KAREN E. SCOTT, Magistrate Judge.
Plaintiff Julian Rivera Vargas appeals the final decision of the Commissioner denying his application for Social Security Disability Insurance Benefits ("DIB").
On November 16, 2016, Plaintiff filed an application for Social Security DIB alleging a disability onset date of March 15, 2012 due to multiple impairments. AR 148. A hearing was held before an Administrative Law Judge ("ALJ") on August 12, 2014. AR 29-54. The ALJ issued an unfavorable decision on September 25, 2014. AR 10-27.
The ALJ found that Plaintiff remained insured through June 30, 2013. AR 16, 18. The ALJ found that Plaintiff had the following severe impairments: disc disease of the cervical spine, disc disease of the lumbar spine, and right shoulder impingement syndrome. AR 18. The ALJ also found that Plaintiff had hypertension and diabetes, but that these were non-severe. AR 18-19.
The ALJ determined that Plaintiff had the residual functional capacity ("RFC") to perform a range of medium work. AR 19. The ALJ found Plaintiff can lift and/or carry 50 pounds occasionally and 25 pounds frequently; can stand and/or walk for 6 hours out of an 8-hour workday; can sit for 6 hours out of an 8-hour workday; can occasionally climb ladders, ropes or scaffolds; can frequently climb ramps and stairs; can frequently balance, stoop, kneel, crouch, and crawl; and can perform occasional overhead reaching with the right upper extremity. AR 19. Based on this RFC and the testimony of a vocational expert ("VE"), the ALJ determined that Plaintiff could perform his past relevant work as a floor installer. AR 22-23.
Plaintiff requested review from the Appeals Council, which denied review on March 24, 2016. AR 1-9. On that date, the ALJ's decision became the final decision of the Commissioner.
Under 42 U.S.C. § 405(g), a district court may review the Commissioner's decision to deny benefits. The ALJ's findings and decision should be upheld if they are free from legal error and are supported by substantial evidence based on the record as a whole. 42 U.S.C. § 405(g);
"A decision of the ALJ will not be reversed for errors that are harmless."
A person is "disabled" for purposes of receiving Social Security benefits if he is unable to engage in any substantial gainful activity owing to a physical or mental impairment that is expected to result in death or which has lasted, or is expected to last, for a continuous period of at least 12 months. 42 U.S.C. § 423(d)(1)(A);
The ALJ follows a five-step sequential evaluation process in assessing whether a claimant is disabled. 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4);
If the claimant is not engaged in substantial gainful activity, the second step requires the Commissioner to determine whether the claimant has a "severe" impairment or combination of impairments significantly limiting his ability to do basic work activities; if not, a finding of not disabled is made and the claim must be denied.
If the claimant has a "severe" impairment or combination of impairments, the third step requires the Commissioner to determine whether the impairment or combination of impairments meets or equals an impairment in the Listing of Impairments ("Listing") set forth at 20 C.F.R., Part 404, Subpart P, Appendix 1; if so, disability is conclusively presumed and benefits are awarded.
If the claimant's impairment or combination of impairments does not meet or equal an impairment in the Listing, the fourth step requires the Commissioner to determine whether the claimant has sufficient residual functional capacity ("RFC") to perform his past work; if so, the claimant is not disabled and the claim must be denied.
If that happens or if the claimant has no past relevant work, the Commissioner then bears the burden of establishing that the claimant is not disabled because he can perform other substantial gainful work available in the national economy. 20 C.F.R. §§ 404.1520(a)(4)(v), 416.920(a)(4)(v). That determination comprises the fifth and final step in the sequential analysis.
Plaintiff's appeal from the ALJ's unfavorable decision presents the following two issues:
(Dkt. 20 [Joint Stipulation or "JS"] at 4.)
Under Issue One, Plaintiff actually makes three separate arguments, only one of which concerns the ALJ's credibility finding. The Court addresses each of these arguments in turn.
Plaintiff argues, "The ALJ committed reversible error in relying upon the opinions of the orthopedic examiner [Dr. Robert MacArthur] and the subsequent opinions rendered by the state agency reviewing physicians [Dr. Thu N. Do and Dr. S. Clancey] when the orthopedic examiner clearly never reviewed any medical evidence in this case including the objective evidence such as the EMG/Nerve Conduction Study and multiple MRI reports." (JS at 6.) The Commissioner responds that any error by Dr. MacArthur in not reviewing the medical records was harmless, because "Drs. Do and Clancey expressly considered the MRI evidence and the EMG/Nerve Conduction Study, and they affirmed Dr. MacArthur's assessment." (JS at 11.) Moreover, the Commissioner argues, Dr. MacArthur did review x-rays of Plaintiff's lumbar and cervical spine, and perform his own complete physical examination. (
In deciding how to resolve conflicts between medical opinions, the ALJ must consider that there are three types of physicians who may offer opinions in Social Security cases: (1) those who directly treated the plaintiff, (2) those who examined but did not treat the plaintiff, and (3) those who did not treat or examine the plaintiff.
