SAM A. CROW, Senior District Judge.
This is an action reviewing the final decision of the Commissioner of Social Security denying the plaintiff disability insurance benefits and supplemental security income payments. The matter has been fully briefed by the parties.
The court's standard of review is set forth in 42 U.S.C. § 405(g), which provides that "the findings of the Commissioner as to any fact, if supported by substantial evidence, shall be conclusive." The court should review the Commissioner's decision to determine only whether the decision was supported by substantial evidence and whether the Commissioner applied the correct legal standards.
The Social Security Act provides that an individual shall be determined to be under a disability only if the claimant can establish that they have a physical or mental impairment expected to result in death or last for a continuous period of twelve months which prevents the claimant from engaging in substantial gainful activity (SGA). The claimant's physical or mental impairment or impairments must be of such severity that they are not only unable to perform their previous work but cannot, considering their age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy. 42 U.S.C. § 423(d).
The Commissioner has established a five-step sequential evaluation process to determine disability. If at any step a finding of disability or non-disability can be made, the Commissioner will not review the claim further. At step one, the agency will find non-disability unless the claimant can show that he or she is not working at a "substantial gainful activity." At step two, the agency will find non-disability unless the claimant shows that he or she has a "severe impairment," which is defined as any "impairment or combination of impairments which significantly limits [the claimant's] physical or mental ability to do basic work activities." At step three, the agency determines whether the impairment which enabled the claimant to survive step two is on the list of impairments presumed severe enough to render one disabled. If the claimant's impairment does not meet or equal a listed impairment, the inquiry proceeds to step four, at which the agency assesses whether the claimant can do his or her previous work; unless the claimant shows that he or she cannot perform their previous work, they are determined not to be disabled. If the claimant survives step four, the fifth and final step requires the agency to consider vocational factors (the claimant's age, education, and past work experience) and to determine whether the claimant is capable of performing other jobs existing in significant numbers in the national economy.
The claimant bears the burden of proof through step four of the analysis.
Before going from step three to step four, the agency will assess the claimant's residual functional capacity (RFC). This RFC assessment is used to evaluate the claim at both step four and step five. 20 C.F.R. §§ 404.1520(a)(4), 404.1520(e,f,g); 416.920(a)(4), 416.920(e,f,g).
On September 11, 2015, administrative law judge (ALJ) Alison K. Brookins issued her decision (R. at 14-27). Plaintiff alleges that she has been disabled since March 22, 2013 (R. at 14). Plaintiff is insured for disability insurance benefits through June 30, 2018 (R. at 16). At step one, the ALJ found that plaintiff has not engaged in substantial gainful activity since the alleged onset date (R. at 16). At step two, the ALJ found that plaintiff has severe impairments (R. at 17). At step three, the ALJ determined that plaintiff's impairments do not meet or equal a listed impairment (R. at 17). After determining plaintiff's RFC (R. at 19-20), the ALJ found at step four that plaintiff is unable to perform past relevant work (R. at 25). At step five, the ALJ found that plaintiff could perform other work that exists in significant numbers in the national economy (R. at 26). Therefore, the ALJ concluded that plaintiff was not disabled (R. at 27).
At step three, the ALJ found that plaintiff had moderate difficulties in concentration, persistence, or pace,
On March 6, 2014, Dr. Schulman, a non-examining state agency medical source, reviewed the record and found that plaintiff had moderate difficulties in maintaining concentration, persistence, or pace (R. at 70). Dr. Schulman indicated in his RFC that plaintiff is moderately limited in her ability to understand, remember, and carry out detailed instructions, and is moderately limited in her ability to maintain attention and concentration for extended periods (R. at 72-73). Dr. Schulman then concluded that plaintiff is able to understand, remember, use judgement, and make decisions for intermediate instructions and tasks (R. at 72), and can attend, concentrate, and maintain pace and persistence for this level of activity (R. at 73). On July 2, 2014, Dr. Blum, a non-examining medical source, reviewed the record. He also found that plaintiff had moderate difficulties in maintaining, concentration, persistence, or pace (R. at 96). He made the same RFC findings as those noted above for Dr. Schulman; he also found a moderate limitation in plaintiff's ability to interact appropriately with the general public (R. at 99, 100). The ALJ accorded considerable weight to their opinions (R. at 25), and the ALJ's RFC and step three findings adopted their opinions as noted above. At step five, the ALJ found that plaintiff could perform three "unskilled" jobs that exist in significant numbers in the national economy (R. at 26, 59). All three unskilled jobs have a SVP (specific vocational preparation) of level 2. 1991 WL 679524, 679616, 679631.
