GEORGE J. LIMBERT, Magistrate Judge.
Darlene R. Owens ("Plaintiff") seeks judicial review of the final decision of Carolyn W. Colvin ("Defendant"), Acting Commissioner of the Social Security Administration ("SSA"), denying her applications for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI"). ECF Dkt. #1. For the following reasons, the Commissioner's decision is affirmed and Plaintiff's complaint is dismissed with prejudice:
On October 28, 2010 and November 2, 2010, Plaintiff applied for SSI and DIB, alleging disability beginning April 20, 2010. ECF Dkt. #12 ("Tr.") at 189-199.
On January 29, 2013, Plaintiff filed the instant suit seeking review of the Decision. ECF Dkt. #1. On May 22, 2013, Plaintiff filed a brief on the merits. ECF Dkt. #17. On June 19, 2013, Defendant filed a brief on the merits. ECF Dkt. #18. A reply brief was filed on July 3, 2013. ECF Dkt. #20.
The ALJ determined that Plaintiff, who was fifty-one years of age on the alleged onset date and fifty-three years of age at the hearing, suffered from cervical and lumbar degenerative disc disease, and adjustment, depressive, and anxiety disorders with a history of alcohol abuse, which qualified as severe impairments under 20 C.F.R. §§ 404.1520(c) and 416.920(c). Tr. at 21. The ALJ further determined that Plaintiff did not have an impairment or combination of impairments that met or medically equaled one of the impairments listed in 20 C.F.R. Part 404, Subpart P, Appendix 1, 20 C.F.R. §§404.1520(d), 404.1525, 404.1526, §416.920(d), 416.925 and 416.926 ("Listings"). Tr. at 22-23.
The ALJ found that Plaintiff had the residual functional capacity ("RFC") to perform light work as defined in 20 C.F.R. §404.1567(b) and 416.967(b), except that she must be permitted to alternate between sitting and standing positions at will, and she is limited to low stress work, defined as work performed at a non-production or low-quota pace. Tr. at 23.
The ALJ ultimately concluded that, although Plaintiff could no longer perform her past work as a picker, there were jobs that existed in significant numbers in the national economy that Plaintiff can perform, including the representative occupations of inspector and assembler. Tr. at 33. As a consequence, the ALJ found that Plaintiff had not been under a disability as defined in the SSA and was not entitled to benefits.
An ALJ must proceed through the required sequential steps for evaluating entitlement to benefits. These steps are:
Hogg v. Sullivan, 987 F.2d 328, 332 (6th Cir. 1992). The claimant has the burden to go forward with the evidence in the first four steps and the Commissioner has the burden in the fifth step. Moon v. Sullivan, 923 F.2d 1175, 1181 (6th Cir. 1990).
Under the Social Security Act, the ALJ weighs the evidence, resolves any conflicts, and makes a determination of disability. This Court's review of such a determination is limited in scope by § 205 of the Act, which states that the "findings of the Commissioner of Social Security as to any fact, if supported by substantial evidence, shall be conclusive." 42 U.S.C. § 405(g). Therefore, this Court's scope of review is limited to determining whether substantial evidence supports the findings of the Commissioner and whether the Commissioner applied the correct legal standards. Abbott v. Sullivan, 905 F.2d 918, 922 (6
The substantial-evidence standard requires the Court to affirm the Commissioner's findings if they are supported by "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Cole v. Astrue, 661 F.3d 931, 937, citing Richardson v. Perales, 402 U.S. 389, 401, 91 S.Ct. 1420, 28 L.Ed.2d 842 (1971) (citation omitted). An ALJ's failure to follow agency rules and regulations "denotes a lack of substantial evidence, even where the conclusion of the ALJ may be justified based upon the record." Cole, supra, citing Blakely v. Comm'r of Soc. Sec., 581 F.3d 399, 407 (6th Cir.2009) (citations omitted). The Court cannot reverse the decision of an ALJ, even if substantial evidence exists in the record that would have supported an opposite conclusion, so long as substantial evidence supports the ALJ's conclusion. Walters v. Comm'r of Soc. Sec., 127 F.3d 525, 528 (6
Prior to sustaining the injury that precipitated Plaintiff's disability applications, she sought treatment for several injuries, including neck and shoulder pain resulting from a fall from a trampoline (she landed on her head) in 1999, a fractured right clavicle she sustained when she fell from a mini-bike (she landed on her shoulder) in 2004, two subsequent re-fractures of the right clavicle, as well as anxiety, nasal polyps, seasonal allergies, irritable bowel syndrome, and high blood pressure. Tr. at 287, 368, 855, 863.
