JOHN E. McDERMOTT, Magistrate Judge.
On January 8, 2015, Susan B. Diaz ("Plaintiff" or "Claimant") filed a complaint seeking review of the decision by the Commissioner of Social Security ("Commissioner") denying Plaintiff's application for Supplemental Security Income ("SSI") benefits. The Commissioner filed an Answer on May 11, 2015. On September 17, 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 bef ore 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 55-year-old female who applied for Supplemental Security Income benefits on October 24, 2008, alleging disability beginning January 1, 2008. (AR 24, 126.) The ALJ determined that Plaintiff has not engaged in substantial gainful activity since October 24, 2008, the application date. (AR 26, 128.)
Plaintiff's claim was denied initially on January 28, 2009. (AR 126.) Plaintiff filed a timely request for hearing, which was held before Administrative Law Judge ("ALJ") Brenton L. Rogozen on May 10, 2010, in Downey, California. (AR 126.) Plaintiff appeared and testified at the hearing and was represented by counsel. (AR 126.) Vocational expert ("VE") Stephen M. Berry also appeared and testified at the hearing. (AR 126.)
The ALJ issued an unfavorable decision on September 14, 2010. (AR 126-135.) On December 12, 2011, the Appeals Council vacated the September 14, 2010, hearing decision and remanded the case. (AR 139-142.)
A remand hearing was held before ALJ Robert S. Eisman on July 18, 2013, in Norwalk, California. (AR 23.) Plaintiff appeared and testified at the hearing. (AR 23.) Plaintiff was represented by counsel. (AR 23.) Medical expert ("ME") Eric D. Schmitter and VE Joseph H. Torres also appeared and testified at the hearing. (AR 23.)
The ALJ issued an unfavorable decision on September 5, 2013. (AR 23-33.) The Appeals Council denied review on November 19, 2014. (AR 1-3.)
As reflected in the Joint Stipulation, Plaintiff raises only the following disputed issue as a ground for reversal and remand:
1. Whether the ALJ properly considered Dr. Payam Moazzaz' examining opinion.
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.
Before making the step four determination, the ALJ first must determine the claimant's residual functional capacity ("RFC"). 20 C.F.R. § 416.920(e). The RFC is "the most [one] can still do despite [his or her] limitations" and represents an assessment "based on all the relevant evidence." 20 C.F.R. §§ 404.1545(a)(1), 416.945(a)(1). The RFC must consider all of the claimant's impairments, including those that are not severe. 20 C.F.R. §§ 416.920(e), 416.945(a)(2); Social Security Ruling ("SSR") 96-8p.
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 October 24, 2008, the application date. (AR 26, 128.)
At step two, the ALJ determined that Plaintiff has the following medically determinable severe impairments: obesity, right knee degenerative joint disease, status post total knee replacement (October 2011); and lumbar spine degenerative disc disease. (AR 26.)
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 26.)
The ALJ then found that prior to February 1, 2012, Plaintiff had the RFC to perform a limited range of medium work as defined in 20 C.F.R. § 416.967(c). (AR 26-27.) As of February 1, 2012, the ALJ found that Plaintiff had the RFC to perform light work, as defined in 20 C.F.R. § 416.967(b), with the following limitations:
(AR 27-31.) In determining the above RFCs, the ALJ made an adverse credibility determination, which Plaintiff does not challenge here. (AR 28.)
At step four, the ALJ found that Plaintiff has no past relevant work. (AR 31.) The ALJ, however, also found that (1) prior to February 1, 2012, considering Claimant's age, education and RFC, there were jobs that existed in significant numbers in the national economy that Claimant could have performed, including the jobs of hand packager, kitchen helper, and laundry laborer (AR 31-32); and that (2) as of February 1, 2012, considering Claimant's age, education and RFC, there are jobs that exist in significant numbers in the national economy that Claimant could perform, including the jobs of cleaner/housekeeping, hand packer, and assembler/small products (AR 32-33). Consequently, the ALJ found that Claimant has not been under a disability since October 24, 2008, the date the application was filed. (AR 33.)
The ALJ decision must be affirmed. The ALJ properly considered the medical evidence in formulating Plaintiff's RFC. The ALJ did not err in rejecting the occasional overhead reaching limitation of Dr. Moazzaz. The ALJ's RFC is supported by substantial evidence.
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. See SSR 96-5p; 20 C.F.R. § 1527(e). In determining a claimant's RFC, an ALJ must consider all relevant evidence in the record, including medical records, lay evidence, and the effects of symptoms, including pain reasonably attributable to the medical condition. Robbins, 446 F.3d at 883.
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.
