JOHN E. McDERMOTT, Magistrate Judge.
On July 22, 2014, Isai Fraire Huecias ("Plaintiff" or "Claimant") filed a complaint seeking review of the decision by the Commissioner of Social Security ("Commissioner") denying Plaintiff's application for Social Security Disability Insurance benefits. The Commissioner filed an Answer on October 21, 2014. On February 19, 2015, the parties filed a Joint Stipulation ("JS"). The matter is now ready for decision.
Pursuant to 28 U.S.C. § 636(c), both parties consented to proceed before this Magistrate Judge. After reviewing the pleadings, transcripts, and administrative record ("AR"), the Court concludes that the Commissioner's decision must be affirmed and this case dismissed with prejudice.
Plaintiff is a 48-year-old male who applied for Social Security Disability Insurance benefits on June 7, 2011, alleging disability beginning August 31, 2008. (AR 14.) The ALJ determined that Plaintiff has not engaged in substantial gainful activity since August 31, 2008, the alleged onset date. (AR 16.)
Plaintiff's claim was denied initially on August 19, 2011 and on reconsideration on December 22, 2011. (AR 14.) Plaintiff filed a timely request for hearing, which was held before Administrative Law Judge ("ALJ") Mark B. Greenberg on October 19, 2012, in Moreno Valley, California. (AR 14.) Claimant appeared and testified at the hearing with the assistance of a Spanish interpreter and was represented by counsel. (AR 14.) Vocational expert ("VE") Corinne J. Porter also appeared and testified at the hearing. (AR 14.)
The ALJ issued an unfavorable decision on January 17, 2013. (AR 14-24.) The Appeals Council denied review on May 21, 2014. (AR 1-3.)
As reflected in the Joint Stipulation, Plaintiff raises the following disputed issues as grounds for reversal and remand:
Under 42 U.S.C. § 405(g), this Court reviews the ALJ's decision to determine whether the ALJ's findings are supported by substantial evidence and free of legal error.
Substantial evidence means "`more than a mere scintilla,' but less than a preponderance."
This Court must review the record as a whole and consider adverse as well as supporting evidence.
The Social Security Act defines disability as the "inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or . . . can be expected to last for a continuous period of not less than 12 months." 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A). The Commissioner has established a five-step sequential process to determine whether a claimant is disabled. 20 C.F.R. §§ 404.1520, 416.920.
The first step is to determine whether the claimant is presently engaging in substantial gainful activity.
If the claimant cannot perform his or her past relevant work or has no past relevant work, the ALJ proceeds to the fifth step and must determine whether the impairment prevents the claimant from performing any other substantial gainful activity.
In this case, the ALJ determined at step one of the sequential process that Plaintiff has not engaged in substantial gainful activity since August 31, 2008, the alleged onset date. (AR 16.)
At step two, the ALJ determined that Plaintiff has the following medically determinable severe impairments: degenerative disc disease, musculoskeletal strain, depression, meniscal injury, knee derangement, patellofemoral syndrome and chronic pain (20 C.F.R. § 404.1520(c)).
At step three, the ALJ determined that Plaintiff does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments. (AR 16-18.)
The ALJ then found that Plaintiff has the RFC to perform the full range of light work as defined in 20 C.F.R. § 404.1567(b) with the following functional limitations:
(AR 18-22.) In determining the above RFC, the ALJ made an adverse credibility determination which Plaintiff does not challenge here. (AR 20.)
At step four, the ALJ found that Plaintiff is unable to perform his past relevant work as a landscape laborer, an assembler of RVs/couch wirer, a heavy equipment operator and a construction worker/laborer. (AR 22-37.) The ALJ, however, also found that, considering Claimant's age, education, work experience, and RFC, there are jobs that exist in significant numbers in the national economy that Claimant can perform, including the jobs of production solderer and garment sorter. (AR 24.)
Consequently, the ALJ found that Claimant was not disabled, within the meaning of the Social Security Act. (AR 24.)
The ALJ decision must be affirmed. The ALJ properly considered the medical evidence, properly rejected the opinion of Plaintiff's treating physician and properly concluded that Plaintiff's impairments did not meet or equal a listing.
The ALJ's RFC is supported by substantial evidence. The ALJ's nondisability determination is supported by substantial evidence and free of legal error.
Plaintiff contends that the ALJ erred in rejecting the opinion of Plaintiff's treating physician, orthopedist Dr. Khalid Ahmed. The Court disagrees.
The ALJ's RFC is not a medical determination but an administrative finding or legal decision reserved to the Commissioner based on consideration of all the relevant evidence, including medical evidence, lay witnesses, and subjective symptoms.
In evaluating medical opinions, the case law and regulations distinguish among the opinions of three types of physicians: (1) those who treat the claimant (treating physicians); (2) those who examine but do not treat the claimant (examining physicians); and (3) those who neither examine nor treat the claimant (non-examining, or consulting, physicians).
