JOHN R. FROESCHNER, Magistrate Judge.
Before the Court, with the consent of the parties, are competing Motions for Summary Judgment filed by Plaintiff Alfred Quintanilla (Dkt. No. 23) and Defendant Carolyn W. Colvin, the Acting Commissioner of the Social Security Administration (Dkt. No. 24). The Motions pertain to Quintanilla's appeal of the denial of his application for Social Security Benefits. Having considered the motions and responsive briefing, the administrative record
Alfred Quintanilla ("Quintanilla") filed an application with the Social Security Administration ("SSA") on May 9, 2009, seeking disability benefits ("DIB") under Title II and supplemental security income ("SSI") under Title XVI. Quintanilla alleges that his disability began on April 25, 2009, due to leukemia, diabetes mellitus, bone and joint aches and weakness and fatigue. (Transcript ("Tr.") 190-199, 217).
After being denied benefits initially and on reconsideration, Quintanilla requested, and was granted, a hearing before an Administrative Law Judge ("ALJ") to review the denial. The ALJ, Bernard J. McKay, held the hearing on September 16, 2010. (Tr. 30-67, 126-171). During the hearing, the ALJ heard testimony from Quintanilla, who was represented by counsel, and from an impartial vocational expert ("VE"), Jeffrey T. Kiel. On November 17, 2010, the ALJ issued a decision that was unfavorable to Quintanilla. (Tr. 10-19).
Quintanilla's attorney requested review by the Appeals Council of the SSA's Office of Hearing and Appeals and submitted additional documents for consideration, but his request was denied on June 14, 2012. (Tr. 1-5, 6-8). Accordingly, the decision of the ALJ became the final decision of the Commissioner and it is from this final decision that the appeal has been taken pursuant to 42 U.S.C. § 405(g).
In this motion, Quintanilla argues that the ALJ's decision is not supported by substantial evidence and that the ALJ failed to adhere to the proper legal standards when evaluating the evidence as it pertains to his residual functional capacity. In particular, Quintanilla contends that (1) the ALJ's failed to consider all his impairments when making the RFC findings; and (2) the ALJ failed to properly evaluate the opinion of his treating physician. He also maintains that, having only the ability to do sedentary work, the ALJ's errors were not harmless because he was considered an individual who was closely approaching advanced age and, as such, the Medical-Vocational Rules would have directed the ALJ make a finding that he was disabled. The Commissioner, in contrast, contends in her motion that there is substantial evidence in the record to support the ALJ's decision, that the decision comports with applicable law, that any deficiency in the ALJ's written decision constitutes harmless error, and that the decision should be affirmed. (Tr. 24).
The Court analyzes Motions under the well-established summary judgment standard. Fed. R. Civ. P. 56(c); see generally, Anderson v. Liberty, Inc., 477 U.S. 242, 248 (1986); Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 576, 586-87 (1986); Burge v. Parish of St. Tammany, 187 F.3d 452, 464 (5
A federal court reviews the Commissioner's denial of benefits only to ascertain whether (1) the final decision is supported by substantial evidence and (2) the Commissioner used the proper legal standards to evaluate the evidence. Brown v. Apfel, 192 F.3d 492, 496 (5
A claimant bears the burden of proving he suffers from a disability under the Social Security Act. Anthony, 954 F.2d at 293. The mere presence of an impairment does not necessarily establish a disability. Id. A claimant is only disabled within the meaning of the Social Security Act if he has a medically determinable physical or mental impairment lasting at least 12 months that prevents his from engaging in substantial gainful activity. 42 U.S.C. § 423(d)(1)(A). To determine whether an individual is disabled, the Commissioner utilizes the five-step sequential evaluation process set forth in the regulations. See Anthony, 954 F.2d at 293; see also Leggett v. Chater, 67 F.3d 558, 563 n.2 (5
The central dispute in this action is the assessment of Quintanilla's residual functional capacity. In particular, the ALJ determined that he had the residual functional capacity to perform a full range of light work as defined in the regulations.
