United States District Court, D. Colorado
ORDER
SCOTT
T. VARHOLAK, UNITED STATES MAGISTRATE JUDGE
This
matter is before the Court on Plaintiff Kristin Bradley's
Complaint seeking review of the Commissioner of Social
Security's decision denying Plaintiff's application
for disability insurance benefits (“DIB”) under
Title II of the Social Security Act (“SSA”), 42
U.S.C. §§ 401 et seq. [#1] The parties
have both consented to proceed before this Court for all
proceedings, including the entry of final judgment, pursuant
to 28 U.S.C. § 636(c) and D.C.COLO.LCivR 72.2.
[See #13] The Court has jurisdiction to review the
Commissioner's final decision pursuant to 42 U.S.C.
§ 405(g). This Court has carefully considered the
Complaint [#1], the Social Security Administrative Record
[#10], the parties' briefing [#15, 16], and the
applicable case law, and has determined that oral argument
would not materially assist in the disposition of this
appeal. For the following reasons, the Court
REVERSES the Commissioner's decision and
REMANDS for further proceedings.
I.
LEGAL STANDARD
A.
Five-Step Process for Determining Disability
The SSA
defines disability as the inability “to engage in any
substantial gainful activity by reason of any medically
determinable physical or mental impairment which can be
expected to result in death or which has lasted or can be
expected to last for a continuous period of not less than 12
months.”[1] 42 U.S.C. § 423(d)(1)(A); Lax v.
Astrue, 489 F.3d 1080, 1084 (10th Cir. 2007).
“This twelve-month duration requirement applies to the
claimant's inability to engage in any substantial gainful
activity, and not just his underlying impairment.”
Lax, 489 F.3d at 1084. “In determining whether
an individual's physical or mental impairment or
impairments are of a sufficient medical severity that such
impairment or impairments could be the basis of eligibility .
. ., the Commissioner [ ] shall consider the combined effect
of all of the individual's impairments without regard to
whether any such impairment, if considered separately, would
be of such severity.” 42 U.S.C. § 423(d)(2)(B).
“The
Commissioner is required to follow a five-step sequential
evaluation process to determine whether a claimant is
disabled.” Hackett v. Barnhart, 395 F.3d 1168,
1171 (10th Cir. 2005). The five-step inquiry is as follows:
1. The Commissioner first determines whether the
claimant's work activity, if any, constitutes substantial
gainful activity;
2. If not, the Commissioner then considers the medical
severity of the claimant's mental and physical
impairments to determine whether any impairment or
combination of impairments is
“severe;”[2]
3. If so, the Commissioner then must consider whether any of
the severe impairment(s) meet or exceed a listed impairment
in the appendix of the regulations;
4. If not, the Commissioner next must determine whether the
claimant's residual functional capacity
(“RFC”)-i.e., the functional capacity
the claimant retains despite his impairments-is sufficient to
allow the claimant to perform his past relevant work, if any;
5. If not, the Commissioner finally must determine whether
the claimant's RFC, age, education, and work experience
are sufficient to permit the claimant to perform other work
in the national economy.
See 20 C.F.R. § 404.1520(a)(4); Grogan v.
Barnhart, 399 F.3d 1257, 1261 (10th Cir. 2005);
Bailey v. Berryhill, 250 F.Supp.3d 782, 784 (D.
Colo. 2017). The claimant bears the burden of establishing a
prima facie case of disability at steps one through
four, after which the burden shifts to the Commissioner at
step five to show that the claimant retains the ability to
perform work in the national economy. Wells v.
Colvin, 727 F.3d 1061, 1064 n.1 (10th Cir. 2013);
Lax, 489 F.3d at 1084. “A finding that the
claimant is disabled or not disabled at any point in the
five-step review is conclusive and terminates the
analysis.” Ryan v. Colvin, 214 F.Supp.3d 1015,
1018 (D. Colo. 2016) (citing Casias v. Sec'y of
Health & Human Servs., 933 F.2d 799, 801 (10th Cir.
1991)).
B.
