R. CLARKE VanDERVORT, Magistrate Judge.
This is an action seeking review of the decision of the Commissioner of Social Security denying Plaintiff's application for Disability Insurance Benefits (DIB), under Title II of the Social Security Act, 42 U.S.C. §§ 401-433. This case is presently pending before the Court on the parties' cross-Motions for Judgment on the Pleadings (Document Nos. 11 and 12.), and Plaintiff's Supplemental Brief (Document No. 13.) and Defendant's Response. (Document No. 14.) Both parties have consented in writing to a decision by the United States Magistrate Judge. (Document Nos. 7 and 8.)
The Plaintiff, Richard Allen Farley, (hereinafter referred to as "Claimant"), filed an application for DIB on December 22, 2011 (protective filing date), alleging disability as of April 14, 2010, due to "hypothyroidsim, degenerative disc, lumbar dessication, back injury, depression/PTSD, knee injuries, tinnitus (bilateral), bilateral plantar fasciitis, hiatal hernia, fatigue, hearing loss (bilateral), and colon polyps." (Tr. at 15, 83, 142-48, 167, 179.) The claim was denied initially and on reconsideration. (Tr. at 83-85, 89-91.) On May 30, 2012, Claimant requested a hearing before an Administrative Law Judge (ALJ). (Tr. at 92-93.) The hearing was held on November 14, 2012, before the Honorable Charlie Paul Andrus. (Tr. at 28-58.) By decision dated November 27, 2012, the ALJ determined that Claimant was not entitled to benefits. (Tr. at 15-27.) The ALJ's decision became the final decision of the Commissioner on March 20, 2013, when the Appeals Council denied Claimant's request for review. (Tr. at 1-6.) On May 22, 2013, Claimant brought the present action seeking judicial review of the administrative decision pursuant to 42 U.S.C. § 405(g). (Document No. 2.)
Under 42 U.S.C. § 423(d)(5), a claimant for disability has the burden of proving a disability.
The Social Security Regulations establish a "sequential evaluation" for the adjudication of disability claims. 20 C.F.R. §§ 404.1520, 416.920 (2012). If an individual is found "not disabled" at any step, further inquiry is unnecessary.
In this particular case, the ALJ determined that Claimant satisfied the first inquiry because he had not engaged in substantial gainful activity since April 14, 2010, his alleged onset date. (Tr. at 17, Finding No. 2.) Under the second inquiry, the ALJ found that Claimant suffered from "degenerative joint disease, tinnitus, depression, and anxiety," which were severe impairments. (Tr. at 17, Finding No. 3.) At the third inquiry, the ALJ concluded that Claimant's impairments did not meet or equal the level of severity of any listing in Appendix 1. (Tr. at 18, Finding No. 4.) The ALJ then found that Claimant had a residual functional capacity for less than a full range of light work as follows:
(Tr. at 19-20, Finding No. 5.) At step four, the ALJ found that Claimant could not return to his past relevant work. (Tr. at 25, Finding No. 6.) On the basis of testimony of a Vocational Expert ("VE") taken at the administrative hearing, the ALJ concluded that Claimant could perform jobs such as a house sitter, order clerk, and night watch person, at the light level of exertion, and as a bench worker and inspector, at the sedentary level of exertion. (Tr. at 26-27, Finding No. 10.) On this basis, benefits were denied. (Tr. at 27, Finding No. 11.)
The sole issue before this Court is whether the final decision of the Commissioner denying the claim is supported by substantial evidence. In
A careful review of the record reveals the decision of the Commissioner is not supported by substantial evidence.
Claimant was born on January 16, 1963, and was 49 years old at the time of the administrative hearing, November 14, 2012. (Tr. at 25, 32, 142.) Claimant had at least a high school education and was able to communicate in English. (Tr. at 26, 33, 178, 180.) In the past, he worked as a United States Navy boiler technician, combat crewmember, border control, outside pump sales person, specialty valve and controls sales person, paint sales person, and water filter sales person. (Tr. at 25, 52-53, 180-81.185-92)
Claimant alleges that the Commissioner's decision is not supported by substantial evidence in three respects. (Document No. 11 at 3-12.) First, he argues that the ALJ improperly assessed Claimant's credibility. (
In response, the ALJ sets forth the standard for evaluating pain and credibility pursuant to the Regulations and
Second, Claimant argues that the ALJ placed an inordinate weight on the fact that neither a treating nor consulting examiner provided a functional assessment regarding his physical or mental abilities, and therefore, failed to develop fully the evidence in the case knowing that Claimant was without the financial means to obtain health care from private sources. (Document No. 11 at 10.)
