NOELLE C. COLLINS, Magistrate Judge.
This is an action under Title 42 U.S.C. § 405(g) for judicial review of the final decision of the Commissioner denying the applications of Tamalitha Jones (Plaintiff) for Disability Insurance Benefits (DIB) under Title II of the Social Security Act (the Act), 42 U.S.C. §§ 401
On April 4, 2012, Plaintiff filed her applications for DIB and SSI, alleging a disability onset date of April 1, 2012. (Tr. 10, 109-21). Plaintiff's applications were denied, and she requested a hearing before an Administrative Law Judge (ALJ). (Tr. 68-72, 83-85). After a hearing, by decision, dated July October 1, 2013, the ALJ found Plaintiff not disabled. (Tr. 10-17). February 4, 2015, the Appeals Council denied Plaintiff's request for review. (Tr. 1-6). As such, the ALJ's decision stands as the final decision of the Commissioner.
Under the Social Security Act, the Commissioner has established a five-step process for determining whether a person is disabled. 20 C.F.R. §§ 416.920, 404.1529. "`If a claimant fails to meet the criteria at any step in the evaluation of disability, the process ends and the claimant is determined to be not disabled.'"
Third, the ALJ must determine whether the claimant has an impairment which meets or equals one of the impairments listed in the Regulations. 20 C.F.R. §§ 416.920(d), 404.1520(d). If the claimant has one of, or the medical equivalent of, these impairments, then the claimant is per se disabled without consideration of the claimant's age, education, or work history.
Fourth, the impairment must prevent the claimant from doing past relevant work. 20 C.F.R. §§ 416.920(f), 404.1520(f). The burden rests with the claimant at this fourth step to establish his or her Residual Functional Capacity (RFC).
Fifth, the severe impairment must prevent the claimant from doing any other work. 20 C.F.R. §§ 416.920(g), 404.1520(g). At this fifth step of the sequential analysis, the Commissioner has the burden of production to show evidence of other jobs in the national economy that can be performed by a person with the claimant's RFC.
It is not the job of the district court to re-weigh the evidence or review the factual record de novo.
To determine whether the Commissioner's final decision is supported by substantial evidence, the court is required to review the administrative record as a whole and to consider:
The issue before the Court is whether substantial evidence supports the Commissioner's final determination that Plaintiff was not disabled.
The ALJ found that Plaintiff met the insured status requirements through September 30, 2015; that Plaintiff had not engaged in substantial gainful activity since her alleged onset date of April 1, 2012; that Plaintiff had the severe impairment of aortic insufficiency; that Plaintiff did not have an impairment or combination of impairments that met or equaled a listed impairment; that Plaintiff had the RFC to perform sedentary work; that Plaintiff could not perform her past relevant work; that considering Plaintiff's RFC, age, education, and work experience, there were jobs, existing in significant numbers in the national economy, which Plaintiff could perform; and that, therefore, Plaintiff was not disabled.
Plaintiff contends that the ALJ's decision is not based on substantial evidence because: the ALJ did not develop the record with medical evidence sufficient to determine Plaintiff's RFC; the ALJ dismissed Plaintiff's testimony when determining her RFC because the ALJ discredited Plaintiff based on the objective medical evidence and her non-compliance with prescribed medical treatment; and the ALJ did not consider Plaintiff's daily activities in regard to his credibility determination. For the following reasons, the court finds Plaintiff's arguments without merit and that the ALJ's decision is based on substantial evidence and is consistent with the Regulations and case law.
The court will first consider the ALJ's credibility determination, as the ALJ's evaluation of Plaintiff's credibility was essential to the ALJ's determination of other issues, including Plaintiff's RFC.
To the extent that the ALJ did not specifically cite
In any case, "[t]he credibility of a claimant's subjective testimony is primarily for the ALJ to decide, not the courts."
First, the ALJ reviewed the objective medical evidence of record and concluded that Plaintiff's physicians found that her condition was stable, and that, therefore, the objective medical evidence did not "correlate with [Plaintiff's] allegations and testimony at the hearing." (Tr. 13-15). "In determining the credibility of the individual's statements, the adjudicator must consider the entire case record, including the objective medical evidence," although a disability determination "cannot be made solely on the basis of objective medical evidence." Social Security Ruling (SSR) 06-7p(4), 1996 WL 374186, at *1 (July 2, 1996). Indeed, a claimant's "symptoms, including pain, will be determined to diminish [her] capacity for basic work activities to the extent that [her] alleged functional limitations and restrictions due to symptoms can reasonably be accepted as consistent with the objective medical evidence and other evidence in the case record."
