings alone or from reports of individual
examinations, such as consultative examinations,” and therefore, when supported by the medical
evidence and consistent with the record, a treating physician’s opinion merits controlling weight.
Doyal v. Barnhart, 331 F.3d 758, 762 (10th Cir. 2003).
If the treating physician’s opinion is inconsistent with the record or not supported by
medical evidence, the opinion does not merit controlling weight but still must be weighed using
the following six factors:
(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; (6) other factors
brought to the ALJ’s attention which tend to support or contradict the opinion.
Watkins v. Barnhart, 350 F.3d 1297, 1301 (10th Cir. 2003) (internal citations and
quotations omitted); see also 20 C.F.R. §§ 404.1527(c), 416.927(c). Not every factor is
applicable in every case, nor should all six factors be seen as absolutely necessary. What
is necessary, however, is that the ALJ give good reasons—reasons that are “sufficiently

7

specific to [be] clear to any subsequent reviewers”— for the weight that she ultimately
assigns to the opinions. Langley, 373 F.3d at 1119; see also 20 C.F.R. §§ 404.1527(c)(2),
416.927(c)(2); Branum v. Barnhart, 385 F.3d 1268, 1275 (10th Cir. 2004).
In sum, when properly rejecting a treating physician’s opinion, an ALJ must
follow two steps. First, the ALJ must find that the opinion is (a) not supported by medical
evidence and/or (b) not consistent with the record. Second, the ALJ must determine what
weight to give the opinion according to the above listed six factors. Like all findings, an
ALJ’s findings in these two steps must be supported by substantial evidence.
In the present case, the ALJ accorded “little weight” to Dr. Tran’s opinion that
Plaintiff cannot lift over ten pounds, has lower extremity weakness, and therefore cannot
work over twenty-five hours per week.1 AR 19. In explaining his reasoning, the ALJ
stated that “[t]here was no explanation for the doctor’s opinion. Furthermore, the opinion
was not consistent with the medical records as a whole or Dr. Tran’s physical
examinations of the claimant.” AR 19. In doing so, the ALJ provided a sufficient basis
for not giving Dr. Tran’s opinion controlling weight.
However, while satisfying the first step in rejecting the opinion of a treating
physician, this analysis fell short of what is required under step two. Under step two, the
ALJ failed to sufficiently analyze the above cited factors to determine how much weight
to give Dr. Tran’s opinion. In other words, the ALJ did not sufficiently support his
decision to reject Dr. Tran’s conclusion that Plaintiff could only work 25 hours per week.
See Watkins, 350 F.3d at 1300 (stating that “resolving the ‘controlling weight’ issue does

 The Court notes that because the ALJ limited Plaintiff to sedentary work, his rejection of Dr. Tran’s

1

opinion is limited to Dr. Tran’s opinions regarding Plaintiff’s lower extremity weakness and inability to
work over twenty-five hours per week. However, on remand, the note from Dr. Tran Plaintiff submitted
after the ALJ’s decision will also be before the ALJ.  

8

not end our review” and that the ALJ must then explain the weight given to the opinion in
light of the relevant factors). As further noted in Watkins, “[a]fter considering the
pertinent factors, the ALJ must give good reasons in [the decision] for the weight he
ultimately assigns the opinion…[A]nd if he rejects the opinion completely, he must then
give specific, legitimate reasons for doing so.” Id. at 1301.
To be sure, for many reasons, including the reasons noted by Defendant, Dr.
Tran’s opinion regarding Plaintiff’s limitations may certainly be susceptible to legitimate
criticism. The ALJ’s opinion, however, failed to provide sufficient justification for
giving little weight to Dr. Tran’s limitation on work hours; therefore, this case must be
remanded for further review consistent with this Opinion. See Id. (stating that a court
must remand when it “cannot meaningfully review the ALJ’s determination absent
findings explaining the weight assigned to the treating physician’s opinion.”).
IV.

Conclusion

For the foregoing reasons, the Court GRANTS Plaintiff’s Motion to Remand to
Agency (ECF No. 19). The Court therefore reverses the Commissioner’s decision
denying Plaintiff benefits and remands this action to the Commissioner to conduct further
proceedings consistent with this Opinion.

___________________________________
UNITED STATES MAGISTRATE JUDGE
Sitting by Consent

9