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Reynolds v. Berryhill

United States District Court, D. Utah

March 9, 2018

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         Plaintiff, under 42 U.S.C. § 405(g), seeks judicial review of the decision of the Acting Commissioner of Social Security (Commissioner) denying her claim for disability insurance benefits (DIB) under Title II of the Social Security Act (the Act). After careful review of the entire record, the parties' briefs, and arguments presented at a hearing held on February 23, 2018, the undersigned concludes the Commissioner's decision is supported by substantial evidence and free of harmful legal error and is, therefore, AFFIRMED.

         This Court reviews the Commissioner's decision to determine whether substantial evidence in the record as a whole supports the factual findings and whether the correct legal standards were applied. See Lax v. Astrue, 489 F.3d 1080, 1084 (10th Cir. 2007). “Substantial evidence is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Id. (citation omitted). The Court may neither “reweigh the evidence [n]or substitute [its] judgment for the [ALJ's].” Id. (citation omitted). Where the evidence as a whole can support either the agency's decision or an award of benefits, the agency's decision must be affirmed. See Ellison v. Sullivan, 929 F.2d 534, 536 (10th Cir. 1990).


         In this case, Plaintiff was 46 years old in September 2013, when she claimed disability based on arthritis, chronic pain, sleep apnea, depression, anxiety, and attention deficit hyperactivity disorder (ADHD) (Administrative Transcript (“Tr.”) 153, 182). She completed the 11th grade and had past relevant work as a warehouse worker (Tr. 183-84). In evaluating her case, the ALJ followed the familiar five-step sequential evaluation process (Tr. 17-30). See generally 20 C.F.R. § 404.1520(a)(4). The ALJ found that Plaintiff had the severe impairments of rheumatoid arthritis, degenerative disc disease, chondromalacia patella, obstructive sleep apnea, affective disorder, ADHD, and anxiety disorder, but that her impairments did not meet or equal the severity of a listed impairment (Tr. 19-22). The ALJ then found Plaintiff retained the residual functional capacity (RFC) to perform a restricted range of unskilled light work (Tr. 22-28). Considering this RFC, the ALJ determined that Plaintiff was capable of performing work existing in significant numbers in the national economy (Tr. 28-30). The ALJ thus concluded that Plaintiff had failed to establish disability under the standards of the Act (Tr. 30).

         I. The ALJ reasonably considered Plaintiff's mental and physical impairments in assessing her RFC for unskilled light work

         Plaintiff first asserts the ALJ “erred by not properly considering all of [her] mental and physical impairments” (Plaintiff's Brief (“Pl. Br.”) 10). Specifically, Plaintiff challenges the ALJ's evaluation of her rheumatoid arthritis, peripheral neuropathy, sleep apnea, and mental impairments (id. at 10-15). The Commissioner, however, argues that the record did not support any additional limitations related to Plaintiff's arthritis, peripheral neuropathy, sleep apnea, or mental impairments, and that the ALJ reasonably considered all of her impairments in assessing her RFC (Defendant's Brief (“Def. Br.”) 8).

         For example, Plaintiff complains the ALJ's RFC “does not include significant manipulative limitations” to account for her rheumatoid arthritis (Pl. Br. at 11). However, the Court finds that the majority of the medical evidence and medical source opinions support the ALJ's determination that Plaintiff remained able to frequently handle and finger despite her arthritis (Tr. 22). Rheumatologist Dr. Lundberg often noted that Plaintiff's hands and wrists looked normal and she showed “full” fist formation (Tr. 519, 571, 681, 688, 692, 696). Plaintiff's primary care physician, Dr. Lundsberg, opined that Plaintiff could perform both fine and gross manipulation frequently (Tr. 553-55). And reviewing state agency physicians Drs. Rothstein and Huebner opined that Plaintiff would not have any manipulative limitations whatsoever (Tr. 79, 93). Based on this record, the ALJ reasonably concluded that Plaintiff retained the ability to frequently handle and finger. See 20 C.F.R. § 404.1546(c) (an ALJ is responsible for assessing RFC); Howard v. Barnhart, 379 F.3d 945, 949 (10th Cir. 2004) (“[T]he ALJ, not a physician, is charged with determining a claimant's RFC from the medical record.”).

