GREGORY G. HOLLOWS, Magistrate Judge.
Plaintiff seeks judicial review of a final decision of the Commissioner of Social Security ("Commissioner") denying his applications for Disability Insurance Benefits ("DIB") and Supplement Security Income ("SSI") under Titles II and XVI, respectively, of the Social Security Act ("Act"). For the reasons that follow, plaintiff's motion for summary judgment is denied, defendant's cross-motion for summary judgment is granted, and judgment is entered for defendant.
Plaintiff, born September 30, 1952, applied on April 18, 2007 for DIB and SSI, alleging that he became disabled on March 9, 2006. (Tr. at 18, 61-64, 101-05, 106-10.) Plaintiff contended that he was unable to work primarily due to Hepatitis C and depression. (Tr. at 127, 313, 340.) Plaintiff's claims were denied initially and upon reconsideration. (Tr. at 18, 61-64.) Thereafter, plaintiff requested a hearing before an administrative law judge ("ALJ"), which was conducted on December 8, 2008 in Stockton, California. (Tr. at 18, 77, 26-60.) David M. Dettmer, an impartial vocational expert ("VE"), also appeared at the hearing. (Tr. at 18, 26.)
Subsequently, in a decision dated March 30, 2009, ALJ Sandra K. Rogers determined that plaintiff was not disabled. (Tr. at 25.) The ALJ made the following findings:
(Tr. at 20-25.) The ALJ's decision became the final decision of the Commissioner when the Appeals Council denied plaintiff's request for review on November 18, 2010. (Tr. at 1-5.)
Plaintiff's motion presents three issues for review: (1) whether the ALJ erred in failing to acknowledge a treating physician's opinion concerning plaintiff's left wrist motion restrictions; (2) whether the ALJ improperly evaluated opinion evidence concerning plaintiff's mental impairments; and (3) whether the ALJ erroneously found that plaintiff's hepatitis C was asymptomatic and therefore improperly discredited plaintiff's testimony.
The court reviews the Commissioner's decision to determine whether (1) it is based on proper legal standards pursuant to 42 U.S.C. § 405(g), and (2) substantial evidence in the record as a whole supports it.
Plaintiff contends that the ALJ failed to address the opinion of plaintiff's former treating orthopaedic surgeon, Dr. Craig Bottke, concerning plaintiff's left wrist motion restrictions.
The weight given to medical opinions depends in part on whether they are proffered by treating, examining, or non-examining professionals.
To evaluate whether an ALJ properly rejected a medical opinion, in addition to considering its source, the court considers whether (1) contradictory opinions are in the record; and (2) clinical findings support the opinions. An ALJ may reject an uncontradicted opinion of a treating or examining medical professional only for "clear and convincing" reasons.
In this case, plaintiff, who is right hand dominant, initially sustained a left wrist injury during a motorcycle accident in 1975 for which he underwent surgery and received a silicone scaphoid implant. (Tr. at 45, 353.) Subsequently, on March 13, 2000, plaintiff again injured his wrist while picking up a box of saws weighing around seventy pounds at work. (Tr. at 353.) Upon evaluation by orthopaedic surgeon Dr. Bottke, he was found to have severe left wrist silicone synovitis secondary to breakdown of the previous silicone scaphoid implant, aggravated by the lifting injury at work, which may have caused a fracture and displacement of the implant. (Tr. at 353.) Thereafter, he underwent a further surgical procedure involving fusion of the left wrist and the fourth and fifth carpometacarpal joints which were unstable. (Tr. at 353.)
On March 5, 2001, Dr. Bottke completed a "Primary Treating Physician's Permanent and Stationary Report" in connection with plaintiff's workers' compensation claim.
Plaintiff correctly notes that the ALJ's decision failed to explicitly address Dr. Bottke's report. However, Dr. Bottke's March 2001 report is significantly outdated with respect to plaintiff's April 2007 claims, alleging disability as of March 2006, thus limiting its probative value.
