PATRICIA L. COHEN, Magistrate Judge.
Linda Martin (Plaintiff) seeks review of the decision of the Social Security Commissioner, Nancy Berryhill, denying her applications for Disability Insurance Benefits and Supplemental Security Income under the Social Security Act. Because the Court finds that substantial evidence supports the decision to deny benefits, the Court affirms the denial of Plaintiff's applications.
On May 21, 2013 and June 6, 2013, Plaintiff completed applications for Disability Insurance Benefits and Supplemental Security Income.
In his July 24, 2014 decision, the ALJ found that Plaintiff "has not been under a disability, as defined in the Social Security Act, from October 24, 2012, through the date of this decision[.]" (Tr. 124). Subsequent to the ALJ's decision, Plaintiff presented to the SSA Appeals Council several medical records from examinations that occurred after the ALJ issued his decision. (Tr. 8-105). The Appeals Council reviewed the records and concluded that the new information did not pertain to the relevant time period. (
On May 7, 2014, Plaintiff appeared with counsel at an administrative hearing. (Tr. 129). Plaintiff testified that she was fifty-two years old, five feet five inches tall, 160 pounds, and right-handed. (Tr. 134-35). She further testified that she left high school after completing her junior year, but later earned a GED and a certificate in "secretarial and business." (Tr. 136). Plaintiff stated she most recently worked at a cash register and stocked shelves at a store. (
Plaintiff stated that she suffered from a seizure disorder, high blood pressure, arthritis and cramps in the right hand, "a little" arthritis in the left hand, lumbar back pain stemming from degenerative bone deterioration, "sinosis [PHONETIC], psychotic [PHONETIC] nerve damage, [and] bulging discs." (Tr. 138-39). She also suffered: migraine headaches, which lasted half a day and occurred four to five times per month; pain in her neck, shoulders, and hands; lower back pain that felt like someone was "breaking my back or punching me"; and leg pain when walking. (Tr. 164-66). Plaintiff estimated that she could lift less than four pounds, walk for one ten-minute period per day, stand for one ten-minute period per day, and sit in a chair for ten to fifteen minutes per day. (Tr. 167-68). Plaintiff testified she did not drive because she did not have a license and her seizure disorder prevented it, but if she did, she would have problems steering a car and controlling the foot pedals. (Tr. 135, 168-69).
Plaintiff testified that she had a referral for, but had not yet seen, a pain management specialist for her back. (Tr. 142). The only specialist Plaintiff had seen for her back injury was at a Concentra Clinic about one year prior to the hearing. (Tr. 142-43). Plaintiff stated this visit was arranged "through worker's comp[ensation]" after the October 2012 work-related injury. (
At the time of the hearing, Plaintiff was taking medication for high blood pressure, "Pantropozol [PHONETIC] sodium, Norvac [PHONETIC], Proloprosine [PHONETIC]," Tramadol, and Amotrax." (Tr. 147-48). Plaintiff testified that she began taking Amotrax after her last seizure to help prevent migraines. (
On a typical day, Plaintiff awakened between 7:00 a.m. and 9:00 a.m., ate, took her medications, and spent the rest of her morning in bed. (Tr. 150-51). After lunch, Plaintiff usually returned to her bed, where she read or watched television until her boyfriend returned from work around 6:00 p.m. (Tr. 155). The two ate dinner, and Plaintiff tried to sit in a chair as long as possible before her back pain forced her back to bed. (Tr.155-56). Some days, Plaintiff's boyfriend dropped her off at her mother's house on his way to work, and she would visit with her mother and watch television until her boyfriend picked her up around 6:00 p.m. (Tr. 154).
Plaintiff testified that washing dishes was difficult because her hand hurt "really bad and start[ed] cramping." (Tr. 151). She stated she could manage small loads of laundry by herself, vacuum with her left hand, and go to the grocery store with someone else and lean on the cart. (
A vocational expert, Tim Shaner, also testified at the hearing. (Tr. 176). Mr. Shaner stated that both of Plaintiff's past jobs, cleaner and cashier, were classified as unskilled, and "light exertion, both generally and as performed." (Tr. 177). The ALJ asked Mr. Shaner to consider a hypothetical individual:
(
Dr. Asif Qaisrani, a psychiatrist, treated Plaintiff from July 2011 until July 2012. (Tr. 385-98). In July 2011, Dr. Qaisrani noted that Plaintiff was a "questionably reliable" historian. (Tr. 391). Dr. Qaisrani diagnosed Plaintiff with cocaine dependence in remission, post-traumatic stress disorder, borderline personality disorder, and a chronic backache. (Tr. 393). At an appointment with Dr. Qaisrani in September 2011, Plaintiff complained of "severe back pain" but Dr. Qaisrani noted "steady gait and relaxed posture [.]" (Tr. 395).