Standard of Review
In
reviewing the Commissioner's decision, the Court's
review is limited to a determination of “whether the
Commissioner applied the correct legal standards and whether
her factual findings are supported by substantial
evidence.” Vallejo v. Berryhill, 849 F.3d 951,
954 (10th Cir. 2017) (citing Nguyen v. Shalala, 43
F.3d 1400, 1402 (10th Cir. 1994)). “With regard to the
law, reversal may be appropriate when [the Commissioner]
either applies an incorrect legal standard or fails to
demonstrate reliance on the correct legal standards.”
Bailey, 250 F.Supp.3d at 784 (citing Winfrey v.
Chater, 92 F.3d 1017, 1019 (10th Cir.1996)).
“Substantial
evidence is such relevant evidence as a reasonable mind might
accept as adequate to support a conclusion. It requires more
than a scintilla, but less than a preponderance.”
Wall v. Astrue, 561 F.3d 1048, 1052 (10th Cir. 2009)
(quoting Lax, 489 F.3d at 1084). “Evidence is
not substantial if it is overwhelmed by other evidence in the
record or constitutes mere conclusion.”
Grogan, 399 F.3d at 1261-62 (quoting Musgrave v.
Sullivan, 966 F.2d 1371, 1374 (10th Cir. 1992)). The
Court must “meticulously examine the record as a whole,
including anything that may undercut or detract from the
[Commissioner's] findings in order to determine if the
substantiality test has been met.'” Flaherty v.
Astrue, 515 F.3d 1067, 1070 (10th Cir. 2007) (quotation
omitted). The Court, however, “will not reweigh the
evidence or substitute [its] judgment for the
Commissioner's.” Hackett, 395 F.3d at
1172.
II.
BACKGROUND
Plaintiff
was born in 1975. [AR 54, 133][3] Plaintiff has a college degree.
[AR 34, 161] She can communicate in English. [AR 35-47, 159]
On or about July 22, 2016, Plaintiff filed a Title II
application for DIB. [AR 11, 133] Plaintiff claims a
disability onset date of November 30, 2015, thus Plaintiff
was 40 years old at the time of the alleged onset.
[Id.] Plaintiff claims disability based upon severe
fibromyalgia, severe asthma, chronic migraines,
post-traumatic stress disorder (“PTSD”),
pleurisy, hypoglycemia, vocal cord deficiency, sub-clinical
hypothyroidism, orthostatic hypertension, and type 1 Chiari
malformation. [AR 67, 160] Plaintiff worked in a variety of
positions prior to the alleged disability onset date,
including as a teacher and an assistant director of a child
care business. [AR 65, 162] Most recently, Plaintiff worked
selling cosmetics, which she did until her alleged onset
date. [AR 35-36, 160, 162] Plaintiff has not engaged in
substantial gainful activity from her alleged onset date
through her date last insured, which the ALJ determined to be
December 31, 2016. [AR 13]
A.
Medical Background
Plaintiff's
chronic pain began in 2012 or 2013 after she tore her right
anterior cruciate ligament (“ACL”).[4] [AR 35, 218] She
testified that she “worked through it without surgery,
but . . . the pain kept getting worse and worse and then
started spreading throughout [her] body.” [AR 35]
Medical records further reflect that Plaintiff suffers from a
history of asthma, allergic rhinitis, and vocal cord
dysfunction. [AR 217]
In
November 2014, Plaintiff went to the emergency room because
of an asthma attack. [AR 419, 428] Plaintiff told hospital
staff that her problems began the previous day during a
martial arts test. [AR 425] Plaintiff indicated that her pain
rated at ten on a scale of ten. [AR 424] Medical records
indicate that she has a long history of asthma with frequent
exacerbation despite medication, often requiring
hospitalization. [AR 422] Plaintiff was treated with steroids
and responded well. [Id.]
