Langley v. Barnhart

• Decision Date: 30 June 2004
• Docket Number: No. 03-7088.,03-7088.
• Citation: 373 F.3d 1116
• Parties: Roberta LANGLEY, Plaintiff-Appellant, v. Jo Anne B. BARNHART, Commissioner, Social Security Administration, Defendant-Appellee.
• Court: U.S. Court of Appeals — Tenth Circuit

Page 1116

373 F.3d 1116

Roberta LANGLEY, Plaintiff-Appellant, v. Jo Anne B. BARNHART, Commissioner, Social Security Administration, Defendant-Appellee.

No. 03-7088.

United States Court of Appeals, Tenth Circuit.

June 30, 2004.

COPYRIGHT MATERIAL OMITTED

Catherine Taylor of Perrine, McGivern, Redemann, Reid, Berry & Taylor, P.L.L.C., Tulsa, OK, for Plaintiff-Appellant.

Sheldon J. Sperling, United States Attorney; Cheryl R. Triplett, Assistant United States Attorney; Tina M. Waddell, Regional Chief Counsel; Michael McGaughran, Deputy Regional Chief Counsel; and Amy J. Mitchell, Assistant Regional Counsel, Office of the General Counsel, Region VI, Social Security Administration, Dallas, TX, for Defendant-Appellee.

Before EBEL, ANDERSON, and BRISCOE, Circuit Judges.

EBEL, Circuit Judge.

Claimant Roberta Langley appeals from a district court order adopting the magistrate judge's recommendation to affirm the Commissioner's denial of her application for Social Security disability benefits. Claimant contends on appeal that the administrative law judge (ALJ) did not properly evaluate the opinions of her treating physicians and erred in determining that she does not have any severe impairments. We reverse and remand for further proceedings.¹

BACKGROUND

Claimant applied for disability benefits on June 1, 2000, claiming an inability to work since December 1, 1997, due to rheumatoid arthritis, chronic fatigue, chronic headaches, depression, and reflux disorder. The Commissioner has established a five-step sequential evaluation process for determining whether a claimant is disabled. See Williams v. Bowen, 844 F.2d 748, 750-52 (10th Cir.1988). In this case, the ALJ determined that claimant was not disabled at step two of the evaluation process. At step two, it is the claimant's burden to demonstrate an impairment, or a combination of impairments, that significantly limit her ability to do basic work activities. See Bowen v. Yuckert, 482 U.S. 137, 146 n. 5, 107 S.Ct. 2287, 96 L.Ed.2d 119 (1987); 20 C.F.R. § 404.1521. After considering the medical evidence and conducting a hearing, the ALJ found that claimant had not met this burden.

STANDARD OF REVIEW

We review the Commissioner's decision to determine whether the correct legal standards were applied and whether the Commissioner's factual findings are supported by substantial evidence in the record. Doyal v. Barnhart, 331 F.3d 758, 760 (10th Cir.2003). "Substantial evidence is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Id. (quotation omitted). "A 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." Bernal v. Bowen, 851 F.2d 297, 299 (10th Cir.1988). This court may "neither reweigh the evidence nor substitute our judgment for that of the agency." Casias v. Sec'y of Health & Human Servs., 933 F.2d 799, 800 (10th Cir.1991).

EVALUATION OF TREATING PHYSICIAN OPINIONS

On appeal, claimant first contends that the ALJ failed to apply correct legal standards in evaluating the opinion of one of her treating physicians, Dr. Hjortsvang, and her treating psychiatrist, Dr. Williams. She contends the ALJ failed to afford their opinions proper weight and to provide specific, legitimate reasons for rejecting their opinions. We agree.

Treating Physician Rule

According to what has come to be known as the treating physician rule, the Commissioner will generally give more weight to medical opinions from treating sources than those from non-treating sources. 20 C.F.R. § 404.1527(d)(2). "In deciding how much weight to give a treating source opinion, an ALJ must first determine whether the opinion qualifies for `controlling weight.'" Watkins v. Barnhart, 350 F.3d 1297, 1300 (10th Cir.2003). To make this determination, the ALJ:

must first consider whether the opinion is well-supported by medically acceptable clinical and laboratory diagnostic techniques. If the answer to this question is `no,' then the inquiry at this stage is complete. If the ALJ finds that the opinion is well-supported, he must then confirm that the opinion is consistent with other substantial evidence in the record. [I]f the opinion is deficient in either of these respects, then it is not entitled to controlling weight.

