DONNA F. MARTINEZ, Magistrate Judge.
Plaintiff, Jose Freitas, seeks judicial review of the denial of his applications for disability insurance benefits ("DIB") and supplemental security income ("SSI").
The standards for determining an individual's entitlement to DIB and SSI, the Commissioner's five-step framework for evaluating disability claims, and the district court's review of the final decision of the Commissioner are well-settled. I am following those standards, but do not repeat them here.
Plaintiff makes several arguments. He contends that the ALJ erred by (a) not finding plaintiff's right-sided weakness to be a severe impairment; (b) failing to consider plaintiff's non-severe impairment in his physical RFC determination; (c) making plaintiff was not disabled within the meaning of the Social Security Act. (R. 21.) Plaintiff appealed the ALJ's decision to the Appeals Council, which denied his request for review on April 15, 2014. (R. 1-4.) internal inconsistencies in his mental RFC determination; (d) incorrectly evaluating the medical opinion evidence; (e) failing to support his credibility assessment with substantial evidence; and (f) improperly relying on the testimony of the vocational expert. I consider each argument in turn.
Plaintiff suffered a stroke on March 6, 2011. (R. 279.) At step 2, the ALJ determined that plaintiff's resulting organic mental disorder is a severe impairment. (R. 12.) Although the ALJ recognized that plaintiff experienced right-sided weakness after his stroke, he explained that "there is no convincing evidence" that the right-sided weakness caused "more than minimal limitations in terms of [plaintiff's] ability to perform basic work activities," and therefore did not find it to be a severe impairment. (R. 13.) Plaintiff contends that this finding is erroneous.
A review of the ALJ's assessment of the severity of plaintiff's impairments reveals no error. The ALJ relied on the medical source statement completed by plaintiff's treating physician, Dr. Evan Schiff, in which he opined that plaintiff's right-sided weakness improved within three months of his stroke and since that time has been no more than "mild." (R. 13, citing R. 394.) Dr. Schiff's opinion is consistent with other evidence of record revealing normal physical examination results. For example, in August 2011, consultative examiner Dr. Yacov Kogan observed that plaintiff walked independently with a normal gait. (R. 328-29.) His motor strength and reflexes also were normal. (
Plaintiff next argues that even if his right-sided weakness is a non-severe impairment, the ALJ erred by not considering the potential functional limitations associated with this impairment when making his RFC assessment.
Contrary to plaintiff's assertion, the ALJ did consider plaintiff's right-sided weakness, but ultimately found that it did not cause any functional limitations. He recounted that during plaintiff's interview with state-agency physician Dr. Wendy Underhill, plaintiff "stated that he believed himself capable of working, even while he had some difficulties due to weakness in his right leg . . . . [T]he claimant reported doing a considerable amount of walking throughout the day, and reported no difficulty handling household chores." (R. 14.) The ALJ also considered plaintiff's own treating physician's statement that his right-sided weakness improved within three months of his stroke and since that time has been no worse than mild. (R. 13, 18; citing R. 95, 394.) The ALJ's physical RFC assessment properly accounted for both severe and non-severe impairments and is supported by substantial evidence.
Plaintiff also takes issue with the ALJ's mental RFC determination, arguing that it is internally inconsistent. The ALJ gave "great weight" to state agency psychologist Dr. Kirk Johnson's opinion that plaintiff has "moderate limitations in terms of the ability to maintain concentration, persistence and pace," but proceeded to find that plaintiff "has the attention span to perform simple work tasks for two-hour intervals throughout an eight-hour workday." (R. 19.) Plaintiff argues that this inconsistency is grounds for remand.
Plaintiff's argument conflates two distinct assessments. "It is well established that a step three determination is not an RFC assessment, but instead is used to rate the severity of mental impairment . . . . Therefore, a determination made at step three need not carry over verbatim to the ultimate RFC determination because the two determinations require their own distinct analysis and conclusion."
First, at step 3, when considering the severity of plaintiff's organic mental disorder, the ALJ explained:
(R. 15.)
The ALJ determined that plaintiff has not had any episodes of decompensation and has only mild limitations in activities of daily living and social functioning. As to deficiencies in concentration, persistence and pace, the ALJ concluded that plaintiff has moderate limitations and "may have problems understanding, remembering and carrying out complex or detailed instructions." (R. 15.) The ALJ continued, however, that plaintiff "retains the ability to remember, understand and complete simple, routine and repetitive tasks on a sustained basis . . . [and] remains capable of sustaining concentration and pace for 2-hour intervals and complete assigned simple tasks." (R. 15-16.)
Separate from the step 3 determination is the mental RFC assessment, in which the ALJ considered plaintiff's ability to understand, remember, and carry out instructions. The ALJ summarized the evidence of record, including plaintiff's own statements and testimony, before concluding that he "is limited to performing unskilled jobs involving simple, routine and repetitive tasks, with short and simple instructions and few workplace changes. [He] has the attention span to perform simple work tasks for two-hour intervals throughout an eight-hour workday." (R. 19.) The ALJ's step 3 finding that plaintiff has moderate limitations in concentration, persistence and pace is not inconsistent with his mental RFC determination that plaintiff has the attention span to perform simple work tasks for two-hour intervals throughout an eight-hour workday.