In response, the Commissioner notes that contrary to Claimant's argument, Elizabeth Bodkin, M.A., conducted an examination on behalf of the agency. (Document No. 12 at 17 n. 6.) Ms. Bodkin completed a mental status examination and clinical interview, but did not complete a separate medical source statement. (
Finally, Claimant argues that the Commissioner's decision is not supported by substantial evidence in light of Dr. Guberman's January 3, 2013, disability exam, and Mr. Reeser's January 14, 2013, psychological evaluation, which Claimant submitted to the Appeals Council for consideration. (Document No. 11 at 11-12.) Claimant contends that the reports reinforce his credibility and that of the VA and are in response to the ALJ's statement that the record was void of any functional assessments from treating or consulting sources. (
In response, the Commissioner contends that the Appeals Council explained that it reviewed the newly submitted evidence and found that it was not material, which was a more than an adequate explanation. (Document No. 12 at 18.) Citing
In his Supplemental Brief, Claimant argues that his subsequent award of disability benefits, one day after the ALJ's decision, entitles him to a sentence six remand. (Document No. 13 at 1-2.) Citing
In response, the Commissioner asserts that Claimant fails to meet his burden of proving that the evidence relating to his subsequent award of benefits is relevant to the matter at hand. (Document No. 14 at 1.) Regarding Dr. Guberman's evaluation, the Commissioner notes that despite his opinion of disability since Claimant's alleged onset date of April 14, 2010, Claimant's subsequent award of benefits did not find him disabled until November 28, 2012. (
Regarding the VA decision, the Commissioner notes that the VA found Claimant to be entitled to individual unemployability as of January 14, 2013, with an assignment of 70% mental disability, because that is the date that private treatment records showed his condition worsened. (
The Court has reviewed all the evidence of record, including the medical evidence, and will discuss it below in relation to Claimant's arguments.
On May 4, 2010, x-rays of Claimant's right foot revealed focal asymmetric soft tissue swelling with no acute bony abnormality. (Tr. at 250.) On May 12, 2010, Dr. A'Nedra Fulle Terry, D.P.M., examined Claimant for his painful right heel of six months. (Tr. at 295-97, 548-49.) Claimant reported that the pain was worse with running and with standing after rest. (Tr. at 296, 548.) Dr. Terry diagnosed left plantar fasciitis and heel spur. (Tr. at 297, 548.) He recommended that Claimant treat with ice, Ibuprofen, Medrol dose pack, stretching exercises, 1st step orthotics, and an injection to the right heel. (
On June 28, 2011, Stephanie L. Disney, an audiologist, conducted testing which revealed moderate sensorineural hearing loss in the left ear and mild sensorineural hearing loss in the right ear. (Tr. at 276-79.) She ordered new hearing aids for Claimant. (Tr. at 279.)
Dr. Michael Lupashunski, D.P.M., examined Claimant for his plantar Fasciitis with heel spur on July 13, 2011. (Tr. at 272.) He noted that Claimant had received multiple medications with little success, as well as over-the-counter insoles with some help. (
On September 1, 2011, Kristin D. Martin, an audiologist, reported that with Claimant's new hearing aids, he was able to repeat words and answer questions without visual assistance when speech was presented at normal conversational intensity. (Tr. at 468-69.) Claimant was pleased with the sound quality and physical fit of the new hearing aids and was motivated to use the new devices. (Tr. at 469.)
