ELIZABETH D. LaPORTE, Magistrate Judge.
On April 11, 2014, Plaintiff Marlene Estella Williams filed this suit pursuant to 42 U.S.C. § 405(g) seeking judicial review of a decision denying her claim for supplemental security income benefits ("SSI") under Title XVI of the Social Security Act, 42 U.S.C. § 400
Plaintiff Marlene Estelle Williams initially filed an application for SSI on November 1, 2007. Administrative Record ("AR") at 138-144. In her initial application, she claimed that she became disabled on December 1, 2005 as a result of vertigo, depression, anxiety, morbid obesity and hypertension. AR 163. Ms. Williams alleged that her impairments limited her ability to work because of dizziness, an inability to concentrate, depression and inability to sit or stand for long periods of time. AR 163. Ms. Williams' application was denied initially, upon reconsideration, and by an Administrative Law Judge ("ALJ") in a decision dated June 4, 2010. AR 17-26.
In her 2010 opinion, ALJ Maxine Benmour found that Plaintiff had the following severe impairments: back, knee, and shoulder pain; obesity; depressive disorder; anxiety; hypertension; and carpal tunnel syndrome. AR 22. Although the ALJ acknowledged that such impairments could cause significant limitations in work activities, the ALJ concluded that Plaintiff did not have an impairment or combination of impairments that met or medically equaled one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1 (20 C.F.R. §§ 419.920(d), 416.925, and 416.926). AR 22. The ALJ also determined that Plaintiff had the residual functional capacity to perform sedentary work. AR 23. In making this determination, the ALJ acknowledged that "whenever statements about the intensity, persistence, or functionally limiting effects of pain or other symptoms are not substantiated by objective medical evidence," the ALJ must "make a finding on the credibility of the statements based on a consideration of the entire case record." AR 24. The ALJ found that although Plaintiff's medically determinable impairments could reasonably be expected to cause the alleged symptoms, Plaintiff's "statements concerning the intensity, persistence and limiting effects of these symptoms are not credible to the extent they are inconsistent with the above residual functional capacity assessment." AR 24. The ALJ reasoned briefly:
AR 24. In light of Plaintiff's residual functional capacity, age, education, and work experience, the ALJ found that jobs existed in significant numbers in the national economy that Plaintiff could perform after consultation with a vocational expert. AR 25. Consequently, the ALJ found that Plaintiff was not disabled for purposes of SSI benefits. AR 26. The Appeals Counsel denied Plaintiff's request for review of the ALJ's decision, and thus the ALJ's decision became the final decision of the Commissioner of Social Security. AR 1-3.
On June 16, 2012, Plaintiff timely commenced an action for judicial review pursuant to 42 U.S.C. § 405(g) seeking judicial review of the ALJ's 2010 decision to deny her claim for social security benefits, and she filed a motion for summary judgment asking this Court to either reverse the final judgment of the Commissioner and find her disabled or remand this case to the ALJ for a new hearing. Plaintiff argued that the ALJ erred by: (1) failing to consider the combined effect of her obesity on her other impairments; (2) failing to properly credit her treating medical provider(s); (3) discounting her testimony as not credible and failing to provide sufficient detail in the credibility determination, making meaningful review impossible; (4) failing to recognize that her mental impairments support a finding of disability; and (5) failing to provide a proper hypothetical to the Vocational Expert for analysis.
On March 22, 2013, this Court granted in part and denied in part the cross-motions for summary judgment and remanded the case for further proceedings consistent with the Court's opinion. AR 763-803. The Court rejected most of Plaintiff's challenges to the ALJ decision but "remand[ed] on the very limited basis that the ALJ erred in failing to provide adequate reasons to support her credibility determination."
On the record before it, the Court determined that the ALJ's opinion did not provide sufficiently clear and convincing reasons for discrediting Plaintiff's pain testimony and remanded for the ALJ to either provide clear and convincing reasons or properly credit Plaintiff's testimony.
The Court also found that the ALJ gave insufficient reasons for discrediting Plaintiff's testimony that she was disabled in part due to medication-related fatigue.
Based on these conclusions, the Court further found that the ALJ might have given the Vocational Expert an improper hypothetical, stating: "[I]f Plaintiff's pain and fatigue testimony is given additional credit on remand, then it is possible that the ALJ's RFC assessment would be different. If that is the case, then the hypothetical posed to the VE might have been incorrect."
