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Swartzbaugh v. Berryhill, 3:17-cv-00045. (2018)

Court: District Court, M.D. Pennsylvania Number: infdco20180425e87 Visitors: 9
Filed: Mar. 30, 2018
Latest Update: Mar. 30, 2018
Summary: REPORT AND RECOMMENDATION JOSEPH F. SAPORITO, JR. , Magistrate Judge . The plaintiff, Mark A. Swartzbaugh brought this action under 42 U.S.C. 1383(c)(3), and, as incorporated by reference, 42 U.S.C. 405(g), seeking judicial review of the final decision of the Commissioner of Social Security denying claim for disability and disability insurance benefits under Title II of the Social Security Act (the "Act"). This matter has been referred to the undersigned United States Magistrate Judge
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REPORT AND RECOMMENDATION

The plaintiff, Mark A. Swartzbaugh brought this action under 42 U.S.C. § 1383(c)(3), and, as incorporated by reference, 42 U.S.C. § 405(g), seeking judicial review of the final decision of the Commissioner of Social Security denying claim for disability and disability insurance benefits under Title II of the Social Security Act (the "Act").

This matter has been referred to the undersigned United States Magistrate Judge to prepare a report and recommended disposition pursuant to the provisions of 28 U.S.C. § 636(b)(1)(B) and Rule 72(b) of the Federal Rules of Civil Procedure. For the reasons expressed herein, we recommend that the final decision of the Commissioner be AFFIRMED.

I. PROCEDURAL BACKGROUND

Swartzbaugh is an adult individual born May 14, 1965. He was forty-six years old at the time of the alleged onset of disability—August 1, 2011. (Tr. 18).

Swartzbaugh's age at the onset date makes him a "younger person" under the Commissioner's regulations whose age generally does not affect his ability to adjust to other work. See 20 C.F.R. §416.963.

On July 15, 2013, Swartzbaugh protectively filed an application for benefits under Title II of the Social Security Act alleging disability as of August 1, 2011. In his application, Swartzbaugh alleged that the following impairments prevent him from engaging in any work: fibromyalgia, lack of mental concentration, fatigue, brain fog, difficulty to concentrate on tasks, joint pain, headaches and depression. (Tr. 178).

Swartzbaugh's claim was initially denied on October 11, 2013. Thereafter, he filed a timely request for an administrative hearing. His request was granted. Swartzbaugh appeared in York, PA at the hearing before Administrative Law Judge ("ALJ") Reana K. Sweeney who presided over the hearing in Harrisburg, Pennsylvania on December 11, 2014. At the hearing, Swartzbaugh represented himself. Swartzbaugh appeared at a supplemental hearing held on February 19, 2015. In addition, impartial vocational expert Brian Bierley ("VE") appeared at the hearing.

On March 31, 2015, the ALJ denied Swartzbaugh's application for benefits in a written decision. On May 28, 2015, Swartzbaugh sought further review of his claims by the Appeals Council of the Office of Disability Adjudication and Review, but his request was denied on November 4, 2016. This makes the ALJ's March 2015 decision the final decision subject to judicial review by this Court.

Swartzbaugh filed a timely complaint in this Court on January 6, 2017. (Doc. 1). In his complaint, Swartzbaugh alleges that the final decision of the Commissioner is not supported by substantial evidence and is contrary to law and regulation.

On May 17, 2017, the Commissioner filed her answer, in which she maintains that the ALJ's decision was made in accordance with the law and is supported by substantial evidence. (Doc. 7).

This matter has been fully briefed by the parties and is ripe for decision. (Docs. 11, 12, and 15).

II. FACTUAL BACKGROUND

At the time of the administrative hearings, Swartzbaugh was forty nine years old and resided in York, Pennsylvania, which is in the Middle District of Pennsylvania. Swartzbaugh completed a high school education and holds a degree in business administration. (Tr. 42).

Swartzbaugh resides with his wife, mother, and 18 year old son. (Tr. 37). Swartzbaugh stated that he was discharged from his previous employer due to his performance. (Tr. 40).

Swartzbaugh possesses a driver's license (Tr. 41).

Swartzbaugh stated that he does volunteer work for Pennsylvania Friends of Jazz, where he serves on the board. He stated the board meets six times a year. (Tr. 47). He stated he plays jazz (drums) approximately six times per month. (Tr. 47). Swartzbaugh stated that he used to play tennis for exercise but has not played since November, 2013. (Tr. 50).

Swartzbaugh testified that he has been diagnosed with sleep apnea and has a CPAP machine, but probably only uses it for approximately four hours a night. (Tr. 57).

Swartzbaugh testified that in a typical day, he wakes up around 3:00 p.m. (Tr. 62). He brushes his teeth, makes a pot of coffee, and then takes his medications. He then sits on a chair, watches television, and drinks coffee. Then about 5:00 p.m. he will start to make dinner. After dinner, he typically falls asleep in the living room on a recliner. (Tr. 63-64). He then sleeps for about two hours and wakes up to clean up dinner. He will then use the computer to surf the internet and look at social media. (Tr. 64). He spends approximately two hours on the computer. (Tr. 64).

