JOHN W. LUNGSTRUM, District Judge.
Plaintiff seeks review of a decision of the Commissioner of Social Security (hereinafter Commissioner) denying disability insurance benefits (DIB) and supplemental security income (SSI) under sections 216(i), 223, 1602, and 1614(a)(3)(A) of the Social Security Act. 42 U.S.C. §§ 416(i), 423, 1381a, and 1382c(a)(3)(A) (hereinafter the Act). Finding no error, the court ORDERS that judgment shall be entered pursuant to the fourth sentence of 42 U.S.C. § 405(g) AFFIRMING the Commissioner's decision.
Plaintiff applied for both DIB and SSI on February 26, 2007, alleging disability beginning January 7, 2007. (R. 8, 110-18). The applications were denied initially and upon reconsideration, and Plaintiff requested a hearing before an Administrative Law Judge (ALJ). (R. 8, 45-53, 63). Plaintiff's request was granted, and Plaintiff appeared with counsel for a hearing before ALJ Michael R. Dayton on January 6, 2009. (R. 8, 23-43). At the hearing, a vocational expert also appeared, but testimony was taken only from Plaintiff. (R. 8, 23-43). After the hearing, Plaintiff was referred both to a consultant psychologist, Dr. Moeller, for a mental status examination and for psychological testing; and to a consultant physician, Dr. Estivo, for a physical examination. (R. 12-13, 343-80). On September 23, 2009, ALJ Dayton issued a decision finding at step two of the Commissioner's sequential evaluation process that Plaintiff does not have a severe impairment or combination of impairments, and denying Plaintiff's applications for benefits. (R. 8-16).
Plaintiff disagreed with the ALJ's decision, and sought (R. 19-22, 44) but was denied review by the Appeals Council. (R. 1-4). Therefore, the ALJ's decision is the final decision of the Commissioner. (R. 1);
The court's jurisdiction and review are guided by the Act.
An individual is under a disability only if that individual can establish that he has a physical or mental impairment which prevents him from engaging in any substantial gainful activity, and which is expected to result in death or to last for a continuous period of at least twelve months.
The Commissioner uses a five-step sequential process to evaluate disability. 20 C.F.R. §§ 404.1520, 416.920 (2009);
The Commissioner next evaluates steps four and five of the sequential process— determining whether claimant can perform his past relevant work; and whether, when considering vocational factors of age, education, and work experience, claimant is able to perform other work in the economy.
Plaintiff claims the ALJ erred in ignoring a CT scan performed on August 14, 2008, improperly discounted the medical opinion of Dr. Muhnall, a physician who examined Plaintiff, and improperly accorded controlling weight to the opinions of non-examining state agency physicians and psychologists. (Pl. Br. 17-20). He argues that because of these errors the ALJ failed to recognize that Plaintiff has made the "de minimis" showing required at step two of the sequential evaluation process, and, therefore, the ALJ's step two finding that Plaintiff has no severe impairment or combination of impairments cannot stand. (Pl. Br. 17-21). The Commissioner argues that the ALJ properly considered the August 14, 2008 CT scan, properly discounted the opinion of Dr. Munhall, and did not accord controlling weight to the non-examining state agency physicians. (Comm'r Br. 5-9). Therefore, he argues the ALJ properly determined that Plaintiff does not have a severe impairment or combination of impairments, and that substantial evidence in the record supports the ALJ's finding.
At step two of the sequential evaluation process, the Commissioner determines if Plaintiff has a medically determinable impairment or a combination of impairments that is "severe" and has lasted, or is expected to last for twelve months. 20 C.F.R. §§ 404.1520(a)(4)(ii) (citing § 404.1509), 416.920(a)(4)(ii) (citing § 416.909). An impairment is not considered severe if it does not significantly limit plaintiff's physical or mental ability to do basic work activities. 20 C.F.R. §§ 404.1521, 416.921. The regulations define "basic work activities" as "the abilities and aptitudes necessary to do most jobs."
The Tenth Circuit has interpreted the regulations and determined that it is a plaintiff's burden to establish a "severe" impairment or combination of impairments at step two of the sequential evaluation process.
