ROBERT B. KUGLER, District Judge.
This matter comes before the Court on an appeal filed by Plaintiff Theresa Porter ("Plaintiff") from a decision of the Acting Commissioner of Social Security, Carolyn W. Colvin (the "Commissioner"), denying Plaintiff disability insurance benefits ("DIB") pursuant to 42 U.S.C. § 423,
On September 22, 2010, Plaintiff protectively filed a Title II application for a period of disability and DIB, alleging October 1, 2007 as the disability onset date. Tr. 83-86, 165-71, 194. Plaintiff alleged disability due to degenerative and discogenic disorders of the back and affective/mood disorders. Tr. 83-86. Plaintiff's initial claim was denied on January 29, 2011. Tr. 90. Plaintiff subsequently filed a Request for Reconsideration, Tr. 94, which was denied on August 23, 2011. Tr. 95-96. Thereafter, Plaintiff filed a Request for Hearing by an Administrative Law Judge. Tr. 98-101. This hearing took place on January 4, 2013, before ALJ Nicholas Cerulli, during which Plaintiff was represented by an attorney. Tr. 39-82. On January 11, 2013, the ALJ issued a decision finding Plaintiff not disabled and thus denying benefits. Tr. 17-32. Plaintiff then filed a Request for Review by the Appeals Council on March 6, 2013, which was denied on May 8, 2014. Tr. 1-4. This appeal followed.
Plaintiff visited Cumberland Orthopedic on October 3, 2007, complaining of an injury to her back that she sustained while moving her son's bed. Tr. 770. Dr. Jennifer Vanderbeck examined Plaintiff during this visit, and observed that Plaintiff was suffering from severe pain in her back radiating down both legs.
On October 8, 2007, Plaintiff had X-rays conducted by Dr. Susan Finder of Eastland Diagnostic Institute in Vineland, New Jersey. Tr. 423-27. X-rays of Plaintiff's cervical spine, thoracic spine, and lumbar spine were reported as unremarkable and showed no fractures, vertebral body anomalies or bone lesions. Tr. 424-25, 427. An MRI of Plaintiffs lumbar spine, conducted on October 30, 2007, revealed a small central disc herniation with annular tear at L4-L5 that impinged nerve roots, and an otherwise intact spinal canal, well maintained intervertebral disc spaces, and normal signal intensity of the bones and muscular structures. Tr. 434.
On October 17, 2007, Plaintiff had her first visit with Dr. Andrew Glass of Coastal Physicians & Surgeons. Tr. 643. Dr. Glass examined Plaintiff, and noted Plaintiff was in severe pain, had restricted anterior flexion to 30 degrees, left paramedian lower lumbar and lumbosacral point tenderness with paravertebral muscular spasm, positive left sciatic notch tenderness, and positive left straight leg raising. Tr. 643-44. Dr. Glass also wrote Plaintiff a note stating she could not work pending her next evaluation. Tr. 688. Plaintiff continued to visit Dr. Glass through 2011. Tr. 616. On November 6, 2007, December 5, 2007, and January 10, 2008, Dr. Glass continued to report that Plaintiff had restricted anterior flexion, bilateral lower point tenderness, bilaterally antalgic gait with stooped posture, and 5/5 power throughout. Tr. 640-42. Dr. Glass also provided Plaintiff with notes excusing her from work on these dates, as well as on February 5, 2008. Tr. 681-83, 685-86.
Dr. Glass examined Plaintiff on February 26, 2008, and reported that Plaintiff had 4+/5 in bilateral tibialis anterior, bilaterally antalgic gait with stooped posture, L4-5 herniated nucleus pulposus, and grade 5 internal disc disruption at the L4-5 level. Tr. 639. At this visit he discussed treatment options with Plaintiff, and they settled on surgery consisting of L4-5 laminectomy, discectomy, posterior lumbar interbody arthrodesis, instrumentation with pedicular screw fixation and posterolateral arthrodesis, otherwise known as a low-back fusion. Tr. 45, 639. Dr. Glass gave Plaintiff a note excusing her from work until her scheduled surgery on April 4, 2008. Tr. 680.