Plaintiff next argues that the ALJ did not properly evaluate the medical opinion evidence, specifically, the opinions of his treating physician Dr. Schiff; consultative examiner Dr. Kogan; and state agency document reviewer Dr. Tracy.
Plaintiff asserts that the ALJ should have given controlling weight to the opinion of his treating physician, Dr. Schiff. Dr. Schiff wrote a brief letter dated June 12, 2012,
Under the treating physician rule, a treating physician's opinion is accorded controlling weight when that opinion is "well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in [the] record." 20 C.F.R. § 404.1527(c)(2);
Here, the ALJ assigned "little weight" to Dr. Schiff's opinion, explaining that
(R. 19.)
The ALJ considered the supportability of Dr. Schiff's opinion against the record as a whole and provided "good reasons" for his assignment of weight. There is no error.
Plaintiff argues that the ALJ erred by failing to explicitly state the weight he assigned to the opinion of consultative examiner Dr. Kogan, who made normal physical examination findings and assessed no functional limitations. (R. 328-29.) Plaintiff does not offer any controlling case law to support his argument that an ALJ's failure to assign specific weight to a medical source opinion constitutes reversible error. In any event, the ALJ discussed Dr. Kogan's opinion at length (R. 13, 18-19),
Plaintiff next argues that the ALJ erred by giving "great weight" to non-examining state agency document reviewer Dr. Tracy, who wrote that plaintiff "states he has leg pain. He has not been to a doctor, his [physical examination] was normal and he can walk two miles. Pain is not a MDI [medically determinable impairment] and is subjective — no dx to support this allegation." (R. 95.)
The ALJ properly relied on Dr. Tracy's report, which is supported by substantial evidence and is consistent with the other evidence of record, including Dr. Kogan's opinion that plaintiff has no physical functional limitations; Dr. Schiff's normal examination findings; and Dr. Schiff's opinion that plaintiff's experienced only "mild" symptoms within three months of his stroke. (R. 328-29, 378, 394.)
Plaintiff's next argument is that the ALJ failed to explain his determination that plaintiff's statements concerning the intensity, persistence, and limiting effects of his symptoms were not entirely credible.
To the contrary, the ALJ explained that the objective medical evidence does not support plaintiff's allegation of substantial functional limitation. It is apparent from the ALJ's decision that he considered the factors set forth in the regulations and ruling concerning credibility.
The ALJ's credibility assessment is thorough and supported by substantial evidence. The court will not "second-guess the credibility finding . . . where the ALJ identified specific record-based reasons for his ruling."
Finally, plaintiff argues that at step 5, the Commissioner failed to meet her burden of proof
The vocational expert testified that plaintiff could perform the following jobs: hand packager, production worker, and production inspector. (R. 21.) All three have a reasoning development level of 2, which, according to the Dictionary of Occupational Titles ("DOT"), requires the application of "common sense understanding to carry out detailed but uninvolved written or oral instructions." Plaintiff asserts that the ALJ limited him to reasoning level 1 jobs
Judges in this district have held that limitations to "short, simple instructions" are not inconsistent with reasoning development level 2.
For these reasons, plaintiff's motion to reverse the decision of the Commissioner (doc. #8) is DENIED and defendant's motion to affirm the decision of the Commissioner (doc. #9) is GRANTED.
This is not a recommended ruling. The consent of the parties allows this magistrate judge to direct the entry of a judgment of the district court in accordance with the Federal Rules of Civil Procedure. Appeals can be made directly to the appropriate United States Court of Appeals from this judgment.
SO ORDERED.
The ALJ found at step 1 that plaintiff has not engaged in substantial gainful activity since his alleged onset date. (R. 12.) At step 2, the ALJ found that plaintiff has the following severe impairment: organic mental disorder (status post cerebrovascular accident). (R. 12.) He found at step 3 that plaintiff's condition did not meet or medically equal a listed impairment. (R. 14.) He determined that plaintiff retained the residual functional capacity ("RFC") to perform a full range of work at all exertional levels, except that plaintiff is limited to performing unskilled jobs involving simple, routine and repetitive tasks, with short, simple instructions and few workplace changes. (R. 16.) The ALJ concluded that plaintiff has the attention span to perform simple tasks for two-hour intervals during an eight-hour workday. (R. 16.) At step 4, the ALJ determined that plaintiff is unable to perform his past relevant work. (R. 20.) At step 5, considering plaintiff's age, education, work experience, and RFC, the ALJ found that jobs exist in significant numbers in the national economy that plaintiff could perform. (R. 20.) He thus concluded that
(R. 394.)
(R. 18.)