CAROLYN K. DELANEY, Magistrate Judge.
Plaintiff seeks judicial review of a final decision of the Commissioner of Social Security ("Commissioner") denying applications for Disability Income Benefits ("DIB") and Supplemental Security Income ("SSI") under Titles II and XVI of the Social Security Act ("Act"), respectively. For the reasons discussed below, the court will deny plaintiff's motion for summary judgment and grant the Commissioner's cross-motion for summary judgment.
Plaintiff, born August 29, 1962, applied on November 2, 2009 for DIB and on February 5, 2010 for SSI, alleging disability beginning September 4, 2009. Administrative Transcript ("AT") 133, 137. Plaintiff alleged she was unable to work due to depression, bipolar disorder, mood disorder, sleep apnea, diabetes, and high blood pressure. AT 151. In a decision dated April 5, 2012, the ALJ determined that plaintiff was not disabled.
AT 23-29.
Plaintiff argues that the ALJ improperly evaluated the medical evidence and improperly discredited her.
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.
The record as a whole must be considered,
Plaintiff contends the ALJ failed to consider plaintiff's heart problems in assessing the severity of her impairments. An impairment is "not severe" only if it "would have no more than a minimal effect on an individual's ability to work, even if the individual's age, education, or work experience were specifically considered." SSR 85-28. The purpose of step two is to identify claimants whose medical impairment is so slight that it is unlikely they would be disabled even if age, education, and experience were taken into account.
In determining whether plaintiff had a severe impairment or a severe combination of impairments, the ALJ did not specifically assess plaintiff's impairments related to her heart problems. Plaintiff argues that this error at step two necessarily makes the ALJ's findings in steps three, four and five erroneous as well. However, the ALJ's failure to assess the severity of plaintiff's heart condition at step two was harmless because the ALJ found that plaintiff had severe impairments of diabetes mellitus, neuropathy, and obesity and considered the limitations associated with plaintiff's heart condition at the other steps of the sequential process. AT 23;
Plaintiff contends the ALJ improperly rejected the opinions of Dr. David Smith and Dr. Anthony Edwards. 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.
Dr. Smith, plaintiff's treating cardiologist, provided a Cardiac Residual Functional Capacity Questionnaire dated January 25, 2012. AT 830. Dr. Smith reported that he had seen plaintiff on five separate occasions from July 2010 to January 2012. AT 827. He diagnosed plaintiff with ventricular tachycardia and noted that plaintiff had a defibrillator placement. AT 827. Dr. Smith further reported that plaintiff experienced fatigue, had no anginal pain, and would have good and bad days. AT 827, 830. Dr. Smith opined that plaintiff was limited to sitting for two hours in an eight-hour day and standing and/or walking for less than two hours in an eight-hour day. AT 829. According to Dr. Smith, plaintiff could lift and carry less than 10 pounds frequently, 10 pounds occasionally, and 20 pounds rarely, required a job that allows her to switch from sitting, standing and walking, and may, at times, need to take unscheduled breaks during an eight-hour work day. AT 829-30. Dr. Smith also reported that plaintiff had limitations arising from diabetic neuropathy, left ankle edema, and was unsteady on her feet. AT 830. The ALJ gave Dr. Smith's opinion little weight. AT 27.
On the other hand, the ALJ gave great weight to the opinion of Dr. George Nickles, a State agency medical consultant. AT 27. Dr. Nickles opined that plaintiff could occasionally lift 20 pounds, frequently lift 10 pounds, stand and/or walk for at least two hours in an eight-hour workday, and sit for a total of six hours in an eight-hour workday. AT 733.
The ALJ concluded that Dr. Smith's findings were not supported by the medical evidence. AT 27. Specifically, the ALJ noted that records show plaintiff's diabetes has been well-controlled since the onset of her disability (AT 348 [diabetes is stable]), few significant treatment notes show complaints of neuropathic pain and edema in the lower extremities (AT 998-1003), and plaintiff's heart problems stabilized within six months after her defibrillator implantation (AT 782 [Dr. Smith noting plaintiff was "clinically stable"]). AT 27. The ALJ also noted that, "[a]s of January 2012, plaintiff did not have significant symptoms of fatigue." AT 27. In support of this finding, the ALJ cited Dr. Smith's progress notes from a January 17, 2012 visit with plaintiff wherein there was no mention of fatigue. AT 27, 782-83.
Plaintiff contends the ALJ's reasons are insufficient to reject Dr. Smith's opinion. According to plaintiff, the medical records relating to her heart condition were generated by Dr. Smith and, thus, Dr. Smith's opinion is consistent with the medical record (i.e., his own treatment notes). However, the record, as a whole—including Dr. Smith's progress notes, indicate that plaintiff's heart condition stabilized. (AT 782). Plaintiff further contends that, since Dr. Smith did not treat plaintiff's diabetes, the ALJ's findings centered around the symptoms of diabetes were insufficient to reject Dr. Smith's findings. This is a mischaracterization of the ALJ's opinion. Plaintiff also contends that the fact she does not have angina is not a valid reason for rejecting his opinion because plaintiff's heart condition involves arrhythmia. However, the ALJ did not use Dr. Smith's finding regarding plaintiff's lack of angina as a reason for rejecting the opinion. AT 26-27. Finally, plaintiff asserts that she reported experiencing fatigue in September 2011. That plaintiff reported experiencing fatigue in September 2011 does not undermine the ALJ's reasoning that plaintiff's symptoms of fatigue were short-lived, and, in January 2012, she did not report experiencing fatigue to Dr. Smith. AT 27, 782-83, 786. The ALJ's reason for discounting Dr. Smith's opinion as lacking evidentiary support is specific and legitimate and supported by the record. The ALJ did not err in rejecting the opinion of Dr. Smith.