On August 27, 2010 and September 12, 2012, Plaintiff filed additional applications for disability benefits and requested an amended alleged onset date of May 6, 2010 in lieu of December 1, 2005 based on an additional severe impairment of carpal tunnel syndrome. AR 863. Following this Court's remand of
On December 5, 2013, the ALJ held a hearing on the consolidated claims. AR 727-753. During the hearing, Plaintiff testified that she has pain in both hands, had surgery related to carpal tunnel syndrome on her right side in May 2010 but continues to have pain "to a certain extent," and surgery on her left hand is anticipated. AR 730-31. She stated that she can pick things up, but sometimes drops what she has picked up. AR 734-35. She also testified that she suffers from shoulder and back pain most of the day, and neck pain once a day, if at all. AR 738-739, 741. She was taking Percocet for pain, but switched to Norco. AR 733. She testified that she has no pain when she takes her pain medication, but it makes her sleepy and tired. AR 733, 736. According to Plaintiff, her pain medication works to relieve her pain approximately two of every four hours. AR 745-746.
Plaintiff testified that she takes Lamictal for bipolar disorder, Klonopin for anxiety, Gabapentin for nerves, Atenolol for her heart, Albuterol for asthma, Omeprazole for acid reflux, a medication for vertigo, and a sleeping pill. AR 736-39. According to Plaintiff, her vertigo occurs only when she is lying down and she has no vertigo when she takes her medication. AR 739. She has a machine to help manage her sleep apnea. AR 740. Plaintiff testified that she has trouble sitting for more than 45 minutes without back pain, but medication helps. AR 741. She testified that she has problems with walking and standing due to a cyst on her foot. AR 741-42. She claims she can walk for about 20 minutes and stand for 15 minutes and lift approximately 10-15 pounds.
A vocational expert ("VE"), Mr. Van Winkle, testified at Plaintiff's 2013 hearing. AR 751-752. The ALJ presented the VE with the hypothetical of a person of Plaintiff's age and background limited to lifting and carrying 10 to 20 pounds, sitting six hours in an eight hour day and standing or walking for two, occasional climbing, balancing, stooping, kneeling, crouching and crawling, frequent bilateral handling and fingering, who is also required to avoid concentrated exposure to hazards. AR 750-51. The VE testified that there were jobs in the regional or national economy that such a hypothetical person could do, such as production inspector and bench assembler. AR 751-52. The ALJ then adjusted the hypothetical to include the restriction that the individual would need to lie down for three or four hours during the workday. The VE testified that there are no jobs in the national economy that such a person could do. AR 752.
On January 31, 2014, the ALJ issued an unfavorable post-hearing decision on the consolidated claims including the claim remanded from this Court. AR 706-724. The ALJ characterized this Court's remand order as follows:
AR 710 (internal citations omitted). In her 2014 opinion, the ALJ stated that she considered medical evidence dated prior to the amended alleged onset date of May 6, 2010 for "historical context" as well as new evidence post-dating Plaintiff's carpal tunnel surgery. AR 715. Ultimately, considering the record as a whole, the ALJ determined that Plaintiff "has not been under a disability within the meaning of the Social Security Act since October 31, 2007, the date the application was filed." AR 710,
At step one of the sequential evaluation process, the ALJ found that Plaintiff has not engaged in substantial gainful activity since May 6, 2010, the amended alleged onset date, or ever. AR 712, 718. At step two, the ALJ found that Plaintiff has the following severe impairments that cause significant limitations on her ability to perform basic work activities: "vertigo, bilateral knee degenerative joint disease (DJD), lumbar spine degenerative disc disease (DDD), morbid obesity, carpal tunnel syndrome (CTS), coronary artery disease (CAD), and depression." AR 712.
At step four, the ALJ determined that Plaintiff has the residual functional capacity to perform sedentary work as follows: "able to lift and/or carry 20 pounds occasionally and 10 pounds frequently; sit for 6 hours in an 8 hour workday; stand and or/walk for 2 hours in an 8 hour workday; cannot climb ladders, ropes or scaffolds; occasionally climb ramps and stairs; occasionally balance, stoop, kneel, crouch, and crawl; frequently handle and finger bilaterally; must avoid concentrated exposure to fumes, odors, dusts, gases, and poor ventilation; must avoid all exposure to hazards; and is limited to simple repetitive tasks with occasional contact with supervisors, co-workers, and the public." AR 714.
