ALAN C. KAY, SR., District Judge.
For the reasons below, the Court AFFIRMS the administrative law judge's denial of benefits and supplemental security income to Plaintiff.
On January 30, 2014, Plaintiff Tina Cajigal (formerly known as Tina Young) filed an application for a period of disability and for disability insurance benefits. Administrative Record ("AR") 66;
Plaintiff's claims were initially denied on September 25, 2014, AR 66-74, and upon reconsideration on February 26, 2015. AR 91-103. Thereafter, on March 10, 2015, Plaintiff filed a written request for a hearing before an administrative law judge ("ALJ"), AR 121, and a hearing was held on May 26, 2016, AR 134. On June 27, 2016, the ALJ issued a written decision finding Plaintiff not disabled. AR 18-30. Plaintiff filed a request with the Appeals Council to review the ALJ's decision on August 23, 2016. AR 160-61. The Appeals Council denied her request and adopted the ALJ's decision as the final decision of the Commission on July 21, 2017. AR 1-4.
Plaintiff filed her complaint on September 22, 2017, seeking a review of the denial of her applications. ECF No. 1. On May 1, 2018, Plaintiff filed her opening brief ("Op. Br."). ECF No. 17. Defendant, the Acting Commissioner of Social Security ("Commissioner"), filed her answering brief on May 18, 2018 ("Ans. Br."). ECF No. 20. Plaintiff filed her reply brief on May 25, 2018 ("Reply Br."). ECF No. 21.
The Court has scheduled a hearing on Plaintiff's requested review of the Commissioner's decision at 11:00 a.m. on Wednesday, June 13, 2018.
A district court has jurisdiction pursuant to 42 U.S.C. § 405(g) to review final decisions of the Commissioner of Social Security.
In determining the existence of substantial evidence, the administrative record must be considered as a whole, weighing the evidence that both supports and detracts from the Commissioner's factual conclusions.
Moreover, "[i]f the evidence can reasonably support either affirming or reversing, the reviewing court may not substitute its judgment for that of the Commissioner."
"To establish a claimant's eligibility for disability benefits under the Social Security Act, it must be shown that: (a) the claimant suffers from a medically determinable physical or mental impairment that can be expected to result in death or that has lasted or can be expected to last for a continuous period of not less than twelve months; and (b) the impairment renders the claimant incapable of performing the work that the claimant previously performed and incapable of performing any other substantial gainful employment that exists in the national economy."
The Social Security regulations set forth a five-step sequential process for determining whether a claimant is disabled.
At step one, the ALJ considers a claimant's work activity, if any. 20 C.F.R. § 404.1520(a)(4)(i). Where the ALJ finds the claimant is engaged in substantial gainful activity, he will determine that the claimant is not disabled, regardless of the claimant's medical condition, age, education, or work experience. 20 C.F.R. § 404.1520(b). Substantial gainful activity is work that is defined as both substantial—
Step two requires the ALJ to consider the medical severity of the claimant's impairments. 20 C.F.R. § 404.1520(a) (4)(ii). Only if the claimant has an impairment or combination of impairments that "significantly limits [her] physical or mental ability to do basic work activities" will the analysis proceed to step three. 20 C.F.R. § 404.1520(c). If not, the ALJ will find that the claimant is not disabled and the analysis ends. 20 C.F.R. § 404.1520(a)(4)(ii).
The severity of the claimant's impairments is also considered at step three. 20 C.F.R. § 404.1520(a)(4)(iii). There, the ALJ determines whether a claimant's impairments meet or medically equal the criteria of an impairment specifically described in the regulations.
At step four, the ALJ determines the claimant's residual functional capacity ("RFC").
At the fifth and final step, the ALJ will once again consider the claimant's RFC—along with her age, education, and work experience—in order to determine whether the claimant can perform other work. 20 C.F.R. § 404.1520(a)(4)(v). Here, the Commissioner is responsible for providing "evidence that demonstrates that other work exists in significant numbers in the national economy that [the claimant] can do." 20 C.F.R. § 404.1560(c)(2). If the claimant is unable to perform other work, she is deemed disabled; if she can make an adjustment to other available work, she is considered not disabled. 20 C.F.R. § 404.1520(g)(1).
At step one, the ALJ found that Plaintiff had not engaged in gainful activity since May 3, 2012, the alleged onset date, and at step two, that she suffered from the following severe impairments: post laminectomy syndrome in the lumbar spine and degenerative lumbar disc disease. AR 23. At step three, the ALJ found that Plaintiff did not have an impairment or a combination of impairments that met or medically equaled the severity of an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. AR 24. Plaintiff does not contest the findings the ALJ made at these steps.
