Opinion ID: 808708
Heading Depth: 1
Heading Rank: 1

Heading: ALJ’s evaluation of medical-source evidence

Text: We begin with Ms. Keyes-Zachary’s argument about the medical-source evidence. The centerpiece of this argument is her contention that the ALJ failed to weigh the medical opinions in the file. It is the ALJ’s duty to give consideration to all the medical opinions in the record. See 20 C.F.R. §§ 404.1527(c), 416.927(c). He must also discuss the weight he assigns to such opinions. See id. §§ 404.1527(e)(2)(ii), 416.927(e)(2)(ii) (“[T]he administrative law judge must explain in the decision the weight given to the opinions of a State agency medical or psychological consultant or other program -4- physician, psychologist, or other medical specialist, as the administrative law judge must do for any opinions from treating sources, nontreating sources, and other nonexamining sources who do not work for us.”). Ms. Keyes-Zachary cites five opinions that allegedly were not weighed: three consulting-examiner reports; a comprehensive mental-health assessment from a mental-health provider; and a mental-status form from a treating physician. But with two minor exceptions, which we will discuss, she does not identify any inconsistencies either among these medical opinions or between the opinions and the ALJ’s RFC. See Howard v. Barnhart, 379 F.3d 945, 947 (10th Cir. 2004) (“When the ALJ does not need to reject or weigh evidence unfavorably in order to determine a claimant’s RFC, the need for express analysis is weakened.”).
The first opinion that Ms. Keyes-Zachary complains was not properly weighed is a psychological evaluation prepared by a consulting psychologist, Dr. Minor W. Gordon, Ph.D. Dr. Gordon concluded that she suffered from dysthymic disorder, mild to moderate; learning disabilities; and mild impairment at Axis IV. He gave her a GAF (Global Assessment of Functioning) score of 65.1 The ALJ discussed Dr. 1 The GAF is a 100-point scale divided into ten numerical ranges, which permits clinicians to assign a single ranged score to a person’s psychological, social, and occupational functioning. See American Psychiatric Ass’n, Diagnostic and Statistical Manual of Mental Disorders 32, 34 (Text Revision 4th ed. 2000). GAF scores are situated along the following “hypothetical continuum of mental health [and] illness”: (continued) -5-  91-100: “Superior functioning in a wide range of activities, life’s problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms.”  81-90: “Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members).”  71-80: “If symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork).”  61-70: “Some mild symptoms (e.g., depressed mood and mild insomnia), OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships.”  51-60: “Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers).”  41-50: “Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job).”  31-40: “Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child beats up younger children, is defiant at home, and is failing at school).”  21-30: “Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends).”  11-20: “Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) OR occasionally fails to maintain minimal personal hygiene (e.g., smears feces) OR gross impairment in communication (e.g., largely incoherent or mute).”  1-10: “Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death.”  0: “Inadequate information.” (continued) -6- Gordon’s report at some length but never explicitly stated whether he found it persuasive or what weight he assigned to it. This alleged error in the ALJ’s decision did not, however, prejudice Ms. Keyes-Zachary, because giving greater weight to Dr. Gordon’s opinion would not have helped her. Dr. Gordon accompanied his report with a mentalmedical-source statement opining that she had “no limitation” or “no significant limitation” in every category relevant to work function. The ALJ noted this lack of limitations in Dr. Gordon’s opinion and developed a mental RFC consistent with Dr. Gordon’s findings in some areas but more favorable to Ms. Keyes-Zachary than Dr. Gordon’s findings in other areas.2 Cf. Allen v. Barnhart, 357 F.3d 1140, 1145 (10th Cir. 2004) (approving harmless-error analysis when “based on material the ALJ did at least consider (just not properly), we could confidently say that no reasonable Id. at 34 (emphasis omitted). 2 Ms. Keyes-Zachary’s reply brief argues that in his mental-medical-source statement Dr. Gordon actually found her less mentally restricted in the areas of activities of daily living, social functioning, and concentration, persistence and pace than the ALJ did in his decision. She complains that the Commissioner has “failed to explain this inconsistency.” Reply Br. at 7. Ms. Keyes-Zachary does not say how it could possibly benefit her to have the ALJ explain his failure to adopt the more unfavorable portions of Dr. Gordon’s opinion or how his failure to provide such an explanation is even error. See Chapo v. Astrue, 682 F.3d 1285, 1288 (10th Cir. 2012) (“[W]e are aware of no controlling authority holding that the full adverse force of a medical opinion cannot be moderated favorably [toward the claimant] unless the ALJ provides an explanation for extending the claimant such a benefit.”). -7- administrative factfinder, following the correct analysis, could have resolved the factual matter in any other way.”).
