Court Opinion

ID: 8406446
Source: CourtListenerOpinion
Date Created: 2022-10-28 15:00:53.550634+00
Date Added: 2024-06-11T16:47:13.612185
License: Public Domain

Appellate Case: 21-4136     Document: 010110760039      Date Filed: 10/28/2022       Page: 1
                                                                                 FILED
                                                                     United States Court of Appeals
                       UNITED STATES COURT OF APPEALS                        Tenth Circuit

                              FOR THE TENTH CIRCUIT                          October 28, 2022
                          _________________________________
                                                                         Christopher M. Wolpert
                                                                             Clerk of Court
  SHIRLEY NIELSEN,

        Plaintiff - Appellant,

  v.                                                         No. 21-4136
                                                    (D.C. No. 2:20-CV-00666-JCB)
  COMMISSIONER, SSA,                                           (D. Utah)

        Defendant - Appellee.
                       _________________________________

                              ORDER AND JUDGMENT*
                          _________________________________

 Before TYMKOVICH, BALDOCK, and CARSON, Circuit Judges.
                  _________________________________

       Shirley Nielsen appeals the district court’s judgment affirming the

 Commissioner’s denial of her application for Supplemental Security Income benefits.

 We have jurisdiction under 28 U.S.C. § 1291 and 42 U.S.C. § 405(g) and affirm.

                                    I. Background

       Ms. Nielsen applied for Supplemental Security Income benefits in January

 2018, asserting disability due to a heart condition, fibromyalgia, migraines, and

       *
         After examining the briefs and appellate record, this panel has determined
 unanimously that oral argument would not materially assist in the determination of
 this appeal. See Fed. R. App. P. 34(a)(2); 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 This order and judgment is not binding
 precedent, except under the doctrines of law of the case, res judicata, and collateral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. It may be cited, however, for its persuasive value consistent with
 Fed. R. App. P. 32.1 and 10th Cir. R. 32.1.
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 anxiety. After her application was denied initially and upon reconsideration,

 Ms. Nielsen had a hearing before an administrative law judge (ALJ). She told the

 ALJ she could sit for 20 minutes, stand for 15 minutes, walk one block, and lift

 10 pounds. She also said her hands cramp up but she has no problem with buttons or

 zippers, she spends two or three days per week in her bedroom due to chronic

 migraines, she does not drive because of anxiety, and she does household chores.

 She further stated she has no side effects from her medications. As for social

 activities, Ms. Nielsen said she goes out with her sisters, goes out to dinner,

 participates in an annual parade, and camps once a year.

       In a written decision, the ALJ followed the five-step sequential evaluation

 process used to review disability claims. See Fischer-Ross v. Barnhart, 431 F.3d

 729, 731 (10th Cir. 2005) (explaining five-step process). Pertinent here, the ALJ

 found Ms. Nielsen has two severe impairments—fibromyalgia and migraine

 headaches—but none of her impairments, alone or in combination, met or medically

 equaled the severity of one of the impairments listed as disabling in the

 Commissioner’s regulations.1 The ALJ then found that although Ms. Nielsen’s

 impairments could reasonably be causing her alleged symptoms, her testimony about

 the intensity, persistence, and limiting effects of those symptoms was not entirely

 consistent with the medical evidence and other evidence in the record. After

       1
         The ALJ found Ms. Nielsen has non-severe hyperlipidemia, hypertension,
 gastroesophageal reflux disease, hypothyroidism, paroxysmal supraventricular
 tachycardia, depression, and anxiety.
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 reviewing the evidence, the ALJ found Ms. Nielsen had the residual functional

 capacity (RFC) to perform the full range of light work.2

       Key to the RFC finding—and central to this appeal—is the ALJ’s rejection of

 the opinions of Ms. Nielsen’s treating physician, Alisa Knowlton, M.D., that

 Ms. Nielsen was so limited in her mental and physical functional abilities that she

