P. BRADLEY MURRAY, Magistrate Judge.
Plaintiff Channing R. Knapp brings this action, pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3), seeking judicial review of a final decision of the Commissioner of Social Security ("the Commissioner") denying his claim for a Period of Disability and Disability Insurance Benefits ("DIB") under Title II of the Social Security Act ("the Act"). The parties have consented to the exercise of jurisdiction by the Magistrate Judge, pursuant to 28 U.S.C. § 636(c), for all proceedings in this Court. (Doc. 19 ("In accordance with the provisions of 28 U.S.C. 636(c) and Fed. R. Civ. P. 73, the parties in this case consent to have a United States Magistrate Judge conduct any and all proceedings in this case, . . . order the entry of a final judgment, and conduct all post-judgment proceedings.")). See also Doc. 21. Upon consideration of the administrative record, Knapp's brief, the Commissioner's brief, and the arguments made at the hearing on May 9, 2018 before the undersigned Magistrate Judge, it is determined that the Commissioner's decision denying benefits should be affirmed.
Knapp applied for a Period of Disability and DIB, under Title II of the Act, 42 U.S.C. §§ 423-425, on January 18, 2015, alleging disability beginning on August 29, 2014. (Tr. 150-51). His application was denied at the initial level of administrative review on March 11, 2015. (Tr. 70-84). On April 2, 2015, Knapp requested a hearing by an Administrative Law Judge (ALJ). (Tr. 94-95). After a hearing was held on July 14, 2016, the ALJ issued an unfavorable decision finding that Knapp was not under a disability from the date the application was filed through the date of the decision, September 20, 2016. (Tr. 52-69, 11-24). Knapp appealed the ALJ's decision to the Appeals Council, and, on August 21, 2017, the Appeals Council denied his request for review of the ALJ's decision, thereby making the ALJ's decision the final decision of the Commissioner. (Tr. 1-5).
After exhausting his administrative remedies, Knapp sought judicial review in this Court, pursuant to 42 U.S.C. §§ 405(g) and 1383(c). (Doc. 1). The Commissioner filed an answer and the social security transcript on January 9, 2018. (Docs. 11, 12). Both parties filed briefs setting forth their respective positions. (Docs. 14, 16). Oral argument was held on May 9, 2018. (Doc. 20). The case is now ripe for decision.
Knapp alleges that the ALJ's decision to deny him benefits is in error for the following reasons:
1. The ALJ erred by relying upon a non-examining reviewing physician's opinion to support his residual functional capacity (RFC), and
2. The ALJ erred because her assessment of Knapp's RFC was not supported by substantial evidence.
(Doc. 14 at pp.1-2).
Knapp was born on October 26, 1973, and was 41 years old at the time he filed his claim for benefits. (Tr. 55). Knapp alleged disability due to multiple disc problems in his back, back pain after lower back surgery, pain and/or numbness in his legs, knees, feet, ankles, and wrists, and irritable bowel syndrome. (Tr. 59-60, 167). The highest grade in school he completed was 10
After considering all of the evidence, the ALJ made the following findings that are relevant to the issues presented in her September 23, 2016 decision:
The claimant alleges that he has bad knees and bad discs in his neck and experiences pain from shoulder to shoulder, lower back pain, lumbar radiculopathy, general joint pain and popping, and popping in his shoulders and ankles. He has problems sitting for long, can only stand and walk about 10 minutes at a time each, and does not sleep well. He can lift things, but pays for it later. He spends much of the day sitting in a recliner and changing positions to get comfortable. He has a history of a failed back surgery. He has been in pain management, and his medications have been changed over the years in an attempt to find ones that work. Medications help somewhat, but he experiences the side effect of fatigue. Due to pain and medication side effects, he is not able to concentrate long enough to watch a movie. He had difficulties during the FCE on March 22, 2016. He felt terrible and was bedridden for a day afterwards.
