SUZANNE H. SEGAL, Magistrate Judge.
David Allen Highfill ("Plaintiff") seeks review of the final decision of the Commissioner of the Social Security Administration ("the Commissioner") denying his application for Supplemental Security Income ("SSI"). The parties consented, pursuant to 28 U.S.C. § 636(c), to the jurisdiction of the undersigned United States Magistrate Judge. For the reasons stated below, the decision of the Commissioner is AFFIRMED.
Plaintiff filed an application for Supplemental Security Income ("SSI") on June 30, 2010. (Administrative Record ("AR") 15, 189). Plaintiff alleged disability beginning on June 29, 2005, due to major depressive disorder, chronic headaches, and a heart impairment. (AR 129). Plaintiff's application was initially denied on April 6, 2011 (AR 70-73), and denied on reconsideration on August 4, 2011 (AR 75-79). Plaintiff requested a hearing on August 17, 2011. (AR 82). A hearing was held before Administrative Law Judge ("ALJ") Joseph D. Schloss on August 20, 2012 ("ALJ hearing"). (AR 29). Plaintiff was represented by counsel. (
Plaintiff was born on August 28, 1965. (AR 125). He was thirty-nine years old on June 29, 2005, his alleged disability onset date (
On December 22, 2009, Dr. Joseph Davis at Arrowhead Regional Medical Center ("ARMC") performed surgery on Plaintiff to remove his gallbladder. (AR 405-08). On or around July 29, 2011, Plaintiff was treated at ARMC by Dr. Linna Kho for chronic diarrhea (AR 369-70) and tested for colitis and Crohn's disease per the direction of Dr. Bruce Sabha. (AR 380). On April 16, 2012, Dr. Andrew Song conducted an MRI scan of Plaintiff's left knee at the Center. (AR 365). The MRI showed an intact reconstructed anterior cruciate ligament, tears of the medial and lateral menisci and moderate-sized joint effusion in the left knee. (
Plaintiff also received treatment at the Department of Corrections Parole Outpatient Clinic ("POC") from April 12, 2010, until August 8, 2011.
Dr. Banafshe Ardebili, a state agency examining psychologist, conducted a Complete Mental Evaluation of Plaintiff on February 21, 2011 at MSLA — Palm Springs. (AR 220-26). She assessed Plaintiff with a GAF score of fifty-eight. (AR 224). Dr. Ardebili found that Plaintiff was able to understand and carry out short, simple instructions and perform basic self-care skills, including preparing simple meals and managing his own funds. (AR 225). She determined that Plaintiff was able to make simple work-related decisions without additional supervision, maintain attention and concentration, maintain persistence and maintain day-to-day activities. (
Dr. Sohail Afra, a state agency examining internist, performed a Complete Internal Medicine Evaluation of Plaintiff on February 7, 2011 at MSLA — Palm Springs. (AR 215-19). Dr. Afra found that Plaintiff had hypertension, latent tuberculosis, and a significant psychiatric history. (AR 219). However, he concluded that Plaintiff had no functional restrictions. (
Dr. Andres Kerns, a non-examining consulting psychologist, completed a Mental Residual Functional Capacity Assessment of Plaintiff on April 1, 2011. (AR 232-35). Dr. Kerns found that Plaintiff was able to meet the basic mental and emotional requirements of competitive, remunerative, unskilled work and that he would be able to understand, carry out and remember simple instructions, make simple work-related decisions, respond appropriately to supervision, co-workers and work situations, and deal with changes in a routine work setting on a sustained basis. (AR 234). He also opined that Plaintiff would "do best" in a job requiring minimal social interaction. (
Dr. J. Frankel, a non-examining consulting physician, completed a Physical Residual Functional Capacity Assessment of Plaintiff on March 25, 2011. (AR 227-31). Dr. Frankel diagnosed Plaintiff with latent tuberculosis. (AR 227). He found that Plaintiff had no functional restrictions (AR 228-30), but that he should avoid concentrated exposure to extreme cold and heat, wetness, humidity, fumes, odors, dusts, gases, poor ventilation and hazards because of his latent tuberculosis. (AR 230).