In fact, the record contains much more recent evidence of plaintiff's hand function. On August 16, 2007, Dr. Philip Seu, a consultative examiner, tested plaintiff's hand function as part of his evaluation. (Tr. at 298-302.) Dr. Seu found that plaintiff had full motor strength (5/5) in his wrist flexors and extensors bilaterally and full grip strength (5/5) bilaterally. (Tr. at 301.) Although plaintiff had no range of motion of the left wrist, plaintiff's finger and thumb joints had between 70-90 degree flexion and extension bilaterally. (Tr. at 300.) Dr. Seu then opined that plaintiff had no manipulative limitations on reaching, handling, feeling, grasping, and fingering. (Tr. at 302.) Although plaintiff makes much of the fact that plaintiff's left wrist is permanently fused and has no range of motion, this is not dispositive of plaintiff's resulting functional limitations. Dr. Seu acknowledged that plaintiff in 2007 still had no range of motion of the left wrist, but nonetheless concluded based on his examination that plaintiff had no resulting limitations on reaching, handling, feeling, grasping, and fingering. (Tr. at 302.)
Moreover, whatever concern the court may have concerning any residual conflict between Dr. Bottke's 2001 report and Dr. Seu's 2007 assessment is dispelled by the fact that plaintiff actually performed at least one of the two occupations identified by the ALJ as past relevant work plaintiff could perform at step four — bottling line attendant — for several years after Dr. Bottke's report. (Tr. at 24-25, 40, 44, 50-52, 128, 135.) According to the Dictionary of Occupational Titles excerpt provided by plaintiff's counsel, this position requires frequent reaching, handling, and fingering, and a medium degree of finger dexterity and manual dexterity. (Tr. at 177-80, 356-59.) Plaintiff himself indicated that the position, as he performed it, required handling, grabbing, and grasping objects for 8 hours a day. (Tr. at 136.) There is no evidence in the record that plaintiff stopped working as a bottling line attendant due to any wrist problems — indeed, although plaintiff's counsel raised the issue at the administrative hearing and in subsequent correspondence/briefing, plaintiff did not even identify any hand/wrist problems and corresponding limitations in his May 2007 disability report or upon examination by Dr. Seu in August 2007. (Tr. at 127, 298-302.) There is also no record evidence suggesting that his wrist condition had worsened since.
In light of the above, the court concludes that the ALJ's failure to discuss Dr. Bottke's report was inconsequential to the nondisability determination and thus harmless. As such, remand is not warranted on this basis.
Because plaintiff has not received treatment for any mental health condition, the record does not contain any opinion from a treating psychiatrist or psychologist. However, plaintiff argues that the ALJ improperly evaluated the opinion evidence from two examining sources who provided opinions concerning plaintiff's mental impairments.
At the request of the Commissioner, consultative examiner and board-certified psychiatrist Dr. Manolito Castillo performed a psychiatric evaluation of plaintiff on January 8, 2008. (Tr. at 313-16.) He noted that plaintiff's chief complaints were hepatitis C and depression. (Tr. at 313.) Plaintiff reported that his life dramatically changed after he started taking interferon for his hepatitis C, and he started experiencing depression, anger, and suicidal thoughts. (Tr. at 313.) After his interferon treatment was discontinued, plaintiff continued to be depressed with low energy levels, reduced sleep, reduced appetite, a lack of interest in pleasurable activities, and reduced memory and concentration. (Tr. at 313.) Dr. Castillo performed a mental status examination, which indicated that plaintiff's mannerisms, social behavior, orientation, attention span, memory, abstraction ability, judgment, and thought processes were normal. (Tr. at 314-15.) Although plaintiff described his mood as depressed, Dr. Castillo observed his affect as euthymic, i.e. normal. (Tr. at 314.)
Based on the examination, Dr. Castillo diagnosed plaintiff with a depressive disorder and assessed a GAF score of 60.