Where a treating doctor's opinion is not contradicted by another doctor, it may be rejected only for "clear and convincing" reasons.
Plaintiff asserts that he is unable to work due to neck pain with radiation into his upper extremities, lower back pain with radiation into his lower extremities, knee pain and depression.
The ALJ, however, properly concluded that the medical evidence does not support the degree of functional limitations alleged by Claimant. (AR 19.) The ALJ cited MRIs of the cervical and lumbar spine taken in August 2010 that showed lumbar strain, multilevel degenerative disc disease, disc protusions and right lower extremity radiculopathy. (AR 19, 718.) An orthopedic examination by Dr. Jason Chiu in September 2010, however, was normal except for lumbar pain and decreased range of motion. (AR 19, 718-19.) He was able to sit comfortably in no distress, required no assistance with movement and demonstrated a negative straight leg raising test. (AR 19, 712, 714.) Claimant was told he was not a surgical candidate and was advised to avoid lifting, pushing, pulling or carrying over 50 pounds. (AR 19, 719-720.) Claimant's physical examinations for the remainder of 2010 were normal with only a decreased range of motion in his spine. (AR 19.)
Claimant has received lumbar and cervical steroid injections from his treating orthopedist, Dr. Khalid Ahmed. (AR 19-20.) Although Dr. Ahmed reported decreased range of motion in Plaintiff's spine, there is no evidence in the record that Dr. Ahmed ever advised Claimant he needed surgery or prescribed a cane or indicated more aggressive treatment was necessary. (AR 20.) Nor is there any evidence Plaintiff underwent physical therapy, chiropractic care, massage therapy, utilized a TENS unit or required emergency care due to back or neck pain. (AR 20.) The ALJ found, based on all the medical evidence, Claimant's alleged back and neck pain were well managed with pain medication and periodic epidural injections. (AR 20.) Dr. Ahmed also reported that Claimant's right knee was stable with normal range of motion, and Plaintiff never reported any limitations caused by right knee pain. (AR 20.)
On July 23, 2011, a consulting orthopedist, Dr. Terrance P. Flanagan, examined Plaintiff and found him in no acute distress, able to sit and stand with normal posture, able to rise from his chair and get on and off the table without difficulty. (AR 20.) The examination was unremarkable except for decreased range of motion in his neck and back as well as tenderness in his knees, shoulders and hips. (AR 20.) Dr. Flanagan diagnosed cervic/thoracic/lumbar myofascial strain, cervical/lumbar degenerative disc disease, bilateral gluteal/trapezial strain, left patellofemoral syndrome and right medial meniscal injury. (AR 20-21.) He determined Plaintiff was capable of sitting, standing and walking for six hours out of an eight hour workday. (AR 21.) Dr. Flanagan assessed Claimant with a medium exertional RFC but could only frequently climb, stoop, kneel and crouch. (AR 21.) He did not require the use of an assistive device. (AR 21.) Indeed, Dr. Flanagan found that Claimant's gait was exaggerated and the ALJ found he was never prescribed a cane for ambulation. Three other State agency reviewing physicians also gave Plaintiff medium RFC assessments with few limitations. (AR 21.)
Thus, the ALJ found that Plaintiff's alleged limitations were not credible based on Claimant's longitudinal clinical presentation, type of and response to treatment, daily activities
Against the weight of all of the above evidence, Claimant nonetheless asserts that he is precluded from all work, based on a February 21, 2012 checklist medical source statement from Dr. Ahmed. (AR 21, 1846-48.) In the statement, Dr. Ahmed determined that Plaintiff could not lift/carry more than 10 pounds, could only sit/stand/walk for 15 minutes at a time, while needing to lie down at unpredictable intervals during the day. (AR 21, 1846-47.) Dr. Ahmed based his opinion on Plaintiff's neck and back pain, and opined Plaintiff would miss work more than 3 days per month. (AR 21, 1847, 1848.)
The ALJ, however, gave Dr. Ahmed's opinion little weight. (AR 21.) Plaintiff contends that the ALJ erred in discounting Dr. Ahmed's opinion because the ALJ's reasons were conclusory, objective medical evidence supported by Dr. Ahmed's opinion and there is no evidence that Dr. Ahmed based his opinion on Plaintiff's subjective complaints as the ALJ found. Plaintiff also argues that, if the medical evidence is not sufficient to support Dr. Ahmed's opinion, the ALJ had a duty to recontact Dr. Ahmed to obtain clarification and/or additional evidence. The Court disagrees.
First, the ALJ discounted Dr. Ahmed's opinion because it was a checklist medical statement not supported by his treating notes or by the medical evidence, and is vague with little support from clinical findings or diagnostic studies. (AR 21.) An ALJ may reject a treating physician's opinion that is conclusionary in the form of a checklist, and where the treatment notes do not provide objective medical evidence of the limitations asserted.
