Najera v. Social Security Administration
ORDER by Magistrate Judge Gregory J. Fouratt DENYING 18 Motion to Remand to Agency. (jlr)
UNITED STATES DISTRICT COURT
DISTRICT OF NEW MEXICO
Civ. No. 16‐455 GJF
NANCY A. BERRYHILL, Acting
Commissioner of the Social Security
ORDER DENYING PLAINTIFF’S MOTION TO REMAND
THIS MATTER is before the Court on Plaintiff’s “Motion to Reverse and Remand to
Agency for Rehearing, with Supporting Memorandum” (“Motion”) [ECF No. 18]. Having
meticulously reviewed the entire record, considered the parties’ arguments, and being otherwise
fully advised, the Court finds that substantial evidence supports the Commissioner’s decision to
deny benefits and that the proper legal standards were applied. For the following reasons, the
Court will DENY Plaintiff’s Motion.
On August 10, 2012, Plaintiff applied for Social Security Disability Insurance (“SSDI”)
benefits and Supplemental Security Income (“SSI”), alleging that her disability began on April 5,
2012. Administrative R. (“AR”) 197-209. She based her application for disability benefits on
the following impairments: (i) congestive heart failure, (ii) post-traumatic stress disorder
(“PTSD”), (iii) bipolar disorder, and (iv) depression. AR 231. Plaintiff’s applications were
initially denied on January 23, 2013 [AR 125-131], and upon reconsideration on April 29, 2013
[AR 132-136]. Plaintiff then filed a written request for a hearing and on May 28, 2014,
Administrative Law Judge (“ALJ”) Donna Montano held a hearing in Albuquerque, New
Plaintiff testified at the hearing and was represented by attorney Feliz Martone.
Additionally, the ALJ heard testimony from Mary Diane Weber, an impartial vocational expert,
and Susan Bolton, Plaintiff’s case manager. AR 31-74.
On September 23, 2014, ALJ Montano issued her decision, finding that Plaintiff was not
disabled under the Social Security Act and therefore ineligible for disability insurance benefits or
supplemental security income. AR 25. Plaintiff filed a request for review by the Appeals
Council, which was denied on April 12, 2016. AR 1-11. Consequently, the ALJ’s decision
became the final decision of the Commissioner. Plaintiff timely filed this appeal on May 19,
2016. See Pl.’s Compl., ECF No. 1.
Plaintiff filed subsequent applications for SSDI and SSI benefits on May 12, 2016. Pl.’s
Mot. 3. On October 6, 2016, Plaintiff’s application for SSI benefits was approved. Id. at 4.
A. Standard of Review
When the Appeals Council denies a claimant’s request for review, the ALJ’s decision
becomes the final decision of the agency. 1 The Court’s review of that final agency decision is
both factual and legal. See Maes v. Astrue, 522 F.3d 1093, 1096 (10th Cir. 2008) (citing
Hamilton v. Sec’y of Health & Human Servs., 961 F.2d 1495, 1497-98 (10th Cir. 1992)) (“The
standard of review in a social security appeal is whether the correct legal standards were applied
and whether the decision is supported by substantial evidence.”).
The factual findings at the administrative level are conclusive “if supported by substantial
evidence.” 42 U.S.C. § 405(g) (2012). “Substantial evidence is such relevant evidence as a
reasonable mind might accept as adequate to support a conclusion.” Langley v. Barnhart, 373
A court’s review is limited to the Commissioner’s final decision, 42 U.S.C. § 405(g) (2012), which generally is the
ALJ’s decision, not the Appeals Council’s denial of review. 20 C.F.R. § 404.981 (2017); O’Dell v. Shalala, 44 F.3d
855, 858 (10th Cir. 1994).
F.3d 1116, 1118 (10th Cir. 2004); Hamlin v. Barnhart, 365 F.3d 1208, 1214 (10th Cir. 2004);
Doyal v. Barnhart, 331 F.3d 758, 760 (10th Cir. 2003). An ALJ’s 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.” Langley, 373 F.3d at 1118; Hamlin, 365 F.3d at 1214.
Substantial evidence does not, however, require a preponderance of the evidence. See 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)).
