LYNN ADELMAN, District Judge.
In this action for judicial review, plaintiff Jenny St. George argues that an Administrative Law Judge ("ALJ") erred in denying her applications for social security disability benefits by failing to provide a sufficient explanation for discounting the medical opinions of her treating providers and her statements regarding the limiting effects of her symptoms. On review of the record and the submissions, I remand for further proceedings.
Plaintiff applied for supplemental security income ("SSI") and disability insurance benefits ("DIB") in April 2013, alleging a disability onset date of September 30, 2008.
After plaintiff filed her applications, the agency arranged for a mental status evaluation with Christopher Ovide, Ed.D., on November 21, 2013. (Tr. at 525.) Dr. Ovide noted:
(Tr. at 531.) Dr. Ovide diagnosed anxiety disorder, NOS v. panic attack; cannabis abuse v. dependence; alcohol abuse v. dependence, reported to be in full remission; cocaine, ecstasy, and LSD abuse, in full remission; personality disorder, NOS, with cluster B traits; and a GAF of 55.
(Tr. at 532.)
The agency denied the application initially on December 3, 2013 (Tr. at 165), based on the review of Dimitri Teague, M.D., who concluded that plaintiff could perform light work with occasional use of her left leg for pushing/pulling or operating foot controls; occasional climbing of ramps/stairs; never climbing ladders/ropes/scaffolds; frequent balancing; occasional stooping, kneeling, crouching, and crawling; avoiding concentrated exposure to fumes, odors, dusts, etc., and avoiding all exposure to hazards (machinery, heights, etc.) (Tr. at 91-92) and David Biscardi, Ph.D., who concluded that plaintiff retained the capacity to understand, remember, carry out, and sustain performance of one to three step tasks (but would become overwhelmed if the procedures were more complicated), complete a normal workday, interact with co-workers/supervisors, and adapt to changes/stressors associated with simple, routine competitive activities. (Tr. at 94).
Plaintiff requested reconsideration (Tr. at 170), but the agency maintained the denial on May 30, 2014 (Tr. at 173) based on the review of Neal Bente, M.D., who concluded that plaintiff could perform light work, with a number of additional postural and environmental limitations (Tr. at 129-31) and Ellen Rozenfeld, Psy.D., who agreed with Dr. Biscardi's evaluation (Tr. at 133). Plaintiff then requested a hearing before an ALJ. (Tr. at 185.)
Prior to the hearing, plaintiff submitted several reports from her treating providers, which endorsed a number of significant — and, at times, divergent — limitations on her ability to sustain work. On September 11, 2014, Dr. Matthew Schubert, plaintiff's primary care physician, prepared a report in which he indicated that he had treated plaintiff since September 24, 2013, and listed diagnoses of anxiety and bipolar disorder; chronic back, neck, and ankle pain; COPD; depression; and panic attacks. Her prognosis was "fair pending treatment." (Tr. at 942.) He indicated that her symptoms began "well before [he] knew her." (Tr. at 943.) He recommended "no physical activities" and a "stress free work place." (Tr. at 943.) He indicated that she could occasionally lift 10 pounds, never more; stand/walk no more than two hours in an eight hour day and continuously walk two to four blocks; and sit with no limitation. (Tr. at 943.) He further indicated that she could rarely move her neck, stoop, crouch, or climb. She could frequently use her hands and fingers, but rarely reach with her arms. He further indicated that her symptoms would frequently interfere with the performance of simple work tasks. Her impairments also produced "bad days" such that she would likely be absent from work more than three times per month. Her medications did not cause side effects affecting her ability to work. (Tr. at 944.) He estimated that she could participate in work or work readiness activities one to two hours per day. (Tr. at 945.)
On September 18, 2014, Dr. Florin Stuleanu, plaintiff's pulmonologist, completed a report, listing a diagnosis of COPD with a fair prognosis. (Tr. at 1566.) He indicated that plaintiff could occasionally lift 20 pounds, frequently 10; stand and walk no more than six hours in an eight-hour day; and sit no more than two hours in a day. (Tr. at 1567.) She could frequently move her neck and engage in postural movements. She had no significant limitations with handing, fingering, and reaching. Her symptoms would rarely interfere with the performance of simple work tasks. Her impairments did produce bad days, and she would likely be absent from work about twice per month. Her medications did not cause side effects. (Tr. at 1568.) Dr. Stuleanu thought plaintiff could engage in work activities six hours per day. (Tr. at 1569.)