Plaintiff argues that limiting plaintiff to simple and intermediate work fails to account for plaintiff's moderate limitations in concentration, persistence, or pace. However, in the case of
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Dr. Schulman and Dr. Blum (in Section I) indicated that plaintiff had moderate limitations in her ability to understand, remember, and carry out detailed instructions, and in her ability to maintain attention and concentration for extended periods. Their Section III narrative findings limited plaintiff to intermediate instructions and tasks. The ALJ, in her RFC findings, limited plaintiff to simple and intermediate instructions and tasks.
The opinions of physicians, psychologists, or psychiatrists who have seen a claimant over a period of time for purposes of treatment are given more weight than the views of consulting physicians or those who only review the medical records and never examine the claimant. The opinion of an examining physician is generally entitled to less weight than that of a treating physician, and the opinion of an agency physician who has never seen the claimant is entitled to the least weight of all.
A treating physician's opinion about the nature and severity of the claimant's impairments should be given controlling weight by the Commissioner if well supported by clinical and laboratory diagnostic techniques and if it is not inconsistent with other substantial evidence in the record.
After considering the above factors, the ALJ must give good reasons in his/her decision for the weight he/she ultimately assigns the opinion. If the ALJ rejects the opinion completely, he/she must then give specific, legitimate reasons for doing so.
Plaintiff argues that the ALJ erred by relying on the non-examining medical sources (Dr. Schulman and Dr. Blum) in making her mental RFC findings, and in discounting the opinions of plaintiff's treatment provider, ARNP (advanced registered nurse practitioner) Garton. As this court has previously noted, the ALJ gave considerable weight to the opinions of Dr. Schulman and Dr. Blum.
ARNP Garton filled out two mental capacity assessment forms. The first, dated November 27, 2013, states that plaintiff has marked limitations in 9 categories, and an extreme limitation in 1 category (R. at 421-423). The second, dated October 30, 2014, and also signed by Dr. Ibarra, states that plaintiff has marked limitations in 7 categories and extreme limitations in 6 categories (R. at 539-541). The ALJ found that her opinions were only entitled to limited weight due to the lack of support for the more extreme limitations or restrictions. The ALJ stated that the treatment notes indicate that plaintiff's attention, concentration, and memory has been generally intact or adequate. Her GAF scores have generally been in the range consistent with moderate symptoms with only a few exceptions. The ALJ noted that plaintiff was pursuing further education through online courses. The ALJ concluded that this evidence does not support the marked and extreme limitations assessed by ARNP Garton on the form check boxes (R. at 24).
The ALJ gave greater weight to the opinion of Dr. Blum, who reviewed the first assessment from ARNP Garton. Dr. Blum stated that there is no detail describing how the symptoms support the opinions of marked and extreme limitations (R. at 97).
The court will not reweigh the evidence or substitute its judgment for that of the Commissioner.
The court will not reweigh the evidence. The ALJ set out in some detail her reasons for discounting the opinions of ARNP Garton. The ALJ set out in further detail plaintiff's mental treatment records, including the moderate GAF scores noted in the medical records (R. at 21-22). Dr. Blum's report indicates that there is no detail in ARNP Garton's report describing how plaintiff's symptoms support the opinions of ARNP Garton that plaintiff has marked and extreme limitations. The court finds that there is sufficient evidence which a reasonable mind might accept as adequate to give greater weight to the opinions of Dr. Schulman and Dr. Blum, and to discount the opinions of ARNP Garton and Dr. Ibarra.