Ms. Keyes-Zachary also mentions a physical-consultative-examination report prepared by Dr. Sri K. Reddy. The report itself expresses few conclusions about her physical capacities, but Dr. Reddy’s accompanying physical-medical-source statement opined that Ms. Keyes-Zachary could sit, stand, or walk for eight hours at a time and for eight hours in an eight-hour workday and otherwise found only modest limitations. The ALJ discussed this record but did not expressly weigh it. His RFC, however, is generally consistent with Dr. Reddy’s findings. There is no reason to believe that a further analysis or weighing of this opinion could advance Ms. Keyes-Zachary’s claim of disability. The alleged error is harmless. 3. Therapist Blasdel’s mental-health assessment Next is a mental-health assessment performed by therapist Bob Blasdel. Mr. Blasdel is neither a physician nor a psychologist; his credentials are stated as “MS, LADC, LMFT.” Id. at 823. The ALJ did discuss his report in two paragraphs, but did not provide any analysis from which it can be determined what weight he gave to it. Although Mr. Blasdel is not an “acceptable medical source” such as a medical doctor or a licensed psychologist, see 20 C.F.R. § 404.1513(a), the ALJ was still required to explain the amount of weight he gave to the opinions he expressed: -8- [T]he adjudicator generally should explain the weight given to opinions from these “other sources,” or otherwise ensure that the discussion of the evidence in the determination or decision allows a claimant or subsequent reviewer to follow the adjudicator’s reasoning, when such opinions may have an effect on the outcome of the case. SSR 06-03p, 2006 WL 2329939, at  (Aug. 9, 2006). Most of Mr. Blasdel’s report is a narrative summary of statements by Ms. Keyes-Zachary. These portions of the report do not express any opinions concerning her “symptoms, diagnosis and prognosis, what [she] can still do despite the impairment(s), [or her] physical and mental restrictions.” Id. at . The ALJ was not required to assign a weight to Mr. Blasdel’s narrative of statements relayed to him by Ms. Keyes-Zachary. There are, however, a few statements scattered throughout the report that might be considered “opinions” in the broad sense described by SSR 06-03p. Mr. Blasdel noted, for example, that Ms. Keyes-Zachary’s “intellectual level is estimated to be within the borderline average range” and that her “cognitive abilities are essentially intact.” Aplt. App., Vol. 5 at 818. He stated that her “clinical presentation includes moderately severe depression with an element of increased anxiety” and he estimated her readiness for change as “fair.” Id. He opined that “it is very much possible that she has some learning/processing deficits,” id. at 822, and noted “[p]otential negative factors” that might affect her therapy including “a multitude of psychiatric issues” and “very poor coping skills,” id. at 823. He also made some passing common-sense observations, noting that Ms. Keyes-Zachary’s -9- “aggressive behavior could be considered quite risky,” id. at 819, and that “[s]he could probably benefit from additional positive social interaction,” id. at 821. None of these observations, however, offers an assessment of the effect of Ms. KeyesZachary’s mental limitations on her ability to work. The file includes much more directly relevant evidence on these issues from acceptable medical sources. The ALJ’s failure to assign a specific weight to Mr. Blasdel’s observations therefore did not represent harmful error. Of more concern was Mr. Blasdel’s assignment to Ms. Keyes-Zachary of a current GAF score of 46, and a highest GAF score in the previous year of 50. The vocational expert (VE) testified that scores in this range would eliminate all jobs because a person with these GAF scores cannot maintain a job. This low GAF score is inconsistent with other GAF evidence in the record, and the ALJ did not explain how he weighed the conflicting GAF evidence. But this lack of comparative analysis and weighing does not require reversal. In the case of a nonacceptable medical source like Mr. Blasdel, the ALJ’s decision is sufficient if it permits us to “follow the adjudicator’s reasoning.” SSR 06-03p, 2006 WL 2329939, at . Particularly given the VE’s testimony on the GAF-score issue, it is obvious that the ALJ gave little or no weight to Mr. Blasdel’s GAF opinion. Simply put, had he assigned great weight to the low GAF score, he would not have developed the mental RFC for Ms. Keyes-Zachary that he did. - 10 - We further note that Ms. Keyes-Zachary fails to show that the ALJ erred by rejecting or assigning only modest weight to Mr. Blasdel’s low GAF score in light of the other GAF evidence in the record. Dr. Gordon’s report, assigning Ms. Keyes-Zachary a GAF score of 65, was prepared by an “acceptable medical source” and hence qualified as a medical opinion, while the GAF score of 45, assessed by a counselor, was not. See 20 C.F.R. §§ 404.1513(a), 416.913(a). This alone justifies reliance on Dr. Gordon’s higher GAF score. See SSR 06–03p, 2006 WL 2329939, at  (“The fact that a medical opinion is from an acceptable medical source is a factor that may justify giving that opinion greater weight than an opinion from a medical source who is not an acceptable medical source because . . . acceptable medical sources are the most qualified health care professionals.” (internal quotation marks omitted)). In sum, we discern no harmful error here. 4. Dr. Crall’s disability examination Stephanie C. Crall, Ph.D., conducted a disability examination of Ms. Keyes-Zachary on December 19, 2008. The ALJ mentioned her evaluation, noting that Dr. Crall had found Ms. Keyes-Zachary to be suffering from “major depressive disorder, moderate, chronic and anxiety disorder.” Id., Vol. 3 at 474. He did not state what weight he assigned to the opinion. Dr. Crall’s most specific opinion concerning Ms. Keyes-Zachary’s mental RFC was as follows: - 11 - In the opinion of this evaluator, her ability to engage in work-related mental activities, such as sustaining attention, understanding, and remembering and to persist at such activities was likely adequate for simple and some complex tasks. Functional limitations appeared more likely due to physical rather than mental impairments. Id., Vol. 5 at 838. These specific limitations that Dr. Crall assigned to Ms. Keyes-Zachary were not inconsistent with the limitations the ALJ placed in her RFC. See id., Vol. 3 at 469 (limiting Ms. Keyes-Zachary to “simple, repetitive and routine tasks” and slightly limiting her “contact with the general public, co-workers and supervisors”). Any error in failing to specify the weight given to the opinion was harmless. 