JOHN J. McCONNELL, JR., District Judge.
Plaintiff Dale W. Rankin brings this action for judicial review of the Social Security Commissioner's ("the Commissioner") final decision, as issued in accordance with the ruling of an Administrative Law Judge ("ALJ") on March 15, 2012, denying his claim for Disability Income Benefits ("DIB") and Supplemental Security Income ("SSI") under Titles II and XIV of the Social Security Act.
Mr. Rankin is a 38-year-old man who last worked in 2010. Over the years, he has worked in construction, as an apprentice plumber, a machinist, and in shipping
The Commissioner initially denied his request. He requested review of his case and a hearing before an ALJ. Mr. Rankin and a vocational expert testified during the hearing. Post-hearing, the ALJ determined that Mr. Rankin was not disabled in a manner such that he was entitled to receive SSI or DIB benefits. Mr. Rankin requested a review of the ruling, which the Appeals Council denied. Upon this denial, the ALJ's decision became the Commissioner's final ruling. Before the Court are Mr. Rankin's Motion to Reverse (ECF No. 8) and the Commissioner's Motion to Affirm. (ECF No. 11.)
Mr. Rankin had lumbar spinal fusion surgery in December 2007 after unsuccessful physical therapy to treat the aftereffects of a car accident. (Tr. at 439-443.) After his March 5, 2010 disability onset date, he began treating with several doctors, raising physical issues from chronic back pain and insomnia to emotional issues such as anxiety and depression. He saw Dr. Stephen M. Scott in June 2010 for issues with his left foot. (Id. at 396-97.) Dr. Scott diagnosed him with a back disorder NOS, pain in limb, insomnia, anxiety disorder, headache, and sciatica. (Id. at 396.)
In August 2010, Mr. Rankin saw Dr. Gary L'Europa, complaining of short-term memory loss. (Id. at 306-309.) His test results, however, were normal and Dr. L'Europa opined that his memory may have been affected by the medications he was taking. (Id. at 308-309.) Observing his inability to flex his left foot, Dr. L'Europa prescribed continued physical therapy. (Id. at 309.) Mr. Rankin treated four times with a physical therapist, but was discharged because the treatment did not appear to help his recovery.
Mr. Rankin visited his primary care physician, Dr. Jason Austin, on September 10, 2010. Dr. Austin gave him a letter indicating that he was permanently disabled and incapable of working due to L-5 radiculopathy with foot drop and chronic pain. (Id. at 361.) That same month, Mr. Rankin was evaluated by Dr. Stuart Schneiderman for his pain. (Id. at 382-385.) Dr. Schneiderman opined that Mr. Rankin had "low back pain, degenerative disc disease, lumbar facet joint syndrome, sacroiliac joint dysfunction, status post-surgery, status post trauma, and possible RSD of the leg and lower back." (Id. at 384.) Mr. Rankin denied serious depression, memory loss, and shortness of breath upon examination. (Id. at 383.) Dr. Schneiderman recommended lumbar facet joint injections, but Mr. Rankin declined based on a past bad experience with cortisone injections. (Id. at 384.)
Mr. Rankin continued to treat with Dr. Austin, seeing him every two months, for
Mr. Rankin also treated with Susan D. Mandel, a licensed social worker, to "deal with the long-term consequences of his 7/05 automobile accident." (Id. at 566.) He saw her approximately thirteen times from April to July 2011 and discussed his medical complaints as well as his goals for the future. (Id. at 566-67.)
On May 20, 2011, Mr. Rankin sought Dr. Schneiderman's help again for pain in his lower back that radiated down his legs. (Id. at 520.) The doctor again recommended injections; Mr. Rankin was open to those if they were covered by his insurance and indicated that he would determine if injections were a covered service. (Id.) Mr. Rankin did not follow up with Dr. Schneiderman's office about the injections.
To address his breathing difficulties, Mr. Rankin treated with Dr. William J. Beliveau in April and August 2011. (Id. at 516, 574.) He was diagnosed with mild sleep apnea and dyspnea, a mild obstructive restrictive ventilator defect consistent with asthma. (Id. at 574-585.)