At steps four and five, the ALJ determined that Plaintiff has the RFC to perform light work. AR 24. The ALJ found that Plaintiff "could not climb ladders, ropes and scaffolds but otherwise would have occasional limitation in postural movements; she must avoid moderate exposure to hazards; and she must alternate positions, approximately every 30 minutes from sitting to standing, and from standing to sitting . . . ." AR 24. The ALJ further determined at step four that Plaintiff is unable to perform any past relevant work. AR 28. At step five, the ALJ concluded that Plaintiff is not disabled because there is other work she can perform in the national economy.
Based on the ALJ's finding that Plaintiff was not disabled, the ALJ denied Plaintiff's applications for disability insurance benefits and supplemental security income. AR 30.
Plaintiff contends that the ALJ erred in finding that she could perform light work because the ALJ's decision was based on outdated medical records. Op. Br. at 20; Reply at 2. According to Plaintiff, the evidence that the ALJ considered was "clearly outdated by a number of years prior to the time of the May 26, 2016 Administrative hearing," and thus the ALJ's decision was not supported by substantial evidence. Op. Br. at 20.
Courts have explained that "it is the responsibility of the ALJ, not the claimant's physician, to determine residual functional capacity."
However, "[n]o authority suggests that the regulations require the ALJ to continue developing the record until disability is established; the regulations require only that the ALJ assist the claimant in developing a complete record."
Plaintiff contends that the ALJ erred by failing to "request an updated RFC from either Ms. Cajigal's current treating physician (Dr. Jerald Garcia) or . . . an updated RFC to be conducted by an independent physician." Op. Br. at 20. But the ALJ both left the record open for submission of additional evidence and found Plaintiff's condition virtually unchanged from the time of her previous function capacity evaluation and medical examinations. AR 27. Accordingly, "[t]he ALJ was not required to order an updated RFC examination and sufficiently met [her] duty to develop the record by leaving the record open for submission of additional evidence."
First, the ALJ left the record open following the hearing to allow for consideration of additional evidence. The ALJ specifically left the record open to consider Dr. Peter Diamond's April 15, 2016 report, issued after his March 21, 2016 examination. AR 27, 51, 63-64.
Additionally, despite Plaintiff's argument that the ALJ should have requested an updated RFC from Dr. Garcia (Plaintiff's pain management doctor since July 2013, AR 26), the ALJ considered evidence from Dr. Garcia developed in close proximity to the hearing. In determining that Plaintiff could perform light work, the ALJ considered Dr. Garcia's May 2015 progress notes, which described Plaintiff as having "acceptable" gait and "acceptable" range of motion in the lumbar spine. AR 27; Ans. Br. at 7. Dr. Garcia's progress notes also recorded Plaintiff's motor strength at 5/5 or "full." AR 27.
The ALJ also considered Dr. Garcia's February 26, 2016 examination. AR 27. This examination, consistent with Dr. Diamond's examination records submitted after the hearing, concluded with Dr. Garcia's opinion that Plaintiff's condition was "relatively unchanged." AR 27. And, as the ALJ noted, this evidence was also consistent with the medical records from Plaintiff's treating physicians, including Dr. Peter Lum.
In sum, the ALJ found that "there is little change in the examinations since the functional capacity evaluation in January 2013 finding [Plaintiff] capable of light exertion." AR 28;
The ALJ explicitly left the record open for additional evidence and compared more recent medical opinions with the record as a whole.
Plaintiff next claims that the ALJ erred by closing the record before Plaintiff had an electromyography ("EMG") and another surgical consultation. Op. Br. at 23; Reply at 1. Although the ALJ permitted Plaintiff to submit Dr. Diamond's supplemental report after the hearing, Plaintiff contends that the ALJ was obligated to keep the record open to consider any post-hearing EMG or surgical consultation.
Regarding Plaintiff's pending surgical consultation or any future procedures, however, the ALJ stated:
AR 28. As already stated, "[n]o authority suggests that the regulations require the ALJ to continue developing the record until disability is established; the regulations require only that the ALJ assist the claimant in developing a complete record."
Plaintiff seems to mischaracterize the medical record and her testimony from the hearing. First, in connection with the purported EMG test referral, Plaintiff testified that she saw Dr. Diamond in March or April 2016, and that he referred her to a nerve doctor for "some kind of testing." AR 44-45. Plaintiff's attorney questioned whether Plaintiff had yet received Dr. Diamond's report from her March or April visit, to which Plaintiff replied, "No, I've been asking for it." However, the ALJ left the record open after the hearing and specifically considered Dr. Diamond's April 15, 2016 report on Plaintiff's March 21, 2016 examination.
