United States District Court, D. Colorado
Michael E. Hegarty, United States Magistrate Judge.
Jean Mary Maron, appeals from the Social Security
Administration (“SSA”) Commissioner's final
decision denying her application for disability insurance
benefits, filed pursuant to Title II of the Social Security
Act, 42 U.S.C. §§ 401-33. Jurisdiction is proper
under 42 U.S.C. § 405(g). The parties have not requested
oral argument, and the Court finds it would not materially
assist in its determination of this appeal. Because the ALJ
failed to properly analyze the evidence in the medical record
at step three, the Court reverses the Administrative Law
Judge's (“ALJ”) decision and remands this
case to the Commissioner for further
alleges she first became disabled on November 1, 2012, after
which she has not engaged in any substantial gainful
employment. [AR 120]. The SSA initially denied
Plaintiff's application for disability benefits on June
16, 2014. [AR 70-77]. At Plaintiff's request, an ALJ
scheduled a hearing for August 17, 2015. [AR 93]. Plaintiff
and a vocational expert testified at the hearing. [AR 27-48].
On August 28, 2015, the ALJ issued a written ruling, which
found Plaintiff was not disabled since November 1, 2012. [AR
11-18]. According to the ALJ, although Plaintiff has severe
impairments, they do not meet the severity of one of the
impairments listed in 20 C.F.R. Part 404, Subpart P, Appendix
1. [AR 13-17]. Furthermore, the ALJ found that, despite
Plaintiff's limitations, she is capable of performing her
past work as a receptionist. [AR 17-18]. The SSA Appeals
Council subsequently denied Plaintiff's request for
review of the ALJ's determination, making the SSA
Commissioner's denial final for the purpose of judicial
review. [AR 1-6]; see 20 C.F.R. § 416.1481.
Plaintiff timely filed her Complaint with this Court seeking
review of the ALJ/Commissioner's final decision. ECF No.
was born on August 25, 1955; she was fifty-eight years old
when she filed her application for disability benefits. [AR
120]. Plaintiff claims she became disabled on November 1,
2012 due to constant pain in her legs, knees, neck, and lower
back. [AR 170]. The relevant portion of Plaintiff's
medical history begins in November 2011, when a doctor at
Littleton Adventist Hospital performed a bone density exam
and diagnosed Plaintiff with osteoporosis. [AR
249].Then, on December 8, 2011, Plaintiff
reported to the same hospital with complaints of “leg
pain, flank pain, and dysuria.” [AR 251]. The doctor
concluded that Plaintiff's pain was associated with the
fact that she was “relatively immunosuppresed by being
on prednisone chronically for Cushing syndrome.” [AR
254]. Because Plaintiff continued to report pain, she
underwent an X-ray of her hips on September 21, 2012. [AR
284]. The X-ray revealed “no acute fracture” and
“no acute osseous abnormality.” [Id.]
Plaintiff also received an X-ray of her lumbar spine on
October 16, 2012, which showed normal results other than mild
arthritic changes. [AR 283].
October 2012, Plaintiff began seeing a rheumatologist, Dr.
Anita Zachariah, for muscle pains, fatigue, weakness, and
tingling or numbness. [AR 635-71]. Because Dr. Zachariah
believed that Plaintiff's pain may have been due to
lumbar radiculopathy, she ordered Plaintiff to undergo an
MRI. [AR 638]. The MRI revealed, inter alia, that
Plaintiff had mild degenerative desiccation in the C5-6 and
C6-7 discs, broad annular bulge and or disc protrusion at
¶ 5-6, and “small left paracentral and lateral
focal disc protrusion at ¶ 6-7, which distorts the left
anterolateral thecal sac.” [AR 631]. After reviewing
the results of the MRI on November 9, 2012, Dr. Zachariah
stated that the MRI “showed mild disc
herniation.” [AR 635]. Although Plaintiff continued to
complain of muscle weakness and fatigue, Dr. Zachariah's
November 9, 2012 physical examination noted no abnormalities
other than a positive straight leg raise test and a positive
Tinel's sign for carpel tunnel syndrome. [AR 637].
Neither Plaintiff nor Dr. Zachariah noted any changes to
Plaintiff's conditions during a December 14, 2012
visit. [AR 639-43].
February 22, 2013, Dr. Amelia Scott Barrett examined
Plaintiff for bulging discs and leg pain. [AR 335]. Dr.
Barrett concluded that Plaintiff “presents with right
leg weakness and pain that may be due to a lumbar
radiculopathy.” [AR 337]. Accordingly, Dr. Barrett
ordered an MRI and physical therapy to treat cervical disc
herniation. [Id.] After reviewing the results, Dr.
Barrett concluded the MRI showed no abnormalities. [AR 339].
Plaintiff also complained of hip pain, Dr. Barrett refereed
Plaintiff to Dr. Craig Loucks, an orthopedic surgeon, who
ordered an MRI of Plaintiff's hip. [AR 339, 362-64]. The
MRI revealed osteoarthritic changes of the right hip and
tearing of the labrum. [AR 376]. Dr. Loucks concluded that
the images of Plaintiff's hip were “fairly
impressive, ” and “certainly account for her
ongoing pain that is affecting her quality of life as well as
her activities of daily living.” [AR 361]. Accordingly,
Dr. Loucks performed a right total hip arthroplasty on July
30, 2013. [AR 361, 369-71]. Thirteen days after the surgery,
a physician's assistant noted that, although Plaintiff is
still walking with a cane, she is “doing very
well”overall [AR 360]. During a subsequent follow-up
appointment on September 13, 2013, Plaintiff stated that
“her hip is feeling reasonably well.” [AR 358].