On November 17, 2014, Dr. Vijay Khiani, a GI specialist, completed a medical source statement. (Tr. at 1453.) Dr. Khiani indicated that he first saw plaintiff on September 29, 2014 and listed a diagnosis of Crohn's disease, with a prognosis "TBD." (Tr. at 1450.) He identified symptoms of abdominal pain and cramping, weight loss, nausea, fatigue, change in bowel habits, gas, and bloating. He indicated that plaintiff experienced right sided mid and lower abdominal pain, sharp pressure, and cramping. He further identified clinical findings and objective signs from an MRI, Prometheus panel, and colonoscopy. (Tr. at 1450.) He found it difficult to assess her ability to sit, stand, and walk, noting they were trying to treat her significant abdominal pain related to inflammation. She would need a job that permits ready access to a restroom, up to several times per day. (Tr. at 1451.) He further indicated that she would sometimes need to lie down or rest at unpredictable intervals during a working day; how often was unclear. He stated that she should avoid heavy lifting but did not provide specific figures. He also crossed out the questions regarding time off task, work stress, and absences. (Tr. at 1452.)
On February 10, 2015, Dr. Schubert prepared a letter stating:
(Tr. at 755.) On August 31, 2015, Dr. Schubert prepared another letter saying the same thing. (Tr. at 771.)
On September 4, 2015, Dr. Srihari Ramanujam, plaintiff's gastroenterologist, prepared a report listing a diagnosis of Crohn's disease. For a prognosis, he indicated the disease was chronic, with periodic flares. (Tr. at 773.) He wrote that her symptoms began August 2014. She was currently on a biologic medication — Remicade — and they were hoping for control of inflammation, although she may have continued symptoms. (Tr. at 774.) Asked to assess her physical abilities (lifting, standing/walking, sitting, using arms and hands), he wrote "N/A." (Tr. at 774-75.) He did check "frequently" when asked how often her symptoms would interfere with the ability to perform simple work tasks. He also indicated that her impairment would produce good and bad days, and more than three absences per month. (Tr. at 775.) Asked how many hours per day she could work, he wrote: "Hard to say — need to clarify with other medical providers for her other conditions." (Tr. at 776.) At the end of the report, he added: "Please note that [a] majority of these questions cannot be addressed by our GI specialty. This patient has
On February 15, 2016, Dr. Schubert prepared another report, listing impairments of chronic neck, back, ankle, and abdominal pain; Crohn's disease; and chronic obstructive lung disease. (Tr. at 1128.) In this report, he indicated that plaintiff could occasionally lift five pounds or less, stand/walk less than one hour in an eight-hour workday (and just five minutes at a time), sit without limitation, and never engage in postural movements (e.g., climbing, kneeling, crouching, crawling). (Tr. at 1127-28.) She could occasionally reach with both arms, and frequently use her hands and fingers. He attributed these limitations to chronic back pain. (Tr. at 1129.) He also identified environmental limitations of temperature extremes, noise, vibration, and hazards (machinery, heights), stating that "heat or cold affect her joints — pain." (Tr. at 1129.) He concluded that this assessment applied to the time period of February 15, 2016 to August 15, 2016. (Tr. at 1129.)
On March 2, 2016, Cynthia Koopmeiners, PA-C, who worked with Dr. Ramanujam, prepared a medical source statement, listing diagnoses of Crohn's-mild and abdominal pain (not related to Crohn's). She listed symptoms of abdominal pain and cramping, weight loss, vomiting, and nausea. (Tr. at 1584.) She indicated that plaintiff needed a job that permits ready access to a bathroom, and that plaintiff would need to take unscheduled breaks of 30 minutes' duration three times per day; the need for such breaks could be sudden. Koopmeiners further indicated that plaintiff would need to lie down two to four times per day, for one to two hours. She would be off task 25% or more of the time due to her symptoms and was incapable of even low stress work, as stress would cause a flare of symptoms. (Tr. at 1585.) Plaintiff would also have good and bad days, and would likely be absent more than four days per month. (Tr. at 1586.)
Finally, on March 9, 2016, Dr. Schubert prepared a letter stating:
(Tr. at 1588.)
