CHARLES A. STAMPELOS, Magistrate Judge.
This is a Social Security case referred to the undersigned United States Magistrate Judge upon consent of the parties and reference by District Judge Maurice M. Paul. Doc. 13. See Fed. R. Civ. P. 73; 28 U.S.C. § 636(c). After careful consideration of the entire Record, the Court affirms the decision of the Commissioner.
On June 30, 2008, Plaintiff, Thomas Mackperson, Jr., filed a Title II application for a period of disability and Disability Insurance Benefits and a Title XVI application for Supplemental Security Income, alleging disability beginning May 12, 2008. R. 18, 155-62, 228. (Citations to the Record shall be by the symbol "R." followed by a page number that appears in the lower right corner.) Plaintiff's date last insured, or the date by which his disability must have commenced in order to receive benefits under Title II, is March 30, 2013. R. 18.
Plaintiff's applications were denied initially on October 14, 2008, and upon reconsideration on May 1, 2009. R. 18, 102-09, 114-19. On June 12, 2009, Plaintiff filed a request for hearing. R. 18, 120. On September 29, 2010, Plaintiff appeared and testified at a hearing conducted by Administrative Law Judge (ALJ) Philemina M. Jones in Ocala, Florida. R. 18, 35-97. Dennis M. O'Connor, an impartial vocational expert, testified during the hearing. R. 18, 79-96. Plaintiff was represented by Marcia Green, a paralegal representative from Three Rivers Legal Services. R. 18, 37, 128. Ms. Green provided the ALJ with a Pre-Hearing Memorandum. R. 274-78. Ms. Green withdrew as Plaintiff's representative on January 5, 2011, R. 5, and Plaintiff was thereafter represented by Pamela C. Dunmore, a non-attorney representative, and N. Albert Bacharach, Jr., an attorney. R. 6-8.
On December 14, 2010, the ALJ issued a decision denying Plaintiff's applications for benefits. R. 28. On January 11, 2011, Plaintiff filed a request for review and submitted additional evidence, R. 1-2, 14, which was denied by the Appeals Council on June 29, 2012. R. 1-4.
On August 28, 2012, Plaintiff filed a complaint with the United States District Court seeking review of the ALJ's decision that is the final decision of the Commissioner. Doc. 1. The parties filed memoranda of law, docs. 16 and 19, and those have been considered.
The ALJ made several findings relative to the issues raised in this appeal:
This Court must determine whether the Commissioner's decision is supported by substantial evidence in the record and premised upon correct legal principles. 42 U.S.C. § 405(g);
"In making an initial determination of disability, the examiner must consider four factors: `(1) objective medical facts or clinical findings; (2) diagnosis of examining physicians; (3) subjective evidence of pain and disability as testified to by the claimant and corroborated by [other observers, including family members], and (4) the claimant's age, education, and work history.'"
A disability is defined as a physical or mental impairment of such severity that the claimant is not only unable to do past relevant work, "but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy." 42 U.S.C. § 423(d)(2)(A). A disability is 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); see 20 C.F.R. § 404.1509 (duration requirement). Both the "impairment" and the "inability" must be expected to last not less than 12 months.
The Commissioner analyzes a claim in five steps. 20 C.F.R. §§ 404.1520(a)(4)(i)-(v), 416.920(a)(4)(i)-(v):
1. Is the individual currently engaged in substantial gainful activity?
2. Does the individual have any severe impairments?
3. Does the individual have any severe impairments that meet or equal those listed in Appendix 1 of 20 C.F.R. Part 404, Subpart P?
4. Does the individual have any impairments which prevent past relevant work?
5. Do the individual's impairments prevent other work? A positive finding at step one or a negative finding at step two results in disapproval of the application for benefits. A positive finding at step three results in approval of the application for benefits. At step four, the claimant bears the burden of establishing a severe impairment that precludes the performance of past relevant work. Consideration is given to the assessment of the claimant's RFC and the claimant's past relevant work. If the claimant can still do past relevant work, there will be a finding that the claimant is not disabled. If the claimant carries this burden, however, the burden shifts to the Commissioner at step five to establish that despite the claimant's impairments, the claimant is able to perform other work in the national economy in light of the claimant's RFC, age, education, and work experience.
Plaintiff does not disagree with the ALJ's factual recitations and, as a result, they are incorporated herein. Doc. 16. Rather, Plaintiff argues only that the ALJ erred in rejecting Plaintiff's claim of pain. Id. at 28-32.
