MONTE C. RICHARDSON, Magistrate Judge.
This cause is before the Court on Plaintiff's appeal of an administrative decision denying his application for Supplemental Security Income. The Court has reviewed the record, the briefs, and the applicable law. For the reasons set forth herein, the Commissioner's decision is
Plaintiff protectively filed an application for Supplemental Security Income ("SSI") on June 16, 2003, alleging an inability to work since March 15, 2003. (Tr. 79-81). The Social Security Administration ("SSA") denied Plaintiff's application initially on September 11, 2003, and again upon reconsideration on February 13, 2004. (Tr. 52-55, 57-60). On March 9, 2004, Plaintiff requested a hearing before an Administrative Law Judge (the "ALJ") and his case was heard on May 3, 2007. (Tr. 61, 308-323). On June 18, 2007, the ALJ issued a decision finding Plaintiff not disabled. (Tr. 14-23). Plaintiff filed a Request for Review by the Appeals Council, which was denied on January 4, 2008. (Tr. 6-11, 340-342).
On September 5, 2008, the Appeals Council granted Plaintiff's request for an extension of time to file a civil action. (Tr. 5). Plaintiff filed a Complaint in the U.S. District Court on October 6, 2008. (Case Number 5:08-CV-427-Oc-GRJ). Subsequently, the Commissioner moved for a remand of Plaintiff's case. (Tr. 355-356). The District Court entered a judgment granting the Commissioner's motion on June 29, 2009. (Tr. 351). The Court's remand Order directed the ALJ to hold a hearing and provide Plaintiff the opportunity to submit additional medical records, consider the medical opinion of Dr. Radin, and re-evaluate the evidence as a whole to consider whether Plaintiff had a severe mental impairment. (Tr. 353-354). The ALJ held a supplemental hearing on December 6, 2010 (Tr. 447-460) and issued a decision finding Plaintiff not disabled on January 3, 2011. (Tr. 328-339). On March 29, 2011, the Appeals Council denied Plaintiff's request for review. (Tr. 324-326). Accordingly, the ALJ's January 3, 2011 decision is the final decision of the Commissioner. Plaintiff timely filed a Complaint in the U.S. District Court on May 18, 2011. (Doc. 1).
Plaintiff claims to be disabled since March 15, 2003, due to hypertension, enlarged heart, fatigue, and nerve damage in the neck and shoulder area. (Tr. 79-81, 144).
Plaintiff was born on April 17, 1963 and was forty-seven years of age on the date of the ALJ's decision. (Tr. 79, 339). He attended school through the eleventh grade and has past relevant work experience as a cook, dishwasher, laborer in a metal processing facility, and production worker in a warehouse. (Tr. 145, 150-155). The following provides a brief summary of Plaintiff's medical history. Because Plaintiff's appeal concerns his left arm impairments and mental impairments, the Court will confine its discussion to records concerning those conditions.
On November 11, 1996, Plaintiff was involuntarily admitted to Circles of Care, Inc. due to depression and suicidal thoughts. (Tr. 179-186). During that visit, Plaintiff's urine toxicology tested positive for cocaine use and Plaintiff admitted to a four to five year history of abusing the drug. (Tr. 179). Plaintiff was examined by Dr. Mosher, who noted Plaintiff exhibited no evidence of any psychotic symptamology or suicidal ideation, but only wanted treatment for his addiction.
On December 18, 1997, Plaintiff was referred to Dr. Nitin Hate for examination in response to a previous disability claim. (Tr. 189-191). Dr. Hate noted Plaintiff sustained a knife injury to his left arm in 1992, which required surgical intervention. (Tr. 189). Dr. Hate indicated the injury had resulted in nerve damage and atrophy of Plaintiff's left biceps along with numbness and weakness below the site of injury.
On December 30, 1997, a state agency medical expert administered a Residual Functional Capacity ("RFC") assessment. (Tr. 192-199). The medical expert noted Plaintiff's history of stab wound and resulting weakness of Plaintiff's left upper extremity. (Tr. 93). The assessment found Plaintiff could occasionally lift twenty pounds, frequently lift ten pounds, and was not able push or pull with his left arm.
On March 3, 1998, Plaintiff underwent another RFC assessment. This assessment agreed with the previous that Plaintiff was able to lift twenty pounds occasionally, lift ten pounds frequently, and was limited in his ability to reach overhead. However, this assessment indicated Plaintiff could frequently push or pull with his left arm and was not limited in his capacity for handling, fingering, or feeling in that arm. (Tr. 111, 113). The state agency medical expert also found Plaintiff was capable of performing light work. (Tr. 115).
