ERIN L. WIEDEMANN, Magistrate Judge.
Plaintiff, Mark Keen, brings this action pursuant to 42 U.S.C. § 405(g), seeking judicial review of a decision of the Commissioner of the Social Security Administration (Commissioner) denying his claims for a period of disability and disability insurance benefits (DIB) and supplemental security income (SSI) under the provisions of Titles II and XVI of the Social Security Act (Act). In this judicial review, the Court must determine whether there is substantial evidence in the administrative record to support the Commissioner's decision.
Plaintiff protectively filed his current applications for DIB and SSI on October 17, 2012, alleging an inability to work since May 15, 2012, due to left wrist pain subsequent to two surgeries, left elbow pain associated with a healed dislocation and cubital tunnel syndrome, breathing difficulty secondary to chronic obstructive pulmonary disease (COPD), and right hand pain. (Doc. 10, pp. 20, 54, 64). An administrative hearing was held on January 16, 2014, at which Plaintiff appeared with counsel and testified. (Doc. 10, pp. 31-51).
By written decision dated June 13, 2014, the ALJ found that during the relevant time period, Plaintiff had an impairment or combination of impairments that were severe. (Doc. 9, p. 19). Specifically, the ALJ found Plaintiff had the following severe impairments: chronic obstructive pulmonary disease (COPD), left wrist status post fusion, left elbow pain secondary to cubital tunnel syndrome, and right hand pain. However, after reviewing all of the evidence presented, the ALJ determined that Plaintiff's impairments did not meet or equal the level of severity of any impairment listed in the Listing of Impairments found in Appendix I, Subpart P, Regulation No. 4. (Doc. 10, p. 19-20). The ALJ found that Plaintiff retained the residual functional capacity (RFC) to:
(Doc. 10, p. 20). With the help of a vocational expert (VE), the ALJ determined that while Plaintiff was unable to perform his past relevant work, he could perform work as a counter clerk, an usher or lobby attendant, and an assembly worker. (Doc. 10, p. 25).
Plaintiff then requested a review of the hearing decision by the Appeals Council, which denied that request on September 9, 2015. (Doc. 10, pp. 5-8, 12). Subsequently, Plaintiff filed this action. (Doc. 1). This case is before the undersigned pursuant to the consent of the parties. (Doc. 7). Both parties have filed appeal briefs, and the case is now ready for decision. (Docs.11, 12).
The Court has reviewed the entire transcript. The complete set of facts and arguments are presented in the parties' briefs, and are repeated here only to the extent necessary.
This Court's role is to determine whether the Commissioner's findings are supported by substantial evidence on the record as a whole.
It is well-established that a claimant for Social Security disability benefits has the burden of proving his disability by establishing a physical or mental disability that has lasted at least one year and that prevents him from engaging in any substantial gainful activity.
The Commissioner's regulations require her to apply a five-step sequential evaluation process to each claim for disability benefits: (1) whether the claimant has engaged in substantial gainful activity since filing his claim; (2) whether the claimant has a severe physical and/or mental impairment or combination of impairments; (3) whether the impairment(s) meet or equal an impairment in the listings; (4) whether the impairment(s) prevent the claimant from doing past relevant work; and, (5) whether the claimant is able to perform other work in the national economy given his age, education, and experience.
Plaintiff makes the following arguments on appeal: 1) the ALJ erred in failing to evaluate Plaintiff's subjective complaints in accordance with
Plaintiff argues that the ALJ erred in failing to fully develop the record regarding the extent of Plaintiff's manipulative limitations; specifically, that there were no examining physicians that provided recent medical opinions as to Plaintiff's manipulative restrictions. The ALJ has a duty to fully and fairly develop the record.
In this case, the record consists of physical RFC assessments completed by non-examining medical consultants; a consultative physical evaluation; and Plaintiff's medical records, which included clinic notes from his orthopedist, hospital records, and imaging results. Moreover, the medical evidence showed that Plaintiff did not undergo the Functional Capacity Evaluation recommended by Dr. Henley in February 2010 (after Plaintiff reached maximum medical improvement). Furthermore, Plaintiff failed to submit additional evidence of a consultative examination either at the January 16, 2014 hearing before the ALJ or at the Appeals Council phase of the case. After reviewing the entire record, the Court finds the record before the ALJ contained the evidence required to make a full and informed decision regarding Plaintiff's capabilities during the relevant time period. Accordingly, the undersigned finds the ALJ fully and fairly developed the record.
The ALJ was required to consider all the evidence relating to Plaintiff's subjective complaints including evidence presented by third parties that relates to: (1) Plaintiff's daily activities; (2) the duration, frequency, and intensity of his pain; (3) precipitating and aggravating factors; (4) dosage, effectiveness, and side effects of his medication; and (5) functional restrictions.
