F I L E D
United States Court of Appeals
Tenth Circuit
UNITED STATES COURT OF APPEALS
FEB 3 1999
FOR THE TENTH CIRCUIT
PATRICK FISHER
Clerk
SHERRY L. HODGSON,
Plaintiff-Appellant,
v. No. 98-2067
(D.C. No. CIV-97-258-BB/DJS)
KENNETH S. APFEL, Commissioner, (D. N.M.)
Social Security Administration,
Defendant-Appellee.
ORDER AND JUDGMENT *
Before PORFILIO, BARRETT, and KELLY , Circuit Judges.
After examining the briefs and appellate record, 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This order and judgment is not binding precedent, except under the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.
Plaintiff filed an application for disability insurance benefits in 1991,
alleging an onset date of July 12, 1991. Plaintiff indicated she was unable to
work due to stomach problems, stress, and pain in her hands, especially with
writing or typing. In connection with this application, plaintiff was evaluated by
Dr. Hughson, a psychiatrist. The examination took place shortly after plaintiff’s
alcoholic son had been killed in an accident, leaving his young child in the care of
plaintiff and her husband. Plaintiff told Dr. Hughson that she had been depressed
for the past six years, which coincided with the worst of her son’s alcoholism. By
Dr. Hughson’s assessment, plaintiff was “clearly depressed and still very much
not finished with grieving over the death of her son. . . . At present, her
depression is such that she could clearly not muster enough energy to devote to a
paying job. However, she would be a good candidate for aggressive
antidepressant, pharmacotherapy and psychotherapy . . . .” Appellant’s App., Vol.
II at 140. Dr. Hughson gave a diagnosis of “[m]ajor depression, single episode”
and “[p]ersonality disorder, mixed, with dependent and passive and avoidant
features.” Id.
Plaintiff’s 1991 application was denied on initial review in October 1991
and was denied again on reconsideration in March 1992. The agency concluded
that plaintiff’s hand pain was controlled with medication, that her stomach
problems did not prevent her from working, and that, with medical treatment, her
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depression was not expected to last twelve continuous months. Plaintiff did not
pursue a de novo hearing before an administrative law judge (ALJ) on her 1991
application. Instead, she returned to work in August 1992, where she remained
until June 3, 1993.
In 1994, plaintiff filed the present application for disability insurance
benefits, alleging an onset date of May 30, 1993. Plaintiff indicated she was
unable to work due to neck pain, back pain, leg pain, tennis elbow, and arthritis.
In her vocational report, plaintiff described her past relevant work as largely
clerical and secretarial, involving a lot of work at a computer. She indicated that
her past jobs required a total of two hours walking, two hours standing, and four
hours sitting in a typical eight-hour day, as well as constant bending. Plaintiff
stated that using the computer irritated her arthritis and sitting bothered her back
and neck. She related that she had previously quit jobs due to health problems,
explaining: “I have really tried to work and when the stress and pain cause so
much absences that I have to quit I will recuperate and after a period of time go
back to work and try again.” Id. at 87.
Plaintiff’s medical records indicate that she was treated by Dr. Altman, an
orthopedic surgeon, from January 1992 through August 1996. Initially, plaintiff’s
complaints predominantly involved her right hand and wrist and her elbows. Dr.
Altman diagnosed plaintiff with very mild osteoarthritis in her right hand, a
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ganglion on the DIP joint of her right index finger, and tennis elbow. Plaintiff
continued to have problems with her left elbow through the spring of 1993, but
thereafter her complaints centered primarily on her lower back and left knee.
Plaintiff had arthroscopic surgery on her left knee in October 1993, but was
complaining of pain again within a few months. An MRI of plaintiff’s lumbar
spine in 1994 revealed degenerative facet changes. Plaintiff subsequently
received nerve blocks and facet injections in her spine, as well as injections in her
knee, from which she received some temporary pain relief. Plaintiff took
Darvocet regularly for her pain and told one physician that she would not be able
to do her daily activities without it.
After plaintiff’s present application was denied initially and on
reconsideration, she requested and received a de novo hearing before an ALJ in
December 1995. Plaintiff was represented by a nonattorney advocate at the
hearing. She testified that she was not able to stand, walk, or sit for prolonged
periods of time, and she asked to stand part way through the hearing. Plaintiff
also testified that she was limited in her ability to bend and squat, and that her
elbow problems flared up when she used a computer or typewriter. While
plaintiff’s past jobs entailed a lot of computer work, she testified that she rarely
tried to type or work on a computer anymore. When asked the primary reason
why she could no longer work, plaintiff listed her need to put her legs up to rest
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every half-hour, her need to take Darvocet regularly, her inability to sit or stand
for prolonged periods, and her generally unreliable health.
On March 27, 1996, the ALJ issued his decision denying plaintiff’s
application for benefits at step four of the sequential analysis. See 20 C.F.R.
§ 404.1520 (describing the steps). The ALJ concluded plaintiff’s back and leg
problems constituted severe impairments, but determined they did not prevent her
from doing a full range of light work. The ALJ did not mention plaintiff’s
problems with her hands or elbows, nor did he consider whether she had any
mental impairments. The ALJ determined plaintiff could return to her past
relevant work as a clerk/receptionist, secretary, data entry processor, or computer
operator and, therefore, she was not disabled. Plaintiff subsequently retained an
attorney and appealed the ALJ’s decision to the Appeals Council. Plaintiff’s
attorney submitted numerous pieces of additional evidence to the Appeals
Council. See id. § 404.970(b) (authorizing claimants to submit new and material
evidence to Appeals Council relating to period on or before ALJ’s decision).