On March 20, 2000, Plaintiff was referred to Dr. Jack Bergstresser. (Tr. 226). Plaintiff's ability to raise and lower his left arm was recorded at 4/5 and his grip strength was recorded as 5/5 in both arms. (Tr. 227). Dr. Bergstresser further noted Plaintiff was well oriented to time and place, had a normal affect and demeanor, and related well to his staff. (Tr. 227). Overall, Dr. Bergstresser found Plaintiff was mildly impaired from using flexion in his left arm and did not identify any mental impairments. (Tr. 227-228).
On March 30, 2000, Plaintiff underwent a third RFC assessment. This assessment agreed with the previous two that Plaintiff was able to lift twenty pounds occasionally and ten pounds frequently. (Tr. 133). The assessment also found Plaintiff was unlimited in his ability to push or pull with either arm and had no established limitations in reaching, handling, fingering, feeling, or any other manipulative limitations. (Tr. 135).
On March 14, 2002, Plaintiff was admitted to the Community Medical Clinic in Titusville, Florida for a physical examination. (Tr. 234-237). Plaintiff complained of left cervical neck pain radiating to his left thoracic back area.
On February 5, 2004, Plaintiff was evaluated by Dr. Radin, a psychiatrist from Circles of Care, Inc. (Tr. 67-68). Plaintiff reported feeling depressed with suicidal thoughts, experiencing mood swings, feeling worthless, and a sense of not being well. (Tr. 68). Dr. Radin noted Plaintiff was courteous and cooperative, but also hypervigilant and suspicious.
On February 11, 2010, Plaintiff was referred to Thomas Guidera, Ph.D. for a psychological evaluation. (Tr. 428-430). Dr. Guidera observed that Plaintiff was accompanied during this visit by his partner, Patricia Daniels. Ms. Daniels conveyed to Dr. Guidera that Plaintiff acted frightened or depressed at times and avoided going outside. (Tr. 428). Dr. Guidera noted Plaintiff would not sit in the room with the evaluator alone, was shaking while in the waiting room, and stated he did not want to go into the office.
On April 23, 2010, Plaintiff' underwent another mental status examination; this time by Dr. David Greenblum. (Tr. 431-434). Plaintiff reported feelings of hopelessness, suicidal ideation without planning, depressed mood, lack of energy, and anxiety. (Tr. 431). In addition to these complaints, Plaintiff exhibited reduced psychomotor activity and constricted affect. (Tr. 433). Dr. Greenblum noted Plaintiff was not hallucinating, not delusional, and his speech was relevant.
On April 26, 2010, Plaintiff underwent an MRI of his left shoulder. (TR. 414-415). The MRI indicated no visible rotator cuff tear, but showed acromioclavicular joint hypertrophy and type two acromion. (Tr. 414). Dr. Hanna, administered an injection of Depo-medrol and Marcaine into Plaintiff's left shoulder to relieve his symptoms. (Tr. 405). In a follow up appointment on June 1, 2010, Plaintiff reported partial relief and other treatment options were discussed. (Tr. 403). Dr. Hanna administered an arthroscopy of Plaintiff's left shoulder in August of 2010. (Tr. 402).
Plaintiff attended physical therapy after his left arm arthroscopy. A Physical Occupational Therapy Evaluation dated August 20, 2010 stated Plaintiff was unable to carry a garbage can, lift a garbage can lid, pour a gallon of milk, or reach over shoulder height with his left arm prior to therapy. (Tr. 440). The Plaintiff's Plan of Care indicated four weeks of therapy was expected to increase Plaintiff's range of motion to enable him to reach overhead without limitation and increase his left arm strength to enable him to lift twenty pounds with his left arm. (Tr. 438). The Plan referred to participation in production line work along with these goals and indicated Plaintiff had good "Rehab Potential."
A claimant is entitled to disability benefits when he is unable to engage in substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to either result in death or last for a continuous period of not less than 12 months. 42 U.S.C. §§ 416(i), 423(d)(1)(A); 20 C.F.R. § 416.905. The ALJ must follow a five step sequential evaluation in determining whether a claimant applying for supplemental security income is disabled.
In the instant case, the ALJ found Plaintiff satisfied the first step and had not engaged in substantial gainful activity since his alleged onset date of March 15, 2003. (Tr. 333). At step two, the ALJ found Plaintiff's history of scoliosis, history of left arm/shoulder stab wound and tendonitis, history of left knee internal derangement and effusion, history of cardiomyopathy and hypertension, mild obesity, and depressive disorder with anxiety constituted severe impairments.