“The record must demonstrate that the ALJ considered all of the evidence, but an ALJ is
not required to discuss every piece of evidence.” Clifton v. Chater, 79 F.3d 1007, 1009-10 (10th
Cir. 1996) (citation omitted). “Rather, in addition to discussing the evidence supporting his
decision, the ALJ also must discuss the uncontroverted evidence he chooses not to rely upon, as
well as significantly probative evidence he rejects.” Id. at 1010. “The possibility of drawing two
inconsistent conclusions from the evidence does not prevent an administrative agency’s findings
from being supported by substantial evidence.”
Lax, 489 F.3d at 1084.
A court should
meticulously review the entire record but should neither re-weigh the evidence nor substitute its
judgment for that of the Commissioner. Langley, 373 F.3d at 1118; Hamlin, 365 F.3d at 1214.
As for the review of the ALJ’s legal decisions, the Court examines “whether the ALJ
followed the specific rules of law that must be followed in weighing particular types of evidence
in disability cases.” Lax, 489 F.3d at 1084. The Court may reverse and remand if the ALJ failed
“to apply the correct legal standards, or to show . . . that she has done so.” Winfrey v. Chater, 92
F.3d 1017, 1019 (10th Cir. 1996).
Ultimately, if substantial evidence supports the ALJ’s findings and the correct legal
standards were applied, the Commissioner’s decision stands and the plaintiff is not entitled to
relief. Langley, 373 F.3d at 1118; Hamlin, 365 F.3d at 1214, Doyal, 331 F.3d at 760.
B. Sequential Evaluation Process
The SSA has devised a five-step sequential evaluation process to determine disability. See
Barnhart v. Thomas, 540 U.S. 20, 24 (2003); 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4) (2017).
At the first three steps, the ALJ considers the claimant’s current work activity, the medical
severity of the claimant’s impairments, and the requirements of the Listing of Impairments. See
20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4), & Pt. 404, Subpt. P, App. 1.
If a claimant’s
impairments are not equal to one of those in the Listing of Impairments, then the ALJ proceeds to
the first of three phases of step four and determines the claimant’s RFC. See Winfrey, 92 F.3d at
1023; 20 C.F.R. §§ 404.1520(e), 416.920(e). In phase two, the ALJ determines the physical and
mental demands of the claimant’s past relevant work, and in the third phase, compares the
claimant’s RFC with the functional requirements of his past relevant work to determine if the
claimant is still capable of performing his past work. See Winfrey, 92 F.3d at 1023; 20 C.F.R. §§
404.1520(f), 416.920(f). If a claimant is not prevented from performing his past work, then he is
not disabled. 20 C.F.R. §§ 404.1520(f), 416.920(f). The claimant bears the burden of proof on
the question of disability for the first four steps, and then the burden of proof shifts to the
Commissioner at step five. See Bowen v. Yuckert, 482 U.S. 137, 146 (1987); Talbot v. Heckler,
814 F.2d 1456, 1460 (10th Cir. 1987).
If the claimant cannot return to his past work, then the Commissioner bears the burden at
the fifth step of showing that the claimant is nonetheless capable of performing other jobs existing
in significant numbers in the national economy. See Thomas, 540 U.S. at 24-25; see also
Williams v. Bowen, 844 F.2d 748, 750-51 (10th Cir. 1988) (discussing the five-step sequential
evaluation process in detail).
SUMMARY OF ARGUMENTS
Plaintiff advances two arguments. First, she argues that the ALJ did not apply proper
legal standards in evaluating medical opinion evidence, specifically, opinion evidence from
Plaintiff’s primary care physician. Pl.’s Mot. 10-15. Second, Plaintiff argues that the ALJ
committed reversible error in crafting Plaintiff’s residual functional capacity (“RFC”) because
the ALJ didn’t properly consider and incorporate Plaintiff’s non-severe impairments. Id. at 1618. In response, the Commissioner argues that the ALJ reasonably and properly evaluated all
relevant evidence, including medical opinion evidence, and determined that Plaintiff retained
capacity to perform light work. Def.’s Resp. 7.