After reviewing the administrative record, it is clear that the ALJ properly considered and evaluated Plaintiff's subjective complaints, including the
However, in a Function Report dated April 23, 2013, Plaintiff indicated that he was able to take care of his personal needs, including bathing, caring for his hair, shaving, feeding himself and using the toilet, with occasional help from his wife to tie his shoes. (Doc. 10, p. 240). Plaintiff also indicated that he was able to assist with mowing the lawn, which took approximately one-half of a day; drive a car; go out alone; shop in stores with his wife; and pay bills, count change, and use a money order. (Doc. 10, pp. 241-242). According to Plaintiff's responses, he was only taking Ibuprofen for his conditions. (Doc. 10, p. 246).
With regard to the objective medical evidence, the ALJ noted the following by Dr. Noel Henley, Plaintiff's treating orthopedist: Dr. Henley's repeated advice to Plaintiff to wean off of his pain medication; Dr. Henley's notes that indicated (on more than one occasion) Plaintiff's "exaggerated" pain response to palpitation; Dr. Henley's notes that Plaintiff provided inconsistent complaints of left wrist pain; Dr. Henley's office notes where he opined that Plaintiff had reached maximum medical improvement to his left wrist; and Dr. Henley's recommendation that a functional capacity evaluation was necessary to determine permanent restrictions (although there was no evidence that Plaintiff underwent such an evaluation). (Doc. 10, pp. 21-22). The ALJ also noted that Plaintiff last saw Dr. Henley in February 2010, and did not seek medical treatment again for his wrist, hand or arm until March 2013, when he visited the Northwest Medical Center Emergency Room. At that time, an x-ray of Plaintiff's left wrist showed no fracture, and Plaintiff was prescribed pain medication and discharged. (Doc. 10, p. 22).
With regard to Plaintiff's additional allegations of pain in his left elbow, left finger and hand, and left shoulder, the ALJ noted that Dr. Henley diagnosed Plaintiff with a possible left ulnar nerve compression with cubital tunnel syndrome in Plaintiff's left elbow, for which Plaintiff underwent conservative treatment. However, Plaintiff declined to undergo the recommended release surgery on his elbow. (Doc. 10, p. 22). With respect to Plaintiff's left shoulder, the evidence revealed that in 2009, Plaintiff declined to undergo the recommended physical therapy because his condition had improved and he no longer needed the physical therapy. Medical records dated in 2009 also revealed Plaintiff's left fingers showed a well-healed middle finger metacarpal fracture. (Doc. 10, p. 22).
With regard to Plaintiff's complaints of difficulty breathing, shortness of breath, and chest pain, the ALJ noted that Plaintiff received emergency room treatment for such symptoms in January and August 2012, when he was diagnosed with acute bronchitis and COPD. The ALJ further noted that pulmonary testing from December of 2012 revealed normal results. The Court also notes that despite medical providers recommending that Plaintiff stop smoking, Plaintiff's medical records showed that Plaintiff continued to smoke cigarettes during the time period in question.
Based on a review of the record as a whole, the Court finds substantial evidence supports the ALJ's credibility assessment and because the ALJ provided good reasons for discounting Plaintiff's subjective complaints, this Court defers to the ALJ's credibility determination.
RFC is the most a person can do despite that person's limitations. 20 C.F.R. § 404.1545, 416.945. It is assessed using all relevant evidence in the record.
"The [social security] regulations provide that a treating physician's opinion ... will be granted `controlling weight,' provided the opinion is `well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in [the] record.'"
In the present case, the ALJ considered the medical assessments of treating, examining, and non-examining agency medical consultants, Plaintiff's subjective complaints, and his medical records when he determined Plaintiff could perform light work with the following exceptions: frequently handle and reach, including overhead reaching, using the left upper extremity; finger frequently using the right hand; and avoidance of even moderate exposure to fumes, odors, dust, gases and poorly ventilated areas. The Court notes that in determining Plaintiff's RFC, the ALJ specifically discussed the medical opinions of treating, examining and non-examining medical professionals, and set forth the reasons for the weight given to the opinions.
Based on the record as a whole, the Court finds substantial evidence to support the ALJ's RFC determination.
After thoroughly reviewing the hearing transcript along with the entire evidence of record, the Court finds that the hypothetical the ALJ posed to the vocational expert fully set forth the impairments which the ALJ accepted as true and which were supported by the record as a whole.
Accordingly, having carefully reviewed the record, the undersigned finds substantial evidence supporting the ALJ's decision denying the Plaintiff benefits, and thus the decision should be affirmed. The undersigned further finds that the Plaintiff's Complaint should be dismissed with prejudice.