The ALJ determined Plaintiff retained an RFC sufficient to perform light work as defined in 20 C.F.R. § 416.967(b), but only of a non-stressful nature. (Tr. 335). At step four, the ALJ found Plaintiff was unable to perform past relevant work. (Tr. 338). At step five, the ALJ relied on the medical-vocational guidelines (the "grids") and found Plaintiff was able to perform a significant number of jobs in the national economy based on his age, education, work experience, and RFC. Consequently, the ALJ found Plaintiff was not disabled. (Tr. 339).
The scope of this Court's review is limited to determining whether the ALJ applied the correct legal standards and whether the findings are supported by substantial evidence.
Plaintiff raises three issues on appeal. (Doc. 22, pp. 12-22). First, Plaintiff argues the ALJ erred by failing to comply with the Court's June 26, 2009 remand Order. (Doc. 22, pp. 12-18). Second, Plaintiff argues the ALJ erred in failing to assign any arm limitations to Plaintiff. (Doc. 22, pp. 18-19). Finally, Plaintiff argues the ALJ improperly relied on the grids in determining he was not disabled. (Doc. 22, pp. 19-22). The Court will address each of these claims.
Plaintiff argues the ALJ failed to comply with the remand orders from the District Court and Appeals Council. (Doc. 22, pp. 12-18). Specifically, Plaintiff asserts the ALJ failed to properly consider Dr. Radin's evaluation in determining whether he had a severe mental impairment. (Doc. 22, p. 12). Plaintiff asserts the ALJ erred by rejecting Dr. Radin's opinion and failing to provide reasons for doing so. (Doc. 22, p. 13). Plaintiff also asserts the ALJ erred in finding Plaintiff's depressive disorder posed only mild functional limitations.
Plaintiff first argues the ALJ failed to properly address the psychological evaluation conducted by Dr. Radin on February 5, 2004. (Doc. 22, p. 13). Plaintiff asserts the ALJ was required to state with particularity the weight given to the evaluation and the reasons for giving that weight.
The ALJ is required to consider all evidence of record in making a disability determination. 20 C.F.R. § 416.920. However, the ALJ is not required to discuss all of the evidence presented in rendering his decision. Rather, the ALJ must discuss why he rejected any significant probative evidence.
The Court finds there is sufficient evidence to indicate the ALJ properly considered Dr. Radin's evaluation. The ALJ acknowledged the evaluation in his decision and summarized the findings therein. (Tr. 337). Specifically, the ALJ noted Dr. Radin found Plaintiff courteous, cooperative, appropriate, and intelligent enough to give informed consent for treatment. (Tr. 337). The ALJ also provided that Dr. Radin found Plaintiff's memory was okay and he was oriented to time, place, and person.
Although the ALJ did not indicate the weight given to Dr. Radin's evaluation, the Court finds this was not reversible error because the document does not constitute significant probative evidence. In considering the contents of the evaluation, certain findings can be quickly dismissed as having little or no probative value. For example, Dr. Radin's indications that Plaintiff was courteous, cooperative, appropriate, and intelligent enough to give informed consent for treatment and cooperate with needed care fall within this category. Also included in this category are the findings that Plaintiff was well oriented to time, place, and person. However, certain findings in the evaluation cannot be so quickly characterized. For example, the evaluation indicated Plaintiff reported being depressed and having some suicidal thoughts in the past without serious intent, reported having a sense of worthlessness and not being well, exhibited a depressed affect following a dysthymic mood, was "a little bit hypervigilant and suspicious," exhibited evasive and avoidant traits, showed questionable motivation for treatment, and was diagnosed with a Depressive Disorder Not Otherwise Specified. However, these findings are not inconsistent with the ALJ's conclusion that Plaintiff suffered from a depressive disorder with anxiety which posed mild functional limitations and the ALJ did not clearly reject these findings in rendering his decision. The finding which appears to offer the most probative value is Plaintiff's GAF score of 50, which indicates the presence of serious symptoms. Because Plaintiff's low GAF score does appear inconsistent with the ALJ's conclusion that Plaintiff suffered only mild functional limitations, the Court considers it further below.
The Commissioner is correct in noting that courts give only limited weight to a claimant's GAF score in determining whether he is disabled.
