ROBERT S. BALLOU, Magistrate Judge.
Plaintiff Thomas Fitzgerald Brown ("Brown") filed this action challenging the final decision of the Commissioner of Social Security ("Commissioner") determining that he was not disabled and therefore not eligible for supplemental security income ("SSI") under the Social Security Act ("Act") 42 U.S.C. §§ 1381-1383f, 1614(a)(3)(A). Specifically, Brown alleges the Commissioner (1) failed to properly consider new and material evidence which Brown presented to the Social Security Administration's Appeals Council and (2) improperly crafted Brown's residual function capacity.
This court has jurisdiction pursuant to 42 U.S.C. § 405(g). This case is before me by referral pursuant to 28 U.S.C. § 636(b)(1)(B). The case is ripe for decision. I have carefully reviewed the administrative record, the legal memoranda, the argument of counsel, and the applicable law. I conclude that substantial evidence supports the Commissioner's decision, that the Appeals Council properly considered the evidence presented to it, and that the ALJ correctly developed Brown's residual functional capacity. Accordingly, I
Section 405(g) of Title 42 of the United States Code authorizes judicial review of the Commissioner's denial of social security benefits.
The plaintiff bears the burden of proving that he suffers under a "disability" as that term is interpreted under the Act.
The Commissioner uses a five-step process to evaluate a disability claim.
In cases such as this, where the claimant has submitted additional evidence to the Appeals Council, and the Appeals Council considered that evidence, this court must review the record as a whole, including the new evidence, to determine whether substantial evidence supports the Commissioner's findings.
Brown was born March 16, 1962. R. 41. He completed high school, took special education classes, and reports that he is limited in his reading ability. R. 51. Brown has worked as a lumber stacker, which is classified as unskilled heavy work, and as an automobile mechanic.
Brown filed his claim for SSI on November 28, 2008. R. 125. He initially claimed a disability onset date of September 1, 2003. R. 125. The Commissioner denied Brown's application initially and upon reconsideration. R. 61-65, 69-70. Administrative Law Judge ("ALJ") Charles Boyer held a hearing on March 5, 2010, at which Brown, represented by counsel, and a vocational expert testified. R. 36-58. At the hearing, Brown amended his alleged onset date to January 20, 2009. R. 38.
The ALJ issued his decision denying Brown's claim on June 7, 2010. R. 22-30. The ALJ found that Brown suffered from the severe impairments of cervical degenerative disc disease, status post a C5-C7 cervical decompression and fusion in 2005, hypertension, and myofascial pain, along with a non-severe knee impairment. R. 24, 25. The ALJ found that none of these impairments, either individually or in combination, met or medically equal a listed impairment. R. 25. The ALJ further found that Brown has retained an RFC to perform simple, light work. R. 26. The ALJ found that Brown is unable to perform any past relevant work, but that there are jobs, which exist in significant numbers in the national economy, which Brown can perform, given his age, education, work experience, and RFC. R. 28-29. As such, the ALJ concluded that Brown is not disabled. R. 29.
Brown filed an appeal with the Social Security Administration's Appeals Council and included four additional exhibits in his request of review. On December 20, 2011 the Appeals Council denied Brown's request for a review of the ALJ's decision, thereby rendering the decision of the ALJ the final decision of the Commissioner. R. 1-4. On August 30, 2011, Brown filed his complaint in this court seeking judicial review of the ALJ's decision (Dkt. No. 1).
Brown seeks a remand based upon the recommendation of his neurosurgeon, Dr. William Broaddus, that he is a candidate for a cervical fusion at the C4-5 level. Dr. Broaddus, after seeing Brown only once, stated that Brown had a borad based disc bulge at C4-C5 and that a fusion at that level could provide significant improvement of his symptoms. Brown obtained this opinion following the ALJ's decision and presented it for the first time to the Appeals Council. Brown contends that the opinion is new and material evidence sufficient to warrant a remand. I find that the opinion is neither new nor material and thus does not warrant remand.
Brown's primary medical issue relates to pain resulting from problems with his cervical spine. Brown suffered from cervical stenosis and in 2005 underwent surgical decompression and fusion at C5 through C6 and C7 in 2005.
Brown had a cervical MRI on July 30, 2009, which revealed that he had persistent moderate narrowing of the spinal canal at C4-C5 due to a broad-based disc bulge. R. 349, 369. Brown saw Dr. John Jane, a neurosurgeon at the University of Virginia, on September 9, 2009, who found that Brown had myelomacial in his spinal cord (softening of the cord). Dr. Jane noted that he would "at least consider surgery," if Brown had severe nerve compression symptoms in his arm, but only after a trial run of steroid injections. R. 341, 359. Throughout the fall of 2009, the University of Virginia Medical Center attempted to contact Brown to discuss his medical condition and to schedule a follow up appointment. R. 354, 356, 358.
