Sawyer v. Barnhart , 89 F. App'x 148 ( 2004 )

F I L E D
United States Court of Appeals
Tenth Circuit
UNITED STATES COURT OF APPEALS
FEB 9 2004
FOR THE TENTH CIRCUIT
PATRICK FISHER
Clerk
AVA SAWYER,
Plaintiff-Appellant,
v. No. 03-7014
(D.C. No. 01-CV-629-S)
JO ANNE B. BARNHART, (E.D. Okla.)
Commissioner, Social Security
Administration,
Defendant-Appellee.
ORDER AND JUDGMENT *
Before O’BRIEN and BALDOCK , Circuit Judges, and BRORBY , Senior Circuit
Judge.
After examining the briefs and appellate records, this panel has determined
unanimously to grant the parties’ request for a decision on the briefs without oral
argument. See Fed. R. App. P. 34(f); 10th Cir. R. 34.1(G). The case is therefore
ordered submitted without oral argument.
*
This order and judgment is not binding precedent, except under the
doctrines of law of the case, res judicata, and collateral estoppel. The court
generally disfavors the citation of orders and judgments; nevertheless, an order
and judgment may be cited under the terms and conditions of 10th Cir. R. 36.3.
Claimant Ava Sawyer appeals the district court’s affirmance of the decision
by the Commissioner of Social Security denying her application for disability
benefits and supplemental security income. Because the Commissioner’s decision
was supported by substantial evidence and no legal errors occurred, we affirm.
Background
In July 1995, claimant sought emergency treatment for right-sided
abdominal pain. She was diagnosed with entiritis and was given medication.
Later that month, she was diagnosed with a small ovarian cyst. In August 1985,
claimant was diagnosed with minimal diverticulosis of the lower left colon. CT
scans of her stomach and abdominal organs were unremarkable.
On February 14, 1996, claimant injured her lower back at work. The
workers’ compensation carrier sent claimant to Dr. Wood, who diagnosed
claimant with a lumbar sprain. Aplt’s App. at 188. Claimant underwent physical
therapy during March and April 1996, with significant improvement noted. Id. at
244. She was discharged from physical therapy on April 26, 1996. Id.
On May 14, 1996, claimant returned to Dr. Wood complaining of continued
pain and right leg weakness. Examination revealed some loss of muscle tone in
the hip flexors and adductors, with some decrease in muscle strength. Id. at 187.
Because of the possibility of radiculopathy, Dr. Wood referred claimant to
Dr. Duncan in June 1996.
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In June 1996, Dr. Duncan’s examination revealed symmetrical reflexes, and
normal motor, sensory, and cerebellar exams. Claimant’s range of motion in her
lumbar spine was restricted, but she did not have a definitive positive straight leg
raising test. Id. at 152. Dr. Duncan ordered a lumbar spine series of x-rays which
showed unremarkable results. Id. at 151. Claimant’s EMG did not reveal any
abnormalities, although Dr. Duncan noted that the findings did “not entirely
exclude a radiculopathy.” Id. at 148. An MRI “didn’t show dramatic changes,”
id. at 146, showing “[d]egenerative disc disease at L4/L5 and L5-S1 with minimal
posterior disc protrusion. . . . No evidence of central canal stenosis or neural
foraminal narrowing.” Id. at 140. In July 1996, Dr. Duncan suggested physical
therapy as he did not “see a specific indication for surgery.” Id. at 146.
In August 1996, claimant received an epidural steroid injection at Valley
View Regional Hospital. Discharge notes reported that claimant was in no
apparent distress. Id. at 143. She underwent physical therapy from July through
September 1996. Notes show that claimant’s condition improved, and during
September, she began canceling her appointments. Id. at 153-56. On
September 13, 1996, Dr. Duncan opined that claimant could perform light duty
without lifting more than fifteen pounds, and released her from his care. Id. at
145.
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On October 3, 1996, claimant returned to Dr. Wood. Claimant reported that
she had good days and bad days with her back, that standing for long periods
caused pain, and that sitting for long periods caused stiffness. Id. at 187.