         Plaintiff next alleges the ALJ “erroneously found [her] peripheral neuropathy to be a ‘non-severe impairment'” (Pl. Br. 12). A severe impairment, however, is one that “significantly limits” an individual's physical or mental ability to perform basic work activities. 20 C.F.R. § 404.1520(c). Here, the Court finds little evidence demonstrating that Plaintiff's peripheral neuropathy “significantly” limited her ability to perform basic work activities. Instead, an EMG study showed she retained intact sensation to light touch, her nerve conduction studies were all normal, and there was “no electrodiagnostic evidence of a . . . neuropathy . . . in either lower extremity” (Tr. 282-84). And while she complained of numbness in the soles of her feet on occasion, her physical examination actually revealed that her neurological examination was normal with “light touch intact on soles” (Tr. 601). Further, physician assistant (“PA”) Johnson, the only treatment provider to expressly assign limitations based on Plaintiff's peripheral neuropathy, opined that Plaintiff remained able to stand for four hours at one time and up to six hours in a workday, which was consistent with the ALJ's RFC assessment (Tr. 548-49). Thus, Plaintiff has failed to support her claims that peripheral neuropathy would “significantly limit” her ability to perform basic work activities, and the Court concludes the ALJ reasonably determined that this was not a severe impairment. See 20 C.F.R. § 404.1520(c); Hawkins v. Chater, 113 F.3d 1162, 1169 (10th Cir. 1997) (at step two, a claimant has the burden to “demonstrate an impairment or combination of impairments that significantly limits the claimant's ability to do basic work activity.” (citing 20 C.F.R. § 404.1520(c))).

         Plaintiff also complains the ALJ did not account for her sleep apnea and related fatigue in assessing her RFC (Pl. Br. 13). However, the ALJ included limitations to account for Plaintiff's mental impairments, including that she could only make “simple work-related judgments and decisions, ” could “understand, remember, and carry out only short and simple instructions, ” and could perform “goal-oriented work but not fast-paced work” (Tr. 22). Plaintiff further argues that three of her doctors opined she would have “at least moderate to severe fatigue and malaise throughout the day” (Pl. Br. 13 (citing Tr. 547-49, 553-55, 568-70)). However, Dr. Lundberg, Dr. Lundsberg and PA Johnson actually opined that Plaintiff's fatigue and malaise would be no more than moderate (Tr. 548, 554, 569). And Dr. Lundsberg explicitly opined that Plaintiff's mental limitations generally did not preclude her from performance of any aspect of a job, and that she would only be precluded for five percent of a work day in the area of maintaining attention and concentration (Tr. 550-51). He also did not believe that Plaintiff was unable to obtain and retain work because of her medical impairments and limitations (Tr. 552). Therefore, the Court concludes that Plaintiff has failed to show that her sleep apnea resulted in any mental limitations beyond those already assessed by the ALJ.

         Plaintiff next asserts the ALJ “made contradictory findings regarding the severity of [her] mental impairments” (Pl. Br. 14-15). Plaintiff appears to be asserting that because the ALJ found that she had moderate difficulties in concentration, persistence, or pace at step three of the sequential evaluation process, the ALJ was required to include other, greater mental limitations in assessing Plaintiff's RFC. However, as discussed above, the ALJ limited Plaintiff to only “simple work-related judgments and decisions, ” understanding, remembering, and carrying out “only short and simple instructions, ” and performing “goal-oriented work but not fast-paced work” (Tr. 22). This finding is consistent with the ALJ's step three finding. As the Commissioner notes, in assessing Plaintiff with “moderate” limitations in concentration, persistence, or pace, the ALJ expressly stated that these limitations were “not a residual functional capacity assessment but are used to rate the severity of mental impairments at steps 2 and 3 of the sequential evaluation process” (Tr. 22). Further, the ALJ noted that, despite these moderate limitations, Plaintiff remained able to manage her own finances, organize her medication, and follow simple instructions (Tr. 21). The ALJ therefore reasonably concluded that Plaintiff was able to maintain focus, attention, and concentration “sufficiently long enough to permit the timely and appropriate completion of tasks commonly found in work settings” (Tr. 21). See Vigil v. Colvin, 805 F.3d 1199, 1204 (10th Cir. 2015) (rejecting Plaintiff's argument that a limitation to unskilled work cannot accommodate severe mental impairments: “There may be cases in which an ALJ's limitation to ‘unskilled' work does not adequately address a claimant's mental limitations. But in this case, we conclude that limiting the plaintiff to an SVP of only one or two, adequately took into account his moderate limitations in concentration, persistence, and pace.” (internal citation omitted)); Bales v. Colvin, 576 F. App'x 792, 798 (10th Cir. 2014) (unpublished) (affirming the ALJ's decision that Plaintiff was capable of unskilled work despite the ALJ's finding “of a moderate limitation in concentration, persistence, or pace at step three”). Thus, the Court finds the ALJ reasonably considered Plaintiff's mental and physical impairments in assessing her RFC for unskilled light work and Plaintiff has failed to demonstrate that any additional limitations were warranted.

         II. The ALJ reasonably evaluated the medical source opinions

         Plaintiff next asserts the ALJ did not appropriately evaluate the medical source opinions (Pl. Br. 15-20). The Commissioner argues that the ALJ reasonably evaluated all of the medical source opinions, and assessed an RFC that took these opinions into consideration (Def. Br. 13-19). The Court finds Plaintiff's claims to be without merit.

         The ALJ in this case was faced with several differing medical opinions from treating and reviewing sources regarding Plaintiff's physical and mental abilities. Here, the ALJ weighed each of these opinions and determined that Plaintiff retained the RFC to perform a restricted range of light work, after finding that she was slightly more limited than indicated by the reviewing physicians, but less limited than indicated by her treating physicians. The Court concludes ...

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