Adamson v. Social Security Administration

Filing 20

OPINION AND ORDER by Magistrate Judge Jason A. Robertson. (jpc, Deputy Clerk)

IN THE UNITED STATES DISTRICT COURT FOR THE
EASTERN DISTRICT OF OKLAHOMA
NITA JO ADAMSON,

)
)
)
)
)
)
)
)
)
)

Plaintiff,
v.
COMMISSIONER OF THE SOCIAL
SECURITY ADMINISTRATION,
Defendant.

Case No. CIV-23-012-JAR

OPINION AND ORDER

Plaintiff Nita Jo Adamson (the “Claimant”) requests judicial
review of the decision of the Commissioner of the Social Security
Administration (the “Commissioner”) denying Claimant’s application
for disability benefits under the Social Security Act.

Claimant

appeals the decision of the Administrative Law Judge (“ALJ”) and
asserts that the Commissioner erred because the ALJ incorrectly
determined

that Claimant was

not disabled.

For the

reasons

discussed below, it is ordered that the Commissioner’s decision be
REVERSED and the case REMANDED for further proceedings.
Social Security Law and Standard of Review
Disability under the Social Security Act is defined as the
“inability to engage in any substantial gainful activity by reason
of any medically determinable physical or mental impairment. . .”
42 U.S.C. § 423(d)(1)(A).

A claimant is disabled under the Social

Security

Act

“only

if

his

physical

or

mental

impairment

or

impairments are of such severity that he is not only unable to do
his previous work but cannot, considering his age, education, and
work experience, engage in any other kind of substantial gainful
work which exists in the national economy. . .”
§423(d)(2)(A).

42 U.S.C.

Social Security regulations implement a five-step

sequential process to evaluate a disability claim.

See, 20 C.F.R.

§§ 404.1520, 416.920.1
Judicial

review

of

the

Commissioner’s

limited in scope by 42 U.S.C. § 405(g).
limited

to

two

inquiries:

first,

1

determination

is

This Court’s review is

whether

the

decision

was

Step one requires the claimant to establish that he is not engaged in
substantial gainful activity, as defined by 20 C.F.R. §§ 404.1510, 416.910.
Step two requires that the claimant establish that he has a medically severe
impairment or combination of impairments that significantly limit his ability
to do basic work activities. 20 C.F.R. §§ 404.1521, 416.921. If the claimant
is engaged in substantial gainful activity (step one) or if the claimant’s
impairment is not medically severe (step two), disability benefits are denied.
At step three, the claimant’s impairment is compared with certain impairments
listed in 20 C.F.R. Pt. 404, Subpt. P, App. 1. A claimant suffering from a
listed impairment or impairments “medically equivalent” to a listed impairment
is determined to be disabled without further inquiry. If not, the evaluation
proceeds to step four, where claimant must establish that he does not retain
the residual functional capacity (“RFC”) to perform his past relevant work. If
the claimant’s step four burden is met, the burden shifts to the Commissioner
to establish at step five that work exists in significant numbers in the national
economy which the claimant – taking into account his age, education, work
experience, and RFC – can perform.
Disability benefits are denied if the
Commissioner shows that the impairment which precluded the performance of past
relevant work does not preclude alternative work. See generally, Williams v.
Bowen, 844 F.2d 748, 750-51 (10th Cir. 1988).

2

supported

by

substantial

evidence;

correct legal standards were applied.
1162,

1164

(10th

Cir.

and,

second,

whether

the

Hawkins v. Chater, 113 F.3d

1997)(citation

omitted).

The

term

“substantial evidence” has been interpreted by the United States
Supreme Court to require “more than a mere scintilla.
such relevant evidence

as a

It means

reasonable mind might accept as

adequate to support a conclusion.”

Richardson v. Perales, 402

U.S. 389, 401 (1971) (quoting Consolidated Edison Co. v. NLRB, 305
U.S. 197, 229 (1938)).

The court may not re-weigh the evidence

nor substitute its discretion for that of the agency.

Casias v.

Secretary of Health & Human Servs., 933 F.2d 799, 800 (10th Cir.
1991).

Nevertheless, the court must review the record as a whole,

and the “substantiality of the evidence must take into account
whatever

in

the

record

fairly

detracts

from

its

weight.”

Universal Camera Corp. v. NLRB, 340 U.S. 474, 488 (1951); see also,
Casias, 933 F.2d at 800-01.
Claimant’s Background
Claimant was 61 years old at the time of the ALJ’s decision.
Claimant completed her high school education.
in the past as a payroll clerk.

Claimant has worked

Claimant alleges an inability to

work beginning January 25, 2021 due to limitations resulting from
3

degenerative disc disease, hypertension, coronary artery disease,
left knee osteoarthritis, left hip degenerative joint disease,
obesity, hyperlipidemia, migraine headaches, and bursitis.
Procedural History
On

February

24,

2021,

Claimant

protectively

filed

for

disability insurance benefits under Title II (42 U.S.C. § 401, et
seq.) of the Social Security Act.

