MARGARET A. NAGLE, Magistrate Judge.
Plaintiff filed a Complaint on March 26, 2013, seeking review of the denial of plaintiff's application for a period of disability, disability insurance benefits ("DIB"), and supplemental security income ("SSI"). (ECF No. 1.) On April 23, 2013, the parties consented, pursuant to 28 U.S.C. § 636(c), to proceed before the undersigned United States Magistrate Judge. (ECF No. 9.) The parties filed a Joint Stipulation on December 4, 2013, in which plaintiff seeks an order reversing the Commissioner's decision and remanding this case for the payment of benefits or, alternatively, for further administrative proceedings; and the Commissioner requests that her decision be affirmed or, alternatively, remanded for further administrative proceedings. (ECF No.
Plaintiff filed applications for DIB and SSI on July 10, 2009, and March 18, 2010, respectively. (Administrative Record ("A.R.") 281-84, 285-87, 288, 289-96.) Plaintiff, who was born on February 9, 1964 (id. 18),
After the Commissioner denied plaintiff's application initially and upon reconsideration, plaintiff requested a hearing. (A.R. 152-54.) On December 13, 2010, plaintiff, who was represented by a non-attorney representative, appeared and testified at a hearing before Administrative Law Judge Sharilyn Hopson ("ALJ Hopson"). (Id. 28-63, 221-22.) On February 3, 2011, ALJ Hopson denied plaintiff's claim (id. 100-14), finding that plaintiff retains the capacity to perform a reduced range of light work, including the jobs of order clerk, small items assembler, and production inspection and checker, and therefore he is not disabled (id.).
On February 14, 2012, the Appeals Council vacated ALJ Hopson's decision, finding that: (1) ALJ Hopson's determination of plaintiff's residual functional capacity ("RFC") did not reflect her finding of a severe mental impairment resulting in moderate limitations in concentration, persistence, or pace; (2) ALJ Hopson failed to assign specific weight to the opinion of treating physician Victor Meceda, M.D.
On June 1, 2012, plaintiff, who was represented by counsel, appeared and testified at a hearing before ALJ Mark B. Greenberg (the "ALJ"). (A.R. 64-93, 271.) Vocational expert Ronald K. Hatakeyama ("the VE") also testified. (Id. 10, 85-93.) On June 15, 2012 the ALJ denied plaintiff's claim (id. 10-20), and on January 30, 2013, the Appeals Council denied plaintiff's request for review of the ALJ's decision (id. 1-6). That decision is now at issue in this action.
In his June 15, 2012, decision, the ALJ found that plaintiff met the insured status requirements of the Social Security Act through December 31, 2013, and has not engaged in substantial gainful activity since February 23, 2009, the alleged onset date of his disability. (A.R. 12.) The ALJ determined that plaintiff has the severe impairments of obesity, Crohn's disease, pyoderma gangrenosum, and obstructive sleep apnea. (Id.) The ALJ also determined that plaintiff has the medically determinable mental impairments of depression and anxiety, but these impairments are nonsevere because they "cause no more than `mild' limitation in any of the first three functional areas and `no' episodes of decompensation which have been of extended duration in the fourth area." (Id. 14.) The ALJ concluded that plaintiff does not have an impairment or combination of impairments that meets or medically equals the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1 (20 C.F.R. §§ 404.1520(d), 404.1525, 404.1526, 416.920(d), 416.925, 416.926). (Id.)
After reviewing the record, the ALJ determined that plaintiff has the RFC to perform sedentary work with the following nonexertional limitations: requires a sit/stand option; requires a cane for ambulation; occasional postural activities
Based on plaintiff's age, education,
Thus, the ALJ concluded that plaintiff has not been under a disability, as defined in the Social Security Act, since February 23, 2009, the alleged onset date, through June 15, 2012, the date of the ALJ's decision. (A.R. 20.)
Under 42 U.S.C. § 405(g), this Court reviews the Commissioner's decision to determine whether it is free from legal error and supported by substantial evidence in the record as a whole.
Although this Court cannot substitute its discretion for that of the Commissioner, the Court nonetheless must review the record as a whole, "weighing both the evidence that supports and the evidence that detracts from the [Commissioner's] conclusion."