The ALJ summarized Plaintiff's hearing testimony:
R. 23; see R. 38-78, 82, 85-86 (Plaintiff's hearing testimony).
Immediately thereafter, the ALJ concluded, using boilerplate language, 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 credible to the extent they are inconsistent with the above [RFC] assessment." R. 23. (The ALJ found that Plaintiff had the RFC to perform sedentary work with several exceptions, see supra at 3. R. 22.)
The ALJ referred to the Eleventh Circuit standard for assessing a claimant's subjective complaints of pain and then summarized the medical evidence and other evidence. R. 23. (Plaintiff does not take issue with the standard used by the ALJ. Rather, Plaintiff argues that the ALJ erred in applying the standard in this case. Doc. 16 at 28-33.)
R. 23-26.
Mr. O'Connor testified, without objection, as an impartial vocational expert. R. 18, 79-96. Mr. O'Connor was familiar with Plaintiff's past relevant work and opined that Plaintiff could not perform any of his past relevant work. R. 79-84. The ALJ asked Mr. O'Connor a series of hypothetical questions and whether jobs existed in the national economy for an individual with Plaintiff's vocational profile. R. 79-95. When considered in the aggregate, Mr. O'Connor testified that a hypothetical individual with Plaintiff's vocational profile could perform a significant number of jobs in the national economy if he was limited to sedentary work
Plaintiff argues the ALJ improperly discounted the credibility of Plaintiff's subjective complaints (as to "chronicitiy and severity") of pain because the complaints are supported by the objective medical evidence. Doc. 16 at 28-32. The ALJ, however, considered the relevant medical evidence in light of Plaintiff's complaints and did not err in discounting Plaintiff's credibility. R. 22-26. The ALJ explained that although it was reasonable to conclude that Plaintiff had some pain and limitations due to the effects of his impairments, the evidence as a whole did not substantiate a reasonable medical basis for the type and degree of debilitating pain described by Plaintiff. R. 25. Substantial evidence supports the ALJ's credibility findings.
Pain is subjectively experienced by the claimant, but that does not mean that only a mental health professional may express an opinion as to the effects of pain. To establish a disability based on testimony of pain and other symptoms, the claimant must satisfy two parts of a three-part test showing: (1) evidence of an underlying medical condition; and (2) either (a) objective medical evidence confirming the severity of the alleged pain; or (b) that the objectively determined medical condition can reasonably be expected to give rise to the claimed pain.
To analyze a claimant subjective complaints, the ALJ considers the entire record, including the medical records; third-party and Plaintiff's statements; the claimant's daily activities; the duration, frequency, intensity of pain or other subjective complaint; the dosage, effectiveness, and side effects of medication; precipitating or aggravating factors; and functional restrictions. See 20 C.F.R §§ 404.1529; 416.929 (explaining how symptoms and pain are evaluated); 404.1545(e); 416.945(e) (regarding RFC, total limiting effects). The Eleventh Circuit has stated that "credibility determinations are the province of the ALJ."
In this case, the ALJ concluded that Plaintiff had underlying medical impairments that could reasonably be expected to cause his alleged pain and other symptoms, but that Plaintiff's statements regarding the severity of his symptoms, including the intensity, persistence, and limiting effects of these symptoms were not supported by or consistent with the evidence of record. R. 25. Consequently, the ALJ found Plaintiff's statements only partially credible. R. 24-25.
In making this finding, the ALJ did not conclude that Plaintiff's statements were not fully credible because they conflicted with the RFC finding, as Plaintiff asserts. Doc. 16 at 29. Rather, the ALJ provided a detailed explanation with reference to specific evidence in the record, both medical and nonmedical, to explain the basis for her credibility finding. R. 22-26. In doing so, the ALJ discussed Plaintiff's medical history and the medical signs and laboratory findings regarding his low back and right upper extremity impairments, as well as his headaches and his somatoform pain disorder. R. 23-26. The ALJ also discussed the treatment sought by Plaintiff for his impairments and his reported activities of daily living. R. 23-26.