On March 17, 2016, plaintiff appeared with a non-attorney representative for her hearing before the ALJ. The ALJ also summoned a vocational expert ("VE") to testify. (Tr. at 45-47.)
Plaintiff testified that she was 37 years old and lived with her two sons, then ages 19 and eight. (Tr. at 52.) She dropped out of school after the tenth grade because she was pregnant and had not obtained a GED. (Tr. at 53.) She stood 5'2" and weighed 122 pounds, down about 30 pounds over the past year. She last worked part-time at Burlington Coat Factory. (Tr. at 54.) She left that job because the lifting was too much for her back. She had not looked for work since then due to her illnesses. (Tr. at 55.) She testified to previous employment at Walgreen's as a cashier and in the photography department (Tr. at 62-63), as a part-time bartender (Tr. at 63), and watching children at a school during recess (Tr. at 64).
Plaintiff testified that on a typical day she woke up and sat on the side of her bed, took medications for pain, then laid back down and waited for the pills to kick in before getting out of bed and starting her day. She testified that she had more bad days than good, where she would stay in bed curled up in pain. On a good day, she could do some light chores, although her sons did most of the work for her. (Tr. at 55.) She stayed in her pajamas a good portion of the time she was at home, unless she had a doctor's appointment, then she got dressed. She primarily made microwave meals or ordered out; she cooked about once per week. She could do some dishes, although standing caused pain; her older son helped a lot with that. Her older son also did the laundry. Her sons did the vacuuming and sweeping. Once per month she grocery shopped with her older son. (Tr. at 56.) She testified that she had been unable to do these types of daily activities for the last two years. (Tr. at 56-57.) She later testified that she sometimes played catch with her son. (Tr. at 66.)
Plaintiff testified that she constantly experienced pain in her stomach, through to her back. Sitting or laying down a certain way aggravated the pain. She used a heating pad or an ice pack to try to alleviate the pain. She also took medications, which caused side effects of dizziness, shakiness, and fatigue. She was in pain all day, every day. (Tr. at 57.) About twice per month she experienced a flare where she would repeatedly throw up, requiring a trip to the hospital. (Tr. at 57-58.) She later indicated that she had been hospitalized in November, December, and February. (Tr. at 67-68.)
Plaintiff testified that she had the abdominal pain for about two years; her doctors were uncertain of the cause; they did not think it was caused by her Crohn's disease alone. (Tr. at 66.) Plaintiff testified that she got about four to six hours of sleep per night, tossing and turning due to pain; she napped during the day. She also experienced migraine headaches about three times per month, for which she took medication. (Tr. at 58, 73-74.)
Plaintiff testified that she did not try to lift anything because of pain. Sitting also caused pain, so she leaned to the side. (Tr. at 58.) She walked with a slight limp due to her ankle. (Tr. at 59.) She lacked mobility and experienced pain if she moved in a certain way. Other than wearing a brace, she had not received any treatment for her ankle for several years. (Tr. at 73.)
Plaintiff had good days and bad days with her breathing depending on the weather; she had two inhalers for that. Exposure to dust caused her to break out in hives; she had an Epipen for that. She also saw a psychiatrist and took the medications Alprazolam and Amitriptyline. (Tr. at 59.) She later testified that she saw a psychiatrist every three months, who gave her Alprazolam. She had not seen any counselors or therapists in the past year. (Tr. at 69.) The medications were effective. (Tr. at 69.) She had previously seen a therapist every other week for about a year. (Tr. at 70.) She saw Dr. Shubert, her primary physician for about three years, two to three times per month. (Tr. at 71.)
Plaintiff had never driven; he son drove her. (Tr. at 61-62.) Before he started driving, she took the bus. (Tr. at 62.) She had a tablet device, which she used to pay bills on line, play games, and look things up on the internet. (Tr. at 72-73.) She denied having trouble getting along with others but indicated that she mostly kept to herself; she dropped her old friends due to her past drug problem. (Tr. at 74.) She denied having trouble interacting with people socially but did allege trouble concentrating, which she attributed to her medications. (Tr. at 74-75.)
The ALJ then turned to the VE, indicating that he found the cashier job at Walgreen's to be plaintiff's only past relevant work. The VE classified this job as light, SVP 3.
