DOUGLAS HARPOOL, District Judge.
Before the Court is Plaintiff's appeal of the Commissioner's denial of her application for supplemental security income (SSI) under Title XVI of the Social Security Act ("Act"), 42 U.S.C. §§ 1381-1385. Plaintiff has exhausted her administrative remedies and the matter is now ripe for judicial review.
Plaintiff was born in 1982 and underwent significant lumbar spinal surgery in her teen years in order to correct scoliosis and remove a spinal tumor.
Plaintiff claims disability due to "scoliosis caused by tumor on spine." Her major complaint is sharp back and hip pain that radiates down her left leg roughly four or five times a day. Plaintiff states that her back pain is constant but it is worse when standing/walking. She reports that standing/walking causes her legs to go numb after roughly fifteen minutes. Plaintiff states that her back pain is also exacerbated by sitting for long periods of time. She reports having to change positions and either stand up or lay down to alleviate the pain. In addition to back and hip pain, Plaintiff states that she suffers from knee pain, a constantly swollen left leg, numbness in her left arm while lifting, depression, and anxiety.
According to Plaintiff, pain limits her ability to stand/walk, bend, lift more than ten pounds, wipe after using the restroom, and sleep. She takes pain medication but stated that the medication only reduces her pain from a "10" to a "7." Plaintiff testified that her boyfriend completes most of the household chores but she can occasionally use public transportation, shop for groceries, cook, fold laundry, and generally care for her own personal needs. Plaintiff testified that she spends roughly half of the day sitting and the other half of the day laying in bed or on the couch either watching movies, reading, using the computer, or talking on the phone.
Plaintiff's medical records reveal that Plaintiff has been diagnosed with obesity, depression, and back pain with sciatica. Radiological testing shows extensive reconstruction surgery throughout Plaintiff's thoracolumbar spine, including fusion hardware extending from T11-L4 and degenerative changes in the disk spaces below the fusion at L4-L5 and L5-S1. Physician observations indicate that Plaintiff walks with an antalgic gait, sometimes displays a decreased range of motion in her lumbar back, and sometimes presents with a slightly swollen left leg that has normal strength. On one occasion, Plaintiff exhibited a decreased range of motion in her left knee due to pain. Other than noted above, Plaintiff's medical records generally indicate that Plaintiff presents as normal.
The ALJ found that Plaintiff suffers from severe impairments including a history of scoliosis, status post placement of Harrington rod and fusion, degenerative disc disease of the lumbar spine, morbid obesity, and depression. He determined that Plaintiff's impairments do not amount to an impairment or combination of impairments that meets the severity of one of those listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. The ALJ assessed that Plaintiff retains the residual functional capacity to perform sedentary work as defined in 20 C.F.R. § 416.967(c), except that Plaintiff: "can lift and carry 10 pounds occasionally and less than 10 pounds frequently; stand and/or walk 2 hours in an 8-hour workday; sit 6 hours in an 8-hour workday; push/pull some weights; must alternate sitting and standing every 30 minutes; no climbing ladders, ropes, or scaffolds; occasional climbing ramps and stairs; occasional balancing, stooping, kneeling, crouching, and crawling; must avoid concentrated exposure to hazards such as unprotected heights and dangerous moving machinery; and can perform simple, routine, repetitive tasks." The ALJ found that Plaintiff's impairments do not preclude her from performing work that exists in significant numbers in the national economy, including work as a charge account clerk, food order clerk, or document preparer. Based on these findings, the ALJ concluded that Plaintiff is not disabled under section 1614(a)(3)(A) of the Act.
"Judicial review of the Commissioner's decision is limited to ascertaining whether substantial evidence in the record as a whole supports the Commissioner's findings." Freeman v. Apfel, 208 F.3d 687, 690 (8th Cir. 2000). Substantial evidence is less than a preponderance of the evidence and requires enough evidence to allow a reasonable person to find adequate support for the Commissioner's conclusion. See id. This standard requires a court to consider both the evidence that supports the Commissioner's decision and the evidence that detracts from it. Finch v. Astrue, 547 F.3d 933, 935 (8th Cir. 2008). That the reviewing court would come to a different conclusion is not a sufficient basis for reversal. Wiese v. Astrue, 552 F.3d 728, 730 (8th Cir. 2009). "If, after review, we find it possible to draw two inconsistent positions from the evidence and one of those positions represents the Commissioner's findings, we must affirm the denial of benefits." Id. (quoting Mapes v. Chater, 82 F.3d 259, 262 (8th Cir. 1996)).