Shortly before sustaining the injury that precipitated Plaintiff's disability applications, at an appointment on March 24, 2010 with Brenda S. Buis, D.O., Plaintiff's primary care physician, Plaintiff complained of bilateral pain in her legs, with more severe pain in her left leg, which began a month prior to the appointment. She reported that it felt like "blood squishing through her leg." Tr. at 867. Plaintiff returned to Dr. Buis' office on April 6, 2010 for an evaluation of doppler studies performed on March 25, 2010. Tr. at 865. Plaintiff reported no alleviation of her pain, but the treatment notes do not include any analysis of the doppler studies. Dr. Buis instructed Plaintiff to return in one week.
On April 15, 2010, Plaintiff slipped on "a bunch of plastic zip-ties" that had been left on the floor at work and injured her back. Tr. at 347-348, 365. At an appointment on April 20, 2010 (the alleged onset date) with Dr. Buis, Plaintiff complained of back pain in her right upper and right lower back and requested an MRI. Tr. at 863-864.
On April 21, 2010, Plaintiff visited Bina Mehta, M.D. her established pain management provider from prior injuries, Tr. at 728-755, 1027-1096, 1119-20, and reported chronic stabbing neck pain radiating into her skull and shoulders, weakness in her legs, numbness in her toes, aching in her scapular area, and tightness and spasms in her neck. Tr. at 1149. Plaintiff had no difficulties in motor strength, gait, reflexes, or sensation, but Dr. Mehta noted numerous trigger points, a restricted range of head and neck motion, and tenderness in the thoracic/rib area. Tr. at 1150-1152. Dr. Mehta diagnosed neck and thoracic spine sprain and strain. Tr. at 1152. He provided a note that Plaintiff could not work until April 30, 2010 and prescribed pain medication. Tr. at 1152.
Dr. Buis' treatment notes from April 28, 2010 indicate that Plaintiff was there to review a nerve conduction study performed on April 13, 2010. Tr. at 840. Plaintiff described herself as "achy." Tr. at 840. However, no analysis of the nerve conduction study is included in Dr. Buis' treatment notes. Likewise, at an appointment on May 3, 2010, Plaintiff sought an evaluation and review of an MRI. Tr. at 836. No analysis appears in the treatment notes. Plaintiff returned to Dr. Buis on May 10, 2010 and she continued to report bilateral leg pain, with no improvement from prior therapies. Tr. at 834. Again, under the heading "Chief Complaint," Dr. Buis writes, "Pt states here to evaluate lab results done on 5-10-10," however no analysis appears in the treatment notes. Tr. at 833.
On June 1, 2010, Dr. Mehta wrote a second note that Plaintiff could not work until July 6, 2010. Tr. at 296. On June 7, 2010, Plaintiff visited Michael Pryce, M.D., a workers' compensation physician who treated her previous injuries to her clavicle. Tr. at 349. She reported neck, shoulder, and back pain. Tr. at 365-67. Dr. Pryce diagnosed lumbar and cervical spine pain with right shoulder pain and bursitis. Tr. at 367. His examination revealed reasonable range of motion in Plaintiff's cervical spine and good range of motion in Plaintiff's lumbar spine and her extremities. Tr. at 366.
On June 14, 2010, Dr. Pryce reviewed the results of an MRI of Plaintiff's cervical spine and noted: (1) disc osteophyte complexes causing mild spinal stenosis and cord impingement at C4-5, C5-6, and C6-7; (2) moderate narrowing of the neural foramina at C4-5; and (3) severe narrowing of the neural foramina at C5-6 and C6-7. Tr. at 345-346, 374-375, 765-766, 1117-1118.
On June 21, 2010, Dr. Pryce reviewed the results of an MRI of Plaintiff's lumbar spine, which revealed: (1) multi-level facet arthropathy and degenerative disc disease without spinal stenosis; (2) right extraforaminal nuclear protrusion at L3-4 causing mild displacement of the left L3 nerve root; (4) right foraminal/extraforaminal nuclear protrusion at L4-5 contacting the left L4 nerve root; and (5) hepatomegaly. Tr. at 343, 372-73, 767-68.