Post-surgery, on April 14, 2008, Dr. Glass reported that Plaintiff was ambulating independently, her neurological testing power was 5/5 throughout, and her sensory exam was without dermatomal deficit. Tr. 637. Dr. Glass also suggested Plaintiff begin a progressive ambulation program. Tr. 637. On April 29, 2008, Dr. Glass reported that Plaintiff's back pain was slowly improving, and that X-rays revealed satisfactory prosthetic position, instrumentation position and spinal alignment. Tr. 636. On June 26, 2008, Plaintiff visited Dr. Glass, reporting increased low back pain after she was involved a minor car accident, and Dr. Glass noted her lumbar anterior flexion was restricted to 45 degrees with left paramedian lower lumbar point tenderness, her neurological testing power was 5/5 throughout, and her sensory exam was without dermatomal deficit. Tr. 635. Dr. Glass also reported Plaintiff had 5/5 power and sensory exam without dermatomal deficit from examinations on May 27, 2008 and July 10, 2008. Tr. 633-34. He also noted on July 10 that Plaintiff had lower lumbar point tenderness, and suggested Plaintiff begin postoperative physical therapy. Tr. 633.
Physical therapy records with Heartland Rehabilitation Services indicate that Plaintiff initially attended therapy three times a week from November 2007 to January 9, 2008. Tr. 327-44. Plaintiff resumed her therapy on July 21, 2008 and attended until August 11, 2008. Tr. 346-54. On August 12, 2008, Dr. Glass reported that the physical therapy was actually making Plaintiff feel worse, and placed the plan on hold pending neurosurgical reevaluation. Tr. 632. On visits ranging from September 24, 2008 to February 13, 2009, Dr. Glass reported that Plaintiff had restricted anterior flexion movement with bilateral lower lumbar point tenderness, but no focal motor or sensory deficit and neurological testing power of 5/5 throughout. Tr. 628-31. Dr. Glass also gave Plaintiff a note, dated October 17, 2008, excusing her from work pending a December 11, 2008 evaluation. Tr. 677.
On her February 13, 2009 visit, because of continuing pain, Dr. Glass suggested Plaintiff try Lyrica, but noted on March 10, 2009, that Plaintiff experienced "intolerable side effects" from the Lyrica and no pain relief. Tr. 625, 628. Furthermore, from June 18, 2009 to June 23, 2011, Dr. Glass consistently reported that Plaintiff had continued back pain, limited anterior flexion movement and lumbar point tenderness, but no focal motor or sensory deficit and 5/5 power. Tr. 616-24. Plaintiff and Dr. Glass also continued to discuss treatment options, including a spinal cord stimulator trial.
Dr. Glass completed a Physical Residual Functional Capacity ("RFC") Questionnaire on November 1, 2011. Tr. 737-40. Dr. Glass indicated that Plaintiff's impairments lasted or could be expected to last at least twelve months, and that she frequently experienced pain severe enough to interfere with attention and concentration needed to perform even simple work tasks. Tr. 738-39. He indicated "N/A" to whether Plaintiff could tolerate work stress, and indicated that Plaintiff could only stand or sit for 30 minutes at a time. Tr. 739.
Plaintiff also received treatment with anesthesiologist Dr. Keith D. Strenger of PainCare, P.C., beginning on January 17, 2008. Tr. 462. Dr. Strenger recommended Plaintiff undergo a provocative lumbar discography. Tr. 462-65. On February 19, 2008 Dr. Strenger diagnosed Plaintiff with lumbar degenerative disc disease and degerenarative joint disease, symptomatic L4-L5 disc with grade V midline posterior annular tear, discogenic axial low back pain, and left lumbar radiculopathy, and suggested surgery with Dr. Glass. Tr. 460-61.
Plaintiff did not return to see Dr. Strenger until April 2, 2009, when he reported that Plaintiff's straight leg raise was negative bilaterally but that she remained in pain. Tr. 457-58. In his diagnostic impression, Dr. Strenger reported that Plaintiff had lumbar degenerative disc disease and degenerative joint disease status post L4-L5 posterior lumber instrumented interbody fusion, possible failed back syndrome-post laminectomy syndrome, chronic depression with some symptom amplification, extreme morbid obesity, and lumbar radiculopathy. Tr. 458. To address her pain, Dr. Strenger performed nerve root blocks on April 20, 2009. Tr. 454. On May 8, 2009, Plaintiff indicated to Dr. Strenger that although she initially felt an 80 percent relief of pain, that pain has subsequently returned and persisted. Tr. 454. At this visit, Dr. Strenger otherwise provided the same diagnostic impressions as her pre-procedure visit. Tr. 455. Dr. Strenger performed another round of nerve root blocks on June 1, 2009, but reported on June 12, 2009 that they did not alleviate Plaintiff's pain and that Plaintiff's response to the blocks was negative. Tr. 451-52. On July 16, 2009, Dr. Strenger noted that Plaintiff should see a pain psychologist, and that Plaintiff's depression could be acting as a pain amplifier. Tr. 448-49. He suggested Plaintiff use a spinal cord stimulator, which she was reluctant to try. Tr. 449. Dr. Strenger also noted that Plaintiff was "somewhat resistant" to weight loss and home-based exercise, and had made little progress in these areas.