The ALJ found that Claimant has the severe medically determinable impairments of obesity, right knee degenerative joint disease, status post total knee replacement, and lumbar spine degenerative disc disease. (AR 26.) There is no finding of any medically determinable impairment of the upper extremity or shoulder that would result in any manipulative or reaching limitations. Nonetheless, Plaintiff contends that the ALJ erred in rejecting the occasional overhead reaching limitation assessed by examining orthopedist Dr. Payam Moazzaz. (AR 575-580.)
Dr. Moazzaz' February 18, 2012, report indicates Plaintiff presented with complaints of bilateral wrist and hand pain, right knee pain and lower back pain. (AR 525.) There was no complaint of upper extremity impairment or of problems or pain in reaching. Dr. Moazzaz noted a February 2009 neurologic examination, which demonstrates 5/5 strength throughout all motor groups. (AR 576.) He found full pain-free range of motion of the shoulder, elbow and forearm, and bilateral wrists and fingers, with no tenderness to palpation. (AR 577-578.) He also found 5/5 strength in deltoid, external rotators, biceps, triceps, wrist extensors, wrist flexors, and interrosei musculature, bilaterally. (AR 578.) He further found sensation in the upper extremity to be intact. (AR 579.) Dr. Moazzaz found that Claimant's motor examination is intact throughout the upper and lower extremities. (AR 580.) Dr. Moazzaz diagnosed mild spondylolisthesis, obesity, status post right total knee arthoplasty, and bilateral carpel tunnel syndrome. (AR 29, 579.) There was no diagnosis of any upper extremity impairment.
Dr. Moazzaz assessed Plaintiff with a light work RFC. (AR 580.) She can stand, walk, and sit six hours out of an eight hour day. (AR 580.) Climbing, stooping, kneeling, and crouching may be done occasionally. (AR 580.) Overhead activities may be done occasionally. (AR 580.) Use of the hands for fine and gross manipulative movements may be done frequently. (AR 580.) She does not require the use of any assistive device. (AR 580.)
The ALJ gave Dr. Moazzaz' opinion "substantial weight" (AR 30), but did not adopt his limitation to occasional overhead activities. (AR 27.) Plaintiff contends that the ALJ failed to provide specific, legitimate reasons for rejecting this limitation. Plaintiff also contends that the alleged error is not harmless because an occasional overhead reaching limitation would preclude the identified alternate occupations (cleaner, hand packer, and assembler), which require frequent or constant reaching.
An ALJ, however, "need not discuss
Dr. Moazzaz did not diagnose any upper extremity impairment that would result in an overhead reaching limitation. The record in this case is 940 pages, but is devoid of any medical evidence of any upper extremity impairment that would support a reaching restriction of any kind. Indeed, Dr. Moazzaz in his own report found full pain free range of motion and motor strength in the upper extremities. In the absence of any finding or medical evidence of an upper extremity impairment, the ALJ did not err in disregarding Dr. Moazzaz' occasional overhead reaching limitation. An ALJ may reject an examining physician's opinion when that opinion is inconsistent with the physician's own report and when the opinion is not supported by clinical findings. 20 C.F.R. § 416.927(d)(3);
Plaintiff, moreover, did not complain to Dr. Moazzaz of any upper extremity impairments or any pain or limitations in reaching. (AR 575.) Nor did she make such a complaint to any other medical source in the record. At the July 18, 2013, hearing, Plaintiff did not make any complaints about her upper extremities or of pain or limitations in reaching. (AR 75-95.) The ALJ repeatedly asked her about any other problems she had and she only identified problems with her back and knees, but made no mention of upper extremities or reaching. (AR 82.) Claimant's attorney, in argument at the end of the hearing, never mentioned upper extremity impairments, pain in reaching or Dr. Moazzaz' occasional overhead reaching limitation. (AR 100-101.) Only after the hearing and issuance of the ALJ decision did Plaintiff raise the issue of Dr. Moazzaz' overhead reaching limitation.
Nor is it the case that the ALJ failed to discuss upper extremity impairments or reaching limitations. In the prior ALJ opinion of September 14, 2010, which covers a portion of the disability period applicable here, the ALJ noted the January 2009 report of consulting orthopedist Dr. Timothy Ross.
In the absence of medical evidence of an upper extremity impairment that would support an overhead reaching limitation, the ALJ was not obliged to discuss Dr. Moazzaz' occasional overhead reaching limitation. Dr. Moazzaz' opinion in this regard was neither significant nor probative.
The ALJ's RFC is supported by substantial evidence. The ALJ's nondisability determination is supported by substantial evidence and free of legal error.
IT IS HEREBY ORDERED that Judgment be entered affirming the decision of the Commissioner of Social Security and dismissing this case with prejudice.