 was unable to work at all.3 Dr. Knowlton rendered her opinions on check-box RFC

 forms—one form in January 2018 assessing physical capacity, and two forms in

 August 2018 assessing physical and mental capacity. The ALJ found Dr. Knowlton’s

 opinions unpersuasive for multiple reasons: (1) “Dr. Knowlton provided little

 support, explanation, or rationale for her opinions”; (2) the opinions “contain[ed]

 multiple internal inconsistencies”; (3) they were “not supported by her treatment

 notes”; (4) they “appear[ed] to be based entirely on [Ms. Nielsen’s] subjective

 complaints”; (5) they were “inconsistent with the objective results” of two

 “consultative examination[s]” showing normal physical and mental abilities except

 for “mildly impaired memory and concentration”; and (6) they were “inconsistent

       2
         Light work includes the ability to lift and carry ten pounds frequently and
 twenty pounds occasionally, and to stand and walk, off and on, for about six hours in
 an eight-hour workday or sit most of the time with pushing and pulling of arm-hand
 or leg-foot controls. See 20 C.F.R. § 416.967(b) (explaining the physical
 requirements for light work); SSR 83-10, 1983 WL 31251, at *5-6 (1983) (same).
       3
         We need not recount all of Dr. Knowlton’s RFC opinions, but they were
 inconsistent with light work in many regards, including (at their most restrictive) that
 Ms. Nielsen could sit, stand, and walk less than 2 hours in an 8-hour workday; could
 never carry more than 10 pounds; had significant limitations in reaching, handling,
 and fingering; and would need unscheduled breaks every 30 minutes.
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 with the persuasive prior administrative medical findings.” Aplt. App., Vol. 1 at 49.

 The ALJ instead found partly or fully persuasive other medical opinions and prior

 administrative medical findings that were consistent with Ms. Nielsen’s ability to

 perform the full range of light work. Accordingly, at step four, the ALJ found

 Ms. Nielsen could return to her past relevant work as a cashier and therefore she was

 not disabled.

       Ms. Nielsen sought review in the district court, which affirmed the

 Commissioner’s decision. She appeals.

                                II. Standard of Review

       “We review the district court’s decision de novo and independently determine

 whether the ALJ’s decision is free from legal error and supported by substantial

 evidence.” Fischer-Ross, 431 F.3d at 731. “Substantial evidence is such relevant

 evidence as a reasonable mind might accept as adequate to support a conclusion.”

 Barnett v. Apfel, 231 F.3d 687, 689 (10th Cir. 2000) (internal quotation marks

 omitted). “[T]he threshold for such evidentiary sufficiency is not high,” but it is

 “more than a mere scintilla.” Biestek v. Berryhill, 139 S. Ct. 1148, 1154 (2019)

 (internal quotation marks omitted). We cannot “reweigh the evidence” or “substitute

 our judgment for that of the agency.” Barnett, 231 F.3d at 689 (internal quotation

 marks omitted).

                                     III. Discussion

       Ms. Nielsen raises one issue on appeal—whether the ALJ evaluated the

 supportability and consistency of the medical opinion evidence in accordance with

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 20 C.F.R. § 416.920c. Under that regulation, which applies to claims like Ms. Nielsen’s

 that were filed on or after March 27, 2017, the ALJ does “not defer or give any specific

 evidentiary weight, including controlling weight, to any medical opinion(s) or prior

 administrative medical finding(s), including those from [the claimant’s] medical

 sources.” § 416.920c(a). Rather, the ALJ considers the persuasiveness of medical

 opinions and prior administrative medical findings using five factors: supportability,

 consistency, relationship with the claimant, specialization, and other factors such as

 “evidence showing a medical source has familiarity with the other evidence in the claim

 or an understanding of [the agency’s] disability program’s policies and evidentiary

 requirements,” § 416.920c(c)(5).