In this regard, after Plaintiff reported that she felt dizzy and weak while standing at work, Plaintiff's primary care doctor detected a heart murmur and referred her to Yousf Abduinabi, M.D., at Gateway Cardiology. Dr. Abduinabi saw Plaintiff on March 9, 2012, and reported that Plaintiff said she had shortness of breath and difficulty breathing with exertion, and that she had no chest discomfort, palpitations, swelling, loss of consciousness, or leg pain. Dr. Abduinabi further reported that Plaintiff had non-labored breathing, clear breath sounds, and normal heart rhythms and sounds, except for a heart murmur. Dr. Abduinabi diagnosed Plaintiff with tobacco abuse, shortness of breath, and a heart murmur. Dr. Abduinabi's impression included normal left ventricular systolic function, normal right ventricular size and function, normal "four cardiac chamber size," left ventricular hypertrophy, thickened and calcified aortic valves with decreased opening, normal appearing ascending aorta and aortic arch, normal inferior vena cava, moderate to severe aortic stenosis, severe aortic insufficiency, and mild mitral regurgitation, tricuspid regurgitation, pulmonary hypertension, and pulmonic insufficiency. (Tr. 215-18).
As considered by the ALJ, a cardiac catheterization, performed on April 3, 2012, showed that Plaintiff had normal left ventricular function, but severe aortic insufficiency. Additionally, the cardiac catheterization showed that Plaintiff had normal pulmonary function. (Tr. 14, 219).
When Dr. Abduinabi saw Plaintiff, on April 18, 2012, she told Dr. Abduinabi that she was doing "ok," except for some fatigue, weakness, and dizziness. Dr. Abduinabi reported that Plaintiff had no chest discomfort suggestive of ischemia; that Plaintiff said she had no palpitations, syncope, or claudication; that Plaintiff had no transient ischemic attacks (TIA) or "stroke-like symptoms"; that Plaintiff was negative for chest pain, diaphoresis, orthopnea, palpitation, and syncope; that Plaintiff's respirations were "non-labored"; that her breath sounds were "clear throughout"; that Plaintiff had a regular cardiac rhythm; that Plaintiff had a "diastolic rumble murmur"; that, except for Plaintiff's heart murmur, review of Plaintiff's systems was normal; and that Plaintiff did not have clubbing, cyanosis, or edema in her extremities. (Tr. 213-14). On April 3, 2012, Bassam Aljoundi, M.D., referred Plaintiff for a possible aortic valve replacement, based on test results. (Tr. 219-20).
When Plaintiff presented to Melinda Peterson, D.O., on August 3, 2012, she said that she had a "hard time getting Medicaid to approve" the dental work which was a prerequisite for her recommended aortic valve replacement, but that she was having teeth removed in a few days and was on antibiotics in preparation for the procedure. Dr. Peterson told Plaintiff to avoid strenuous physical activity and extreme temperatures and to rest, and provided Plaintiff with a letter stating that her condition impaired her ability to "perform any occupational tasks." (Tr. 240-41, 334).
Plaintiff presented to Gateway Cardiology, on August 29, 2012, with shortness of breath. Liwa Younis, M.D., reported that Plaintiff was a candidate for valvular replacement, but that she first needed to have dental work completed, including that she have teeth pulled.
On November 21, 2012, Plaintiff told Jennifer Curtis, a nurse practitioner, that she was "on modified bed rest due to dizziness, [shortness of breath], and fatigue"; that she was trying to find an oral surgeon to remove teeth; and that she felt well, "with minor complaints." Nurse Curtis reported that Plaintiff said she had chest pain, which was worse at night; that Plaintiff did not have swelling in her extremities; that Plaintiff was "well-nourished" and "well-groomed"; that Plaintiff's strength and tone were "normal overall with no atrophy, spasticity or tremors"; and that Plaintiff had normal gait and station. (Tr. 238-39).