By her October 2013 follow-up, Plaintiff had no pain in the
hip joint and was “thrilled with the results of the hip
replacement.” [AR 357].
also in the fall of 2013, Plaintiff began reporting severe
knee pain, and that “her fibromyalgia is flaring all
over now . . . .” [AR 652, 659]. Accordingly, Dr. Loucks
ordered an MRI of Plaintiff's knee on October 14, 2013.
[AR 365]. The imaging revealed no internal derangement other
than mild cartilage degeneration and probable denervation at
the lateral head of her gastroc, soleus, and anterolateral
musculature. [AR 357]. Dr. Loucks noted that some of
Plaintiff's neurological symptoms seemed “bizarre,
” but stated that this was better left to her
neurologist and rheumatologist. [Id.]
Plaintiff returned to Dr. Zachariah on December 20, 2013, Dr.
Zachariah stated that Plaintiff was “doing well on her
regimen now.” [AR 662-66]. On February 24,
2014-Plaintiff's last recorded visit with Dr.
Zachariah-Plaintiff noted that her pain is intermittent,
depending on her activity. [AR 667].
visited Dr. Laura Moran for a consultative evaluation on June
5, 2014. [AR 682-85]. After examining Plaintiff and reviewing
her records, Dr. Moran concluded that Plaintiff “can
alternate activities of sitting, standing, and walking as
needed for her comfort for a total of 8 hours per day. She
can lift and carry about 20 pounds. She is able to bend. She
is unable to squat. She is able to . . . do all daily
self-care activities.” [AR 652].
Zachariah completed medical source questionnaires in July
2014 and June 2015. [AR 688-702]. In the first statement, Dr.
Zachariah noted that Plaintiff had chronic moderate to severe
fibromyalgia, neuropathy, and back pain. [AR 668]. She also
stated that Plaintiff could not sit or stand for longer than
thirty minutes at one time, and Plaintiff would have to take
five minute breaks every thirty minutes. [AR 689-90].
Accordingly, Plaintiff would be off task approximately 15% of
the work day, and she would be absent from work about three
days per month. [AR 691]. In the June 2015 statement, Dr.
Zachariah increased the time of Plaintiff's required
breaks from five minutes to twenty minutes each, and noted
that Plaintiff could not sit for more than one hour total in
any given workday. [AR 700]. Finally, Dr. Zachariah believed
Plaintiff would have to miss up to four days of work per
month. [AR 702].
hearing was held before an ALJ on August 17, 2015. [AR
25-49]. Plaintiff and a vocational expert testified at the
hearing. [Id.] Plaintiff first stated that her
osteoarthritis, osteoporosis, muscle atrophy, degenerative
disc disease, and fibromyalgia are causing her significant
pain and fatigue, which keep her from working. [AR 29-30].
Regarding the fatigue, Plaintiff testified that,
“[s]ome days I don't shower. I don't dress.
It's hard to do even a few chores around the house. I get
worn down, and there are days I can't even get across the
street to say hi to a neighbor.” [AR 30].
also testified about her work history as a receptionist for
an optometrist. [AR 33]. Plaintiff stated that she worked for
ten years “checking patients in and out, taking copays
and money, charting, scheduling, pulling files, scanning,
[and] phones.” [Id.] Although she stopped
working regularly in November 2012, Plaintiff testified that
her employer held the job open for her until January 2013.
[AR 34]. Because Plaintiff was in so much pain that she could
not leave the house, her employer eventually asked her to
then discussed her ability to conduct activities of daily
living. [AR 36-38]. According to Plaintiff, she wakes up
between 6:30 a.m. and 9:00 a.m. and makes breakfast if
“there's something easy to fix.” [AR 36].
Then, Plaintiff does dishes, but usually is in too much pain
to do all of them. [Id.] She generally tries to do
laundry and pay bills, but often feels as though she cannot
be active for more than three or four hours of the day.
[Id.] Plaintiff stated that she “very rarely
drive[s] [herself] anywhere” because of her blurred
visions and the pain she experiences when getting in and out
of the car. [AR 36-37].
then posed a series of hypotheticals to the vocational
expert. [AR 41]. First, the ALJ asked the expert to consider
whether an individual who is limited to light exertional work
with occasional posturals could maintain employment as a
receptionist. [Id.] The vocational expert responded
that the hypothetical individual could perform that job.
[Id.] The ALJ then asked the expert whether an
individual who is limited to light work and frequent
handling, fingering, and feeling with both upper extremities
could work as a receptionist. [Id.] The vocational
expert again responded in the affirmative. [Id.] For
the third and fourth hypotheticals, the ALJ posed the same
limitations as hypotheticals one and two, except he changed
the exertional level to sedentary. [AR 41-42]. The expert
testified that both individuals could maintain employment as
a receptionist. [AR 42].
for Plaintiff then examined the vocational expert. [AR
42-46]. First, counsel asked the expert whether an individual
who is required to take three to four twenty minute breaks
per day could perform work as a receptionist. [AR 44].
According to the expert, this person could not maintain
employment. [Id.] Additionally, the expert testified
that an individual who would be off task more than 25% of ...