        The most important factors are supportability and consistency. § 416.920c(a).

 “Supportability” examines how closely connected a medical opinion is to the evidence

 and the medical source’s explanations: “The more relevant the objective medical

 evidence and supporting explanations presented by a medical source are to support his or

 her medical opinion(s) or prior administrative medical finding(s), the more persuasive the

 medical opinions or prior administrative medical finding(s) will be.” § 416.920c(c)(1).

 “Consistency,” on the other hand, compares a medical opinion or prior administrative

 medical findings to the evidence: “The more consistent a medical opinion(s) or prior

 administrative medical finding(s) is with the evidence from other medical sources and

 nonmedical sources in the claim, the more persuasive the medical opinion(s) or prior

 administrative medical findings(s) will be.” § 416.920c(c)(2). An ALJ must explain how

 he or she “considered the supportability and consistency factors.” § 416.920c(b)(2). An

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 ALJ must consider factors three through five (relationship with the claimant,

 specialization, and other factors) but is not required to explicitly discuss them unless

 there are differing medical opinions on an issue and those opinions are equally

 well-supported and consistent with the record. See § 416.920c(b)(2), (3).

          Ms. Nielsen contends the ALJ did not adequately explain how Dr. Knowlton’s

 opinions were unsupported by or inconsistent with the record. She advances multiple

 arguments, including whether the ALJ erred in evaluating the opinions of other medical

 sources as part of his inconsistency analysis.

 A.       Supportability

          We begin with an internal inconsistency the ALJ noted in one of Dr. Knowlton’s

 RFC forms—that Ms. Nielsen “can sit at one time” for 30 minutes but also that she

 “must . . . walk” every 15 minutes. Aplt. App., Vol. 4 at 79–80. Ms. Nielsen complains

 this inconsistency merely shows the difference between what she “can do with her

 conditions, and what she should do with her conditions.” Aplt. Opening Br. at 24. We

 are not persuaded. There is an obvious inconsistency between being able to sit for 30

 minutes at a time and a requirement to walk (“must . . . walk”) every 15 minutes, and the

 ALJ properly considered it. If that were the only basis for rejecting Dr. Knowlton’s

 opinions regarding physical RFC, we might agree with Ms. Nielsen that the inconsistency

 should call into question only the sit/walk findings, rather than undermine the

 supportability of all of Dr. Knowlton’s physical RFC opinions. But it was not the only

 basis.

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        Ms. Nielsen takes issue with the ALJ’s findings that Dr. Knowlton’s opinions

 were “not supported by her treatment notes, which show[ed] no objective evidence of

 physical or mental abnormalities,” and were not supported by the course of treatment,

 “which showed no evidence of referrals to specialists, orders for laboratory testing or

 imaging, or more intense treatment regimens beyond conservative medication

 management.” Aplt. App., Vol. 1 at 49. She observes that when a claimant has

 fibromyalgia and objective medical evidence fails to substantiate the claimant’s

 statements about the resulting functional limitations, Social Security Ruling 12-2P,

 2012 WL 3104869 (July 25, 2012) (SSR 12-2P), instructs an ALJ to evaluate the

 supportability of a medical source’s opinion based on the nature of the treatment

 provided. See id. at *5. To that end, she points out that she saw Dr. Knowlton for

 medication checks every few months from January 2017 through October 2018, and on

 each visit Dr. Knowlton prescribed three drugs, including a narcotic, for pain

 management. She also maintains that fibromyalgia is a chronic condition generally

 treated by medications to limit pain and fatigue and points out that we have noted it is

 error to require objective evidence of fibromyalgia because it is “a disease that eludes

 such measurement,” Moore v. Barnhart, 114 F. App’x 983, 992 (10th Cir. 2004) (internal

 quotation marks omitted). We disagree with these arguments for multiple reasons.