On April 27, 2016, the ALJ issued an unfavorable decision. (Tr. at 18.) The ALJ noted that plaintiff met the insured status requirements through September 30, 2013. He further noted that she had not engaged substantial gainful activity since September 30, 2008, the alleged onset date. While she did some work after that date, her wages were not sufficient to reach the level of substantial gainful activity. (Tr. at 23.)
The ALJ next found that plaintiff suffered from the severe impairments of degenerative disc disease of the lumbar and cervical spine, asthma/chronic obstructive pulmonary disease ("COPD"), left ankle status post fracture and open reduction internal fixation, Crohn's disease/inflammatory bowel disease ("IBD"), gastroesophageal reflux disease ("GERD"), an affective disorder, and an anxiety disorder. (Tr. at 23-24.) Plaintiff reported suffering migraine headaches, but the ALJ found this condition non-severe as the record did not document significant treatment or significant, ongoing limitations, and plaintiff testified that medication helped. (Tr. at 24.) None of the severe impairments, the ALJ determined, qualified as conclusively disabling under the agency's Listing of impairments. (Tr. at 24-26.)
The ALJ then determined that plaintiff retained the RFC to perform light work, with no more than occasional pushing/pulling and operation of foot controls with the left lower extremity; never climbing ladders, ropes, or scaffolds; frequently balancing; occasionally climbing ramps and stairs, stooping, kneeling, crouching, and crawling; avoiding concentrated wetness, excessive vibration, and pulmonary irritants; avoiding all hazards; and limited to simple, routine, and repetitive tasks, and low stress work with only occasional workplace changes. In making this determination, the ALJ considered plaintiff's statements and the medical opinion evidence. (Tr. at 26.)
After acknowledging the two-step test for symptom evaluation set forth in the regulations (Tr. at 26-27), the ALJ summarized plaintiff's claims. Plaintiff complained of daily pain in the lower back, left ankle, and right buttock; stomach pain; and difficulty sleeping. She further alleged difficulties with a variety of functions, including lifting, squatting, bending, standing, reaching, walking sitting, kneeling, climbing, remembering, and concentrating. She also testified that she experienced side effects from her medications, including dizziness, shakiness, and tiredness. (Tr. at 27.)
The ALJ then stated:
(Tr. at 27.)
In support of this conclusion, the ALJ considered each of plaintiff's impairments and their associated symptoms. The record documented treatment for pain related to degenerative disc disease of the lumbar and cervical spine, including medications, injections, and chiropractic. (Tr. at 27.) However, x-rays and MRI scans revealed only mild abnormalities, and physical exams were often normal. (Tr. at 27-28.) Plaintiff also received medications for breathing problems, but respiratory exams were often normal, and she seemed to respond well to treatment. (Tr. at 28-29.) The record also documented an ankle fracture, for which she underwent surgery in September 2009. According to subsequent records, the fracture healed, with few residual symptoms; exams showed normal gait, strength, and range of motion; and plaintiff reported engaging in a variety of activities without any difficulty. Plaintiff did undergo a follow procedure in April 2013 for removal of the hardware in the left ankle due to pain, but subsequent exams showed that the ankle healed uneventfully. (Tr. at 29.) Plaintiff had also been diagnosed with Crohn's disease/IBD, but in 2015 treating physicians noted the condition to be under excellent control or in remission, and that her abdominal pain was out of out of proportion to her symptoms. A January 2016 endoscopy revealed findings consistent with "very mild" Crohn's disease, and the physician reviewing the findings did not believe that her Crohn's disease accounted for her abdominal pain. (Tr. at 29.) Later that month, a treating physician noted that plaintiff did not have a firm diagnosis as to why she was having intermittent abdominal pain. In February 2016, a treating physician opined that plaintiff had mild Crohn's disease, which did not explain her abdominal pain. (Tr. at 30.) The record also documented a history of GERD, but this condition was well-controlled with medication. (Tr. at 30.) Finally, the record documented treatment for anxiety and depression with therapy and medications. However, mental status exams generally revealed normal memory, attention/concentration, insight and judgment. (Tr. at 30-31.)
The ALJ then turned to the opinion evidence, first from the agency consultants. The ALJ gave great weight to the opinions of the medical consultants, Drs. Teague and Bente, who concluded that plaintiff could perform a reduced range of light work. (Tr. at 31.) The ALJ noted that Drs. Teague and Bente had knowledge of social security disability programs, provided an adequate explanation for their opinions, and supported their opinions with relevant medical evidence from the record. He further found their opinions generally consistent with the overall record, which supported a range of light work. (Tr. at 31.)
