CAROLYN K. DELANEY, Magistrate Judge.
Plaintiff seeks judicial review of a final decision of the Commissioner of Social Security ("Commissioner") denying an application for Supplemental Security Income ("SSI") under Title XVI of the Social Security Act ("Act"). For the reasons discussed below, the court will deny plaintiff's motion for summary judgment and grant the Commissioner's cross-motion for summary judgment.
Plaintiff, born December 24, 1966 applied on April 6, 2012 for SSI, alleging disability beginning October 25, 2011. Administrative Transcript ("AT") 18, 200. Plaintiff alleged she was unable to work due to severe pain in her lower back, upper shoulders, and upper arms, a back injury, diminished range of motion in her neck, and radiation into her right forearm. AT 79. Initially, upon reconsideration, and ultimately in a decision by the ALJ dated October 1, 2014, plaintiff was found not disabled.
AT 20-26.
Plaintiff argues that the ALJ committed the following errors in finding her not disabled: (1) the ALJ failed to articulate legitimate reasons for rejecting the opinions of Ms. Mendoza's treating physicians; and (2) the ALJ failed to articulate clear and convincing reasons for rejecting Ms. Mendoza's and her daughter's statements regarding her pain and functional limitations.
The court reviews the Commissioner's decision to determine whether (1) it is based on proper legal standards pursuant to 42 U.S.C. § 405(g), and (2) substantial evidence in the record as a whole supports it.
The record as a whole must be considered,
Plaintiff asserts that two treating physicians, Dr. Barzaga and Dr. Francisco, diagnosed her with fibromyalgia, citing related symptoms and functional limitations, and that the ALJ erred in according their opinions "reduced weight." Defendant counters that the ALJ properly evaluated conflicting evidence, explaining his interpretation of plaintiff's medical records in a lengthy discussion, and that his findings are reasonable and entitled to deference. The court addresses these doctors' opinions in turn.
Dr. Graciela Barzaga evaluated plaintiff on June 24, 2013. AT 445-447. She noted plaintiff's "low back pain and diffuse pain since 2001." AT 445. Plaintiff reported to Dr. Barzaga that her "memory is impaired, she is always tired" and that she had daily headaches for the past seven years. AT 445. Plaintiff also reported "intermittent numbness of both hands." AT 445. Except for a vitamin D deficiency, plaintiff's laboratory studies were all normal. AT 445. Examining plaintiff, Dr. Barzaga found that she was in "good health," with a negative neurological examination and a normal range of motion in her spine. AT 445-447. However, plaintiff had "more than 18 trigger areas" in her back. AT 446. Dr. Barzaga also noted "slight swelling of the matacarpophalangeal joints." AT 447. Dr. Barzaga diagnosed fibromyalgia
Six months later, in December 2013, Dr. Barzaga filled out a Fibromyalgia Medical Source Statement for plaintiff. AT 416-420. She indicated that plaintiff met the criteria for fibromyalgia and listed her symptoms and associated conditions: a history of widespread pain, 11 of 18 specified tender points, cognitive dysfunction ("fibro fog"), insomnia, and fatigue. AT 416. Dr. Barzaga identified pain located in the lumbrosacral spine, cervical spine, both legs, and both knees, ankles, and feet. AT 417. She identified hormonal changes and sleep problems as factors precipitating pain. AT 417. Dr. Barzaga concluded that plaintiff lacked "the stamina and endurance to work an easy job 8 hours per day, 5 days per week (with normal breaks every two hours)," citing fatigue as the reason. AT 418. Dr. Barzaga opined that plaintiff would need to take unscheduled breaks once an hour, due to fatigue and muscle weakness. AT 419. She also stated that plaintiff had significant limitations in reaching, handling, or fingering objects. AT 419. Dr. Barzaga opined that plaintiff was incapable of even "low stress" work. AT 420. She also stated that plaintiff was likely to be absent from work more than four days per month. AT 420.
After summarizing Dr. Barzaga's findings, the ALJ assessed her opinion as follows:
AT 23. The ALJ noted that Dr. Barzaga's examination results were consistent with the findings of Dr. Van Kirk, who performed a consultative orthopedic examination of plaintiff in July 2012 (AT 338-342), but "entirely inconsistent with the opinions of Dr. Van Kirk and the State agency non-examining doctors, who did not find a basis for limiting the claimant beyond a medium [RFC] due to normal examination findings and no objective clinical signs . . . that would prevent the claimant from doing such activities." AT 23.
As referenced by the ALJ, Dr. Van Kirk evaluated plaintiff for neck and low back pain in 2012. He noted plaintiff's report that her neck and back pain began after a 1997 car accident, and diagnosed likely degenerative disc disease. AT 338-339. He further noted that plaintiff lived with her children, was able to cook and do "simple household chores such as vacuuming and mopping," took several walks per day, and drove a car. AT 339. Dr. Van Kirk observed that plaintiff appeared "in no acute distress. She sits comfortably in her examination chair. She gets up and out of the chair, walks around the examination room, and gets on and off the examination table without difficulty." AT 339. Dr. Van Kirk concluded that plaintiff had no manipulative limitations, except she should not be required to work with her arms over her head (such as painting a ceiling), as this would cause pain in her neck and shoulders. AT 342. He found various other functional limitations, but nothing approaching Dr. Barzaga's conclusion that plaintiff could not work at all. AT 341-342.
State agency non-examining physician Dr. Gilpeer reviewed plaintiff's medical records and determined that she had some exertional limitation (e.g., could stand or walk with normal breaks for about 6 hours in an 8-hour workday), but no manipulative limitations and a medium RFC. AT 84-86. On reconsideration, state agency non-examining physician Dr. Ligot similarly found plaintiff to have a medium RFC and found her not disabled. AT 98.
