JACQUELINE CHOOLJIAN, Magistrate Judge.
On January 5, 2018, plaintiff, by and through her guardian ad litem, filed a Complaint seeking review of the Commissioner of Social Security's denial of plaintiff's application for benefits. The parties have consented to proceed before the undersigned United States Magistrate Judge.
This matter is before the Court on the parties' cross motions for summary judgment, respectively ("Plaintiff's Motion") and ("Defendant's Motion") (collectively "Motions"). The Court has taken the Motions under submission without oral argument.
Based on the record as a whole and the applicable law, the decision of the Commissioner is AFFIRMED. The findings of the Administrative Law Judge ("ALJ") are supported by substantial evidence and are free from material error.
On November 22, 2013, plaintiff filed an application for Supplemental Security Income alleging disability beginning on February 15, 2011, essentially due to multiple mental limitations, ADHD, and dyslexia. (Administrative Record ("AR") 22, 131, 158). The ALJ examined the medical record and heard testimony from plaintiff, plaintiff's father, and a medical expert. (AR 32-40).
On August 9, 2016, the ALJ determined that plaintiff was not disabled through the date of the decision essentially because the record lacked "medical signs or laboratory findings to substantiate the existence of a medically determinable impairment." (AR 22-27).
On November 8, 2017, the Appeals Council denied plaintiff's application for review. (AR 1).
To qualify for childhood disability benefits an "individual under the age of 18" (i.e., "child" or "claimant") must establish that she has "a medically determinable physical or mental impairment, which results in marked and severe functional limitations, and which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." 42 U.S.C. § 1382c(a)(3)(C)(I); 20 C.F.R. §§ 416.902, 416.906;
In assessing whether a child is disabled, an ALJ is required to use the following three-step sequential evaluation process:
20 C.F.R. §§ 416.924(a), 416.926a;
A federal court may set aside a denial of benefits only when the Commissioner's "final decision" was "based on legal error or not supported by substantial evidence in the record." 42 U.S.C. § 405(g);
Substantial evidence is "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion."
Plaintiff essentially contends that the ALJ erroneously found no medically determinable impairment at step two of the sequential evaluation process for childhood disability. (Plaintiff's Motion at 4-7). Plaintiff has not shown that a reversal or remand is warranted on the asserted basis.
At step two, a claimant must establish that she has a severe medically determinable physical or mental impairment(s).
A claimant may be found "not disabled" at step two if she fails to present evidence of a medically determinable impairment, or the evidence establishes only "a slight abnormality or a combination of slight abnormalities that causes no more than minimal functional limitations. . . ." 20 C.F.R. §§ 416.921, 416.924(c).
Here, plaintiff has not shown that the ALJ materially erred at step two.
First, plaintiff points to nothing in the record which reflects, as she suggests (Plaintiff's Motion at 5) (citing AR 262-63, 281-82), that her poor grades and substandard performance on standardized testing were the product of any specific medically determinable impairment.
Second, the January 28, 2014, treatment note plaintiff cites in support of the proposition that she had "exhibited objective symptoms related to a mental impairment" actually reflects that it was plaintiff's mother who noted that plaintiff was being "bullied at school" and "[d]ropping weight" (AR 317), not a physician as plaintiff seems to suggest (Plaintiff's Motion at 5). Moreover, the medical expert testified that evidence that plaintiff "was noted to be somewhat anxious and depressed and referred to mental health" did not establish any "specific impairment[.]" (AR 36-37). Similarly, the March 29, 2016 treatment note plaintiff claims "did show medical signs not inconsistent with a medically determinable impairment[]" (Plaintiff's Motion at 5) (citing AR 335), more precisely reflects that plaintiff's grandmother (again, not a physician) had been the individual who reported that plaintiff "had suffered abuse in the family," and that plaintiff "[had] psychological problems, dreams, acting out, [] a somatization disorder," and "a learning disability." (AR 335). In addition, plaintiff's assertion that "[s]he appeared as alert and oriented but anxious in June 2016" does not, as plaintiff suggests (Plaintiff's Motion at 5), establish the presence of any identifiable medically determinable psychological impairment, especially given the physician's other findings in the cited medical record that plaintiff was generally "alert and cooperative" and a "[w]ell appearing child, appropriate for age, [with] no acute distress." (AR 328, 330).
Third, plaintiff has not shown that the ALJ's challenged statement — i.e., that "the medical record reflected no diagnosis" ("challenged statement") (AR 26) — necessarily "mischaracterized" the medical evidence. While the April 8, 2016, Behavioral Health Initial Evaluation Coordination of Care Report ("April 2016 Report") cited by plaintiff does appear to list several diagnoses for plaintiff (i.e., post-traumatic stress disorder, bipolar disorder), the April 2016 Report does not clearly identify the specific individual who made any of the diagnoses much less whether such individual was an "acceptable medical source." (AR 292-94). Moreover, it is unclear whether the April 2016 Report itself — which is boldly marked "FOR DRAFT USE [etc.]" across the front of each of its pages — actually contains any significant or probative evidence that might arguably conflict with the challenged statement. (AR 292-94) (emphasis in original);
Here, the medical expert interpreted the pertinent medical evidence much like the ALJ, and reached the same conclusion that "the medical evidence really doesn't establish any medical impairments." (AR 36);
Even assuming the ALJ's challenged statement was inconsistent with the diagnoses listed in the April 2016 Report, plaintiff fails to show that any error was more than harmless. The mere diagnosis of an impairment does not establish a medically determinable impairment. 20 C.F.R. § 416.921 (noting, in part, that Commissioner "will not use . . . a diagnosis" to establish the existence of a medically determinable impairment). Moreover, plaintiff fails to show that the superfluous challenged statement materially detracted from the ALJ's fundamental factual finding at step two — i.e., that plaintiff had failed to present "objective medical evidence" from an "acceptable medical source" which was required to establish a medically determinable impairment (AR 26) (citing SSR 06-3p) — which independently supported the ALJ's non-disability determination.
Plaintiff further contends that "the ALJ should have arranged for a consultative examination of [plaintiff]" essentially because the record "does not contain any IQ or formal consultative examination to determine [plaintiff's] level of functioning." (Plaintiff's Motion at 6). Plaintiff has not shown that the ALJ failed properly to develop the record in the asserted manner.
Accordingly, a reversal or remand is not warranted on any of the asserted grounds.
For the foregoing reasons, the decision of the Commissioner of Social Security is AFFIRMED.
LET JUDGMENT BE ENTERED ACCORDINGLY.