JOHN E. McDERMOTT, Magistrate Judge.
On December 5, 2017, Valerie Christina Vetrano ("Plaintiff" or "Claimant") filed a complaint seeking review of the decision by the Commissioner of Social Security ("Commissioner") denying Plaintiff's application for Social Security Disability Insurance benefits. (Dkt. 1.) The Commissioner filed an Answer on March 22, 2018. (Dkt. 14.) On August 17, 2018, the parties filed a Joint Stipulation ("JS"). (Dkt. 19.) On January 4, 2019, this Court ordered supplemental briefing on whether Plaintiff meets or equals a listing, which was due January 25, 2019. (Dkt. 21.) On January 9, 2019, the Court stayed this case on application by the Commissioner due to a lapse in appropriations. (Dkt. 23.) On January 30, 2019, when the shutdown was over, the Court lifted the stay and ordered the parties to file their supplemental briefs by February 9, 2019. (Dkt. 24.) Plaintiff filed her brief on January 31, 2019. (Dkt. 27.) The Commissioner filed her Supplemental Briefing on February 20, 2019. (Dkt. 28.) The matter is now ready for decision.
Pursuant to 28 U.S.C. § 636(c), both parties consented to proceed bef ore this Magistrate Judge. After reviewing the pleadings, transcripts, and administrative record ("AR"), the Court concludes that the Commissioner's decision must be affirmed and this case dismissed with prejudice.
Plaintiff is a 45 year-old female who applied for Social Security Disability Insurance benefits on November 8, 2013, alleging disability beginning December 30, 2012. (AR 21.) The ALJ determined that Plaintiff had not engaged in substantial gainful activity since December 30, 2012, the alleged onset date. (AR 23.)
Plaintiff's claim was denied initially on November 8, 2013, and on reconsideration on July 14, 2014. (AR 21.) Plaintiff filed a timely request for hearing on September 9, 2014. (AR 21.) On April 5, 2016, the Administrative Law Judge ("ALJ") Michael B. Richardson held a video hearing from Moreno Valley, California. (AR 21.) Plaintiff appeared and testified in Indio, California. (AR 21.) Plaintiff was represented by counsel. (AR 21.) Vocational expert ("VE") Erin M. Welsh also appeared and testified at the hearing. (AR 21.)
The ALJ issued an unfavorable decision on April 15, 2016. (AR 21-32.) The Appeals Council denied review on November 2, 2017. (AR 1-4.)
As reflected in the Joint Stipulation, Plaintiff raises the following disputed issues as grounds for reversal and remand:
Under 42 U.S.C. § 405(g), this Court reviews the ALJ's decision to determine whether the ALJ's findings are supported by substantial evidence and free of legal error.
Substantial evidence means "`more than a mere scintilla,' but less than a preponderance."
This Court must review the record as a whole and consider adverse as well as supporting evidence.
The Social Security Act defines disability as the "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 . . . can be expected to last for a continuous period of not less than 12 months." 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A). The Commissioner has established a five-step sequential process to determine whether a claimant is disabled. 20 C.F.R. §§ 404.1520, 416.920.
The first step is to determine whether the claimant is presently engaging in substantial gainful activity.
If the claimant cannot perform his or her past relevant work or has no past relevant work, the ALJ proceeds to the fifth step and must determine whether the impairment prevents the claimant from performing any other substantial gainful activity.
In this case, the ALJ determined at step one of the sequential process that Plaintiff has not engaged in substantial gainful activity since December 30, 2012, the alleged onset date. (AR 23.)
At step two, the ALJ determined that Plaintiff has the following medically determinable severe impairments: post-laminectomy syndrome of the thoracic spine; mild degenerative disc disease of the lumbar spine at L4-5 with lumbago and radiculopathy; and Crohn's disease. (AR 23-25.)
At step three, the ALJ determined that Plaintiff does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments. (AR 25-26.)
The ALJ then found that Plaintiff had the RFC to perform a range of light work as defined in 20 CFR § 404.1567(b) with the following limitations:
(AR 26-30.) In determining the above RFC, the ALJ made a determination that Plaintiff's subjective symptom allegations were "not entirely consistent" with the medical and other evidence of record. (AR 27.)
At step four, the ALJ found that Plaintiff is not able to perform her past relevant work as a waitress, paper route distributor, food server, loan processing clerk, and sales representative. (AR 30.) The ALJ, however, also found that, considering Claimant's age, education, work experience, and RFC, there are jobs that exist in significant numbers in the national economy that Claimant can perform, including the jobs of mail room clerk, office helper, and information clerk. (AR 31-32.)
