ERIN L. WIEDEMANN, Magistrate Judge.
Plaintiff, Joyce Cole, 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 her claim for supplemental security income (SSI) under the provisions of Title 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 her current application for SSI on May 20, 2011, alleging an inability to work since May 1, 2011, due to the following conditions: chronic obstructive pulmonary disease (COPD), bilateral carpal tunnel syndrome, and back problems. (Tr. 245, 248). An administrative hearing was held on September 18, 2012, at which Plaintiff appeared with counsel and testified. (Tr. 31-58). On May 31, 2013, the ALJ issued a decision denying benefits. (Tr. 90-102). The Appeals Council remanded the case back to the ALJ for further consideration on May 9, 2014. (Tr. 108-111). A second administrative hearing was held on September 22, 2014, at which Plaintiff also appeared with counsel and testified. (Tr. 59-85).
On January 13, 2015, the ALJ issued a written opinion, finding that the Plaintiff had severe impairments of COPD, obesity, degenerative disc disease, and major depressive disorder. (Tr. 15). After reviewing the evidence in its entirety, the ALJ determined that the Plaintiff's impairments did not meet or equal the level of severity of any listed impairments described in Appendix 1 of the Regulations (20 CFR, Subpart P, Appendix 1). (Tr. 16-17). The ALJ found Plaintiff retained the residual functional capacity (RFC) to:
(Tr. 18-24). The ALJ propounded interrogatories to the vocational expert (VE), and through her responses the ALJ determined that Plaintiff was capable of performing work as a surveillance system monitor, addressing clerk, or photo copy document preparer. (Tr. 24-25).
Subsequently, on March 18, 2015, Plaintiff requested review by the Appeals Council of the hearing decision. (Tr. 5-8). The Appeals Council denied her request on April 21, 2016. (Tr. 1-4). Plaintiff then filed this action on June 24, 2016. (Doc. 1). This case is before the undersigned pursuant to the consent of the parties. (Doc. 6). Both parties have submitted briefs, and the case is now ready for decision. (Docs. 13, 14).
The Court has reviewed the transcript in its entirety. 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 her disability by establishing a physical or mental disability that has lasted at least one year and that prevents her 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 her 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 her age, education, and experience.
Plaintiff makes the following arguments on appeal: 1) that the ALJ erred failing to fully and fairly develop the record; 2) that the ALJ erred in his credibility determination; 3) that the ALJ erred in his RFC determination; and 4) that the ALJ erred in disregarding the opinions and findings of the primary treating physician, Dr. Routsong.
Plaintiff argues that the ALJ erred in failing to fully develop the record in that he failed to order a consultative neurological examination in order to further evaluate Plaintiff's alleged carpal tunnel syndrome. 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 and Plaintiff's medical records, which include clinic notes from a neurologist, hospital records, and imaging results. Moreover, the medical evidence showed that Plaintiff merely reported that she had a history of carpal tunnel syndrome, that she had not undergone any testing specifically for carpal tunnel syndrome, and that she did not seek or receive any aggressive medical treatment for carpal tunnel syndrome. Furthermore, Plaintiff failed to submit additional evidence of a consultative examination at either hearing before the ALJ or at the Appeals Council phases 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.
Plaintiff argues that the ALJ erred in failing to consider all of her impairments in combination. The ALJ stated that in determining Plaintiff's RFC, he considered "all of the claimant's impairments, including impairments that are not severe." (Tr. 14). The ALJ further found that Plaintiff did not have an impairment or combination of impairments that met or medically equaled one of the listed impairments found in Appendix I, Subpart P, Regulation No. 4. (Tr. 16-17). Such language demonstrates the ALJ considered the combined effect of Plaintiff's impairments.
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 her pain; (3) precipitating and aggravating factors; (4) dosage, effectiveness, and side effects of her 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
With respect to Plaintiff's back pain and COPD, the record revealed that Plaintiff was treated conservatively and appeared to experience some relief with the use of medication and other conservative measures.
The record also revealed that on at least two occasions, Plaintiff reported that she was not taking her medication as prescribed for her COPD. (Tr. 417, 556). Furthermore, Plaintiff's medical providers repeatedly recommended that Plaintiff stop smoking and despite these recommendations, Plaintiff continued to smoke throughout the relevant time period.
Moreover, based on Plaintiff's medical records, Plaintiff was not consistent in seeking medical attention and would go months without seeing a physician.
With respect to Plaintiff's alleged mental impairments, the record fails to establish that Plaintiff sought on-going and consistent treatment from a mental health provider.