The ALJ's discussion of the evidence in her 2014 opinion in part repeats her 2010 opinion. In the 2014 opinion, the ALJ again relied in part on state agency medical consultant Dr. Dipsia's RFC assessment from March 25, 2008. AR 715. The ALJ afforded very little weight to state agency medical consultant Dr. Gallucci's mental RFC assessment of March 20, 2008 because the ALJ found that Plaintiff's mental limitations are greater than those found by Dr. Gallucci. AR 716. It does not appear that the record contained any opinion from a consulting examiner after 2008. As she did previously, the ALJ afforded reduced weight to Plaintiff's treating nurse practitioner Darrel Brown's opinion that Plaintiff could stand/walk and sit zero to two hours in an eight hour workday because he failed to provide an explanation for Ms. Williams' inability to sit based on issues with her knee and hand, and knee and spine x-rays showed only mild findings. In contrast, the ALJ found the state agency's limitation that Ms. Williams could only sit for two hours in an eight-hour workday to be credible because of her obesity and diagnosis of internal derangement. The ALJ found that there was limited evidence regarding Plaintiff's alleged limitations regarding the use of her hands and no evidence from any source of an inability to perform repetitive motions with her hands. However, in light of Plaintiff's carpal tunnel surgery and recent evidence and Plaintiff's hearing testimony, and in contrast to Dr. Dipsia's RFC assessment that no manipulative limitations had been established, the ALJ limited Plaintiff to frequent handling and fingering. AR 716. The ALJ found that the limitation of "simple jobs with occasional contact with people" was reasonable in light of Ms. Williams' documented depression and anxiety. AR 717. The ALJ found that the Plaintiff's GAF score of 60 at Redbud Family Health Center in August 2008 was not severe enough to limit her to any further restriction, and found that the much lower GAF score of 45 in January 2010 was explained by the loss of her friend who had passed away that afternoon. AR 25. The ALJ stated that there was no RFC assessment from a treating mental health source that limited her to any further restriction. AR 717.
In developing this RFC assessment, the ALJ found that Plaintiff'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 credible[.]" AR 715. Regarding pain, the ALJ noted Plaintiff's testimony that she has no pain when she takes Percocet and Norco pain medication, she has had very limited treatment, and there is no recommendation for another surgery on the right hand or one on the left hand. AR 717. The ALJ found that Plaintiff's testimony regarding her hands was consistent with the manipulative limitations in the RFC, and her difficulty with bending despite medication was also reflected. AR 717. Regarding fatigue and vertigo, the ALJ further acknowledged Plaintiff's testimony that she suffers from drowsiness and vertigo from her medications, but noted Plaintiff's unequivocal testimony that medication helps with vertigo. AR 739.
At step five, the ALJ determined that Plaintiff was 42 years old at the time of her alleged onset date, has no past relevant work, has a high school education and is able to communicate in English. Based on her age, education, work experience and RFC, and relying on the testimony of a vocational expert, the ALJ determined that there are jobs existing in significant numbers in the national economy that Plaintiff could perform and therefore Plaintiff is not disabled. AR 718-19.
Ms. Williams was born on May 9, 1967 in El Salvador. AR 138, 465. She was raised in the United States and has a high school education. AR 465. Ms. Williams has four children, one of whom lived with her as of the time of her 2013 hearing before the ALJ. AR 742-43. Her children's father died suddenly of a heart attack in 2007. AR 465. Prior to her alleged onset date, Ms. Williams only had three short-term jobs in the last fifteen years. AR 53;
Ms. Williams' medical record reflects a history of medical issues. Redbud Family Health Center (a.k.a Adventist Health, a.k.a Clearlake Family Health Center) and St. Helena Hospital Clearlake appear to have been her primary health care facilities for many years.
A detailed description of the medical evidence in the record in
For
On May 6, 2010, Plaintiff underwent surgery for a right carpal tunnel release. AR 873-74. On May 4, 2011, Dr. Axtell performed a follow-up examination of Plaintiff and gave her a cortisone injection in her left wrist. He noted that "based on her poor result from the previous carpal tunnel release, we are going to try to hold off on any further surgery for her." AR 877. In July 2011, Plaintiff returned to Dr. Axtell, who noted that the cortisone injection helped her significantly, "though it is giving her more symptoms now." AR 878.