Medical Expert David Jarmon testified at the ALJ hearing regarding Plaintiff's mental health history. (AR 31-36). Dr. Jarmon stated that Plaintiff had been diagnosed with bipolar disorder, but noted that Plaintiff's symptoms were well-managed when he took medication. (AR 33). Dr. Jarmon also testified that although Plaintiff had been diagnosed with schizoaffective disorder on September 27, 2010,
At the hearing, Dr. Jarmon also pointed out that the record did not show evidence of psychosis, despite Dr. Ardebili's diagnosis, and found that Dr. Ardebili's record did not indicate the severity of Plaintiff's depression. (AR 35-36). Dr. Jarmon noted that when Plaintiff was compliant with his medication, he was moderately limited in activities of daily living, mildly limited in social functioning and moderately limited in concentration and pace. (AR 34). He also noted that Plaintiff had not had any episodes of decompensation with the medication, and that the record showed no evidence that Plaintiff had abused drugs after his alleged disability onset date. (
Vocational Expert ("VE") Abbe May identified Plaintiff's past relevant work in the Dictionary of Occupational Titles ("DOT") as a plumber's assistant. (AR 47). According to the VE, this was semi-skilled work requiring vocational preparation level four and performed at a heavy level of exertion. (AR 47-48).
The ALJ posed two hypotheticals to the VE. In the first hypothetical, the ALJ asked if a forty-seven year old individual with a high school education and the same past relevant work as Plaintiff, who had no exertional limitations but should not be exposed to extreme cold, heat, wetness, humidity, fumes, dust, odors, gases or poor ventilation would be able to perform the plumber's job. (AR 48). Ultimately, it was determined that such an individual would not be able to perform Plaintiff's past relevant work. (AR 48-49). However, the hypothetical individual would be capable of other jobs such as a hand packager and laundry worker. (AR 49-50).
In the second hypothetical, the ALJ asked whether the same individual could perform these alternative jobs if he were limited to lifting and carrying twenty pounds occasionally and ten pounds frequently, could occasionally push, pull and kneel with the left lower extremity and had no limitations on the right, could not crawl, work with ladders, ropes or scaffolds or work at unprotected heights, and could not have public contact or perform team-oriented tasks.
Plaintiff testified at the ALJ hearing that he had supported himself with general relief and food stamps for the past two years. (AR 36-37). He also stated that he had lived alone in a trailer without water or electrical power since his release from prison in September 2010. (AR 37-38). During the day, Plaintiff read occasionally but did not watch television or listen to radio. (AR 46). Plaintiff prepared his own meals and testified that he mainly ate "tortillas and peanut butter." (AR 46-47). Plaintiff admitted that he had been arrested ten times and convicted at least seven times. (See AR 38). Plaintiff admitted that he had been diagnosed with polysubstance abuse in September 2010 (AR 34), but stated that had not consumed alcohol in the past twelve years and had not used methamphetamine in the past nine years. (AR 44).
Plaintiff testified that it was very difficult for him to work or to exercise, and that he had gained about forty pounds in the previous two years. (AR 38-39). He also "stay[ed] in bed a lot." (
Plaintiff testified that he wore a knee brace on his left knee because he fell off a ladder in 1996 or 1997. (AR 40). The injury had required surgery. (
Plaintiff testified that he suffered from back pain and headaches. (AR 43). He added that he had a "really bad migraine" "[a]t least every two weeks for about three days." (
Plaintiff testified that his mental health problems were more debilitating than his physical issues. (AR 44). Even a trip to the supermarket was overwhelming because "there's just too many things going on." (
Plaintiff completed a Function Report in conjunction with his application on October 11, 2010. (AR 138-47). He reported that he lived in a trailer without power or water. (AR 140). He went into town to shop for food and water daily, but had trouble with personal care and needed his mother's help to get places. (AR 140-42). He needed "hours" to wash three pairs of socks and two pairs of shorts. (AR 142). He reported that he "[didn't] like people" and was unable to keep a job. (AR 143, 145). He also used a brace on his knee sometimes and always wore glasses. (AR 146). In answering the question "How well do you follow written instructions?" Plaintiff stated, "You tell me." (AR 145).
Plaintiff's mother, Frances Douglas, completed a Third Party Function Report on October 12, 2010. (AR 150-58). She described Plaintiff as "in pain, can't work, sleeps 12 [hours] a day, moody and antisocial." (AR 151). He also had anxiety and was unable to sleep. (AR 152). After Plaintiff ceased being able to work, he became more depressed and "[did] less." (AR 155). She also described Plaintiff as "suicidal" and "more remote" since he stopped working. (AR 155-56). Plaintiff also needed reminders to change his clothes and put on a coat. (AR 153).
Ms. Douglas stated that Plaintiff had trouble getting along with other people because "people [didn't] like him" and because of his bipolar disorder. (AR 156-57). She also suggested that Plaintiff's bipolar disorder prevented him from keeping a job. (AR 157). Plaintiff "stay[ed] away if possible" from authority figures, and he did not handle stress or changes in routine well. (
She reported that Plaintiff took his medication, filled out "this kind of paperwork," and took sleeping pills every day. (AR 151). He ate junk food and could not cook. (AR 153). Ms. Douglas also verified that Plaintiff wore a brace on his left knee that had been prescribed to him in 1996 and that he wore glasses every day. (AR 157).