Plaintiff began treatment with another anesthesiologist, Dr. Malind Patharkar of Advanced Spine and Pain, LLC, on May 18, 2011. Tr. 749-51. At this examination, Dr. Patharkar noted that Plaintiff had hypersensitivity to touch on the left side of her back, range of motion and rotation reduced by 25 to 30 percent, and positive straight leg raise test on the left side at 60 degrees. Tr. 750. He also noted that Plaintiff had 5/5 motor strength, and sensory of the upper and lower extremities was intact without any focal deficits. Tr. 750. Dr. Patharkar diagnosed Plaintiff with displacement of lumbar discs, lumbar radiculitis, clinical, lumbar degeneration of intervertebral disc, post laminectomy syndrome, and lower back pain syndrome, and planned to treat Plaintiff with steroid injections. Tr. 751. On June 30, 2011 and August 16, 2011, Dr. Patharkar gave Plaintiff Transforanimal Lumbar Epidural Steroid Injections. Tr. 753-54. Dr. Patharkar's treatment records from June 15, 2011, to March 14, 2012, indicated that Plaintiff had limited range of motion, tightness/spasm, and tenderness upon palpation but 5/5 power in her back. Tr. 866-73. Follow up appointments by Dr. Patharkar's Nurse Practitioner Maryann Masci, ranging from April 25, 2012, to May 25, 2012, indicate that Plaintiff continued to experience pain, described on average as a 5 out of 10 on a pain scale. Tr. 875-82. On July 18, 2012, Plaintiff experienced pain at the level of 8 or 9 out of 10, and on August 15, 2012, she reported pain at 6 out of 10. Tr. 883-87. The nurse noted that standing, walking, weather changes, and lifting heavy weights worsened these pains.
Diagnostic testing throughout this time period revealed the following. A May 21, 2008 X-ray of the lumbar spine showed no fracture, vertebral body anomaly, or bone lesion. Tr. 473. Plaintiff also had an X-ray taken of her lumbar spine on October 6, 2008, which showed an intact spinal canal and no disc herniation or significant enhancing epidural scar formation. Tr. 471. A February 27, 2009 Electromyogram revealed mild abnormality with chronic early denervation within the left L4-5 myotome, and otherwise no evidence of neuropathy or myopathy. Tr. 627. An MRI of Plaintiff's lumbar spine taken on July 30, 2012 revealed intervertebral gait on L4-L5 with no disc herniation, and minimal disc bulge on L5-S1 with no canal narrowing. Tr. 891, 893. The MRI operator concluded that Plaintiff was "status post fusion and decompression at the L4 and L5 levels," and that there was no disc herniation, no stenosis, and good alignment of the vertebrae. Tr. 892.
Plaintiff also underwent several one-time consultative examinations with state agency doctors. On April 23, 2009, Plaintiff saw Dr. Nityashuba Khona, who noted that Plaintiff had full range of motion and 5/5 strength in both her upper and lower extremities, and a normal straight leg raise test bilaterally. Tr. 773-74. Plaintiff underwent a consultative exam with Dr. Ronald Bagner on June 27, 2011, who observed that Plaintiff had antalgic gait and had difficulty getting on and off the examination table, but had no motor or sensory abnormality in the upper or lower extremities, and a 5/5 grip bilaterally. Tr. 711-12. Dr. Bagner also noted that Plaintiff had back pain on straight leg raising on her left side but not her right. Tr. 711.