On October 25, 2011, Claimant was examined by Dr. Ramon S. Lansang, Jr., M.D., for complaints of right elbow pain. (Tr. at 457-58.) Claimant reported that he was employed as a golf pro and played golf, hitting the ball using the right arm. (Tr. at 457.) He was concerned that his part-time livelihood depended on his ability to play golf. (Tr. at 459.) Dr. Lansang noted on exam that Claimant had focal tenderness at the lateral epicondyle, no warmth, and pain with wrist extension and gripping. (Tr. at 458.) Dr. Lansang ordered EMG/Nerve Conduction Studies of Claimant's right elbow which were consistent with a diagnosis of lateral epicondylitis, with tendinopathy, with evidence of superficial radial nerve syndrome with demelination and slowing. (Tr. at 264-65.) Dr. Lansang recommended that Claimant be treated conservatively, including physical therapy, for at least six months prior to considering surgical referrals. (Tr. at 266.)
On November 1, 2011, Dr. Lansang examined Claimant for his reports of pain of right lateral arm pain. (Tr. at 261.) He noted that Claimant's arm was about the same and prescribed physical therapy once a week for six weeks that consisted of therapeutic exercises, manual therapy, and pain modalities. (Tr. at 261-62.) He opined that Claimant's rehabilitation potential was good. (Tr. at 262.)
The x-rays of Claimant's right elbow on November 9, 2011, showed an olecranon spur and an ill-defined sclerotic focus in the proximal ulna. (Tr. at 249.) Dr. Richard B. Manis, M.D., an orthopedic surgeon, diagnosed lateral epicondylitis ("tennis elbow") and prescribed a TENS unit, a right elbow brace, and home exercises. (Tr. at 254-55.)
On November 22, 2011, x-rays of Claimant's lumbosacral spine revealed mild scoliosis and mild arthritic changes. (Tr. at 245.) The x-rays of his bilateral knees demonstrated mild arthritic changes. (Tr. at 246.) Chest x-rays revealed no active disease. (Tr. at 248.)
Claimant presented to the VA Clinic on January 13, 2012, with complaints of low back pain, post status a fall on January 8, 2012. (Tr. at 597-98.) Claimant reported having used Ibuprofen, ice, and heat, without relief. (Tr. at 597.) He described the pain as throbbing in nature that ranged from a level five to eight out of ten in intensity. (
On February 27, 2012, Narendra Parishak, M.D., a state agency physician, reviewed Claimant's medical records and completed a physical RFC assessment. (Tr. at 64-67.) Dr. Parishak opined that Claimant was capable of performing medium exertional level work, with frequent postural limitations and that required no concentrated exposure to extreme cold, noise, or vibration. (Tr. at 65-66.) Dr. Parishak's findings were based in part on Claimant's x-rays, mild scoliosis of the lumbar spine, mild degenerative disease of the knee, and his hearing test without significant abnormality. (Tr. at 66.)
On April 30, 2010, Mr. Vincent, a licensed social worker, conducted a mental health consult for Claimant's complaints that he had "a lot of issues" and that he did not "trust people very often." (Tr. at 293-94, 550-51.) Claimant discussed family and relationship issues. (Tr. at 293, 550.) Mental status exam essentially was normal except that Mr. Vincent noted Claimant was detached and had fair insight. (Tr. at 294, 551.) He diagnosed anxiety NOS, PTSD rule out, and assessed a GAF of 54. (
On May 13, 2011, Ms. Lewis, a licensed social worker, conducted a mental status exam for complaints of depression, anxiety, poor sleep, and PTSD. (Tr. at 282-85, 536-38.) Claimant reported depression after nine tours of military duty and separation from his family. (Tr. at 282, 537.) Ms. Lewis observed that Claimant was oriented fully, was cooperative and maintained good eye contact, had an appropriate affect, maintained spontaneous and normal speech, exhibited a linear thought process, had intact memory, denied suicidal or homicidal ideation, and ambulated independently. (
On May 26, 2011, Claimant saw Pamela J. Carte, a licensed independent clinical social worker, for a comprehensive mental health evaluation at the VA. (Tr. at 510-12, 522-27.) Claimant reported that he was laid off from his job at the golf course due to his physical problems and was enrolled currently in school to complete a degree in physical education. (Tr. at 523.) He hoped to pursue a career as a football coach. (