In order to qualify for benefits under the Social Security Act and accompanying regulations, a claimant must prove that she is disabled. Halverson v. Astrue, 600 F.3d 922, 929 (8th Cir. 2010). Disability is defined as "the inability to do 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." 20 C.F.R. § 416.905(a).
The Social Security Administration has established a five-step process for determining whether an individual is disabled. See id. at § 416.920(a). The five-step process considers whether: "(1) the claimant was employed; (2) she was severely impaired; (3) her impairment was, or was comparable to, a listed impairment; (4) she could perform past relevant work; and if not, (5) whether she could perform any other kind of work." Halverson, 600 F.3d at 929. If the ALJ determines at step three the claimant's impairments do not meet or equal one of the listed impairments, then the ALJ must assess the claimant's residual functional capacity ("RFC") prior to proceeding to step four. 20 C.F.R. § 416.920(e). RFC is defined as the most that a claimant can still do despite his or her limitations. Id. at § 416.945(a)(1). A claimant's RFC is determined by the ALJ "based on all of the relevant medical and other evidence." Id. at § 416.945(a)(3).
In the present case, all three of Plaintiff's arguments surround the ALJ's determination of Plaintiff's RFC. First, Plaintiff argues the ALJ failed to sufficiently develop the record in order to properly determine Plaintiff's RFC. Second, Plaintiff claims the ALJ erred when, in assessing the RFC, he found Plaintiff not fully credible regarding the extent of her reported limitations. Third, Plaintiff argues the ALJ's RFC and associated hypothetical question were unsupported by substantial evidence.
Plaintiff first argues that, in determining Plaintiff's RFC, the ALJ should have ordered a consultative examination or re-contacted a physician regarding Plaintiff's physical limitations. Plaintiff claims "the ALJ is not qualified to concoct the physical RFC based upon the raw medical data."
"It is the ALJ's responsibility to determine a claimant's RFC based on all relevant evidence, including medical records, observations of treating physicians and others, and claimant's own descriptions of his limitations." Tellez v. Barnhart, 403 F.3d 953, 957 (8th Cir. 2005) (quoting Pearsall v. Massanari, 274 F.3d 1211, 1217 (8th Cir. 2001)). It is the claimant's burden to provide evidence regarding his or her RFC. 20 C.F.R. § 416.945(a)(3); see also Mayfield v. Astrue, No. 11-3412-CV-S-REL-SSA, 2012 WL 5904331, at *19 (W.D. Mo. Nov. 26, 2012); Peterson v. Colvin, No. 13-0329-CV-W-ODS, 2013 WL 6237868, at *4 (W.D. Mo. Dec. 3, 2013). Only if the evidence presented is considered "insufficient or inconsistent" is the ALJ required to take additional action to re-contact a physician or arrange a consultative examination. See id. at § 416.920b; see also Martise v. Astrue, 641 F.3d 909, 926-27 (8th Cir. 2011); Halverson v. Astrue, 600 F.3d 922, 933 (8th Cir. 2010); Johnson v. Astrue, 627 F.3d 316, 319-20 (8th Cir. 2010).
Eighth Circuit case law reveals that an ALJ can appropriately determine a claimant's RFC without a specific medical opinion so long as there is sufficient medical evidence in the record. See Tellez v. Barnhart, 403 F.3d 953, 956-57 (8th Cir. 2005) ("Tellez contends that the ALJ did not `fully and fairly develop the record' concerning her limitations and that if the `ALJ did not believe that the professional opinions available ... were sufficient to allow him to form an opinion, he should have further developed the record.' However, there is no indication that the ALJ felt unable to make the assessment he did and his conclusion is supported by substantial evidence."); Mayfield v. Astrue, No. 11-3412-CV-S-REL-SSA, 2012 WL 5904331, at *19 (W.D. Mo. Nov. 26, 2012) ("In assessing plaintiff's residual functional capacity, the ALJ was not required to rely entirely on any particular physician's opinion, and the ALJ's decision is not defective simply because there was no opinion evidence from a treating or examining physician regarding plaintiff's residual functional capacity.").
Therefore, it is clear that the ALJ in this case did not err in fashioning Plaintiff's RFC. The ALJ considered medical records, observations of treating physicians, and Plaintiff's own description of her limitations. The ALJ cited Plaintiff's disability report, functional report, and hearing testimony, as well as medical records from April 2010, May 2010, June 2011, August 2011, September 2011, November 2011, March 2012, and April 2012. He highlighted Dr. Clarke's opinion that Plaintiff is likely unable to perform any work that stresses the spine.