In April 2010, Dr. Anthony Edwards performed a psychological evaluation of plaintiff. AT 670. Dr. Edwards observed that plaintiff wept the entire session from arrival, through the assessment, and after. AT 670. Dr. Edwards noted plaintiff was trembling, which plaintiff attributed to being upset because she had moved to Nevada to be with her boyfriend and recently received a message from him saying that he was going back to his wife. AT 672. Plaintiff admitted suicidal and homicidal ideation, stating that she did not try to kill herself, instead she would hit herself. AT 672. As to plaintiff's cognitive functions, Dr. Edwards noted that plaintiff was oriented to person, place, time and purpose, had very poor ability to perform abstract reasoning, and demonstrated poor judgment, but her short-term and delayed memories were very good. AT 672. Dr. Edwards opined that plaintiff had low average to average range of cognitive abilities. AT 673. She could define simple and moderately complex words, her abstract reasoning was poor, her short-term and delayed memories were very good, her bank of general knowledge was poor, judgment was poor, and she could perform detailed and simple 1- or 2-step instructions. AT 673-74. Dr. Edwards further opined that appropriate interaction with supervisors, coworker, and the general public was not possible for plaintiff at the time of the examination because plaintiff's mood was variable, she wept throughout the examination, and hit herself. AT 674. Dr. Edwards also opined that plaintiff did not have the ability to maintain concentration and attention sufficient to carry out specific tasks based on plaintiff's inability to: discriminate between simple shapes and figure sizes, draw complex and abstract shapes, complete a multiple-step task involving drawing parallel lines across the page, and spell the word "triangle" correctly. AT 674. His prognosis for plaintiff was very poor. AT 675.
The ALJ gave little weight to the opinion of Dr. Edwards because it was inconsistent with plaintiff's testimony and the medical record. AT 27. The ALJ discounted the opinion as to plaintiff's limitations in social functioning and concentration, persistence and pace because, at the time of examination, plaintiff was working, could drive herself to work, spent evenings talking to others on the phone or in a Yahoo chat room, and could perform most daily living activities independently. AT 27, 673. The ALJ also noted that Dr. Edwards concluded plaintiff's problems appeared to be connected with her boyfriend. The ALJ also discussed plaintiff's treatment records from 2009 to 2010 demonstrating that plaintiff's mental symptoms were related to her being laid off from her previous job and unemployed (AT 356, 358), and, after her heart attack, she complained of anxiety and depression because she feared she would die due to her heart problems (AT 834). AT 27. The ALJ also noted that from August to December 2011, plaintiff was alert, oriented, cooperative, and had no deficits in memory, judgment, insight, impulse control, or intellectual function, and reported good energy. AT 27, 831-840, 993-1007.
Plaintiff contends that her daily activities are insufficient to provide a basis for rejecting the opinion of Dr. Edwards, noting that "[t]he Social Security Act does not require claimants to be utterly incapacitated to be eligible for benefits."
Plaintiff further contends that the ALJ failed to provide sufficient reasons for discrediting her subjective complaints. The ALJ determines whether a disability applicant is credible, and the court defers to the ALJ's discretion if the ALJ used the proper process and provided proper reasons.
In evaluating whether subjective complaints are credible, the ALJ should first consider objective medical evidence and then consider other factors.
Plaintiff reported that she was unable to work due to a combination of impairments including depression, bipolar disorder, mood disorder, sleep apnea, diabetes, and high blood pressure. AT 151. At the hearing before the ALJ, she testified that she could not be employed because of her heart problems. AT 58. The ALJ found plaintiff's statements concerning the intensity, persistence and limiting effects of plaintiff's symptoms not credible based on plaintiff's treatment history. AT 26. The ALJ noted that plaintiff's treatment history was sporadic and that she had a record of improvement after her heart attack in July 2011. AT 26. As explained above, the record indicates that plaintiff's diabetes has been well-controlled (AT 348), she has had few complaints of neuropathic pain and edema (AT 998-1003), and, as of January 2012, her heart problems had stabilized (AT 782). Significantly, the ALJ noted that plaintiff had not sought medical attention for any of her symptoms from the middle of 2010 to the middle of 2011, concluding that "[t]his year and half-long gap in treatment-seeking history during the claimant's alleged period of disability tends to undermine her overall credibility regarding the severity of symptoms." AT 26. The facts considered by the ALJ in discrediting plaintiff are valid and supported by the record. The credibility finding will not be disturbed.
For the reasons stated herein, IT IS HEREBY ORDERED that:
and
The claimant bears the burden of proof in the first four steps of the sequential evaluation process.