On March 7, 2013, Plaintiff reported shortness of breath with exertion, "occasional chest pressure," and "occasional dizziness." She was negative for joint pain. On examination, Plaintiff's breath sounds were "clear throughout"; she had a diastolic heart murmur; she had no lower extremity edema; and her respirations were non-labored. The impression was severe aortic insufficiency, with no signs or symptoms of congestive heart failure. (Tr. 227-28). Upon examination, on March 15, 2013, Anil Gupta, M.D., reported that Plaintiff had no edema in her lower extremities; that she was "well-nourished and well-groomed"; that her "strength and tone [were] normal overall with no atrophy, spasticity or tremors"; and that Plaintiff had normal gait and station. Also on this date, Dr. Gupta provided Plaintiff with a note stating that she required dental work in order to have "pre-op clearance for AVR." (Tr. 236-37).
When Plaintiff presented, on July 8, 2013, for an annual examination, Nurse Practitioner Michelle Marcus reported that Plaintiff felt "well with minor complaints," and that Plaintiff had normal breath sounds, gait, station, and posture and regular heart rhythm and breath sounds. (Tr. 280-81). When Plaintiff presented to Nurse Practitioner Marcus, on August 9, 2013, it was noted that Plaintiff was "[n]ot in acute distress"; that she was well nourished; that she had normal posture and gait; and that her pain level was "0/10." (Tr. 274).
The last treatment note of record, dated August 12, 2013, reflects that Plaintiff denied edema; that she had no chest discomfort suggestive of ischemia; that Plaintiff had "no symptoms attributable to valvular heart disease"; that Plaintiff was negative for lower extremity clubbing, cyanosis, and edema; that Plaintiff had a normal gait; and that she was negative for joint pain and "dizziness." (Tr. 263-64).
To the extent Plaintiff argues that substantial evidence does not support the ALJ's determination that the objective medical evidence was inconsistent with Plaintiff's allegations regarding the severity of her conditions, the court finds, based on the foregoing evidence, that the ALJ's determination, in this regard, is based on substantial evidence and is consistent with the Regulations and case law.
Second, the ALJ considered that Plaintiff was non-compliant with recommended medical treatment.
In regard to Plaintiff's non-compliance, the ALJ considered that the record indicated that Plaintiff had not kept dental appointments necessary for her to have the recommended heart valve surgery and that, at the hearing, "she did not offer any convincing reasons why [the recommended surgery] had not yet been performed." (Tr. 14-15). In particular, as considered by the ALJ, Plaintiff's medical providers diagnosed her heart condition and recommended surgery to correct this condition in April 2012, but that, at the time of the October 2013 hearing, Plaintiff had not completed the required dental work and had recently stopped smoking. (Tr. 46-49).
Plaintiff acknowledged at the hearing that her doctors wanted her to have stopped smoking "for a nice little length of time before [she] had [] the surgery." She also testified that she was still waiting for "the dental work to go through" and that she had "been checking with a lot of different places that [could] finish up [her] dental work. Plaintiff additionally testified that she stopped smoking sometime after August 12, 2013, at which time she was still smoking a half package of cigarettes a day. (Tr. 35-36, 263).
Additionally, the record reflects that Dr. Abduinabi counseled Plaintiff on smoking cessation when he first saw her, in March 2012, and again in April 2012. (Tr. 214, 218). Dr. Peterson counseled Plaintiff to stop smoking in August 2012. (241). On August 29, 2012, Dr. Younis noted that Plaintiff had begun the recommended dental work, and suggested that she accelerate it and also counseled Plaintiff to stop smoking. (Tr. 224). Records from Gateway Cardiology, dated December 3, 2012, reflect that Plaintiff needed "to have AVR," but that she did "not keep appt. with dental clinic to have teeth pulled prior to surgery." (Tr. 225).
Dr. Gupta reported, on March 7, 2013, that Plaintiff needed to have three teeth pulled in order for her to have surgery, and that Plaintiff said she had a dental appointment on March 19, 2013, but noted that Plaintiff had "been non-compliant," in that she did not get a recommended electrocardiogram (EKG) in November 2012. (Tr. 236). Also, Nizar Assi, M.D., reported, on March 7, 2013, that he "highlighted the importance of [Plaintiff's] finishing her dental work ASAP so she [could] proceed with AVR." Dr. Assi also instructed Plaintiff "on tobacco cessation." (Tr. 228). Also, when Plaintiff presented, on August 9, 2013, requesting that Nurse Practitioner Marcus complete a disability form, Nurse Practitioner Marcus refused to do so, and noted that Plaintiff had a "strong smell of tobacco on her clothing," and that, although Dr. Gupta ordered an EKG for Plaintiff, she "refused to wait to have this performed and [had] not returned." (Tr. 274). Finally, in the last medical note in the record, dated August 12, 2013, it was reported that Plaintiff smoked a half package of cigarettes a day; that she needed to have her "teeth problems addressed prior to surgical intervention (AVR)"; that she had an appointment with a dental clinic; and that she would "need [to] follow up with CTS for AVR." (Tr. 263-64).