Subsequently, on November 27, 2008, at the request of plaintiff's counsel, psychiatrist Dr. Les Kalman performed another psychiatric evaluation of plaintiff. (Tr. at 339-48.) Plaintiff again reported similar complaints to Dr. Kalman, including depression, exhaustion, and difficulty concentrating and making decisions, with thoughts of suicide. (Tr. at 340-41.) Upon examination, Dr. Kalman found that plaintiff was pleasant and cooperative, had average speech and good eye contact, was alert and oriented, had good memory, and had above average intelligence. (Tr. at 341-42.) His abstractions were generally intact, he had good insight and judgment, and his form of thought was logical and goal oriented, although he was noted to be depressed and frustrated. (Tr. at 342.)
Dr. Kalman diagnosed plaintiff with an adjustment disorder, with depression secondary to his medical condition (which he noted to be hepatitis C, hypertension, and chronic back pain), and assessed a GAF score of 55, stating that his condition was not expected to improve significantly in the next twelve months. (Tr. at 343.) He stated that plaintiff was competent to manage his own funds. (Tr. at 343.)
Furthermore, Dr. Kalman opined that plaintiff was "not significantly limited"
Dr. Kalman noted that unruly, demanding, or disagreeable customers even on an infrequent basis; production demands or quotas; a demand for precision; and a need to make quick and accurate, independent decisions in problem solving on a consistent basis would increase plaintiff's level of impairment. (Tr. at 347.) Finally, he stated that plaintiff would be unable to complete a workday at least three or four times a month, and estimated the date of onset of these limitations to be 2006. (Tr. at 348.)
As an initial matter, plaintiff contends that the ALJ erroneously concluded that Dr. Castillo's and Dr. Kalman's opinions were inconsistent. Certainly, at an initial glance, the opinions appear somewhat similar in that they both assessed moderate limitations in plaintiff's ability to complete complex/detailed tasks and concentrate for two-hour periods. However, upon closer examination, Dr. Kalman's specific definitions of terms such as "mildly limited" and "moderately limited" are substantially different from the conventional understanding of these terms as used in Social Security cases.
Therefore, if anything, it is clear that Dr. Castillo's and Dr. Kalman's opinions were not consistent. Moreover, at the hearing the ALJ and VE specifically discussed Dr. Kalman's unique definitions, indicating that the ALJ clearly recognized that Dr. Kalman was not employing the conventional definitions of these terms as used in the Social Security context.
Plaintiff next argues that the ALJ failed to provide specific and legitimate reasons for rejecting Dr. Kalman's opinion. The court disagrees. The ALJ correctly noted that Dr. Kalman failed to provide any objective evidence to support his excessive findings (as noted above), which were also not supported by the other record evidence. (Tr. at 23.)
Finally, plaintiff contends that the ALJ improperly evaluated Dr. Castillo's opinion in several ways. First, plaintiff points out that the ALJ inaccurately stated that Dr. Castillo reported that plaintiff "was able to interact with co-workers, supervisors, and the general public." (Tr. at 21.) However, Dr. Castillo found no limitation in plaintiff's ability to "socially interact with others at an age-appropriate level." (Tr. at 315.) Although plaintiff's counsel selectively interprets Dr. Castillo's assessment to be limited to informal social situations (e.g. interaction with friends and family), Dr. Castillo placed no such qualifier on his assessment. Consultative examiners are well aware that their opinions are sought primarily with respect to a claimant's work-related limitations and it can be reasonably inferred that Dr. Castillo would have included such an important qualifier if it were necessary. Moreover, even Dr. Kalman opined that plaintiff was not significantly limited in his ability to interact appropriately with the general public or customers, ask simple questions or request assistance from supervisors, and maintain socially appropriate behavior. (Tr. at 346-47.) Thus, the ALJ's finding is supported by substantial evidence.
Second, plaintiff argues that, contrary to the ALJ's summary in his decision, Dr. Castillo never stated that plaintiff "could withstand the stress and pressures associated with an eight-hour workday and day-to-day activities." (Tr. at 21.) While it is true that Dr. Castillo never literally used those words, the ALJ reasonably drew such an inference from Dr. Castillo's report.