Swartzbaugh testified that he practices his drums typically two times a week.( Tr. 65).

III. STANDARD OF REVIEW

When reviewing the denial of disability benefits, the Court's review is limited to determining whether those findings are supported by substantial evidence in the administrative record. See 42 U.S.C. § 405(g) (sentence five); Johnson v. Comm'r of Soc. Sec., 529 F.3d 198, 200 (3d Cir. 2008); Ficca v. Astrue, 901 F.Supp.2d 533, 536 (M.D. Pa. 2012). Substantial evidence "does not mean a large or considerable amount of evidence, but rather such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Pierce v. Underwood, 487 U.S. 552 (1988). Substantial evidence is less than a preponderance of the evidence but more than a mere scintilla. Richardson v. Perales, 402 U.S. 389, 401 (1971). A single piece of evidence is not substantial evidence if the ALJ ignores countervailing evidence or fails to resolve a conflict created by the evidence. Mason v. Shalala, 994 F.2d 1058, 1064 (3d Cir. 1993). In an adequately developed factual record, substantial evidence may be "something less than the weight of the evidence, and the possibility of drawing two inconsistent conclusions from the evidence does not prevent [the ALJ's decision] from being supported by substantial evidence." Consolo v. Fed. Maritime Comm'n, 383 U.S. 607, 620 (1966). "In determining if the Commissioner's decision is supported by substantial evidence the court must scrutinize the record as a whole." Leslie v. Barnhart, 304 F.Supp.2d 623, 627 (M.D. Pa. 2003). The question before the Court, therefore, is not whether the claimant is disabled, but whether the Commissioner's finding that he or she is not disabled is supported by substantial evidence and was reached based upon a correct application of the relevant law. See Arnold v. Colvin, No. 3:12-CV-02417, 2014 WL 940205, at *1 (M.D. Pa. Mar. 11, 2014) ("[I]t has been held that an ALJ's errors of law denote a lack of substantial evidence.") (alterations omitted); Burton v. Schweiker, 512 F.Supp. 913, 914 (W.D. Pa. 1981) ("The [Commissioner]'s determination as to the status of a claim requires the correct application of the law to the facts."); see also Wright v. Sullivan, 900 F.2d 675, 678 (3d Cir. 1990) (noting that the scope of review on legal matters is plenary); Ficca, 901 F. Supp. 2d at 536 ("[T]he court has plenary review of all legal issues . . . .").

To receive disability benefits, a claimant must demonstrate an "inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." 42 U.S.C. § 423(d)(1)(A); see also 20 C.F.R. § 404.1505(a). To satisfy this requirement, a claimant must have a severe physical or mental impairment2 that makes it impossible to do his or her previous work or any other substantial gainful activity3 that exists in the national economy. 42 U.S.C. § 423(d)(2)(A); 20 C.F.R. § 404.1505(a).

The Commissioner follows a five-step sequential evaluation process in determining whether a claimant is disabled under the Social Security Act. 20 C.F.R. § 404.1520(a). Under this process, the Commissioner must determine, in sequence: (1) whether the claimant is engaged in substantial gainful activity; (2) whether the claimant has a severe impairment; (3) whether the claimant's impairment meets or equals a listed impairment;4 (4) whether the claimant is able to do past relevant work, considering his or her residual functional capacity ("RFC");5 and (5) whether the claimant is able to do any other work, considering his or her RFC, age, education, and work experience. Id. The claimant bears the initial burden of demonstrating a medically determinable impairment that prevents him or her from doing past relevant work. 42 U.S.C. § 423(d)(5); 20 C.F.R. § 404.1512; Mason, 994 F.2d at 1064. Once the claimant has established at step four that he or she cannot do past relevant work, the burden then shifts to the Commissioner at step five to show that jobs exist in significant numbers in the national economy that the claimant could perform consistent with his or her RFC, age, education, and past work experience. 20 C.F.R. § 404.1512(f); Mason, 994 F.2d at 1064.

IV. THE ALJ'S DECISION

In her March 31, 2015, decision, the ALJ determined that Swartzbaugh met the insured status requirement6 of the Act through December 31, 2015. (Tr. 20). At step one of the five-step process, the ALJ determined that Swartzbaugh did not engage in any substantial gainful activity between his alleged onset date of August 1, 2011, and the date of the ALJ's decision. (Id.). At step two, the ALJ determined that Swartzbaugh had the following severe impairment: obstructive sleep apnea. (Id.). The ALJ also considered several other health conditions found in the claimant's medical history, finding each to be non-severe. (Tr. 20-24). At step three, the ALJ determined that Swartzbaugh did not have an impairment, or combination of impairments, that met or medically equaled the severity of any one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (Tr. 24).

Prior to step four, the ALJ determined Swartzbaugh's RFC based on the evidence of record, including the claimant's testimony, the findings and opinions of treating and examining medical sources, the opinions of a non-examining state agency medical consultant. The ALJ determined that Swartzbaugh retained the RFC to perform a limited range of medium work, as defined in 20 C.F.R. § 404.1567(c), with certain non-exertional restrictions. (Id.). Specifically, the ALJ found that:

[T]he claimant requires normal breaks throughout the workday, including a 15 minute early shift break, 30 minute lunch break and 15 minute late shift break, with 2 unscheduled 5 minute breaks. The claimant is limited to occasionally crawling on his hand[s] and knees or feet. The claimant is prohibited from operating motor vehicles or large pieces of equipment.