On September 23, 2014, ALJ Montano issued a decision denying Plaintiff’s applications
for SSDI and SSI benefits. In doing so, the ALJ conducted the five-step sequential evaluation
process. AR 15-25. At step one, the ALJ found that Plaintiff had not engaged in substantial
gainful activity since April 5, 2012, the date of her alleged disability onset. AR 17. At step two,
the ALJ determined Plaintiff had the following severe impairments: cardiomyopathy and obesity.
The ALJ found these impairments to be severe because “[t]hese impairments cause a more than
minimal impact on the [Plaintiff’s] ability to maintain and perform basic work activities.” AR
18. At this step, the ALJ also determined Plaintiff had the following non-severe impairments:
cocaine dependence in remission, methamphetamine dependence in remission, alcohol
dependence in remission, depression, anxiety, posttraumatic stress disorder, and bipolar disorder.
The ALJ determined that because the limitations, singly and in combination, “do not cause more
than minimal limitation in the [Plaintiff’s] ability to perform basic mental work activities,” they
are therefore non-severe. AR 18.
At step three, the ALJ concluded that Plaintiff did not have an impairment or
combination of impairments that met or medically equaled the severity of a listed impairment in
20 C.F.R. Part 404, Subpart P, Appendix 1. 2 The ALJ primarily relied on medical opinion
evidence to reach this conclusion. Focusing first on Plaintiff’s cardiomyopathy, the ALJ found
that “[Plaintiff’s] medical records do not show that she experienced systolic or diastolic failure to
meet or medically equal [L]isting 4.02,” which is entitled “chronic heart failure.” AR 19. The
ALJ next focused on Plaintiff’s obesity, and found that “the medical evidence of record does not
support a finding.” AR 20.
Before step four, the ALJ determined Plaintiff had the following RFC: “to perform the
full range of light work as defined in 20 C.F.R. §§ 404.1567(b) and 416.967(b).” AR 20.
Sections 404.1567(b) and 416.967(b) define light work as:
Light work 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) (2017). In support of this RFC assessment, the ALJ found
that “[Plaintiff’s] medically determinable impairments could reasonably be expected to cause the
alleged symptoms; however, [Plaintiff’s] statements concerning the intensity, persistence and
limiting effects of these symptoms are not entirely credible . . . .” AR 22. Then, the ALJ
detailed the many factors she considered. The ALJ explained her reasoning for assigning great
weight to the state agency medical consultants’ mental and physical assessments. The ALJ also
The specific sections of the Code of Federal Regulations the ALJ referenced include: 20 C.F.R. §§ 404.1520(d),
404.1525, 404.1526, 416.920(d), 416.925, and 416.926 (2016). AR 19.
related her reasoning for giving little weight to the opinions of Dr. Bohan, Plaintiff’s primary
Ultimately, the ALJ concluded that “as a whole, the [Plaintiff’s]
cardiomyopathy continues to be treated with medication when the [Plaintiff] remains compliant
and that she has been asked to refrain from heavy work only.” AR 24.
Plaintiff’s past work was classified by the vocational expert as a detail manager and
telemarketing supervisor. At step four, the ALJ determined that Plaintiff was able to perform
past relevant work because such work “does not require the performance of work-related
activities precluded by the [Plaintiff’s] residual functional capacity.” AR 24. Subsequently, the
ALJ concluded that Plaintiff was not disabled under the meaning of the Social Security Act from
April 5, 2012, through the date of the decision. AR 25.
A. Medical Opinion Evidence
Plaintiff begins her challenge to the ALJ’s determination that she was not legally disabled
by taking aim at the ALJ’s treatment of medical opinions offered by Dr. Juliane Bohan,
Plaintiff’s primary care physician. Pl.’s Mot. 10-15. The records reflect that Dr. Bohan served
as Plaintiff’s primary care physician since June 2012, when Dr. Bohan advised her to establish
regular care in a primary care clinic. At the time, Plaintiff was being seen regularly in a
cardiology clinic. AR 392. Between June 19, 2012, and September 23, 2014, the date of the
ALJ’s decision, Dr. Bohan treated Plaintiff on approximately 11 occasions, for issues ranging
from alcohol addiction to prescription management for Plaintiff’s heart condition. See AR 35255, 356-68, 366-70, 373-76, 380-83, 392, 478-81, 493-96, 518-20, 525-27, 532-37.