Dr. Diamond's report also opined that Plaintiff is at "maximum medical improvement, and has not improved materially since I saw her on 7/15/13, at which time I felt that she was stable and ratable." AR 1114. Under these circumstances, the ALJ was under no duty to further develop the record as to Dr. Diamond's supposed referral of Plaintiff for an EMG.
Second, with respect to Plaintiff's surgical consultation, Plaintiff claims that the ALJ erred when he closed the record despite Plaintiff testifying that she had "a surgical consult pending." Op. Br. at 24; Reply at 1. But Plaintiff's testimony at the hearing belies her current position. Plaintiff testified at the hearing that she "just found out" that "worker's comp had approved [her] in November of last year" for a consultation with a neurosurgeon, but Plaintiff "was not told until [her] last visit last month" to Dr. Garcia. AR 45-46. Plaintiff testified that Dr. Garcia informed her that consultation with a neurosurgeon "was approved in November
Plaintiff did not testify that she had a surgical consultation pending at the time of the hearing. AR 45-47. The ALJ did consider the testimony that Plaintiff had earlier been approved for another surgical consult, but with the time for that allowed consult having expired, the ALJ accurately concluded that "[t]he last surgical consult of record found further surgery not warranted." AR 28.
Plaintiff's testimony indicates that neither a surgical consultation nor an EMG were pending at the time of the ALJ's decision. In contrast, the ALJ kept the record open to allow for the addition of Dr. Diamond's supplemental report, AR 63, which was the only evidence Plaintiff's testimony made clear was forthcoming, AR 44-45. Considering Plaintiff's testimony and the ALJ's reasoning, the Court does not conclude that the ALJ failed to fully and fairly develop the record.
Plaintiff argues that the ALJ erred by discrediting certain of her testimony. Op. Br. at 21-23; Reply at 4-5. In the decision, the ALJ stated:
AR 25.
"An individual's statement as to pain or other symptoms shall not alone be conclusive evidence of disability." 42 U.S.C. § 423(d)(5)(A). Rather, to assess "the credibility of a claimant's testimony regarding subjective pain or the intensity of symptoms, the ALJ engages in a two-step analysis."
Plaintiff contends that the ALJ ignored testimony— supported by the independent evaluations of Dr. Diamond and Dr. Garcia—confirming her symptoms and limitations. Op. Br. at 22. The ALJ's decision, however, addressed and specifically rejected Plaintiff's testimony on permissible grounds. AR. 27-28; Ans. Br. at 15. The ALJ first found that while there was evidence in the record substantiating Plaintiff's statements that she needed to alternate between sitting and standing every thirty minutes, the medical record did not substantiate her statements that she was more limited. AR 28.
The ALJ noted that the evidence showed little change in the examinations since the FCE in January 2013 finding Plaintiff capable of light exertion, and stated that the last surgical consultation in the record determined that additional surgery was not warranted. AR 28. Further, the ALJ considered Dr. Garcia's May 2015 progress notes, which recorded Plaintiff's motor strength at 5/5 or "full," and February 2016 examination, which characterized Plaintiff's condition as "relatively unchanged." AR 27. These results, the ALJ found, were consistent with Dr. Diamond's March 2016 evaluation in which he opined that Plaintiff was at "maximum medical improvement, and has not improved materially since I saw her on 7/15/13, at which time I felt that she was stable and ratable." AR 1114. These inconsistencies between the medical record and Plaintiff's testimony were a permissible basis on which the ALJ could make a negative credibility finding. AR 28;
The ALJ also considered Plaintiff's testimony about her daily activities. AR 28;
Finally, the ALJ noted that Plaintiff participated in a vocational rehabilitation program and sought employment. AR 26. Despite Plaintiff's contention that the ALJ's reasoning "penalized" her for enrolling in the program, Reply at 4, Plaintiff's participation therein is a proper ground on which to discredit her subjective pain testimony.
Considering Plaintiff's testimony about her daily activities, along with the ALJ's evaluation of the medical record, the ALJ stated that the RFC determination was "supported by the nature of the activities of daily living [in which Plaintiff engaged] and the medical history." AR 28. The Court finds that nothing in the record shows the ALJ arbitrarily disregarded Plaintiff's testimony in making this determination.
Plaintiff argues that the ALJ propounded inaccurate hypothetical questions to the vocational expert ("VE"). Op. Br. at 25-27; Reply at 8. At step five of the process for determining disability, the Commissioner has the burden "to demonstrate that the claimant is not disabled and can engage in work that exists in significant numbers in the national economy."