Dr. Pryce opined that it was "well within the realm of reasonable medical certainty" that Plaintiff's herniated discs were caused by her work injury. Tr. at 343. Dr. Pryce's treatment notes also reveal that Plaintiff believed that her Worker's Compensation file had been altered by her employer.
At an appointment with Dr. Buis on June 25, 2010, Plaintiff requested a referral to a neurologist. Tr. at 831. Plaintiff also requested analysis of the MRI performed for Dr. Pryce, which is not included in the treatment notes. The treatment notes reveal that the appointment was twentyfive minutes in length and included "counseling regarding coping mechanisms [and] smoking cessation program." Tr. at 832.
On July 13, 2010, Plaintiff visited Hugh J. Miller, M.D., a neurologist, complaining of bilateral leg pain for the last three years. Tr. at 378-381. She denied any weakness in her legs, and also denied any back or neck pain, other than "mild aches" since her fall in April of 2010. Tr. at 378. Plaintiff disclosed smoking, drinking alcohol, and "weightlifting daily." Tr. at 379. Dr. Miller diagnosed probable small fiber peripheral neuropathy possibly related to alcohol use. Tr. at 380. Dr. Miller instructed Plaintiff to stop smoking and drinking alcohol. Tr. at 380-381. Plaintiff agreed to stop drinking prior to starting any medication. Tr. at 381. Dr. Miller reviewed Plaintiffs' June 9, 2010 MRIs and noted no compression of the spinal cord and no intrinsic lesions of the cord at the cervical spine, and no compression or stenosis, but mild degenerative changes, at the lumbar spine. Tr. at 380.
Plaintiff underwent treatment for her cervical and lumbar pain in August, September, and October of 2010. She received multiple cervical and lumbar epidural steroid injections. Tr. at 769-773, 787, 790, 798, 800, 807.
On November 23, 2010, Plaintiff reported to Dr. Buis that pain medication provided moderate improvement in her symptoms, but that she continued to suffer severe back pain. Tr. at 825-26. Plaintiff returned to Dr. Pryce on December 1, 2010, when he noted "a lot of problems with her neck and radicular pain in both upper and lower extremities," as well as depression. Tr. at 974. Dr. Pryce considered Plaintiff "heading towards a full and complete disability."Tr. at 974. Four weeks later, on December 29, 2010, Dr. Pryce noted large masses on each of her elbows and on her thighs, but Plaintiff explained that Dr. Buis had conducted "all kinds of appropriate lab tests" with normal results. Tr. at 973. Following an examination, Dr. Pryce suspected possible blood dyscrasia. Tr. at 973.
An MRI of Plaintiff's thoracic spine performed on November 29, 2010 was grossly similar in appearance to a prior study from August of 2009. Tr. at 987.
Plaintiff returned to Dr. Mehta regularly through 2011. Tr. at 983-986, 1140, 1144, 1017-1026, 1175-1187. On March 4, 2011, Dr. Mehta completed a "Residual Functional Capacity Questionnaire" on Plaintiff's behalf in which he concluded that Plaintiff is disabled within the meaning of the Act. Tr. at 945. Specifically, Dr. Mehta opined that Plaintiff could occasionally lift and carry up to ten pounds; sit for four hours, stand for two hours, walk for two hours, and work a total of four hours in an eight-hour day; never bend, squat, or crawl; occasionally climb, reach, stoop, crouch, and kneel; occasionally tolerate exposure to unprotected heights, moving machinery, temperature changes, and environmental irritants such as dust, fumes, and gases; and frequently drive auto equipment; but would be absent from work more than three times a month. Tr. at 946-947.
On April 20, 2011, Dr. Pryce noted that Plaintiff had trouble moving due to stiff joints and was depressed. Tr. at 972. He wrote that "with all of the depression, all of the somatic complaints that this woman has that she certainly qualifies for 100% disability under SSI." Tr. at 972. Dr. Pryce continued to opine that Plaintiff needed disability through August of 2011. Tr. at 1190.