The ALJ must give specific and legitimate reasons for rejecting a treating physician's opinion in favor of a non-treating physician's contradictory opinion or an examining physician's opinion in favor of a non-examining physician's opinion.
However, "[t]he ALJ need not accept the opinion of any physician, including a treating physician, if that opinion is brief, conclusory, and inadequately supported by clinical findings."
"When an examining physician relies on the same clinical findings as a treating physician, but differs only in his or her conclusions, the conclusions of the examining physician are not substantial evidence."
If an examining physician did not review all of the plaintiff's treatment records, this may be a reason for giving greater weight to the opinion of a treating physician who is more familiar with the longitudinal treatment record; yet there is no
The ALJ reviewed medical opinions from the following sources:
(1) Plaintiff's treating chiropractor in connection with her worker's compensation claim, Mahbobeh Soltani, DC; (2) examining physician orthopedist Dr. Robert MacArthur, MD; (3) two non-examining State agency medical consultants, Drs. Do and Clancey; and (4) a functional capacity evaluation by chiropractor Holli Banes, DC.
The ALJ gave Soltani's and Banes's opinions little weight because chiropractors are not acceptable medical sources under Social Security regulations. AR 22.
Dr. MacArthur examined Plaintiff on March 23, 2013. AR 292. Although he noted that "no orthopaedic records were available for review," he did review x-rays of Plaintiff's cervical and lumbar spine. AR 293, 296-97. He also conducted a "historical interview" with Plaintiff, who he found to be "a credible historian." AR 292-93.
Dr. MacArthur noted that Plaintiff "was able to get on and off the examination table without assistance," that he was "in apparent comfort throughout the interview and evaluation process," and that he did "not appear to be in acute or chronic distress." AR 294. He found that Plaintiff had a normal gait and did not use any assistive devices for ambulation. AR 294. He found, "All joint ranges of motion are within normal limits," although the right shoulder was "positive for mild impingement at 160 degrees, +/- Jobe's test[.]" AR 295. He found slight limitations on Plaintiff's range of motion in the cervical and thoracolumbar spine. AR 295. A straight leg test was negative in both legs. AR 296. Regarding Plaintiff's hands and feet, he observed that Plaintiff "was able to manipulate the use of a pen with ease" and that Plaintiff did "not restrict the use of either hand during examination." AR 296. He also found that Plaintiff had normal motor and grip strength. AR 296.
Based on the physical examination and x-rays, Dr. MacArthur diagnosed Plaintiff with multilevel degenerative disc disease in the cervical and lumbar spine, as well as a "probable partial tear rotator cuff and mild impingement" in the right shoulder. AR 297. The RFC he assessed was for the most part consistent with the RFC ultimately assessed by the ALJ, namely: that Plaintiff could perform a range of medium work as follows: (1) lift and/or carry 50 pounds occasionally and 25 pounds frequently; (2) stand and/or walk up to 6 hours in a normal 8-hour workday; (3) sit for up to 6 hours in an 8-hour work day; and (4) occasionally climb ladders, ropes, and scaffolds. AR 297-98. The ALJ imposed one limitation that Dr. MacArthur did not: the ALJ limited Plaintiff to only occasional overhead reaching, whereas Dr. MacArthur opined that Plaintiff could reach without limitations in all directions, including overhead.
Plaintiff argues it was error for the ALJ to rely on Dr. MacArthur's opinion because Dr. MacArthur did not review "objective evidence such as the EMG/Nerve Conduction Study and multiple MRI reports." (JS at 6.)
The EMG/Nerve Conduction Study that Plaintiff cites was performed on June 8, 2012 and found "severe peripheral neuropathy" and "possible left S1 radiculopathy." AR 281. The MRIs Plaintiff refers to were performed on April, August, and September of 2012. AR 287-90. The April 2012 MRI of Plaintiff's cervical spine showed "cervical muscular spasm," a "remote central compression fracture of the C6 vertebral body"; "mild spondylosis" of the C3-C4, C5-C6, and C6-C7 vertebrae; and disc herniation, protrusion, and bulging of various vertebrae. AR 285, 290. The August 2012 MRI of Plaintiff's cervical spine found evidence of disc bulging and spinal stenosis. AR 287. The September 2012 MRI of Plaintiff's right shoulder was "consistent with small intrasubstance tears and tendinitis and a possible "stress reaction or bone bruise." AR 288.