Claimant saw James E. Overfelt, a nurse practitioner, on June 9 and 28, 2011, for medication management, at which times he assessed anxiety and insomnia. (Tr. at 476-79, 493-96.) On July 28, 2011, Claimant saw Mr. Overfelt for medication management and for anxiety and insomnia. (Tr. at 470-72.) Claimant reported that the medication was "strong stuff and it helps." (Tr. at 471.) He indicated that the Bupropion helped his mood and that the Hydroxyzine helped improve his sleep even though he used it only intermittently. (
On October 25, 2011, Sandra L. Skar, a psychiatrist, saw Claimant at the VA Telemental Health Clinic. (Tr. at 459-61.) Ms. Skar noted an essentially normal mental status exam and diagnosed anxiety disorder NOS, adjustment disorder, and assessed a GAF of 65. (Tr. at 461.) She continued Claimant's medications. (
Claimant saw Mr. Overfelt on November 28, 2011, for medication management. (Tr. at 354-57.) Claimant reported that he was not doing well and that his thyroid affected his mood, which he believed was caused by his increased tinnitus. (Tr. at 355.) He reported that he slept well with Vistaril. (
On December 5, 2011, Mr. Overfelt saw Claimant for a medication management session. (Tr. at 327-30.) Mr. Overfelt reported that Claimant had a defensive and suspicious attitude, normal affect, irritated and congruent affect, impaired and true insight, good judgment, and normal thought processes and content. (Tr. at 329.) He diagnosed depression, anxiety, and assessed a GAF of 60. (
On January 5, 2012, Claimant presented to the VA for a medication management session with Mr. Overfelt. (Tr. at 302-08.) Claimant reported that Bupropion helped his anxiety, but he was unsure whether it helped his depression. (Tr. at 303.) Claimant was concerned that his thyroid level was too low and was affecting his mood and activity level. (
Mr. Overfelt saw Claimant for medication management on February 8, 2012, at which time Claimant reported that Wellbutrin helped with irritability but did not help with depression. (Tr. at 580-82.) Mr. Overfelt noted that Claimant was focused on obtaining his benefits. (
On February 28, 2012, Ms. Bodkin conducted a mental status examination at the request of the state agency. (Tr. at 560-64.) Claimant drove himself to the hearing, presented with a normal gait and posture, and ambulated without any assistive devices. (Tr. at 560.) He reported difficulty sleeping, a poor appetite, crying episodes, a dysphoric mood for two weeks, and symptoms of posttraumatic stress disorder ("PTSD"). (Tr. at 561.) He indicated that he had been going to the VAMC for the past two years and monthly for psychological treatment. (
Ms. Bodkin observed that Claimant had a good attitude and was cooperative, interacted appropriately, maintained normal eye contact, had adequate verbal responses, spontaneously generated conversation, spoke relevantly and coherently, spoke with a normal tone and pace, was oriented fully, had a dysphoric mood and restricted affect, had no delusions or hallucinations, had fair insight, denied suicidal or homicidal ideation, and had normal judgment, memory, concentration, and psychomotor behavior. (Tr. at 562.) She diagnosed PTSD and major depressive disorder, recurrent, moderate. (
On March 15, 2012, Clifton R. Hudson, Ph.D.., a licensed psychologist, evaluated Claimant for PTSD. (Tr. at 566-78, 1036-49.) Dr. Hudson noted that there "were some clinical and psychometric indicators of over-reporting...that necessarily interfere with accurate diagnosis and assessment of functional impairment." (Tr. at 577, 1047.) Dr. Hudson noted that forensically, "it is possible that [Claimant] does have legitimate symptoms of anxiety and depression, and it is possible that he does not." (Tr. at 578, 1048.) He noted that it was difficult to make such a determination due to the fact that Claimant had over-reported his symptoms significantly. (
On May 4, 2012, Claimant was admitted to the hospital and transferred from Huntington VAMC to Lexington VAMC due to suicidal ideation following his brother's death from a drug overdose and his son's arrest for drugs the night prior to his admission. (Tr. at 634-35.) Claimant received psychotropic medications, his mood improved and he denied suicidal ideation, and he was discharged home on May 10, 2012. (
On June 11, 2012, Claimant was admitted voluntarily for worsening depression and suicidal ideation following the death of his dog. (Tr. at 632-34.) Claimant was restarted on psychotropic medications and was discharged home on June 15, 2012, with diagnoses of adjustment disorder and an assessed GAF of 65. (Tr. at 632.)