Consequently, the ALJ found that Claimant is not disabled, within the meaning of the Social Security Act. (AR 32.)
The ALJ decision must be affirmed. Plaintiff does not meet or equal a Listing. The ALJ properly considered the medical evidence in assessing Plaintiff's RFC. The ALJ properly discounted Plaintiff's subjective symptom allegations. The ALJ's RFC is supported by substantial evidence.
Plaintiff alleges that she cannot work because of chronic back pain and persistent symptoms of abdominal pain and diarrhea due to Crohn's disease, an inflammatory bowel disease. (AR 26-30.) The ALJ did find that Plaintiff has post-laminectomy syndrome of the thoracic spine; mild degenerative disc disease of the lumbar spine with lumbago and radiculopathy; and Crohn's disease. (AR 23.) The ALJ assessed an RFC for a restricted range of light work. (AR 26.)
At step three of the sequential process, the ALJ found that Claimant's medically determinable physical impairments do not meet the criteria of "any" Listing, including Listings 1.02 and 5.06.
Social Security regulations provide that a claimant is disabled if he or she meets or medically equals a listed impairment. Section 416.920(a)(4)(iii) ("If you have an impairment that meets or equals one of our listings . . . we will find that you are disabled"); Section 416.920(d) ("If you have an impairment(s) which . . . is listed in Appendix 1 or is equal to a listed impairment(s), we will find you disabled without considering your age, education, and work experience"). In other words, if a claimant meets or equals a listing, he or she will be found disabled at this step "without further inquiry."
The listings in Appendix 1 describe specific impairments considered "severe enough to prevent an individual from doing gainful activity, regardless of his or her age, education, or work experience." Section 404.1525. An impairment that meets a listing must satisfy all the medical criteria required for that listing. Section 404.1525(c)(3);
Medical equivalence will be found if the impairment "is at least equal in severity and duration to the criteria of any listed impairment." (Section 404.1526(a)). Medical equivalence is based on symptoms, signs, and laboratory findings, but not subjective symptoms. Section 404.1529(d)(3).
Plaintiff contends that her medically determinable impairment of Crohn's disease satisfies the criteria of Listings 5.06(B) and 5.08. Listing 5.06(B) for inflammatory bowel disease requires a claimant to meet two of six listed impairments:
Listing 5.08 addresses weight loss due to any digestive disorder:
Plaintiff contends that she meets the criteria set forth in 5.06(B)(4) and (5), and 5.08. As to 5.06(B)(4), she cites to medical records that she had anal pain and two perineal/rectal draining abscesses, on November 22, 2014, and May 11, 2015. (AR 627-628, 637-638.) The ALJ decision confirms perirectal abscess drainage in November 2014 and May 2015. (AR 29.) The ALJ also cited to a consulting report from Dr. Anthony Weiss dated September 17, 2015, indicating that Plaintiff had "a perirectal abscess which was treated in November 2014 which required drainage." (AR 29, 540.) In the Joint Stipulation (JS at 23:1-2), the Com missioner stated, "Plaintiff required drainage of a perirectal abscess in November 2014 and again in May 2015."
The record evidence regarding the November 2014 perirectal abscess drainage, however, is nonetheless conflicting. In the Supplemental Briefing, the Commissioner concedes once again that Plaintiff has presented evidence of one draining abscess on May 11, 2015, but now contests that there was any abscess drainage in November 2014, although Plaintiff was sent to the ER for drainage. (AR 582; Dkt. 28, 3:20-4:10.) The Commissioner cites to a November 20, 2014 report from ER physician Eric Ory that "she needs no incision and no drainage." (AR 643.) Dr. Cristina Jenkins who performed the May 11, 2015 surgery noted in her history that, "In November she developed perirectal pain and an anorectal abscess — it was not drained and It spontaneously opened on its own." (AR 758.) In conflict with this report is a November 22, 2014 ER report, relied on by Plaintiff, that appears to say "abscess now draining" (AR 638), although the language is hard to read.
It is not for this Court or the Commissioner to rewrite the ALJ decision, which documented abscess drainage in November 2014 and May 2015. (AR 29.) In view of the ALJ's lengthy summary and analysis of Plaintiff's Crohn's disease (AR 29-30), the Court must assume that the ALJ weighed the conflicting evidence and concluded that perirectal abscess drainage occurred in both November 2014 and May 2015.