The ALJ found that there was evidence substantiating Plaintiff's statements that she needed to alternate between sitting and standing every thirty minutes due to pain, but found that the medical record did not substantiate her statements that she was more limited. AR 28. Plaintiff's testimony that the ALJ found to be unsubstantiated, for example, included her subjective pain testimony regarding shooting pains down her leg and her need to lie down frequently. AR 28, 49. Accordingly, the ALJ determined that Plaintiff had an RFC to perform light work, but "could not climb ladders, ropes and scaffolds but otherwise would have occasional limitation in postural movements; she must avoid moderate exposure to hazards; and she must alternate positions, approximately every 30 minutes from sitting to standing, and from standing to sitting . . . ." AR 24.
Consistent with this determination, the ALJ's first hypothetical to the VE asked: "[A]ssume a person of claimant's age, education and prior work experience who's able to perform light work with no ladders, ropes and scaffolds with occasional postural, and further the individual would need to avoid moderate exposure to hazards. Would such a person be able to perform any of the prior work?" AR 57. The VE answered "Yes, Your Honor, it looks like pretty much all of it would fit. I don't see any reason why not." AR 57.
The ALJ then, incorporating Plaintiff's limitations ultimately found to be substantiated, said: "[I]f we add to hypothetical one [that] the person would have to alternate positions approximately every 30 minutes from sitting to standing and from standing to sitting[,] what impact might that have on the prior work?" AR 57. This hypothetical—which ultimately served as the basis for the ALJ's determination—was appropriately based on the ALJ's interpretation of the evidence in the record as a whole because the ALJ was not required to include limitations found to be unsupported by substantial evidence.
After the ALJ posed this hypothetical to the VE, the VE responded that Plaintiff would be unable to perform prior work but could perform:
AR 57-58.
The ALJ continued to pose various hypotheticals to the VE. AR 56-62. These hypotheticals required the VE to consider the effect of various limitations to which Plaintiff testified on Plaintiff's prospects for employment.
The ALJ's reliance on the VE's testimony thus did not result in error.
Moreover, Plaintiff has not demonstrated any deficiency in the ALJ's hypothetical questions posed to the VE.
Plaintiff also states that the VE: (1) was precluded from answering counsel's question regarding a parking lot attendant job; and (2) did not have access to the medical records and thus "basically could ignore" Plaintiff's medical records in answering the hypotheticals. Op. Br. at 26. Plaintiff's arguments misapprehend the role of the VE. At step five, vocational experts assist ALJs by testifying about: "(1) what jobs the claimant, given his or her residual functional capacity, would be able to do; and (2) the availability of such jobs in the national economy."
With these principles in mind, the testimony at the hearing shows that no error occurred. There, in response to the VE's testimony that Plaintiff could perform cashier II jobs (which are done "typically in a workstation or a booth or a parking lot station," AR 62), Plaintiff's attorney asked:
AR 62. The VE responded: "Are you talking about, that's not the job I gave." AR 62. And the ALJ then stated: "That's not an appropriate question for the vocational expert. . . . He doesn't have access to the medical records nor is he a medical expert." AR 62-63. Plaintiff's counsel responded, "Oh, I see. You don't have access to the medical records. . . . I'm sorry." AR 63.
First, Plaintiff's counsel's question—"Could [Plaintiff] do something like that based on her limitations in the record?"—is not a proper question for a VE, who responds to an ALJ's hypotheticals rooted in the ALJ's evaluation of the medical record.
Second, the ALJ's response—that the VE does not have access to the medical record—is accurate and reflects that the ALJ's hypotheticals, where properly framed, include the limitations the ALJ finds substantiated by the medical record.
Additionally, as the VE attempted to clarify at the hearing, the VE never suggested that Plaintiff could perform work as a "parking lot attendant." The VE instead opined that Plaintiff could perform cashier II jobs (which are done "typically in a workstation or a booth or a parking lot station," AR 62). Plaintiff's attorney's question was thus inaccurate, leaving aside any other considerations.
In sum, the VE answered complete hypotheticals based on Plaintiff's age, education, work experience, and RFC. The exclusion of a single question about a single type of employment disconnected from the VE's actual testimony (such as Plaintiff's attorney's aforesaid question about parking lot attendants) and dependent on an analysis of the medical record does not show that the ALJ erred.
For the foregoing reasons, the Court AFFIRMS the ALJ's denial of benefits and supplemental security income to Plaintiff.
IT IS SO ORDERED.