The ALJ further noted that plaintiff's daily activities suggested a greater level of functioning than she had alleged. For example, in April 2013, plaintiff reported that she was able to walk one to two miles, climb one flight of stairs, and could perform yard work, household cleaning, and grocery shopping. (Tr. at 32.)
The ALJ also gave great weight to the opinions of the psychological consultants, Drs. Biscardi and Rozenfeld, who found no more than moderate mental limitations. The ALJ noted that Drs. Biscardi and Rozenfeld also had knowledge of social security disability programs, provided an adequate explanation for their opinions, and supported their opinions with relevant medical evidence from the record. Additionally, their opinions were consistent with the record, which included multiple mental status exams revealing normal or largely normal findings. (Tr. at 32.)
The ALJ gave some weight to the opinions of consultative examiner Dr. Ovide, who found mild limitations in plaintiff's ability to carry out simple instructions, respond appropriately to supervisors and co-workers, and concentrate, but marked limitation in her ability to work at a reasonable pace and severe limitation in her ability to withstand routine work stress. The ALJ noted that Dr. Ovide had the opportunity to examine plaintiff and that the record generally supported the mild limitations he assessed. However, the more severe limitations in ability to work at a reasonable pace and withstand stress were not, the ALJ concluded, supported by the record, which suggested no more than moderate limitations and contained multiple mental status exams revealing normal or largely normal findings. (Tr. at 32.)
The ALJ then turned to the opinions of the treating sources. He first summarized the various reports from Dr. Schubert, plaintiff's family medicine physician. (Tr. at 32-33.) The ALJ noted that Dr. Schubert had a treating relationship with plaintiff but found that his opinions were not entitled to controlling weight; he instead have them little weight. The ALJ found that Dr. Schubert's opinions were not well supported by the record as a whole. For example, Dr. Schubert repeatedly opined that plaintiff could not work due to abdominal/pelvic pain caused by Crohn's disease and/or endometriosis. However, a January 5, 2016 endoscopy revealed "very mild" Crohn's disease, and the reviewing physician did not believe that plaintiff's Crohn's disease accounted for her abdominal pain. Also, on January 25, 2016, Dr. Schubert noted that plaintiff did not have a firm diagnosis as to why she was having chronic intermittent abdominal pain, and her gastroenterologist did not believe that her Crohn's disease was the "complete culprit" of all of her pain. In addition, the record did not document a definitive diagnosis of endometriosis. For example, on April 22, 2015, the treating physician noted that plaintiff had suspected endometriosis, and on August 31, 2015, Dr. Schubert noted that plaintiff had "presumed" endometriosis. Finally, the ALJ found that the significant limitations Dr. Schubert assessed in September 2014 and February 2016 were not consistent with the overall record; rather, the overall record supported a range of light work, consistent with the opinions of Drs. Teague and Bente. (Tr. at 33.)
The ALJ also considered the opinion of Dr. Ramanujam, a treating gastroenterologist, who in September 2015 opined that plaintiff's Crohn's disease and GI issues would result in symptoms that would frequently interfere with plaintiff's performance of simple work tasks and would cause more than three absences per month, but that she would not have any other functional limitations. Although Dr. Ramanujam had a treating relationship with plaintiff, the ALJ gave his opinion only some weight, as the record did not support the limitations he imposed. For example, on April 24, 2015, Dr. Ramanujam noted that plaintiff's Crohn's disease was under "excellent control" and his assessment was that it was stable and in remission. (Tr. at 33.) Also, the January 5, 2016, endoscopy revealed findings consistent with "very mild" Crohn's disease, and Dr. Ramanujam did not believe that plaintiff's Crohn's disease accounted for her abdominal pain. (Tr. at 33-34.) Therefore, Dr. Ramanujam's own treatment notes did not support his opinion that plaintiff's GI symptoms would frequently interfere with her performance of simple tasks or result in her being absent more than three times per month. However, the same evidence did support Dr. Ramanujam's opinion that plaintiff's Crohn's disease and GI issues had not resulted in any other significant functional limitations. (Tr. at 34.)