Mr. Rankin filed an application for disability insurance benefits and for supplemental security income on September 15, 2010. These claims were denied and Mr. Rankin requested a hearing, at which he and Ruth Baruch, a vocational expert, testified. The ALJ denied Mr. Rankin benefits, finding that Mr. Rankin was not disabled from March 5, 2010 to the date of the decision. (Id. at 10-22.)
The ALJ concluded that Mr. Rankin had the RFC to perform light work such as light unskilled production type jobs such as bench assembler, hand packager, inspector, or printed circuit board assembler and those jobs exist in significant numbers in the economy. (Id. at 15.)
A district court's role in reviewing the Commissioner's decision is limited. Although questions of law are reviewed de novo, "[t]he 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). The term "substantial evidence" is "more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 401, 91 S.Ct. 1420, 28 L.Ed.2d 842 (1971) (quoting Consolidated Edison Co. v. N.L.R.B., 305 U.S. 197, 229, 59 S.Ct. 206, 83 L.Ed. 126 (1938)).
The determination of substantiality must be made upon an evaluation of the record as a whole. Ortiz v. Sec'y of Health and Human Servs., 955 F.2d 765, 769 (1st Cir. 1991) ("`We must uphold the Secretary's findings ... if a reasonable mind, reviewing the evidence in the record as a whole, could accept it as adequate to support his conclusion.'" (quoting Rodriguez v. Sec'y of Health and Human Servs., 647 F.2d 218, 222 (1st Cir.1981))). In reviewing the record, the Court must avoid reinterpreting the evidence or otherwise substituting its own judgment for that of the Secretary. See Colon v. Sec'y of Health and Human
The court must reverse the ALJ's decision on plenary review, however, if the ALJ applies incorrect law, or if the ALJ fails to provide the court with sufficient reasoning to determine that he or she properly applied the law. Nguyen v. Chater, 172 F.3d 31, 35 (1st Cir.1999) (per curiam), accord Cornelius v. Sullivan, 936 F.2d 1143, 1145 (11th Cir.1991). Remand is unnecessary where all of the essential evidence was before the Appeals Council when it denied review, and the evidence establishes without any doubt that the claimant was disabled. Seavey v. Barnhart, 276 F.3d 1, 11 (1st Cir.2001) (citing Mowery v. Heckler, 771 F.2d 966, 973 (6th Cir.1985)).
The ALJ must follow five well-known steps in evaluating a claim of disability. See 20 C.F.R. §§ 404.1520, 416.920. First, if a claimant is working at a substantial gainful activity, he is not disabled. 20 C.F.R. § 404.1520(b). Second, if a claimant does not have any impairment or combination of impairments, which significantly limit his physical or mental ability to do basic work activities, then he does not have a severe impairment and is not disabled. 20 C.F.R. § 404.1520(c). Third, if a claimant's impairments meet or equal an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1, he is disabled. 20 C.F.R. § 404.1520(d). Fourth, if a claimant's impairments do not prevent him from doing past relevant work, he is not disabled. 20 C.F.R. § 404.1520(e). Fifth, if a claimant's impairments (considering his residual functional capacity ("RFC"), age, education and past work) prevent him from doing other work that exists in the national economy, then he is disabled. 20 C.F.R. § 404.1520(f). Significantly, the claimant bears the burden of proof at steps one through four, but the Commissioner bears the burden of proving step five. Goodermote v. Sec'y of Health & Human Servs., 690 F.2d 5, 7 (1st Cir.1982).
In considering whether a claimant's physical and mental impairments are severe enough to qualify for disability, the ALJ must consider the combined effect of all of the claimant's impairments, and must consider any medically severe combination of impairments throughout the disability determination process. 42 U.S.C. § 423(d)(2)(B). Accordingly, the ALJ must make specific and pronounced findings when deciding whether an individual is disabled. Davis v. Shalala, 985 F.2d 528, 534 (11th Cir.1993).