Plaintiff argues that the ALJ erred by not obtaining additional medical evidence regarding plaintiff's physical impairments, and that insufficient evidence supports the ALJ's physical RFC findings. In general, the ALJ limited plaintiff to sedentary work, with some additional limitations (R. at 19-20). The ALJ rejected the opinion of Dr. Geis, a non-examining consultative physician, who found that plaintiff's physical limitations were non-severe. The ALJ relied on the evidence of diabetes with neuropathy and degenerative joint disease of the left knee, obesity and hypertension to find that plaintiff is limited to a range of sedentary work (R. at 24). However, the ALJ did not rely on medical opinion evidence in making her physical RFC findings.
In a counseled case, the ALJ may ordinarily require counsel to identify the issue or issues requiring further development. In the absence of such a request by counsel, the court will not impose a duty on the ALJ to order a consultative examination unless the need for one is clearly established in the record.
Plaintiff did not request a consultative examination, and at the hearing, counsel indicated that all the information or medical records they had sought were in the record for this case (R. at 39-41). Although the ALJ has a duty to develop the record, such a duty does not permit a claimant, through counsel, to state that the record is complete, and then fault the ALJ for not seeking additional medical evidence. The court will not ordinarily reverse or remand for failure to develop the record when a claimant is represented by counsel who affirmatively submits to the ALJ that the record is complete, especially when any missing records are not obvious from the administrative record or otherwise brought to the attention of the ALJ.
Furthermore, an exact correspondence between a medical opinion and the RFC is not required. In reaching his RFC determination, an ALJ is permitted, and indeed required, to rely on all of the record evidence, including but not limited to medical opinions in the file.
In conclusion, the court finds that plaintiff failed to establish the need for a consultative examination, or the need to seek other medical records. As noted above, plaintiff's counsel did not request a consultative examination, and stated that the record was complete. Plaintiff fails to cite to any evidence in the record that would trigger a duty by the ALJ to recontact a medical source to supplement or clarify the evidence. Plaintiff argues that the ALJ should have inquired into the extent of Dr. Ibarra's treatment records. However, as was the case with Dr. Kimball in
This case is distinguishable from the court's ruling regarding claimant's mental impairment in
As noted above, although there is no medical opinion evidence directly supporting the ALJ's physical RFC findings, an exact correspondence is not required between a medical opinion and the RFC. An ALJ can rely on all the record evidence, including but not limited to medical opinions when making her RFC findings. The ALJ discussed the medical evidence in some detail, and no medical evidence conflicts with or contradicts the ALJ's physical RFC findings. The court therefore finds that substantial evidence supports the ALJ's physical RFC findings.
Credibility determinations are peculiarly the province of the finder of fact, and a court will not upset such determinations when supported by substantial evidence. However, findings as to credibility should be closely and affirmatively linked to substantial evidence and not just a conclusion in the guise of findings.
When analyzing evidence of pain, the court does not require a formalistic factor-by-factor recitation of the evidence. So long as the ALJ sets forth the specific evidence he relies on in evaluating the claimant's credibility, the ALJ will be deemed to have satisfied the requirements set forth in
The court finds no clear error by the ALJ in her credibility analysis. The ALJ discussed in some detail plaintiff's testimony and statements, work activities questionnaires, the medical record, and the medical opinion evidence regarding plaintiff's mental limitations (R. at 20-25). The ALJ reasonably relied on the medical evidence and the medical opinion evidence to find that plaintiff was not fully credible. The court will not reweigh the evidence. The balance of the ALJ's credibility analysis was supported by substantial evidence in the record.
IT IS THEREFORE ORDERED that the judgment of the Commissioner is affirmed pursuant to sentence four of 42 U.S.C. § 405(g).
The psychiatric review technique findings described in 20 C.F.R. § 404.1520a are not an RFC assessment but are used to rate the severity of mental impairments at steps 2 and 3 of the sequential evaluation process. The mental RFC assessment used at steps 4 and 5 of the sequential evaluation process requires a more detailed assessment by itemizing various functions contained in the broad categories set out in 20 C.F.R. § 404.1520a. SSR 96-8p, 1996 WL 374184 at *4. In assessing RFC, the ALJ must consider limitations and restrictions imposed by all of an individual's impairments, even those that are not "severe."