Furthermore, several state consultants performed RFC assessments on Plaintiff. On May 12, 2009, Dr. M. McLamon found that Plaintiff could occasionally lift 20 pounds, frequently lift 10 pounds, stand/walk for two hours in an eight-hour workday, sit for six hours in an eight-hour workday, and had unlimited push or pull ability. Tr. 778. He also noted Plaintiff could climb ramps and stairs frequently, ladders and ropes occasionally, could stoop, kneel, and crouch frequently, and crawl occasionally. Tr. 779. Dr. McLamon determined that Plaintiff's exertional activities were limited, and stated "onset 10/08 as alleged would be supported" (presumably referring to the alleged October 2007 onset date). Tr. 784. Dr. Melvin Golish affirmed this determination on November 16, 2009. Tr. 785. On January 28, 2011, Dr. Seung Park found that Plaintiff could stand and walk for four hours in an eight-hour workday, could sit for six hours, could occasionally climb and crawl, and had unlimited ability to push and pull. Tr. 29-30, 501. Dr. Joseph Udomsaph confirmed both Dr. Park's and Dr. McLamon's RFC determinations on August 23, 2011. Tr. 30, 734.
Plaintiff completed a Social Security Adult Functioning Report on December 4, 2010. Tr. 208. In this report, Plaintiff indicated she goes shopping for groceries and is able to pay bills and count change. Tr. 211. She stated she visits her brother who lives a mile away almost every day. Tr. 212. Furthermore, Plaintiff's husband, William Porter, completed an Adult Third Party Function Report on December 4, 2010. Tr. 220. Mr. Porter reported that Plaintiff cannot lift more than 20 pounds, cannot go up stairs without using handrails or taking breaks, and cannot sit for long periods of time. Tr. 225. He noted that Plaintiff is often unable to complete household tasks because of her back and leg pain. Tr. 222.
At her hearing before the ALJ, Plaintiff stated that she was 41 years old, 5'9" tall, and weighed 240 pounds, having gained fifty pounds since her surgery due to lack of exercise because of pain. Tr. 48-49. She stated that she is able to get up in the morning to get her children ready for school, and helps pack their lunches. Tr. 50. She is able to drive a car, but does so as little as possible because she experiences back and leg pain when she drives. Tr. 50. She stated she experiences pain in her lower back and left leg "all the time," and that it lasts all day, and that the pain in her leg "feels like somebody is stabbing my leg. Cold sensation." Tr. 56. She testified that she has a lot of bad days with regards to her pain where the pain level is an 8 out of 10. Tr. 56-57. The pain has also begun to spread to her right leg. Tr. 58.
Plaintiff stated that her back pain prevents her from working. Tr. 56. Plaintiff also testified that she is only able to lift and carry two pounds at one time, and is only able to sit down for fifteen minutes to a half hour at a time. Tr. 65. She stated she can only stand for less than 10 minutes at a time, and can only walk less than a quarter of a mile before having to stop. Tr. 65. Plaintiff further stated she cannot bend, stoop, squat or kneel, and cannot reach very far with her arms because of her back pain. Tr. 65-66. Additionally, Plaintiff noted she cannot complete tasks because her pain affects her ability to concentrate. Tr. 67.
Plaintiff testified that she underwent physical therapy three days a week for approximately three months after her April 2008 surgery, but that it actually made her condition worse. Tr. 60. She stated she also currently takes several medications for pain including Cymbalta, Lyrica, and Trazodone, but that they do not provide any pain relief. Tr. 60-61. She further noted that she underwent multiple injections with Dr. Patharkar, but these procedures did not provide any tangible pain relief. Tr. 61. She had not yet undergone the spinal cord stimulator treatment, and was hesitant to try it, but stated she was now willing to undergo the procedure because she was "tired of being in pain." Tr. 62.
On July 13, 2011, Plaintiff underwent a mental status examination with Dr. Theodore Brown Jr., Ph. D. Tr. 715. Dr. Brown found that Plaintiff had a coherent and goal directed thought process, but had below average cognitive and intellectual functioning. Tr. 717. As such, he diagnosed her with "Adjustment Disorder with Mixed Depressed Anxiety Features due to Back Pain," and assigned a Global Assessment of Functioning ("GAF") score of 55 to 60.
Plaintiff also underwent a Psychiatric Review Technique with Dr. Clara Castillo-Velez on August 22, 2011. Tr. 720. Dr. Castillo-Velez determined that Plaintiff had non-severe impairments that stemmed from 12.04 Affective Disorders and 12.06 Anxiety-Related Disorders.