On June 13, 2011, Plaintiff visited Jeffrey S. Tharp, D.O., a orthopedic spine surgeon, for a consultation. Tr. at 1170-71. She reported longstanding diffuse non-dermatomal cervical and lumbar pain and aches in her legs. Tr. at 1170. On examination, Dr. Tharp noted a normal stance and gait, good strength with heel and toe ambulation, a limited range of back motion, diminished reflexes, intact sensation, full strength, and a negative straight leg-raising test. Tr. at 1170-171.
Dr. Tharp diagnosed cervical, thoracic, and lumbar degenerative disc disease, spondylosis with axial pain, and probable disc and facet arthropathy causing some stenosis of the lower extremities. Tr. at 1171. Dr. Tharp recommended continued conservative care, including epidural steroid injections. Tr. at 1171. In the event that epidural injections did not successfully diminish her pain, Dr. Tharp suggested another MRI and EMG. He wrote, "If that shows discopathology that is compressive correlate and EMG/NCT and then I will gladly see her in re-surgical evaluation." Tr. at 1171.
In June of 2011, Dr. Mehta treatment notes document tenderness and restricted range of motion in the spine, and Plaintiff had joint swelling and pain, along with muscle cramps and weakness. Tr. at 1181-1182, 1185. On August 10, 2011, Dr. Pryce stated that she looks terrible when she stands, that "she tucks her pelvis up underneath her because of the pain" and his conclusion after an examination was that "she really is not progressing well." Tr. at 1190. On August 15, 2011 Dr. Mehta again found her to have tenderness and restricted range of motion in the spine. Tr. at 1177. Dr. Pryce's examination on September 19, 2011 noted a "terrible paravertebral spasm in her neck and back," and that she still has trouble with the shoulder. Tr. at 1189.
On August 15, 2011, Dr. Mehta noted a slow, intact gait, mildly restricted cervical and lumbar ranges of motion, full strength, normal reflexes, and a negative straight leg-raising test. Tr. at 1177. Plaintiff reported being satisfied with her treatment and that her medication "takes the edge off the pain and allows her to perform her ADL's." Tr. at 1175. Dr. Mehta transferred Plaintiff to another pain management provider since he "had nothing further to offer." Tr. at 1178.
Plaintiff visited James Bressi, D.O., at Summit Pain Specialists on October 4, 2011. Tr. at 1192-1195. An examination of her spine and extremities found her to be positive for pain, tenderness, muscle spasms, limited range of motion, and radicular pain in different areas. Tr. at 1193. She was diagnosed with a variety of conditions involving the spinal region, including cervical and lumbar radiculitis. Tr. at 1195.
Plaintiff returned to Dr. Buis for treatment of back pain and depression through February 2012. Tr. at 1200-1215, 1229-1235. Examinations established muscle tenderness with limited range of motion. Tr. at 1202, 1209, 1213. Plaintiff was diagnosed with chronic pain syndrome. Tr. at 1202, 1206, 1209, 1213. On May 15, 2012, Dr. Buis completed a "Residual Functional Capacity Form — Physical," indicating that Plaintiff was essentially disabled within the meaning of the Act. Tr. at 1241. Specifically, Dr. Buis opined that Plaintiff could sit, stand, and walk for one hour; required a sit/stand option; could frequently lift up to ten pounds; never squat, reach below the waist, push, pull, or use her feet for foot controls; occasionally bend, crawl, climb, and reach above or at waist level; never be exposed to unprotected heights, moving machinery, temperature extremes, or environmental irritants; drive automotive equipment on a moderate basis; and would be absent from work three or more days each month. Tr. at 1241.
On December 22, 2010, W. Jerry McCloud, M.D., a state agency physician, reviewed the medical evidence of record and opined that Plaintiff could perform light exertional work. Tr. at 80-81, 92-93. On May 31, 2011, Gary Hinzman, M.D., a second state agency physician, reviewed the medical evidence of record and concurred that Plaintiff could perform a full range of light exertional work. Tr. at 111-112, 128-129.
Plaintiff attended high school through the eleventh grade and does not have a high school diploma. Tr. at 220. She testified that her injury in 2010 "really ruined the rest of [her] back." Tr. at 47. She was already having problems with part of her upper back at the time, and the fall affected her lower back and the rest of her upper back. At the time of the hearing, she was prescribed Vicodin, 1000 mg., five times a day. Tr. at 47-48. She testified that she is also prescribed an antidepressant, an anti-anxiety medication, Atelvia for the treatment of osteopenia, and Valtrex. Tr. at 48.