The ALJ focused on treatment notes from two of Dr. Bohan’s visits with Plaintiff, those
being November 2013 and May 2014. AR 23. Plaintiff saw Dr. Bohan on November 8, 2013,
for a standard follow-up appointment, at which Dr. Bohan reviewed a variety of issues, including
Plaintiff’s heart failure test (brain natriuretic peptide) results, her recent weight gain, her
psychiatric problems, and medication management issues. AR 478-81. In relevant part, Dr.
Bohan wrote in her impression and plan:
She is applying for disability. I do believe that in addition to her multiple medical
problems that her psychiatric issues preclude her from being gainfully employed.
She has significant impulse control problem. In addition, because she is on a
large dose of Furosemide, she has frequent urination. This in combination with
her significantly impaired exercise capacity, keeps her from being able to hold
down a job.
Plaintiff again saw Dr. Bohan on May 30, 2014, for a standard follow-up appointment, at
which Dr. Bohan reviewed Plaintiff’s medical history, in similar fashion to the November 2013
appointment. AR 532-37. In relevant part, Dr. Bohan wrote in her notes:
She is applying for disability. She did have a disability evaluation but no decision
has been made about whether or not she would qualify. I have sent all of her
medical records to the disability attorney. I do believe she is eligible for disability
because she not only has significant heart disease, but also has significant social
anxiety and posttraumatic stress disorder, which precludes her from being able to
be gainfully employed.
The ALJ assigned “little weight” to Dr. Bohan’s opinions, explaining that “an opinion on
whether an individual is disabled goes to an issue reserved to the Commissioner and therefore
cannot be given special significance.”
Plaintiff argues that the ALJ improperly
dismissed Dr. Bohan’s opinions entirely and did not conduct the proper legal analysis, as dictated
by Social Security Ruling (“SSR”) 96-5p. Pl.’s Mot. 14. Accordingly, Plaintiff argues that this
Court should remand this case to require the ALJ to conduct the proper legal analysis. Id. at 15.
The Commissioner contends that the ALJ did consider Dr. Bohan’s opinions and reasonably
concluded they were entitled to little weight because they trespassed on issues reserved to the
Commissioner. Def.’s Resp. 8. Furthermore, the Commissioner defends the ALJ’s treatment of
Dr. Bohan’s opinions by arguing that “Dr. Bohan did not actually assess Plaintiff with any
functional limitations that would be of assistance to the ALJ in determining her RFC.” Id.
Social Security Ruling 96-5p provides guidance as to how to treat medical source
opinions on issues that are reserved to the Commissioner. See SSR 96-5p, 1996 WL 374183
(July 2, 1996). Under 20 C.F.R. § 404.1527(e) and § 416.927(e), one relevant example of such
an issue is whether an individual is considered disabled under the Social Security Act. Id. at *2.
The Ruling provides that “treating source opinions on issues that are reserved to the
Commissioner are never entitled to controlling weight or special significance.” Id. The Ruling
also provides, however, that “adjudicators must always carefully consider medical source
opinions about any issue, including opinions about issues that are reserved to the
Commissioner.” Id. When evaluating medical source opinions on issues that are reserved to the
Commissioner, the Ruling mandates that the adjudicator must apply the applicable factors in 20
C.F.R. §§ 404.1527(d) and 416.927(d). Id.
The Court concludes that the ALJ did not violate SSR 96-5p in evaluating Dr. Bohan’s
opinions. Pursuant to 20 C.F.R. § 404.1527 and § 416.927, the ALJ properly chose not to give
controlling weight to Dr. Bohan’s personal belief that Plaintiff’s multiple medical problems
precluded her from being able to maintain gainful employment. The determination of whether
Plaintiff is disabled is entirely within the province of the Commissioner, and the ALJ made no
error in rejecting these opinions.
