TIMOTHY S. BLACK, District Judge.
This is a Social Security disability benefits appeal. At issue is whether the administrative law judge ("ALJ") erred in finding Plaintiff "not disabled" and therefore not entitled to disability insurance benefits ("DIB") and supplemental security income ("SSI"). (See Administrative Transcript ("Tr.") (Tr. 18-27) (ALJ's decision)).
Plaintiff protectively filed for DIB and SSI in January 2009, alleging an onset date of December 15, 2005. (Tr. 201, 205). Plaintiff alleged disability due to degenerative joint disease of the knees, back and neck pain, obesity, and hypertension. (Tr. 20). The application was initially denied on April 9, 2009. (Tr. 82, 85). The application was denied upon reconsideration on July 30, 2009. (Tr. 89-93). Plaintiff requested a hearing on February 2, 2010. (Tr. 98-100). A hearing was held on July 28, 2011, before ALJ Gregory Kenyon. (Tr. 34-49). A supplemental hearing was held on December 2, 2011, before ALJ Kenyon. (Tr. 50-77). Plaintiff was represented by counsel at both hearings. (Id.)
An unfavorable decision was rendered on February 21, 2012. (Tr. 15-27). The ALJ found Plaintiff not disabled, because she was able to perform sedentary work.
Plaintiff filed a request for review of the hearing decision on March 13, 2012. (Tr. 10-14). The Appeals Council denied the request on March 24, 2013. (Tr. 1-5). Plaintiff then timely filed a complaint in this Court.
At the time of the first hearing, Plaintiff was 41 years old and was considered to be a "younger person" for Social Security purposes. See 20 C.F.R. §§ 404.1563(c); 416.963(c). Plaintiff has a high school education and past relevant work
The ALJ's "Findings," which represent the rationale of his decision, were as follows:
(Tr. 20-26).
In sum, the ALJ concluded that Plaintiff was not under a disability as defined by the Social Security Regulations, and, therefore, was not entitled to DIB or SSI. (Tr. 27).
On appeal, Plaintiff argues that: (1) the ALJ failed to properly consider an examining source opinion pursuant to SSR 96-5P; (2) the ALJ had a duty to recontact the consultative examiner under 20 C.F.R.§404.1520(b) and failed to meet that duty; and (3) the ALJ's residual functional capacity ("RFC") is not supported by the evidence.
The Court's inquiry on appeal is to determine whether the ALJ's non-disability finding is supported by substantial evidence. 42 U.S.C. § 405(g). Substantial evidence is "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 401 (1971). In performing this review, the Court considers the record as a whole. Hephner v. Mathews, 574 F.2d 359, 362 (6th Cir. 1978). If substantial evidence supports the ALJ's denial of benefits, that finding must be affirmed, even if substantial evidence also exists in the record upon which the ALJ could have found plaintiff disabled. As the Sixth Circuit has explained:
Felisky v. Bowen, 35 F.3d 1027, 1035 (6th Cir. 1994).
The claimant bears the ultimate burden to prove by sufficient evidence that she is entitled to disability benefits. 20 C.F.R. § 404.1512(a). That is, she must present sufficient evidence to show that, during the relevant time period, she suffered from an impairment, or combination of impairments, expected to last at least twelve months, that left her unable to perform any job in the national economy. 42 U.S.C. § 423(d)(1)(A).
Plaintiff sought treatment in 2008 and 2009 for ongoing knee and back pain, which worsened if she was on her feet all day. (Tr. 20). Examinations demonstrated few objective findings other than thoracic and lumbar paravertebral muscle spasm and joint line tenderness. (Tr. 21). Plaintiff's primary physician noted the effects of her morbid obesity on her knee pain, and he recommended weight loss. (Id.)
