CHRISTINE M. ARGUELLO, District Judge.
This matter is before the Court on Plaintiff Todd E. Lindsey's appeal of the Commissioner's February 9, 2011 decision denying his claim for Disability Insurance Benefits pursuant to Title II of the Social Security Act, 42 U.S.C. §§ 401-33. (AR at 18-29.)
Plaintiff was born on October 17, 1970, and was 36 years old on his alleged disability onset date of December 31, 2006. (AR at 23, 27.) Plaintiff is a high school graduate, is able to communicate in English, and has past relevant work as a manager, auto servicer (medium, SVP-7), and working manager (heavy, SVP-3). (AR at 27, 28, 148.)
Plaintiff applied for Title II Disability Insurance Benefits on May 19, 2009, alleging disability due to a bad back and knees, a right shoulder problem, and chronic headaches. (AR at 142.) He asserted that he had been disabled since December 31, 2006. (AR at 143.) Plaintiff's claim was denied initially on October 19, 2009. (AR at 65-72.) He requested a hearing with an Administrative Law Judge ("ALJ") (AR at 76-77), which was held on January 25, 2011 (AR at 34-64). At the hearing, Plaintiff was represented by counsel. (AR at 34.) Plaintiff testified, as did a Vocational Expert ("VE").
On February 9, 2011, the ALJ issued a decision, finding that Plaintiff was not disabled at any time from December 31, 2006, through the date of her decision. (AR at 21.) In applying the five-step sequential evaluation process outlined in 20 C.F.R. § 404.1520 to determine whether Plaintiff was disabled, the ALJ determined that:
Thereafter, Plaintiff timely filed a request with the Appeals Council for review, which the Council denied on May 24, 2012. (AR at 12.)
On August 27, 2012, Plaintiff filed a Complaint, seeking judicial review of the denial of Social Security Benefits. (Doc. # 1.) The Social Security Administrative Record was filed with the Court on November 5, 2012. (Doc. # 10.) On January 18, 2013, Plaintiff filed his Opening Brief. (Doc. # 17.) The Commissioner responded on March 13, 2013 (Doc. # 20), and Plaintiff replied on April 1, 2013 (Doc. # 21).
In his appeal, Plaintiff asserts four arguments in support of his contention that the ALJ committed legal errors and that her decision was not supported by substantial evidence. (Doc. # 17 at 2.) Specifically, Plaintiff argues that the ALJ erred by: (1) failing to give proper weight to the opinions of Plaintiff's treating physician, Dr. Jack L. Rook; (2) failing to properly consider Plaintiff's nonexertional impairments; (3) failing to consider a lay witness statement regarding Plaintiff's limitations; and (4) failing to properly evaluate Plaintiff's pain complaints pursuant to Luna v. Bowen, 834 F.2d 161 (10th Cir. 1987). (Doc. # 17 at 2.) Plaintiff additionally alleges that the Appeals Council erred by failing to consider additional evidence submitted to it after the hearing. (Id.)
The record in this case is composed of the evidence that was considered by the ALJ.
The qualifications for disability insurance benefits under the Social Security Act are that the claimant meets the insured status requirements, is less than sixty-five years of age, and is under a "disability." Flint v. Sullivan, 951 F.2d 264, 267 (10th Cir. 1991). The Social Security Act defines a disability as an "inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment 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 twelve months." 42 U.S.C. § 423(d).
In determining whether a claimant is disabled, the ALJ must consider the following five-step inquiry: (1) whether the claimant is currently employed; (2) whether the claimant has a severe impairment; (3) whether the claimant's impairment is one that the Commissioner considers conclusively disabling by meeting the requirements of a listing; (4) if the claimant does not have a conclusively disabling impairment, whether he can perform his past relevant work, and (5) whether the claimant is capable of performing any work in the national economy. 20 C.F.R. § 404.1520(a)(4). The claimant bears the burden of establishing a disability at steps one through four. See, e.g., Gonzales v. Astrue, No. 11-cv-02344, 2012 WL 4356243, at *2 (D. Colo. Sept. 24, 2012) (unpublished). If the claimant reaches step five, the burden then shifts to the Commissioner to show that "the claimant is capable of performing work in the national economy." Id.
According to the "treating physician rule," the Commissioner will generally "give more weight to medical opinions from treating sources than those from non-treating sources." Langley v. Barnhart, 373 F.3d 1116, 1119 (10th Cir. 2004); see also 20 C.F.R. § 404.1527(c)(2). In fact, "A treating physician's opinion must be given substantial weight unless good cause is shown to disregard it." Goatcher v. U.S. Dep't of Health & Human Servs., 52 F.3d 288, 289-90 (10th Cir. 1995). A treating physician's opinion is accorded this weight because of the unique perspective he has to the medical evidence that cannot be obtained from the objective medical findings alone or from reports of individual examinations. See Robinson v. Barnhart, 366 F.3d 1078, 1084 (10th Cir. 2004).
"In deciding how much weight to give a treating source opinion, an ALJ must first determine whether the opinion qualifies for `controlling weight.'" Watkins v. Barnhart, 350 F.3d 1297, 1300 (10th Cir. 2003). To do so, the ALJ:
Id. (internal quotation marks and citations omitted).
