Opinion ID: 168285
Heading Depth: 3
Heading Rank: 2

Heading: Traumatic Origin Provisions of SSR 83-20

Text: M r. Blea contends that his disabilities are of traumatic origin under SSR 83-20, and therefore the onset date should be the date he was shot in the foot - June 1997. The A LJ, without explicit consideration of SSR 83-20, did not use this date, finding that “M r. Blea’s [gunshot] wound initially heeled [sic] well and he displayed minimal pain in the foot.” Aplt’s App. vol. I at 21. On appeal, M r. Blea renews his argument that the ALJ’s implicit decision that his disability was not of traumatic origin was unsupported by the medical evidence and contrary to SSR 83-20. He states that “[t]he twelve month requirement under SSR 83-20 was met when, according to the evidence, claimant’s disabling post-traumatic arthritis had developed as a result of his injury of June 1997 and had presented itself by the following year in June 1998.” Aplt’s Br. at 10. The government responds that the medical evidence available 1 At oral argument, the attorney representing the Commissioner contended that SSR 83-20 did not apply to M r. Blea’s case because the plain wording of SSR 83-20 stated that a medical advisor w as only required if the onset of a disability occurred prior to the date of the first recorded medical examination. As the Commissioner is well aware, we do not generally address arguments made for the first time at oral argument. United States v. Gonzalez-Coronado, 419 F.3d 1090, 1094 n.7 (10th Cir. 2005). W e further note, however, that this argument misconstrues SSR 83-20, which, as we explain above, requires the assistance of a medical advisor w henever “onset” must be inferred. 13 from June 1997 to June 1998 shows that M r. Blea had been steadily improving and could ambulate effectively; thus, the ALJ correctly decided that the onset date of M r. B lea’s impairments did not correspond to the gunshot injury. W e begin our analysis of M r. Blea’s argument by noting that SSR 83-20 and our precedent do not require an ALJ to consult with a medical advisor to determine whether a disability is of traumatic origin. W e have previously held that “a medical advisor need be called only if the medical evidence of onset is ambiguous.” Reid v. Chater, 71 F.3d 372, 374 (10th Cir. 1995). If a disability is of traumatic origin, the onset date would not be ambiguous; indeed, it would most often be “self-evident.” M ason v. Apfel, 2 F. Supp. 2d 142, 149 (D . M ass. 1998). Thus, our task at this point is to determine if the A LJ’s decision that M r. Blea’s onset date was not the date of the gunshot injury comported with the traumaticinjury provisions of SSR 83-20 and was supported by substantial evidence. M r. Blea asserts that symptoms of his post-traumatic arthritis presented sometime in the twelve months after the gunshot injury, but he does not cite any part of the record that supports this assertion, even though the record contains ample medical evidence for the time period June 1997 to June 1998. Our review of the record shows that at the time of the gunshot wound, and during the healing process thereafter, there were no indications that M r. Blea was “expected to be unable to engage in substantial gainful activity . . . for a continuous period of at least 12 months” due to post-traumatic arthritis or dysthymia. SSR 83-20, at 2. 14 Although M r. Blea still suffered from pain, by January 1998, seven months after the injury, he was “able to ambulate with minimal restrictions.” Aplt’s App. vol. I at 161. In M arch 1998, he sought the advice of a foot and ankle specialist, who prescribed a new orthotic to assist M r. Blea in w alking. The specialist’s notes state that, besides some numbness, M r. Blea was “doing well and is not interested in any further surgery.” Id. at 156. Finally, a doctor’s notes from June 1998 indicate that M r. Blea had “no pain proximally where he had the previous bone graft,” supporting the ALJ’s conclusion that M r. Blea was not exhibiting symptoms of post-traumatic arthritis at that visit. Id. at 154. Therefore, we conclude that the ALJ’s decision not to use the date of the gunshot as the onset date did not conflict with SSR 83–20, and that it was supported by substantial evidence. 3. Provisions of SSR 83-20 Relating to Slowly Progressing Impairments The issue of whether M r. Blea’s disabilities are slowly progressive impairments, where “[d]etermining the proper onset date is particularly difficult,” SSR 83-20 at 3, is a much closer question. M r. Blea contends that even if the provisions of SSR 83-20 relating to traumatic origin do not apply to this case, the ALJ erred by failing to call a medical advisor to assist in setting an onset date. The Commissioner replies that the ALJ was not obligated to consult with a medical advisor because there was substantial evidence to conclude, at step five of the five-step sequential analysis, that M r. Blea retained the capacity to perform 15 sedentary work. W e begin by rejecting the Commissioner’s position because it fails to address the crux of the issue. The ALJ’s finding of residual functional capacity at step five does not mean that the ALJ can ignore the clear directives of SSR 83-20, which is “binding on all components of the Social Security Administration.” 