KENDALL J. NEWMAN, Magistrate Judge.
Plaintiff seeks judicial review of a final decision by the Commissioner of Social Security ("Commissioner") denying plaintiff's applications for Supplemental Security Income ("SSI") under Title XVI of the Social Security Act ("Act").
For the reasons discussed below, the court DENIES plaintiff's motion for summary judgment, GRANTS the Commissioner's cross-motion for summary judgment, and enters judgment for the Commissioner.
Plaintiff was born on June 25, 1975, has a GED, and is able to communicate in English. (Administrative Transcript ("AT") 261, 264, 266.)
On appeal, plaintiff raises the following issues: (1) whether the ALJ properly evaluated the medical opinion evidence and the medical evidence as a whole when determining plaintiff's residual functional capacity ("RFC"); (2) whether the ALJ properly evaluated the credibility of the plaintiff's testimony; (3) whether the ALJ breached her duty to develop the record; (4) whether the ALJ properly found at step three that plaintiff's impairments did not meet or equal a Listing; and (5) whether the ALJ posed proper hypothetical questions to the vocational expert.
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 ALJ evaluated plaintiff's entitlement to SSI pursuant to the Commissioner's standard five-step analytical framework.
Before proceeding to step four, the ALJ assessed plaintiff's RFC as follows:
(AT 24.)
At step four, the ALJ found, based on the VE's testimony, that plaintiff was unable to perform any past relevant work. (AT 26.) At step five, the ALJ determined that, in light of plaintiff's age (a younger individual), education, work experience, and residual functional capacity, there were jobs that existed in significant numbers in the national economy that plaintiff could perform. (AT 26-27.) Thus, the ALJ concluded that plaintiff had not been under a disability, as defined in the Act, from August 27, 2010, through the date of the ALJ's decision. (AT 28.)
First, plaintiff argues that the ALJ improperly evaluated the medical opinion evidence in the record when determining plaintiff's RFC. In particular, he asserts that the ALJ improperly considered the opinions of Dr. Kinnison, Dr. Boyce, Dr. Jone and Dr. Fahlberg with regard to the limitations caused by his physical impairments. He further argues that the ALJ failed to consider any limitations arising out of the combined effects of plaintiff's physical and mental impairments. The court addresses each argument in turn and finds them to lack merit.
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.
Here, when determining plaintiff's physical RFC, the ALJ considered and weighed the examining opinion of Dr. Kinnison, the medical expert opinion of Dr. Boyce, who testified during the hearing, and the non-examining opinions of state agency consultative physicians Dr. Jone and Dr. Fahlberg. (AT 26.)
Dr. Kinnison examined plaintiff on December 18, 2010, at the request of the Commissioner. (AT 397.) While no previous medical records were provided for review, Dr. Kinnison performed a full physical examination and diagnosed plaintiff with "right lower extremity chronic edema and cellulitis." (AT 398-400.) Dr. Kinnison opined that plaintiff could stand and walk up to six hours daily and that his sitting capacity was unlimited. (AT 400.) Dr. Kinnison further opined that plaintiff could lift twenty pounds occasionally and ten pounds frequently, and could climb frequently. (
Dr. Boyce gave his expert medical opinion at the hearing on April 24, 2013, after a review of plaintiff's medical records.
Non-examining physicians Dr. Jone and Dr. Fahlberg reviewed plaintiff's medical records then-available to them and opined that plaintiff had no severe physical impairments. (AT 417, 567.)
When discussing the medical opinion evidence, the ALJ gave more weight to the opinion of Dr. Kinnison than she gave to Dr. Boyce's opinion because Dr. Kinnison had an opportunity to examine the plaintiff, while Dr. Boyce had only reviewed plaintiff's medical records and testified at his hearing. This reason for favoring Dr. Kinnison's examining opinion over that of Dr. Boyce's non-examining opinion was clearly proper as examining opinions are generally entitled to more weight than those issued by physicians who only reviewed the claimant's medical records and did not conduct their own independent examination.
The ALJ assigned little weight to the opinions of Drs. Jone and Fahlberg because a significant amount of additional and material medical evidence was developed after those opinions were issued. (AT 26.) Because those physicians opined that plaintiff had no severe physical impairments, and thus had restrictions less severe than those ultimately determined by the ALJ, the ALJ's assignment of reduced weight to their opinions was in plaintiff's favor and therefore provides no support for plaintiff's contention that the ALJ's consideration of those opinions constituted prejudicial error.