The ALJ stated his step two finding: "The claimant does not have an impairment or combination of impairments that has significantly limited (or is expected to significantly limit) the ability to perform basic work-related activities for 12 consecutive months; therefore, the claimant does not have a severe impairment or combination of impairments (20 CFR 404.1521
Plaintiff points to the report of a CT scan performed on August 14, 2008, after Plaintiff was involved in a motor vehicle accident, and argues that report indicated "the possibility of a non-displaced fracture" in Plaintiff's lower thoracic spine. (Pl. Br. 20) (citing R. 303). Plaintiff argues that the ALJ made a medical decision that this evidence was irrelevant, and ignored the report in his decision, thus ignoring the "potential real basis of Plaintiff's ongoing allegations of chronic and severe pain." (Pl. Br. 20). The Commissioner points out that the report indicating the possibility of a fracture was the report of a CT scan of Plaintiff's abdomen and pelvis, but that the next day a CT scan was performed on Plaintiff's thoracic spine which was negative. (Comm'r Br. 5-6). The Commissioner argues that substantial record evidence supports the ALJ's finding that CT scans of Plaintiff's cervical, thoracic, and lumbar spines were negative.
As the parties appear to agree, the record shows that after a motor vehicle accident, Plaintiff was given a CT scan of his abdomen and pelvis at 9:38 p.m. on August 14, 2008. (R. 303) (Ex. 8F, p.16). The report showed an "Admitting Diagnosis" of thoracic spine fracture and abdominal pain after a motor vehicle crash.
(R. 303). The conclusions to be gleaned from this report, are that this CT was intended to evaluate Plaintiff's abdomen and pelvis, that there was no definite acute abnormality in the abdomen or pelvis, that there was a linear lucency in the T10 and T11 vertebral bodies which could result from either draining veins or a nondisplaced fracture, and that clinical correlation was recommended to determine whether there was a nondisplaced fracture.
Shortly after 7:30 a.m. the next morning, Plaintiff was given CT scans of the cervical spine and of the thoracic/lumbar spine. (R. 304-05) (Ex. 8F, pp.17-18). On these reports, the "Admitting Diagnosis" was a thoracic spine fracture after a motor vehicle crash.
The ALJ and Plaintiff's counsel discussed this very issue at the hearing:
(R. 40-41). In this dialogue, the ALJ explained his view that the CT scan on the first day was of the pelvis/abdomen area, and the scan of the thoracic lumbar spine on the next day clarified that there was no fracture in the thoracic spine despite the possibility of a fracture which had been recognized in the CT scan of the abdomen/pelvis. Counsel admitted, "That's right." (R. 41) But he noted that Plaintiff was later examined by Dr. Hufford at MidAmerica Orthopedics. (R. 41). In the decision, the ALJ did not mention the pelvis/abdomen CT scan, but noted that CT scans "of the cervical, thoracic and lumbar spine were obtained and found to be negative." (R. 12) (citing Ex. 8F, pp.17-18).
It is not clear why counsel referred to Dr. Hufford's exam, because that exam does not help his argument. Dr. Hufford examined Plaintiff for the first time on December 8, 2008, almost four months after the motor vehicle crash, and he did not diagnose any fracture of the thoracic spine. Rather, he diagnosed Plaintiff with a motor vehicle crash "with primary
As the discussion above reveals, substantial record evidence supports the ALJ's finding that CT scans of the cervical, thoracic, and lumbar spine were negative. In context, and in light of the evidence as discussed above, the CT scan of Plaintiff's pelvis/abdomen to which Plaintiff appeals, and which suggested the possibility of a non-displaced spinal fracture is neither uncontroverted nor significantly probative evidence, and Plaintiff has shown no error in the ALJ's failure to discuss that evidence in the decision.
Plaintiff also argues that the ALJ improperly discounted the opinion of Dr. Munhall, who had performed an independent medical examination of Plaintiff, and that the ALJ made an ambiguous finding that Dr. Munhall's opinion is "not consistent with the rest of the medical record." (Pl. Br. 18) (quoting without citation). He argues that if the examination were properly assessed, it would reveal residual neck and back pain resulting in Permanent Modified Duty for Plaintiff and restrictions in Plaintiff's abilities which would at least satisfy the "de minimis" standard used at step two to show a severe impairment. (Pl. Br. 17-19). Plaintiff concludes this argument by stating that the "ALJ discounted Dr. Munhall's opinion simply because it was not in line with the thrust of a denied claim — that is, it pointed to disability and had to be muted in order to deny the claim!" (Pl. Br. 19). The Commissioner argues that Dr. Munhall's opinion was properly considered and discounted because: Plaintiff was working when the opinion was formulated, the examination occurred before Plaintiff's alleged onset date, the opinion was not supported by Dr. Munhall's examination findings, and the opinion was not supported by the record as a whole. (Comm'r Br. 6).