(Id.).

Pursuant to 20 C.F.R. § 404.152(c) and Social Security Ruling 96-7p, 1996 WL 374186, the ALJ considered Swartzbaugh's testimony and found that "the claimant's medically determinable impairments could reasonably be expected to cause the alleged symptoms; however, the claimant's statements concerning the intensity, persistence and limiting effects of these symptoms are not entirely credible . . . ." (Tr. 25).

The ALJ then reviewed the claimant's medical treatment history with respect to his sleep apnea. (Tr. 25-26).

In February 2013, the claimant was examined by Carol St. George, D.O, a physician board-certified in diseases of the ears, nose, and throat. (Tr. 365). Dr. St. George noted that the claimant underwent uvulopalatopharyngoplasty in 2008 with no follow-up. (Tr. 365). Dr. St. George noted that Swartzbaugh reported feeling well enough that he stopped using his CPAP machine until about 2011. (Id.). Swartzbaugh reported to Dr. St. George that he had experienced increased fatigue and poor sleep, which did not improve upon resumption of CPAP therapy. (Id.). Swartzbaugh reported that his headgear was easily knocked off at night, and that he was always feeling lightheaded and suffered from "brain fog." (Id.). On examination, however, Dr. St. George found only mild inferior turbinate congestion, and he found excellent configuration from the 2008 palatoplasty. (Id.).

Dr. St. George examined the claimant again in July 2013, after a sleep study had been conducted. (Tr. 364). The sleep study documented eight obstructive apneas during REM sleep. (Id.). Snoring was eliminated with ten centimeters of water pressure. (Id.). Dr. St. George noted that Swartzbaugh reported using his CPAP machine only three times per week. (Id.). On examination, Dr. St. George found mild right-sided nasal congestion and diagnosed Swartzbaugh with mild sleep apnea. (Id.). Dr. St. George recommended fitting for a SomnoGuard appliance to address the claimant's snoring. (Id.).

Dr. St. George examined the claimant a third time in February 2014. (Tr. 355). The claimant reported being unable to tolerate the SomnoGuard appliance, and that while it stopped his snoring, he continued to suffer from fatigue. (Id.). On examination, Dr. St. George found mild left-sided nasal congestion and a left septal deviation. (Id.). Swartzbaugh stated that he was interested in resuming CPAP therapy. (Id.).

In May 2014, the claimant was examined by Michael Green, M.D., a pulmonologist. (Tr. 350-51). Dr. Green noted that the claimant complained of sleep apnea with persistent daytime sleepiness. (Id.). On examination, Dr. Green found that Swartzbaugh's oxygen saturations were 100% on room air and he appeared to be comfortable and free from acute distress. (Id.). In July 2014, Sandra Warren, PA-C, a physician assistant at Dr. Green's practice noted that the claimant's Epworth Sleepiness Scale rating was 15 out of 24. (Tr. 348-49). She noted that he was in no respiratory distress and his oxygen saturations were 99% on room air. (Id.). She noted that his respiratory effort was normal, and that he had a 60% compliance rate. (Id.). In October 2014, PA Warren noted that Swartzbaugh reported using his CPAP machine for at least six hours per night, with 100% compliance. (Tr. 340-44). The claimant reported to her that he slept better without the CPAP machine, but still experienced daytime sleepiness. (Id.).

On October 3, 2014, the claimant was examined by Richard H. Daly, Jr., M.D., his treating family physician. (Tr. 288). Swartzbaugh complained to Dr. Daly that the CPAP machine was not helping with his sleep. (Id.).

Pursuant to 20 C.F.R. § 404.1527(c), the ALJ considered the medical opinion of Barry Hart, Ph.D., who performed a consultative examination of the claimant at the request of the state Bureau of Disability Determination. (Tr. 22). Dr. Hart diagnosed the claimant with depressive disorder, noted that he was capable of looking after the family finances (and did so), and opined that Swartzbaugh's "concentration may well be an impediment to his ability to hold down a job at this time." (Tr. 276). In a separate statement prepared the same day, Dr. Hart opined that the claimant had marked restrictions in understanding, remembering, and carrying out complex instructions and in his ability to make judgments on complex work-related decisions, and moderate restrictions in understanding, remembering, and carrying out simple instructions and in his ability to make judgments on simple work-related decisions. (Tr. 376). Dr. Hart further opined that the claimant had moderate restrictions in interacting appropriately with the public, supervisors, and co-workers, and in his ability to respond appropriately to usual work situations and to changes in a routine work setting. (Tr. 377). The ALJ afforded "limited weight" to Dr. Hart's opinion because it was without adequate evidentiary support and it was inconsistent with Dr. Hart's own objective findings. (Tr. 22).