On May 5, 2009, Quintanilla applied for benefits due to leukemia, diabetes mellitus, bone and joint aches and weakness and fatigue. (Tr. 190-199, 217). On the date of his alleged onset, April 25, 2009, Quintanilla was nearly fifty years old. (Tr. 213). He attended high school through 10
The medical records in this case date back to 2008. These early records (i.e., December 2008 and January 2009) relate to the care Quintanilla received for his diabetes. (Tr. 397-401, 402, 404-407). Despite having been diagnosed with diabetes years before, the records reflect that Quintanilla had not taken medication to control his diabetes since 2004. Dr. McFarland, who was Quintanilla's family practice doctor, ordered tests and determined that Quintanilla had elevated glucose levels. Dr.McFarland diagnosed Quintanilla with uncontrolled diabetes, prescribed him with medication, instructed him to monitor his blood sugar levels and to return for a follow-up visit. (Tr. 397-401, 402, 404-407).
The records reflect that approximately three months later (i.e., April 25, 2009), Quintanilla presented at the emergency room ("ER") at Memorial Medical Center due to the development of an abscess on his groin that was accompanied by fever. (Tr. 221, 296-319). Based on the records, Quintanilla denied experiencing any specific muscle or joint pain, stiffness or gout; he had no swelling, warmth, pain or redness over the joints; no limitations of activities reported; and no weakness or muscle cramps. (Tr. 523). Quintanilla underwent physical examination and he was found to have a full range of motion in his neck without pain, shoulder shrug and range of motion without weakness, and a full range of motion without tenderness in his joints and extremities. (Tr. 524-525). Consistent with the findings from the physical examination, a whole body scan revealed only minor degenerative changes of the sacroiliac joints, minor degenerative changes of the shoulder and knee joints, and no evidence of abnormal uptake in the axial or appendicular skeletons to suggest a fracture or metastatic disease. (Tr. 420). Nonetheless, Quintanilla was hospitalized because additional testing (i.e., blood work, a biopsy and a bone scan) revealed that Quintanilla had type II diabetes and chronic lymphocytic leukemia ("CLL"). (Tr. 221, 296-303, 418-424). The doctors determined that the type of leukemia that Quintanilla had "usually progress very slowly and have a significantly better clinical outcome than ZAP-70 — positive cases." (Tr. 411). After Quintanilla's conditions (i.e., the diabetes and the CLL) were stabilized, he was discharged from the hospital on May 4, 2009. (Tr. 307-308, 325).
Shortly after his discharge from the hospital, Quintanilla saw Dr. Ahmad Qadri, M.D., P.A. on May 13, 2009 (Tr. 429-430) and then visits to Dr. McFarland followed on May 14 and May 20, 2009. (Tr. 392-394). The notes from these visits reflect Quintanilla's report that his energy level was poor and that he was experiencing weakness and "severe fatigue." (Tr. 394, 429-430). Quintanilla was examined and the notes reflect that he had a full range of motion with no bone or muscle tenderness. Additionally, Dr. Qadri advised Quintanilla that no intervention was needed at that time, but routine follow-up visits were recommended. (Tr. 429-430).
While continuing to treat Quintanilla's diabetic condition (Tr. 704-705, 714-716), Dr. McFarland referred him to M.D. Anderson for further evaluation and/or treatment of his leukemia. (Tr. 748). On September 14, 2009, Quintanilla first met with Dr. Wierda, a specialist at M.D. Anderson, and, a month later he returned for a follow-up visit. (Tr. 725-728, 729-730).