Nonetheless, Plaintiff does not meet other criteria for Listings 5.06(B)(4) and (B)(5) or for 5.08. Those Listings do not apply unless the impairments occur "despite continuing treatment as prescribed" and for 5.06(B)(4) there must be pain "not completely controlled by prescribed narcotic medication." Here, the ALJ documented that medication effectively controlled Plaintiff's Crohn's disease. (AR 27.) Plaintiff has a long history with Crohn's disease, for which she was prescribed Remicade in 2002. (AR 29.) Claimant did well on this medication until 2012 when she developed infectious osteomyelitis with staphylococcus infection. (AR 29.) Plaintiff stopped taking medication and was not under any medication maintenance for her Crohn's disease. (AR 29.) While off treatment, Claimant experienced cramps, diarrhea, and weight loss during the period at issue. (AR 29, 540, 738, 745-46, 752.) She was not taking any maintenance medication for her Crohn's disease before the November 2014 abscess drainage. (AR 738-39.) Listing 5.06(B)(4), however, requires "pain not completely controlled by prescribed narcotic medication." Listings 5.06(B)(4) and (5) and 5.08 require "continuing treatment as prescribed." Here, Plaintiff has not met her burden to show that she had pain not controlled by prescribed narcotic medication and despite continuing treatment prior to the November 2014 abscess drainage.
Plaintiff also was non-compliant with her medication before the May 2015 biopsy: on 4/14/15 "only taking ½ of an immodium pill per day" (AR 739) compared to "doing well overall since starting VSL, she has had more formed stools and decreased frequency" on 5/27/15. (AR 739.) Plaintiff has failed to demonstrated that her symptoms under any of the Listings continued during the period when she was compliant with recommended medical treatment.
Plaintiff argues that she stopped medication in 2012 because of its side effects, but at the time of the November 2014 abscess drainage Claimant was prescribed several medications and her condition became stable with medication thereafter. (AR 29, 27.) Impairments that can be effectively controlled with medication are not disabling.
Plaintiff has not proven that her pain, abscess drainage, diarrhea, and weight loss symptoms were not amenable to medication and medical treatment in the period just prior to and through November 2014 or for any period thereafter. As a result, Plaintiff does not meet the criteria for Listings 5.06(B)(4) or (B)(5), or 5.08.
Plaintiff challenges the ALJ's interpretation of the record evidence, but it is the ALJ's responsibility to resolve conflicts in the medical evidence.
The ALJ's step three determination that Plaintiff does not meet or equal a Listed impairment is supported by substantial evidence.
Plaintiff contends that the ALJ erred in rejecting the opinions of two physicians, Dr. Zadeh and Dr. Moeller-Bertram. The Court disagrees.
The ALJ's RFC is not a medical determination but an administrative finding or legal decision reserved to the Commissioner based on consideration of all the relevant evidence, including medical evidence, lay witnesses, and subjective symptoms. See SSR 96-5p; 20 C.F.R. § 1527(e). In determining a claimant's RFC, an ALJ must consider all relevant evidence in the record, including medical records, lay evidence, and the effects of symptoms, including pain reasonably attributable to the medical condition. Robbins, 446 F.3d at 883.
In evaluating medical opinions, the case law and regulations distinguish among the opinions of three types of physicians: (1) those who treat the claimant (treating physicians); (2) those who examine but do not treat the claimant (examining physicians); and (3) those who neither examine nor treat the claimant (non-examining, or consulting, physicians).
Where a treating doctor's opinion is not contradicted by another doctor, it may be rejected only for "clear and convincing" reasons.
Dr. Homan A. Zadeh, Plaintiff's treating gastroenterologist, filled out a Crohn's, Colitis and Incontinence Functional Capacity Questionnaire on October 7, 2014. (AR 30, 537-539.) Dr. Zadeh stated: (1) Plaintiff would require unscheduled restroom breaks during an 8 hour work day; (2) she would need to lie down to rest at unpredictable intervals during a work day; and (3) her symptoms would interfere with her attention and concentration to perform even simple tasks. (AR 538-539.)
The ALJ gave Dr. Zadeh's opinion "some weight," in particular his opinion that Plaintiff would require unscheduled restroom breaks throughout the day due to her Crohn's disease. (AR 30.) The ALJ included additional restroom breaks in the Claimant's RFC. (AR 30.) Specifically, the RFC provides: "She requires four additional restroom breaks of five minutes per day. She requires easy access to restroom facilities." (AR 26.)