Pursuant to 20 C.F.R. § 404.1527(e) and Social Security Ruling 96-6p, 1996 WL 374180, the ALJ considered a state agency assessment of Swartzbaugh's mental RFC, prepared by a psychological consultant who is also an expert in Social Security disability programs, as the medical opinion of a non-examining medical source. (Tr. 22-23). On October 10, 2013, medical consultant Michael Suminski, Ph.D., found that Swartzbaugh suffered from a severe affective disorder which caused moderate limitations to his ability to carry out detailed instructions and his ability to maintain attention and concentration for extended periods; Dr. Suminski found no significant limitations in any other areas. (Tr. 93-96).7 Ultimately, the ALJ afforded "little weight" to the state agency consultant's opinion because the available medical evidence of record did not support a finding that he had severe mental health impairments, but rather indicated that Swartzbaugh was oriented, he was cooperative, his concentration was reasonable, his thought process was coherent and goal directed, and his intelligence was within average range. (Tr. 22-23).

Pursuant to 20 C.F.R. § 404.1527(e) and Social Security Ruling 96-6p, 1996 WL 374180, the ALJ considered a state agency assessment of Swartzbaugh's physical RFC, prepared by a medical consultant who is also an expert in Social Security disability programs, as the medical opinion of a non-examining medical source. (Tr. 26). On September 12, 2013, medical consultant Jerry Brenner, D.O., found no objective evidence of a severe or medically determinable physical impairment. (Tr. 26, 93). Ultimately, the ALJ afforded "little weight" to the state agency consultant's opinion because it was inconsistent with objective findings throughout the medical evidence of record clearly indicating a physical impairment of obstructive sleep apnea that had more than a minimal impact on the claimant's ability to perform work activity. (Tr. 26).

Pursuant to 20 C.F.R. § 404.1527(c), the ALJ considered the medical opinion of Dr. Daly, the claimant's treating family physician. (Tr. 26). On December 1, 2014, Dr. Daly prepared a letter in support of the claimant's request for disability benefits, stating:

Mark suffers from severe sleep disturbance including disturbed circadian rhythm. He has been diagnosed with sleep apnea and uses a CPAP machine compliantly. Such sleep disturbance leads Mr. Swartzbaugh to profound fatigue and difficulty with activities of daily living. In my opinion, his disturbed sleep and profound fatigue makes gainful employment impossible.

(Tr. 373). Dr. Daly's letter did not include any additional observations or findings. (Id.). The ALJ afforded "limited weight" to Dr. Daly's opinion because "it is without adequate evidentiary support and it is inconsistent with the objective findings noted throughout the medical evidence of record, which indicate that the claimant is in no acute distress, he appears comfortable upon examination[,] and he has no more than mild congestion with oxygen saturations of 100%." (Id.).

The ALJ then provided further explanation in support of her finding that the claimant was not entirely credible regarding the extent and severity of his impairment and limitations, stating:

The claimant's allegations have not been entirely consistent with the objective findings, in that the treatment received by the claimant relative to his impairments has been routine and conservative in nature. The record indicates that the claimant's treatment relative to sleep apnea has consisted entirely of routine follow up with his treating practitioners. The record also indicates that the claimant has a history of non-compliance with prescribed treatment, failing to use his CPAP machine more than 3 times per week and refusing to adjust his sleep schedule. Additionally, the record indicates that the claimant's treatment relative to alleged mental health impairments has consisted entirely of routine follow up with Dr. Daly. The claimant noted that his symptoms are improved with medication. It was also noted that the claimant is resistant to psychological evaluation, as he does not feel that he needs a psychological consultation. Further, the claimant's subjective allegations are not supported by the objective findings noted throughout the evidence of record. The claimant alleged that he has increased joint pain with increased standing and walking. However, the claimant admitted that his pain is improved with medication. The record indicates that the claimant ambulates with a normal gait and he has no tenderness throughout his joints. The claimant alleged that he cannot work because he cannot focus or perform tasks mentally. However, the record indicates that the claimant is oriented, his mental status is within normal limits, his concentration is reasonable and his intelligence is within the average to above average range. The claimant participates in various activities of daily living. The claimant testified that he volunteers on the Board of the Pennsylvania Friends of Jazz. He testified that the Board meets 6 times per year. He testified that he plays drums 6 times per month. He testified that he makes dinner. He testified that he uses his computer for social media and searching the Internet. He testified that he spends 2 hours on the computer. He testified that he sometimes practices drums. The claimant reported that he has no difficulty performing activities of personal care. He reported that he prepares meals and he does household chores, including laundry and mowing. He reported that he drives and he goes shopping for food and personal items. He reported that he is able to manage his own finances. An individual with the impairments of the severity alleged by the claimant would not likely to be able to perform the above discussed activities of daily living on a regular basis. In sum, the above residual functional capacity assessment is supported by the claimant's impairments and associated symptoms and by the objective clinical findings noted throughout the medical evidence of record.

(Tr. 26-27 (citations omitted)).

At step four of the five-step process, the ALJ determined that Swartzbaugh was not capable of performing past relevant work as an advertising sales person, a media sales representative, or an automobile sales person, based on the testimony by a vocational expert. (Tr. 27; see also Tr. 69-72).

