MICHAEL J. NEWMAN, Magistrate Judge.
This is a Social Security disability benefits appeal brought pursuant to 42 U.S.C. § 405(g) and § 1383(c). At issue is whether the Administrative Law Judge ("ALJ") erred in finding that Plaintiff Paula Fields ("Plaintiff") was "not disabled" and therefore unentitled to Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI"). Plaintiff additionally argues that new medical evidence merits a remand to the Commissioner under the Sixth Sentence of 42 U.S.C. § 405(g).
This case is before the Court upon Plaintiff's Statement of Errors (doc. 9), the Commissioner's Memorandum in Opposition (doc. 12), Plaintiff's Reply (doc. 13), and the administrative record.
Plaintiff filed her applications for DIB and SSI on September 19, 2003, asserting that she has been under a "disability" since January 15, 2002. See Administrative Transcript ("Tr.") 92-94, 433-34. Plaintiff subsequently amended her alleged disability onset date to June 1, 2003, however. Tr. 55, 453. Plaintiff claims she is disabled due to chronic cluster headaches, cardiac arrhythmia, heart disease, generalized osteoarthritis with degenerative lumbar disc disease of the "L.S. spine," asthma, and lupus inhibitor. Tr. 109.
Following initial administrative denials of her applications, Plaintiff received a hearing before Administrative Law Judge Daniel R. Shell ("ALJ" or "ALJ Shell") on February 28, 2006. Tr. 450-73. On November, 21, 2006, ALJ Shell issued a written decision, concluding that Plaintiff could perform a limited range of light work and was thus "not disabled." Tr. 55-67.
Specifically, the ALJ's "Findings," which represent the rationale of his decision, were as follows:
Tr. 66-67.
Thereafter, the Appeals Council denied Plaintiff's request for review, making the ALJ's non-disability finding the final administrative decision of the Commissioner. Tr. 40-43; see Casey v. Sec'y of Health & Human Servs., 987 F.2d 1230, 1233 (6th Cir. 1993). Shortly thereafter, Plaintiff asked the Appeals Council to re-open its denial of review to consider additional evidence, i.e., medical records showing that Plaintiff had undergone left knee replacement surgery in August 2007. See tr. 13-39. The Appeals Council denied Plaintiff's request on November 5, 2010.
At the time of the administrative hearing, Plaintiff was 50 years old and thus considered a person "closely approaching advanced age." See 20 C.F.R. §§ 404.1563(d), 416.963. Plaintiff has an Associate's degree in office systems administration with a word processing speciality. Tr. 115, 462. She has past relevant work as a data entry clerk, computer operator and routing clerk, among other positions. Tr. 115, 130, 469.
Plaintiff testified at the administrative hearing that she last worked in data entry in January 2006. Tr. 453-54. She testified that she could no longer work because she had trouble sitting at a desk for a long period of time due to osteoarthritis in her knees. Tr. 462-63. Her knees tend to lock up when she tries to stand up, and she is unable to stand in one spot for sustained periods. Tr. 463. She testified that propping her feet up alleviates her knee pain.
Plaintiff also testified that she has bilateral hip pain and a small fracture in her lower back. Tr. 463. As a result, it is difficult for her stand on her feet, and although a cane helps her stand, it causes pain in her left arm. Tr. 463-64.
Plaintiff additionally testified that she has debilitating "cluster headaches." Tr. 464. She testified that her headaches come and go. Tr. 468. They may subside for six months to a year, and then return for three weeks to six months. Tr. 469. She recently visited a pain clinic to treat her headaches. Tr. 464-65.
Plaintiff further testified that she suffers from cardiac arrhythmia and heart disease. Tr. 465. She takes beta blockers. Tr. 466.
Vanessa Harris, a vocational expert ("VE"), also testified at the hearing. Tr. 469-72. The ALJ proposed a series of hypotheticals regarding Plaintiff's RFC to the VE. See id. Based on Plaintiff's RFC, age, education, and work experience, the VE testified that Plaintiff could perform her past relevant work as a computer operator, routing clerk, marker, order clerk and data entry clerk. Tr. 470-71. The VE reported that substantial numbers of such jobs exist in the regional economy. Tr. 471-72.
The Court's inquiry on an appeal such as this is to determine (1) whether the ALJ's non-disability finding is supported by substantial evidence, and (2) whether the ALJ employed the correct legal criteria. 42 U.S.C. § 405(g); Bowen v. Comm'r of Soc. Sec., 478 F.3d 742, 745-46 (6th Cir. 2007). In performing this review, the Court must consider the record as a whole. Hephner v. Mathews, 574 F.2d 359, 362 (6th Cir. 1978).