During his initial visit, Quintanilla reported that he experienced fatigue that he rated as an "8/10" in terms of severity. (Tr. 729). A physical examination was performed and Dr. Wierda noted his findings as follows:
(Tr.729, 810-812). Dr. Wierda ordered additional testing which included blood work and a bone marrow test. (Tr. 729, 802, 810-812). Based on his exam and the results of the tests, Dr. Wierda diagnosed Quintanilla as a patient with "relatively recently diagnosed previously untreated chronic lymphocytic leukemia" ("CLL"), however, he noted that Quintanilla had "a stable white blood cell count." (Tr. 729). Dr. Wierda also expressed his opinion that there was no indication for immediate treatment and, unless otherwise indicated, only annual follow-up visits were necessary. (Tr. 726, 729). Although Dr. Wierda acknowledged that Quintanilla "does have symptoms of fatigue which is prominent," he commented that "this may be related to his diabetes more than his CLL" and advised Quintanilla to follow-up with "his primary care physician for a check of a hemoglobin A1c and [recommended that there be] tighter glycemic control and monitoring." (Tr. 726, 729-730).
The records reflect that Quintanilla next saw Dr. McFarland in or around mid-2010, for follow-up care. (Tr. 736). During the visit, Dr. McFarland advised Quintanilla to monitor and record his blood sugar levels (Tr. 736) and, for further evaluation of his leukemia, Dr. McFarland referred Quintanilla back to Dr. Qadri or M.D. Anderson. (Tr.736-737).
Quintanilla returned to M.D. Anderson to see Dr. Wierda on June 30, 2010. (Tr. 722-724). According to the notes, Quintanilla's chief complaint was that his bones ached in his upper and lower extremities, however, he clarified that he had not experienced any fever, only mild night sweats, no respiratory symptoms, no gastrointestinal symptoms, no genitourinary symptoms, no headaches or focal neurologic symptoms and no "significant illnesses or problems since his last clinic visit." (Tr. 722). Quintanilla underwent a physical examination which yielded no significant findings and his pain level on examination was noted to be "zero." (Tr. 722). Additional tests were performed which revealed that Quintanilla's "serum electrolytes and liver function tests[were] all within normal limits" and that his "[q]uantitative immunoglobulins [were] within normal limits." (Tr. 722). Based on the examination and the results of the lab tests, Dr. Wierda documented his assessment as follows:
(Tr. 722).
Within days of seeing Dr. Wierda, Quintanilla saw Dr. McFarland on July 2, 2010, regarding his "bones ache." (Tr. 734-735). A physical examination was performed, however, no significant findings were noted. (Tr. 735). Nonetheless, due to his continued complaints of pain in his bones, Dr. McFarland ordered a bone destiny test, as well as additional blood work. (Tr. 734).
When Quintanilla returned to see Dr. McFarland on July 16, 2010, to discuss the results of the bone density study, the notes reflect that Quintanilla reported that he was doing "ok." (Tr. 773-774, 780-781). The notes also contain a statement attributed to Quintanilla — in particular, that he was "convinced that blood sugar in 200s [was] okay." (Tr. 773). Dr. McFarland's notes reflect that he prescribed new medication to treat Quintanilla's hypertension and that he ordered addition testing — in the form of CT scans — of Quintanilla's spine. (Tr. 773; 761-766, 782-788). The cervical CT scan, which was performed a short time later, revealed "no definite marrow changes," "no definite evidence of focal disk herniation," and "[m]ild to moderate degenerative changes of the cervical spine." (Tr. 761). The thoracic CT scan revealed no acute fracture or subluxation, no significant disk disease or canal stenosis and only "mild degenerative changes involving the cervical spine." (Tr. 763-764). Finally, the lumbar CT scan revealed "diffuse asymmetrical bulging of the anulus with possible mild narrowing of the proximal left neural foramen at L4-L5" and "Grade 1 anterolisthesis with bilateral spondylolysis and possible rightsided foraminal stenosis."
On August 17, 2010, Quintanilla saw Dr. McFarland for routine lab work. (Tr. 769-770, 776-777). During his visit, Quintanilla complained that he had a knot on his left leg, that he experienced fatigue and that his "bones are hurting." (Tr. 769). Quintanilla also reported that, with medication, his blood sugars were ranging between 130-160. (Tr. 769). According to the notes, a physical examination was performed, but no significant findings were noted in the records. (Tr. 770).