        First, the ALJ did not err in relying on the lack of objective findings. SSR 12-2P

 directs that objective evidence is relevant to determining whether medically determinable

 fibromyalgia is disabling: “[B]efore we find that a person with [a medically determinable

 impairment] of [fibromyalgia] is disabled, we must ensure there is sufficient objective

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 evidence to support a finding that the person’s impairment(s) so limits the person’s

 functional abilities that it precludes him or her from performing any substantial gainful

 activity.” 2012 WL 3104869, at *2 (emphasis added).4 Moreover, the portion of

 SSR 12-2P that Ms. Nielsen relies on directs consideration of “all of the evidence in the

 case record”:

        If objective medical evidence does not substantiate the person’s statements
        about the intensity, persistence, and functionally limiting effects of
        symptoms, we consider all of the evidence in the case record, including the
        person’s daily activities, medications or other treatments the person uses, or
        has used, to alleviate symptoms; the nature and frequency of the person’s
        attempts to obtain medical treatment for symptoms; and statements by other
        people about the person’s symptoms.
 Id. at *5 (emphasis added); see also id. at *6 (“We base our RFC assessment on all

 relevant evidence in the case record.” (emphasis added)). “All of the evidence in the case

 record” necessarily includes, as one factor in the analysis, the objective medical evidence

 (Dr. Knowlton’s treatment notes) that failed to substantiate the claimant’s statements

 about what she can do despite her symptoms. It therefore was proper for the ALJ to note

 the lack of objective evidence supporting Dr. Knowlton’s opinions regarding

 Ms. Nielsen’s functional limitations as one of the reasons for rejecting those opinions.

        Second, the ALJ did consider the evidence of Dr. Knowlton’s course of treatment

 in addition to the lack of objective evidence and found that her opinion was “not

 supported by her course of treatment for the claimant.” Aplt. App., Vol. 1 at 49.

        4
         Fibromyalgia “is a complex medical condition characterized primarily by
 widespread pain in the joints, muscles, tendons, or nearby soft tissues that has
 persisted for at least 3 months.” SSR 12-2p, 2012 WL 3104869, at *2.
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 Although Ms. Nielsen cites medications Dr. Knowlton prescribed for pain management,

 the ALJ could reasonably have concluded the prescription of such medications was

 insufficient to support the limitations Dr. Knowlton found, particularly given the lack of

 objective evidence of physical or mental functional limitations.

        Third, Ms. Nielsen’s argument overlooks Dr. Knowlton’s observation that by

 August 2018, she had gotten Ms. Nielsen’s “pain under . . . control,” id., Vol. 4 at 142,

 and that in nearly every treatment note during this period, Dr. Knowlton recorded that

 Ms. Nielsen either “appear[ed] in no acute distress,” id. at 65, or “appear[ed] healthy, in

 no acute distress,” id. at 67, 69, 70, 72, 102, 104, 136. Dr. Knowlton also recorded the

 same observation when she saw Ms. Nielsen to complete the August 2018 RFC forms.

 See id. at 143. The ALJ discussed this evidence and also considered that despite

 complaints “of chronic pain, fatigue, and migraines,” Ms. Nielsen had “been treated on a

 stable dosage of medication,” including “opiod[s],” id., Vol. 1 at 50. And nothing in

 Dr. Knowlton’s treatment notes suggests that the course of treatment supports the

 extreme functional limitations she proposed in the RFC forms.

        Fourth, we are not persuaded by Ms. Nielsen’s reliance on Moore for its statement

 that an ALJ errs by requiring objective evidence of fibromyalgia because it is “a disease

 that eludes [objective] measurement,” 114 F. App’x at 992 (internal quotation marks

 omitted). Moore is unpublished and therefore not precedential, and it also predates

 SSR 12-2P’s directive to consider objective evidence. Moore is further distinguishable

 on its facts because the ALJ there “seemed to require that [fibromyalgia] be established

 by a formalistic clinical or laboratory test.” Id. at 990 (emphasis added) (footnote

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  omitted). The ALJ here found that Ms. Nielsen has fibromyalgia, and only the resulting

  limitations were at issue. We therefore consider Moore unpersuasive with respect to the

  facts of this case.