At the time of the hearing, Plaintiff's residence was in foreclosure. She lived there with her twenty-six year old son. Plaintiff drove "a couple miles around the house," including trips to the grocery store, which was near her home. Plaintiff testified that both of her sons and her neighbor helped her around the house.
Plaintiff further testified that she no longer drank alcohol because she takes so much prescription medication. However, later in her testimony, Plaintiff stated that she limits her alcohol consumption to the weekends, and she does not believe that it affects her depression. She explained that her statement in the treatment notes that she was lifting weights daily was actually a reference to the weight of the material she lifted at work. Tr. at 49.
Plaintiff identified Dr. Miller as a "company doctor" and accused him of falsifying records on behalf of her employer. Tr. at 51. She testified that she was not drinking heavily at that time, and recalled that Dr. Miller, who was not a company doctor, but, instead, the neurologist to whom Plaintiff was referred by Dr. Buis at Plaintiff's request, was rude to her. Tr. at 52. When asked how much alcohol she was drinking in the summer of 2010, she responded "hardly none" because "[her] whole body was shaking inside." Tr. at 52. Plaintiff conceded that she may have been drinking alcohol up to five times a day before the accident in April of 2010. Tr. at 53. However, Dr. Mehta's treatment records dated November 12, 2010 document a positive urine screen revealing both alcohol and marijuana use. Tr. at 778.
Plaintiff testified that she must divide her house cleaning into two days because she cannot clean the whole house in one day. Tr. at 54. She further testified that if she does anything physical, she must rest for the following two days. She rarely prepares meals. Tr. at 59. Her son assists her with household chores. Tr. at 63. She is capable of performing two to four hours of housework, but she must lay down afterward, and she experiences pain the following couple of days.
She experiences pain in both of her legs, her hips, her lower back, her upper back, and in her shoulders and shoulder blades. Tr. at 54. She can stand for thirty minutes then her legs start shaking. Tr. at 55. Plaintiff shops for groceries, but not often, and she relies on the shopping cart for support. Plaintiff believes that she can walk across the street to her neighbor's backyard.
She has had a few falls. Tr. at 56. Plaintiff treats her back pain with heat and ice. She sees a chiropractor and gets epidural injections every six months. Plaintiff believes that, without treatment, she could not walk. Tr. at 57.
Plaintiff also experiences neck pain that limits the range of motion in her neck. She testified that she owns a laptop computer, and that she can use it for up to one hour, then she must get up or lay down. She also experiences numbness in her arms, which occurs when she reaches above her head. Tr. at 59. She testified that she can lift a maximum of ten pounds.
Plaintiff further testified that she is depressed because she has lost everything. Tr. at 59. She suffers from anxiety and is angry with her employer for "putting [her] in the streets" after her years of service. Plaintiff has "bad days" every couple of weeks when she does not want to get dressed. Tr. at 60. However, she testified that she is improving with treatment. She has difficulty concentrating, but that problem is also improving with treatment. Tr. at 62.
The ALJ gave little weight to the opinion of Dr. Pryce. Specifically, the ALJ wrote:
Tr. at 26-27.
The ALJ further wrote:
Tr. at 29.
The ALJ also gave little weight to the opinion of Dr. Buis. The ALJ wrote:
Tr. at 30.
With respect to Dr. Mehta, the ALJ observed:
Tr. at 31
The ALJ, instead, credited the opinions of the agency physicians because they were consistent with the manifest evidence in the record. Tr. at 31. The ALJ wrote, "While the medical evidence establishes that [Plaintiff] has documented degenerative spinal impairments, with some evidence of radiculopathy, the medical evidence does not support the magnitude of pain and dysfunction asserted by [Plaintiff.] According these agency opinions significant weight, therefore, I find that [Plaintiff] has the residual capacity for light work set forth above." Tr. at 31.