The Court will uphold the Commissioner's decision when the evidence is susceptible to more than one rational interpretation.
Plaintiff alleges that the ALJ erred in rejecting the functionality assessments of treating physicians Drs. Meceda, Jafri, and Joo. (Joint Stip. at 7, 14.) Specifically, he argues that the ALJ's rationales for rejecting significant portions of their opinions were not specific and legitimate. (Id.)
An ALJ is obligated to take into account all medical opinions of record. 20 C.F.R. § 416.927(b). It is the responsibility of the ALJ to resolve conflicts in medical testimony and analyze evidence.
The opinions of treating physicians are entitled to the greatest weight, because the treating physician is hired to cure and has a better opportunity to know and observe the claimant.
On May 24, 2010, Dr. Meceda completed a Physical Capacities form in conjunction with plaintiff's state disability claim. (Joint Stip. at 14; A.R. at 697-701.) In that form, he estimated that plaintiff could sit for up to two hours in an eight-hour workday and stand/walk for up to two hours at a time but for a total of no more than four hours a day. (A.R. 697.) Dr. Meceda indicated that: plaintiff's medication causes him to use the bathroom every three to four hours; he has arthritis secondary to Crohn's disease that would restrict use of his hands/fingers and feet for repetitive motions; and he is allergic to dust and cannot tolerate changes in temperature. (Id.) He also opined that plaintiff could occasionally balance but could never lift or carry ten pounds and could never engage in postural activities. (Id. 698.) Dr. Meceda noted plaintiff's medications cause him to go to the bathroom frequently and make him drowsy "but relieve his pain." (Id.)
The ALJ gave "great weight" to the portion of Dr. Meceda's 2010 assessment relating to the stand/walk/sit findings, as well as to the environmental restrictions "such as exposure to dust and heights," and incorporated these findings into the RFC by providing for a sit/stand option and "restrictions against exposure to lung irritants and climbing ladders, ropes and scaffolds (heights)." (A.R. 17.) The ALJ also stated the following with respect to Dr. Meceda's opinion:
(Id. (citations omitted).)
Thus, the ALJ rejected only Dr. Meceda's opinion that plaintiff's arthritis precluded the repetitive use of his hands and feet
Plaintiff concedes that there is nothing in Dr. Meceda's treatment records "that would specifically support the arthritis diagnosis," but he contends that this was not an adequate basis for rejecting Dr. Meceda's opinion of plaintiff's limitations because Dr. Meceda provided "no treatment notes or tests at all." (Joint Stip. at 15.) Plaintiff contends that, because there was no supporting evidence of any kind from the treating source, the ALJ should have contacted the doctor for further information instead of assuming that it did not exist. (Id.) Plaintiff also argues that the ALJ should have found Dr. Meceda's opinions supported by plaintiff's testimony that he had difficulty grasping with his hands and that arthritis is a "highly common complication of inflammatory bowel disorders such as Crohn's [d]isease." (Id. (footnote omitted).)
The Court does not agree that the ALJ was under an obligation to obtain additional records from Dr. Meceda. Although a claimant bears the burden of proving disability, the ALJ in a social security case has an independent "`duty to fully and fairly develop the record and to assure that the claimant's interests are considered."
Moreover, in her February 3, 2011 decision, ALJ Hopson also noted this same lack of support in Dr. Meceda's records for these purported limitations. (A.R. 110.) Despite the fact that more than 16 months elapsed between ALJ Hopson's decision and the subsequent hearing, plaintiff and his counsel neither obtained relevant records from Dr. Meceda nor identified any additional evidence that the ALJ could have obtained from Dr. Meceda to support these limitations. Plaintiff has not provided any evidence demonstrating that the arthritis limits his ability to use his fingers to manipulate objects
In short, the detailed and extensive medical records did not include any reference to a disabling arthritic condition sufficient to put the ALJ on notice that the record might need to be augmented. Accordingly, plaintiff has failed to establish that the ALJ's duty to develop the record was triggered.