Plaintiff also supplemented the record for
In April 2011, Dr. Park examined Plaintiff for possible coronary artery disease but found that most of her tests were normal through she had left myocardial ischemia. AR 906-07. Thereafter Plaintiff went to the emergency room for chest pain and palpitations but doctors found no evidence of acute heart injury. AR 908-912.
In May 2011, Plaintiff sought a second opinion from cardiologist Dr. Clair after Dr. Park recommended an angiogram. Dr. Clair also recommended a coronary angiography. AR 868. In March and April 2012, Plaintiff returned to Dr. Clair due to chest pain and palpitations, and he found that she did not have significant coronary artery disease but scheduled a stress test. AR 881-87. Her stress test results were normal, and exercise was recommended. AR 890-91. In May 2013, Dr. Clair reexamined Plaintiff, found nothing significant, and determined to see her again in a year. AR 893.
From at least June through September 2013, Plaintiff was seen on several occasions for foot pain resulting from a cyst. AR 895-903. In August 2012, an examination revealed relatively limited disk disease in her spine. AR 917.
According to 42 U.S.C. § 405(g), the Court's jurisdiction is limited to determining whether the findings of fact in the ALJ's decision are supported by substantial evidence or were premised on legal error. 42 U.S.C. § 405(g);
To determine whether the ALJ's decision is supported by substantial evidence, courts review the administrative record as a whole, weighing both the evidence that supports and detracts from the ALJ's decision.
In order to qualify for disability insurance benefits, Plaintiff must demonstrate an "inability 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 SSA utilizes a five-step sequential evaluation process in making a determination of disability. 20 C.F.R. § 404.1520 (2009);
First, the SSA looks to the claimant's work activity, if any; if the claimant engages in substantial gainful activity, he or she is not disabled. 20 C.F.R. § 404.1520(a)(4)(I). Second, the SSA considers whether the claimant suffers from a severe impairment or number of impairments which has lasted or is expected to last twelve months or end in death. 20 C.F.R. § 404.1520(a)(4)(ii). Third, the SSA considers the severity of the impairments; the claimant is disabled if he or she has an impairment that meets or equals one of the listings set forth in 20 C.F.R., part 404, subpart P, appendix 1, which sets forth impairments whose level of severity conclusively establishes disability, irrespective of vocational factors. 20 C.F.R. § 404.1520(a)(4)(iii). Fourth, the SSA considers the residual functional capacity ("RFC") and past relevant work; if the claimant can still engage in past relevant work, he or she is not disabled. 20 C.F.R. § 404.1520(a)(4)(iv). Fifth, the SSA again considers the RFC and age, education, and work experience to see if the claimant is able to make an adjustment to another occupation in the national economy. 20 C.F.R. § 404.1520(a)(4)(v); 20 C.F.R. § 404.1560(c).
In determining whether a claimant's testimony regarding subjective pain or symptoms is credible, the ALJ must engage in a two-step process.
In her motion for summary judgment, Plaintiff argues that: (1) her testimony is credible and should be credited fully; (2) the ALJ inaccurately and incompletely reported the medical records; (3) the ALJ failed to properly weigh all of her treating source opinions; and (4) the ALJ failed to properly determine the limitations stemming from Plaintiff's coronary artery disease, vertigo and bipolar disorder. In its opposition and cross-motion for summary judgment, the Government does not specifically address any of Plaintiff's arguments, instead generally contending that substantial evidence supports the ALJ's decision and it is free of legal error.
On Reply, Plaintiff abandons most of her arguments, focusing entirely on the ALJ's alleged failure to comply with the Court's remand order to give clear and convincing reasons for rejecting Plaintiff's pain and fatigue testimony or credit her testimony as true. Plaintiff argues that the ALJ should only have re-considered evidence and testimony relating to Plaintiff's pain and fatigue, and contends that although additional evidence was submitted after remand, it was not substantially different from the other evidence and her complaints are the same or worse. Reply at 3.
In its prior Order granting in part and denying in part the cross-motions for summary judgment and remanding the case, the Court found that the ALJ's opinion in
Plaintiff argues that the ALJ's opinion in
In her 2014 decision, the ALJ again found that Plaintiff'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 credible[.]" AR 715. Regarding hand pain, the ALJ noted Plaintiff's testimony that she has no pain when she takes Percocet and Norco pain medication, she has had very limited treatment, and there is no recommendation for another surgery on the right hand or one on the left hand. AR 717. The ALJ also noted Plaintiff's testimony that medication helps with her shoulder, neck and back pain, and that difficulty with bending is reflected in the RFC.