Plaintiff next argues the ALJ erred when he found Plaintiff not fully credible regarding her reported limitations. The ALJ stated:
Admin. Tr. 24. Plaintiff argues the ALJ's credibility determination is unsupported by substantial evidence because the ALJ did not assess the required factors, because the connection between the reported limitations and the medical evidence was not weak, and because Plaintiff's reported limitations remained consistent throughout the record.
Once the ALJ finds a medical impairment that could reasonably be expected to produce the claimant's pain or other symptoms alleged, the ALJ must "evaluate the intensity and persistence of [the claimant's] symptoms so that [the ALJ] can determine how [the claimant's] symptoms limit [her] capacity for work." 20 C.F.R. § 416.929(b)-(c). To evaluate the intensity and persistence of a claimant's symptoms, the ALJ should consider the objective medical evidence along with other factors such as the claimant's work record, claimant and third-party reports regarding the claimant's daily activities, pain, precipitating and aggravating factors, medication, and functional restrictions, and non-medical treatments and measures taken to relieve symptoms. See id. at § 416.929(c). The ALJ need not explicitly discuss each of these factors but must adequately explain his credibility findings. Steed v. Astrue, 524 F.3d 872, 876 (8th Cir. 2008).
Because "symptoms sometimes suggest a greater severity of impairment than can be shown by objective medical evidence alone," 20 C.F.R. § 416.929(c)(3), the ALJ "may not disregard a claimant's subjective complaints solely because the objective medical evidence does not fully support them." Polaski v. Heckler, 739 F.2d 1320, 1322 (8th Cir. 1984). Rather, the ALJ may disbelieve subjective complaints regarding intensity and persistence of pain where there are inconsistencies in the evidence as a whole, considering the factors cited above. Id. Credibility determinations are primarily for the Commissioner and courts will "defer to the ALJ's credibility finding if the ALJ `explicitly discredits a claimant's testimony and gives a good reason for doing so.'" Buckner v. Astrue, 646 F.3d 549, 558 (8th Cir. 2011) (quoting Wildman v. Astrue, 596 F.3d 959, 968 (8th Cir. 2010)).
Here, the ALJ made an express finding that Plaintiff's statements concerning intensity, persistence, and limiting effects of her symptoms were not fully credible. The ALJ detailed Plaintiff's statements regarding the extent of her symptoms and limitations. He then highlighted medical records that he believed were inconsistent with the severity of back and leg pain reported by Plaintiff and called into question the extent of Plaintiff's limitations due to mental impairments.
The decision of the ALJ clearly shows that the ALJ considered the appropriate factors in evaluating Plaintiff's credibility regarding the intensity and persistence of her symptoms. The factors assessed by the ALJ show inconsistencies in the record as a whole such that the ALJ did not err in disregarding certain of Plaintiff's subjective complaints. Accordingly, the Court finds the ALJ's credibility determination is supported by substantial evidence. See Halverson v. Astrue, 600 F.3d 922, 932 (8th Cir. 2010) ("If an ALJ explicitly discredits the claimant's testimony and gives good reason for doing so, we will normally defer to the ALJ's credibility determination."); Steed v. Astrue, 524 F.3d 872, 876 (8th Cir. 2008) (where substantial evidence would support both the ALJ's conclusion that claimant is not credible and the claimant's assertion to the contrary, the court should find no error because the ALJ — who was able to observe the claimant during his hearing — is in a better position to make such determinations).
Finally, Plaintiff argues the ALJ's Step Five determination is unsupported by substantial evidence because the ALJ's allegedly erroneous credibility assessment rendered his RFC and hypothetical question incomplete. The Court notes that a hypothetical question posed to a vocational expert "need only include impairments that the ALJ finds credible." Smith v. Colvin, 756 F.3d 621, 627 (8th Cir. 2014). Here, the ALJ's hypothetical question included only those impairments that he found credible; as discussed above, the ALJ's credibility assessment was not unsupported by substantial evidence.
Furthermore, the ALJ's final RFC determination is supported by substantial evidence. The ALJ found Plaintiff could perform no more than a limited range of sedentary work, which itself reflects significant limitation. Such a finding is consistent with Plaintiff's medical records that show degeneration in Plaintiff's lumbar spine and diagnose Plaintiff with back pain accompanied by sciatica. The ALJ further included specific limitations in Plaintiff's RFC that largely reflect Plaintiff's self-reported symptoms and limitations,
For the reasons set forth herein, there is substantial evidence on the record as a whole to support the ALJ's disability determination. Accordingly, the Commissioner's denial of benefits is hereby