On March 1, 2011, Quintanilla saw Dr. Qadri. (Tr. 823-824). During the visit, Quintanilla complained that he had a poor energy level and that he felt weak. (Tr. 823-824). Dr. Qadri performed a physical examination, however, aside fromt he existence of an enlarged lymph node in the groin area, his notes from the exam reflect nothing remarkable. (Tr. 823). Dr. Qadri's diagnosed Quintanilla with CLL and a small lymphocytic lymphoma and he advised Quintanilla to return in six months for a follow-up visit. (Tr. 823).
Quintanilla saw Dr. Qadri on June 21, 2011, and complained of an enlarged lymph node. (Tr. 825). Dr. Qadri performed a physical examination, but the notes reflect no remarkable findings and his impression of Quintanilla's condition remained unchanged from his prior visit. Nonetheless, Dr. Qadri ordered chest and abdomen CT scans, but the scans showed no evidence of abnormalities. (Tr. 820-822, 825). When Quintanilla returned to see De. Qadri approximately two weeks later, the notes reflect that Quintanilla reported that he "feels fine." (Tr. 826-827). A physical examination was performed and no changes were found in comparison to his prior visit. (Tr. 827). Dr. Qadri instructed Quintanilla to return for a follow-up visit, with labs, in three months. (Tr. 828).
Quintanilla was present and testified before the ALJ at the hearing held on September 16, 2010. (Tr. 32-71). During the hearing, Quintanilla stated that he continues to see his family practice doctor, Dr. McFarland, for the treatment of his diabetes. He explained that he takes prescription medication to control his diabetes. (Tr. 48, 60-63). Quintanilla testified that he experienced fatigue when his blood sugar level went down and that he was on a new medication that had been very effective in controlling his diabetes. (Tr. 60-63). He also explained that he takes prescription medication to control hi hypertension and that he takes some other medication for the "soft tissue" or arthritis pain that he experiences in his lower back. (Tr. 49), In terms of his CLL (leukemia), Quintanilla clarified that he has not yet started chemotherapy and there are no definite plans to do so until his lab results are reviewed. (Tr. 56).
In terms of his daily activities, Quintanilla testified that due to the pain and fatigue, he tends to sleep a lot — taking three or four naps a day. (Tr. 45-46, 51-52, 59). Quintanilla stated that when he wasn't hurting really bad, he would help his finacé around the house and with the shopping. (Tr. 51-52). He testified that his financé drove most of the time, but he explained that he drove "every time [he] gets the chance," which he clarified was "[m]aybe like five, six times" a week. (Tr. 54). Quintanilla explained that he spent some time during the day watching television — albeit not a significant amount of time because he doesn't have cable — and that he also spent time sitting outside getting some sun. (Tr. 52). Finally, he testified that he was able to attend to his own grooming, but that his financé assisted him when he experienced swelling in the lymph nodes in his groin area. (Tr. 53).
Residual functional capacity ("RFC") is a "term of art [that] merely designates the ability to work despite physical or mental impairments." Carter v. Heckler, 712 F.2d 137, 140 ((5
Quintanilla insists that the ALJ's determination is flawed because the ALJ failed to consider all of his impairments and the limiting effects resulting from his conditions when determining his RFC. (Dkt. No. 23 at 4, 7). In particular, he contends that while the "record is replete with [his] complaints of bone pain throughout his body and fatigue," the ALJ ignored this evidence and failed to explain his reasons for rejecting his subjective complaints. (Dkt.No. 24 at 4).