As noted above, Dr. MacArthur found that Plaintiff had multilevel degenerative disc disease of the cervical and lumbar spine, based on x-rays he reviewed. AR 297. The EMG/Nerve Conduction Study and MRIs are consistent with this diagnosis, and Plaintiff does not explain how they show a more limited RFC than that found by Dr. MacArthur. (JS at 5-6.) To the extent Plaintiff is arguing that these tests show that Plaintiff suffered from more functional limitations due to pain, the ALJ was entitled to rely on Dr. MacArthur's independent observation that Plaintiff appeared to be in no acute distress during the March 2013 exam, which was conducted at least 6 months after those tests. AR 294.
The Court finds no error in the ALJ relying on Dr. MacArthur's opinion. This is particularly true because the record contains no contrary opinion from a treating physician, other than the opinions from Plaintiff's treating chiropractors. The ALJ appropriately gave those opinions little weight, as discussed above, and Plaintiff does not challenge that finding.
In concluding that Plaintiff's diabetes was not severe, the ALJ made the following findings:
AR 19.
Plaintiff argues that the ALJ failed to account for additional side effects of his diabetes, other than retinopathy and the lack of end organ damage. (JS at 6.) Plaintiff cites evidence that he had peripheral neuropathy, kidney disease, and an abnormally high hemoglobin A1c level of 11.4 in September 2013. (
Regarding peripheral neuropathy, Plaintiff cites an electro-diagnostic study performed on June 8, 2012, which showed "severe peripheral neuropathy." (JS at 5, citing AR 281). Although Plaintiff asserts that this "is attributable to Plaintiff's severe diabetic condition" (JS at 6), the Commissioner is correct that Plaintiff has not cited, and this Court has not found, evidence in the AR that a physician ever reached this conclusion.
Regarding kidney disease, on February 14, 2014, Dr. Vien Doan, D.O. diagnosed Plaintiff with "Diabetic nephropathy secondary to longstanding type II diabetes." AR 474.
Regarding the A1c, it is true that Plaintiff had an elevated A1c of 11.4 in September 2013.
One high A1c test does not undermine the ALJ's finding that Plaintiff's diabetes "should be amenable to proper control by adherence to recommended medical management and medication compliance." AR 19. After the September 2013 A1c test, Plaintiff began treatment with Dr. Vien Don, DO and Dr. Chao H. Sun, MD for his diabetes. He began keeping daily logs of his blood glucose readings. AR 466-70 (readings between February and June 2014), AR 240 (readings between July and August 2014). In February 2014, Dr. Don commented that Plaintiff's A1c was too high, and he would "add Onglyza and follow up in 1 month with home readings." AR 474. In May 2014, Dr. Sun recommended that Plaintiff continue his current medications and focus on "dietary control." AR 459. The blood glucose levels in Plaintiff's logs declined slightly after these treatments: in February, his blood glucose readings were as high as 227, but after March, his blood glucose readings did not rise over 200 and generally fell in the 160-180 range. AR 466-70, AR 240. These records support the ALJ's finding that Plaintiff's diabetes could be controlled through compliance with recommended treatments.
In sum, the ALJ's finding that Plaintiff's diabetes was not a severe impairment is supported by substantial evidence.
An ALJ's assessment of symptom severity and claimant credibility is entitled to "great weight."
If the ALJ finds testimony as to the severity of a claimant's pain and impairments is unreliable, "the ALJ must make a credibility determination with findings sufficiently specific to permit the court to conclude that the ALJ did not arbitrarily discredit claimant's testimony."
In evaluating a claimant's subjective symptom testimony, the ALJ engages in a two-step analysis.
Second, if the claimant meets the first test, the ALJ may discredit the claimant's subjective symptom testimony only if he makes specific findings that support the conclusion.
The ALJ may also use ordinary techniques of credibility evaluation, such as considering the claimant's reputation for lying and inconsistencies in his statements or between his statements and his conduct.
Plaintiff testified that he could lift about 10 pounds, sit for 15 minutes, stand for 30 minutes, and that he had trouble reaching overhead with the right upper extremity. AR 20 (ALJ's findings), 31-47 (Plaintiff's testimony). The ALJ found that Plaintiff's "statements concerning the intensity, persistence and limiting effects of [his] symptoms are not entirely credible" because Plaintiff's reported activities of daily living contradicted Plaintiff's allegations of disability:
AR 20. The ALJ also noted that Plaintiff "did not indicate that he required a cane or other assistive devices for ambulation" and that "he was taking NSAIDs for pain, along with other medications for his diabetes mellitus and hypertension." AR 20 (citing Plaintiff's testimony and Exhibit 8E, p. 3 [AR 218]).