Plaintiff also underwent several psychological examinations with Dr. Ellen Shupe, Ph.D., beginning on November 1, 2011. Tr. 796. Dr. Shupe diagnosed Plaintiff with depression, anxiety, and chronic pain, and noted that Plaintiff had limitations in her ability to participate in family activities and an inability to tolerate the physical demands of retail work. Tr. 796. She also noted that Plaintiff had mild levels of environmental stress and functional impairment, and assigned her a GAF score of 64. Tr. 796. Dr. Shupe examined Plaintiff again on December 13, 2011, finding that Plaintiff now had moderate levels of environmental stress and functional impairment. Tr. 795. Dr. Shupe continued to see Plaintiff from January 5, 2012 to May 3, 2012, noting that environmental stress and functional impairment remained at the moderate level. Tr. 791-94. On the May 3 visit, Dr. Shupe discussed using the spinal cord stimulator with Plaintiff, and subsequently wrote a report to Dr. Patharkar regarding this examination. Tr. 788-89, 791. In the report, Dr. Shupe noted that Plaintiff's function varied from being able to do some household tasks and light exercise to being unable to sustain any physical activity for an extended period, and that she experiences episodes of depressed mood that could be reduced in intensity with Cymbalta, but was not experiencing depression at the time. Tr. 788. Dr. Shupe further recommended that Plaintiff not undergo the spinal cord stimulation because she was not psychologically prepared for the procedure. Tr. 789-90. Additionally, Dr. Shupe examined Plaintiff on May 30, 2012, noting that she was much improved, that she remained consistent in her role as a parent, and that she maintained satisfying social interactions, thus reducing her levels of environmental stress to mild. Tr. 790.
At the hearing before the ALJ, Plaintiff stated that she had received treatment from a psychiatrist for depression that stemmed from the effects of her pain. Tr. 64. She stated that she took Cymbalta for the depression, which helped with the symptoms and relieved her feelings of aggravation and discouragement. Tr. 64-65.
Plaintiff has the education of a high school graduate. Tr. 46. Plaintiff had difficulties in school — she was placed in smaller, special needs classrooms, and had been diagnosed with comprehensive problems, reading problems, and limited math skills. Tr. 46. Plaintiff had worked between the years 1994 and 2003 as a pharmacy technician at a drug store; her duties included taking prescriptions, answering phones, and checking customers out at the register. Tr. 55-56. Plaintiff next worked as a bank teller between the years 2003 and 2004, but experienced difficulties because she had a hard time following the steps required for handling the money. Tr. 55. Plaintiff's counsel stated that Plaintiff left this job because her education limited her ability to perform. Tr. 47, 74. Plaintiff then became self-employed in a house and motel cleaning business during 2005 and 2006, but stopped this business because she was not making any money. Tr. 54-55. Plaintiff last held a job in 2007 at Shoprite, where she worked in customer service and at the checkout register. Tr. 54. She stated that she did not have any difficulties performing this job.
At the hearing, vocational expert ("VE") Marian R. Marracco testified that Plaintiff could not perform any past relevant work. Tr. 79. She further testified that a hypothetical individual of Plaintiff's age, education, relevant work experience, and RFC could perform the following jobs that exist in the national economy: small parts assembler, of which there are 235,910 jobs nationally and 1,470 jobs regionally; lens inserter, of which there are 235,910 jobs nationally and 5,540 jobs regionally; and laminator, of which there are 66,330 jobs nationally and 1,740 jobs regionally. Tr. 79. The VE indicated that these numbers were consistent with the information found in the Dictionary of Occupational Titles ("DOT"). Tr. 79.
District court review of the Commissioner's final decision is limited to ascertaining whether the decision is supported by substantial evidence.
Nevertheless, the reviewing court must be wary of treating "the existence
The Commissioner conducts a five-step inquiry to determine whether a claimant is disabled, and therefore eligible for DIB benefits. 20 C.F.R. § 404.1520(a)(4);
At step one, the ALJ found that Plaintiff did not engage in substantial gainful activity during the period from her alleged onset date through her date last insured. Tr. 22. At step two, the ALJ found that Plaintiff had the severe impairments of degenerative disc disease, lumbar discogenic syndrome, status post lumbar fusion, and obesity.
At step three, the ALJ found that Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1.