On August 14, 2012, Claimant expressed concerns about taking his medications, which were causing nightmares. (Tr. at 923-27.) Mr. Overfelt diagnosed anxiety disorder and assessed a GAF of 50.
On September 24, 2012, Claimant presented to Amanda L. Barnett, BSN, RN, a staff nurse, with complaints of irregular sleep, nightmares, depression, and pain. (Tr. at 907-10.) Claimant reported that his energy was "not very good." (Tr. at 909.) Ms. Barnett observed that Claimant's mood and affect were congruent and that his mental status exam was unremarkable. (Tr. at 910.) She assessed suicidal ideation even though Claimant specifically denied such thoughts, depressive disorder NOS, anxiety, and insomnia. (
On March 14, 2012, Paula J. Brickham, Ph.D., a state agency psychologist, completed a Psychiatric Review Technique on which she opined that Claimant did not have a severe mental impairment. (Tr. at 61-63.) She further opined that Claimant's mental impairments resulted in only mild difficulties in maintaining social functioning, but resulted in no restrictions in activities of daily living, concentration, persistence, or pace, or episodes of decompensation of extended duration. (Tr. at 63.)
On January 3, 2013, Dr. Guberman examined Claimant for complaints of low back pain, multiple other joint symptoms, hiatal hernia, diarrhea, and headaches, at the referral of Claimant's attorney. (Document No. 11, Exhibit 1 at 1.) Physical exam revealed a mildly antalgic, but steady gait; moderate tenderness in his cervical, thoracic, and lumbar spine; moderate tenderness and crepitations of the right shoulder and knees; mild tenderness of the elbows, wrists, and hands, with mild swelling of the wrists and right wrist; moderate tenderness of the right ankle, especially the plantar aspect and heel and mild tenderness of the left ankle; no evidence of muscle weakness; intact sensation; and an ability to walk on his toes and heels, an ability to walk heel to toe, and an ability to squat two thirds of the way with difficulty. (
Dr. Guberman also completed a form Medical Assessment of Ability to Do Work-Related Activities (Physical), on which he opined that Claimant was capable of lifting or carrying a maximum of twenty pounds occasionally and ten pounds frequently; walking two to three hours in an eight hour day for thirty minutes at a time; sitting for four hours total and for one hour without interruption; could never climb, balance, kneel, or crawl; and could occasionally stoop or crouch. (
On January 14, 2013, Mr. Reeser, conducted a psychological evaluation at the request of Claimant's attorney. (Document No. 11, Exhibit 2 at 1-8.) On mental status exam, Mr. Reeser noted that Claimant was friendly and cooperative, his verbal content was marked by anger and sadness, his affect was appropriate and his mood was depressed and anxious, his thought processes were logically formed and the flow was normal, he reported content suggestive of possible visual hallucinations, he reported possible delusional content, he was oriented, his memory was good, and he had good insight and judgment. (
Mr. Reeser administered the Millon Clinical Multiaxial Inventory III (MCM III), which presented some validity concerns, was interpretable. (
Mr. Reeser diagnosed PTSD; schizoaffective disorder; major depressive disorder, recurrent moderate; adjustment disorder; anxiety disorder NOS; depressive disorder NOS; and assessed a GAF of 55. (
Mr. Reeser also completed a form Medical Source Statement of Ability to Do Work-Related Activities (Mental), on which he opined that Claimant had extreme limitation in his ability to interact appropriately with the public; marked limitation in his ability to interact appropriately with supervisors and co-workers, respond appropriately to usual work situations and to changes in a routine work setting, make judgments on complex work-related decisions, and understand, remember, and carry out complex instructions. (
Claimant first alleges that the ALJ erred in assessing Claimant's credibility. (Document No. 11 at 7-10.) A two-step process is used to determine whether a claimant is disabled by pain or other symptoms. First, objective medical evidence must show the existence of a medical impairment that reasonably could be expected to produce the pain or symptoms alleged. 20 C.F.R. §§ 404.1529(b) and 416.929(b) (2012); SSR 96-7p;
A claimant's symptoms, including pain, are considered to diminish his capacity to work to the extent that alleged functional limitations are reasonably consistent with objective medical and other evidence. 20 C.F.R. §§ 404.1529(c)(4) and 416.929(c)(4) (2012). Additionally, the Regulations provide that:
20 C.F.R. §§ 404.1529(c)(3) and 416.929(c)(3) (2012).
SSR 96-7p, 1996 WL 374186 (July 2, 1996). SSR 96-7p specifically requires consideration of the "type, dosage, effectiveness, and side effects of any medication the individual takes or has taken to alleviate pain or other symptoms" in assessing the credibility of an individual's statements. Significantly, SSR 96-7p requires the adjudicator to engage in the credibility assessment as early as step two in the sequential analysis; i.e., the ALJ must consider the impact of the symptoms on a claimant's ability to function along with the objective medical and other evidence in determining whether the claimant's impairment is "severe" within the meaning of the Regulations. A "severe" impairment is one which significantly limits the physical or mental ability to do basic work activities. 20 C.F.R. §§ 404.1520(c) and 416.920(c).
The ALJ noted the requirements of the applicable law and Regulations with regard to assessing pain, symptoms, and credibility. (Tr. at 20.) The ALJ found at the first step of the analysis that Claimant's "medically determinable impairments could reasonably be expected to cause the alleged symptoms." (Tr. at 24.) Thus, the ALJ made an adequate threshold finding and proceeded to consider the intensity and persistence of Claimant's alleged symptoms and the extent to which they affected Claimant's ability to work. (Tr. at 20-25.) At the second step of the analysis, the ALJ concluded that "the [C]laimant's statements concerning the intensity, persistence and limiting effects of these symptoms are not credible to the extent they are inconsistent with the above residual functional capacity assessment." (Tr. at 24.)
In assessing Claimant's pain and credibility, the ALJ provided a very detailed overview of Claimant's testimony and reports. (Tr. at 21-25.) He then analyzed Claimant's testimony and reports and contrasted it with the medical evidence. (Tr. at 20-25.) Regarding low back and joint pain, the ALJ noted that x-rays of the lumbar spine revealed only mild scoliosis and mild arthritis and multifocal spurring. (Tr. at 20, 245, 565.) The x-rays of the knees revealed only mild degenerative changes. (Tr. at 20, 248.) Likewise, x-rays of the right elbow showed some spurring and examination revealed some tenderness with minimal swelling and pain with intact hand sensation and only somewhat diminished wrist sensation. (Tr. at 20, 249.) Furthermore, Claimant reported that he walked around in the woods with his dog, maintained his father's cabin and property, and occasionally golfed, which undermined his reports of disabling pain. (Tr. at 24, 563.) Claimant's hearing loss was corrected with hearing aids as he did not report any problems with conversational hearing. (Tr. at 20, 468-69.)
Regarding his depression and anxiety, the ALJ noted that Claimant was treated with medications for anxiety and major depressive disorders and that he tested positive for PTSD. (Tr. at 20.) The ALJ considered Dr. Hudson's report that Claimant grossly over-reported symptoms and his functional impairment, but that he had symptoms of mild anxiety and depression. (Tr. at 20, 566-78, 1036-49.) He also noted Claimant's hospitalizations for suicidal ideation in May and July, 2012, but that his mood improved and he was discharged. (Tr. at 20, 632-34, 634-35.)