The ALJ summarized Dr. Munhall's examination and report:
(R. 12).
He later discussed Dr. Munhall's opinion in relation to Plaintiff's allegations and the other record evidence:
(R. 14). He concluded that Dr. Munhall's limitations should be given no weight, stating "they are not supported in a review of his records or the evidence as a whole."
It is significant to note that Dr. Munhall is not a treating source as defined in the regulations. Therefore, his opinion is worthy of no special consideration beyond that of any acceptable medical source who has examined Plaintiff.
Where a treating source opinion is not given controlling weight,
As the ALJ noted, Dr. Munhall's opinion was formulated before Plaintiff ceased working, and before he alleges onset of disability. No doctor who has examined Plaintiff since Dr. Munhall's examination has proposed any work limitations. (R. 249-55, 257-62, 288-380). The medical tests and examinations in the record, other than the singular opinion of Dr. Munhall, have been unremarkable and have proposed no work restrictions.
Moreover, as quoted above, Plaintiff argues that the "ALJ discounted Dr. Munhall's opinion simply because it was not in line with the thrust of a denied claim — that is, it pointed to disability and had to be muted in order to deny the claim!" (Pl. Br. 19). Counsel's argument on behalf of Plaintiff implies that the ALJ was somehow deliberately biased. But, he ignores the rationale given by the ALJ in discounting Dr. Munhall's opinion, and he points to no evidentiary basis for his assertion that the opinion was rejected merely because the ALJ wanted to mute it in order to deny the claim. Plaintiff has shown no error in the ALJ's rejection of Dr. Munhall's opinion, and as discussed above, substantial record evidence supports that determination.
Plaintiff argues that the ALJ apparently accorded controlling weight "to the non-examining DDS reviewers in siding with them in determining that Claimant's mental and/or physical impairments are `non-severe.'" (Pl. Br. 17). The Commissioner argues that the ALJ did not give controlling weight to any medical opinion, but instead considered the record as a whole and stated his agreement with the opinions of Dr. Moeller and Dr. Estivo, and stated that these opinions were consistent with the opinion of the state agency medical consultant who reviewed the record evidence and found no severe impairments. (Comm'r Br. 8-9).
Plaintiff quotes from the decision regarding the weight the ALJ accorded to the medical opinions of Drs. Moeller and Estivo, and to the medical opinions of the "medical experts at the lower level:"
(Pl. Br. 17) (quoting R. 14). However, Plaintiff did not discuss the ALJ's earlier summary and discussion of the reports of Dr. Moeller and Dr. Estivo. (R. 12-13). In that summary, the ALJ noted that Dr. Moeller indicated Plaintiff was "claiming more impairment than objectively exists," found "no psychological difficulties that would preclude employment," felt malingering needed to be ruled out, and found "no impairment in the ability to understand, remember and carry out instruction and only slight limitation in the ability to respond appropriately to work pressures in a usual work setting with no other problem in the ability to respond appropriately to supervision, co-workers and work pressures in a work setting." (R. 12-13) (citing Ex. 11F (R. 343-54)). The ALJ discussed intelligence testing that Dr. Moeller administered to Plaintiff, noted the test results were not consistent with other records or with Plaintiff's ability to read, and that the test results were invalid and "supported the claim of malingering." (R. 13) (citing Ex. 12F (R. 355-71)). Finally, the ALJ summarized Dr. Estivo's report of examination, noting that it was unremarkable, that Dr. Estivo "found no objective evidence for which to attribute [Plaintiff's] complaints of pain," "would not recommend any specific work restrictions," and completed a functional assessment "finding no limits in lifting, sitting, standing, walking, postural limitations, manipulative limitations, visual/communicative limitations, or environmental limitations." (R. 13) (citing Ex. 13F (R. 372-80)). Finally, in the sentence immediately following the portion of the decision quoted by Plaintiff, the ALJ found that the evidence received into the record after the reconsideration evaluation of Dr. Goering would not alter any findings the lower level medical experts made regarding RFC. (R. 14).