Id. (quotations omitted); see also § 404.1527(d)(2).

Even if a treating physician's opinion is not entitled to controlling weight, "[t]reating source medical opinions are still entitled to deference and must be weighed using all of the factors provided in [§] 404.1527.'" Id. (quoting Social Security Ruling (SSR) 96-2p, 1996 WL 374188, at *4).

Those factors are:

(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.

Id. at 1301 (quotation omitted).

"Under the regulations, the agency rulings, and our case law, an ALJ must give good reasons ... for the weight assigned to a treating physician's opinion," that are "sufficiently specific to make clear to any subsequent reviewers the weight the adjudicator gave to the treating source's medical opinion and the reason for that weight." Id. at 1300 (quotations omitted). "[I]f the ALJ rejects the opinion completely, he must then give specific, legitimate reasons for doing so." Id. at 1301 (quotations omitted).

Dr. Hjortsvang's Opinion

Dr. Hjortsvang, who treated claimant for several months, completed a medical source statement in which he reported that claimant has fairly severe degenerative joint disorder with limited movement in her legs, knees, hips, and shoulders. Dr. Hjortsvang stated that claimant suffers from chronic pain and has limited mobility and decreased balance. Dr. Hjortsvang also reported that claimant can frequently lift only ten pounds; stand or walk less than one hour in an eight-hour day; sit three hours in a typical day, and can never climb, balance, kneel, crouch, or crawl, and can only occasionally stoop, reach, handle, or finger objects. Dr. Hjortsvang stated that he based his assessment of her limitations on his shoulder examinations of claimant showing she experienced pain when her shoulder was extended only ninety to one-hundred degrees and his observation that she usually walked with a stoop.

The ALJ rejected Dr. Hjortsvang's report, stating that his "opinion is wholly unsupported by the claimant's medical records, and, frankly, is ridiculous. There is no objective medical evidence of any impairment which could be expected to cause such limitations." Aplt.App. at 29. The ALJ found that Dr. Hjortsvang "did not describe a medically determinable impairment that could reasonably cause such limitations," and that his assessment was not well-supported by clinical signs because he failed to reference any medical reports that supported his conclusions or indicate how his treatment of claimant supported his conclusions. Id. The ALJ stated that Dr. Hjortsvang's "assessment is clearly based upon the claimant's subjective complaints" and that "[h]is own treatment records clearly do not support his pessimistic functional assessment." Id. The ALJ wrote, "[a]ll in all, I find his account of the claimant's limitations to be more an act of courtesy to a patient, rather than a genuine medical assessment of discrete functional limitations based upon clinically established pathologies." Id. The ALJ found that Dr. Hjortsvang's assessment was unsupported by, and inconsistent with, the credible evidence of record, and declined to give it controlling weight.

Although claimant contends that Dr. Hjortsvang's opinion was entitled to controlling weight, she does not dispute the ALJ's finding that Dr. Hjortsvang's report is not well-supported by medically acceptable clinical and laboratory diagnostic techniques. Neither Dr. Hjortsvang's treatment notes nor his medical source statement indicate that he performed diagnostic tests to evaluate claimant's severe degenerative joint disease, such as X-rays, joint taps, magnetic resonance imaging, a bone scan, or computed tomography. Therefore, we conclude the ALJ was entitled to give Dr. Hjortsvang's report less than controlling weight. See Watkins, 350 F.3d at 1300.

The ALJ was not entitled, however, to completely reject Dr. Hjortsvang's opinion on this basis. As noted above, even if a treating physician's opinion is not entitled to controlling weight, it is "still entitled to deference and must be weighed using all of the [relevant] factors." Id. (quotation omitted).

[A]djudicators must remember that a finding that a treating source medical opinion is not well-supported by medically acceptable clinical and laboratory diagnostic techniques or is inconsistent with the other substantial evidence in the case record means only that the opinion is not entitled to `controlling weight,' not that the opinion should be rejected.

Id. (quoting SSR 96-2p, 1996 WL 374188, at *4). Here, contrary to the requirements of SSR 96-2p, the ALJ completely rejected Dr. Hjortsvang's opinion once he determined it was not entitled to controlling weight, without any consideration of what lesser weight the opinion should be given or discussion of the relevant factors set forth in § 404.1527.

Moreover, some of the reasons given by the ALJ for rejecting Dr. Hjortsvang's opinion are not supported by the record. Contrary to the ALJ's finding, Dr. Hjortsvang's medical records do describe medically determinable impairments that could reasonably cause the described limitations. He...