In this case, the ALJ found that Mr. Rankin met his burden of proving steps one through four. The ALJ decided that he was not disabled, however, because it found that his RFC permitted him to perform other work existing in the economy. It is the ALJ's finding on this fifth ground that forms the basis of Mr. Rankin's appeal.
Following the five steps, the ALJ found: that Mr. Rankin had not engaged in substantial gainful activity since March 5, 2010, the alleged onset of his disability (Tr. at 12); that Mr. Rankin had severe impairments including: pain disorder with both psychological and physical components, somatoform disorder, major depression, degenerative disc disease of the lumbar spine status post-fusion, left drop foot, and possible RSD (id. at 13); that Mr. Rankin did not have an impairment or combination of impairments which met or medically equaled one of the listed impairments in 20
Disability is defined as the "inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment" or combination of impairments "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), (d)(2)(B); see also 20 C.F.R. § 404.1509 ("Unless your impairment is expected to result in death, it must have lasted or must be expected to last for a continuous period of at least 12 months. We call this the duration requirement."). The ALJ found that Mr. Rankin was not disabled in accordance with the statute. Mr. Rankin's two main issues in this appeal are the ALJ's decision to give greater weight to the medical opinions of two non-treating doctors, essentially rejecting his treating doctors' opinions and his negative evaluation of Mr. Rankin's credibility as to his pain and limitations resulting therefrom.
Relevant to this case, medical opinions from treating sources generally are given "more weight" "since these sources are likely to be the medical professionals most able to provide a detailed, longitudinal picture of [a claimant's] medical impairment(s) and may bring a unique perspective to the medical evidence that cannot be obtained from the objective medical findings alone or from reports of individual examinations, such as consultative examinations or brief hospitalizations." 20 C.F.R. § 404.1527(c)(2). When "a treating source's opinion on the issue(s) of the nature and severity of [the claimant's] impairment(s) is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in [the claimant's] case record," the regulations state that it is given "controlling weight." Id.; see also Polanco-Quinones v. Astrue, 477 Fed.Appx. 745, 746 (1st Cir.2012). Conversely, if "a treating doctor's opinion is inconsistent with other substantial evidence in the record, the requirement of `controlling weight' does not apply." Shaw v. Sec'y of Health & Human Servs., No. 93-2173, 1994 WL 251000, at *3 (1st Cir. June 9, 1994). "All things being equal, however, a treating doctor's report may be entitled to `greater' weight than an inconsistent non-treating source." Id.
When a treating physician's opinion does not warrant controlling weight, the ALJ must nevertheless weigh the medical opinion based on other factors included in the Commissioner's regulations. 20 C.F.R. §§ 404.1527(c), 416.927. Those factors are: (1) the "[l]ength of the treatment relationship and the frequency of examination," 20 C.F.R. § 404.1527(c)(2)(i); (2) the "[n]ature and extent of the treatment relationship," 20 C.F.R. § 404.1527(c)(2)(ii); (3) the supportability of the opinion, 20 C.F.R. § 404.1527(c)(3); (4) the consistency of the opinion "with the record as a whole," 20 C.F.R. § 404.1527(c)(4); (5) the specialization of the source, 20 C.F.R.