Plaintiff contends that the ALJ ignored Dr. Zadeh's two other limitations and rejected those limitations without articulating any reason for doing so. Plaintiff is incorrect. The ALJ did give reasons for rejecting Dr. Zadeh's other limitations elsewhere in the decision. There is no requirement that these reasons appear anywhere in particular in the decision.
Regarding Plaintiff's ability to maintain concentration and attention, the ALJ addressed that issue in his step two severity determination. There was no need to address it again later in the decision when discussing Dr. Zadeh's opinion. The ALJ gave great weight to the opinions of consulting psychologist Dr. Kara Cross and State agency reviewing psychologists Dr. R. Paxton and Dr. Heather Barrons. (AR 24-25.) On January 31, 2014, Dr. Cross conducted a mental status examination and found Claimant's thoughts to be coherent and organized. (AR 24-25, 490-496.) She was alert and oriented with good insight and judgment. (AR 25.) She specifically assessed Plaintiff with no limitations in the ability to maintain concentration and attention. (AR 495.) Dr. Cross assessed no Axis 1 diagnosis. (AR 25, 494.) Although a mental status examination in May 2014 revealed poor concentration, later mental status examinations revealed unremarkable findings and the ability to maintain concentration. (AR 25.) Based on the entire record, the ALJ concluded that Claim ant has only mild limitations in concentration, persistence and pace. (AR 24.) Dr. Cross and the two State agency psychologists found Claimant's mental impairments to be nonsevere, an assessment the ALJ adopted. (AR 25.) These opinions plainly contradict Dr. Zadeh's opinion regarding Plaintiff's ability to maintain concentration and attention. The contradicting opinions of other physicians provide specific, legitimate reasons for rejecting a physician's opinion.
Additionally, the medical records indicate that medications have been effective in controlling Claimant's symptoms that Dr. Zadeh indicated would interfere with her ability to maintain concentration and attention. (AR 27, 29.) Impairments that can be controlled effectively with medication are not disabling.
Regarding Dr. Zadeh's opinion that Plaintiff would need to lie down and rest at unpredictable levels, the ALJ found that Plaintiff could perform light work. The ALJ acknowledged Plaintiff's back pain but also noted that imaging of her lumbar spine revealed only mild findings with no evidence of significant stenosis. (AR 27.) Imaging of Claimant's thoracic spine revealed no evidence of root impingement, severe stenosis, progressive neurological deficits, infections, or fractures. (AR 27.) There was no evidence of gait abnormalities and Claimant was not prescribed an assistive device for ambulation. (AR 27.) State agency physicians Dr. R. Jacobs and Dr. Stuart Larkin each opined Plaintiff retained the physical capacity to perform a range of light work. (AR 104-105, 116-118.) These findings and opinions contradict Dr. Zadeh's opinion that Plaintiff would need to lie down or rest at unpredictable intervals each work day.
The ALJ rejected Dr. Zadeh's opinions for specific, legitimate reasons supported by substantial evidence.
Dr. Tobias Moeller-Bertram, a pain management physician, completed a Physical Residual Functional Capacity Questionnaire on April 4, 2016. (AR 30, 857-860.) He opined Plaintiff could perform less than sedentary work, lift less than 10 pounds frequently, sit for four hours but no more than 20 minutes at a time, stand for no more than 45 minutes at a time, and would miss more than four days of work per month. (AR 858-860.) As the ALJ noted, Dr. Moeller-Bertram's assessed limitations would preclude all work. (AR 30.)
The ALJ gave little weight to Dr. Moeller-Bertram's opinion because he did not provide any objective medical evidence to support such restrictive limitations. (AR 30.) The ALJ also found that Dr. Moeller-Bertram's opinion is not supported by the diagnostic and objective clinical findings in the record. (AR 30.) Additionally, the ALJ noted the medical file indicates some improvement of her pain with treatment. (AR 30.) Thus, the ALJ regarded Dr. Moeller-Bertram's opinion as conclusory and consequently gave it no probative value and rejected it. (AR 30.) The ALJ need not accept the opinion of a doctor that is brief, conclusory, in the form of a checklist, inadequately supported by clinical findings, does not have supportive objective evidence, is contradicted by other evidence, is not supported by the record as a whole, or is unsupported by or inconsistent with his or her treatment notes.