Plaintiff argues, first, that the ALJ "failed to specify which statements by Plaintiff concerning pain, functional limitations, and other symptoms were not `sufficiently credible,'" arguing this is error under
Second, Plaintiff argues that none of his reported activities of daily living "equate to full time medium work activity." (JS at 9.) Plaintiff notes that, in the exertion questionnaire, for "virtually every activity" Plaintiff "has a caveat that he must take breaks in order to complete those tasks." (
In the exertion questionnaire, Plaintiff stated: "I have a hard time doing any activities or chores. I try, but I am always in so much pain." AR 216 (emphasis added). Yet at the hearing, Plaintiff testified that he was taking Excedrin and Tylenol for his pain; he did not indicate taking a narcotic painkiller. AR 41-42. He also reported doing grocery shopping, yard work, and some housework, as discussed below.
In the exertion questionnaire, Plaintiff stated that he does his own grocery shopping once a week and can carry "light objects, groceries, from my car to my house." AR 217. He also stated he could carry "groceries, 1 gallon of milk, very light objects, maybe once or twice a day." AR 217. At the hearing, he testified that he goes grocery shopping every 15 days with his wife. AR 45. He testified that his wife was under a disability with her arms, but that she still did most of the housework; he testified, "I help her a little." AR 45.
Plaintiff testified that he could stand for only 20-30 minutes at one time. AR 44. In the exertion questionnaire, Plaintiff stated that, when doing housework or chores, he has to stop after about 15 minutes "because the pain in my neck, my back and my right shoulder/arm is unbearable." AR 218. Yet in the exertion questionnaire, Plaintiff also stated that he cuts his own grass about once a month, which takes him about 3 hours "with breaks in between," and that he waters his plants daily, which takes him 1-2 hours. AR 217. He did qualify that "sometimes my right arm and my back start to bother me and I get a migraine and I have to quit that day and continue the next day. I can't always do it and I rely on my son to help me." AR 217.
In the exertion questionnaire, Plaintiff stated he could drive a car 30 to 45 minutes at a time. AR 217. At the hearing, however, he testified he could sit for only 15 minutes at one time. AR 44.
Overall, the Court finds that inconsistencies between Plaintiff's hearing testimony and his exertion questionnaire undermined Plaintiff's credibility.
"At step four of the sequential analysis, the claimant has the burden to prove that he cannot perform his prior relevant work `either as actually performed or as generally performed in the national economy.'"
Plaintiff testified that he has a seventh-grade education. AR 34. He speaks only a few words of English and cannot read English. AR 35. Plaintiff testified that for several years starting in about 1994, he worked installing wood floors. AR 37. He testified this job required him to lift about 30 pounds. AR 37.
The VE opined, "Based on the testimony, it sounds like floor installers [sic] the only one that would qualify as SGA. ... So that's the title, floor installer. DOT Code is 860.381-022." AR 47. The title of the entry at DOT Code 860.381-022 is "carpenter," although the entry indicates that such work "may be designated," among other things, "Hardwood-Floor Installer (construction)" or "Wood-Strip-Block Floor Installer (construction)."
Based on the VE's testimony, the ALJ made the following findings:
AR 23.
Plaintiff argues that the ALJ "mischaracterized his past relevant work and ... reached the conclusion that [Plaintiff] is capable of performing an occupation described as a carpenter when in fact Plaintiff's description of his past work is clearly not that of a carpenter." (JS at 16.) Plaintiff argues that Plaintiff's past work should have been characterized as an "installer," as described in DOT 869.684-026. (JS at 17.)
Plaintiff relies on the Work History Report completed by Plaintiff on January 28, 2013 in conjunction with his application for benefits. (
Any error on this point was harmless. The ALJ concluded that Plaintiff could perform a range of medium work, including lifting and/or carrying 50 pounds occasionally and 25 pounds frequently; standing and/or walking for 6 hours out of an 8-hour workday; and sitting for 6 hours out of an 8-hour workday. AR 19. Assuming that Plaintiff's past work should have been classified as an "installer," the DOT states that that position requires medium work consistent with the RFC found by the ALJ.
Plaintiff argues, "The fact that [Plaintiff] was never released to return to his past work is inconsistent with the ALJ's conclusion that [Plaintiff] was in fact capable of performing that occupation." (JS at 18.) Plaintiff appears to be referring to the fact that his treating chiropractor for worker's compensation purposes never released him to return to work. As discussed above, a chiropractor is not an acceptable medical source, and a disability finding made in the worker's compensation context is not binding in the Social Security context.
Based on the foregoing, IT IS ORDERED that judgment shall be entered AFFIRMING the decision of the Commissioner denying benefits.