After careful consideration of the evidence, the undersigned finds that the claimant's medically determinable impairments could reasonably be expected to cause the alleged symptoms; however, the claimant's statements concerning the intensity, persistence, and limiting effects of these symptoms are not entirely consistent with the medical evidence and other evidence in the record for the reasons explained in this decision.
The medical evidence of record documents the claimant's severe physical impairments of degenerative disc disease, degenerative joint disease, and obesity since the alleged onset date. He has complained of lower back pain; lumbar radiculopathy, worse on the left side; neck pain; cervical radiculopathy, worse on the left side; bilateral knee pain; bilateral ankle pain and giving out; upper back pain; mid back pain; right shoulder pain; bilateral shoulder popping; bilateral arm pain; bilateral leg pain; widespread joint pain; popping in his joints; his pain being exacerbated by prolonged sitting, standing, walking, and lifting; and pain interfering with his ability to concentrate (Exhibits 5F, 7F, 11F, 13F, and 14F).
Findings of neck tenderness and tightness; mid back tenderness; lower back tenderness, muscle spasm, stiffness, positive facet loading sign, positive Patrick's sign, and decreased range of motion; positive straight leg raising results; somewhat reduced bilateral hip strength; bilateral knee tenderness, mild crepitus, and positive grinding test results; left ankle tenderness; antalgic gait; decreased light touch sensation in the left arm; right shoulder tenderness, positive Neer's and Hawkins' signs, and mildly decreased range of motion; and mildly decreased left shoulder range of motion have been noted intermittently on examination since the alleged onset date (Exhibits 5F, 7F, 9F, 11F, and 13F). However, normal neck examination results, normal lower back strength, normal bilateral lower extremity examination results, normal bilateral lower extremity motor function, bilateral normal knee range of motion and negative anterior and posterior drawer signs, bilateral ankle normal range of motion and negative anterior and posterior drawer signs, normal muscle bulk and tone, normal gait and station, ability to stand without difficulty, normal reflexes, intact sensation, mostly normal musculoskeletal examination results, and normal attention and concentration abilities have also been noted (Exhibits 5F, 7F, 9F, 11F, 12F, and l5F). He is 5'7" tall, and his weight has been recorded at between 260 and 306 pounds since the alleged onset date, (Exhibits 3F, 9F, 12F, 14F, 15F, and 16F), which correlates to a body mass index between 40.7 and 47.9.
[In depth discussion of medical records]
The FCE on March 22, 2016 demonstrated that the claimant had the tolerance for lifting in the light physical demand level of 20 pounds from the knee to overhead level with frequent intermittent sitting, standing, and walking (Exhibit 17F). The remaining limitations addressed in the FCE are generally consistent with light work activity (SSRs 83-14 and 85-15). Some inconsistencies with the claimant's performance were noted during the FCE, and he displayed some fear avoidance and self-limiting behaviors with material handling.
On June 17, 2016, Dr. Hall noted that the claimant had reported complaints of intractable pain but summarized the FCE conclusions and cited the exam as an objective evaluation of the claimant's physical ability; he did not challenge the results in any respect other than to remark that the claimant's condition could be expected to worsen with time (Exhibit 18F).
As for opinion evidence, although Physical Therapist Washicheck and Physical Therapist Assistant Brenes are not acceptable medical sources for medical opinion purposes, the undersigned has considered their FCE under SSR 06-03p and gives it great weight (Exhibit 17F). They administered the FCE, and the FCE conclusions are generally consistent with the record as a whole. Moreover, Dr. Hall cited the FCE conclusions as an objective evaluation of the claimant's physical ability; he did not question or challenge the conclusions in any respect other than to note that the claimant's condition could be expected to worsen with time (Exhibit 18F).
On March 10, 2015, James Sims, M.D., a State agency medical consultant, completed a physical residual functional capacity (PRFC) assessment indicating that the claimant could perform a range of light work (Exhibit 1A). The undersigned gives substantial weight to Dr. Sims' PRFC assessment. Dr. Sims is familiar with Social Security law and regulations, and his PRFC assessment is generally consistent with the record as a whole.