Furthermore, after careful review of the ALJ’s decision and each of Dr. Bohan’s 11 sets
of treatment notes, the Court concludes that the ALJ sufficiently reviewed and weighed Dr.
Bohan’s opinions in accordance with the law. In sum, each of Plaintiff’s 11 visits with Dr.
Bohan included a narrative review of the following issues: Plaintiff’s issues with alcohol
addiction and substance abuse, medication management and resulting side effects from new
prescriptions, results of Plaintiff’s multiple echocardiograms, and Plaintiff’s behavioral health
issues. See AR 352-55, 356-68, 366-70, 373-76, 380-83, 392, 478-81, 493-96, 518-20, 525-27,
532-37. Dr. Bohan did not assess Plaintiff with functional limitations that an ALJ normally
considers when determining whether a claimant is disabled, such as how long Plaintiff can sit or
stand or whether Plaintiff would be able to maintain regular attendance at work in spite of her
medical conditions. Instead, Dr. Bohan’s treatment notes are indicative of continued follow-ups
and monitoring of multiple medications. The ALJ’s decision reflects her review of the medical
records, including review of Plaintiff’s heart failure tests, her medication adjustments, her
obesity, and her mental impairments. See AR 20-24.
Although the Court would have preferred the ALJ offer more explanation, her decision to
assign Dr. Bohan’s opinions little weight was explained sufficiently enough throughout the
narrative to permit meaningful judicial review. As articulated by SSR 96-5p, the law requires
that adjudicators carefully consider medical source opinions about any issue. It does not require,
however, a detailed explanation of each regulatory factor the ALJ considered when coming to
her conclusion. The ALJ described in detail the medical records she reviewed, though she did
not explicitly mention Dr. Bohan by name each time. She explained Plaintiff’s presentation
during numerous appointments, effects of prescription medication, and the results of her multiple
tests related to her heart failure condition. Upon review, this Court must only determine whether
there is sufficient evidence that the ALJ properly considered the medical source opinions. The
Court finds that the ALJ’s decision sufficiently demonstrates that she thoroughly and properly
reviewed the medical records pertaining to Plaintiff’s multiple medical conditions, most
importantly her heart failure and her obesity. Because the ALJ conducted a sufficient review in
accordance with SSR 96-5p, her decision to assign little weight to Dr. Bohan’s opinions was not
B. Assessment of Residual Functional Capacity
Plaintiff’s second challenge to the ALJ’s decision takes aim at the ALJ’s RFC
determination that Plaintiff could perform “the full range of light work.” Pl.’s Mot. 16-18. She
argues that the RFC failed to include the limiting effects of Plaintiff’s non-severe mental
impairments and that this omission constitutes reversible error.
responds that Plaintiff fails to identify any specific functional mental limitations supported by the
record that the ALJ failed to incorporate into her RFC. Def.’s Resp. 10-12.
The RFC is “an administrative assessment of the extent to which an individual’s
medically determinable impairment(s), including any related symptoms, such as pain, may cause
physical or mental limitations or restrictions that may affect his or her capacity to do workrelated physical and mental activities.” SSR 96-8P, 1996 WL 374184 (July 2, 1996). The RFC
is the individual’s maximum ability “to do sustained work activities in an ordinary work setting
on a regular and continuing basis.” Id. The RFC assessment must be based on all of the
evidence in the record. 3 Id.
When assessing an individual’s RFC, “the ALJ must consider the combined effect of all
medically determinable impairments, whether severe or not.” Wells v. Colvin, 727 F.3d 1061,
1069 (10th Cir. 2013) (citing 20 C.F.R. §§ 404.1545(a)(2), 416.945(a)(2)). Furthermore, “the
Evidence considered includes: medical history, medical signs and laboratory findings, the effects of treatment,
reports of daily activities, lay evidence, recorded observations, medical source statements, effects of symptoms
(including pain) that are reasonably attributed to a medically determinable impairment, evidence from attempts to
work, need for a structured living environment, and work evaluations. SSR 96-8P, 1996 WL 374184 (July 2, 1996).