To qualify for disability benefits, a claimant must demonstrate a medically determinable physical or mental impairment that prevents him from engaging in substantial gainful activity and that is expected to result in death or to last for a continuous period of at least twelve months.
To decide if a claimant is disabled and therefore entitled to benefits, an ALJ conducts a five-step inquiry. 20 C.F.R. §§ 404.1520, 416.920. The steps are:
The claimant has the burden of proof at steps one through four and the Commissioner has the burden of proof at step five.
The ALJ employed the five-step sequential evaluation process and concluded that Plaintiff was not disabled within the meaning of the Social Security Act. (
At step one, the ALJ found that Plaintiff had not been engaged in substantial gainful employment since his alleged disability onset date of June 30, 2010. (AR 17).
At step two, the ALJ found that Plaintiff had the severe impairments of headaches, essential hypertension, latent pulmonary tuberculosis, meniscal tears in the left knee and polysubstance abuse. (AR 17). Although Plaintiff also alleged having a heart impairment implant, the ALJ found no objective medical evidence that a heart implant had been installed. (
At step three, the ALJ found that Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1 (20 C.F.R. §§ 404.1520(d), 416.1525, 414.1526, 416.920(d), 416.925, 416.926). (AR 17-19). The severity of Plaintiff's mental impairments did not meet or medically equal the criteria of listings 12.03, 12.04, 12.08 or 12.09.
(AR 19). In reaching this opinion, the ALJ specified that he had considered all of Plaintiff's symptoms and the extent to which they could reasonably be accepted as consistent with the objective medical evidence and other evidence, based on the requirements of 20 C.F.R. 416.929 and SSRs 96-4p and 96-7p. (
In assessing Plaintiff's credibility, the ALJ followed a two-step process in which he first determined whether there was an underlying medically determinable physical or mental impairment(s) that could have reasonably been expected to produce the Plaintiff's pain or other symptoms. (AR 19-20). Then, after the underlying impairment(s) had been shown, he evaluated the intensity, persistence, and limiting effects of Plaintiff's symptoms to determine the extent to which they limited Plaintiff's functioning. (AR 19-22). Ultimately, the ALJ found that Plaintiff's medically determinable impairments could have reasonably been expected to have caused the alleged symptoms. (AR 20). However, the ALJ also found that Plaintiff's statements regarding the intensity, persistence and limiting effects of these symptoms were not credible to the extent that they were incompatible with Plaintiff's RFC. (
The ALJ questioned Plaintiff's testimony and subjective complaints and found inconsistencies that diminished his overall credibility. (AR 19-22). The ALJ noted that when Plaintiff saw Dr. Afra, the state agency examining physician, he said that his main complaints were hypertension and headaches. (AR 21). However, Plaintiff alleged knee, shoulder and back pain. (AR 21-22). The ALJ also opined that Plaintiff provided inconsistent statements regarding his daily activities. (AR 22). For example, the ALJ remarked that Plaintiff told Dr. Ardebili, the examining psychologist, that he did household chores, made simple meals, shopped and walked his dog. (
The ALJ also reviewed the specific findings of Plaintiff's physicians and questioned the objective medical evidence. The ALJ noted that Dr. Frankel, the non-examining consulting physician, assessed limitations due to latent tuberculosis that exceeded Plaintiff's own complaints. (AR 20-21). The ALJ also noted that Dr. Afra, the state agency examining physician, assessed Plaintiff with no functional restrictions despite an MRI of Plaintiff's left knee from April 16, 2012, showing an intact reconstructed anterior cruciate ligament, tears of the medial and lateral menisci and joint effusion. (AR 20). The ALJ gave minimal weight to the opinions of Drs. Frankel and Afra in order to give great consideration to Plaintiff's allegations that he had functional restrictions beyond those assessed by Drs. Frankel and Afra. (AR 21). The ALJ found that the opinions of Drs. Ardebili and Kerns, who had assessed Plaintiff's mental health, to be consistent with Plaintiff's description of his difficulties with dealing with others and consistent with the medical record as a whole. (
At step four, the ALJ found that Plaintiff was unable to perform his past relevant work as a plumber's assistant. (AR 23). However, at step five, the ALJ found that, considering Plaintiff's age, education, work experience and RFC, he could perform jobs that exist in significant numbers in the national economy. (AR 23). The ALJ found that Plaintiff could perform other jobs such as laundry worker, collator or mail sorter. (AR 24). Accordingly, the ALJ found that Plaintiff was not disabled within the meaning of the Social Security Act. (
Under 42 U.S.C. § 405(g), a district court may review the Commissioner's decision to deny benefits. "[The] court may set aside the Commissioner's denial of benefits when the ALJ's findings are based on legal error or are not supported by substantial evidence in the record as a whole."