Plaintiff advances a single argument in this appeal. Plaintiff contends that the ALJ erred in assigning little weight to the opinions of two treating physicians, Dr. Buis and Dr. Mehta, both of whom opined that she is unable to lift more than ten pounds. Plaintiff reasons that, based upon these conclusions, she is only capable of sedentary
An ALJ must adhere to certain standards when reviewing medical evidence in support of a claim for social security. Most importantly, the ALJ must generally give greater deference to the opinions of the claimant's treating physicians than to those of non-treating physicians. SSR 96-2p, 1996 WL 374188 (July 2, 1996); Wilson, 378 F.3d at 544. A presumption exists that the opinion of a treating physician is entitled to great deference. Id.; Rogers, supra, at 243 (6th Cir. 2007). If that presumption is not rebutted, the ALJ must afford controlling weight to the opinion of the treating physician if that opinion regarding the nature and severity of a claimant's conditions is "well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with other substantial evidence in [the] case record." Wilson, 378 F.3d at 544.
When an ALJ determines that a treating physician's opinion is not entitled to controlling weight, he must consider the following factors in determining the weight to give to that opinion: the length, frequency, nature, and extent of the treatment relationship; the supportability and consistency of the physician's conclusions; the specialization of the physician; and any other relevant factors. Id.
If an ALJ decides to discount or reject a treating physician's opinion, he must provide "good reasons" for doing so. SSR 96-2p. The ALJ must provide reasons that are "sufficiently specific to make clear to any subsequent reviewers the weight the adjudicator gave to the treating source's medical opinion and the reasons for that weight." Id. This allows a claimant to understand how his case is determined, especially when he knows that his treating physician has deemed him disabled and he may therefore "`be bewildered when told by an administrative bureaucracy that he is not, unless some reason for the agency's decision is supplied.'" Wilson v. Commisioner of Social Security, 378 F.3d 541, 544 (6
On the other hand, "opinions from nontreating and nonexamining sources are never assessed for `controlling weight.'" Gayheart v. Comm'r of Soc. Sec., 710 F.3d 365, 376 (6
In Gayheart, the Sixth Circuit recognized that conflicting substantial evidence must consist of "more than the medical opinions of the nontreating and nonexamining doctors." The Sixth Circuit reasoned that "[o]therwise the treating-physician rule would have no practical force because the treating source's opinion would have controlling weight only when the other sources agreed with that opinion." Gayheart at 377. However, "[t]he determination of disability is [ultimately] the prerogative of the [Commissioner], not the treating physician." Warner v. Comm'r of Soc. Sec., 375 F.3d 387, 390 (6th Cir. 2004) quoting Harris v. Heckler, 756 F.2d 431, 435 (6th Cir.1985).
Here, the ALJ clearly articulated his reasons for rejecting the opinions of Drs. Pryce, Buis, and Mehta. First, the ALJ opined that Dr. Pryce's conclusion that Plaintiff was completely disabled was not supported by Dr. Pryce's treatment notes, which did not include sufficient examination or analysis by Dr. Pryce. Moreover, the ALJ cited the fact that Dr. Pryce's treatment notes were often directly at odds with his conclusion insofar as he frequently recorded normal findings with respect to Plaintiff's spinal problems. Dr. Buis' treatment notes contained several references to various diagnostic tests, but her treatment notes did not include any analysis of those tests. The ALJ further observed that Dr. Buis' conclusions were at odds with one another, particularly with respect to Plaintiff's ability to sit, stand, walk, and drive. Similarly, Dr. Mehta's treatment notes failed to support Dr. Mehta's dire conclusions regarding Plaintiff's ability to perform full-time work. Dr. Mehta opined that Plaintiff was able to sit for four hours, and stand and walk for two hours, but, nonetheless concluded that Plaintiff could only work four hours per day. Due to the fact that the opinions of Plaintiff's physicians regarding her ability to work were internally inconsistent, as well as inconsistent with other substantial evidence in the record, the ALJ did not err in giving little weight to those opinions, including Dr. Mehta's opinion that Plaintiff could only lift ten pounds occasionally. Instead, the ALJ credited the opinions of the agency physicians, which he found were supported by substantial evidence in the record. State agency physicians are "highly qualified . . . experts in Social Security disability evaluation." 20 C.F.R. § 404.1527(f)(2)(i), 416.927(f)(2)(i).
For the foregoing reasons, the Commissioner's decision is AFFIRMED and Plaintiff's complaint is DISMISSED with prejudice.