The ALJ further considered the opinion of Dr. Kiahni, who indicated in November 2014 that plaintiff had significant abdominal pain related to inflammation, and that it was difficult to assess her functional limitations. Dr. Kiahni further indicated that plaintiff would need to take unscheduled restroom breaks up to several times per day, she would sometimes need to lie down or rest at unpredictable intervals during a workday, and she should avoid heavy lifting. The ALJ gave little weight to this opinion. At the time he assessed plaintiff's functioning, Dr. Kiahni had been treating her for less than two months. In addition, his credentials were not clear from the medical source statement he completed. Dr. Kiahni also stated that it was "difficult" to assess plaintiff's functioning and did not complete much of the functional assessment form. (Tr. at 34.)
The ALJ also considered the opinion of treating pulmonologist, Dr. Stuleanu, who in September 2014 generally indicated that plaintiff could handle light work but indicated that she would be absent from work an average of about twice per month and could perform work or work-readiness activities for six hours per day, five days per week. The ALJ gave little weight to Dr. Stuleanu's opinion. Although Dr. Stuleanu had a treating relationship with plaintiff, he was a pulmonologist and only treated her COPD/asthma, and the record documented that her COPD/asthma did not result in significant limitations. In particular, pulmonary function tests in September 2014 and December 2014 revealed normal results. Therefore, the ALJ concluded that plaintiff's COPD/asthma would not result in two absences per month or a limitation to part-time work. (Tr. at 34.)
Finally, the ALJ considered the March 2016 opinion of the treating physician's assistant, Cynthia Koopmeiners. The ALJ gave little weight to PA Koopmeiners's opinion, as she did not provide an adequate explanation for the significant limitations she assessed. In addition, her opinion was not consistent with the medical evidence in the record. For example, on April 24, 2015, Dr. Ramanujam noted that plaintiff's Crohn's disease was under "excellent control," and his assessment was that it was stable and in remission. (Tr. at 34.) Also, on January 5, 2016, an endoscopy revealed findings that were consistent with "very mild" Crohn's disease. (Tr. at 34-35.) Further, Koopmeiners's opinion was inconsistent with the opinion of Dr. Ramanujam, who was more qualified to render an opinion on plaintiff's GI issues as a medical doctor and gastroenterologist. (Tr. at 35.)
The ALJ also considered the third-party function report completed by plaintiff's brother, Mr. Hildreth. His allegations regarding plaintiff's functioning were similar to her's. However, in some instances, he indicated that she could do less than she had alleged. For example, Hildreth reported that plaintiff did not spend time with others, whereas plaintiff reported that she did spend time with others. As a result, the ALJ found that his allegations were not an entirely reliable reflection of plaintiff's functional abilities. (Tr. at 35.)
In sum, the ALJ found the RFC supported by the overall record; the reliable opinions from Drs. Teague, Bente, Biscardi, and Rozenfeld; and plaintiff's reported activities. Based on this RFC, the ALJ determined that plaintiff could not perform her past relevant work as a cashier. (Tr. at 35.) However, he concluded that she could do a number of other jobs, as identified by the VE, including housekeeper, laundry worker, and assembler. He accordingly found her not disabled. (Tr. at 36.)
On June 19, 2017, the Appeals Council denied review (Tr. at 1), making the ALJ's decision the final word from the agency on plaintiff's application.
The court will reverse an ALJ's decision if it is not supported by substantial evidence or if it is the result of an error of law.
Under the regulations applicable to plaintiff's claim, a treating physician's opinion on the nature and severity of a claimant's medical condition "is entitled to controlling weight if it is well supported by medical findings and consistent with other record evidence."
Plaintiff argues that the ALJ should have given greater weight to the reports from her various providers. (Pl.'s Br. at 17-21.) The Commissioner responds that plaintiff's argument amounts to a request that the court re-weigh the evidence. The Commissioner further contends that, because the treating providers' reports diverged in important respects, it was impossible for the ALJ to give controlling or significant weight to all of them. (Def.'s Br. at 6.) While the Commissioner's arguments have some force,
The ALJ discounted Dr. Schubert's reports primarily because he attributed plaintiff's abdominal pain to Crohn's disease and/or endometriosis, but testing revealed her Crohn's disease to be mild, her gastroenterologist did not believe that Crohn's accounted for of all of her pain, and the record did not document a definitive diagnosis of endometriosis. That plaintiff's doctors could not identify a single, definitive cause of her pain does not mean that she did not experience severe pain. The record documents numerous hospitalizations for abdominal pain, nausea, and vomiting, for which she received IV fluids and pain medication.