To the extent that Plaintiff asserts that she was unable to seek treatment for her physical or mental conditions due to a lack of finances, the record is void of any indication that Plaintiff had been denied treatment due to the lack of funds.
With regard to the statement by Plaintiff's roommate, Geneva Dobbs, the ALJ properly considered this evidence, but found it unpersuasive. This determination was within the ALJ's province.
While it is clear that Plaintiff suffers with some degree of limitation, she has not established that she was unable to engage in any gainful activity during the relevant time period. Accordingly, the Court concludes that substantial evidence supports the ALJ's conclusion that Plaintiff's subjective complaints were not totally credible.
RFC is the most a person can do despite that person's limitations.
In deciding whether a claimant is disabled, the ALJ considers medical opinions along with "the rest of the relevant evidence" in the record. 20 C.F.R. § 416.927(b). "It is the ALJ's function to resolve conflicts among the opinions of various treating and examining physicians. The ALJ may reject the conclusions of any medical expert, whether hired by the claimant or the government, if they are inconsistent with the record as a whole."
The SSA regulations set forth how the ALJ weighs medical opinions. The regulations provide that "unless [the ALJ] give[s] a treating source's opinion controlling weight . . . [the ALJ] consider[s] all of the following factors in deciding the weight [to] give to any medical opinion": (1) examining relationship; (2) treating relationship; (3) supportability of the opinion; (4) consistency; (5) specialization; and, (6) "any factors [the applicant] or others bring[s] to [the ALJ's] attention." 20 C.F.R. § 416.927(c). The regulations provide that if the ALJ finds "that a treating source's opinion on the issue(s) of the nature and severity of [the applicant'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 applicant's] record, [the ALJ] will give it controlling weight."
In finding Plaintiff able to perform light work, the ALJ considered Plaintiff's subjective complaints and the medical records of her treating, examining and non-examining physicians. Specifically, the ALJ addressed the relevant medical records, and the medical opinions of treating, examining and non-examining medical professionals, and set forth the reasons for the weight given to the opinions.
In her argument, Plaintiff alleges that the ALJ failed to give proper weight to the opinion of Dr. Rodney Routsong and failed to incorporate Dr. Routsong's findings into the RFC determination. The ALJ noted that Dr. Routsong's opinion did not contain any evidence upon which he could conclude that Plaintiff suffered for years with her conditions (other than Plaintiff's own subjective report) and did not contain any evidence to support his conclusion that Plaintiff's conditions were inoperable. (Tr. 23). The Court points out that the medical record contains only one document from Dr. Routsong. (Tr. 584-585). In that document, Dr. Routsong noted Plaintiff's history of low back pain, COPD and headaches; that Plaintiff had suffered from these problems for several years; that her problems had not resolved with treatment; and that surgery would not help. (Tr. 584). The document did not reference any diagnostic testing and as the ALJ noted, his conclusions appeared to be based on Plaintiff's subjective complaints. A few months prior to Dr. Routsong's report, Dr. Brian Bracy examined Plaintiff and his treatment notes reflected that Plaintiff's cervical spine inspection revealed normal findings and that an x-ray of Plaintiff's cervical spine revealed no deformities. (Tr. 575, 577, 580). His treatment notes further indicated that Plaintiff appeared comfortable, exhibited a normal gait, exhibited no deformities in her extremities, and exhibited no cyanosis, clubbing or edema. (Tr. 574-582). In addition, Dr. Bracy noted and that Plaintiff's examination revealed normal tone and strength and that Plaintiff's COPD seemed well controlled with medication. (Tr. 574-582).
"Because [Dr. Routsong's] determination contradicted other objective evidence in the record, the ALJ's decision to give less weight to [Dr. Routsong's] determination was reasonable."
The ALJ also discussed the findings of the mental assessments of the non-examining medical consultants and gave them some weight based on Plaintiff's admitted ability to attend medical appointments, drive for short distances, and shop in stores for food on a regular basis. (Tr. 23). The ALJ also discussed and gave great weight to examining consultant, Dr. Terry Efird, and his Mental Diagnostic Evaluation, where he opined that Plaintiff could communicate in a reasonably intelligible and effective manner; had the capacity to perform basic cognitive tasks required for work-like activities; had the mental capacity to persist with tasks if desired; and appeared to have the capability of completing work like tasks within a reasonable time frame. (Tr. 464). The ALJ also provided some weight to the physical assessments by the non-examining medical consultants; however, the ALJ ultimately determined that Plaintiff was more limited based upon additional evidence entered in to the record after the opinions were rendered. (Tr. 23).
The ALJ also took Plaintiff's obesity into account when determining that Plaintiff could perform sedentary work with limitations.
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.