5. The Mental-Status Form Finally, Ms. Keyes-Zachary points to a mental-status form completed on March 30, 2009, diagnosing her with major depression (recurrent moderately) and generalized anxiety. It is unclear who completed this one-page form, which is signed only with a sideways “S.” Ms. Keyes-Zachary asserts without discussion that it was prepared by an unspecified treating physician. Although the person who completed the form attributed a number of mental limitations to Ms. Keyes-Zachary, the only specific work-related limitation is not inconsistent with the ALJ’s RFC. The form states that she can “remember, comprehend and carry out (simple) (complex) instructions on an independent basis.” Aplt. App., Vol. 5 at 908. We discern no harmful error in the ALJ’s failure to specify the weight he accorded to this opinion. - 12 - B. ALJ’s alleged failure to consider medical evidence The ALJ found that Ms. Keyes-Zachary’s medical evidence contained “few objective findings that would substantiate the level of pain that she alleges,” and that the record also failed “to demonstrate the presence of any pathological clinical signs, significant medical findings, or any neurological abnormalities that would establish the existence of a pattern of pain of such severity as to prevent her from engaging in any work on a sustained basis.” Id., Vol. 3 at 474. Ms. Keyes-Zachary contends that in reaching these conclusions, the ALJ mischaracterized or inadequately considered certain medical evidence.3 The regulations require the ALJ to “consider all evidence in [the] case record when [he] make[s] a determination or decision whether [claimant is] disabled.” 20 C.F.R. § 404.1520(a)(3). He may not “pick and choose among medical reports, using portions of evidence favorable to his position while ignoring other evidence.” Hardman v. Barnhart, 362 F.3d 676, 681 (10th Cir. 2004). Ms. Keyes-Zachary notes that Dr. Gary R. Lee, a physical consultative examiner (“CE”) who saw her in November 2004, determined that she had “decreased, painful ROM [range of motion] with tenderness of the spine.” Although Dr. Lee did make such findings, this decreased or painful range of motion was 3 Because of the heading under which this argument appears in Ms. KeyesZachary’s brief, we view the argument as an assertion that the ALJ’s findings concerning the state of the medical record are unsupported by substantial evidence, rather than as part of a more general attack on his conclusions concerning Ms. KeyesZachary’s credibility, which are the subject of her second issue, discussed infra. - 13 - consistent with the ALJ’s conclusion that she is able to do a limited range of light work. Dr. Lee noted that she could extend her back 20◦ out of an expected 25 and could flex it 70◦ out of an expected 90; that she could laterally flex her back 20◦ on both left and right out of an expected 25; that she could extend her neck by 30◦ out of an expected 60, and flex her neck by 40◦ out of an expected 50; and that she had a right extension value for her elbow of negative 5◦, while the expected value was 0. Otherwise, all his ROM findings were normal. Ms. Keyes-Zachary next cites examination results from Dr. Sri K. Reddy, the CE who examined her in September 2006. These results do not support her attack on the ALJ’s findings. Dr. Reddy found that she had “functional” ROM in various joints, but also noted that she had tenderness in the spine and knees and some reduced sensation in her feet. Id. She appears to believe that these exam results support her argument about significantly limiting pain. (We note that Ms. KeyesZachary simultaneously attacks Dr. Reddy for failing to measure and report ROMs specifically and instead simply concluding that they were “functional”; she does not, however, cite any authority requiring a consultative examiner to report specific ROM values.) But despite his findings concerning tenderness and reduced sensation, Dr. Reddy opined that Ms. Keyes-Zachary could sit, stand, and walk for up to eight hours at a time in an eight-hour day, and could frequently lift up to 25 pounds and frequently carry 20 pounds. - 14 - Neither Dr. Lee’s nor Dr. Reddy’s examination undermines the ALJ’s conclusions concerning the severity of Ms. Keyes-Zachary’s physical impairments. To the extent that she raises additional issues involving the ALJ’s evaluation of the medical evidence, her arguments lack merit or are insufficiently developed for our review. In sum, we reject Ms. Keyes-Zachary’s contention that the ALJ’s opinion does not adequately evaluate and discuss the medical-source evidence. Where, as here, we can follow the adjudicator’s reasoning in conducting our review, and can determine that correct legal standards have been applied, merely technical omissions in the ALJ’s reasoning do not dictate reversal. In conducting our review, we should, indeed must, exercise common sense. The more comprehensive the ALJ’s explanation, the easier our task; but we cannot insist on technical perfection.