It is the claimant who bears the initial burden of proving the existence of a disability. 42 U.S.C. § 423(d)(5); 20 C.F.R. § 404.1512; Rossi v. Califano, 602 F.2d 55, 57 (3d Cir. 1979). Once the claimant has established at step four that he cannot do any work he has done in the past because of his impairments, the burden shifts to the Commissioner at step five to show that jobs exist in significant numbers in the national economy which the claimant could perform consistent with his RFC, age, education, and past work experience. Rossi, 602 F.2d at 57.

The ALJ found that Swartzbaugh was forty-six years old on the alleged disability onset date, which is defined as a "younger individual age 18-49," with at least a high school education and the ability to communicate in English. (Tr. 27). According to the testimony given by a vocational expert, a significant number of jobs exist in the national economy for an individual of Swartzbaugh's age, education, work experience, and RFC as determined by the ALJ. (Tr. 28, 73-76). These jobs include general merchandise salesperson (200,000 nationally), furniture sales person (200,000 nationally), hand packager (250,000 nationally), and machine feeder (190,000 nationally). (Id.). Having found a significant number of jobs to which the claimant was capable of making a successful adjustment, the ALJ concluded that Swartzbaugh was therefore not disabled as of his date of the ALJ's decision. (Tr. 28).

V. ANALYSIS

Mindful of our obligation to liberally construe the filings of pro se litigants, see generally Mala v. Crown Bay Marina, Inc., 704 F.3d 239, 244-46 (3d Cir. 2013), Swartzbaugh appears to assert that the ALJ's decision is not supported by substantial evidence because: (1) in determining Swartzbaugh's RFC, the ALJ weighed the evidence incorrectly, viewing several pieces of information out of context and improperly crediting information in his medical treatment records that Swartzbaugh claims to be false; (2) the ALJ improperly weighed the medical opinion evidence presented; and (3) the ALJ improperly found Swartzbaugh's testimony to be only partially credible.

A. Medical Opinions

The claimant challenges the ALJ's determination to afford "limited weight" to the medical opinions of Dr. Hart and Dr. Daly.

1. Treating Physician Opinion

The claimant argues that the ALJ erred in giving "limited weight" to his treating physician's opinion that his "disturbed sleep and profound fatigue makes gainful employment impossible."

To be a "medical opinion" entitled to "controlling weight" an opinion must come from a "treating source," it must be "well-supported by medically acceptable clinical and laboratory diagnostic techniques," and it must be "not inconsistent with the other substantial evidence in your case record." 20 C.F.R. § 404.1527(a)(2), (c)(2); Soc. Sec. Ruling 96-2p, 1996 WL 374188, at *2.8 Under the Social Security regulations in effect at the time of the ALJ's decision in this case, a "treating source" is defined as a "physician, psychologist, or other acceptable medical source who provides you, or has provided you, with medical treatment or evaluation and who has, or has had, an ongoing treatment relationship with you." 20 C.F.R. § 404.1502. As to what constitutes an "ongoing treatment relationship," the regulation states:

Generally, we will consider that you have an ongoing treatment relationship with an acceptable medical source when the medical evidence establishes that you see, or have seen, the source with a frequency consistent with accepted medical practice for the type of treatment and/or evaluation required for your medical condition(s). We may consider an acceptable medical source who has treated or evaluated you only a few times or only after long intervals (e.g., twice a year) to be your treating source if the nature and frequency of the treatment or evaluation is typical for your condition(s).

Id. § 404.1502.

If not well-supported by medically acceptable clinical and diagnostic techniques or inconsistent with other substantial evidence in the case record, a treating source medical opinion is nevertheless entitled to deference. Soc. Sec. Ruling 96-2p, 1996 WL 374188, at *4. Ordinarily, it will be afforded "great weight." See id. at *2; Morales v. Apfel, 225 F.3d 310, 317 (3d Cir. 2000). See generally 20 C.F.R. § 404.1527(c) (detailing factors considered in evaluating weight given to a medical opinion).

Here, Dr. Daly's opinion that the claimant's "disturbed sleep and profound fatigue makes gainful employment impossible" is not a medical opinion, but rather an opinion on whether Swartzbaugh is disabled, an issue expressly reserved to the Commissioner. See 20 C.F.R. § 404.1527(d)(1); Dixon v. Comm'r of Soc. Sec., 183 Fed. App'x 248, 251 (3d Cir. 2006) ("[O]pinions on disability are not medical opinions and are not given any special significance."); Snow v. Astrue, Civil Action No. 12-5 Erie, 2013 WL 501377, at *8 (W.D. Pa. Jan. 15, 2013) ("The ultimate determination as to whether a claimant is disabled is reserved to the Commissioner."). "Medical sources . . . sometimes offer opinions . . . about an individual's ability to do past relevant work or any other type of work. Because these are administrative findings that may determine whether an individual is disabled, they are reserved to the Commissioner. . . . [T]hey can never be entitled to controlling weight or given special significance." Soc. Sec. Ruling 96-5p, 1996 WL 374183, at *5; see also Dixon, 183 Fed. App'x at 252 (finding that treating source opinions stating that a claimant was unable to do specific jobs "reflected the treating professionals' opinions on disability, [and] they were properly afforded no special significance"); Snow, 2013 WL 501377, at *8 ("Since medical doctors typically lack the vocational expertise needed to ascertain whether an individual's limitations would preclude the performance of specific jobs, their opinions as to whether a claimant is `disabled' carry little weight. . . . Questions pertaining to employer expectations are more appropriately addressed by a vocational expert.").