"Substantial evidence is more than a scintilla, but less than a preponderance."
Plaintiff contends that the ALJ improperly rejected the opinion of examining psychologist Banafshe Ardebili in assessing Plaintiff's residual functional capacity and thus propounded an incomplete hypothetical to the vocational expert that did not take all of Plaintiff's limitations into consideration. (Memorandum in Support of Complaint ("MSC"), Dkt. No. 18, at 3-5). The Court disagrees.
The Ninth Circuit recognizes three types of physicians: (1) treating physicians who examine and treat, (2) examining physicians who examine but do not treat, and (3) non-examining physicians who neither examine nor treat.
Plaintiff contends that the ALJ improperly rejected Dr. Ardebili's medical opinion because he did not provide specific and legitimate reasons for rejecting part of her opinion. (MSC at 4-5). Plaintiff contends that the ALJ implicitly rejected Dr. Ardebili's opinion because the ALJ did not adopt the assessment that Plaintiff needed to work in a "supervised, structured environment" in the RFC. (MSC at 5).
After taking a medical history and performing an examination of Plaintiff, Dr. Ardebili completed a Functional Assessment in a report prepared for the Commissioner. (AR 220-26). In her assessment, Dr. Ardebili identified Plaintiff's specific functional limitations. (AR 225). She found that Plaintiff had a moderate inability to interact appropriately with supervisors, coworkers and peers and that he had a mild inability to understand and carry out detailed instructions, to accept instructions from supervisors and to maintain pace. (AR 225). Dr. Ardebili opined that Plaintiff could understand and carry out short, simple instructions, perform basic self-care skills, perform simple work-related decisions with additional supervision, maintain attention and concentration, and maintain persistence and day-to-day activities. (
In her assessment, Dr. Ardebili also included the opinion that Plaintiff "would optimally thrive in a supervised, structured environment." (
The ALJ gave Dr. Ardebili's opinion great weight and found "the opinion[] to be consistent with the record as a whole." (AR 21). The ALJ assessed Plaintiff with the RFC to perform light work and appropriately factored Dr. Ardebili's limitations into Plaintiff's RFC. (
Furthermore, the ALJ specifically considered Dr. Ardebili's opinions on Plaintiff's limitations and incorporated her limitations in Plaintiff's RFC:
(AR 22). Contrary to Plaintiff's contention, the ALJ did not reject Dr. Ardebili's findings. (
Under the five-step evaluation process, if a claimant shows that he cannot return to his or her previous job, the burden shifts to the Commissioner to show that the claimant can do other work.
Here, the ALJ posed two complete hypotheticals to the VE in which the depiction of Plaintiff's disability was accurate, detailed and supported by the medical record. (AR 47-51). In the first hypothetical, the ALJ asked whether an individual who was the same age and had the same educational background and work experience as Plaintiff and had no exertional limitations, but should not be exposed to extreme cold, heat, wetness, humidity, fumes, dust, odors, gases or poor ventilation, would be able to perform the plumber's job. (AR 48). The VE testified that such a hypothetical individual could not perform the job of a plumber, but could be employed as a hand packager or laundry worker. (AR 48-50). In the second hypothetical, the ALJ asked whether the hypothetical individual could perform either of those jobs if he or she could only lift and carry twenty pounds occasionally and ten pounds frequently, could occasionally push, pull and kneel with the left lower extremity and had no limitations on the right, could not crawl, work with ladders, ropes or scaffolds, or work at unprotected heights, and could not have public contact or perform team-oriented tasks. (AR 50-51). The VE testified that the hypothetical individual could perform the job of a laundry worker, collator and mail sorter. (
The hypotheticals that the ALJ posed are supported by the medical record. In the first hypothetical, the ALJ incorporated the environmental limitations that Dr. Frankel suggested after he examined Plaintiff and diagnosed him with latent tuberculosis. (
Where an ALJ properly weighs the opinions of a claimant's physicians and arrives at a proper RFC, the court must uphold the ALJ's decision.
Consistent with the foregoing, it is ORDERED that the Judgment be entered AFFIRMING the decision of the Commissioner. The Clerk of the Court shall serve copies of this order and the Judgment on counsel for both parties.