AUTUMN D. SPAETH, Magistrate Judge.
Plaintiff Pologa R.
Plaintiff last worked on December 12, 2014 as a truck driver and testified he stopped working due to his sleep apnea. (Administrative Record "AR" 173). When Plaintiff filed his claim for social security benefits on February 12, 2015, he alleged disability beginning December 12, 2014 (AR 263), based on sleep apnea, diabetes type 2, gout, hemorrhoid and hypertension. (AR 195).
Plaintiff here makes no claim of error related to any of his asserted medical conditions other than daytime somnolence related to sleep apnea.
Plaintiff's medical records reveal that Plaintiff has been diagnosed with sleep apnea, resulting in daytime somnolence. (AR 333, 335, 468, 729). In medical progress notes from January 2015, the status of Plaintiff's sleep apnea was described as "severe exacerbation" and "inadequately controlled" and that Plaintiff was on disability "[r]eported to DMV for severe sleep apnea with noncompliance." (AR 333-34). Plaintiff was prescribed medical treatment in the form of a continuous positive airway pressure ("CPAP") machine, which Plaintiff's medical records contain several notes of non-compliance in Plaintiff's use of the CPAP machine. (AR 334, 643). The medical notes state that while he previously reported noncompliance with his CPAP, after switching to nasal pillows, he began using the CPAP compliantly. (AR 643). In August 2016, Plaintiff was referred for a PAP (positive airway pressure) titration study (sleep study). (AR 645). The medical notes also state that, after the sleep study, Plaintiff switched to an automated positive airway pressure ("APAP") machine and that his symptoms related to sleep apnea had improved with "[f]ar less episodes of daytime somnolence," but did note that he had some remaining "residual fatigue." (AR 643 and 646). The medical notes of March 2017 further indicate that Plaintiff had "requested extension of off-work note until he completes his hearing to his DMV commercial license renew", that Plaintiff was "using APAP compliantly", that he had "[n]o issues" and that he "[c]ontinues to have resolution of his daytime somnolence since starting APAP." (AR 643).
Important to note for purposes of this review of the ALJ's decision, Plaintiff's medical records do not contain any notations that his sleep apnea and resulting daytime somnolence, even when Plaintiff was noncompliant with his medical treatment, required him to take a 2-3 hour nap once every day or prevented him from working. Indeed, Plaintiff makes no assertion here that his medical records contain this physical limitation or that any physician prescribed or discussed such a limitation with him. The only evidence of this allegedly required 2-3 hour daily nap is Plaintiff's own statements and testimony.
Plaintiff's DIB application was denied initially on July 14, 2015. (AR 204). Thereafter, Plaintiff filed a request for hearing by an Administrative Law Judge on September 3, 2015. (AR 210-211). A hearing was held before ALJ Michael D. Radensky on May 8, 2017. (AR 170-194). Plaintiff, represented by counsel, appeared and testified at the hearing, as well as vocational consultant Jeanine Metildi.
On June 28, 2017, the ALJ found that Plaintiff was "not disabled" within the meaning of the Social Security Act.
In the ALJ's decision of June 28, 2017 (AR 13-27), the ALJ followed the required five-step sequential evaluation process to assess whether Plaintiff was disabled under the Social Security Act.
The ALJ then found that Plaintiff had the following Residual Functional Capacity
(AR 19).
At
At
Plaintiff's Motion for Summary Judgment raises only one issue for review: that the ALJ failed to account for Plaintiff's daytime somnolence in assessing Plaintiff's residual functional capacity ("RFC").
A United States District Court may review the Commissioner's decision to deny benefits pursuant to 42 U.S.C. § 405(g). The District Court is not a trier of the facts but is confined to ascertaining by the record before it if the Commissioner's decision is based upon substantial evidence.
"[T]he Commissioner's decision cannot be affirmed simply by isolating a specific quantum of supporting evidence. Rather, a court must consider the record as a whole, weighing both evidence that supports and evidence that detracts from the Secretary's conclusion."
Plaintiff contends that the ALJ did not properly consider his complaints of daytime somnolence in the RFC, which concluded he could perform a range of light work. Plaintiff points to his own statements concerning his daytime somnolence as well as to medical records describing his sleep apnea and somnolence. Plaintiff argues the ALJ should have accounted for his daytime somnolence in the RFC.
Plaintiff's main argument that he is unable to work appears to be that his daytime somnolence requires him to nap multiple times a day for two to three hours at a time. Plaintiff points to no medical evidence documenting these daily naps or any medical advice to take daily naps to treat his somnolence. Rather, Plaintiff relies solely on his own statements and testimony of this purported condition. (AR 180-81, 307). Plaintiff's testimony alone will not establish that he is disabled. See 42 U.S.C. § 423(d)(5)(A) ("An individual's statement as to pain or other symptoms shall not alone be conclusive evidence of disability").