Ultimately, the ALJ's RFC determination adopted all of the limitations articulated by Dr. Kinnison with the addition of a limitation against food handling, which was the sole limitation articulated by Dr. Boyce. (AT 26.) This determination was based on a proper finding that Dr. Kinnison's examining opinion was somewhat more persuasive than Dr. Boyce's non-examining opinion. Furthermore, the ALJ properly discounted the opinions of the state agency non-examining physicians that plaintiff had no functional limitations. Even had the ALJ erred in weighing those physicians' opinions, it would have been harmless error as none of those physicians opined limitations greater than those determined by the ALJ. Accordingly, plaintiff's argument that the ALJ improperly weighed the opinion evidence in the record concerning plaintiff's physical impairments is without merit.
Plaintiff appears to contend further that the ALJ erred by failing to consider additional opinions in the record concerning his physical impairments. However, the records plaintiff cites to in support of this argument provide little more than diagnoses and some minimal treatment recommendations; they do not contain any discussion or medical judgment as to how plaintiff's impairments restricted him functionally.
There are also additional opinions in the record regarding plaintiff's mental impairments that the ALJ considered and weighed at step two of the analysis (AT 23); however, none of them articulated anything more than mild limitations to social and time management abilities. (AT 58-63, 395, 401-07.) Even the most restrictive opinion, by Dr. Palmer, still found plaintiff capable of performing complex tasks and work activities on a consistent basis without special or additional instruction. (AT 395.) Based on this evidence, the ALJ found that plaintiff's mental impairments were non-severe, in other words, that they imposed no more than a minimal or de minimis limitation on his ability to do work-related activities, a finding plaintiff does not challenge.
Plaintiff also contends that the ALJ failed to properly consider the combined effect of plaintiff's mental and physical impairments reflected in the medical record when she determined plaintiff's RFC. Specifically, plaintiff asserts that the "ALJ erred to[sic] disregard Dr. Palmer's specific opinion that `Plaintiff's mental condition appears to be seriously exacerbated by his physical problems.'" (ECF No. 10 at 21 (citing AT 393.)) The regulations require an ALJ to consider the combined effects of all impairments both severe and non-severe in formulating an RFC. 20 CFR §416.945(a)(2). However, this single statement plaintiff relies on in support of his argument does not show how the ALJ erroneously failed to consider the combined effect of plaintiff's impairments when determining plaintiff's RFC. To be sure, in making her determination, the ALJ considered the entire record and "considered all symptoms and the extent to which these symptoms can reasonably be accepted as consistent with the objective medical evidence and other evidence." (AT 24.) Furthermore, the ALJ expressly discussed the evidence in the record regarding plaintiff's mental impairments, including Dr. Palmer's clinical records, and determined that plaintiff did not have any severe mental impairments, even in light of his severe physical impairments. (AT 19-24.)
Moreover, Dr. Palmer's statement only indicates that, in Dr. Palmer's opinion, the impact of plaintiff's mental impairments would have been lessened if plaintiff's physical impairments were not present. (AT 393.) Even after taking into account the perceived impact plaintiff's physical impairments had on his mental functioning, Dr. Palmer opined that plaintiff had no greater than mild mental limitations. (AT 395.) Such mild limitations were consistent with the ALJ's RFC determination. Therefore, plaintiff's argument that the ALJ committed prejudicial error regarding how she considered the combined impact of plaintiff's mental and physical impairments is without merit.
For the reasons discussed above, the ALJ's consideration of the medical evidence in the record was proper and her RFC decision was supported by substantial evidence. Furthermore, plaintiff has not identified any limitation articulated in any opinion regarding either plaintiff's physical or mental health that indicates that plaintiff's functional capacity was more limited than the RFC adopted by the ALJ. Accordingly, plaintiff's argument that the ALJ committed prejudicial error in her consideration of the medical evidence is without merit.
Next, plaintiff contends that the ALJ improperly found plaintiff's own testimony regarding the extent of his symptoms and functional limitations to be less than fully credible.
In
"The ALJ must specifically identify what testimony is credible and what testimony undermines the claimant's complaints."
In support of her adverse credibility determination, the ALJ relied on inconsistencies in plaintiff's testimony regarding his work history, history of substance abuse, and frequency of "flareups" of cellulitis requiring hospitalization, and the conservative medical treatment plaintiff received along with his failure to seek treatment. (AT 25-26.) For the reasons discussed below, the ALJ provided clear and convincing reasons for discounting plaintiff's testimony that were supported by substantial evidence in the record.
First, the ALJ properly considered plaintiff's work history in support of her adverse credibility determination.
The ALJ also legitimately referenced the inconsistencies in the record regarding plaintiff's substance abuse. (AT 21-22.)