At a
doctor's appointment in early December 2014, Plaintiff
expressed anxiety and vocal cord dysfunction, and the
treating physician noted that Plaintiff suffered from vocal
cord paresis that “certainly d[id] not improve the
situation.” [AR 214] At an anemia check-up on or about
December 5, 2014, Plaintiff reported that she was “very
fatigued” and, based upon a review of laboratory
results, mild anemia was indicated. [AR 259] At a cardiology
consultation several days later, Plaintiff stated that her
chest pain rated from eight to ten out of ten, and could last
anywhere from several days to several weeks in duration. [AR
224] The notes from the consultation indicated that Plaintiff
was “quite active” but that the chest pain had
“sidelined her such that she [wa]s no longer able to
work or to compete” in martial arts events.
[Id.] Plaintiff indicated that she was becoming
increasingly fatigued. [AR 225]
On or
about December 11, 2014, Plaintiff returned to the emergency
room complaining of chest pain. [AR 414, 418] Plaintiff rated
her pain as ten out of ten. [AR 256, 408] Medical records
reflect an unsteady gait and that Plaintiff needed assistance
walking. [AR 411] At a rheumatology consultation several days
later, Plaintiff reported to physicians that ibuprofen and
steroids helped with her chest pain, but do not eliminate the
pain. [AR 274] Plaintiff further indicated that she was
starting to notice weakness in her arm, pain and locking in
her shoulder, and chronic numbness down the arm.
[Id.]
By
January 2015, Plaintiff began feeling better and described
her pain as three out of ten. [AR 271] Ibuprofen improved,
but did not eliminate, the pain. [Id.] An x-ray
revealed some degenerative disk disease. [Id.] In
February 2015, Plaintiff told medical providers that she was
“feeling very well, ” that her “pain ha[d]
subsided, ” and that she “fe[lt] like she [wa]s
back, if not better than she ha[d] been before.” [AR
255, 269] She rated her pain as zero out of ten. [AR 269] She
was active and getting ready for competitive martial arts
events. [Id.]
In
early April 2015, however, Plaintiff twice returned to the
emergency room with chest pain. [AR 243, 367, 387] The
emergency room treatment providers diagnosed her with
bronchitis. [AR 243, 376, 391] Plaintiff was given a Z-Pak at
her first emergency room visit, but returned to the hospital
two days later complaining of increased chest pain. [AR 243]
During this second visit, Plaintiff rated the pain as seven
on a scale of ten. [AR 379] Plaintiff described herself as
“very active, especially with martial arts.”
[Id.] Over the next several weeks, Plaintiff's
pain initially lessened [AR 250], but by April 24, 2015, had
returned [AR 246, 248]. An examination at the end of April
2015 reflected “marked tenderness” to
Plaintiff's left upper chest wall. [AR 246] Further chest
pain was noted in medical records from May 2015, along with a
note that physicians had been unable to diagnose the cause of
Plaintiff's pain. [AR 265]
On June
1, 2015, Plaintiff was again seen at a hospital for
evaluation of her chest pain. [AR 287] Records indicate that
it was “uncertain if [Plaintiff] ha[d] an underlying
inflammatory disorder, but she d[id] have elevated
inflammatory markers associated with her episodes.”
[Id.] The records further indicate that her symptoms
were improved with Medrol, and Plaintiff “[wa]s back to
her normal level of competition.” [Id.]
In
August 2015, Plaintiff went to the emergency room once and
was seen by a clinic twice. [AR 290-95, 359] She complained
of chest pain which had transitioned from sporadic pain to
“more chronic symptoms.” [AR 292] At the
emergency room, Plaintiff reported that her pain rated ten
out of ten. [AR 364] During a clinic visit, she explained
that the pain was so severe, at times, that she remained in
bed for many days a week. [AR 292] Plaintiff also complained
of dizziness and weakness, but denied any numbness or
tingling. [AR 290] A physical examination revealed chest wall
tenderness. [AR 291] Nonetheless, she was continuing her
martial arts training, which appeared to make the pain worse.
[AR 290, 292]
In
September 2015, Plaintiff was treated on several occasions
for her pain, including three emergency room visits and a
clinic visit. [AR 297, 324, 335, 344] By now, the pain had
spread to other parts of her body, including her neck, back,
feet, and chest. [AR 296-97] The pain was so severe that on
one occasion she needed to be transported by ambulance to the
emergency room. [AR 297, 324] On that trip to the emergency
room she was nauseous and ...