Turning first to the ALJ's evaluation of Mr. Rankin's treating doctor's opinions, the ALJ determined that neither Dr. Austin nor Dr. Constantine Vafidis gave opinions supported by the evidence and thus were not deserving of significant weight. Without weighing the opinions, the Court finds that the ALJ's conclusions are supported by substantial evidence and affirms his decision. Although Dr. Austin treated Mr. Rankin regularly starting in 2010, he provided little explanation for his conclusion that Mr. Rankin was permanently and completely disabled and not able to do any work. (Tr. at 20, 412.) Dr. Austin opined that Mr. Rankin could not sit, stand, walk, carry any weight, bend, squat, kneel, crawl, or use either of his hands to grasp, reach, push or pull. (Id. at 412.) In fact, that conclusory statement conflicted with Dr. Austin's record notes of office visits with Mr. Rankin indicating that he exhibited strength and gait that was normal. (Id. at 388, 390, 394, 549. 551, 553, 560.) The ALJ noted that Dr. Austin's records from March 2011 through June 2011 showed no physical abnormalities. (Id. at 18.) Finally, as the Government points out, Dr. Austin's opinion that Mr. Rankin was incapable of performing any work due to his disabilities conflicted with the report of Mr. Rankin's other "treating" doctor, Dr. Vafidis, who determined that Mr. Rankin retained the ability to occasionally lift and carry up to twenty pounds and could stand, walk, and climb. (Id. at 598-599.) Dr. Austin's opinion that Mr. Rankin could not sustain any full-time, ongoing work was also inconsistent with Mr. Rankin's own testimony about his daily activities and, as the ALJ noted in his decision, Dr. Austin's notes do not indicate that Mr. Rankin ever reported those extensive restrictions. (Id. at 20.)
Dr. Vafidis' opinion suffers from similar deficits. While it appears that Mr. Rankin only saw Dr. Vafidis once, causing the Court to question Mr. Rankin's characterization of him as a "treating doctor" entitled to any deference, Dr. Vafidis's ultimate conclusion as to disability was inconsistent with his own notes, as the ALJ observed in his decision. (Id.) Moreover, Mr. Rankin saw Dr. Vafidis, not for symptoms relating to his back pain and physical limitations, but reporting unexplained fatigue.
Moreover, Mr. Rankin has shown no error in the ALJ's decision to credit the non-treating consultants. Dr. Thomas
Dr. Stephen Clifford, the consulting psychologist, gave an opinion that Mr. Rankin was capable of understanding, remembering and carrying out simple routines found in unskilled work. (Id. at 19.) This opinion is based on Mr. Rankin's psychological records and his testimony at the hearing.
Mr. Rankin disagrees with the weight the ALJ gave to the varying medical evaluations and opinions and essentially asks this court to re-weigh the medical evidence.
The Court will now examine the ALJ's evaluation of whether Mr. Rankin's assessment of his own limitations and pain was credible. Mr. Rankin asserts that the ALJ's finding that he was not entirely credible is not based on substantial evidence in the record. (ECF No. 9 at 7-9.) The Commissioner counters that the ALJ's credibility determination rested on evidentiary conflicts in the record. (ECF No. 11 at 8-14.)
A reviewing court will not disturb a clearly articulated credibility finding with substantial supporting evidence in the record. See Frustaglia v. Sec'y of Health and Human Servs., 829 F.2d 192, 195 (1st Cir.1987). The Court, therefore, must look to the decision and record evidence to
First, it is important to note that the ALJ did not find Mr. Rankin entirely incredible. The ALJ concluded that "the claimant's subjective complaints are credible to the extent they are consistent with the limitations" in the RFC. (Tr. at 19.) The ALJ further acknowledged that Mr. Rankin "may experience pain because of his accident, but the claimant has not had much recent medical treatment and has not followed through with his doctors' recommendations, suggesting that his pain is not as severe or limiting as alleged." (Id.) The ALJ did not entirely disregard Mr. Rankin's testimony in light of the record, but gave it the weight he believed was supported by the record. The record evidence shows that, despite doctor recommendations, Mr. Rankin had not gone to physical therapy since 2010. (Id. at 314, 323-335, 528.) Mr. Rankin met with a pain specialist twice, but rejected the recommended treatment the first visit. (Id. at 384.) He seemed interested in the injections at the second treatment, but failed to follow up with receiving them. (Id. at 382-385, 520.)
Moreover, Mr. Rankin's own hearing testimony and self-reporting is inconsistent with total disability.
Therefore, the Court upholds the Commissioner's final decision to deny Mr. Rankin benefits because his decision contained sufficient reasoning to determine that he properly applied the law and demonstrated that it was based on substantial evidence in the record.
The Court DENIES Dale W. Rankin's Motion to Reverse (ECF No. 8) and GRANTS the Commissioner's Motion to Affirm. (ECF No. 11.)
IT IS SO ORDERED.