Moving to the step four RFC determination, the ALJ found Plaintiff had the RFC to perform sedentary work as defined in 20 C.F.R. 404.1567(a), except that Plaintiff could
In his RFC reasoning, the ALJ first noted he was taking Plaintiff's obesity into consideration. Tr. 26. Regarding Plaintiff's lumbar degenerative disc disease, the ALJ found no evidence in the record that would suggest her impairment is of such severity as would preclude Plaintiff from all work related activities.
In addition, the ALJ referenced the consultative exams of Dr. Khona, which found that Plaintiff had a normal gait and could walk without the use of an assistive device, 5/5 strength, negative straight-leg raising bilaterally, "no lumbar muscle spasm or trigger points, and no muscle atrophy or sensory abnormality." Tr. 27. Regarding Dr. Bagner's June 27, 2011 report, the ALJ noted that although Dr. Bagner found Plaintiff had positive straight-leg raising on the left, Plaintiff did not need assistance to ambulate and had no motor or sensory abnormalities.
The ALJ next turned to the opinion evidence of Plaintiff and her doctors. He noted that although Plaintiff testified that she was severely restricted, she could get her kids ready for school, pack their lunches, can drive, dress, bathe and groom herself, and participates in household chores with her husband. Tr. 28. The ALJ further cited Plaintiff's Adult Function Report, on which Plaintiff stated she could prepare meals with assistance from her husband, wash dishes, make beds, and shop for groceries.
The ALJ gave little weight to Dr. Glass's determination that Plaintiff was to remain out of work, and that Plaintiff could lift and carry less than 10 pounds rarely and could sit and stand for less than two hours in an eight-hour workday. Tr. 29. The ALJ found that Dr. Glass's opinions were inconsistent with the objective medical evidence and the record as a whole, including Dr. Glass's own treatment notes, which noted that Plaintiff had negative straight-leg raising, 5/5 muscle power, and no sensory dermatome deficits.
The ALJ gave great weight to Dr. Vanderbeck's October 3, 2007 opinion, which found that Plaintiff was limited to light duty work. Tr. 29. The ALJ referred to Dr. Vanderbeck as Plaintiff's "treating physician," stating, "the undersigned assigns great weight to Dr. Vanderbeck's opinion to the extent that it is consistent with the residual functional capacity assessment" because "Dr. Vanderbeck is a treating specialist who has seen the claimant on a regular basis and is therefore best able to provide a detailed longitudinal picture of [Plaintiff's] impairments and resulting limitation (20 CFR 404.1527(d) and SSR 96-2p)."
The ALJ further gave great weight to the opinion of Dr. Khona, in which he determined that Plaintiff could be trained for desk jobs.
The ALJ gave little weight to the part of Dr. McLamon's RFC assessment that indicated Plaintiff could lift and carry 20 pounds occasionally, 10 pounds frequently, had unlimited ability to push and pull, and could climb ramps and stairs, stoop, kneel, crouch, and occasionally climb ladders, again giving Plaintiff benefit of the doubt that she was more limited than this assessment.
Lastly, the ALJ assigned great weight to the psychiatric assessment of Dr. Castillo-Velez, who found that Plaintiff was mildly limited in the activities of daily living, social functioning, and concentration.
At step five, the ALJ found that through the date last insured, Plaintiff was unable to perform any past relevant work.
Plaintiff presents four arguments on appeal of the Commissioner's final decision. First, Plaintiff contends that the ALJ failed to appropriately weigh the opinion evidence of Plaintiff's treating physician, Dr. Glass, and other critical medical opinions on record. Pl. Br. 7. Next, Plaintiff argues that the ALJ failed to properly evaluate all of the Plaintiff's impairments in formulating Plaintiff's RFC. Pl. Br. 13. Third, Plaintiff maintains that the ALJ improperly discounted Plaintiff's testimony regarding the symptom-related limitations that she suffers. Pl. Br. 21. Fourth, Plaintiff argues that the ALJ improperly denied benefits based on inconsistent and unreliable testimony of the VE. Pl. Br. 24. The Court will address these arguments in turn.
As the trier of fact, the ALJ has the duty to resolve conflicting medical evidence.
Plaintiff argues that the ALJ erred in failing to properly weigh the opinion of Dr. Glass, who found that Plaintiff had less than sedentary work capacities. Plaintiff contends that the ALJ was incorrect in determining that Dr. Glass's RFC opinion was inconsistent with Dr. Glass's own treatment notes, the opinions of other doctors in the record, and the evidence in the record as a whole. Additionally, Plaintiff argues that the ALJ erred in giving great weight to the opinion of Dr. Vanderbeck that Plaintiff could perform "light duty" work, due to his perceived status as Plaintiff's treating physician.