Regarding Dr. Duncan’s recommendation that she return to work on light duty,
claimant felt that there was “no light duty she could perform in her job class.” Id.
at 187. Claimant saw Dr. Wood a last time on October 31, 1996. Dr. Wood
diagnosed claimant with a lumbar strain that was improving slowly, and released
her for light duty with very little lifting, and with the ability to alternate sitting,
standing, and walking. Id. at 186. Dr. Wood advised that claimant should be
limited to thirty hours of work for the first month. Id. Although claimant was
supposed to make another appointment with Dr. Wood in three weeks, she failed
to do so.
On November 5, 1996, claimant was examined by Dr. Hastings of
Professional Medical Services. He reported claimant’s complaints of pain and
stiffness in the low back that worsened with bending, stooping, lifting, or
twisting. Id. at 179. Claimant also complained of pain radiating into the legs
bilaterally, with the right leg worse than the left, and pain when getting in and out
of chairs. Physical examination showed spasm in claimant’s paravertebral
muscles from T-10 to T-12 bilaterally and in her lumbosacral region. Id. at 180.
Claimant had reduced range of motion and positive straight leg raising bilaterally.
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She had deep tendon reflexes of 2/4, with normal strength and a normal gait. Id.
The physician found claimant temporarily totally disabled from her usual
occupation, and recommended that she be evaluated by an orthopedic surgeon. Id.
Claimant was re-examined by Dr. Hastings on January 29, 1997. Although
claimant still had pain in the paravertebral muscles and lumbosacral area
bilaterally, Dr. Hastings did not note any muscle spasm. Id. at 183. Claimant’s
range of motion was limited to twenty-five degrees of flexion, ten degrees of
extension, ten degrees lateral flexion bilaterally, and straight leg raising at thirty
degrees bilaterally. Id. Dr. Hastings rated claimant as having sustained a
permanent partial impairment of thirty-two percent to the whole person. Id. He
recommended that claimant “undergo vocational rehabilitation in order to learn a
more sedentary type of employment.” Id. at 184. Claimant’s workers’
compensation case was closed in April 1997, at which time she received a $9,000
settlement. Id. at 58.
The record also contains the treatment records of claimant’s family
physician, Dr. Carpenter, from 1991 through 1999. Id. at 190-94, 235. Although
Dr. Carpenter’s records show a long history of treating claimant with
antidepressants, sleep aids, and for gynecological needs, there are no references to
claimant’s back and leg condition until November 1998, where a single note
reports that claimant had good days and bad days with her back. Id. at 235.
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Claimant filed her application for benefits in May 1998, alleging she
became unable to work on February 14, 1996, due to bulging discs in her back,
migraine headaches, hypoglycemia, tunnel vision, ulcers, and nervousness.
Claimant’s insured status expired on September 30, 1997.
On August 4, 1998, claimant underwent a mental status examination with
Dr. Mynatt, who diagnosed claimant as having a major depressive episode, which
was moderate and recurring, and unresolved post traumatic stress disorder. Id. at
198. He opined that claimant was functioning at a level of 60, which meant she
either had moderate physical symptoms of depression or moderate difficulty in
social, occupational, or school functioning. See American Psychiatric Assoc.,
Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed. 1994).
On August 15, 1998, claimant was examined by consulting physician
McClimans. Claimant reported headaches; no visual disorders other than those
corrected by glasses; occasional symptoms of a spastic colon, but no ulcers or
other abdominal conditions; weakness and paresthesias in her right leg; and
depression and nervousness. Aplt’s App. at 201-02. Physical examination
showed decreased sensation on the right leg, back pain upon palpitation but no
spasms; slight decrease in lumbar motion, but full range of motion in all
extremities; slight decrease in right leg strength; normal gait; and positive right
leg raising in both the seated and supine positions. Id. at 202-03. Dr. McClimans
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diagnosed claimant with chronic low back pain with radiculopathy of the right
leg, and noted her history of other medical conditions. Id. at 203. His range of
motion evaluation showed that other than a slight restriction in claimant’s back
extension and flexion, she had normal range of motion, and she experienced no
pain during the evaluation. Id. at 204-06.