Nor is there objective evidence in the records from Riverside County Regional Medical Center, where Dr. Meceda had his practice, to support Dr. Meceda's extreme limitations. (A.R. 488-596, 636-90, 699-820; 847-1070, 1090-1183.) The Court's review of the voluminous treatment notes from this facility reflect only occasional mentions of arthritis or nonspecific "joint pain" and no complaints of finger, hand, or foot pain.
For instance, a September 12, 2011 treatment note mentions a history of arthritis, but that note appears to relate to plaintiff's complaint that he cannot stand for "long hours due to hip/leg pains." (A.R. 1100-01.) Similarly, an April 13, 2011 clinic note states that plaintiff is seeking disability on the limited basis of Crohn's disease and "DJD [degenerative joint disease] of knee causing pain and decreased ability to ambulate." (Id. 1120.) That note also indicates that the DJD was "first documented in chart on 2/26/10 on DMV disabled persons placard in which pt was given a permanent placard. Subsequent documentation on 5/24/10 for disability documentation request [illegible] stating arthritis 2/2 Crohn's disease and on 12/10/10 for further disability documentation request." (Id.) The Court is unable to find the documents referred to in this note. In treatment notes dated November 4, 2009, and May 7, 2010, there is a reference to "joint pain" with no further explanation. (Id. 640, 1171.) Finally, a treatment note for a December 10, 2010 office visit states: plaintiff was "here to have disability paperwork for SSI hearing next week"; "Pt walks with cane — unable to ambulate beyond few feet"; and "DJD — knees." (Id. 1137-38).
In sum, the few documents that mention joint pain refer primarily to an issue with plaintiff's knees, and the ALJ took these documents into account when he limited plaintiff to sedentary work, use of a cane for ambulating, and a preclusion from walking on uneven terrain. The Court finds nothing in the record to support Dr. Meceda's limitations relating to plaintiff's alleged extreme difficulties with repetitive hand or foot movements; no specific treatment notes, lab reports, x-rays, MRIs, or other documents corroborate those limitations.
Additionally, treatment notes from the Riverside County Regional Medical Center reflect that plaintiff's Crohn's disease was well controlled by medication, and he ceased to have severe flare ups requiring hospitalization.
An ALJ may properly discount a treating physician's opinion that is not supported by the medical record, including his own treatment notes.
Next, the ALJ noted that Dr. Girgis' consulting examination "recorded an entirely unremarkable musculoskeletal examination." (A.R. 17.) On October 30, 2009, Dr. Girgis performed a complete physical examination and found no musculoskeletal problems (id. 597-600), and reported nothing significant enough to cause any manipulative or lifting limitations. Indeed, Dr. Girgis noted that plaintiff's grip force was 20-20-20 pounds and 20-20-25 pounds in his right and left hands respectively. (Id. 599.) Similarly, Dr. Landau, testifying at the first hearing, stated that, although arthritis is a complication of the ulcerative colitis condition, he had searched the record for any evidence of arthritis and was unable to find any.
Finally, the ALJ observed that plaintiff's activities of daily living, including his ability "to attend to self care independently, shop, drive an automobile, cook and build model cars" were inconsistent with Dr. Meceda's limitations in that they "seemingly exceed" the restrictions reported by Dr. Meceda, "particularly in regard [to] the preclusions against use of the hands." (A.R. 17.) Plaintiff himself testified at the first hearing that although he had trouble grasping and lifting heavier items, such as a milk jug, he had no trouble putting together the models he makes as a hobby. (Id. 49-50.) Plaintiff testified that he can "use [his hands] doing little things," and while his hands "don't hurt" doing this, his fingers "just get tired of, you know folding . . . ." (Id. 51.) Similarly, at the more recent hearing, plaintiff was asked by his attorney and the ALJ about physical symptoms that keep him from being able to work, and he did not mention any hand or foot manipulative limitations. (Id. 69-79, 84-85.) Instead, plaintiff testified that he plays dominos and cards, activities which would seem to require some degree of manual dexterity. (Id. 85.) Inconsistency between a treating physician's opinion and a claimant's daily activities may be a specific and legitimate reason for rejecting the opinion.
