KENDALL J. NEWMAN, Magistrate Judge.
Plaintiff Tom Lee seeks judicial review of a final decision by the Commissioner of Social Security ("Commissioner") denying his application for Disability Insurance Benefits ("DIB") under Title II of the Social Security Act ("Act").
After carefully considering the record and the parties' briefing, the court DENIES plaintiff's motion for summary judgment, GRANTS the Commissioner's cross-motion for summary judgment, and enters judgment for the Commissioner.
Plaintiff was born on September 18, 1966; has a GED; and previously worked as a heavy equipment operator.
On appeal, plaintiff raises the following issues: (1) whether the ALJ improperly weighed the medical opinion evidence; (2) whether the ALJ improperly assessed plaintiff's credibility; and (3) whether the ALJ's step five finding lacks substantial evidence.
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.
"[A] reviewing court, in dealing with a determination or judgment which an administrative agency alone is authorized to make, must judge the propriety of such action solely by the grounds invoked by the agency."
The ALJ evaluated plaintiff's entitlement to DIB pursuant to the Commissioner's standard five-step analytical framework.
Before proceeding to step four, the ALJ assessed plaintiff's RFC, finding that plaintiff could perform less than the full range of light work as defined in 20 C.F.R. § 416.1567(b); more specifically, that plaintiff:
(AT 24.) At step four, the ALJ determined that plaintiff was unable to perform any past relevant work. (AT 29.) However, at step five, the ALJ found that, in light of plaintiff's age, education, work experience, RFC, and the vocational expert's ("VE") testimony, there were jobs that existed in significant numbers in the national economy that plaintiff could perform. (AT 30.) Thus, the ALJ concluded that plaintiff had not been disabled from August 9, 2011, his alleged disability onset date, through April 13, 2016, the date of the ALJ's decision. (AT 31.)
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) there are contradictory opinions 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.
In this case, plaintiff argues that the ALJ improperly discounted the opinions of treating physicians, Dr. Cynthia Dillon and Dr. Leonard Soloniuk, and examining physician, Dr. Michael Sommer. Because the doctors' opinions were contradicted by other medical opinions in the record, the ALJ was required to provide specific and legitimate reasons to discount their opinions. As discussed below, the court concludes the ALJ properly discharged that obligation.
Plaintiff asserts the ALJ erred by giving little weight to the opinion of plaintiff's treating physician, Dr. Dillon, who filled out a RFC questionnaire on April 16, 2014, diagnosing plaintiff with cervical and lumbar radiculopathy, decreased flexion and extension in plaintiff's neck and back, sensory changes in a C5 distribution, and atrophy in plaintiff's right deltoid muscle, and noting he needed to use a cane to avoid falls and decrease pain, that he tended to drop items, and that his pain was partially controlled with opiates with a poor prognosis. (AT 28-29, 1949-51.) The ALJ gave little weight to Dr. Dillon's opinion, noting it was not supported by objective evidence and inconsistent with the record as a whole, was primarily based on plaintiff's subjective complaints, and was inconsistent with evidence that showed plaintiff's chronic pain was adequately managed with injections and medication. (AT 29.)
The ALJ noted "Dr. Dillon primarily summarized in the treatment notes the claimant's subjective complaints, diagnoses, and treatment, but he did not provide objective clinical or diagnostic findings to support the functional assessment." (AT 29.) In discussing the objective evidence in the medical record, the ALJ pointed out that in 2012, Dr. Soloniuk found that plaintiff was able to "transfer station to station without assistance and ambulates with a steady gait." (AT 26, 214, 226, 232, 479.) On November 26, 2013, plaintiff's gait was observed to be normal. (AT 26, 527.) The ALJ further observed that in a January 2016 examination, plaintiff's strength was 5/5 in all extremities, tone was normal, there was no wasting or fasciculations, reflexes were 2+ and symmetrical, gait and coordination were normal, Romberg and Babinski were negative, there were no limits to his range of motion, and he was alert and oriented times three. (AT 27, 2154.) The ALJ also noted plaintiff's December 9, 2015 report to Dr. Soloniuk that Norco remains his saving grace; taken twice per day it allows him to maintain fundamental chores throughout the course of the day. (AT 27, 2174.)