After claimant’s application was denied at the first and second
administrative levels, family physician Carpenter submitted an evaluation of
claimant’s residual functional capabilities in March 1999. Dr. Carpenter opined
that claimant could not lift more than ten pounds, could only stand and walk for
two hours total out of an eight-hour day, and could stand and walk continuously
for an hour and fifteen minutes. Id. at 233. She opined that claimant could sit
continuously for an hour, for a total of three hours out of the eight-hour day, and
that claimant’s ability to push and pull controls was limited. Id. She also opined
that claimant was limited in her abilities to climb, balance, stoop, kneel, crouch,
crawl, and reach, and that claimant had environmental restrictions. Id. at 234.
Discussion
On April 7, 1999, claimant participated in a hearing before an
administrative law judge (ALJ). Claimant was represented by counsel. On
June 23, 1999, the ALJ issued his decision, finding that claimant was not disabled
before her insured status expired in September 1997, and that she had not become
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disabled thereafter. Although she could not return to her former employment, the
ALJ found that claimant retained the ability to perform sedentary work. The
Appeals Council denied review, making the ALJ’s decision the final
determination of the Commissioner. The district court affirmed.
We review the Commissioner’s decision to determine only whether it is
supported by substantial evidence and whether legal errors occurred. See Qualls
v. Apfel, 206 F.3d 1368, 1371 (10th Cir. 2000). Substantial evidence is that
which “a reasonable mind might accept as adequate to support a conclusion.”
Casias v. Sec’y of Health & Human Servs., 933 F.2d 799, 801 (10th Cir. 1991)
(quotation omitted). We may not reweigh the evidence or substitute our judgment
for that of the agency. Id.Claimant argues that the ALJ erred in not giving controlling weight to
Dr. Carpenter’s opinion of her abilities and that the ALJ’s finding that claimant
could perform sedentary work was contrary to the record. Claimant also argues
that the ALJ erred in concluding that her depression was not a severe impairment.
A treating physician’s opinion is to be given controlling weight when it is
well-supported by clinical evidence and is not inconsistent with the record. See
Watkins v. Barnhart, 350 F.3d 1297, 1300 (10th Cir. 2003). Here, the ALJ
refused to give controlling weight to Dr. Carpenter’s assessment of claimant’s
abilities because it was not supported by clinical evidence and it was contrary to
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the medical record. Noting the limited back treatment provided by Dr. Carpenter
and her cursory treatment notes, the ALJ refused to give any weight to the family
physician’s limitation on claimant’s ability to sit because it was totally
unsupported by any clinical findings and was contrary to the record, including
Dr. Carpenter’s own notes. Aplt’s App. at 22. As the ALJ considered the
appropriate factors and gave specific, legitimate reasons for rejecting
Dr. Carpenter’s opinion, no legal error occurred. See id. at 1301. Moreover, the
ALJ’s conclusion that claimant can perform sedentary work is well-supported by
the findings and opinions of the doctors who treated claimant’s back in 1996 and
1997.
With regard to claimant’s mental condition, the ALJ agreed that claimant
suffered from depression, but found that her depression was not severe enough to
affect her ability to work. This finding was based on the opinion of agency
medical consultants who reviewed claimant’s file. To support his finding that
claimant’s depression was not severe, the ALJ noted her lack of treatment with a
mental health professional; her activities showing that she had the ability to
interact with others and to concentrate and stay on task; and the absence of
episodes of decompensation. See Aplt’s App. at 23-24. The ALJ rejected
consulting psychiatrist Mynatt’s opinion based on the paucity of his underlying
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findings. Id. at 23. Because the ALJ’s factual finding regarding the severity of
claimant’s depression is supported by substantial evidence, it must be affirmed.
The judgment of the district court is AFFIRMED.
Entered for the Court
Bobby R. Baldock
Circuit Judge
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