         Ms. Nielsen also argues the ALJ erred in rejecting Dr. Knowlton’s opinions

  because Dr. Knowlton relied on her subjective complaints. She premises this argument

  on the holding of Arakas v. Commissioner, 983 F.3d 83, 97 (4th Cir. 2020), that “ALJs

  may not rely on objective medical evidence (or the lack thereof)—even as just one of

  multiple factors—to discount a claimant’s subjective complaints regarding symptoms of

  fibromyalgia.” From that premise, Ms. Nielsen contends it was plausible for

  Dr. Knowlton to rely on Ms. Nielsen’s subjective complaints when opining on her

  functional capacity. But extending Arakas’s holding regarding the analysis of a

  claimant’s subjective complaints to the evaluation of a medical opinion would require us

  to ignore the dictate that supportability, which is one of the two most important factors in

  evaluating a medical opinion, see § 416.920c(b)(2), rests on “the objective medical

  evidence and supporting explanations presented by a medical source,” § 416.920c(c)(1).

  Cf. Newbold v. Colvin, 718 F.3d 1257, 1267–68 (10th Cir. 2013) (affirming ALJ’s

  adverse credibility finding in fibromyalgia case that was based in part on inconsistency

  between subjective complaints and objective medical evidence). It also would require

  ignoring SSR 12-2P’s tenet (discussed above) that objective evidence is relevant to

  evaluating the limiting effects of fibromyalgia. Moreover, Dr. Knowlton provided no

  support for her RFC opinions other than Ms. Nielsen’s subjective statements, she

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  conducted no tests of Ms. Nielsen’s functional abilities, and her treatment notes contain

  no findings regarding such abilities.

         Although not directly implicating supportability or consistency, Ms. Nielsen faults

  the ALJ for not addressing Dr. Knowlton’s opinion that she would need to take

  unscheduled breaks and would likely miss at least four days of work per month. The ALJ

  did not expressly discuss this specific limitation, but the reason for the ALJ’s rejection of

  it (that Dr. Knowlton’s opinions were unsupported and inconsistent with other record

  evidence) is evident from his analysis. No more was required. See § 416.920c(b)(1)

  (“[W]hen a medical source provides multiple medical opinion(s) or prior administrative

  medical finding(s), we will articulate how we considered the medical opinions or

  prior administrative medical findings from that medical source together in a single

  analysis . . . . We are not required to articulate how we considered each medical opinion

  or prior administrative medical finding from one medical source individually.”);

  Revisions to Rules Regarding the Evaluation of Medical Evidence, 82 Fed. Reg. 5844,

  5858 (Jan. 18, 2017) (“[T]he articulation requirements in [§ 416.920c] will allow a

  subsequent reviewer or a reviewing court to trace the path of an adjudicator’s reasoning,

  and will not impede a reviewer’s ability to review a determination or decision, or a

  court’s ability to review our final decision.”); cf. Oldham v. Astrue, 509 F.3d 1254, 1258

  (10th Cir. 2007) (requiring, under predecessor to § 416.920c, that an ALJ need only

  provide “good reasons” for the weight afforded to a medical opinion).