Furthermore, the ALJ observed that Dr. Dillon's opinion is inconsistent with plaintiff's admitted activities of daily living. (AT 29.) For example, plaintiff admitted at his hearing that he did not use a cane as opined by Dr. Dillon. (AT 52-53, 1950.) Plaintiff also testified that he could change light bulbs, did small jobs around the house, went on walks for exercise, and could do a limited amount of fishing. (AT 25, 54, 2178.) An ALJ may reject an opinion when the physician sets forth restrictions that "appear to be inconsistent with the level of activity that [the claimant] engaged in."
Finally, the ALJ's decision to give little weight to Dr. Dillon's opinion is further bolstered by the opinions of the state agency physicians, Dr. Gilpeer and Dr. Jaituni, who, after reviewing plaintiff's records, both concluded that there was significant evidence that plaintiff could perform light exertional work. (AT 63-87.) The ALJ reasonably relied on those opinions because of their consistency with the medical evidence.
In sum, the ALJ provided specific and legitimate reasons to discount Dr. Dillon's opinion. While plaintiff undoubtedly suffers from symptoms of his back and neck injury resulting in limitations to his daily life, the ALJ properly weighed the conflicting evidence and ultimately found, based on substantial evidence in the record as a whole, that such limitations were not present at a disabling level. The court thus defers to the ALJ's rational resolution of conflicting evidence and ambiguities in the record.
Next, plaintiff argues the ALJ erred in failing to specifically address or assign weight to the opinion of plaintiff's treating doctor, Dr. Soloniuk, that plaintiff would need periodic rest intervals throughout the day in addition to normal breaks because of his back and neck pain and his severe migraines. (AT 2173-74.) The ALJ never explicitly mentioned Dr. Soloniuk in his decision, but he cited to the doctor's medical evidence at several points. (AT 26, 214, 231-33.) When the ALJ noted that plaintiff was able to "transfer to station to station without assistance and ambulates with a steady gait," this medical evidence was observed by Gretchen Michael PA-C under Dr. Soloniuk's review. (AT 214.) The ALJ also referenced medical observations on plaintiff's daily activities, concentration, persistence, and pace made by William Casavant P.A. under Dr. Soloniuk's review. (AT 25, 2178, 2181.) The medical finding that plaintiff's medication allows him to "maintain fundamental chores throughout the course of the day" was also conducted under the review of Dr. Soloniuk. (AT 27, 2174.) Although Dr. Soloniuk administered plaintiff's steroid injections, it is unclear from any of his notes if he ever made any direct clinical findings himself as to plaintiff's functional capacities. (AT 2191-2200.)
Plaintiff argues the ALJ needed to specifically address Dr. Soloniuk's opinion, but the ALJ indicated that he read and considered all of the medical evidence in the record. (AT 26, 2211-2224.) Moreover, when "interpreting the evidence and developing the record, the ALJ does not need to `discuss every piece of evidence.'"
Lastly, plaintiff asserts the ALJ erred in rejecting critical aspects of the opinion of examining doctor, Dr. Sommer, that plaintiff could not repeatedly bend, stoop, move his neck, or move his arms at or above shoulder level. However, the ALJ indicated he gave significant weight to the opinion of Dr. Sommer that plaintiff is precluded from heavy work. (AT 29, 2131.) In his RFC finding, the ALJ indicated that plaintiff could only occasionally crouch, stoop, reach overhead bilaterally, and move his neck. (AT 24.) The ALJ's decision is fully consistent with Dr. Sommer's opinion. (AT 2131.)