Even though Dr. Daly's opinion is not a treating source medical opinion entitled to controlling weight, his opinion is nevertheless relevant evidence that must be considered and weighed by the ALJ. See 20 C.F.R. § 404.1527(d); Soc. Sec. Ruling 96-5p, 1996 WL 374183, at *3 ("[O]pinions from any medical source on issues reserved to the Commissioner must never be ignored."); Soc. Sec. Ruling 96-8p, 1996 WL 374184, at *7 n.8; Ray v. Astrue, 649 F.Supp.2d 391, 402 n.26 (E.D. Pa. 2009) ("Evidence that does not deserve great weight does not necessarily deserve no weight at all."). The following factors must be considered to determine the appropriate weight to which the opinion is entitled: (1) the length of treatment and frequency of examination; (2) the nature and extent of the treatment relationship; (3) the opinion's support by medical evidence; (4) the opinion's consistency with the record as a whole; and (5) the treating physician's specialization. 20 C.F.R. § 404.1527(c)(2)-(5); see also Soc. Sec. Ruling 96-5p, 1996 WL 374183, at *3 ("In evaluating the opinions of medical sources on issues reserved to the Commissioner, the adjudicator must apply the applicable factors in 20 CFR 404.1527[(c)] . . . .").9 None of these factors may be omitted or disregarded by the ALJ in considering the weight of the opinion. See Casillas v. Astrue, 671 F.Supp.2d 635, 643-44 (E.D. Pa. 2009) (stating that the ALJ "must consider" the factors set forth in 20 C.F.R. § 404.1527(c) in determining what weight to give a medical source opinion); Waldron v. Astrue, No. 1:07-CV-2040, 2008 WL 4452350, at *1 (M.D. Pa. Sept. 30, 2008) (same). In addition, the ALJ must consider any other factors that tend to support or contradict the opinion, but only if brought to his or her attention. 20 C.F.R. § 404.1527(c)(6).

In determining the amount of weight to give Dr. Daly's opinion, the ALJ here clearly articulated his consideration of factors (1), (2), and (5), expressly describing Dr. Daly as the claimant's "primary care practitioner," and noting the several occasions over the course of years in which Dr. Daly examined the claimant. (Tr. 20-22, 26). Moreover, the medical records considered by the ALJ clearly identified Dr. Daly's specialty in family and sports medicine. (See, e.g., Tr. 373). With respect to factors (3) and (4), the ALJ expressly considered and found this opinion to be "without adequate evidentiary support and . . . inconsistent with the objective findings noted throughout the medical evidence of record." (Tr. 26). In particular, the ALJ noted that the medical evidence "indicate[s] that the claimant is in no acute distress, he appears comfortable upon examination[,] and he has no more than mild congestion with oxygen saturations of 100%." (Id.). No additional factors appear to have been brought to the ALJ's attention for consideration.

Accordingly, we find that there is substantial evidence in the administrative record to support the ALJ's finding that Dr. Daly's opinion that the claimant's "disturbed sleep and profound fatigue makes gainful employment impossible" was entitled to "limited weight," and her determination of the weight given to Dr. Daly's opinion was adequately explained and otherwise based upon a correct application of relevant law. See generally Dixon, 183 Fed. App'x at 251-52 (giving medical source opinions on disability "no special significance"); Snow, 2013 WL 501377, at *8 (giving medical source opinion on disability "little weight").

2. Examining Psychological Consultant Opinion

The claimant argues that the ALJ erred in giving "limited weight" to an examining psychological consultant's opinion that his "concentration may well be an impediment to his ability to hold down a job at this time."

An ALJ is required to evaluate every medical opinion in the record, regardless of the source of the opinion. 20 C.F.R. § 404.1527(c). In determining the appropriate weight to which a non-treating source's medical opinion is entitled, the ALJ must consider the following factors: (1) whether the medical source actually examined the claimant; (2) the degree to which the medical opinion is supported by relevant evidence; (3) the degree to which the medical opinion is consistent with the record as a whole; and (4) the medical source's specialization. 20 C.F.R. § 404.1527(c)(1) & (3)-(5). In addition, the ALJ must consider any other factors that tend to support or contradict the medical opinion, but only if brought to his or her attention. See id. § 404.1527(c)(6).

Here, the ALJ considered the opinion of an examining psychological consultant—that the claimant's "concentration may well be an impediment to his ability to hold down a job at this time"—and gave it "limited weight." (Tr. 22). In determining the appropriate weight to give to Dr. Hart's opinion, the ALJ clearly articulated his consideration of factors (1), (2), and (3), and there is nothing in the record to indicate a specialization by Dr. Hart within the field of psychology. (See id.). No additional factors appear to have been brought to the ALJ's attention for consideration.