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  B.     Consistency

         We next address Ms. Nielsen’s arguments concerning the ALJ’s findings that

  Dr. Knowlton’s were inconsistent with other record evidence. We begin with the ALJ’s

  reliance on the inconsistency between the extreme functional limitations in

  Dr. Knowlton’s opinions and the objective findings of the consulting examiners showing

  generally normal physical and mental functioning. As Ms. Nielsen observes, one of those

  examiners, Joseph Fyans, M.D., found she had “tenderness to palpation over the scalp,

  through the length of the spine and the posterior trunk diffusely,” and “some mild to

  moderate spasming of the right lower thoracic/lumbar paraspinal muscles.” Aplt. App.,

  Vol. 4 at 93. But that hardly shows Dr. Knowlton’s extreme limitations were consistent

  with Dr. Fyans’s objective findings, particularly given that Dr. Fyans also found

  Ms. Nielsen had normal gait, strength, coordination, range of motion, and reflexes, and

  she was “able to perform all higher level ambulatory activities without difficulty,”

  id. at 94. And contrary to Ms. Nielsen’s argument, Dr. Fyans’s finding of diffuse

  tenderness does not call into question his qualifications to assess Ms. Nielsen’s physical

  limitations through objective examination; whether she has fibromyalgia is not in dispute,

  only the resulting limitations are contested.5 Nor does the absence of Dr. Fyans’s

  background and certifications from the record or any lack of clarity whether he reviewed

  Ms. Nielsen’s medical records cast doubt on his ability to conduct an objective

         5
          To find that a claimant has fibromyalgia, there must be a showing of, among
  other things, “[a]t least 11 [of 18 specific] positive tender points on physical
  examination . . . bilaterally . . . and both above and below the waist.” SSR 12-2P,
  2012 WL 3104869, at *3.
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  examination of Ms. Nielsen’s functional limitations. As a state agency consulting

  physician, Dr. Fyans was required to “have a good understanding of [Social Security]

  disability programs and their evidentiary requirements,” 20 C.F.R. § 416.919n, and is

  viewed as an “expert[] in the evaluation of medical issues in disability claims under the

  [Social Security] Act,” SSR 17-2P, 2017 WL 3928306, at *3 (Mar. 27, 2017).6 And

  Dr. Fyans’s report recites Ms. Nielsen’s subjective complaints and lists multiple

  conditions in the “Past Medical History” section, Aplt. App., Vol. 4 at 91, suggesting he

  was familiar with Ms. Nielsen’s medical history.

         Ms. Nielsen further questions reliance on Dr. Fyans’s findings because

  fibromyalgia is a “condition causing pain, not loss of range of motion, strength, or ability

  to ambulate.” Aplt. Opening Br. at 31.7 But the inquiry for disability purposes is

  whether pain is “so severe, by itself or in conjunction with other impairments, as to

  preclude any substantial gainful employment.” Brown v. Bowen, 801 F.2d 361, 362–63

  (10th Cir. 1986) (internal quotation marks omitted). Range of motion, strength, and

  ability to ambulate are relevant to that inquiry.

         Ms. Nielsen further posits that because fibromyalgia requires consideration of the

  patient’s “longitudinal record whenever possible,” SSR 12-2P, 2012 WL 3104869, at *6,

         6
           As the Commissioner points out, nothing in the record suggests that
  Dr. Knowlton was any more qualified to assess fibromyalgia or the resulting
  limitations than Dr. Fyans.
         7
          The ALJ found only partly persuasive Dr. Fyans’s opinion that none of his
  findings would limit Ms. Nielsen’s ability to work because it was supported by his
  examination results but was inconsistent with the prior administrative medical
  findings that Ms. Nielsen would be limited to the full range of light work.
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  the ALJ should have considered whether Ms. Nielsen was just having a good day when

  she saw Dr. Fyans. The longitudinal record, however, consists primarily of

  Dr. Knowlton’s treatment notes generated at Ms. Nielsen’s periodic medication-check

  appointments, and as previously discussed, nothing in those notes calls into doubt the

  ALJ’s reliance on Dr. Fyans’s findings and the inconsistency between those findings and

  Dr. Knowlton’s RFC opinions.