Dr. Vanderbeck was not Plaintiff's treating physician. The record reflects that Dr. Vanderbeck only examined Plaintiff once, on October 3, 2007, just a few days after the alleged onset date. Tr. 770. The ALJ correctly recognized that under 20 C.F.R. § 404.1527 and SSR 96-2p, the treating source should be considered as a persuasive source in determining an RFC assessment. Tr. 29. However, Social Security Regulations define the "treating source" as:
20 C.F.R. § 404.1502. Under this standard, Dr. Glass rather than Dr. Vanderbeck qualifies as Plaintiff's treating physician, since Dr. Glass consistently evaluated Plaintiff from 2007 to 2011, and performed Plaintiff's back fusion surgery. Tr. 616-643. Based on the ALJ's own rationale as to why Dr. Vanderbeck's opinion was entitled to great weight, great weight can be awarded instead to the assessment of Dr. Glass.
The Court recognizes that, even correcting for the identity of the treating source, "controlling weight" can only be given to the opinion of Dr. Glass if it is "not inconsistent" with the other "substantial evidence" in the record. SSR 96-2p; 20 C.F.R. § 404.1527(c)(2). The ALJ assigned little weight to Dr. Glass's opinion because he found it to be inconsistent with Dr. Glass's own treatment notes, as well as the treatment notes of Drs. Strenger, Khona, and Bagner. Tr. 29. Specifically, the ALJ points to the findings of Drs. Glass and Strenger that Plaintiff had 5/5 muscle power, negative leg raise bilaterally, and no sensory deficits. Tr. 29. The ALJ further cited the evaluation notes of Drs. Khona and Bagner, which indicated that Plaintiff had 5/5 strength, negative straight-leg raising bilaterally, and that Plaintiff did not need a cane or crutches to ambulate. Tr. 29. Based on these reports, the ALJ found Dr. Glass's opinion to be inconsistent with the record as a whole. Tr. 29.
"[A]n ALJ may not reject pertinent or probative evidence without explanation."
Even if Dr. Glass's opinion may not be entitled to controlling weight, this Court finds that it may still be entitled to deference.
Plaintiff next argues that the ALJ erred in conducting the function-by-function assessment of Plaintiff's limitations stemming from both severe and non-severe impairments, pursuant to SSR 96-8p. Specifically, Plaintiff argues the ALJ "failed to properly find the Plaintiff's depression and anxiety to be severe impairments that significantly limit the claimant's ability to function and sustain gainful employment." Pl. Br. 17. Plaintiff cites the findings of Dr. Brown, which indicated "an adjustment disorder with mixed depressed anxiety causing at least moderate limitations in social and occupational function as evidenced by the assigned GAF score of 55-60." Pl. Br. 17. Plaintiff also cites Dr. Strenger's report, which noted that Plaintiff had "depression superimposed upon her chronic pain." Pl. Br. 17. Plaintiff further argues that the ALJ erred by giving great weight to the findings of Dr. Castillo-Velez, which indicated Plaintiff had only mild limitations, because the ALJ gave no consideration for why he accepted this evidence and not the conflicting evidence of Drs. Brown and Strenger. Pl. Br. 18. As such, Plaintiff argues that her psychiatric impairments should have been deemed "severe" at step two of the sequential analysis and then considered on a "function-by-function" basis in order to properly formulate Plaintiff's RFC. Pl. Br. 17-18.
Reading the ALJ's opinion as a whole, Plaintiff's argument is without merit. The ALJ's step two determinations that Plaintiff's anxiety and depression were non-severe impairments considered the evidence of Drs. Strenger and Brown, as well as evidence from Dr. Shupe, and found that Plaintiff's GAF scores indicated only moderate or mild symptomology. Tr. 23. The ALJ also cited other evidence indicating that Plaintiff's anxiety and depression were not severe. Tr. 23.
Plaintiff further argues that the RFC determination was deficient because it "fails to define critical terms," namely "unskilled" work, and therefore it is impossible for a VE to respond to the ALJ's hypothetical, and for a reviewing court to determine if Plaintiff's limitations were addressed in discussing the RFC. Pl. Br. 18-19. Plaintiff argues that the ALJ's statement that "a limitation of unskilled work that involves routine and repetitive tasks was assigned to consider [Plaintiff's] pain and non-severe depression and anxiety," Tr. 28, was not sufficient to constitute a full appraisal of Plaintiff's limitations regarding the formulation of an RFC.