Plaintiff's medical records fail to support his claim of disability based on daytime somnolence. As Defendant notes, "Plaintiff fails to point to any medical opinion stating that he needed to nap during the day, that his drowsiness prevented him from working, or that he had any other limitations not included in the ALJ's RFC finding." [Dkt. No. 21, p. 2]. Indeed, the only medical evidence Plaintiff cites for support is that of Bryan King, M.D., which the ALJ gave "little weight", who also happened to note in March 2017 that Plaintiff's sleep apnea had significantly improved with treatment. (AR 643-46). A physician's notation that Plaintiff's somnolence had improved is not evidence that it had previously been fully disabling. Moreover, the ALJ discounted Dr. King's report, giving it little weight, for the specific and legitimate reason that it did not "document clinical signs and findings consistent with the extreme limitation Dr. King assesses" and because it "uncritically endorse[d] the claimant's subjective complaints. . . ." (AR 21).
Plaintiff asserts that the ALJ did not properly evaluate his testimony regarding daytime somnolence. Defendant, on the other hand, contends the ALJ properly evaluated Plaintiff's subjective statements, finding them inconsistent with the record.
A claimant carries the burden of producing objective medical evidence of his or her impairments and showing that the impairments could reasonably be expected to produce some degree of the alleged symptoms.
Once a claimant has met the burden of producing objective medical evidence, an ALJ can reject the claimant's subjective complaint "only upon (1) finding evidence of malingering, or (2) expressing clear and convincing reasons for doing so."
The ALJ may consider at least the following factors when weighing the claimant's credibility: (1) his or her reputation for truthfulness; (2) inconsistencies either in the claimant's testimony or between the claimant's testimony and his or her conduct; (3) his or her daily activities; (4) his or her work record; and (5) testimony from physicians and third parties concerning the nature, severity, and effect of the symptoms of which she complains.
Having carefully reviewed the record, the Court finds that the ALJ provided specific, clear and convincing reasons for discounting Plaintiff's subjective complaints. The ALJ found that Plaintiff's subjective complaints were not consistent with the objective medical record; that the medical opinions of record undermined Plaintiff's subjective complaints; and that Plaintiff's daily activities were inconsistent with his subjective complaints.
The ALJ performed a thorough review and analysis of Plaintiff's entire medical record and found Plaintiff's testimony inconsistent with the medical records. While Plaintiff was diagnosed with sleep apnea as reflected in his records, Plaintiff fails to point to any objective evidence to support his claim that he required daily naps of two to three hours per day. The ALJ noted this lack of supporting evidence in the decision. Thus, the ALJ provided specific, clear and convincing reasons why Plaintiff's subjective complaints are not supported by the objective medical records. "Although lack of medical evidence cannot form the sole basis for discounting pain testimony, it is a factor that the ALJ can consider in his credibility analysis."
In addition, medical opinions in the record and cited to by the ALJ in his finding of a restricted light RFC for the relevant period, undermine Plaintiff's testimony. Gayle M. Kookootsedes, M.D. opined that Plaintiff could perform a range of medium work, but was limited in his ability to work at heights or to operate heavy machinery or a motor vehicle due to his history of sleep apnea and daytime somnolence. (AR 410-16). The ALJ properly relied upon this opinion in discounting Plaintiff's subjective complaints.
The ALJ also found that Plaintiff's daily activities undermined his testimony. In March 2017, Plaintiff requested an "off-work note" from Dr. King to complete his hearing to have his DMV commercial license renewed and described that he "continues to have resolution of his daytime somnolence since starting APAP." (AR 643). In September 2015, nine months after filing for disability, Plaintiff also reported that he exercised for 150 minutes or more at a "moderate or strenuous level," three times a week. (AR 435). An ALJ is permitted to consider daily living activities in his credibility analysis.
Finally, the ALJ also discounted Plaintiff's subjective complaints on the grounds that Plaintiff had received conservative treatment during the period at issue and that numerous times throughout the medical records Plaintiff was noted to be non-compliant with his prescribed treatment for sleep apnea. (AR 20). Both of these grounds were permissible reasons to discount Plaintiff's subjective complaints.
Based on the clear, convincing and specific reasons for partially rejecting Plaintiff's subjective complaints and the substantial evidence to support the ALJ's determination, the Court concludes that the ALJ did not commit error by not including additional restrictions beyond those already included in the RFC due to Plaintiff's daytime somnolence.
For the reasons stated above, the decision of the Social Security Commissioner is AFFIRMED, and the action is DISMISSED with prejudice. Judgment shall be entered accordingly.