The ALJ's reasons for discrediting Plaintiff's pain testimony a second time are more specific than those given in her previous opinion and are sufficiently "clear and convincing." Plaintiff points out that the ALJ relied on the efficacy of Plaintiff's pain medications, including Plaintiff's testimony about her relief with medication, but did not mention her testimony that medication relieved her pain only about two of every four hours. Plaintiff also argues that the ALJ relied on Plaintiff's lack of hand surgery but did not mention that the reason that there was no recommendation for an additional carpal tunnel surgery on Plaintiff's left hand or one on her right was because of the "poor result" of the first surgery. AR 877. However, these omissions do not amount to a failure to provide clear and convincing reasons for rejecting Plaintiff's credibility regarding the degree of her pain, where Plaintiff's own testimony also reflected significant use of her hands (i.e., writing with a pen) and shoulder and neck pain only once a day. Further, the ALJ noted that cortisone injections helped Plaintiff significantly. The Court will not "second guess" the ALJ's finding on this issue.
Regarding fatigue, the ALJ acknowledged Plaintiff's testimony that she suffers from drowsiness and vertigo from her medications, but noted Plaintiff's testimony that medication helps with vertigo. The ALJ rejected Plaintiff's testimony that she needs to sleep for one to one and one-half hours three times a week and lies in bed for three to four hours every day because "there is no evidence in the medical record that claimant reported this level of fatigue to her doctors. Also, there is no opinion from any treating source since the claimant's amended AOD of May 6, 2010 that she suffers from such severe pain and fatigue that she cannot perform any type of work." AR 717. Plaintiff argues that the ALJ ignored repeated reports of excessive daytime sleepiness, citing pages 921, 925, 932, 933, 937, 959-960, 961, 965, and 969 of the Administrative Record. However, none of these records reflect any self or medical report of excessive daytime sleepiness. At most, they reflect that Plaintiff self-reported some level of fatigue on occasion to Ms. Payette (AR 921, 931, 937, 955), but also reported that she was "energized" and getting good sleep at other times (AR 926, 933, 949, 951). While not as detailed as they could be, the reasons given by the ALJ in her second decision to discredit Plaintiff's testimony regarding the level of her fatigue are sufficient, especially given the lack of medical evidence relating to the degree of Plaintiff's fatigue and the undisputed fact that she never reported a need to sleep for several hours a day to any doctor. The ALJ's decision on this issue is also affirmed.
In her moving papers, Plaintiff made several other arguments which she abandoned on reply. However, for the sake of completeness these arguments are addressed briefly herein.
First, Plaintiff initially argued that the ALJ committed error by failing to discuss medical records from treating physician Dr. McQuaid, who saw Plaintiff for foot pain due to a cyst in 2013, and Drs. Mizl, Jennings and an unknown doctor, who signed off on Ms. Payette's mental evaluations of Plaintiff from 2009 through 2013.
Similarly, the ALJ's failure to specifically discuss the doctors who signed off on Ms. Payette's mental health evaluations of Plaintiff was, at most, harmless error. These doctors do not appear to have conducted any independent evaluation of Plaintiff and thus their opinions are the same as those contained in Ms. Payette's reports, which were considered. Plaintiff argues that the ALJ failed to properly consider all of Ms. Payette's reports relating to her mental health from 2009 through 2013.
Further, Plaintiff contended in her moving papers that the ALJ failed to properly determine the limitations from her alleged coronary artery disease, vertigo and bipolar disorder and instead relied on the outdated 2008 opinions of consultative examiners Dr. Golnick-Hallows and Dr. Galluci. She points out that neither consultative examiner reviewed any medical evidence after 2008, and there was no effort to obtain an updated examination based on the full medical record. However, the ALJ did take into account Plaintiff's coronary artery disease by limiting her to avoiding concentrated exposure to fumes, odors, dusts, gases and poor ventilation. AR 717. Plaintiff contends that these limitations are not tethered to any medical report, but any error in imposing these limitations was harmless given that they are more stringent than anything suggested in the medical reports relating to Plaintiff's heart health.
Finally, as discussed above, this Court previously held that Plaintiff's mental impairments, including bipolar disorder, do not support a finding of disability and Plaintiff has not cited any new or additional evidence that would alter this determination.
For all of the foregoing reasons, the Court DENIES Plaintiff's Motion for Summary Judgment and GRANTS Defendant's Cross-Motion for Summary Judgment.