SSR 96-8p notes that a "function-by-function basis" refers to the functions articulated by paragraphs (b), (c), and (d) of 20 C.F.R. § 404.1545. SSR 96-8p, 1996 WL 374184, at *1 (July 2, 1996). Paragraph (c), which addresses mental abilities, states:
20 C.F.R. § 404.1545(c). It appears that Plaintiff is arguing that the ALJ should have provided more detail regarding the mental impairments in his RFC determination. However, the ALJ had already detailed the extent of Plaintiff's mental impairments in determining that they were nonsevere at step two; to again explain the extent of Plaintiff's mental limitations in making the RFC determination would be redundant. The ALJ is not required "to use particular language or adhere to a particular format in conducting his analysis."
Plaintiff also argues that the ALJ failed to properly consider Plaintiff's obesity pursuant to SSR 02-1p because he did not discuss how this impairment created limitations that still allowed Plaintiff to perform sedentary work. The Court does not agree. The ALJ stated:
Tr. 26 (emphasis added.). The ALJ also articulated that "[a] limitation of occasional pushing and pulling with the left lower extremity, and all postural movements occasionally but no climbing ropes, ladders or scaffolds, and avoiding concentrated exposure to extreme cold, wetness, humidity, vibration, and hazards was assigned to consider [Plaintiff's] degenerative disc disease
Plaintiff contends that the ALJ erred in discounting Plaintiff's subjective complaints of pain and limitations, as well as the statements of her husband, Mr. Porter, because the medical evidence actually supports their opinions. Plaintiff is presumably referring to her statements at her hearing before the ALJ that she experiences pain "all the time," that the pain in her leg "feels like somebody is stabbing my leg," and that on many days her pain is an 8 out of 10, as well as Mr. Porter's statements regarding Plaintiff's ability to perform work in his Adult Third Party Functioning Report. Tr. 56-57, 220-27. Plaintiff maintains that their statements should have been granted greater weight because they were supported by the treatment notes of Drs. Glass, Strenger, and Patharker, which indicated that Plaintiff remained in pain despite treatment. Plaintiff further asserts that the ALJ merely used stock language that stated a conclusion as to her and Mr. Porter's credibility, and failed to provide an actual credibility assessment.
Plaintiff's argument makes the Court question counsel's familiarity with legal writing. The ALJ did offer a conclusion, stating that that he "finds that [Plaintiff's] statements concerning the intensity, persistence and limiting effects of these symptoms are not entirely credible
Plaintiff argues that the ALJ may not discount her complaints without contrary medical evidence, citing
Plaintiff argues that the VE provided an overstated and inaccurate estimate of the jobs that Plaintiff could perform in the national economy, and thus the ALJ erred in his step five determination that Plaintiff was not disabled. Specifically, Plaintiff asserts that the figures provided regarding both the lens inserter and small parts assembler positions—that there were 235,910 jobs nationally—were incorrect because they were derived from the Bureau of Labor Statistics Standard Occupational Classification ("SOC"), and not the DOT, as stated by the VE. According to Plaintiff, the DOT code speaks to only one specific occupation, while the SOC code includes many different occupations. The number the VE put forth for lens inserter and small parts assembler actually referred to SOC code 51-9399, which is the category of "Production Workers, All Other." There are 1,589 DOT occupations under this SOC, with lens inserter and small parts assembler being just two of them. Pl. Br. 24. Thus, because the individual job numbers for lens inserter and small parts assembler provided were incorrect, the ALJ had no way to determine whether "significant" jobs existed in the national economy pursuant to 20 C.F.R. 404.1560(c)(2). Pl. Br. 25.
At step five, the Commissioner bears the burden of proof to show that the plaintiff can perform alternative work that exists in significant numbers in the national economy given her age, education, past work experience, and RFC. 20 C.F.R. §§ 404.1520(g), 404.1560(c);
Moreover, the VE also testified that Plaintiff could perform the position of laminator, which exists at the numbers of 66,330 nationally and 1,740 regionally. Tr. 79. The Third Circuit has found that as few as 200 jobs can be indicative of the existence of significant work in the local and national economy.
The Court finds that remand is appropriate.