JOI ELIZABETH PEAKE, Magistrate Judge.
Plaintiff Timothy Barge ("Plaintiff") brought this action pursuant to Sections 205(g) and 1631(c)(3) of the Social Security Act (the "Act"), as amended (42 U.S.C. §§ 405(g) and 1383(c)(3)), to obtain judicial review of a final decision of the Commissioner of Social Security denying his claims for Disability Insurance Benefits and Supplemental Security Income under, respectively, Titles II and XVI of the Act. The parties have filed cross-motions for judgment, and the administrative record has been certified to the Court for review.
Plaintiff protectively filed his applications for Disability Insurance Benefits and Supplemental Security Income Benefits on August 6, 2013, alleging a disability onset date of October 1, 2010. (Tr. at 26, 195-203.)
Following the hearing, the ALJ concluded that Plaintiff was not disabled within the meaning of the Act. (Tr. at 34.) On February 18, 2016, the Appeals Council denied Plaintiff's request for review of the decision, thereby making the ALJ's conclusion the Commissioner's final decision for purposes of judicial review. (Tr. at 1-5.)
Federal law "authorizes judicial review of the Social Security Commissioner's denial of social security benefits."
"Substantial evidence means `such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.'"
"In reviewing for substantial evidence, the court should not undertake to re-weigh conflicting evidence, make credibility determinations, or substitute its judgment for that of the [ALJ]."
In undertaking this limited review, the Court notes that in administrative proceedings, "[a] claimant for disability benefits bears the burden of proving a disability."
"The Commissioner uses a five-step process to evaluate disability claims."
A finding adverse to the claimant at any of several points in this five-step sequence forecloses a disability designation and ends the inquiry. For example, "[t]he first step determines whether the claimant is engaged in `substantial gainful activity.' If the claimant is working, benefits are denied. The second step determines if the claimant is `severely' disabled. If not, benefits are denied."
On the other hand, if a claimant carries his or her burden at each of the first two steps, and establishes at step three that the impairment "equals or exceeds in severity one or more of the impairments listed in Appendix I of the regulations," then "the claimant is disabled."
In the present case, the ALJ found that Plaintiff had not engaged in "substantial gainful activity" since his amended alleged onset date. Plaintiff therefore met his burden at step one of the sequential evaluation process. At step two, the ALJ further determined that Plaintiff suffered from the following severe impairments: heart disease, including congestive heart failure; asthma; hypertension; chronic low back pain; sleep apnea; and obesity.
(Tr. at 28.) The ALJ found at step three that none of these impairments met or equaled a disability listing. Therefore, the ALJ assessed Plaintiff's RFC and determined that Plaintiff could perform light work, "except that he must avoid concentrated exposure to respiratory irritants and to hazardous conditions." (Tr. at 29.) Based on this determination and the testimony of the vocational expert, the ALJ found at step four of the analysis that Plaintiff could perform his past relevant work as a telemarketer. (Tr. at 33.) The ALJ also made an alternative finding at step five that, given Plaintiff's age, education, work experience, and RFC, he could perform other jobs available in the national economy. (Tr. at 33-34.) Therefore, the ALJ concluded that Plaintiff was not disabled under the Act. (Tr. at 34.)
Plaintiff now contends that the ALJ erred in (1) failing to include peripheral edema and gout among Plaintiff's severe impairments at step two, (2) finding that Plaintiff can perform light work, "particularly in light of the fact that he requires a cane for ambulation," and (3) failing to consider the impact of Plaintiff's obesity on his RFC. (Pl.'s Br. [Doc. #13] at 3.) After careful review of the record, the Court finds that none of Plaintiff's contentions merit remand.
Plaintiff first contends that the ALJ erred in failing include peripheral edema and gout among his severe impairments at step two of the sequential analysis. (Pl.'s Br. at 6-8.)
In the present case, Plaintiff testified that he experienced edema as a result of his congestive heart failure, which prevents his body from eliminating fluids normally. (Tr. at 49.) Plaintiff's brief further cites to treatment records regarding his edema, and these treatment records also generally link Plaintiff's edema to his congestive heart failure and hypertension. (Pl. Br. at 7, Tr. at 342, 345, 388-89, 391, 398-400, 420, 579, 632.) The ALJ addressed Plaintiff's hypertension and chronic heart failure at length in determining Plaintiff's RFC, finding that Plaintiff "has a diagnosis of heart failure, but a review of significant developments in his cardiac history shows that his grade III diastolic dysfunction is stable and not disabling." (Tr. at 31.) The ALJ reviewed the results of Plaintiff's echocardiograms, myocardial perfusion study, and stress test, and noted that "[o]n January 9, 2015, Dr. Williamson stated that his grade III diastolic dysfunction was stable and that he did not currently require any medical treatment." (Tr. at 32, 569.) The ALJ also noted that Plaintiff's hypertension was not disabling because medical records show that it was controlled with medication. (Tr. at 32.) Thus, the ALJ addressed the underlying medical conditions in determining Plaintiff's RFC. Moreover, the ALJ also specifically addressed Plaintiff's edema at step two, and found that "the medical evidence shows that the condition can be controlled with diuretic medicines and compression stockings." (Tr. at 29.) As to this finding, Plaintiff contends that "[i]n June 2014, it was noted that plaintiff had not seen improvement in his bilateral leg swelling despite an increased dose of Lasix." (Pl. Br. at 7.) However, Plaintiff's increased edema in May and June of 2014 (Tr. at 497, 494, 491) had begun to respond and improve a few weeks later by July 2014 (Tr. at 490) ("Today he states his legs are better as he wore the stockings yesterday"), and was much better two months later in September 2014 (Tr. at 488) ("Leg edema: He reports that this is much better. Compliant with Lasix 80mg BID, low salt diet, and compression stockings."). A medical record from a year later in July 2015 notes that Plaintiff "[h]as had some swelling in his ankles for a few days after he ran out of lasix about a week ago." (Tr. at 579.) These are the records cited by the ALJ in concluding that Plaintiff's edema could be controlled with diuretic medicines and compression stockings. (Tr. at 29.) Finally, Plaintiff fails to describe any functional limitations attributable to his lower extremity edema. Although he testified that swelling in his hands limited his ability to "use them like [he] used to" (Tr. at 50), the only treatment notes chronicling any issues with Plaintiff's hands predate his alleged onset date (Tr. at 394, 398). These notes further characterize Plaintiff's hand issues as joint pain and swelling, indicating the possibility of an arthritic process, rather than edema. (
The same holds true for Plaintiff's allegations regarding gout. The record reflects treatment for a single episode of gout in March and April 2015 (Tr. at 477, 480, 482, 589) that had resolved a month later by May 2015 (Tr. at 585). The treatment record from May 2015 notes that Plaintiff "states that gout is much better. He is taking the colchicine twice a day for prophylaxis." (Tr. at 585.) A later reference in January 2016 notes a history of gout that was "stable without acute flare." (Tr. at 632.) Thus, it appears that Plaintiff sought medical treatment for gout only during a brief period in March and April 2015, and any concerns had resolved a month later by May 2015, with no subsequent flares or treatment records.