In light of the above, the court finds that the ALJ provided multiple specific, clear, and convincing reasons for discounting plaintiff's testimony of disabling symptoms and functional limitations beyond the limitations assessed in the ALJ's RFC that were supported by substantial evidence from the record.
Plaintiff contends further that the ALJ failed to adequately develop the record — more specifically, that the ALJ did not make sufficient efforts to obtain the alleged remainder of plaintiff's mental health treatment records, and failed to contact plaintiff's treating physicians for further clarification of their opinions. This argument is devoid of merit.
"The ALJ always has a `special duty to fully and fairly develop the record and to assure that the claimant's interests are considered ... even when the claimant is represented by counsel.'"
It is well established that a claimant bears the burden of providing medical and other evidence that support the existence of a medically determinable impairment.
Nevertheless, as the Ninth Circuit Court of Appeals has also explained:
Here, the ALJ developed a large and reasonably thorough record, including medical opinions, various hospital visits, plaintiff's interactions with the California Department of Corrections health services, and numerous sets of treatment notes. The ALJ also continued the hearing date to allow plaintiff to get new representation and ensure that all relevant documents were in the record. (AT 87-88.) The ALJ even called two medical experts and a vocational expert to testify at the second hearing to provide medically accurate summaries of the record and allow the ALJ to understand the impact of plaintiff's alleged limitations. (AT 46.) These steps clearly indicate that the ALJtook all reasonable measures to fulfill her duty to develop the record.
Plaintiff had every opportunity to present any additional evidence he felt was necessary or desirable. Dr. Largo's treatment notes were requested by the state agency both during plaintiff's initial application and on reconsideration, but were not provided until the case was before an ALJ. (AT 432.) Additionally, even after plaintiff's hearing date was continued, multiple documents were not provided in a timely fashion for the second hearing. (AT 48-49.) At the second hearing, plaintiff's counsel stated that he was not aware of any missing documents material to plaintiff's case. (AT 43-44.) Therefore, any lack of evidence in the record falls squarely on plaintiff and cannot be shifted onto the shoulders of the ALJ, who took numerous measures to ensure that the record was fully developed before issuing a decision.
Plaintiff also appears to argue that the ALJ erred in determining that plaintiff's impairment's did not meet or equal listing-level severity. Plaintiff's motion mentions the ALJ's decision with regard to the listings only once, in a parenthetical example of how the ALJ failed to consider the combined effects of plaintiff's mental and physical impairments. (ECF No. 10 at 21.) To the extent that plaintiff intends to challenge the ALJ's determination that plaintiff's impairments did not meet or equal listing-level severity, he does not in any way assert that he meets a particular listing set forth in 20 CFR Part 404, Subpart P, Appendix 1, let alone show that he satisfies the requirements for such a listing. Therefore, to the extent plaintiff attempts to raise an argument with regard to the ALJ's step three determination, his argument is not well taken.
Finally, plaintiff argues that the ALJ erred at step five by relying on VE testimony that lacked evidentiary value because it was based on improper hypothetical questions that failed to include all of plaintiff's functional limitations.
An ALJ may pose a range of hypothetical questions to a vocational expert, based on alternate interpretations of the evidence. However, the hypothetical that ultimately serves as the basis for the ALJ's determination, i.e., the hypothetical that is predicated on the ALJ's final RFC determination, must account for all of the limitations and restrictions of the particular claimant that are supported by substantial evidence in the record as a whole.
Plaintiff asserts that because the ALJ failed to properly evaluate the medical evidence and find plaintiff's testimony credible, the hypotheticals she posed to the VE based on the limitations contained in her RFC determination were improper as they did not reflect all of plaintiff's functional limitations. This argument, however, lacks merit because, for the reasons stated above, the ALJ properly evaluated the medical evidence and gave proper reasons for finding plaintiff's testimony regarding the impact of his impairments not credible. Because the ALJ found plaintiff not credible, she was not required to include any of plaintiff's alleged limitations beyond those already included in the RFC determination. Furthermore, the ALJ posed hypotheticals to the VE that were based on the limitations outlined in the ALJ's RFC determination, which was supported by substantial evidence from the record. Therefore, plaintiff's argument is without merit.
For the foregoing reasons, the court concludes that the ALJ's decision is free from prejudicial error and supported by substantial evidence in the record as a whole. Accordingly, IT IS HEREBY ORDERED that:
1. Plaintiff's motion for summary judgment (ECF No. 10) is DENIED.
2. The Commissioner's cross-motion for summary judgment (ECF No. 11) is GRANTED.
3. Judgment is entered for the Commissioner.
4. The Clerk of Court shall close this case.
The claimant bears the burden of proof in the first four steps of the sequential evaluation process.