Second, the ALJ found that Dr. Ahmed's opinion was not supported by the medical evidence. (AR 21.) The contradictory opinions of other physicians provide specific, legitimate reasons for rejecting a physician's opinion.
Third, the ALJ found that, because there was no evidence that Claimant required treatment other than pain medication and injections which were sufficient to manage his pain, Dr. Ahmed's opinion appeared based in large part on the Claimant's subjective complaints. An ALJ properly may disregard a medical opinion based to a large extent on a claimant's self-reports that have been discredited.
Plaintiff also contends that the ALJ erred by not recontacting Dr. Ahmed to obtain clarification of his opinion and additional evidence. The ALJ does have a duty to develop the record fully and fairly but the duty to conduct further inquiry is triggered only when the evidence is ambiguous or inadequate to allow proper evaluation of the evidence.
The ALJ properly rejected the opinions of Dr. Ahmed for specific, legitimate reasons supported by substantial evidence. The ALJ properly considered the medical evidence and had no duty to recontact Dr. Ahmed. The ALJ's RFC is supported by substantial evidence and free of legal error.
At step three of the sequential process, the ALJ found that "the Claimant's impairments, considered singly and in combination, do not meet or medically equal the criteria of Listings 1.02, 1.04 or any other listing." (AR 16.) Plaintiff contends that this finding is insufficient and that the medical evidence of record establishes that he does meet and/or equal the criteria of Listing 1.04. The Court disagrees.
Social Security regulations provide that a claimant is disabled if he or she meets or medically equals a listed impairment. Section 416.920(a)(4)(iii) ("If you have an impairment that meets or equals one of listings . . . we will find that you are disabled"); Section 416.920(d) ("If you have an impairment(s) which . . . is listed in Appendix 1 or is equal to a listed impairment(s), we will find you disabled without considering your age, education, and work experience"). In other words, if a claimant meets or equals a listing, he or she will be found disabled at this step "without further inquiry."
The listings in Appendix 1 describe specific impairments considered "severe enough to prevent an individual from doing gainful activity, regardless of his or her age, education, or work experience." Section 404.1525. An impairment that meets a listing must satisfy all the medical criteria required for that listing. Section 404.1525(c)(3). An impairment cannot meet a listing based only on a diagnosis. Section 404.1525(d).
Medical equivalence will be found if the impairment "is at least equal in severity and duration to the criteria of any listed impairment." Section 404.1526(a). Medical equivalence is based on symptoms, signs and laboratory findings, but not subjective symptoms. Section 404.1529(d)(3).
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For the first time, however, Plaintiff apparently asserts that he meets Listing 1.04C, one element of which is the inability to ambulate effectively. Listing 1.04 provides as follows:
In 1.00B2, examples of the inability to ambulate effectively include "the inability to walk a block at a reasonable pace on rough or uneven surfaces." The ALJ's RFC provides that Plaintiff "cannot walk on uneven terrain." On that basis, Plaintiff alleges that he meets the criteria in Listing 1.04C.
An impairment that meets a listing, however, must satisfy all the medical criteria required for that listing. 20 C.F.R. § 404.1525(c)(3). The medical evidence indicates Plaintiff has degenerative disc disease but Listing 1.04 also requires "compromise of a nerve root (including the caudia equina) or the spinal cord." Plaintiff cites to no medical evidence of a compromised nerve root or spinal cord. The ALJ, moreover, found no obvious cord-flattening or indentation of the cervical spine. (AR 19.) Listing 1.04C requires evidence of "lumbar spine stenosis resulting in pseudoclaudication." Again, Plaintiff points to no evidence of pseudoclaudication. The ALJ, moreover, noted only moderate central canal stenosis (AR 19) but nonetheless assessed Claimant with a light work RFC. Plaintiff, who has the burden of proof at step three,
The ALJ, moreover, discussed the combined effects of Plaintiff's impairments before concluding that Plaintiff did not equal Listing 1.04. (AR 16.) In disputing that finding, Plaintiff merely sets forth the same medical evidence he cited in support of Dr. Ahmed's opinion. As in
The ALJ plainly discussed the combined effects of Plaintiff's impairments in determining Plaintiff's RFC. Plaintiff does not explain how a claimant with a residual functional capacity assessment that would permit work could be found disabled at step three of the sequential process.
Plaintiff's assertion that the ALJ failed to elaborate on his step three finding has no merit. The ALJ thoroughly discussed all of the relevant medical evidence of record bearing on Listing 1.04 elsewhere in the decision. None of the evidence accepted by the ALJ establishes any impairments, singly or in combination, that meet or equal Listing 1.04.
IT IS HEREBY ORDERED that Judgment be entered affirming the decision of the Commissioner of Social Security and dismissing this case with prejudice.