Third, plaintiff claims that the ALJ failed to mention Dr. Castillo's assessment that plaintiff was moderately limited in his ability to concentrate for at least two-hour increments in the hearing decision. Again, while this is technically true, the error was clearly inadvertent and harmless, because the ALJ specifically incorporated this limitation into his hypothetical to the VE, who then testified that the hypothetical individual could perform plaintiff's past jobs of bottling line attendant and sampler. (Tr. at 47-48.) The court declines to remand the case merely to allow the ALJ to correct a technical deficiency in the written decision that did not affect the ultimate nondisability determination.
Accordingly, the court concludes that the ALJ's analysis of the opinion evidence concerning plaintiff's mental impairments is supported by substantial evidence in the record as a whole.
Plaintiff was diagnosed with hepatitis C
In August 2005, after testing again showed significantly elevated blood levels indicative of hepatitis C, plaintiff sought treatment from internal medicine and infectious diseases specialist Dr. Salah Bibi, who diagnosed plaintiff with hepatitis C and chronic back pain, and described plaintiff's general appearance as "healthy." (Tr. at 215-21, 290-97.) Plaintiff started treatment with interferon (Pegasys and Ribavirin) on October 19, 2005, and Dr. Bibi noted that he was tolerating the treatment well with minor side effects as of November 2, 2005. (Tr. at 213-14.) However, between late 2005 and early 2006, plaintiff started reporting increasing symptoms of being tired, moody, losing his temper, skin irritation, chest pain, shortness of breath, dizziness, muscle/joint pain, and nausea. (Tr. at 208-12.)
Plaintiff alleges disability as of March 9, 2006, and the medical records reveal that on March 24, 2006, plaintiff reported to Dr. Bibi that he was unable to do his physical work. (Tr. at 207.) In addition to hepatitis C, Dr. Bibi noted that plaintiff had anemia, a low white blood cell count, and general malaise. (Tr. at 207.) On April 11, 2006, plaintiff reported similar symptoms of fatigue and malaise to his primary health care provider, Dr. Jacqueline Galang, but denied any fever, abdominal pain, nausea, vomiting, or diarrhea. (Tr. at 269-70.) Dr. Galang noted that plaintiff's white blood cell count was low, but that his liver function tests were normal. (Tr. at 269.) Subsequently, on April 24, 2006, plaintiff complained of shortness of breath on exertion and difficulty swallowing, and Dr. Bibi interrupted his interferon treatment for two weeks to allow plaintiff to regain his strength and to see if his shortness of breath improves. (Tr. at 206.) On May 8, 2006, plaintiff felt better, his white blood cell count went up, and he had no shortness of breath or swallowing problems, and the interferon treatment was resumed. (Tr. at 205.) Thereafter, on September 6, 2006, Dr. Bibi again halted the interferon treatment for two weeks when plaintiff reported exhaustion and diarrhea with a low white blood cell count and anemia. (Tr. at 201.) Later that month, plaintiff also requested to stop the interferon treatment. (Tr. at 200.) On October 27, 2006, with laboratory tests showing that plaintiff's hepatitis C viral load was still very elevated but that his liver function tests and blood count tests were normal, Dr. Bibi determined that the interferon treatment was unsuccessful and should not be continued. (Tr. at 199, 274.)
On January 3, 2007, Dr. Bibi released plaintiff to return to work at 40 hours per week. (Tr. at 198.) However, on January 15, 2007, Dr. Galang reported that although plaintiff was anxious to return to work, he did not clear his work physical due to high blood pressure. (Tr. at 277.) He had no chest pain, shortness of breath, abdominal pain, diarrhea, joint pain, or weakness, and was observed to be well nourished and well developed. (Tr. at 277-78.) Dr. Galang diagnosed plaintiff with benign hypertension, intermittent heartburn, and some malaise and fatigue; started him on blood pressure medication and a low-salt diet with exercise; and put him on disability until February 12, 2007. (Tr. at 278-79.) On February 12, 2007, after plaintiff sustained a left knee injury, Dr. Galang extended plaintiff's disability until March 5, 2007. (Tr. at 286-88.) Subsequently, on March 5, 2007, plaintiff reported to Dr. Galang that although he had some malaise, he was feeling good with no chest pains, shortness of breath, abdominal pains, nausea, vomiting, fever, or diarrhea; his blood pressure was good; and he was ready to return to work. (Tr. at 260.) He was diagnosed with benign hypertension, hepatitis C without hepatic coma, hyperlipidemia, and arthritis, and Dr. Galang released him to return to work at 40 hours per week on March 7, 2007. (Tr. at 261-62.)