Due to her increasing knee symptoms, Plaintiff was evaluated by orthopedic surgeon, Gerardo Trinidad, M.D., in December 2010. (Tr. 21). Dr. Trinidad noted that the claimant had increased pain, swelling, and giving-way with standing, ambulating, bending, squatting, and going up or down stairs, and that her symptoms had not resolved with anti-inflammatory medications, steroid injections, and Synvisc injections. (Id.) Dr. Trinidad diagnosed severe varus osteoarthritis in the bilateral knees, which resulted in Plaintiff undergoing total knee replacement surgery in January 2011 for her left knee, and April 2011 for her right knee. (Id.)
Further medical evidence indicates that Plaintiff suffers from migraine headaches caused by sensitivity to light and sound; she also has a history of hypertension. (Tr. 21). These issues are both controlled via medications. (Id.)
Plaintiff was briefly hospitalized in January 2008 with dizziness, nausea, and hypertension. Providers discovered that she was experiencing premature ventricular contractions
In February 2008, Plaintiff sought treatment for right leg pain, which revealed superficial thrombophlebitis, but no evidence of deep venous thrombosis. (Tr. 21).
Plaintiff testified that she experiences constant pain in her knees, which increases with activity such as household chores. (Tr. 22). She elevates her legs whenever she is sitting, because her knees continue to swell. (Id.) Plaintiff rates her knee pain, in severity (on a scale of 1 to 10), as a "5" with medication and an "8" without medication. (Id.) Plaintiff also complains of a stabbing pain in her lower back accompanied by numbness in her hips; she rates her back pain as a "6" with medication and an "8" without medication. (Id.) She treats her back pain with a heating pad. (Id.) Further, Plaintiff experiences neck pain which she rates as a "4" with medication and a "6" without medication. (Id.) On average, Plaintiff experiences migraines twice a month, which are brought on by loud noise and light, and tend to last 2 to 3 days at a time. (Id.) When experiencing one of these headaches, she must use prescription medication and must stay in a dark, quiet room. (Id.)
Plaintiff testified that she is only able to lift 10 pounds, stand or walk 20 to 30 minutes at a time, and sit 30 minutes at a time comfortably. (Tr. 23). She occasionally uses a cane to help her get around. (Id.) She cannot bend, kneel, or squat; she also experiences difficulty using stairs. (Id.) One of the side-effects of the pain medication is drowsiness. (Id.) Plaintiff can do a few household chores, such as laundry, and walk around the block for exercise. (Id.) She feels that she cannot work, because she cannot stand for extended period of time or bend without pain, and that physical therapy has not helped with her back symptoms. (Id.)
First, Plaintiff alleges that the ALJ should have given more weight to one-time consultative examiner, Dr. David Herr.
"In assessing the medical evidence supporting a claim for disability benefits, the ALJ must adhere to certain standards." Blakley v. Comm'r of Soc. Sec., 581 F.3d 399, 406 (6th Cir. 2009).
"The ALJ `must' give a treating source opinion controlling weight if the treating source opinion is `well supported by medically acceptable clinical and laboratory diagnostic techniques' and is `not inconsistent with the other substantial evidence in [the] case record.'" Blakley, 581 F.3d at 406. "If the ALJ does not accord controlling weight to a treating physician, the ALJ must still determine how much weight is appropriate by considering a number of factors, including the length of the treatment relationship, supportability of the opinion, consistency of the opinion with the record as a whole, and any specialization of the treating physician." Id. Further, the ALJ gets to decide how to weigh evidence. See 20 C.F.R. 404.1527(c)(1). Unfortunately, in this case, Plaintiff did not have the benefit of a treating physician.
Plaintiff attended a consultative examination with Dr. Herr in August 2011. (Tr. 493). Dr. Herr's assessment consisted in large part of checking boxes. Dr. Herr's report specifies that his findings were based on manual muscle testing, range of motion testing, orthopedic physical examination which focused on the physical medicine abnormalities, review of systems, and a medical interview. (Id.) He reported that Plaintiff's knees were symmetrical in appearance with no swelling, effusion, induration, or deformities, that her knee flexion was somewhat diminished, and that her extension was slightly abnormal. (Id.) Dr. Herr did not find evidence of muscle atrophy, fasciculation, or wasting. (Id.) Dr. Herr noted that some ongoing knee joint symptoms were foreseeable at the time of the examination, because Plaintiff had likely not fully recovered from her knee replacement surgeries. (Id.)