Accordingly, the Court finds that there is substantial evidence in the administrative record to support the ALJ's finding that the examining psychological consultant's opinion was entitled to "limited weight," and that his determination of the weight given to them was adequately explained and otherwise based upon a correct application of relevant law.

B. Claimant Credibility

The claimant challenges the ALJ's determination that his testimony regarding the extent and severity of his impairments and limitations was not entirely credible.

In evaluating a claimant's subjective complaints regarding pain or other symptoms, the ALJ must follow a two-step process. 20 C.F.R. § 404.1529(b),(c); Soc. Sec. Ruling 96-7p, 1996 WL 374186, at *2. First, "[a]llegations of pain and other subjective symptoms must be consistent with objective medical evidence." Hartranft v. Apfel, 181 F.3d 358, 362 (3d Cir. 1999); see also 20 C.F.R. § 404.1529(b); Soc. Sec. Ruling 96-7p, 1996 WL 374186, at *2 ("First, the adjudicator must consider whether there is an underlying medically determinable physical or mental impairment(s) . . . that could reasonably be expected to produce the individual's pain or other symptoms."). Once this threshold obligation has been met, the ALJ must then "evaluate the intensity and persistence of the pain or symptom, and the extent to which it affects the individual's ability to work. This obviously requires the ALJ to determine the extent to which a claimant is accurately stating the degree of pain or the extent to which he or she is disabled by it." Hartranft, 181 F.3d at 362; see also 20 C.F.R. § 404.1529(c); Soc. Sec. Ruling 96-7p, 1996 WL 374186, at *2.

At this second step, unless the claimant's alleged symptoms are fully substantiated by objective medical evidence, the ALJ's finding must be based on consideration of all relevant evidence in the case record. 20 C.F.R. § 404.1529(c)(2),(3); Soc. Sec. Ruling 96-7p, 1996 WL 374186, at *2, *4. "This includes the medical signs and laboratory findings, the individual's own statements about their symptoms, any statements and other information provided by treating or examining physicians or psychologists and other persons about the symptoms and how they affect the individual, and any other relevant evidence in the case record." Soc. Sec. Ruling 96-7p, 1996 WL 374186, at *2. "[A]llegations concerning the intensity and persistence of pain or other symptoms may not be disregarded solely because they are not substantiated by objective medical evidence." Soc. Sec. Ruling 96-7p, 1996 WL 374186, at *6; see also 20 C.F.R. § 404.1529(c)(2).

In considering the claimant's own statements and testimony at step two of this analysis, the ALJ is required to make an explicit credibility determination "whenever the individual's statements about the intensity, persistence, or functionally limiting effects of pain or other symptoms are not substantiated by objective medical evidence." Soc. Sec. Ruling 96-7p, 1996 WL 374186, at *4; see also 20 C.F.R. § 404.1529(c)(4). "The [ALJ's] decision must contain specific reasons for the finding on credibility, supported by the evidence in the case record, and must be sufficiently specific to make clear to the individual and to any subsequent reviewers the weight the adjudicator gave to the individual's statements and the reasons for that weight." Soc. Sec. Ruling 96-7p, 1996 WL 374186, at *4.

Credibility determinations are reserved for the ALJ. Van Horn v. Schweiker, 717 F.2d 871, 873 (3d Cir. 1983). Our analysis is therefore restricted to determining if the ALJ's decision is supported by substantial evidence and whether the ALJ applied the correct legal standard; we may not weigh the evidence, and we will not set the ALJ's decision aside if it is supported by substantial evidence, even if we would have decided the factual inquiry differently. Hartranft v. Apfel, 181 F.3d 358, 360 (3d Cir. 1999).

In this case, the ALJ recounted the substance of Swartzbaugh's hearing testimony in great detail. (Tr. 24-25, 27). Based on her consideration of the whole record, the ALJ found "that the claimant's medically determinable impairments could reasonably be expected to cause the alleged symptoms; however, the claimant's statements concerning the intensity, persistence and limiting effects of these symptoms are not entirely credible." (Tr. 25). The ALJ conducted a detailed review of subjective and objective clinical findings contained in Swartzbaugh's medical treatment records. (Tr. 25-26). The ALJ reviewed the various medical opinions provided in the record before her. (Tr. 22-23, 26). She also reviewed the claimant's own testimony regarding his activities of daily living. (Tr. 27). Moreover, the ALJ provided a clear and detailed explanation of her reasoning in reaching her credibility determination. (Tr. 25-27).

Accordingly, the Court finds that there is substantial evidence in the administrative record to support the ALJ's finding that Swartzbaugh's statements concerning the intensity, persistence and limiting effects of his symptoms were not entirely credible, and that this determination was adequately explained and otherwise based upon a correct application of relevant law.

C. RFC Determination

The claimant challenges the ALJ's determination with respect to his RFC, arguing that the ALJ weighed the evidence before her incorrectly, viewing several pieces of information out of context and improperly crediting information in his medical records that Swartzbaugh claims to be false. Essentially, Swartzbaugh asks us to reweigh the same medical evidence reviewed by the ALJ and reach a different conclusion.