The ALJ recognized that Plaintiff had bulging discs and arthritic changes in his lumbar and cervical spines, including an annular tear and fissure at the L5-S1 level, and that such conditions caused some radiculopathy affecting his lower and upper extremities. R. 20, 23, 287-88, 312, 390-91, 431-33, 480-81. The ALJ did not find, however, the evidence supportive of a finding that Plaintiff experienced debilitating pain "24/7," resulting in severe functional limitations, as he alleged. R. 24, 51-52, 64-67, 71. For example, although Plaintiff claimed significant standing and walking limitations, his gait was often described as normal, or at most only mildly antalgic, and that Plaintiff sometimes walked with or without a cane. R. 24, 283, 285, 296, 299-300, 310, 353, 435, 454-58, 466, 501, 547. As the ALJ noted, on August 30, 2008, Dr. Adhami reported mostly normal physical findings during his consultative examination, including normal muscle strength, normal gait, and full range of motion of all joints, including his right shoulder. R. 23-24, 300-01.
Likewise, Dr. Depaz reported in July 2009 that Plaintiff had full range of motion and 5/5 motor strength of his upper and lower extremities, intact coordination, intact sensation, and a normal gait. R. 466. On August 25, 2009, Plaintiff returned to Dr. Depaz for a follow-up and electrodiagnostic studies. R. 431-33. Dr. Depaz noted, for the most part, normal impressions with a diagnosis of left L5 root dysfunction. R. 433. Dr. Depaz noted: "In today's study, there is electrophysiological evidence of possible left L5 root dysfunction. This is evident by the prolongation of the left common peroneal nerve F-wave by 2mls when compared to the right. No evidence of axonal involvement with normal EMG of the left lower extremity and associated paraspinal muscles. No evidence of peripheral sensorimotor neuropathy. No evidence of S1 involvement." R. 433.
Although Dr. Depaz noted that Plaintiff had some abnormalities in September 2009, he emphasized to Plaintiff that his condition was amenable to treatment and that he should follow through with the treatment plan, including going to physical therapy. R.487. In November 2009 and March 2010, Dr. Depaz noted that although Plaintiff gait was antalgic, it was only mildly antalgic. R. 455, 457. Although Dr. Depaz prescribed a cane for Plaintiff, he noted that he provided the prescription at Plaintiff's request. R. 455, 457, 488; see R. 547-48 (9/7/2010, examination-Plaintiff is alert and in no acute distress; restricted range of motion; Plaintiff walks with a cane; persistent tenderness over cervical and thoracolumbar spine; decreased sensory in the right L5 distribution; motor strength showed no focal weakness; and reflexes were 1+ at the knees and traces at the ankles bilaterally).
The ALJ also noted that Dr. Campbell, who was aware of Plaintiff's complaints and his medical history, stated on June 8, 2009, that "nothing was noted to require surgical decompression." R. 430. Dr. Campbell noted that Plaintiff would benefit seeing a pain management provider to assist with his pain control. In Dr. Campbell's last examination in January 2010, Dr. Campbell reported that Plaintiff had no neurological deficits, his sensation and strength were intact, and his gait normal. R. 502. Dr. Campbell also described Plaintiff's headaches as likely tension-related due to stress. R. 502.
Dr. Arulselvam similarly reported on April 28, 2010, that although Plaintiff walked with a cane and a slow gait, was positive for back pain, and had limited range of motion of his right shoulder, the other results of his examination, including his neurological and psychiatric findings, were normal. R. 501. A month later in May 2010, Dr. Arulselvam's associate reported that a review of Plaintiff's musculoskeletal system was positive for myalgias, back pain, arthralgias and gait problem; and negative for joint swelling. A review of Plaintiff's neurological and psychiatric/behavioral systems was negative. The physical examination indicated that Plaintiff was in no distress, had normal range of motion, exhibited no edema and tenderness during the musculoskeletal examination; and had a normal neurological and psychiatric examination. R. 498-99. On August 31, 2010, Plaintiff's objective examination indicated that Plaintiff had limited range of motion in the spine with pain and an anxious affect. Plaintiff exhibited no edema. A review of systems was positive for back pain; positive for numbness but negative for dizziness (neurological); and positive for sleep disturbance. R. 496-97.
In evaluating Plaintiff's credibility, the ALJ also appropriately referred to his daily activities. R. 25; see 20 C.F.R. § 404.1529(c)(3)(i), 416.929(c)(3)(i) (providing that daily activities are relevant and can be considered by the ALJ when evaluating a claimant's symptoms).