The ALJ also found plaintiff's statements about the severity and limiting effects of her symptoms not entirely credible, as discussed below. AT 23. This finding affected the weight he gave medical opinions deemed to be based largely on plaintiff's subjective complaints.
The weight given to medical opinions depends in part on whether they are proffered by treating, examining, or non-examining professionals.
To evaluate whether an ALJ properly rejected a medical opinion, in addition to considering its source, the court considers whether (1) contradictory opinions are in the record; and (2) clinical findings support the opinions. An ALJ may reject an uncontradicted opinion of a treating or examining medical professional only for "clear and convincing" reasons.
Here, Dr. Barzaga's December 2013 opinion that plaintiff had severe functional limitations was contradicted by portions of her own June 2013 report and other medical evidence. Insofar as the December 2013 opinion was based on plaintiff's subjective complaints, the ALJ found plaintiff less than fully credible. When a treating or examining doctor's opinion is contradicted by the doctor's "other recorded observations and opinions regarding [the claimant's] capabilities, . . . [s]uch a discrepancy is a clear and convincing reason for not relying on the doctor's opinion[.]"
Dr. Marie Francisco, plaintiff's primary treating physician, prepared a Complete Medical Report of Physical and Mental Work-Related Impairments on November 13, 2013. AT 410-414. The report indicated that she began treating plaintiff in October 2011. Her list of diagnoses included fibromyalgia and chronic pain syndrome. Treatments included physical therapy, pain medication, muscle relaxants, diet and exercise, and referral to a specialist. Dr. Francisco indicated that plaintiff's chronic pain syndrome had been minimally responsive to treatment. She described plaintiff's prognosis as "fair on chronic pain/fibromyalgia." Dr. Francisco indicated that, based on plaintiff's interview/findings, she had decreased functional mobility. AT 410.
Dr. Francisco opined that plaintiff could never lift or carry any amount of weight, even up to 10 pounds, and that her sitting, standing, and walking were impaired such that she could only sit for two hours, and stand and walk for one hour each, in an eight-hour workday. AT 411. Dr. Francisco further indicated that plaintiff could "never" climb, balance, stoop, crouch, kneel, crawl, reach, handle, feel, or push/pull, and that she could only occasionally grasp and do fine manipulation in both her right and left hands. AT 412. The report also stated that plaintiff had multiple environmental restrictions and must "avoid all exposure" to heights, moving machinery, vibrations, noise, dust, fumes, odors, smoke, chemicals, wetness, dryness, temperature extremes, and an unspecified "other" due to her decreased functional mobility. AT 413. Lastly, Dr. Francisco indicated that plaintiff's ability to understand and carry out job instructions was poor, and that she "gets confused" and has had learning problems since childhood. AT 414.
Upon review, the ALJ wrote:
AT 23.
Elsewhere, the ALJ noted that, in a third party report, plaintiff's 20-year-old daughter indicated that plaintiff was "able to perform a wide range of activities of daily living including cleaning, cooking, handling money and finances, providing care for her children and driving them to and from school. She also notes that the claimant does not have any problem walking and can pay attention `a long time.' This is entirely inconsistent with the opinion of Dr. Francisco[.]" AT 22;
For similar reasons as with Dr. Barzaga, and in light of the record as discussed above, the court concludes that the ALJ did not err in assigning reduced weight to Dr. Francisco's opinion.
Plaintiff also challenges the ALJ's adverse credibility finding. Specifically, 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 for the reasons explained in this decision." AT 22.
The ALJ determines whether a disability applicant is credible, and the court defers to the ALJ's discretion if the ALJ used the proper process and provided proper reasons.
In evaluating whether subjective complaints are credible, the ALJ should first consider objective medical evidence and then consider other factors.
At the July 2014 hearing, plaintiff testified that she had pain in her neck, shoulders, arms and hands, that she had been diagnosed with fibromyalgia, and that she was taking pain medication that made her tired. AT 54, 57. She testified that she lived with her 11-year-old son
The ALJ did not specify which particular statements "concerning the intensity, persistence and limiting effects" of her symptoms he found not credible. AT 22. However, in evaluating the effects of her symptoms, he cited three Adult Disability Reports by plaintiff in 2011 and 2012 and a 2012 Adult Function report in which plaintiff "reported being able to perform a wide range of daily activities[.]" AT 21-22;
Finally, plaintiff argues that the ALJ did not properly consider her adult daughter's statements about plaintiff's pain and functional limitations. "[L]ay witness testimony as to a claimant's symptoms or how an impairment affects ability to work is competent evidence, and therefore cannot be disregarded without comment."
As noted above, in June 2012 plaintiff's daughter Karissa Arizola filled out an adult third-party function report about plaintiff. AT 261-268. In assessing plaintiff's RFC, the ALJ gave "great weight" to Arizola's statements that plaintiff could "perform a wide range of activities of daily living including cleaning, cooking, handing money and finances, and providing care for her children and driving them to and from school"; and that plaintiff had no problem walking and could pay attention "a long time." AT 22. However, he gave "little weight" to Arizola's statements that "were very similar to the claimant's own responses." AT 22.
Plaintiff argues that the ALJ should have credited Arizola's statements that, e.g., plaintiff couldn't do much housework due to the pain in her hands. However, "[w]here the ALJ has first found a claimant not credible, the ALJ may subsequently reject lay testimony because it essentially reproduces the claimant's testimony."
For the reasons stated herein, IT IS HEREBY ORDERED that:
1. Plaintiff's motion for summary judgment (ECF No. 17) is denied;
2. The Commissioner's cross-motion for summary judgment (ECF No. 18) is granted; and
3. Judgment is entered for the Commissioner.
The claimant bears the burden of proof in the first four steps of the sequential evaluation process.