20 C.F.R. § 402.35(b)(1). It is important to understand that the issue of whether a medical advisor is required under SSR 83-20 does not turn on whether the ALJ could reasonably have determined that [the claimant] was not disabled before [her last insured date]. Rather, when there is no contemporaneous medical documentation, we ask whether the evidence is ambiguous regarding the possibility that the onset of her disability occurred before the expiration of her insured status. If the medical evidence is ambiguous and a retroactive inference is necessary, SSR 83-20 requires the ALJ to call upon the services of a medical advisor to insure that the determination of onset is based upon a “legitimate medical basis.” Grebenick v. Chater, 121 F.3d 1193, 1200-1201 (8th Cir. 1997). Additionally, we note that when an onset date is ambiguous, it is not usually possible for an ALJ to make a decision that is supported by substantial evidence. Finally, the Commissioner’s position ignores the possibility that a medical advisor’s assistance could change the ALJ’s determination at step three (the listed impairment step) of the five-step inquiry, thereby obviating any need to examine residual functional capacity at step five. In contrast to the Commissioner’s argument, our precedent clearly establishes that where “medical evidence of onset is ambiguous,” an ALJ is 16 obligated to call upon the services of a medical advisor. Reid v. Chater, 71 F.3d 372, 374 (10th Cir. 1995); see also Grebenick, 121 F.3d at 1201 (“If the medical evidence is ambiguous, and a retroactive inference is necessary, SSR 83-20 requires the ALJ to call upon the services of a medical advisor to insure that the determination of onset is based upon a ‘legitimate medical basis.’”); see also Bailey v. Chater, 68 F.3d 75, 79 (4th Cir. 1995) (“[I]f the evidence of onset is ambiguous, the ALJ must procure the assistance of a medical advisor in order to render the informed judgment that the Ruling requires.”). Proceedings before an ALJ are not inquisitorial; rather, “[a]n ALJ [has] a duty to develop a full and fair record, and therefore must consult a medical advisor” when evidence of onset is ambiguous. See Henderson v. Apfel, 179 F.3d 507, 513 (7th Cir. 1999) (internal quotation marks omitted). “In the absence of clear evidence documenting the progression of [the claimant’s] condition, the ALJ [does] not have the discretion to forgo consultation with a medical advisor.” Bailey, 68 F.3d at 79. Thus, the issue of whether the ALJ erred by failing to call a medical advisor turns on whether the evidence concerning the onset of M r. Blea’s disabilities was ambiguous, or alternatively, whether the medical evidence clearly documented the progression of his conditions. Below, we examine the medical record w ith respect to both of M r. Blea’s disabilities. W e conclude that M r. Blea’s medical record was ambiguous, did not clearly document the progression of his impairments, and presented a situation where the ALJ needed to infer an 17 onset date both for M r. Blea’s dysthymia and post-traumatic arthritis. Therefore, we remand this case to the ALJ with instructions to follow the provisions of SSR 83-20 and call a medical advisor. 2
The ALJ found that M r. Blea did not prove he suffered from post-traumatic arthritis prior to December 31, 1998, relying primarily on three inferences he made from the medical evidence in the record. First, at a M arch 1998 visit with a specialist, M r. Blea indicated that he was not interested in further surgery. “It is reasonable to infer then, that he was at least partially satisfied with the result of the surgery he had before.” Aplt’s App. vol. I, at 22. Second, with respect to M r. Blea’s June 1998 visit to a doctor for treatment after stubbing his toe while carrying his child, the ALJ determined that “it is apparent that at that time, he was able to ambulate effectively enough to feel comfortable carrying his baby.” Id. 2 W e need not scrutinize M r. Blea’s ancillary argument that the Appeals Council erred by not analyzing new evidence from one of M r. Blea’s treating physicians. In denying review of the ALJ’s decision, the Appeals Council stated “we considered the additional evidence listed. . . . W e found that this information does not provide a basis for changing the Administrative Law Judge’s decision.” Aplt’s App. vol. I at 6-7. The Social Security Administration’s regulations “require[] the Appeals Council to consider evidence submitted with a request for review.” Threet v. Barnhart, 353 F.3d 1185, 1191 (10th Cir. 2003). However, where as here, the Appeals Council states that it has considered the additional evidence, “our general practice, which we see no reason to depart from here, is to take a lower tribunal at its word when it declares that it has considered a matter.” Hackett v. Barnhart, 395 F.3d 1168, 1173 (10th Cir. 2005). Because we remand this case to the ALJ, we need not determine whether the medical evidence here is so strong as to require a change in our general practice. 18 Third, with respect to the gap in medical evidence from June 1998 to January 2000, the A LJ stated that “[i]t stands to reason that if the claimant’s pain w as so severe as to be completely debilitating as alleged, he would have sought medical attention throughout this period.” Id. These inferences are not reasonable because they do not necessarily flow from the facts. First, it is equally reasonable to think that M r. Blea declined further surgery because he did not wish to endure another painful process–an eighth surgery–as it is to think that he was not interested in surgery because he was fully recovered. Second, although he carried his child, he may have done so out of necessity–not because he was fully recovered. Third, as other evidence suggested, it is also reasonable to infer that the gap in medical treatment occurred, not because M r. Blea felt better, but because he was dysthymic and dependent on alcohol. Thus, we find these inferences insufficient to support the ALJ’s decision in light of the