Plaintiff contends that the ALJ erred by discounting plaintiff's testimony regarding his symptoms and functional limitations without providing legally sufficient reasons.
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"The ALJ must specifically identify what testimony is credible and what testimony undermines the claimant's complaints."
As an initial matter, the court notes that the ALJ did not entirely discredit plaintiff's subjective allegations. However, to the extent that the ALJ discounted plaintiff's testimony regarding the degree of his symptoms and functional limitations, the ALJ provided several specific, clear, and convincing reasons for doing so.
The ALJ found that the weight of the medical evidence did not support plaintiff's claims of limitation to the disabling degree alleged. (AT 25.) For example, the ALJ noted that in 2012, Dr. Soloniuk found that plaintiff was able to "transfer station to station without assistance and ambulates with a steady gait." (AT 26, 214, 226, 232, 479.) In 2013, plaintiff's gait was observed to be normal. (AT 26, 527.) In March 2015, he was diagnosed with right shoulder pain, but his shoulder strength was 4.5/5, his left shoulder was normal, and his gait was normal. (AT 2124.) A lumbar spine MRI on August 9, 2015 was negative for disc pathology or stenosis. (AT 27, 2124.) The ALJ further observed that in a January 2016 examination, plaintiff's strength was 5/5 in all extremities, tone was normal, there was no wasting or fasciculations, reflexes were 2+ and symmetrical, gait and coordination were normal, there were no limits to his range of motion, and he was alert and oriented times three. (AT 27, 2154.) The ALJ further observed that plaintiff's medical records showed no significant mental limitations. (AT 27-8, 213, 399, 635, 1976, 2127.)
To be sure, "after a claimant produces objective medical evidence of an underlying impairment, an ALJ may not reject a claimant's subjective complaints based solely on a lack of medical evidence to fully corroborate the alleged severity of pain."
A condition that can be controlled or corrected by medication is not disabling for purposes of determining eligibility for benefits under the Act.
Although the ALJ's observations of the claimant at the hearing may not form the sole basis for discrediting the claimant's testimony, such observations may be used in the overall credibility evaluation.
Finally, substantial evidence supported the ALJ's finding that plaintiff's daily activities were inconsistent with his allegations of severely disabling symptoms and limitations. (AT 25.)
"While a claimant need not vegetate in a dark room in order to be eligible for benefits, the ALJ may discredit a claimant's testimony when the claimant reports participation in everyday activities indicating capacities that are transferable to a work setting. . . . Even where those activities suggest some difficulty functioning, they may be grounds for discrediting the claimant's testimony to the extent that they contradict claims of a totally debilitating impairment."
Here, the ALJ pointed to plaintiff's own testimony and subjective reports in medical evidence that he lived with his family, had a driver's license, watched television, visited his grandmother, could fish a limited amount, walked for exercise, could work on small projects around the house, could change light bulbs, and assisted friends with mechanical work. (AT 25, 54, 2178.) The ALJ rationally concluded that this evidence suggested that plaintiff was exaggerating his functional limitations.
In sum, the court concludes that the ALJ provided multiple specific, clear, and convincing reasons for discounting plaintiff's credibility. To be sure, the record may contain contrary evidence that plaintiff could point to in an attempt to bolster his credibility. However, it is the function of the ALJ to resolve any ambiguities, and the court finds the ALJ's assessment to be reasonable and supported by substantial evidence. As the Ninth Circuit explained:
Plaintiff essentially argues that the ALJ erred by not including additional functional limitations in the RFC for purposes of the VE's hypothetical. However, for the reasons discussed above, the court finds that the ALJ appropriately evaluated the medical opinion evidence and plaintiff's credibility. As such, the RFC is supported by substantial evidence in the record as a whole, and no additional limitations were necessary.
Accordingly, IT IS HEREBY ORDERED that:
The claimant bears the burden of proof in the first four steps of the sequential evaluation process.