In December 2012, Plaintiff visited her primary care physician, Dr. Jacquelyn McFadden. (Tr. 424). A musculoskeletal exam demonstrated "normal range of motion, muscle strength, and stability in all extremities with no pain on inspection." (Tr. 426). On January 11, 2013, Plaintiff underwent an MRI which showed: "grade I anterior degenerative listhesis of L4 on L5; central and lateral stenosis at the lower two levels, most marked at L4-5 where there is severe central and lateral stenosis; and no large focal disc herniation identified." (Tr. 411).
In July 2013, Dr. Eli Shuter examined Plaintiff at St. Louis Connect Care. (445-49). Plaintiff complained of migraine headaches. (Tr. 445). Dr. Shuter's musculoskeletal exam showed no myalgias or arthralgias, no abnormalities on the tandem gait test, and normal arm swing. (Tr. 447-48). Plaintiff also visited Dr. McFadden complaining of facial pain and seizures. (Tr. 416-19). Dr. McFadden noted neck stiffness and that Plaintiff had not fallen in the last year. (Tr. 417-18).
In August 2013, Plaintiff presented to an emergency room with chest pain. (Tr. 461). She did not complain of back or leg pain. (
In October 2013, Dr. Leslie Tharenos completed a consultative exam at the request of the SSA. (Tr. 474-83). Dr. Tharenos noted normal gait "and station" and no use of an assistive device for ambulation. (Tr. 477). Plaintiff was able to heel and toe walk, get off the exam table, move around the room, and squat while holding the exam table "without apparent difficulty[.]" (Tr. 477). Plaintiff had decreased range of motion of the lumbosacral spine and "demonstrate[d] tenderness to superficial palpation of the paraspinal musculature in this region." (
Plaintiff had no difficulty performing a variety of tasks with her right hand, including opening doors, using a knob, picking up and holding a cup, and tying shoelaces. (Tr. 479). Plaintiff had mild difficulty picking up coins, buttoning and unbuttoning, and mild difficulty with pinch strength in her left hand. (
In January 2014, Dr. Ananda DeSilva examined Plaintiff. (Tr. 516-18). Plaintiff complained of hand pain with associated symptoms including decreased mobility, joint tenderness, locking, weakness, and tingling in the arms. (Tr. 516). Plaintiff described the pain as a ten out of ten, but said it was relieved by over-the-counter medicines. (
Plaintiff visited SSM DePaul Health Center in February 2014. (Tr. 376). Dr. Monu Khanna diagnosed Plaintiff with hypercalcemia and prescribed Tylenol, Norvasc, Floricet, and hydralazine. (
Plaintiff followed up with Dr. DeSilva later that month. (Tr. 512-515). Plaintiff's physical exam showed a "normal range of motion, muscle strength and stability in all extremities with no pain on inspection[.]" (Tr. 515). Dr. DeSilva advised Plaintiff to "exercise moderately" and updated Plaintiff's medications to Imitrex, losartan-hydrochlorothiazide, prochlorperazine maleate, pantoprazole sodium, and Norvasc. (
In April 2014, Plaintiff saw Dr. DeSilva for back pain and hypertension. (Tr. 507-11). Plaintiff complained that her back pain was worsening and persistent with no relief. (Tr. 507). Dr. DeSilva's exam revealed tenderness in the cervical spine with mild pain with motion, muscle spasm in the lumbar spine with a mildly reduced range of motion, arthralgia in the left pelvis, and mild pain with motion in the left hip and knee. (Tr. 510). Plaintiff returned to Dr. DeSilva's office in June 2014 complaining of discomfort and right side pain. (Tr. 503-06). The physical exam revealed a muscle spasm in the lumbar spine and mildly reduced range of motion. (
Upon Dr. DeSilva's referral, Plaintiff met with Dr. Guodong Li, at the Barnes Jewish Pain Management Center for sciatica and low back pain in November 2014. (Tr. 54-62). Plaintiff described her pain as "continuous, throbbing, shooting, cramping, gnawing, aching, heavy, tender, tiring-exhausting, [and] sickening[.]" (
In March 2015, a bone density test of Plaintiff's lumbar spine revealed normal bone density of the lumbar spine. (Tr. 16). An MRI of the spine showed grade I spondylolisthesis at L4-5 with mild central stenosis and moderate facet arthropathy, minimal grade I spondylolisthesis at L5-S1 with small annular fissure and facet arthropathy, and no lumbar disc herniation. (Tr. 18-19). In late March 2015, Dr. Ravindra Shitut performed spine surgery on Plaintiff. (Tr. 37).