requirements of SSR 83-20. M r. Blea’s medical record is indisputably incomplete during a pertinent time period, June to December 1998. But, rather than “call[ing] on the services of a medical advisor w hen onset must be inferred,” the ALJ made negative inferences against M r. Blea due to the gap in the medical record. SSR 83-20 at 3. An ALJ may not make negative inferences from an ambiguous record; rather, it must call a medical advisor pursuant to SSR 83-20. Reid, 71 F.3d at 374. “The requirement that, in all but the most plain cases, a 19 medical advisor be consulted prior to inferring an onset date is merely a variation on the most pervasive theme in administrative law–that substantial evidence support an agency’s decisions.” Bailey, 68 F.3d at 80. In this regard, we find the Fourth Circuit’s opinion in Bailey v. Chater, 68 F.3d 75, particularly instructive. In Bailey, a claimant had a number of ailments that he acquired over a few years, including diabetes, anxiety, high blood pressure, and allergies. The A LJ had fixed the claimant’s onset date two years after the date on which she had asserted her disability began. The Fourth Circuit reversed and remanded with instructions for the ALJ to call a medical advisor pursuant to SSR 83-20 because the “evidence regarding the onset date is ambiguous. . . . In the absence of clear evidence documenting the progression of [the claimant’s] condition, the ALJ did not have the discretion to forgo consultation with a medical advisor.” Id. at 79. As in Bailey, the ALJ lacked “clear evidence documenting the progression” of M r. Blea’s post-traumatic arthritis. Id. In June 1998, six months before his last-insured date, M r. Blea appeared not to be experiencing a significant amount of pain; however, by January 2000, approximately one year after his last-insured date, M r. Blea exhibited symptoms, including complaints of pain, difficulty walking, and degenerative changes present on x-rays. The condition was advanced enough by February 2000 to permit a treating physician to diagnose him with “significant post-traumatic arthritis.” Aplt’s App. vol. I, at 150. W ith respect 20 to the critical time, June 1998 to December 1998, however, the medical record before the ALJ was silent. Therefore, the ALJ should have called a medical advisor to assist in making reasonable inferences. W e note that on appeal, we have the benefit of a letter from Dr. Schenck, one of M r. Blea’s treating physicians. See O’Dell, 44 F.3d 859 (holding that any new evidence submitted to the Appeals Council on review “becomes part of the administrative record to be considered when evaluating the Secretary’s decision for substantial evidence.”) In this letter, w hich was provided only to the Appeals Council, not to the ALJ, Dr. Schenck opines that “it is reasonable to assume that M r. Blea’s post-traumatic arthritis with constant pain was present between June 1998 and January 2000.” Aplt’s App. vol. I at 309. This letter further undermines the ALJ’s decision because “[a]n ALJ is required to give controlling weight to a treating physician’s well-supported opinion, so long as it is not inconsistent with other substantial evidence in the record.” Drapeau v. M assanari, 255 F.3d 1211, 1213 (10th Cir. 2001). On remand, the A LJ must address Dr. Schenck’s opinion, as it is now part of the medical record.
The ALJ declined to consider M r. Blea’s claim that his dysthymia disabled him as of June 1997, noting: a review of the medical record failed to provide any docum entation of alleged depression or treatment for depression before D r. Padilla’s evaluation of the claimant on August 28, 2002. M r. Blea reported long21 standing depression in that examination interview but the record did not support the claimant’s subjective report. Due to the complete lack of treatment or even the report of depression prior to December 1998, this impairment is not considered prior to the claimant’s date last insured. Aplt’s App. vol. I, at 21. M r. Blea contends that the ALJ’s findings are not supported by substantial evidence because Dr. Padilla’s evaluation specifically noted that M r. Blea had “been dysthymic for years.” Id. at 246. Additionally, he argues that the ALJ should have called a medical advisor to “further address[] the onset of claimant’s depression.” Aplt’s Br. at 16. The Commissioner contends that the ALJ correctly disposed of M r. Blea’s dysthymia claim because M r. Blea failed to provide medical evidence of his depression prior to his last insured date. The Commissioner’s argument and the ALJ’s decision both contradict the clear dictates of SSR 83-20, which specifically provides, as an example of when an ALJ should call a medical advisor, the situation where “the onset of a disabling impairment[] occurred some time prior to the date of the first recorded medical examination.” SSR 83-20 at 3. Additionally, we note that the A LJ’s reasoning is at tension with the C ommissioner’s earlier determination that there was sufficient medical evidence for the Commissioner to determine that, as of at least M arch 1, 2002, M r. Blea’s dysthymia w as a “medically determinable impairment [] that [was] disabling,” a date prior to any treatment or report of depression. Aplt’s App. vol. I, at 18. As we described above, the ALJ “should call on the services of a medical 22 advisor when onset must be inferred.” SSR 83-20, at 3. The ALJ erred by failing to call a medical advisor “in the absence of clear evidence documenting the progression of [the claimant’s] condition.” Bailey, 68 F.3d at 79. Therefore, on remand, the ALJ should apply SSR 83-20 and call a medical advisor with respect to M r. B lea’s claim of dysthymia as well.