As a preliminary matter, Quintanilla's claim that the ALJ ignored this evidence simply has no merit. A review of the administrative decision clearly reflects that the ALJ considered the entire record when determining Quintanilla's RFC. (Tr. 17). Moreover, the ALJ's decision reflects that he expressly acknowledged that the record contained evidence of Quintanilla's repeated complaints to medical providers that he experienced fatigue and aches and pain in his joints and bones. (Tr. 17). While the ALJ may not have discussed each and every medial finding and opinion in the record, "procedural perfection in administrative proceedings is not required." Mays v. Bowen, 837 F.2d 1362, 1364 (5
Quintanilla next argues that the ALJ failed to explain his reasons for rejecting his subjective complaints. This argument also lacks merit. The law requires the ALJ to make affirmative findings regarding a claimant's subjective complaints. See Falco v. Shalala, 27 F.3d 160, 163 (5
Not dissuaded, Quintanilla argues that the ALJ's credibility determination is flawed because he failed to consider all the objective medical evidence in reaching this conclusion. In particular, Quintanilla argues that the results of the CT scan of his spine adds credence to his subjective complaints of unremitting fatigue and body aches. A review of the administrative decision reflects that the ALJ considered Quintanilla's subjective complaints in light of the objective medical evidence, which included the findings from the CT scan of his spine. The CT scan of Quintanilla's cervical spine revealed no evidence of herniations and only mild to moderate degenerative changes in Quintanilla's cervical spine. (Tr. 761). While the CT scan of his lumbar spine revealed Grade 1 or mild anterolisthesis with bilateral spondylolysis and "possible" right-sided foraminal stenosis at L5-S1 and disc bulging at L4-L5. (Tr. 761-767, 780-781), the repeated physical examinations by his treating doctors revealed no remarkable findings and, in fact, his treating specialists noted that his pain level upon physical examinations was "zero." (Tr. 429-430, 729, 810-812, 722, 770, 772, 823, 827). The ALJ also found that Quintanilla's acknowledged activities were not consistent with the severity of symptoms he claimed. (Tr. 17). For example, the ALJ noted that Quintanilla reported that he drives 5 to 6 times a week, he helps with the household chores, he goes grocery shopping three times a month, he spends time outside, he attends church on Sundays and he is able to care for his own hygiene and grooming. (Tr. 17). Insofar as the ALJ's determination regarding Quintanilla's credibility is supported by substantial evidence in the record, it will not be disturbed by this Court. Chambliss v. Massanari, 269 F.3d 520, 522 (5
Quintanilla next argues the ALJ's RCF determination is not supported by substantial evidence because the ALJ failed to properly analyzed and weigh the opinions of Dr. McFarland, his treating, family/general practice medical doctor. The administrative record contains two opinions expressed by Dr. McFarland — namely, the twice uttered opinion that Quintanilla was unable to work; and the opinion that Quintanilla's exertional limitations restricted him to a limited range of sedentary work. (Tr. 579, 587; 731-733).
Initially, with regard to the first opinion, the ALJ acknowledged that Dr. McFarland expressed the opinion that Quintanilla was unable to work in August 2009 and, again, in April 2010. (Tr. 17, 747, 748). While it is evident from the decision that the ALJ considered Dr. McFarland's opinion concerning his ability to work, the ALJ is not required to give any special significance to the opinion, nor is he required to justify his decision because this determination is expressly reserved for the Commissioner. 28 U.S.C. §404.1527(3); see also, Frank v. Barnhart, 326 F.3d 618, 620 (5
The Court turns to Dr. McFarland's second opinion. In July 2010, Dr. McFarland opined that Quintanilla was limited to performing a limited range of sedentary work.
In the present case, after carefully and properly considering all of the evidence in the record, the ALJ concluded that the record did not support the limitations expressed by Dr. McFarland in his opinion. (Tr. 17). See Greenspan, 38 F.3d at 237 (recognizing that the ALJ has broad discretion to determine medical expert's credibility and to weigh their opinions and that he is not required to adopt opinions in a report that he finds are inconsistent with the medical and other objective evidence of record); see also, Moore v. Sullivan, 919 F.2d 901, 905 (5
Nevertheless, Quintanilla contends the ALJ erred because he failed to consider Dr. McFarland's opinion in accordance with the Fifth Circuit's decision in Newton.
Finally, Quintanilla argues that it was error for the ALJ to rely on the opinion of the non-examining, non-treating State agency physician
Considering the record as a whole, the Court concludes that proper legal standards were adhered to and the Commissioner's decision is supported by substantial evidence. Accordingly, it is the