         Ms. Nielsen also claims that when the other consultative examiner, Michael

  Schreiner, M.D., noted some errors in Ms. Nielsen’s ability to recall numbers, the ALJ

  misconstrued Dr. Schreiner’s findings by stating he found “mildly impaired memory and

  concentration but otherwise grossly normal results in the mental status examination,”

  Aplt. App., Vol. 1 at 49. We disagree. Dr. Schreiner found Ms. Nielsen’s “[r]ecent

  memory was generally fine”; her “[i]mmediate memory was a mild struggle”; and on

  “digits backwards, she made errors on three and four digits” and was unable “to do serial

  three’s backwards from 30,” so that task “was deemed to be too difficult for her” and

  “was discontinued.” Id., Vol. 4 at 87. Ultimately, Dr. Schreiner “deemed that

  [Ms. Nielsen] may have some mild struggles with attention and concentration.” Id. We

  fail to see how the ALJ’s assessment of Dr. Schreiner’s findings was wrong. We also fail

  to see error in the ALJ finding an inconsistency between Dr. Knowlton’s opinions that

  Ms. Nielsen’s memory was moderately impaired and her ability to maintain concentration

  for extended period was extremely impaired, see id. at 115, and Dr. Schreiner’s objective

  findings.

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         Finally, Ms. Nielsen contends the ALJ erred in relying on the opinions of

  Kendrick Morrison, D.O., and Richard Nielsen, M.D., the nonexamining state agency

  consultants who completed the medical portion of the initial denial of benefits and the

  denial upon reconsideration, respectively. The ALJ found persuasive their opinion that

  Ms. Nielsen would be limited to a full range of light work.

         Ms. Nielsen contends the ALJ did not establish whether their opinions were

  consistent with the record. She observes that Dr. Morrison, relying almost exclusively on

  Dr. Fyans’s report, noted that fibromyalgia was not proven, but he failed to note that

  Dr. Fyans did not fully assess whether Ms. Nielsen had fibromyalgia despite finding

  tender points. But again, whether Ms. Nielsen has fibromyalgia is not in question; only

  the resulting functional limitations are, and Ms. Nielsen fails to show the ALJ erred in

  relying on Dr. Morrison’s evaluation of those limitations.

         Ms. Nielsen further notes Dr. Nielsen reviewed Dr. Knowlton’s records, which

  included notations of fatigue and pain, yet upheld the initial denial of benefits despite the

  fact that pain and other symptoms associated with fibromyalgia “may result in exertional

  limitations that prevent a person” from performing a full range of work and may also

  cause “nonexertional physical and mental limitations,” SSR 12-2P, 2012 WL 3104869,

  at *6. But Dr. Knowlton’s observations of fatigue and pain were simply a record of what

  Ms. Nielsen told her; they do not shed light on the extent of Ms. Nielsen’s limitations.

         Last, Ms. Nielsen argues that because both doctors are ear/nose/throat specialists,

  their qualifications to opine on fibromyalgia are questionable. However, Ms. Nielsen

  provides no concrete reason to doubt their qualifications with regard to fibromyalgia, and

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  as state agency consultants, Drs. Morrison and Nielsen were required to “have a good

  understanding of [Social Security] disability programs and their evidentiary

  requirements,” 20 C.F.R. § 416.919n, and are viewed as “experts in the evaluation of

  medical issues in disability claims under the [Social Security] Act,” SSR 17-2P,

  2017 WL 3928306, at *3.8

                                      IV. Conclusion

        Our review of the record convinces us that substantial evidence supports the

  ALJ’s disability determination and that the correct legal standards were applied. We

  therefore affirm the district court’s judgment.

                                               Entered for the Court

                                               Timothy M. Tymkovich
                                               Circuit Judge

        8
          In her reply brief, Ms. Nielsen advances a new argument about the ALJ’s
  evaluation of her migraine headaches. See Aplt. Reply Br. at 19. We see no reason
  to overlook our general rule that arguments raised for the first time in a reply brief
  are waived. See Silverton Snowmobile Club v. U.S. Forest Serv., 433 F.3d 772, 783
  (10th Cir. 2006).

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