Plaintiff also argues the ALJ erred in reaching contradictory findings regarding the severity of his mental impairment. (Doc. 22, p. 13). Specifically, Plaintiff asserts the finding that his depressive disorder posed little or no limitation on the functional areas provided by 20 C.F.R. § 416.920a(c)(3) was contrary to the finding that his depressive disorder was severe. (Doc. 22, p.14). Plaintiff contends such contradictory findings cannot be supported by substantial evidence. (Doc. 22, p. 14-15). The Commissioner responds by arguing that there is no contradiction inherent in finding Plaintiff's impairments are severe yet pose only mild functional limitations. (Doc. 23, pp. 10-11). The Commissioner further asserts that the ALJ's findings regarding the severity of Plaintiff's mental impairments are supported by substantial evidence.
When a claimant presents a colorable claim of mental impairment, the ALJ must complete a Psychiatric Review Technique Form, or incorporate the form's mode of analysis into his decision.
The Court finds the ALJ did not reach inconsistent conclusions in determining Plaintiff's impairments were severe yet had little or no effect on the functional areas provided by 20 C.F.R. § 416.920a(c)(3). The language of 20 C.F.R. § 416.920a(d)(1) anticipates that instances may arise in which evidence indicates there is more than a minimal limitation on a claimant's ability to do basic work activities even though the claimant's impairments pose no more than mild effects on the four functional areas. The section indicates, in those instances, it is appropriate to find the claimant's impairments are severe. 20 C.F.R. § 416.920a(d)(1). Indeed, cases have arisen in which a claimant's mental impairments were determined to be severe even though they had less of an effect on the four functional areas than Plaintiff's depressive disorder does in the instant case.
Additionally, the Court finds the ALJ's conclusions regarding the severity of Plaintiff's impairments are supported by substantial evidence. The ALJ acknowledged evidence indicative of a limitation on the first two functional areas in noting that Plaintiff testified he does not stick to what he starts and cannot deal with crowds. (Tr. 334). However, the Court believes the conclusion that these limitations were no more than mild in nature was well supported by the claimant's testimony that he shops sometimes, has no problems with personal care, has several girlfriends, and has friends but does not socialize regularly. Also, the ALJ acknowledged evidence indicative of a limitation on the third functional area in referring to psychological evaluations which noted Plaintiff showed some difficulties with concentration, focus, and attention and problems attending, listening, and following what was asked of him.
Plaintiff refers to other documents in asserting the ALJ's findings are not supported by substantial evidence. (Doc. 22, p. 16-17). For example, Plaintiff points to Dr. Guidera's statement that Plaintiff had "problems attending, listening, and following what [was] being asked of him," and Dr. Greenblum's statement that Plaintiff reported "feelings of hopelessness, suicidal ideation . . . depressed mood, lack of energy, and anxiety."
Plaintiff next argues the ALJ erred by not assigning left arm limitations despite evidence that he sustained nerve damage and has limited use of his arm. (Doc. 22. p. 18). Plaintiff contends the need for these limitations was supported by the opinions of several medical sources. (Doc 22, p. 18-19). Specifically, Plaintiff points to Dr. Hate's opinion dated December 18, 1997, Dr. Green's RFC assessment dated March 20, 2000, Dr. Bergstresser's opinion dated March 20, 2000, and an evaluation from Community Medical Clinic dated March 14, 2002.
Plaintiff is correct in noting the RFC assessment conducted by Dr. Green on December 30, 1997 indicated Plaintiff was limited in his ability to push, pull, reach, handle, finger, and feel with his left upper extremity. (Tr. 195). However, it bears noting that the RFC assessment conducted on March 12, 1998 found Plaintiff was not limited in these areas, with the exception that he could reach overhead only occasionally. (Tr. 113). The 1998 RFC also explicitly indicated Plaintiff was capable of performing light work with limited overhead activity. (Tr. 112, 115). The findings of the 1998 assessment are bolstered by those provided in the March 20, 2000 assessment, which indicated there were no established limitations in Plaintiff's ability to reach, handle, finger, or feel. (Tr. 135). While the 1997 assessment found Plaintiff was limited in his ability to push/pull with his upper extremities, both of the later assessments found Plaintiff was either unlimited in this capacity or could do so frequently. (Tr. 111, 133, 193). All of the RFC assessments agreed Plaintiff was capable of lifting twenty pounds occasionally and ten pounds frequently. (Tr. 111, 115, 193).