After the hearing before the ALJ, Brown tried on several occasions to have the recommended epidural steroid injections, but these were cancelled each time due to high blood pressure issues. R. 395, 400, 401, 403. Brown also had cardiac complications, having been seen in the Cardiovascular Clinic at UVA due to a history of syncope. R. 397-398. These intervening events prevented Brown from obtaining the recommended epidural steroid injections. Then, on September 12, 2011, Brown saw Dr. Broaddus, a neurosurgeon at Virginia Commonwealth University. R. 436-39. Brown did not see Dr. Broaddus again.
Brown submitted these records, including those of Dr. Broaddus, to Appeals Council. Dr. Broaddus did not make any findings regarding Brown's physical condition that were contradictory to Dr. Jane's, but did find that, given Brown's severe symptoms, he would consider surgery as it could provide significant improvement. R. 438. The Appeals Council accepted this new evidence and made it part of the record, but found that it did not provide a basis for changing the ALJ's decision. R. 2.
Brown argues that Dr. Broaddus's opinion contradicts the ALJ's factual findings that Brown had received only conservative medical treatment for his neck and back pain, and thus the finding that Brown could significantly improve with surgery is new and material evidence which warrants remand. The Commissioner argues that the opinion of Dr. Broaddus does nothing more than confirm the evidence in the medical record presented to the ALJ. In particular, the Commissioner notes that Dr. Broaddus did not find that Brown suffered from any medical condition not considered by the ALJ, nor did Dr. Broaddus find that Brown's condition was more severe than the ALJ concluded it to be.
There is no dispute over the substance of Dr. Broaddus opinion. Brown saw Dr. Broaddus for neck and low back pain. Dr. Broaddus reviewed Brown's medical records and noted that Brown had previously had an anterior diskectomy and fusion at C5 through C7. Dr. Broaddus further noted that the medical record showed that other medical issues, primarily Brown's blood pressure and cardiac problems prevented brown from receiving the recommended epidural steroid injections. R. 436. Dr. Broaddus observed that Brown complained of significant pain in various locations, but that he provided scarce details about the frequency, intensity, and quality of his pain. On physical examination, Dr. Broaddus found that Brown had a significant amount of difficulty raising his arms to chest level and keeping them there due to bilateral shoulder pain. He noted that Brown had to be encouraged to give effort. A straight leg raise test was negative bilaterally, although Brown complained of increased low back pain with straight leg raising. R. 437. Brown performed lumbar flexion and extension movements "rather poorly" and complained of increased back pain with movement. R. 437-38. Dr. Broaddus also reviewed an MRI of Brown's cervical spine taken in July 14, 2011. He found broad-based disk bulging at the C4-C5 level just above the fusion at C5-C7. He also noted significant foraminal stenosis on the left at C3-4. Dr. Broaddus diagnosed Brown with significant degenerative disease at the C4-C5 level and concluded that "given [Brown's] severe symptoms, he would be a candidate for extension of the fusion to C4-C5 anteriorly." Dr. Broaddus determined that he would focus on Brown's cervical spine pathology and defer consideration of a workup of Brown's lumbar systems. R. 438.
Brown argues that Dr. Broaddus's opinion is evidence that is contrary to the ALJ's finding that Brown's condition only required conservative treatment and, as such, it is material in that there is a reasonable possibility it would have changed the outcome of the decision. Brown further asserts that because "the only evidence of record concerning the medical records and opinion of Dr. Broaddus, the expert treating neurosurgeon, is contained in the new evidence submitted to the Appeals Council," Pl.'s Supp. Br. 10, the evidence is new. Additionally, Brown argues that because the Appeals Council accepted the new evidence but did not articulate its analysis, no fact finder has made any findings with respect to Dr. Broaddus's opinion, or attempted to reconcile his opinion with the other evidence of record. As such, Brown asserts that the decision in
Dr. Broaddus did not diagnose Brown as suffering from any latent medical condition that the record before the ALJ failed to identify, or that Brown's condition was any more severe than the ALJ described. As such, the Commissioner argues, his opinion is not new in that it is "largely cumulative—essentially a continuation of Plaintiff's treatment for his previously-identified cervical impairment." Def.'s Br. 8. For purposes of this report and recommendation, I will assume, without deciding, that Dr. Broaddus's opinion is "new," even though the opinions of Drs. Jane and Broaddus essentially differ only on the timing of surgery, with Dr. Broaddus being willing to forego the epidural steroid injections recommended by Dr. Jane.
