Opinion ID: 808708
Heading Depth: 2
Heading Rank: 2

Heading: Failure to seek treatment

Text: In assessing Ms. Keyes-Zachary’s pain complaint, the ALJ said that she received no medical treatment between September 28, 2005, and April 27, 2006. Medical records submitted with her prior appeal to the Appeals Council, however, show that she was treated by Dr. Sharon Little on November 9, 2005, at which time Dr. Little prescribed medications and ordered an x-ray of her left knee. She also had blood work done at a tribal clinic in December 2005. It appears that these records were available to the ALJ, because they were submitted to the Appeals Council on April 12, 2007, and the ALJ did not hold a hearing or reach his decision until 2009. The ALJ’s ignoring the tribal blood work was not reversible error, because the treatment did not relate to her complaint of disabling pain, which is the issue here. As for the visit with Dr. Little, however, although it primarily involved a sinus complaint, Ms. Keyes-Zachary also mentioned her left knee pain and back pain during the appointment. To treat these conditions, Dr. Little refilled her prescription of Lortab and ordered an x-ray of her left knee. Id. at 325. Nevertheless, the ALJ’s error concerning this visit did not harm Ms. Keyes-Zachary. The ALJ’s decision discussed generally Ms. Keyes-Zachary’s use of Lortab, which her physicians did not approve for long-term use. The left knee x-ray Dr. Little ordered during the November 2005 visit turned out to be negative “except for a questionable - 19 - suprapatellar joint effusion.” Aplt. App., Vol. 2 at 270. The ALJ discussed this x-ray record, noting its generally negative findings, but incorrectly stating that the x-ray dated from November of 2006 rather than November 2005. Thus, it appears that the ALJ’s error was in chronology, not the substance of the visit. In our view, the error in stating that Ms. Keyes-Zachary failed to pursue medical treatment between September 2005 and April 2006 could not have had a substantial effect on the ALJ’s assessment of the credibility of her complaint of disabling pain. Ms. Keyes-Zachary also complains that the ALJ wrongfully noted her failure to undergo surgery as a factor in discounting her credibility. She argues that “[s]urgery is not required for an individual to be credible.” Aplt. Br. at 25. She cites an unpublished case, Cook v. Apfel, No. 99-6000, 1999 WL 626166, at  (10th Cir. Aug. 18, 1999), in which the claimant had failed to have surgery to remove her leaking breast implants. In that case, however, the claimant’s doctors had recommended such surgery, and there was evidence that the claimant could not afford the surgery. Here, by contrast, the ALJ noted that “when questioned, [Ms. Keyes-Zachary] admitted she underwent no surgery and stated ‘none has been recommended on the shoulder.’” Aplt. App., Vol. 3 at 470 (emphasis added). He also noted that she had not undergone any surgery on her neck or back. The lack of surgery appears to have been used to discount the severity of the impairments, which is a legitimate consideration for the ALJ’s analysis. Accordingly, the argument lacks merit. - 20 - C. ALJ’s discussion of credible and incredible testimony Ms. Keyes-Zachary complains that the ALJ did not adequately analyze or discuss her hearing testimony. In particular, although he found her testimony credible only to the extent that she could perform a narrowed range of light work, he allegedly failed to explain which portions of the testimony he believed and which portions he found not credible. See Hayden v. Barnhart, 374 F.3d 986, 992 (10th Cir. 2004) (noting ALJ’s failure to “specify what testimony he found not to be credible”). In a related claim of error, she complains that the ALJ “stated that he did not discount all of her complaints, but failed to explain which complaints he did not discount.” Aplt. Br. at 23. These arguments fail to demonstrate reversible error. True, the ALJ did not explicitly state “I find this statement credible” or “I find this statement not credible” for each factual assertion made by Ms. Keyes-Zachary. Instead, he listed many of her specific factual assertions, often following them by a qualifying statement to indicate where he believed her testimony was contradicted or limited by other evidence in the record. A few of these instances will suffice to illustrate the ALJ’s approach: At the time of the hearing, the claimant testified she last worked in December 2001 at American Fiber. However, the claimant then testified she worked from January 2002 through March 2002, as a stocker at a liquor store. [T]he claimant stated when injured, she “hit the cement floor with her shoulder,” which then jammed “everything up.” However, when - 21 - questioned further, the claimant admitted she underwent no surgery and stated “none has been recommended on the shoulder.” The claimant . . . stated she suffers from cardiovascular pulmonary spasms. However, the claimant admitted she has no physical restrictions as related to her heart, stating she “mainly just watches the medications.” [T]he claimant also reported she suffers from headaches “every day,” stating she sometimes wakes up with a headache. However, the claimant then stated she can sometimes “get rid of it” with aspirin. The claimant also reported pain in her lower back and her neck, stating she has spasms in her neck. However, once again, the claimant reported she has not undergone any surgery on her neck or back. Aplt. App., Vol. 3 at 469-70 (emphasis added). Thus, although the