Included in the additional evidence was a report by Dr. Fredman, a
psychiatrist, who examined plaintiff in September 1996. He determined plaintiff
had an eleven-year history of chronic depression and that her son’s alcoholism
and subsequent death, as well as her own physical pain and impairments, were
important external stressors related to the onset of her depression. Dr. Fredman
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concluded the prognosis for plaintiff’s depression was fair without treatment and
good with treatment. He said she had a fair potential for sustained work activity,
though her depression would cause problems handling the stress and pressure of
work. Dr. Fredman concluded plaintiff “likely could perform one or two step
repetitive tasks at a competitive rate and would not have significant difficulty
interacting with coworkers or superiors.” Appellant’s App., Vol. II at 216. He
noted plaintiff was uncomfortable when sitting during the hour-long interview and
had to get up and walk around several times.
Also included in the new materials was a September 1996 disability
evaluation of plaintiff performed by Ken Williams, a vocational expert. Based on
plaintiff’s performance on five different vocational tests, Mr. Williams concluded
plaintiff was “in the high average range of mental ability, and solidly in the
average range in academic skills, with excellent abstract reasoning ability,” but
she was “significantly limited with marked deficits in her ability to use her
fingers, hands, and arms.” Id. at 219. “Observation during testing and interview
also showed she continually shifts and squirms when sitting; must stand and move
around at approximate 20-25 minute intervals, and cannot stand for prolonged
periods.” Id. Mr. Williams concluded that plaintiff was totally disabled and had
been so since May 1993, based on her observed limitations in reaching, handling
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and fingering, as well as her reported limitations in bending, stooping, climbing,
kneeling and lifting, her periodic dizzy spells, and her fatigue.
The Appeals Council denied review after considering the evidence
submitted to the ALJ and the additional evidence submitted to it. As to the new
evidence, the Appeals Council stated: “To the extent this evidence can be found
relevant to the period considered by the Administrative Law Judge, through
March 27, 1996, the Appeals Council finds that it is not a basis for changing his
decision.” Id. at 6. The Appeals Council did not provide any further explanation
of its evaluation of the new evidence, though it must have at least concluded that
each piece of evidence related in some fashion to the period on or before the ALJ
made his decision, because it did not return any of the evidence to plaintiff in
accordance with 20 C.F.R. § 404.976(b)(1). Once the Appeals Council denied
plaintiff’s request for review, the ALJ’s decision became the final decision of the
Commissioner.
We review the Commissioner’s decision to determine whether it is
supported by substantial evidence and whether the Commissioner applied the
correct legal standards. See Winfrey v. Chater , 92 F.3d 1017, 1019 (10th Cir.
1996). In determining whether substantial evidence supports the Commissioner’s
decision, we must examine the record as a whole, including the additional
materials submitted to the Appeals Council. See O’Dell v. Shalala , 44 F.3d 855,
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858, 859 (10th Cir. 1994) . Plaintiff contends that the Commissioner’s decision is
not supported by substantial evidence and that the Commissioner made various
legal errors in denying her application for benefits.
Our review of the Commissioner’s decision is hindered by the Appeals
Council’s failure to provide any explanation of its evaluation of the additional
evidence before it. An even greater stumbling block, and one which we conclude
requires reversal and remand, is the ALJ’s failure to make the findings at step
four necessary for us to evaluate either the factual or the legal basis for his
decision.
Step four of the sequential analysis . . . is comprised of three
phases. In the first phase, the ALJ must evaluate a claimant’s
physical and mental residual functional capacity (RFC), and in the
second phase, he must determine the physical and mental demands of
the claimant’s past relevant work. In the final phase, the ALJ
determines whether the claimant has the ability to meet the job
demands found in phase two despite the mental and/or physical
limitations found in phase one. At each of these phases, the ALJ
must make specific findings.
Winfrey , 92 F.3d at 1023 (citations omitted). When the ALJ assesses the
claimant’s RFC at the beginning of step four, the ALJ should “first identify the
individual’s functional limitations or restrictions and assess his or her work-
related abilities on a function-by-function basis . . . . Only after that may RFC be
expressed in terms of the exertional levels of work, sedentary, light, medium,
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heavy, and very heavy.” Social Security Ruling 96-8p, 1996 WL 374184, at *1
(S.S.A. 1996).
Here, the ALJ failed to make the required findings at each phase of the
fourth step. He did not analyze plaintiff’s ability to do work-related activities on
a function-by-function basis, he did not make any findings about the demands of
her past relevant work, either as she actually performed it or as it is generally
performed in the national economy, and he did not make any comparison of the
demands of her past work with her remaining capabilities. Instead, the ALJ
simply stated that plaintiff could do a full range of light work and that she could
return to her past relevant work. 1
Without any of the required underlying
findings, we can neither evaluate the factual and legal correctness of the ALJ’s
decision that plaintiff could return to her past relevant work, nor determine
whether the new evidence submitted to the Appeals Council would have affected
the ALJ’s decision. Therefore, we must remand the action for further
proceedings.
On remand, the ALJ should consider all of the evidence submitted by
plaintiff and then make the necessary step four findings, as outlined above. If
further record development is necessary to make the required findings, the ALJ
1
The ALJ did not even make a finding as to whether plaintiff’s past work
was performed at the light exertional level.
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should garner the necessary evidence. Because the ALJ’s reconsideration of all
the evidence on remand will likely moot plaintiff’s current challenges, we will not
address those here.
The judgment of the United States District Court for the District of New
Mexico is REVERSED, and the case is REMANDED with instructions to remand
to the Commissioner for further proceedings consistent with this order and
judgment.
Entered for the Court
John C. Porfilio
Circuit Judge
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