New evidence, however, is only material if it creates a reasonable possibility that, upon review of the evidence, the Commissioner would change the outcome of his decision—that is, find the claimant disabled and award benefits.
I am bound to review the record as whole, including the new evidence submitted to the Appeal Council, but that review is limited to determining whether substantial evidence supports the ALJ's decision—not to assume the ALJ's role as the fact finder.
The ALJ specifically cited the fact that Brown had received only conservative treatment in two areas: (1) his assessment of Brown's subjective complaints and (2) his assessment of the opinion of one of Brown's treating physicians, Dr. Laura Howard. As to Brown's subjective complaints, the ALJ found that, while Brown alleged that he suffers from debilitating neck and back pain, "his treatment notes reveal that he has been treated primarily with pain medications for these impairments and has not undergone any surgical intervention, physical therapy, or pain management treatment with steroid injections." R. 27.
As to Brown's neck pain, there is nothing contained in Dr. Broaddus's opinion that is contradictory to, competes with, or calls into doubt the medical records presented to the ALJ. Dr. Jane had diagnosed Brown with a C4-C5 disk bulge, R. 349, 369, and stated on September 9, 2009, that he would "at least consider surgery," but would first have a trial run of steroid injections. R. 341, 359. Dr. Broaddus specifically noted that Brown had attempted steroid injections, but was unable to receive them due to his blood pressure and cardiac problems. R. 436. Thus, there is no conflict between Dr. Jane's opinion and Dr. Broaddus's opinion. The opinions of Dr. Jane and the later opinion of Dr. Broaddus merely reflect the typical progression of medical treatment—attempting more conservative treatment options before progressing to the consideration of more invasive treatment. The approximate year and a half time gap between the opinions of Drs. Jane and Broaddus bolsters this conclusion.
The ALJ also considered the opinion of Dr. Laura Howard, Brown's treating physician. Dr. Howard found that Brown's ability to lift/carrying and to stand/walk were affected by his impairments, that Brown could never crawl, push/pull, handle (gross manipulation), finger (find manipulation), or feel (skin receptors), and that Brown's condition would be expected to cause significant pain resulting in interruption of activities and/or concentration and require unpredictable and/or lengthy period of rest during the day. R. 338. The ALJ afforded Dr. Howard's opinion minimal weight because it was inconsistent with her own treatment notes.
This case is distinguishable from cases Brown relies upon in which the evidence presented to the Appeals Council provided a reasonable possibility of a different outcome. In
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In sum, the opinion of Dr. Broaddus submitted to the Appeals Council does not impugn the potions of the record upon which the ALJ rested his decision. I find that the evidence is not contradictory, does not present material competing testimony, and does not call into doubt any decision grounded in the prior medical reports. As such, there is no reasonable possibility that the ALJ's decision would be changed upon consideration of this evidence. I therefore must find that the the evidence presented to the Appeals Council fails the materiality prong of the
Brown asserts that the ALJ's "RFC finding directly violates SSR 96-8p in that the finding failed to `first identify the individual's functional limitations or restrictions and assess his or her work-related abilities on a function-by-function basis' before expressing the RFC `in terms of the exertional levels of work, sedentary, light, medium, heavy, and very heavy.'" Pl.'s Br. 11. The ALJ did not, however, simply state his ultimate finding and re-state the definition of light work. Instead, the ALJ's opinion discusses at some length both the process the ALJ used in making his RFC finding and the medical evidence of record. R. 26-28. Critically, as part of this discussion of the medical record, the ALJ expressly "agreed with and adopted" the opinions of the state agency physicians. R. 28. In doing so, he adopted the state agency function-by-function analysis as part of his determination of the Plaintiff's RFC for light work.
The ALJ reviewed the medical record as a whole and did not err in adopting the function-by-function analysis of Dr. Cader. As such, I find that the ALJ properly considered Brown's functional limitations and restrictions in crafting his RFC.
For the foregoing reasons, it is
The clerk is directed to transmit the record in this case to the Honorable Norman K. Moon, United States District Judge, and to provide copies of this Report and Recommendation to counsel of record. Both sides are reminded that pursuant to Rule 72(b), they are entitled to note any objections to this Report and Recommendation within fourteen (14) days. Any adjudication of fact or conclusion of law rendered herein by the undersigned that is not specifically objected to within the period prescribed by law may become conclusive upon the parties. Failure to file specific objections pursuant to 28 U.S.C. § 636(b)(1)(C) as to factual recitations or findings, as well as to the conclusion reached by the undersigned, may be construed by any reviewing court as a waiver of such objection.