The ALJ applied the five-step evaluation set forth in 20 C.F.R. § 404.1520 and § 416.920
The ALJ found that Plaintiff retained the residual functional capacity (RFC) to:
(Tr. 123). The ALJ noted that the RFC was consistent with the assessment of the single decisionmaker contained in the October 2013 Disability Determination Explanation forms that accompanied the SSA's denial of Plaintiff's applications.
Based on the testimony of the vocational expert, the ALJ determined that Plaintiff would be able to perform her past jobs as cashier and cleaner. (Tr. 123). The ALJ further found that if Plaintiff's RFC included additional limitations to "only occasional contact with the general public and independent decision-making, no more than occasional changes in the work environment and without strict production pace rate, the claimant could still perform her job as a cleaner [as] it is actually and generally performed." (
The court must affirm the ALJ's decision if it is supported by substantial evidence on the record as a whole.
"If, after reviewing the record, the court finds it is possible to draw two inconsistent positions from the evidence and one of those positions represents the ALJ's findings, the court must affirm the ALJ's decision."
Plaintiff claims that the ALJ erred because: (1) the ALJ relied too heavily on the opinion of the single decision-maker; and (2) substantial evidence did not support the RFC. Respondent counters that: (1) the ALJ merely agreed with the single decision-maker's assessment after evaluating the entire record; and (2) there is substantial evidence to support the ALJ's RFC determination.
A single decision-maker is a disability examiner authorized to adjudicate cases without mandatory concurrence by a physician.
Where an ALJ mentions the single decision-maker's opinion and reaches the same conclusion, it does not follow that the ALJ improperly relied upon the single decision-maker's opinion.
Here, the ALJ did not rely upon the single decision-maker's findings. The ALJ merely noted that the RFC was consistent with the single decision-maker's findings and acknowledged that the single decision-maker's "opinion [could] only be considered as an adjudicatory document[.]" (Tr. 122). The ALJ further explained that he found the single decision-maker's RFC assessment to be "consistent with the findings of the consultative examiner[,]" Dr. Tharenos. (
With regard to the ALJ's RFC determination, Plaintiff also asserts that the ALJ did not adequately account for Plaintiff's spinal stenosis and limited range of motion. Respondent counters that the ALJ considered all medical evidence available at the time and properly determined that Plaintiff maintained the capacity to do a range of light work.
The RFC is "the most [a claimant] can still do despite" his or her physical or mental limitations. 20 C.F.R. §§ 404.1541(a)(1), 416.945(a)(1).
Plaintiff contends the ALJ ignored evidence that substantiates her claims of disabling pain, including a series of doctor's visits between January 2014 and March 2015, culminating in a surgery on March 25, 2015, approximately eight months after the ALJ's decision. While the ALJ's opinion did not detail her medical records from March 2014 to the decision date, July 24, 2014, those records were consistent with earlier records the ALJ discussed in his opinion. By detailing medical records from July 2011 through 2013 that document Plaintiff's spinal stenosis and limited range of motion, the ALJ adequately evaluated and discussed the objective medical evidence of Plaintiff's RFC.
Finally, the Court notes that much of the evidence upon which Plaintiff relied to support her argument that substantial evidence did not support the RFC was dated after the ALJ's decision. 20 C.F.R. § 404.620 (an application is effective through the date of the ALJ's decision). The SSA Appeals Council considered this evidence and concluded: "[I]t does not affect the decision about whether [Plaintiff was] disabled beginning on or before July 24, 2014." (Tr. 2).
Accordingly, the Court concludes that substantial evidence supports the ALJ's RFC assessment, which properly accounted for Plaintiff's pain, spinal stenosis, and limited range of motion during the time relevant to the ALJ's decision. "If substantial evidence supports the Commissioner's conclusions, [a] court does not reverse even if it would reach a different conclusion, or merely because substantial evidence also supports the contrary outcome."
For the reasons discussed above, the Court finds that substantial evidence in the record as a whole supports the Commissioner's decision that Plaintiff is not disabled. Accordingly,
A separate judgment in accordance with this Memorandum and Order is entered this date.