Claimant’s application was

denied initially and upon reconsideration.

On July 5, 2022,

Administrative Law Judge (“ALJ”) Thomas John Wheeler conducted an
administrative

hearing

by

telephone

due

to

circumstances posed by the COVID-19 pandemic.
the ALJ issued an unfavorable decision.
Appeals Council denied review.

the

extraordinary

On July 22, 2022,

On November 14, 2022, the

As a result, the decision of the

ALJ represents the Commissioner’s final decision for purposes of
further appeal.

20 C.F.R. §§ 404.981, 416.1481.

Decision of the Administrative Law Judge
The ALJ made his decision at step four of the sequential
evaluation.

He determined that, while Claimant suffered from

severe impairments, she retained the residual functional capacity
(RFC”) to perform her past relevant work.

4

Error Alleged for Review
Claimant asserts the ALJ erred in (1) failing to properly
evaluate the medical opinion evidence; and (2) failing to provide
the duration for the sit/stand limitations in providing for the
sit/stand option in the RFC.
Evaluation of Opinion Evidence
In his decision, the ALJ determined Claimant suffered from
the severe impairments of degenerative disc disease, hypertension,
coronary

artery

disease,

left

knee

osteoarthritis,

degenerative joint disease, and obesity.

(Tr. 74).

none of Claimant’s conditions met a listing.

Id.

left

hip

The ALJ found
As a result of

the limitations caused by her severe impairments, Claimant was
found

to

retain

the

residual

functional

capacity

of

lifting

carrying, pushing and pulling ten (10) pounds occasionally and
less than ten (10) pounds frequently; stand and/or walk for two
hours out of an eight hour workday; and sit for six hours out of
an eight hour workday. The ALJ also found Claimant would require
that she be able to alternate between sitting and standing on an
hourly basis without leaving the workstation or going off task.
(Tr. 74-75).
After

consultation

with

a
5

vocational

expert,

the

ALJ

determined that Claimant could perform her past relevant work as
a payroll clerk.

(Tr. 80).

Consequently, the ALJ found that

Claimant had not been under a disability from January 25, 2021
through the date of the decision.

(Tr. 80).

At primary issue in this case is whether the ALJ properly
considered the opinions of Dr. Sean Boone, D.O. in arriving at the
RFC.

Dr. Boone completed a Treating Source Statement – Physical

Conditions form on Claimant on two occasions.

The first, dated

June 24, 2024, stated that Dr. Boone had treated Claimant twice a
year since 2018.

He diagnosed Claimant with hypertension, chronic

peripheral edema, coronary artery disease, vitamin D deficiency,
and hyperlipidemia.

He estimated Claimant would be “off task”

more than 25% of the time and would be able to maintain attention
and concentration for less than 30 minutes before requiring a
break.

Dr. Boone estimated Claimant would, on average, be absent

from work more than four days per month.

(Tr. 445).

He further opined that Claimant could “rarely” lift and carry
less than ten pounds due to left arm weakness, shortness of breath
with activity due to “deconditioning”, and weakness in the left
leg.

Dr. Boone found Claimant could sit for four hours in an

eight hour workday and stand/walk for one hour in an eight hour
6

workday.

He also stated that Claimant would require a sit/stand

option at will.

In a narrative statement on Claimant’s condition,

Dr. Boone stated Claimant standing and walking would aggravate her
left arm and leg.

He further found Claimant had chronic edema

that worsens due to vein grafting for bypass surgery.

Dr. Boone

asserted Claimant would have to lie down or recline “every couple
of hours” in an eight hour workday for 30 minutes.
Claimant would also have to elevate her legs.
a cane.

While sitting,

She does not require

(Tr. 446).

With regard to Claimant’s functional abilities, Dr. Boone
found she

could

directions,

and

“rarely” reach overhead,
push/pull

with

her

left

reach

in all other

arm/hand.

She

could

“occasionally” handle and could “frequently” finger and feel.

She

could “occasionally” do these tasks with her right arm/hand.
Claimant could also “rarely” use foot controls with her left foot
and “occasionally” do so with her right foot.

(Tr. 447).

Under “postural activities,” Dr. Boone found Claimant could
“never” climb ladders and scaffolds, crouch, crawl or rotate her
head

and

neck,

“rarely”

climb

“occasionally” balance and stoop.

stairs

and

ramps

and

kneel,

By way of explanation, Dr.

Boone stated, “Pt. experiences vertigo + sometimes blacks out when
7

bending over.”

(Tr. 448).

As for “environmental limitations,” Dr.
Claimant

could

“never”

climb

unprotected

Boone

determined

heights,

moving

mechanical parts, experience humidity and wetness, be exposed to
dust/odors/fumes/pulmonary irritants, be exposed to extreme heat
or vibations.

Claimant could “rarely” experience extreme cold and

could “occasionally” operate a vehicle.

Id.