Additionally, the ALJ noted Claimant's activities in assessing his credibility. (Tr. at 22-23.) Despite Claimant's alleged disability, the ALJ noted that Claimant work at the golf course beginning in June 2010, and worked there for two seasons, from spring to fall, in 2010 and 2011, and worked approximately 30 hours per week. (Tr. at 22, 34-35, 192.) Claimant reported that he worked the job so that he could obtain golf privileges, and therefore, he played golf during that time, too. (
The ALJ also considered the two state agency opinions. (Tr. at 25.) Regarding Dr. Parishak's opinion, the ALJ concluded that Dr. Parishak's assessment was consistent with the evidence but that Claimant was more limited than assessed by Dr. Parishak and further limited Claimant to a sit/stand option at one hour intervals due to his reported knee arthritis. (Tr. at 25, 64-67.) Regarding Dr. Brickham's opinion, the ALJ acknowledged her opinion, but gave Claimant the benefit of the doubt and limited him to simple, routine work. (Tr. at 20, 25.) The ALJ noted that Claimant retained the ability to concentrate if given normal breaks every two hours and was able to relate to supervisors and co-workers in a non-public work setting. (
In view of the foregoing, the undersigned finds that the ALJ conducted a thorough analysis of the relevant evidence, weighed the medical source opinions, and adequately explained his reasons for discounting the credibility of Claimant's statements regarding the intensity, persistence, and limiting effects of his symptoms.
Claimant also argues that under the mutually supportive test recognized in
Claimant also argues that the ALJ's use of boilerplate credibility language warrants remand "because such language provides no basis to determine what weight the [ALJ] gave the Plaintiff's testimony." (Document No. 11 at 9.) Pursuant to SSR 96-7p, the ALJ "must consider the entire case record and give specific reasons for the weight given to the individual's statements." SSR 96-7p, 1996 WL 374186, at *4. "The reasons for the credibility finding must be grounded in the evidence and articulated in the determination or decision."
In this case, it is clear that the ALJ used boilerplate language regarding the two-step credibility analysis. (Tr. at 20.) However, the ALJ went on to explain the specific reasons for his credibility determination and specifically cited the medical evidence, Claimant's testimony and reports, Claimant's activities, and the factors set forth in 20 C.F.R. §§ 404.1529(c)(3) and 416.929(c)(3). Accordingly, pursuant to SSR 96-7p, the Court finds that the ALJ's credibility finding sufficiently was articulated and explained with references to the specific evidence that formed his decision. Thus, the Court finds that the ALJ's credibility decision is supported by substantial evidence of record.
Next Claimant alleges that the ALJ failed in his duty to help him develop the record and placed an inordinate weight on the fact that neither a treating nor consulting examiner provided a functional assessment regarding his physical or mental abilities. (Document No. 11 at 10.) The Court finds Claimant's argument on this point unavailing. Although an ALJ does have a responsibility to help develop the evidence, it is Claimant's responsibility to prove to the Commissioner that he is disabled. 20 C.F.R. § 404.1512(a) (2012).
Finally, Claimant alleges that the additional evidence from Dr. Guberman and Mr. Reeser, which was submitted to the Appeals Council, requires remand. (Document Nos. 11 at 11-12 and 13 at 1-3.) Pursuant to 28 U.S.C. § 405(g), remand is warranted "upon a showing that there is new evidence which is material and that there is good cause for the failure to incorporate such evidence into the record in a prior proceeding[.]"
The Court is not persuaded by Claimant's argument and finds that neither Dr. Guberman's nor Mr. Reeser's additional reports require that this matter be remanded. It is often true in cases of this nature, where benefits are awarded on a second application, that at least some of the evidence may be the same evidence considered by the ALJ.
Respecting Dr. Guberman's opinion, the Court notes that the physician's evaluation was conducted on January 3, 2013, after the ALJ's decision, was a one-time examination, and that his opinion is inconsistent with his rather benign examination findings. As the Commissioner points out, his opinion also is inconsistent with Claimant's admission that he could perform a medium exertion job at a golf course. (Tr. at 192.) His opinion also is inconsistent with the medical imaging evidence of record which indicated only mild findings. Respecting Mr. Reeser, the Court finds that his mental status findings are inconsistent with his opinion. He reported essentially normal findings on exam, yet opined that he was unable to work. Mr. Reeser even assessed a GAF of 55, indicative of only moderate symptoms. Furthermore, Mr. Reeser agreed with the evidence of record that Claimant possibly was exaggerating his symptoms of PTSD.
Accordingly, the Court finds that the opinions of Dr. Guberman and Mr. Reeser are inconsistent with the substantial evidence of record and therefore, neither are material nor warrant a remand for further consideration.