Plaintiff next argues that the ALJ's finding that Plaintiff "can perform light work is not based on substantial evidence due to the fact that [Plaintiff] requires a cane for ambulation." (Pl.'s Br. at 10.) Plaintiff notes that under the applicable regulations, "[t]he requirement to use a hand-held assistive device may . . . impact [a claimant's] functional capacity by virtue of the fact that one or both upper extremities are not available for such activities as lifting, carrying, pushing, and pulling." 20 C.F.R. Part 404, Subpt. P, App. 1 § 1.00(J)(4). Accordingly, an ALJ must consider the impact of a medically required hand-held assistive device on a claimant's RFC. Notably, SSR 96-9p, on which Plaintiff relies, provides the following guidance:
1996 WL 374185, at *7.
Here, as the ALJ noted in his decision, Plaintiff "testified that he uses a cane for walking, but he has not demonstrated that the cane is medically necessary." (Tr. at 32.) Specifically, Plaintiff testified at his October 16, 2015 hearing that he had been using his cane for "about six months" and that he didn't use it every day, "just when [he] plan[ned] on being up on [his] feet a lot." (Tr. at 49.) When asked if a doctor had prescribed the cane, Plaintiff explained that a nurse at the Servant Center, where he lives, had given it to him. (
(Tr. at 31.) The ALJ further reviewed Plaintiff's MRI, which noted mild disc bulges but "[n]one of these are showing any significant spinal stenosis or nerve root entrapment." (Tr. at 31.) The ALJ also have significant weight to the assessment of Dr. Virgili, the State Agency consultant, and the ALJ determined that Dr. Virgili's assessment was
(Tr. at 32.) Overall, no evidence, including Plaintiff's own testimony, suggests that Plaintiff's occasional, non-prescribed cane use was medically required.
Moreover, the Court notes that this assignment of error is based on Plaintiff's contention that the ALJ "erred in finding that [Plaintiff] has the residual functional capacity to perform light work, particularly in light of the fact that he requires a cane for ambulation, thereby incorrectly applying the Medical-Vocational Guidelines." (Pl. Br. at 8.) Specifically, Plaintiff contends that the ALJ should have limited him to sedentary work, rather than light work, which would have resulted in a finding of "disabled" under the Medical Vocational Guidelines at step five of the sequential evaluation process. However, the ALJ in this case found at step four that Plaintiff was capable of performing his past relevant work as a telemarketer. (Tr. at 33.) In making this determination, the ALJ did not apply the Medical Vocational Guidelines.
For all of these reasons, Plaintiff's contention that the ALJ "erred in finding that [Plaintiff] has the residual functional capacity to perform light work, particularly in light of the fact that he requires a cane for ambulation, thereby incorrectly applying the Medical-Vocational Guidelines" is without merit.
Finally, Plaintiff contends that the ALJ failed to consider the impact of his obesity on his ability to work. Because obesity may affect a claimant's ability to perform exertional functions, including sitting, standing, walking, lifting, pushing and pulling, as well as postural functions, such as climbing, balancing, stooping, and crouching, an ALJ must consider obesity when assessing a claimant's RFC. SSR 02-1p, 2002 WL 34686281, at *6 (2002). In the present case, the ALJ included Plaintiff's obesity among his severe impairments at step two of the sequential analysis, noting that:
(Tr. at 28, 414.) Thus, the ALJ determined that according to the medical record, Plaintiff's obesity affected his back pain, his asthma, and his blood pressure, and therefore, rather than discussing Plaintiff's obesity separately, the ALJ considered and discussed those impairments that were exacerbated by his obesity: his back pain, his asthma, and his blood pressure. (Tr. at 31-32.)
Plaintiff now argues that the ALJ's failure to specifically discuss the impact of Plaintiff's obesity on his RFC constitutes reversible error. However, no one, including Plaintiff, identifies any unaddressed limitations he believes his obesity causes.
IT IS THEREFORE RECOMMENDED that the Commissioner's decision finding no disability be AFFIRMED, that Plaintiff's Motion for Judgment on the Pleadings [Doc. #12] be DENIED, that Defendant's Motion for Judgment on the Pleadings [Doc. #14] be GRANTED, and that this action be DISMISSED with prejudice.