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). When 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. Id.
The second judicial inquiry — reviewing the correctness of the ALJ's legal analysis — may result in reversal even if the ALJ's decision is supported by substantial evidence in the record. Rabbers v. Comm'r of Soc. Sec., 582 F.3d 647, 651 (6th Cir. 2009). Thus, "a decision of the Commissioner will not be upheld where the SSA fails to follow its own regulations and where that error prejudices a claimant on the merits or deprives the claimant of a substantial right." Bowen, 478 F.3d at 746.
To qualify for disability benefits, a claimant must suffer 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 12 months. 42 U.S.C. §§ 423(d)(1)(A) (DIB), 1382c(a)(3)(A) (SSI). The impairment must render the claimant unable to engage in the work previously performed or in any other substantial gainful employment that exists in the national economy. 42 U.S.C. §§ 423(d)(2), 1382c(a)(3)(B).
Administrative regulations require a five-step sequential evaluation for disability determinations. 20 C.F.R. § 404.1520. Although a dispositive finding at any step ends the ALJ's review, Colvin v. Barnhart, 475 F.3d 727, 730 (6th Cir. 2007), the complete sequential review poses five questions:
20 C.F.R. § 404.1520(a)(4).
As a preliminary note, Plaintiff's pertinent medical findings and opinions have been adequately summarized in the parties' briefs, see doc. 9 at PageID 57-64; doc. 12 at PageID 81-82, and the Court will not repeat them here.
Plaintiff argues that the ALJ erred in rejecting the disability finding of her treating physician, Dr. D'Allura, and in relying, instead, on the opinion of the state agency reviewers. Doc. 9 at PageID 65-72. For the reasons that follow, the Court finds that the ALJ reasonably decided to not give controlling or deferential weight to Dr. D'Allura's opinion.
Sal D'Allura, D.O. was Plaintiff's primary care physician. Dr. D'Allura treated Plaintiff from 1999 through 2005. Tr. 382. He treated her cardiac problems, cluster migraines, and severe degenerative joint disease. Tr. 168-77, 344-52, 394-99.
Plaintiff relies on two disability findings of Dr. D'Allura. See doc. 9 at PageID 65-66. In September 2003, Dr. D'Allura opined that Plaintiff was prevented from performing "most jobs" due to the following impairments: chronic cluster headaches; cardiac arrhythmia; vavula heart disease; and generalized osteoarthritis with degenerative disc disease of the LS spine. Tr. 168. He concluded that Plaintiff was therefore "permanently disabled."
As support for this first disability opinion, Dr. D'Allura attached six pages of treatment notes (one page for each of six visits). Tr. 172-77. The treatment notes do not provide much detail; they simply list Plaintiff's medical problems, medications, allergies, diagnoses, and briefly state a treatment plan. See id. Dr. D'Allura did not provide any records showing the results of clinical tests performed or other objective medical evidence to substantiate his disability finding.
Additionally, in March 2005, Dr. D'Allura completed interrogatories sent by Plaintiff's counsel. Tr. 387-91. He opined that Plaintiff does not have the RFC to perform even sedentary work on a sustained basis. Tr. 391. When asked what medical findings support these work limitations, Dr. D'Allura's response was cursory and non-specific: "chronic medical problems and medical side effects." See tr. 388-90. He did not provide any more detail for his disability findings. The record contains only seven additional pages of Dr. D'Allura's treatment notes — from October 2004 to March 2005 — to support this disability finding. Tr. 345-51. Like the earlier treatment notes, they simply list Plaintiff's conditions and treatment plan. See id.
The ALJ set forth the correct standards in evaluating a treating physician's opinion. See tr. 60. Applying those standards, the ALJ determined that the disability findings of Dr. D'Allura should not be given controlling or deferential weight. The ALJ's discussed his reasons for reaching that conclusion as follows:
Tr. 60-61 (footnotes omitted).
The Court finds that the ALJ's decision — to not give controlling or deferential weight to Dr. D'Allura's disability finding — is supported by substantial evidence. Although, as a general matter, an adequately supported treating source opinion is entitled to great weight, Blakley v. Comm'r of Soc. Sec., 581 F.3d 399, 406 (6th Cir. 2009), a treating source's broad, conclusory formulations regarding the ultimate issue of disability are not determinative of the question of whether an individual is under a disability. See Kirk v. Sec'y of Health & Human Servs., 667 F.2d 524, 538 (6th Cir. 1981); see also Warner v. Comm'r of Soc. Sec., 375 F.3d 387, 390 (6th Cir. 2004). "`[I]t is an error to give an opinion controlling weight simply because it is the opinion of a treating source if it is not well-supported by medically acceptable clinical and laboratory diagnostic techniques or if it is inconsistent [with the] other substantial evidence in the case record.'" Blakely, 581 F.3d at 406 (quoting Soc. Sec. Rul. 96-2p, 1996 WL 374188, at *2 (July 2, 1996)). "If the ALJ does not accord controlling weight to a treating source, 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.