On December 10, 2010, Dr. Jafri completed a Multiple Impairments Questionnaire. (A.R. 839-46; Joint Stip at 17.) In that form, she noted plaintiff's diagnoses of Crohn's disease, obesity, hypertension, and sarcopenia, finding that plaintiff's prognosis was "poor." (A.R. 839.) She also assessed that in an eight-hour workday, plaintiff could sit for a total of three to four hours (id. 841); stand/walk for one hour (id.); would need to get up and move around once or twice in an eight-hour period for fifteen minutes before sitting down again (id. 841-42); could lift up to ten pounds occasionally and five pounds frequently (id. 842); and has "marked" limitations in the ability to perform gross and fine manipulation and to reach. (Id. 842-43.) She also found that: plaintiff's symptoms would "constantly" interfere with his attention and concentration (id. 844); he would be incapable of even a low stress work environment (id.); he would need to take unscheduled breaks at least once an hour for 15 minutes at a time (id.); and he would be absent from work more than three times a month. (Id. 845.)
The ALJ, adopted "some aspects of the opinion . . . to the extent it is consistent with the residual functional capacity for work as determined" in his decision and further stated the following with respect to Dr. Jafri's opinion:
(Id. 17.)
Thus, the ALJ rejected Dr. Jafri's extreme limitations for the same reasons he rejected Dr. Meceda's extreme limitations, i.e. lack of objective support, conflict with Dr. Girgis' findings, and the extent of plaintiff's daily activities, but also because plaintiff had responded positively to treatment. For the same reasons discussed above, including the Court's discussion of the evidence that plaintiff's medication was controlling his Crohn's disease and/or pain, the Court finds there was no error in the ALJ's discounting of Dr. Jafri's opinion.
On September 12, 2011, Dr. Joo completed a Gastrointestinal Disorders Impairment Questionnaire. (A.R. 1072-77; Joint Stip. at 20.) He noted plaintiff's diagnoses of Crohn's disease and the clinical findings of chronic diarrhea, blood in stool, abdominal pain and cramps, pain, and aphthous ulcers. (A.R. 1073.) He also noted the following: plaintiff's pain was controlled with Ibuprofen or Vicodin; emotional factors contribute to plaintiff's symptoms and functional limitations; plaintiff would periodically experience pain, fatigue, or other symptoms that would interfere with attention and concentration; plaintiff was capable of tolerating moderate work stress; plaintiff could sit for four hours in an eight-hour day; he could stand/walk for two hours in an eight-hour day; he would be able to sit continuously in a work setting but must get up and move around with a cane once an hour for 15 to 20 minutes; he could occasionally lift or carry up to five pounds, and never lift or carry anything over five pounds; he would be absent from work less than once per month; and he would need ready access to a restroom, up to eight times a day for ten minutes at a time. (Id. 1073-77.)
The ALJ noted that his RFC finding was consistent with Dr. Joo's assessment that plaintiff would need to get up and move around after one hour of sitting and needed to use a cane to walk. (A.R. 18.) However, he gave "minimal weight" to the other limitations in Dr. Joo's assessment "in light of the lack of reported restrictions in sitting in the function reports at Exhibits 3E and 5E and the treatment records which describe the flares of the Crohn's disorder with symptoms of pain and diarrhea to a lesser extent." (Id.)
Again, the ALJ's reasons for discounting Dr. Joo's opinions were similar to his reasons for discounting the opinions of Dr. Meceda and Dr. Jafri. As discussed, the record confirms that although plaintiff's Crohn's disease intermittently "flares up," it is well controlled with medication. Moreover, although Dr. Joo reported that plaintiff would need to use the restroom up to eight times per day, plaintiff reported in in June 2010 that he was only experiencing "two bowel movements a day." (A.R. 713.) In October 2009, he also reported to Dr. Girgis that his condition was well controlled. (Id. 623.) The ALJ thus provided specific and legitimate reasons for discounting Dr. Joo's opinions, and there was no error.
For the reasons stated above, the Court finds that the Commissioner's decision is supported by substantial evidence and free from material legal error. Neither reversal of the ALJ's decision nor remand is warranted.
Accordingly, IT IS ORDERED that Judgment shall be entered affirming the decision of the Commissioner of the Social Security Administration.
IT IS FURTHER ORDERED that the Clerk of the Court shall serve copies of this Memorandum Opinion and Order and the Judgment on counsel for plaintiff and for defendant.