Claimant also alleges that remand is required to consider his newly submitted disability rating decision from the VA, which found him unemployable as of January 14, 2013, based on a seventy percent disability rating for anxiety and depressive disorder NOS and a ten percent disability rating for plantar fasciitis. (Document No. 13, Exhibit 4.) Claimant also alleges that the ALJ never addressed in his decision the VA's initial disability rating decision. (Document No. 11 at 9.)
The Regulations define "evidence" to include "[d]ecisions by any governmental or nongovernmental agency about whether you are disabled or blind. 20 C.F.R. § 404.1512(b)(5) (2012). Although decisions of another agency are not binding, the Commissioner is required to evaluate all the evidence, including the decisions by any other agency. See 20 C.F.R. § 404.1504 (2012). Social Security Ruling 06-03p provides that "evidence of a disability decision by another governmental or nongovernmental agency cannot be ignored and must be considered." 2006 WL 2329939, at *7. Furthermore, in considering such other decisions, the ALJ "should explain the consideration given to these decisions in the notice of decision."
Here, the ALJ referred throughout his decision to evidence from the Huntington and Lexington VA Medical Centers, where Claimant primarily received treatment for his impairments for a number of years. Nevertheless, there is no indication in the ALJ's decision that the ALJ considered the VA's initial disability decision, and now the subsequent decision increasing the combined disability rating to eighty percent. The ALJ's decision lacks any explanation of his consideration given to the VA's decision, and therefore, remand is required for further consideration of the VA's disability decision.
After a careful consideration of the evidence of record, the Court finds that the Commissioner's decision is supported by substantial evidence. Accordingly, by Judgment Order entered this day, the Plaintiff's Motions for Judgment on the Pleadings (Document No. 11 and 13.) are
The Clerk of this Court is directed to send a copy of this Memorandum Opinion to counsel of record.
It is nevertheless Claimant's responsibility to prove to the Commissioner that she is disabled. 20 C.F.R. §§ 404.1512(a), 416.912(a) (2012) (stating that "in general, you have to prove to us that you are blind or disabled. This means that you must furnish medical and other evidence that we can use to reach conclusions about your medical impairment(s).") Thus, the claimant is responsible for providing medical evidence to the Commissioner showing that she has an impairment. Id. §§ 404.1512(c), 416.912(c). The Regulations provide that: "You must provide medical evidence showing that you have an impairment(s) and how severe it is during the time you say that you are disabled." §§ 404.1512 (c); 416.912(c)(2012). In Bowen v. Yuckert, 482 U.S. 137, 107 S.Ct. 2287, 96 L.Ed.2d 119 (1987), the Supreme Court noted:
Bowen v. Yuckert, 482 U.S. at 146, n. 5; 107 S.Ct. at 2294, n. 5 (1987). Thus, although the ALJ has a duty to develop the record fully and fairly, he is not required to act as the claimant's counsel. Clark v. Shalala, 28 F.3d 828, 830-31 (8th Cir. 1994). Claimant bears the burden of establishing a prima facie entitlement to benefits. See Hall v. Harris, 658 F.2d 260, 264-65 (4th Cir. 1981); 42 U.S.C.A. § 423(d)(5)(A)("An individual shall not be considered to be under a disability unless he furnishes such medical and other evidence of the existence thereof as the Commissioner of Social Security may require.") Similarly, Claimant "bears the risk of non-persuasion." Seacrist v. Weinberger, 538 F.2d 1054, 1056 (4th Cir. 1976).
The court may, on motion of the Commissioner of Social Security made for good cause shown before the Commissioner files the Commissioner's answer, remand the case to the Commissioner of Social Security for further action by the Commissioner of Social Security, and it may at any time order additional evidence to be taken before the Commissioner of Social Security, but only upon a showing that there is new evidence which is material and that there is good cause for the failure to incorporate such evidence into the record in a prior proceeding; and the Commissioner of Social Security shall, after the case is remanded, and after hearing such additional evidence if so ordered, modify or affirm the Commissioner's findings of fact or the Commissioner's decision, or both, and shall file with the court any such additional and modified findings of fact and decision, and, in any case in which the Commissioner has not made a decision fully favorable to the individual, a transcript of the additional record and testimony upon which the Commissioner's action in modifying or affirming was based.