To the extent Plaintiff contends, based on Social Security Ruling (SSR) 82-59, 1982 WL 21384 (1982), the ALJ improperly considered Plaintiff's non-compliance when determining that her allegations were not fully credible (Doc. 14 at 10), SSR 82-59 "only applies to claimants who would otherwise be disabled within the meaning of the Act; it does not restrict the use of evidence of noncompliance for the disability hearing."
The ALJ in this matter never determined that Plaintiff was disabled and that compliance would restore her ability to work. (Tr. 15). Rather, the ALJ considered Plaintiff's symptoms and limitations as they were without the surgery and determined the extent to which they would limit her engaging in work activities. (Tr. 15). Thus, the "ALJ used the evidence of [Plaintiff's] noncompliance solely to weigh the credibility of [Plaintiff's] subjective claims of pain."
Third, the ALJ considered that Plaintiff's heart condition was not so severe that it required immediate surgery; rather, Plaintiff's doctors delayed the procedure until she could obtain dental treatment. (Tr. 15).
Fourth, the court notes that Plaintiff's blood pressure was controlled with medication. Conditions which can be controlled by treatment are not disabling.
Fifth, the ALJ considered that no treating source, other than Dr. Peterson, issued a medical statement assessing Plaintiff's limitations. (Tr. 15).
Indeed, on August 3, 2012, Dr. Peterson recommended that Plaintiff avoid strenuous tasks, rest, and avoid extreme temperatures. As stated above, Dr. Peterson also wrote a letter, on this same date, stating that Plaintiff had a "serious medical condition which completely impair[ed] her ability to perform any occupational tasks." (Tr. 241, 334). However, the record does not reflect that Dr. Peterson saw Plaintiff other than on the one day that she wrote the letter. 20 C.F.R. §§ 404.1527(d)(2)(i) & 416.927(d)(2)(i) ("Generally, the longer a treating source has treated [a claimant] and the more times [the claimant has] been seen by a treating source, the more weight [the Commissioner] will give to the source's medical opinion."). Further, as stated above, no other physician who saw Plaintiff made suggestions similar to Dr. Peterson's. In any case, the ALJ's limiting Plaintiff to sedentary work was consistent with Dr. Peterson's clinical notes stating that Plaintiff should refrain from strenuous physical activity.
Plaintiff stated in an undated Missouri Supplemental Questionnaire that her doctor told her that "it [would] be a long time before [she] [was] able to lift. [She] would have to take blood thinners for the rest of [her] life. They [] also told [her] that they think [she] may never be able to return to work."
Notably, as stated above, on August 9, 2012, Plaintiff asked Nurse Practitioner Marcus to sign a disability form. In particular, Plaintiff asked her to sign "one [form] for disability and another for not having worked for a year." Plaintiff told Nurse Practitioner Marcus that her cardiologist said she was "too sick to do any work at all"; she could not "do anything because of [her] aortic stenosis." Nurse Practitioner Marcus noted that Plaintiff did not have documentation with her from her cardiologist; that Plaintiff stated that "it [did not] matter"; and that Plaintiff would not tell her the name of her cardiologist. (Tr. 274). Accordingly, Nurse Practitioner Marcus did not complete the form.
Sixth, although Plaintiff argues that the ALJ did not consider her daily activities (Doc. 14 at 14-15), the ALJ questioned Plaintiff extensively, at the administrative hearing, regarding her daily activities, and, in his written decision, he acknowledged Plaintiff's testimony that she said she had difficulty walking up a flight of stairs; that she could not go "shopping anymore"; and that she could not lift ten pounds because "she struggle[d] to catch her breath." (Tr. 13, 32-35). To the extent that the ALJ did not discuss Plaintiff's daily activities in greater depth in his decision, the ALJ's failure to do so does not mean that the ALJ did not consider Plaintiff's assertions regarding her daily activities in their entirety.