The Court finds that ALJ Shell gave good reasons — which find support in the record — for rejecting Dr. D'Allura's disability findings. Dr. D'Allura failed to describe how clinical findings or objective medical evidence demonstrate that Plaintiff is disabled. Rather, he merely stated "chronic medical problems and medical side effects" make Plaintiff unable to perform basic work-related functions. See tr. 388-90.
Moreover, Dr. D'Allura's opinions are inconsistent with other medical opinions in the record. None of the medical specialists to whom Plaintiff was referred by Dr. D'Allura indicated that Plaintiff was disabled. Dr. Karim, who treated Plaintiff's heart condition, informed Dr. D'Allura that Plaintiff was stable. Tr. 337, 339. In addition, Dr. Moncrief conducted a neurological examination of Plaintiff, and reported to Dr. D'Allura that the results were normal. Tr. 371-72.
Further, the opinions of the State agency doctors are inconsistent with Dr. D'Allura's opinions. In February 2004, Dr. Danopulos examined Plaintiff, reviewed her medical history, ordered X-rays of her spine, and conducted various tests on her motor skills and range of motion. Tr. 320-30. While he found "[h]er ability to do any work-related activities like standing, walking, lifting, and carrying are restricted from her early lumbar spine arthritis and left knee moderate arthritis," he did not find her disabled. See tr. 324. Further, Dr. Holbrook reviewed Dr. Danopulos's findings, and opined that Plaintiff had the capacity to perform a reduced range of light work. See tr. 332-36.
In sum, the Court finds Plaintiff's assignment of error is unpersuasive. The ALJ provided good reasons, supported by substantial evidence in the record, to not give controlling or deferential weight to Dr. D'Allura's opinions. Accordingly, the ALJ acted within the "zone of choice" and should therefore be affirmed. Buxton v. Halter, 246 F.3d 762, 772-73 (6th Cir. 2001).
Finally, the Court will address Plaintiff's request that, if the ALJ's decision is not reversed, the case be remanded to the Commissioner for consideration of additional evidence, i.e., records of Plaintiff's subsequent left knee replacement. Doc. 9 at PageID 71; tr. 13-39. Under the Sixth Sentence of 42 U.S.C. § 405(g), the Court may remand a case to the Commissioner for further consideration "only upon a showing that there is new evidence which is material and that there is good cause for the failure to incorporate such evidence into the record in a prior proceeding." See Hollon v. Comm'r of Soc. Sec., 447 F.3d 477, 484 (6th Cir. 2006).
Evidence is "material" if there is "a reasonable probability that the Commissioner would have reached a different disposition of the disability claim if presented with the new evidence." Id. (citation omitted). Further, evidence of a subsequent deterioration or change in the plaintiff's condition after the administrative hearing is deemed immaterial. Wyatt v. Sec'y of Health & Human Servs., 974 F.2d 680, 685 (6th Cir. 1992); Sizemore v. Sec'y of Health & Human Servs., 865 F.2d 709, 711-12 (6th Cir. 1988).
Here, Plaintiff's subsequent left knee replacement surgery in August 2007 is not material to her condition from her June 1, 2003 alleged onset date to the February 28, 2006 administrative hearing date. Cf. Allen v. Comm'r of Soc. Sec., 561 F.3d 646, 653-54 (6th Cir. 2009) (finding that new evidence of surgeries is not "material"); Staples v. Comm'r of Soc. Sec., 159 F. App'x 670, 672 (6th Cir. 2005) (same). This evidence only shows that Plaintiff's left knee deteriorated during the eighteen months following the hearing, which is immaterial to the ALJ's non-disability finding. Wyatt, 974 F.2d at 685. If Plaintiff believes that, since the ALJ's decision, her left knee has deteriorated so as to render her disabled, the appropriate remedy is to initiate a new claim for benefits. See Sizemore, 865 F.2d at 712. Accordingly, a remand to the Commissioner to consider this additional evidence would be inappropriate, and Plaintiff's request for a Sentence Six remand should be denied.