The ALJ reasonably found Dr. Moeller-Bertram's opinion conclusory as the RFC questionnaire is a two page check the box form without any accompanying objective medical evidence (AR 858-859).
Plaintiff identifies little support for Dr. Moeller-Bertram's RFC assessment in his treatment notes. (AR 765-855.) The two records cited by Plaintiff (AR 767-768) only repeat his finding of mildly decreased range of motion and moderate pain. Those same records indicate many normal findings. There is no mention of reaching, handling, and fingering problems. The records document that her current medication regimen is managing her pain without side effects. (AR 771.) An ALJ may reject a physician's opinion if it is unsupported by or inconsistent with his or her treatment notes.
The ALJ also rejected Dr. Moeller-Bertram's opinion because it is "not supported by the diagnostic and objective clinical findings in the record." (AR 30.) This would include the mild imaging evidence of Plaintiff's thoracic and lumbar spine, with no evidence of significant stenosis, nerve root impingement, infections or fractures. (AR 27.) The ALJ also found no evidence of gait abnormalities and Claimant has not been prescribed an assistive device for ambulation. (AR 27.) The ALJ found that medications have been relatively effective in controlling Plaintiff's symptoms. (AR 27.) An ALJ may reject a physician's opinion that is contradicted by other evidence and not supported by the record as a whole.
Further, Dr. Moeller-Bertram's opinion conflicts with the opinions of other physicians of record, including the State agency reviewing physicians who assessed light work RFCs with no manipulative limitations. (AR 102-105, 114-117.) His opinion that Plaintiff's mental limitations were severe enough to interfere with attention and concentration to perform even simple tasks is contradicted by the opinions of Drs. Cross, Paxton, and Barrons who opined Plaintiff had mild, nonsevere mental impairments. (AR 24-25.) The conflicting opinions of other physicians provide specific legitimate reasons for rejecting a physician's opinion.
The ALJ also discounted Dr. Moeller-Bertram's opinion because Claimant had some improvement of her pain with treatment. (AR 30.) Office visit notes reflect that Claimant's pain improved with medication, injections, and acupuncture. (AR 27.) Impairments that can be controlled effectively with medication are not disabling.
The ALJ rejected the opinions of Dr. Moeller-Bertram for specific, legitimate reasons supported by substantial evidence.
Plaintiff contends that the ALJ erred in discounting Plaintiff's subjective symptom allegations. The Court disagrees.
The test for deciding whether to accept a claimant's subjective symptom testimony turns on whether the claimant produces medical evidence of an impairment that reasonably could be expected to produce the pain or other symptoms alleged.
In determining Plaintiff's RFC, the ALJ concluded that Plaintiff's medically determinable impairments reasonably could be expected to cause the alleged symptoms. (AR 28, 27.) The ALJ, however, also found that Plaintiff's statements regarding the intensity, persistence, and limiting effects of these symptoms are "not entirely consistent" with the medical evidence and other evidence of record. (AR 28, 27.) Because the ALJ did not make any finding of malingering, he was required to provide clear and convincing reasons supported by substantial evidence for discounting Plaintiff's subjective symptom allegations.
First, the ALJ found that Plaintiff's subjective symptom allegations were "too extreme in light of the objective medical findings." (AR 27-30.) An ALJ is permitted to consider whether there is a lack of medical evidence to corroborate a claimant's alleged symptoms so long as it is not the only reason for discounting a claimant's allegations.
Second, the ALJ found that medications have been relatively effective in controlling Claimant's symptoms. (AR 27.) Claimant's pain improved with medications, injections, and acupuncture. (AR 27.) Plaintiff herself reported improvement in her diarrhea and abdominal pain with medication for her Crohn's disease. (AR 27.) Impairments that can be controlled with medication and treatment are not disabling.
Third, the ALJ determined that Plaintiff's daily activities are inconsistent with disabling limitations, which is a legitimate consideration in evaluating credibility.
Plaintiff disputes the ALJ's interpretation of the record regarding her subjective symptom allegations, but again it is the ALJ's responsibility to resolve conflicts in the medical evidence and ambiguities in the record.
The ALJ discounted Plaintiff's subjective symptom allegations for clear and convincing reasons supported by substantial evidence.
The ALJ's non-disability determination is supported by substantial evidence and free of legal error.
IT IS HEREBY ORDERED that Judgment be entered affirming the decision of the Commissioner of Social Security and dismissing this action with prejudice.