Additionally, Plaintiff is correct in noting the evaluation conducted by the Community Medical Clinic on March 14, 2002 indicated Plaintiff's grip strength was assessed at one or two out of five. (Tr. 226, 236). While this finding is particularly indicative of serious left arm impairments, it is not consistent with the weight of evidence regarding Plaintiff's grip strength. For example, the Community Medical Center examined Plaintiff's grip strength again on August 5, 2002, and assessed it at four out of five. (Tr. 229). Moreover, Dr. Bergstressor's March 20, 2000 evaluation assessed Plaintiff's grip strength at five out of five and assessed elevation/lowering in his left arm at four out of five. (Tr. 227). As indicated above, the RFC reviews conducted in 1998 and 2000 also indicated Plaintiff was not limited in handling (gross manipulation) or fingering (fine manipulation). (Tr.113, 135).
Overall, the Court believes the weight of the evidence prior to Plaintiff's arthroscopy suggests he was mildly impaired in his ability to reach and lift with his left arm due to his history of knife wound. Indeed, the portions of Dr. Bergstresser's opinion referenced by Plaintiff indicated that his muscle atrophy resulted in a mild impairment from using flexion and lifting with his left upper extremity. (Tr. 227-228). Further, while Plaintiff is correct in noting Dr. Hate's opinion stated Plaintiff was limited in the use of his left arm (Tr. 191), the document goes on to state "Plaintiff's ability to work would depend on the outcome of surgical treatment of his left knee."
During physical therapy following Plaintiff's left arm arthroscopy, Dr. Hanna administered a Physical Operational Therapy Evaluation dated August 20, 2010. The evaluation indicated Plaintiff was unable to lift with his left upper extremity and was unable to reach over shoulder level or behind his back prior to therapy. (Tr. 439). The evaluation further provided that Plaintiff was unable to use his left arm to carry garbage, lift a garbage lid, pour a gallon of milk, or pour a coffee pot. (Tr. 440). However, the Plaintiff's Plan of Care stated that, over the course of his four week treatment, Plaintiff was expected to increase range of motion to 140 degrees so that he would be able to reach overhead without limitation and increase left hand strength so that he would be able to carry twenty pounds with his left hand and take out garbage. (Tr. 438). The Evaluation Plan also aspired to allow Plaintiff to successfully perform production line job duties and indicated Plaintiff had good "Rehab Potential." The Court believes this document suggests Plaintiff was expected to be capable of performing the full range of light work at the conclusion of his physical therapy.
The Court finds there is substantial evidence supporting the ALJ's conclusion that Plaintiff's left arm athroscopy and physical therapy succeeded in rendering Plaintiff able to perform the full range of light work. A post-operative examination on September 8, 2010 stated Plaintiff noticed improvement in his left shoulder pain, range of motion, and strength following the procedure. (Tr. 401). Indeed, Plaintiff exhibited a full active and passive range of motion in his left shoulder.
Finally, Plaintiff argues the ALJ erred in mechanically applying the grids instead of obtaining the testimony of a vocational expert. (Doc. 22, p. 19). Plaintiff asserts the testimony of a vocational expert was required in this case because Plaintiff's left arm impairments and limitation to low stress work significantly reduced the range of light work he was able to perform. (Doc. 22, pp. 19-22). The Commissioner responds by arguing the testimony of a vocational expert was not necessary here because substantial evidence supports the ALJ's finding that Plaintiff's left arm injuries did not hinder his ability to perform light work. (Doc. 23, pp. 18-19). The Commissioner also asserts the ALJ explicitly found Plaintiff's limitation to low stress work had little or no effect on his occupational base for light work, and low stress is entailed in the definition of unskilled work.
Because the ALJ found Plaintiff could not return to his past relevant work, the burden of proof shifted to the Commissioner to establish Plaintiff could perform other work in the national economy.
Because the Court finds substantial evidence supports the ALJ's conclusion that Plaintiff's left arm impairments did not prevent him from performing the full range of light work, it concludes that vocational expert testimony was not required to address the left arm limitations. The Court must now consider whether Plaintiff's depressive disorder necessitated vocational expert testimony.
The fifth step of the sequential process does not require the ALJ to include the limitations posed by a claimant's mental impairments on the four functional areas.
This Court has previously held that a limitation to low stress work is not contained within the definition of unskilled work.
(Tr. 339). Accordingly, the Court finds the ALJ did not fail to reach an explicit finding regarding the effect of Plaintiff's restriction to low stress work on his occupational base and his reliance on the grids was appropriate.
For the foregoing reasons, the Commissioner's decision is hereby