(Tr. 17, 19-20, 21-22, 24).
Eligibility for a Period of Disability and DIB requires that the claimant be disabled. 42 U.S.C. § 423(a)(1)(E). A claimant is disabled if the claimant is unable "to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." 42 U.S.C. §§ 423(d)(1)(A). The impairment must be severe, making the claimant unable to do the claimant's previous work or any other substantial gainful activity that exists in the national economy. 42 U.S.C. § 423(d)(2); 20 C.F.R. §§ 404.1505-11. "Substantial gainful activity means work that . . . [i]nvolves doing significant and productive physical or mental duties [that] [i]s done (or intended) for pay or profit." 20 C.F.R. § 404.1510.
In evaluating whether a claimant is disabled, the ALJ utilizes a five-step sequential evaluation:
Watkins v. Comm'r of Soc. Sec., 457 F. App'x 868, 870 (11th Cir. 2012) (per curiam) (citing 20 C.F.R. §§ 404.1520(a)(4), (c)-(f), 416.920(a)(4), (c)(f); Phillips v. Barnhart, 357 F.3d 1232, 1237 (11
If the claimant appeals an unfavorable ALJ decision, the reviewing court must determine whether the Commissioner's decision to deny benefits was "supported by substantial evidence and based on proper legal standards." Winschel v. Comm'r of Soc. Sec., 631 F.3d 1176, 1178 (11
Knapp alleges that the ALJ in this case reversibly erred by giving substantial weight to the opinion of a non-examining physician concerning his assessment of Knapp's physical residual functional capacity. Knapp also alleges that the ALJ erred because her assessment of his RFC was not supported by substantial evidence. The Court will address each of these claims in turn.
Knapp claims that the ALJ erred in this case by giving substantial weight to the physical residual capacity assessment made by Dr. Sims because he was a non-examining physician who reviewed Knapp's medical records two months after he applied for disability, before many of the medical records submitted to the ALJ had been created, and because he had no history or relationship with Knapp. The relevant social security regulations provide that medical opinions are weighed by considering the following factors: 1) whether the source of the opinion examined the claimant; 2) whether the source treated the claimant and, if so, a) the length of the treatment relationship and the frequency of examination and b) the nature and extent of the treatment relationship; 3) the supportability of the opinion with relevant evidence and by explanations from the source; 4) the consistency of the opinion with the record as a whole; 5) whether the opinion was offered by a specialist about a medical issue related to his or her area of specialty; and 6) any other factors which tend to support or contradict the opinion. 20 C.F.R. § 404.1527(c)(1)-(6); see also Nichols v. Comm'r, Soc. Sec. Admin., No. 16-11334, 2017 WL 526038, at * 5 (11
Knapp seems to base his argument, in part, on an implied assertion that the ALJ only relied on Dr. Sims's opinion in making his assessment of Knapp's RFC. Knapp's argument in this regard is not accurate. The ALJ reviewed and discussed the findings of Knapp's numerous objective tests, his treatment, and the opinion of Dr. Hall, his treating physician, concerning Knapp's physical abilities, as well as the results of the Functional Capacity Evaluation ("FCE") performed on Knapp at the request of Dr. Hall.
Relying on Dillard v. Astrue, 834 F.Supp.2d 1325 (S.D. Ala. 2011), Knapp also argues that the ALJ's consideration of the opinion of Dr. Sims is contrary to the law of this Circuit and that the Court must "include a residual functional capacity assessment by a treating or examining physician." (Doc. 14 at pp. 8-9). However, more recent cases in this district have held that "[i]n order to find that the ALJ's RFC assessment is supported by substantial evidence, . . . it is
In this case, the ALJ supported her decision to give Dr. Sims's opinion substantial weight by stating that his assessment was consistent with the record as a whole and noting his familiarity with Social Security laws and regulations. As noted above, the Court also recognizes that Dr. Sims's opinion was consistent with the results of the FCE and Dr. Hall's opinion. Based upon its review of the record, the Court finds that the ALJ's decision to afford substantial weight to Dr. Sim's opinion was based on substantial evidence and was, thus, not in error.