Dr. Herr diagnosed Plaintiff with morbid obesity; osteoarthritis, status post bilateral knee replacement; degenerative disc disease, cervical spine; degenerative disc disease, lumbar spine; facet arthropathy, cervical and lumbar spine. (Tr. 497). Dr. Herr found these impairments to be permanent, while treatment would only be palliative
Whether a person is disabled is an issue "reserved to the Commissioner." See Warner v. Comm'r of Soc. Sec., 375 F.3d 387, 390 (6th Cir. 2004). "A statement by a medical source that you are `disabled' or `unable to work' does not mean that we will find that you are disabled." See 20 C.F.R. §404.1527(e)(1).
The ALJ's reliance on Dr. Hinzman's non-examining reviewing opinion, that Plaintiff could perform sedentary work,
Social Security Ruling 96-6p. It is important to emphasize that neither Dr. Hinzman nor Dr. Herr had a treatment relationship with the Plaintiff. Therefore, the Court must consider the objective medical evidence in greater detail. (Id.)
Dr. Herr's written statements contradict his own objective results. (Tr. 24). For example, the ALJ noted that there was "no basis for . . . a reaching limitation." (Tr. 25). Dr. Herr's examination showed that Plaintiff's upper extremities had normal range of motion, full strength in all muscle groups, no muscle atrophy, and normal grip strength. (Tr. 496). However, he limited Plaintiff to frequent reaching, allegedly due to "decreased range of motion in her spine and absent reflexes." (Tr. 488). Upon examination, Plaintiff's lower extremities had no muscle atrophy, no swelling, were symmetrical, and "ranges of motion of hips, knees, and ankles [were] normal bilaterally." (Tr. 496). Furthermore, in August 2011, Plaintiff had normal strength in her upper and lower extremities, normal sensation, no spinal tenderness, and no edema. (Tr. 23, 544-546). Dr. Herr restricted Plaintiff to "never climb stairs or ramps." (Tr. 489). However, he later determined that Plaintiff could "climb a few steps at a reasonable pace." (Tr. 491). These inconsistencies are indicative of Dr. Herr accepting Plaintiff's subjective complaints and checking boxes accordingly. As a result, the ALJ was entitled to discount Dr. Herr's assessment because it was not supported by adequate examination or objective medical evidence. Freudenberger v. Astrue, No. 1:09-CV-745, 2011 WL 1114407, at *7 (S.D. Ohio Feb. 28, 2011) ("where conclusions regarding claimant's functional capacity are not substantiated by objective evidence, the ALJ is not required to credit those conclusions.").
With only minor abnormalities and mostly normal objective findings and treatment notes, the ALJ properly noted that Dr. Herr's restrictions were "inconsistent with his own objective physical findings." Walters v. Comm'r of Soc. Sec., 127 F.3d 525, 530 (6th Cir. 1997). Moreover, no other physician thought Plaintiff was nearly as restricted as Dr. Herr. Accordingly, the ALJ gave proper weight to Dr. Herr in finding that Plaintiff did not have disabling impairments.
Next, Plaintiff alleges that the ALJ neglected his duty to re-contact the consultative examiner, Dr. Herr. SSR 96-5p provides that re-contacting an examining physician is an option, not a requirement. 20 C.F.R. §404.1520b. The provision dictates that the ALJ
Finally, Plaintiff alleges that the ALJ's RFC determination is not supported by substantial evidence. Specifically, Plaintiff argues that instead of basing his RFC on medical opinion, the ALJ based Plaintiff's RFC on his own lay opinion.