Plaintiff's brief is confusing regarding the opinions to which he believes the ALJ apparently accorded controlling weight, because he alleges the ALJ "assigned ostensible controlling weight to the non-examining DDS reviewers," but he quotes the portion of the decision in which the ALJ states his agreement with the opinions of Dr. Moeller and Dr. Estivo. (Pl. Br. 17). Several terms need to be discussed in order to untie this knot. "DDS" refers to the state agency, Disability Determination Service, which in Kansas reviews applications for DIB and SSI at the initial and reconsideration levels of review. 20 C.F.R. §§ 404.1601-02, 404.1610-19; 416.1001-02, 416.1010-19. Thus, the "non-examining DDS reviewers" as used by the Plaintiff, refers to DDS consultants who did not examine Plaintiff but formed opinions based upon a review of the record evidence. Similarly, the "medical experts at the lower level" as used in the ALJ's decision refers to the "medical or psychological consultants" "who [are] member[s] of a team that makes disability determinations in a State agency." 20 C.F.R. §§ 404.1616; 416.1016. Therefore, the "non-examining DDS reviewers" and the "medical experts at the lower level" refer to the same individuals, the state agency consultants who did not examine Plaintiff but reviewed the record evidence and provided medical opinions based thereon. The ALJ cites to these opinions at Exhibits 4F and 6F, and a review of the exhibits reveals they are opinions provided by Mr. Johnson (R. 256) and Dr. Goering. (R. 263).
On the other hand, the ALJ, stated that he agreed with the opinions of Dr. Moeller and Dr. Estivo who were non-treating physicians who had, in fact, examined Plaintiff and provided opinions based upon the results of those examinations. See, (R. 12-13) (summarizing the opinions and reports of Drs. Moeller and Estivo); and (R. 343-80) (reports from Drs. Moeller and Estivo). As to the opinions of the "medical experts at the lower level" (Mr. Johnson and Dr. Goering), the ALJ merely noted that their opinions were consistent with those of Dr. Moeller and Dr. Estivo, and were grounded upon the record evidence and upon careful consideration of Plaintiff allegations, and that new evidence received later would not discount their findings. Although Plaintiff apparently (erroneously) conflates all of these opinions under the rubric "non-examining DDS reviewers," that error makes no difference in the court's analysis because the court finds that the ALJ did not give controlling weight to any medical opinion.
As Plaintiff's brief recognizes, "controlling weight" is a term of art used by the Commissioner in weighing treating source opinions. (Pl. Br. 17). "If [the Commissioner] find[s] that a treating source's opinion on the issue(s) of the nature and severity of [the claimant's] impairment(s) [(1)] is well-supported by medically acceptable clinical and laboratory diagnostic techniques and [(2)] is not inconsistent with the other substantial evidence in [claimant's] case record, [the Commissioner] will give it controlling weight." 20 C.F.R. §§ 404.1527(d)(2), 416.927(d)(2);
From this discussion, it becomes apparent that "controlling weight" has a specific meaning and is not merely the quantum of weight given to an opinion which carries the greatest weight in the ALJ's analysis or with which the ALJ agrees. Controlling weight can only be accorded to a treating source opinion. Here, there was no treating source opinion. Therefore, it is not surprising that the ALJ said nothing in his decision regarding controlling weight. Rather, as discussed above he considered Dr. Moeller's opinion and Dr. Estivo's opinion and described how those opinions were consistent with the record evidence. He then explained that he agreed with the opinions and that the opinions were consistent with the state agency consultants' opinions which he noted were grounded in the evidence and in careful consideration, and which were not inconsistent with the evidence received after the consultants' opinions were formulated. Contrary to Plaintiff's argument, there is simply no indication in the decision that the ALJ adopted the DDS opinions or the opinions of Dr. Moeller and Dr. Estivo
Plaintiff argues that the ALJ erred in finding Plaintiff's impairments are not severe because the ALJ erroneously assigned controlling weight to certain opinions, erred in weighing Dr. Munhall's opinion, and erred by ignoring the pelvic/abdomen CT scan performed on August 14, 2008. As the discussion above demonstrates, Plaintiff has not shown error in the findings upon which he bases his argument. Therefore, the court finds that Plaintiff has not met his
In any case, the court notes that Exhibit 6F is an SSA Form 5002 signed on September 26, 2007 at the agency's reconsideration review by "Emil L. Goering, MD." (R. 263). Dr. Goering is an acceptable medical source whose opinion is a medical opinion, and Dr. Goering stated, "All the evidence in this file is reviewed and the 5002 signed 4/12/07 is affirmed as written."