The ALJ discounted Dr. Ramanujam's opinions because, at one point in April 2015, the doctor noted plaintiff's Crohn's disease was under excellent control; the January 2016 endoscopy revealed findings consistent with "very mild" Crohn's disease; and Dr. Ramanujam did not believe that Crohn's accounted for all of plaintiff's abdominal pain. But Crohn's disease may cause periodic flare-ups, as plaintiff's numerous hospitalizations suggest; that she was asymptomatic at times does not mean she could sustain regular, full-time work.
In discounting Dr. Kiahni's opinion, the ALJ reasonably noted that at the time he completed the report Dr. Kiahni had been treating plaintiff for less than two months, and that he left much of the form blank. However, the ALJ also stated that Dr. Kiahni's credentials were not clear from the medical source statement he completed. Dr. Kiahni listed his medical specialty as "GI." (Tr. at 1453.) The ALJ could have also consulted the medical records, which showed that Dr. Khiani saw plaintiff on referral from Dr. Schubert, completing a physical exam and a colonoscopy. (Tr. at 1445.)
The ALJ discounted the opinion of Dr. Stuleanu, the pulmonologist, because he only treated plaintiff's COPD/asthma, and the record, in particular pulmonary function tests in September 2014 and December 2014 (which revealed normal results), indicated that her COPD/asthma did not result in significant limitations such that she would be absent two times per month or limited to part-time work. Dr. Stuleanu's notes indicate that plaintiff's symptoms waxed and waned, and that she experienced breathing problems "every several days." (Tr. at 974.) This evidence, which the ALJ did not mention in evaluating Dr. Stuleanu's report, could be seen as supporting the opinion regarding absences.
Finally, the ALJ gave little weight to the opinion of Dr. Ramanujam's physician's assistant, Cynthia Koopmeiners,
The ALJ also relied on the state agency consultants in determining RFC, but such opinions do not by themselves suffice to reject a treating source report.
The Commissioner's regulations set forth a two-step test for evaluating the credibility of a claimant's statements regarding her symptoms. First, the ALJ must determine whether the claimant suffers from a medically determinable impairment that could reasonably be expected to produce the alleged symptoms. SSR 16-3p, 2016 SSR LEXIS 4, at *5. Second, if the claimant has such an impairment, the ALJ must evaluate the intensity and persistence of the symptoms to determine the extent to which they limit the claimant's ability to work.
Plaintiff begins her argument by analyzing the various factors (Pl.'s Br. at 21-22), but this sort of argument is properly directed to the ALJ. The court reviews the reasons provided by the ALJ, rather than determining credibility in the first instance.
Here, the ALJ followed the two-step process, finding that plaintiff's impairments could reasonably be expected to cause symptoms of the types alleged, but that plaintiff's statements regarding the intensity, persistence, and limiting effects of her symptoms were inconsistent with the medical evidence and other evidence in the record. In support of this conclusion, the ALJ noted that objective medical testing showed no more than mild abnormalities, physical exams revealed largely normal findings, and plaintiff's daily activities suggested a greater level of functioning than she had alleged.
The ALJ appeared to place the greatest weight on the objective medical evidence. As the Seventh Circuit has noted, however, "an ALJ cannot disregard subjective complaints of disabling pain just because a determinable basis for pain of that intensity does not stand out in the medical record."
And, while it is appropriate for an ALJ to consider a claimant's daily activities, he cannot disregard a claimant's limitations in performing such activities.
The Commissioner argues that, even if the ALJ erred in evaluating the treating source reports, I should affirm the denial of the DIB claim because all of those reports were prepared after the date last insured. (Def.'s Br. at 2-3.) In reply, plaintiff notes that she received significant treatment for her various impairments prior to September 30, 2013; that Dr. Ovide prepared his report less than two moths after that date; and that some of her providers treated her prior to the date last insured, and those who didn't had access to her medical records. (Pl.'s Rep. Br. at 1-3.) While the evidence of disability does appear to be stronger after the date last insured, factual disputes over a claimant's alleged onset date are properly addressed by the ALJ, not the court.