Plaintiff argues that Dr. Herr's opinion should have been given controlling weight. (Tr. 25). As explained supra in Section II.B, the ALJ properly determined that Dr. Herr's opinion was not entitled controlling weight, because he only examined Plaintiff on one single occasion, had no treatment relationship, and made inconsistent findings. (Id.)
In determining Plaintiff's RFC, the ALJ is required to consider Plaintiff's symptoms and the extent to which these symptoms could reasonably be accepted as consistent with the objective medical evidence and other evidence, based on the requirements of 20 CFR 404.1529, 416.929 and SSR 96-4p and 96-7p. (Tr. 22). This is a two-step process. (Id.) The first step requires a determination of whether there is an impairment that can be shown by medically acceptable clinical or laboratory diagnostic techniques that could reasonably be expected to produce the claimant's pain or other symptoms. (Id.) Second, once a physical or mental impairment that could reasonably be expected to produce the claimant's pain or other symptoms has been evidenced, then the ALJ must evaluate the intensity, persistence, and limiting effects of the claimant's symptoms to determine the extent to which they limit the claimant's functioning. (Id.) If the aforementioned factors are not substantiated by objective medical evidence, the ALJ must make a finding on the credibility of the statements based on a consideration of the entire case record. (Id.)
The ALJ limited Plaintiff's RFC to sedentary work because of her bilateral knee replacements. In making this determination the ALJ gave partial deference to Dr. Herr's opinion. (Tr. 24).
Dr. Herr submitted a physical capacities questionnaire, where he indicated that Plaintiff could lift consistent with light level work and that she could stand and walk for a combined total of 5 hours per day, but sit for just 4 hours per day. Dr. Herr also indicated that Plaintiff could sit for 30 minutes at a time and stand or walk for just 10 minutes at a time. (Tr. 24). Dr. Herr precluded Plaintiff from performing most postural activities and limited her to frequent reaching. (Tr. 25). Dr. Herr's objective examination results, along with the other medical evidence of record suggests that Plaintiff had a good surgical result from her total knee replacements, without experiencing post-surgical complications. (Id.) Accordingly, the ALJ concluded that there was no basis to restrict Plaintiff to standing and walking for 10 minutes at a time, nor was there any basis to limit Plaintiff to sitting just 30 minutes at a time and for a total of 4 hours per day, because her back pain appears to be of "moderate level severity." (Id.) The ALJ concluded that these findings support a determination that Plaintiff maintains the ability to perform at least sedentary level work. (Id.) This Court agrees.
The ALJ's RFC adoption of a hybrid of restrictions set forth by the examining and reviewing physicians was proper. The ALJ has the discretion "to weigh all the evidence" and he did not abuse that discretion in this case. Collins v. Comm'r of Soc. Sec., 357 F.App'x 663, 668 (6th Cir. 2009). "Given the number of physicians and the variation in their opinions" any decision by the ALJ necessarily required him to "discredit the opinion of at least one physician." Gaskin v. Comm'r of Soc. Sec., 280 F.App'x 472, 476 (6th Cir. 2008). "The findings of the Commissioner are not subject to reversal merely because there exists in the record substantial evidence to support a different conclusion." Buxton v. Halter, 246 F.3d 762, 773 (6th Cir. 2001). Accordingly, the ALJ's RFC is supported by substantial evidence.
The Court's duty on appeal is not to re-weigh the evidence, but to determine whether the decision below is supported by substantial evidence. Raisor v. Schweiker, 540 F.Supp. 686 (S.D. Ohio 1982). Substantial evidence supports the ALJ's finding that Plaintiff could perform at least sedentary work and therefore was not disabled. The issue is not whether the record could support a finding of disability, but rather whether the ALJ's decision is supported by substantial evidence. Casey v. Sec'y of Health & Human Servs., 987 F.2d 1230, 1233 (6th Cir. 1993).
For the foregoing reasons, Plaintiff's assignments of error are unavailing and the ALJ's decision is supported by substantial evidence.