Moreover, as discussed above, an ALJ is not required to address every
In any case, the court notes that Plaintiff stated in a Function Report — Adult that she took a shower in the morning; that the shower took her an hour; that for "most of the day" she had to lie down; and that she remained "bed bound daily." However, she also reported in the Function Report — Adult that she took care of her two children; that she cooked; that she did laundry, that she took care of her home; that she could drive but that it was unsafe for her to do so; that she shopped in stores for food, personal needs, and household supplies; that she could pay bills, handle a savings account, count change, and use a checkbook; that she read and watched television on a daily basis "with no problem"; that she spent times with others on a daily basis; that she did not need someone to accompany her when she went places; and that her disabling conditions did not affect her ability to sit, talk, hear, see, remember, concentrate, understand, follow instructions, use her hands, or get along with others. (Tr. 157-62). Plaintiff also stated in an undated Missouri Supplemental Questionnaire that she played video games, puzzles, or used a computer thirty minutes at a time. (Tr. 166).
In conclusion, the court finds that the ALJ's credibility determination is based on substantial evidence and consistent with the Regulations and case law.
The Regulations define RFC as "what [the claimant] can do" despite her "physical or mental limitations." 20 C.F.R. § 404.1545(a). "When determining whether a claimant can engage in substantial employment, an ALJ must consider the combination of the claimant's mental and physical impairments."
To determine a claimant's RFC, the ALJ must move, analytically, from ascertaining the true extent of the claimant's impairments to determining the kind of work the claimant can still do despite his or her impairments.
As previously discussed, the ALJ found that Plaintiff had the RFC to perform sedentary work. 20 C.F.R. § 404.1567(a) defines sedentary work as follows: "Sedentary work involves lifting no more than 10 pounds at a time and occasionally lifting or carrying articles like docket files, ledgers, and small tools. Although a sedentary job is defined as one which involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking and standing are required occasionally and other sedentary criteria are met." Indeed, SSR 85-15, 1985 WL 56857, at *5, states that "[w]here a person has some limitation in climbing and balancing and it is the only limitation, it would not ordinarily have a significant impact on the broad world of work. . . . If a person can stoop occasionally (from very little up to one-third of the time) in order to lift objects, the sedentary and light occupational base is virtually intact." The sitting requirement for the full range of sedentary work "allows for normal breaks, including lunch, at two hour intervals."
First, the court notes that to prove disability the evidence must establish functional limitations, not just medical diagnosis.
Further, as discussed above in regard to Plaintiff's credibility, it was reported, by Plaintiff's treating doctors and medical providers, that Plaintiff's condition was stable; that her need for surgery was not immediate; that she maintained an active lifestyle; that Plaintiff had no symptoms attributable to valvular heart disease; that Plaintiff was negative for joint pain and edema in her extremities; that she had normal strength, gait, and station; and that Plaintiff was not in acute distress. (Tr. 213-15, 218, 223-24, 228, 236-37, 263-65, 274, 280-81). Notably, since Plaintiff's diagnosis of aortic insufficiency and a heart murmur, she was never hospitalized. When formulating Plaintiff's RFC, the ALJ accommodated Plaintiff's limitations, to the extent he found them credible, including Plaintiff's assertions regarding her dizziness and weakness.
To the extent Plaintiff argues that the ALJ did not include a narrative statement connecting his RFC findings to the medical evidence (Doc. 14 at 6, 10-11), Plaintiff is mistaken. Her argument is without merit and belied by the text of the ALJ's written opinion. Prior to determining Plaintiff's RFC, the ALJ engaged in a lengthy narrative discussion of the relevant medical evidence of record. (Tr. 14-15). Only after doing so, in conjunction with his finding Plaintiff not fully credible, did the ALJ conclude that her symptoms, including shortness of breath, dizziness, or chest pain, would be accommodated by sedentary work, which would limit the extent to which Plaintiff would have to stand, walk, and lift. (Tr. 15).
Indeed, Plaintiff's questioning the ALJ's judgment that the evidence is insufficient to establish disability does not establish a basis upon which the ALJ's decision should be reversed and remanded.
In conclusion, the court that the ALJ's RFC determination is consistent with the relevant evidence of record including the objective medical evidence, the observations of medical providers, and diagnostic test results, as well as Plaintiff's credible limitations; that the ALJ's RFC determination is based on substantial evidence; and that Plaintiff's arguments to the contrary are without merit.
For the reasons set forth above, the court finds that substantial evidence on the record as a whole supports the Commissioner's decision that Plaintiff is not disabled.
Accordingly,
A separate judgment shall be entered incorporating this Memorandum and Order.