ALJ may not have identified any specific incredible statements as part of his evaluation of Ms. Keyes-Zachary’s hearing testimony, his approach performed the essential function of a credibility analysis by indicating to what extent he credited what she said when determining the limiting effect of her symptoms. See Luna, 834 F.2d at 165-66 (identifying specific factors to be considered in determining whether claimant’s testimony concerning effect of symptoms is credible). This approach also supports his ultimate conclusion that Ms. Keyes-Zachary’s statements concerning her symptoms’ intensity, persistence, and limiting effects were not fully credible to the extent that they were inconsistent with his RFC assessment. - 22 - D. Citation to “other reasons” and “other factors” In his conclusions concerning Ms. Keyes-Zachary’s credibility, the ALJ stated: [E]ven if the claimant’s daily activities are truly as limited as alleged, it is difficult to attribute that degree of limitation to the claimant’s medical condition, as opposed to other reasons, in view of the relatively weak medical evidence and other factors discussed in this decision. Overall, the claimant’s reported limited daily activities are considered to be outweighed by the other factors discussed in this decision. Aplt. App., Vol. 3 at 476 (emphasis added). Such conclusory analysis, which neither reveals what “other reasons” or “other factors” prompted the ALJ’s conclusions, nor is tethered to specific evidence, constitutes the type of disfavored boilerplate this court rejected in Hardman, 362 F.3d at 678-79 (in assessing a claimant’s credibility, “the use of standard boilerplate language will not suffice” (internal brackets and quotation marks omitted)). But use of such boilerplate is problematic only when it appears “in the absence of a more thorough analysis.” Id. at 679. In this case, the ALJ’s decision referred to specific evidence in support of its conclusions. As noted earlier, the ALJ discussed Ms. Keyes-Zachary’s testimony and described certain limitations and qualifications regarding her statements about her symptoms. In addition, he analyzed the medical evidence in some detail, including records that showed:  As of December 1, 2002, she had only a small amount of effusion present in her right knee; a negative straight leg raise; and only mild degenerative changes in her right knee with a possible meniscus tear; - 23 -  An examination on November 18, 2003, revealed “mild cervical strain type symptoms”;  Her physical therapy in 2004 resulted in progress with increased range of motion;  An MRI of the thoracic spine on September 22, 2004, was entirely normal;  X-rays taken February 10, 2005, of her lumbar spine revealed only mild degenerative changes; and  X-rays on January 10, 2007 of the cervical spine, were negative, and those of the lumbar spine revealed only mild degenerative changes. The ALJ also detailed many other medical observations reflecting only limited impairment. Thus, the ALJ did not merely rely on boilerplate language in explaining his conclusions. In this context, use of language referring to “other reasons” or “other factors” does not constitute reversible error. E. Persistence of pain complaints and use of medication Ms. Keyes-Zachary complains that the ALJ ignored the consistency and sheer quantity of her complaints to her physicians about pain, and failed to evaluate the evidence that her doctors frequently prescribed her medications for her pain. But this argument about consistency fails to consider that the ALJ rejected her complaint of disabling pain because of lack of intensity, not lack of persistence. See Aplt. App. at 475-76 (“The Administrative Law Judge does not discount all of the claimant’s complaints [of pain]. However, an individual does not have to be entirely pain free - 24 - in order to have the residual functional capacity to engage in substantial gainful activity.”). Concerning Ms. Keyes-Zachary’s use of medication, the ALJ stated, “The record also indicates the claimant has been prescribed and has taken appropriate medications for her alleged impairments, which weighs in the claimant’s favor, but the medical reports reveal that the medications have been relatively effective, when taken as prescribed.” Id. at 476. Thus, the ALJ did credit her with ongoing use of medication to relieve her symptoms. F. Evaluation of knee and back impairments The ALJ noted that when examined on December 1, 2002, Ms. Keyes-Zachary was observed to have only “a small amount of effusion present” in her right knee. Id. Vol. 3 at 471. Ms. Keyes-Zachary asserts that “a small effusion and even mild degenerative changes on an x-ray are still objective medical evidence of abnormalities supporting [her] credibility.” Aplt. Br. at 27-28. She also argues that “[l]ater knee x-rays demonstrated an effusion to still be questionably present.” Id. at 28. Ms. Keyes-Zachary has accurately summarized the later x-ray results: they state “[t]here is questionable evidence of a suprapatellar joint effusion.” Aplt. App., Vol. 2 at 270 (emphasis added). The problem with this argument is that the ALJ never said that he was discounting her knee problems altogether based on these two x-ray results. She fails to show that any discounting of these problems based on the - 25 - mostly negative x-rays represented a mischaracterization or misuse of the medical evidence. Ms. Keyes-Zachary also complains that the ALJ improperly discounted a second set of knee x-rays. In September 2006 a radiologist x-rayed both her knees and reported: Degenerative changes are seen bilaterally. There is medial compartment narrowing also seen bilaterally. There is incomplete fusion of the tibial epiphysis bilaterally. RIGHT KNEE: No fracture or dislocation is evident. No joint effusion is seen. A small superior patellar osteophyte is noted. Enthesophyte is seen involving the inferior portion of the patella. A small bone island is noted in the proximal tibia. LEFT KNEE: A small superior patellar osteophyte is identified. An enthesophyte involves the superior portion of the patella. Id. at 286. The ALJ characterized these x-rays as follows: “There was no significant pathology revealed in either knee.” Id., Vol. 3 at 475. Citing medical-dictionary definitions of the terms used by the radiologist, Ms. Keyes-Zachary complains that the ALJ’s conclusion ignores that there is “significant pathology present on [her] x-rays to explain her pain.” Aplt. Br. at 28. As the ALJ noted, however, these x-rays were taken in connection with a consultative examination performed by Dr. Reddy. Dr. Reddy’s medical-source statement said that while Ms. Keyes-Zachary had tenderness over her patella, she demonstrated normal walking in his office and was capable of sitting, standing, or - 26 - walking for eight hours at a time. In light of these medical opinions, the ALJ’s conclusion that the pathology revealed on the x-rays was “not significant” from a medical standpoint is supported by substantial evidence. Ms. Keyes-Zachary next complains of the ALJ’s commentary about her back problems. She lists some observations by the ALJ about certain medical evidence, along with some later medical records that showed what she characterizes as degenerative changes in her spine. She concludes that “the progression of degenerative changes again supports a worsening of her condition which supports her credibility, not detracts from it.” Id. at 29. Ms. Keyes-Zachary identifies no specific statement to the contrary by the ALJ. We discern no reversible error. G. ALJ’s discussion of activities of daily living Ms. Keyes-Zachary begins this argument by listing her ADLs, and noting that none of them preclude her from disability. The ALJ also listed her ADLs, but he did not specifically rely on her ability to do them to conclude that she could perform substantial gainful activity. Instead, he found he could not put much weight on her limited ADLs because the limitations to which she testified could not be factually verified, and she had failed to show that her limited ADLs were due to her alleged impairments. He also commented that “the restrictions [on her ADLs] appear to be self-imposed.” Id. at 475. Ms. Keyes-Zachary takes issue with this last conclusion. She contends that the ALJ engaged in “rank speculation,” Aplt. Br. at 31, in determining that her - 27 - limitations were self-imposed. She argues that the evidence shows that her limited ADLs are due to her impairments rather than her own choice to limit her daily activities. The ALJ, however, was free to resolve evidentiary conflicts because there is substantial evidence to support his conclusion. Ms. Keyes-Zachary also complains that the ALJ failed to identify any evidence to support his conclusion that the limitations in her daily activities are “not consistent” with the medical and nonmedical evidence. Aplt. App., Vol. 3 at 475-76. It is true that the ALJ should link his findings closely with the evidence and avoid making conclusions in the guise of findings. See Hackett v. Barnhart, 395 F.3d 1168, 1173 (10th Cir. 2005) (“[An ALJ’s] findings as to credibility should be closely and affirmatively linked to substantial evidence and not just a conclusion in the guise of findings.” (internal quotation marks omitted)). Here, however, the ALJ’s findings were closely enough linked to the evidence to pass muster. H. ALJ’s discussion of past relevant work The ALJ stated: “While the claimant testified that she had been in specialeducation classes for reading and spelling, some of her successful past relevant work was semi-skilled and skilled work activity based on vocational expert testimony.” Aplt. App., Vol. 4 at 475. Ms. Keyes-Zachary complains that the medical evidence shows that she had a low intelligence quotient (IQ), with a full scale score authenticated at 84, in the borderline mental retardation range. But this in no way detracts from the ALJ’s point, which is that she was actually performing semi-skilled - 28 - and skilled work in the past. This is true regardless of what her measured IQ happened to be. The disability inquiry has to do with what kind of substantial gainful work the claimant can do, not just with her numerical scores. Ms. Keyes-Zachary also asserts that the ALJ’s finding that she could not return to her past relevant work (PRW) was inconsistent with his use of that same past relevant work to show that her low IQ was not a problem. This assumes that the ALJ thought that the reason she could not go back to work was her low IQ. In his decision, however, the ALJ stated that Ms. Keyes-Zachary could not return to her PRW because (according to the vocational expert who testified at the hearing), her PRW was inconsistent with her RFC. Her RFC, as detailed in the ALJ’s decision, contains both mental and physical limitations. It is clear from the VE’s testimony, however, that her PRW was eliminated because of the physical requirements of the RFC, not her mental abilities. Therefore, there is no merit to her argument that her inability to do her PRW is inconsistent with the ALJ’s findings about her limited IQ.