However, on March 9, 2007, plaintiff informed Dr. Bibi that he had quit his job and that he experienced extreme fatigue, but that his hepatitis was not bothering him. (Tr. at 197.) March 20, 2007 treatment notes from Dr. Galang indicate that plaintiff had again not passed his work physical due to high blood pressure at the time of the test and that Dr. Bibi had put him on disability until May 8, 2007. (Tr. at 197, 263.) Plaintiff reiterated complaints of fatigue and malaise with no fever, abdominal pains, nausea, or vomiting, and Dr. Galang again diagnosed him with benign hypertension and discussed a low cholesterol diet and a need for better blood pressure control. (Tr. at 263-64.) Two days later during a pre-colonoscopy physical assessment,
Plaintiff saw Dr. Galang once more on May 14, 2007 primarily complaining of erectile dysfunction. (Tr. at 265.) He reported that his symptoms were more or less stable with some malaise and fatigue, but that he was able to go on with his daily routines. (Tr. at 265.) Dr. Galang diagnosed plaintiff with erectile dysfunction and prescribed Cialis. (Tr. at 266.) The administrative record contains no further medical records from treating providers between May 2007 and December 2008. As discussed above, plaintiff was examined by consultative examiner Dr. Philip Seu on August 16, 2007. (Tr. at 298-302.) However, at that time, plaintiff's chief complaints were low back pain and joint pain, and after reviewing plaintiff's 2006-2007 medical records and examining plaintiff, Dr. Seu opined that plaintiff's hepatitis C was relatively asymptomatic. (Tr. at 298, 301.)
Finally, in December 2008 plaintiff underwent blood work for hepatitis C at Kaiser Manteca Medical Center. (Tr. at 26, 349-52.) A Dr. Arora stated that the blood work showed that his hepatitis C antibodies were still positive and his liver enzymes elevated, and he was advised to undergo viral load testing and an ultrasound of the liver. (Tr. at 349.)
In this case, there is no dispute that plaintiff has been diagnosed with hepatitis C. Instead, the issue is what functional limitations are attributable to plaintiff's hepatitis C and whether they potentially render plaintiff disabled. Plaintiff argues that, by finding plaintiff's hepatitis C to be largely asymptomatic, the ALJ improperly discredited plaintiff's testimony in this regard — for example, plaintiff's testimony that he became tired with less than two hours of sitting and standing, that after doing about two hours of activity he was "beat" the rest of the day, that he spent several hours a day reclining or sitting down with both feet up, and that he was physically and emotionally unable to get up and go to work in the morning. (Tr. at 33-34, 39.)
"Credibility determinations are the province of the ALJ" and are entitled to deference if the ALJ provides sufficient reasoning supported by substantial evidence.
"General findings are insufficient; rather, the ALJ must identify what testimony is not credible and what evidence undermines the claimant's complaints."
As an initial matter, the court notes that the ALJ did not entirely discredit plaintiff's allegations of fatigue and malaise. Indeed, despite consulting examiner Dr. Seu's assessment that plaintiff had no physical functional limitations, the ALJ limited plaintiff to light work. (Tr. at 22-23, 298-302.) Nevertheless, to the extent that the ALJ discounted plaintiff's testimony regarding his symptoms and functional limitations, the ALJ provided several specific, clear, and convincing reasons for doing so. The ALJ reasoned as follows:
(Tr. at 23.)