As we noted above, our review here is limited to a determination of whether or not the ALJ's decision is supported by substantial evidence. We are not permitted to reweigh the evidence or impose our own factual determinations. See Chandler v. Comm'r of Soc. Sec., 667 F.3d 356, 359 (3d Cir. 2011) ("Courts are not permitted to re-weigh the evidence or impose their own factual determinations."); Williams v. Sullivan, 970 F.2d 1178, 1182 (3d Cir. 1992) ("Neither the district court nor this court is empowered to weigh the evidence or substitute its conclusions for those of the fact-finder."). "The question is not whether Plaintiff demonstrated some findings that could support a finding of disability. The question is whether the ALJ reasonably concluded that the objective medical evidence failed to support his claims." Kirk v. Colvin, Civil Action No. 4:13-CV-02735, 2015 WL 5915748, at *13 (M.D. Pa. Oct. 8, 2015).

In this case, consistent with the regulations and with agency policy, the ALJ developed her RFC determination based on an independent analysis of the relevant evidence, and she addressed the claimant's limitations in terms of work-related functions. See 20 C.F.R. § 404.1545. Based on her administrative finding with respect to Swartzbaugh's residual functional capacity and the testimony of a vocational expert, she determined that the claimant was capable of performing jobs that existed in significant numbers in the national economy.

Accordingly, the Court finds that there is substantial evidence in the administrative record to support the ALJ's finding that Swartzbaugh could perform a limited range of medium work, and that this determination was adequately explained and otherwise based upon a correct application of relevant law.

VI. RECOMMENDATION

For the foregoing reasons, it is recommended that the decision of the Commissioner of Social Security be AFFIRMED and that Swartzbaugh's requests for the award of benefits or remand for a new administrative hearing be DENIED.

NOTICE

NOTICE HEREBY GIVEN that the undersigned has entered the foregoing Report and Recommendation dated March 30, 2018. Any party may obtain a review of the Report and Recommendation pursuant to Local Rule 72.3, which provides:

Any party may object to a magistrate judge's proposed findings, recommendations or report addressing a motion or matter described in 28 U.S.C. § 636(b)(1)(B) or making a recommendation for the disposition of a prisoner case or a habeas corpus petition within fourteen (14) days after being served with a copy thereof. Such party shall file with the clerk of court, and serve on the magistrate judge and all parties, written objections which shall specifically identify the portions of the proposed findings, recommendations or report to which objection is made and the basis for such objections. The briefing requirements set forth in Local Rule 72.2 shall apply. A judge shall make a de novo determination of those portions of the report or specified proposed findings or recommendations to which objection is made and may accept, reject, or modify, in whole or in part, the findings or recommendations made by the magistrate judge. The judge, however, need conduct a new hearing only in his or her discretion or where required by law, and may consider the record developed before the magistrate judge, making his or her own determination on the basis of that record. The judge may also receive further evidence, recall witnesses or recommit the matter to the magistrate judge with instructions.

Failure to file timely objections to the foregoing Report and Recommendation may constitute a waiver of any appellate rights.

FootNotes


1. Pursuant to Rule 25(d) of the Federal Rules of Civil Procedure, Acting Commissioner Nancy A. Berryhill is automatically substituted as the named defendant in place of the former Commissioner of Social Security.
2. A "physical or mental impairment" is an impairment resulting from "anatomical, physiological, or psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques." 42 U.S.C. § 423(d)(3).
3. "Substantial gainful activity" is work that (1) involves performing significant or productive physical or mental duties, and (2) is done (or intended) for pay or profit. 20 C.F.R. § 404.1510.
4. An extensive list of impairments that warrant a finding of disability based solely on medical criteria, without considering vocational criteria, is set forth at 20 C.F.R., Part 404, Subpart P, Appendix 1.
5. "Residual functional capacity" is the most a claimant can do in a work setting despite the physical and mental limitations of his or her impairment(s) and any related symptoms (e.g., pain). 20 C.F.R. § 404.1545(a)(1). In assessing a claimant's RFC, the Commissioner considers all medically determinable impairments, including those that are not severe. Id. § 404.1545(a)(2).
6. "Under 20 C.F.R. § 404.131, [a claimant] is required to establish that he became disabled prior to the expiration of his insured status." Matullo v. Bowen, 926 F.2d 240, 244 (3d Cir. 1990).
7. In doing so, Dr. Suminski explicitly considered Dr. Hart's opinions and found them "not consistent with totality of [medical evidence of record] and treatment." (Tr. 95).
8. We note that the treating physician rule applicable in this case was subsequently eliminated by an amendment to the rules effective March 27, 2017. See Revisions to Rules Regarding the Evaluation of Medical Evidence, 82 Fed. Reg. 5844 (Jan. 18, 2017).
9. We note that 20 C.F.R. § 404.1527 was amended in 2012, with the subsection formerly labeled as § 404.1527(d)—referenced in this quoted language from Social Security Ruling 96-5p—being renumbered as § 404.1527(c), but without any substantive change. See How We Collect and Consider Evidence of Disability, 77 Fed. Reg. 10,651, 10,656 (Feb. 23, 2012) (codified at 20 C.F.R. pt. 404 and 416).
Source:  Leagle

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