On February 22, 2022, Dr. Boone completed a second Treating
Source Statement – Physical Conditions concerning Claimant.

On

this statement, Dr. Boone stated he attends Claimant “2-3 times
year.”

Claimant’s

diagnosed

conditions

are

identified

as

hypertension, coronary artery disease, scianca, peripheral edema,
and hyperlipidemia.

Most of the limitations are identical from

the first statement until Dr. Boone estimated her ability to use
her hands.

(Tr. 493-94).

He stated Claimant could “occasionally”

reach overhead, reach all other, handle, finger, and feel and
“rarely” push/pull with her left arm and hand.
could

“rarely”

reach

overhead,

reach

all

He found Claimant

other,

and

handle,

“occasionally” finger and feel, and “never” push/pull with her
right arm and hand.

(Tr. 495).

Dr. Boone found Claimant could “rarely” use foot controls
8

with her left foot and “never” do so with her right foot.

He

attributed these limitations to diffuse muscle atrophy and range
of motion due to non-use.

He stated Claimant was “physically

unable to exercise and develop muscle.”
On

postural

activities,

Dr.

Id.

Boone

found

in

this

later

statement that Claimant could “never” climb stairs and ramps or
climb ladders and scaffolds, could “rarely” kneel, crouch, and
crawl, and could “occasionally” balance, stoop, and rotate her
head and neck.

In his narrative, Dr. Boone found Claimant had

problems with heights and was “to (sic) weak to get up from sitting
position.” (Tr. 496).
On environmental limitations, Dr. Boone found Clamant could
“never” be at unprotected heights, be around moving mechanical
parts, or

experience extreme

“rarely”

be

exposed

heat and cold.

to

humidity

Claimant could

and

wetness

dust/odors/fumes/pulmonary irritants and vibrations.
“occasionally” operate a vehicle.
The

ALJ

included

persuasive.”

however,

references

His

that

Dr.

explanation

in

some

Boone’s
for

9

She could

Id.
detail

findings in his two statements in the decision.
concluded,

and

doing

Boone’s

(Tr. 77-78).

opinions
so

Dr.

is

He

were

“not

vague,

non-

descriptive, and cryptic.

The ALJ states,

In this case, there is no indication that the
record is ambiguous, unclear, incomplete, only
that
the record does
not
support the
claimant’s own medical sources’ conclusion
regarding function. The doctor’s conclusion
is not wholly consistent with the medical
record. The observations and diagnoses of the
doctor have been detailed in this decision.
(Tr. 80).
The ALJ cites to no evidence in the record to support his
wholesale rejection of Dr. Boone’s expert treating opinions.

The

RFC assessment must always consider and address medical source
opinions.

If the RFC assessment conflicts with an opinion from a

medical source, the ALJ must explain why the opinion was not
adopted. Soc. Sec. R. 96–8p, 1996 WL 374184 at *7.

Soc. Sec. R.

rulings are binding on an ALJ. 20 C.F.R. § 402.35(b)(1); Sullivan
v. Zebley, 493 U.S. 521, 530 n. 9 (1990); Nielson v. Sullivan, 992
F.2d 1118, 1120 (10th Cir. 1993).

When the ALJ fails to provide

a narrative discussion describing how the evidence supports each
conclusion,

citing

to

specific

medical

facts

and

nonmedical

evidence, the court will conclude that his RFC conclusions are not
supported by substantial evidence. See Southard v. Barnhart, 72
Fed.Appx. 781, 784–785 (10th Cir. July 28, 2003).
The ALJ’s dismissive and unexplained statements regarding the
rejection of Dr. Boone’s statements are insufficient for this Court
10

to evaluate the bases upon which such statements rely in other
evidence of record.

This leads to the conclusion that either the

RFC is unsupported or the ALJ’s consideration of Dr. Boone’s
opinions was woefully inadequate.

In either event, the matter

will be remanded for further explanation of his consideration of
Dr. Boone’s opinions and their effect upon the RFC.
Sit/Stand Option
The

single

limitation

set

out

by

Dr.

Boone

which

was

apparently adopted by the ALJ in his RFC was the sit/stand option.
This Court agrees, however, that the ALJ was required to not only
set forth the frequency that the option must be exercised but also
the duration.

Soc. Sec. R. 96-9p.

The duration may have an

effect upon the RFC and the level of work Claimant can perform.
On remand, the ALJ shall rectify this omission.
Conclusion
The

decision

of

the

Commissioner

is

not

supported

by

substantial evidence and the correct legal standards were not
applied.
fourth

Therefore, this Court finds, in accordance with the

sentence

of

42

U.S.C.

§

405(g),

the

ruling

of

the

Commissioner of Social Security Administration should be and is
REVERSED

and

the

case

is

REMANDED

to

proceedings consistent with this decision.
11

Defendant

for

further

IT IS SO ORDERED this 27th day of March, 2024.

______________________________
JASON A. ROBERTSON
UNITED STATES MAGISTRATE JUDGE

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