Substantial evidence supports the ALJ's finding that plaintiff's daily activities are inconsistent with his allegations of disabling symptoms and limitations. (Tr. at 21, 23.) Plaintiff told Dr. Seu that he took care of his elderly mother, which involved meal preparation and help with transportation, and that he did household chores such as cleaning. (Tr. at 299.) Plaintiff also informed Dr. Castillo that he attended to his mother's needs, washed dishes, vacuumed, swept, did laundry, cooked, and was able to utilize public transportation independently, drive, and handle his own funds. (Tr. at 315.) Plaintiff described a typical day to Dr. Kalman as "get up, read the paper, wake his mom, make breakfast, walk the dog, make lunch, do a little in the yard, nap, try to learn the guitar, dinner, bed." (Tr. at 343.) He went outside alone on a daily basis to walk or drive, shopped for groceries once a week, went to the public library and out for coffee once a week, and handled finances. (Tr. at 157-58.) To be sure, the record also contains some contrary evidence, such as plaintiff and his wife's written statements, suggesting that plaintiff's activities are more limited. (Tr. at 154-61, 162-64.) However, it is the function of the ALJ to resolve any ambiguities, and the court finds the ALJ's assessment to be reasonable and supported by substantial evidence.
Also, the ALJ properly considered her personal observations of plaintiff at the hearing as part of the overall credibility evaluation, noting that he was able to participate in the hearing and respond to questioning without any apparent difficulties.
Additionally, as is evident from the chronological summary of medical evidence above, the ALJ reasonably inferred that there was no twelve month period where the claimant's limitations rendered him disabled for purposes of the Social Security Act. While plaintiff's interferon treatment no doubt significantly impacted his physical and mental condition, especially as of his alleged disability onset date of March 9, 2006, he finally ceased the treatment in October 2006, and both his treating physicians released him for full-time work on January 3, 2007 and March 7, 2007. The fact that he did not actually return to work and was put back on state disability benefits was not the result of his hepatitis C, but instead that he did not pass his specific employer's physical exam due to elevated blood pressure at the time. Plaintiff's employer's physical exam is not dispositive of disability for purposes of Social Security benefits and here arguably conflicted with plaintiff's treating physician's diagnosis of benign hypertension and her finding that plaintiff's blood pressure was acceptable when she examined him on March 5, 2007 and released him for work on March 7, 2007. (Tr. at 260, 262.)
Also, the ALJ correctly noted that no treating or examining physician had opined that plaintiff was totally and permanently disabled from all work, and that his allegations of pain and limitations were excessive and not consistent with treatment and medical findings. Notably, his treating physicians only took him off work for definite periods of time, a large portion of which was due to the adverse side effects of the interferon treatment. Consultative examiner Dr. Seu examined plaintiff and found that his hepatitis C was relatively asymptomatic with no resulting physical functional limitations. Although plaintiff's subjective symptom testimony cannot be discredited solely on the basis that it is not quantified by objective medical findings, this was nevertheless a relevant factor for the ALJ to consider.
Furthermore, the ALJ reasonably found that plaintiff's gap in treatment between May 2007 and December 2008 suggests that plaintiff's symptoms and limitations are not as serious as he alleges. Failure to seek consistent treatment is a proper consideration when evaluating credibility.
Therefore, the court concludes that the ALJ provided sufficient clear, convincing, and specific reasons for partially discounting plaintiff's testimony regarding his alleged symptoms and functional limitations, and that substantial evidence supports the finding that plaintiff's hepatitis C is largely asymptomatic and does not render him disabled.
Finally, plaintiff contends that the ALJ's failure to discuss the December 2008 laboratory report submitted after the administrative hearing, showing that plaintiff's hepatitis C antibodies were still positive and his liver enzymes elevated, constitutes reversible error. (Tr. at 349.) This argument lacks merit. The brief report confirms that plaintiff still has hepatitis C, but does not indicate that plaintiff has any specific functional limitations resulting from it. It is well known that persons infected with hepatitis C may be asymptomatic.
Accordingly, for the reasons outlined above, IT IS HEREBY ORDERED that:
1. Plaintiff's motion for summary judgment (dkt. no. 13) is DENIED;
2. Defendant's cross-motion for summary judgment (dkt. no. 16) is GRANTED; and
3. Judgment is entered for defendant.
The claimant bears the burden of proof in the first four steps of the sequential evaluation process.