RFC assessment must include a narrative discussion describing how the evidence supports each
conclusion, citing specific medical facts (e.g., laboratory findings) and nonmedical evidence
(e.g., daily activities, observations).” See Hendron v. Colvin, 767 F.3d 951, 954 (10th Cir. 2014)
(citing SSR 96-8P, 1996 WL 374184 (July 2, 1996)).
The record reflects that the ALJ considered all of the relevant evidence, and Plaintiff fails
to demonstrate that the RFC finding is inconsistent with any medical findings or any specific
The ALJ thoroughly reviewed the medical evidence, which included
treatment notes from Plaintiff’s primary care physician, results from Plaintiff’s multiple heart
failure tests, and reports from consultative examiners. The ALJ discussed Dr. Hughson’s report,
and justified discounting his opinion about Plaintiff’s physical condition as well as his
assignment of a low GAF score. AR 20-23.
The ALJ also reviewed Plaintiff’s own testimony regarding her symptoms and reports of
her daily activities. Additionally, the ALJ reviewed a report from Plaintiff’s neighbor, who
offered her opinions on Plaintiff’s activities and limitations.
The ALJ noted multiple
inconsistencies between Plaintiff’s reported limitations and her daily activities and wrote that
“[t]he [Plaintiff’s] inconsistent statements support the undersigned’s assessment that her
allegations in her disability application are not fully credible.” AR 23. Namely, Plaintiff
reported that she could not walk more than twenty to thirty feet and her neighbor reported that
she was always in bed. AR 20-21. However, Plaintiff also reported to her doctors that she was
making a diligent effort to exercise at the gym daily and her neighbor reported that they attend
church and go for walks together. AR 22.
Specifically focusing on Plaintiff’s alleged mental impairments, there is sufficient
evidence to support Plaintiff’s ability to work in an unrestricted manner.
Plaintiff’s RFC, the ALJ weighed Plaintiff’s testimony alongside reports from consultative
examiners. The Court finds no fault in the ALJ’s reliance on Dr. Hughson, a consultative
psychiatrist who noted that Plaintiff has experienced some symptoms as a result of her mental
impairments for many years, while still being able to successfully maintain gainful employment.
In her Motion, Plaintiff reviewed her history of mental diagnoses, including PTSD and
borderline personality disorder. Pl.’s Mot. 16-17. Overall, what Plaintiff provides the Court is a
review of Plaintiff’s subjective complaints that she reported to various medical professionals and
a timeline of how her medications were adjusted accordingly.
What Plaintiff fails to do,
however, is identify for the Court those specific mental limitations that would affect her ability to
maintain gainful employment and that the ALJ failed to address while determining Plaintiff’s
RFC. Unfortunately for Plaintiff, a generalized blanket assertion such as “[Plaintiff] would have
difficulty with basic work activities due to her mental health” is plainly insufficient to entitle
Plaintiff to a remand.
The ALJ’s assessments of the credibility of Plaintiff and the medical professionals were
hers to make. Those assessments were satisfactorily explained, are consistent with the medical
evidence in the record, and cannot be second-guessed by this Court when conducting its
substantial evidence review. For these reasons, the undersigned rejects Plaintiff’s assertion that
the ALJ erred in determining Plaintiff’s RFC and failed to support her decision with substantial
evidence. Ultimately, Plaintiff’s arguments amount to an invitation to this Court that it should
re-weigh the relevant evidence, which it will not do. See Oldham v. Astrue, 509 F.3d 1254, 1257
(10th Cir. 2007) (“We review only the sufficiency of the evidence, not its weight.”).
For these reasons, the undersigned finds that the ALJ’s decision was supported by
substantial evidence and the correct legal standards were applied.
IT IS THEREFORE ORDERED that Plaintiff’s Motion be DENIED, the
Commissioner’s final decision be AFFIRMED, and this action be DISMISSED.
IT IS SO ORDERED.
THE HONORABLE GREGORY J. FOURATT
UNITED STATES MAGISTRATE JUDGE
Presiding by Consent
Disclaimer: Justia Dockets & Filings provides public litigation records from the federal appellate and district courts. These filings and docket sheets should not be considered findings of fact or liability, nor do they necessarily reflect the view of Justia.
Why Is My Information Online?