Knapp also alleges that the ALJ erred because her assessment of his RFC was not supported by substantial evidence. As noted above, the ALJ found that Knapp had the RFC to perform light work, "except that he needs to be able to alternate between sitting and standing at will, but will not need to leave the work station, and he is unable to work around heights." (Tr. 19). A claimant's RFC is "an assessment of an individual's ability to do sustained work-related physical and mental activities in a work setting on a regular and continuing basis." SSR 96-8p, 1996 WL 374184, at *1. It is an "administrative assessment of the extent to which an individual's medically determinable impairment(s), including any related symptoms, such as pain, may cause physical or mental limitations or restrictions that may affect his or her capacity to do work-related physical and mental activities." SSR 96-8p, 1996 WL 374184, at *2. It represents
Knapp generally asserts that the RFC was not supported by substantial evidence because the ALJ did not include all of the restrictions noted in his Functional Capacity Evaluation (FCE) and did not properly take into account the severity of his back and knee problems in formulating his RFC. (Doc. 14 at pp. 4-8). It is well-settled that the ultimate responsibility for determining a claimant's RFC, in light of the evidence presented, is reserved to the ALJ, not to the claimant's physicians or other experts. See 20 C.F.R. § 404.1546. "[T]he ALJ will evaluate a [physician's] statement [concerning a claimant's capabilities] in light of the other evidence presented and the ultimate determination of disability is reserved for the ALJ." Green v. Soc. Sec. Admin., 223 F. App'x 915, 923 (11
After reviewing Knapp's testimony concerning his limitations and the medical evidence, the ALJ stated the following in assessing his RFC:
A review of the entire record reveals that the ALJ was presented with numerous medical reports and the FCE detailing Knapp's limitations, as well as his own testimony. The ALJ made reference to the medical findings, as well as other evidence, in assigning additional limitations to Knapp's RFC, such as allowing him to alternate between sitting and standing at will, without leaving the work station, and restricting him from working around heights. (Tr. 19). Much of the argument made by Knapp is simply a plea to have the Court reweigh the evidence, which it simply cannot do. Although the Court recognizes that Knapp has had substantial testing and treatment for his back and certainly sympathizes with his complaints, the Court cannot say that the restriction to light work with the additional limitations is not supported by substantial evidence. Knapp's pain management physician, Dr. Hall, referred him to the physical therapist to have the FCE performed to determine his physical capabilities and limitations. (Tr. 397). After reviewing the results of the FCE, Dr. Hall opined that it suggested Knapp would be able to work at a light physical demand level up to 20 pounds lifting. (Tr. 403).
Knapp also mentioned in passing in his brief that the ALJ should have sought clarification concerning two doctors' varying interpretations of his knee x-rays. However, he has failed to demonstrate how these varying interpretations of the x-rays affect the outcome of his case. The ALJ found that he had a severe impairment of degenerative joint disease, and the FCE took into account his physical limitations as a whole, not just those attributable to his back. An ALJ is not required to seek additional evidence when the evidence in the record is sufficient to support the ALJ's decision. See Wilson v. Apfel, 179 F.3d 1276, 1278 (11
Having reviewed the evidence and considered the arguments made by Knapp and being mindful of the admonishment that the reviewing court may not reweigh the evidence or substitute its judgment for that of the Commissioner, the Court finds that the RFC assessment made by the ALJ was supported by substantial evidence. The opinion of Dr. Hall, the results of the FCE, and the totality of the medical evidence constitute substantial evidence supporting the ALJ's RFC assessment, as well as her final decision.
It is well-established that it is not this Court's place to reweigh the evidence or substitute its judgment for that of the Commissioner. This Court is limited to a determination of whether the ALJ's decision is supported by substantial evidence and based on proper legal standards. The Court finds that the ALJ's Decision that Knapp is not entitled to benefits is supported by substantial evidence and based on proper legal standards. Accordingly, it is