The ALJ, nevertheless, did not find Plaintiff without any pain or limitation. The ALJ accounted for Plaintiff's physical impairments and the above findings by restricting him to sedentary work with a sit/stand option with limited pushing and pulling with his upper extremities, no more than occasional balancing, stooping, kneeling, crouching, and crawling, and limited reaching in all directions, including no more than occasional overhead use of his right upper extremity. R. 22. The ALJ also found that Plaintiff should avoid concentrated exposure to fumes, odors, dusts, gases, poor ventilation, and hazards. R. 22. The ALJ's RFC finding took into account not only Plaintiff's back impairment with radiculopathy, but also took into account his right shoulder pain and the problems he allegedly had with reaching while using his non-dominant right upper extremity. R. 51, 55, 66-68, 300-01, 314, 451, 463-64, 466, 496, 501.
The ALJ's RFC finding also took into account Plaintiff's testimony that he could not lift more than 10 pounds and that he could not sit, stand, or walk for prolonged periods. R. 22, 51-52, 56, 63-65. In addition, the RFC finding took into account Plaintiff's asthma condition, which was being maintained on medication, and his alleged postural limitations testified to at the hearing. R. 22, 52, 65-66. The ALJ gave Plaintiff the benefit of the doubt with regard to many of the limitations in the RFC finding, including finding Plaintiff limited to sedentary work, contrary the opinion of Dr. Krishnamurthy, the State agency medical consultant. R. 25-26, 404, 408. Thus, the ALJ reasonably accounted for Plaintiff's subjective complaints of pain and other symptoms as they pertained to his physical impairments.
The ALJ also appropriately considered Plaintiff's mental impairments, noting that although he had depression, anxiety, and a somatoform pain disorder, any alleged limitations from these impairments was not so significant that he could not perform any work activity. R. 22, 25-26. The treatment that Plaintiff received for his mental impairments was minimal. R. 61, 76, 468-73, 508-21. To the extent that Plaintiff claimed that pain affected his ability to focus and concentrate, R. 68, 71, 352, 382-83, the ALJ accounted for this by limiting Plaintiff to routine tasks and by adding the further limitation that Plaintiff's work output may be more variable than the average employee. R. 22. The ALJ also accounted for Plaintiff's alleged social limitations by finding him capable of maintaining adequate work relations, but that he could distract others at times and should not work with the general public or in close proximity to others. R. 22, 352, 382-83.
The above mental limitations were consistent with the evaluation of Dr. Humphreys, who opined on October 6, 2008, that Plaintiff's memory appeared in tact and he was capable of carrying out complex instructions with some mild impairment of concentration for numerical operations and that he had some limited social skills and judgment that would be affected by his depression. R. 354.
Additionally, the ALJ appropriately referred to Dr. Gedney's psychosocial evaluation, where he reported that Plaintiff's complaints of unremitting body pain and pain-related limitations were not congruent with his physical signs or symptoms, which suggested the possibility of secondary gain issues. R. 25-26, 379, 383. As Dr. Gedney noted, Plaintiff's vocal complaints of pain and discomfort increased with focused discussion on his various ailments. R. 379. Further, the results of Plaintiff's personality assessment questionnaire could not be validated because of Plaintiff's over endorsement of symptoms. R. 379, 383. The observations by Dr. Gedney supported the ALJ's overall finding that Plaintiff's alleged physical pain and symptoms were not as debilitating as he alleged.
The ALJ appropriately made her credibility finding based on a review of the whole record and specifically accounted for Plaintiff's alleged pain and other symptoms to the extent that they were reasonably consistent with his medical signs and laboratory findings, and other evidence of record. Based on the ALJ's conclusions, Mr. O'Connor opined that an individual with Plaintiff's particular functional limitations, as found by the ALJ, was capable of performing a significant number of jobs in the national economy, which supported the ALJ's ultimate finding that Plaintiff was not disabled. R. 84, 94-95. In sum, the ALJ's decision is supported by substantial evidence.
Plaintiff argues that there is substantial evidence that detracts from and supports his claim of disability. Plaintiff, however, is requesting this Court to re-weigh the evidence and substitute its discretion for that of the ALJ.
Considering the Record as a whole, the findings of the ALJ are based upon substantial evidence and the ALJ correctly applied the law. Accordingly, the decision of the Commissioner to deny Plaintiff's applications for Social Security benefits is