Even if a treating physician's opinion is not entitled to controlling weight, however, "[t]reating source medical opinions are still entitled to deference and must be weighed using all of the factors provided in 20 C.F.R. § 404.1527." Id. Those factors are:
Drapeau v. Massanari, 255 F.3d 1211, 1213 (10th Cir. 2001); 20 C.F.R. § 404.1527(c). Under Tenth Circuit caselaw, "an ALJ must give good reasons for the weight assigned to a treating physician's opinion that are sufficiently specific to make clear to any subsequent reviewers the weight the adjudicator gave to the treating source's medical opinion and the reason for that weight." Langley, 373 F.3d at 1119 (internal quotation marks and citations omitted).
In the instant case, Plaintiff contends that the ALJ erred by improperly rejecting the opinion of Dr. Rook, Plaintiff's treating physician, and for failing to consider Plaintiff's nonexertional impairments. (Doc. # 17 at 7.) Specifically, Plaintiff argues that "Dr. Rook's opinion should have been given controlling weight with respect to [Plaintiff's] RFC" or at the least, "should have been given significant weight by the ALJ." (Id.) Plaintiff states that the ALJ's improper rejection of Dr. Rook's opinion was determinative to her conclusion that Plaintiff was not disabled. (Id.)
Dr. Rook provided his opinion as to Plaintiff's limitations on a worksheet entitled, "Ability To Do Work-Related Activities (Physical)." (AR 263-67.) On the worksheet, Dr. Rook concluded that Plaintiff, among other things, could not stand or walk for more than one hour, each, during an eight-hour workday, could rarely lift more than 11 pounds, and would not be a reliable or consistent worker. (Id.) Dr. Rook additionally checked boxes indicating that Plaintiff could never kneel, crouch, crawl, or squat, and could only rarely bend or climb. (Id.) Despite Plaintiff's characterization of the worksheet as a "detailed medical source statement outlining [Dr. Rook's] opinion regarding [Plaintiff's] limitations" (Doc. # 17 at 10), Dr. Rook did not list a single medical finding to support his conclusions, even though the worksheet explicitly asked for such information. (See AR 263-67.)
In determining that Dr. Rook's opinion was not entitled controlling weight, or significant weight, the ALJ explicitly cited two factors provided in 20 C.F.R. § 404.1527(c): (1) Dr. Rook's opinion was not supported by the objective medical findings (i.e., Dr. Rook failed to list a single medical finding with his opinion as discussed supra); and (2) Dr. Rook's opinion was not consistent with the other substantial evidence, including his own examination records, (AR at 27). See 20 C.F.R. § 404.1527(c)(3) (supportability); (c)(2)(consistency). An ALJ is not required to "discuss all the § 404.1527(c) factors for each of the medical opinions before him," Oldham, 509 F.3d at 1258, and in the instant case the reasons given by the ALJ are "sufficiently specific to make clear . . . the reason" for the weight the ALJ gave to Dr. Rook's opinion. See Langley, 373 F.3d at 1119.
If an ALJ rejects a treating source's opinion entirely, the ALJ must give specific, legitimate reasons for doing so. Watkins, 350 F.3d at 1301. In its limited reviewing capacity, this Court finds that the ALJ's reasons for disregarding Dr. Rook's opinion are both legitimate and sufficiently specific. In her decision, the ALJ satisfied the requirement of "confirm[ing] that the opinion is consistent [or inconsistent] with other substantial evidence in the record." Id. at 1300. In over two pages of analysis, the ALJ discusses contrary medical findings, including Dr. Rook's own medical records, and those of Dr. Edwin L. Baca. (AR at 25-27.)
Among the records considered by the ALJ were Dr. Rook's treatment notes from September 20, 2001 through November 4, 2010.
In January 2002, Plaintiff returned to Dr. Rook to review his MRI results. (AR at 472.) According to Dr. Rook's notes, the cervical MRI showed a "mild disc bulging at C5-6 and C6-7 without evidence of disc herniation or nerve root impingement." (Id.) Dr. Rook noted that the rest of the cervical MRI "was within normal limits." (Id.) Plaintiff's lumbar spine MRI "demonstrated degenerative changes at L 23 and L5-S1 . . . with no lateralization or nerve or spinal canal compromise." (Id.) Dr. Rook found spondylolysis "on the left at L 5" but not the right side, and "no evidence of spondylolisthesis."
Plaintiff returned to Dr. Rook for Botox injection therapy which was "tolerated well" and that reduced the occurrence and intensity of Plaintiff's headaches and neck pain. (AR 469-70.) In April 2002, Dr. Rook noted that Plaintiff reported that the "effectiveness of the previous Botox injections" was starting to wear off and that he was once again experiencing headaches and neck pain. (AR at 468.) Dr. Rook additionally noted that Plaintiff continued to work full-time. (Id.) The next month, in May 2002, Dr. Rook treated Plaintiff with another round of Botox injection therapy, and noted that MRI imaging on his right shoulder was "significantly abnormal" with "advanced tendonopathy . . . [and] a partial thickness tear of the supraspinatus tendon." (AR at 466.) Dr. Rook referred Plaintiff to Dr. Arnold Ahnfeldt to explore treatment options for his shoulder and knee pain. (Id.) In a later visit in May, Dr. Rook noted that the previous Botox injection therapy was not helpful and that Plaintiff continued to complain of headaches. (AR at 465.) Dr. Rook opined that the headaches did "not sound like migraines" and prescribed "low dose Zanaflex." (Id.) The next month, Dr. Rook noted that Zanaflex had helped "slightly," and that Plaintiff had "a steroid injection performed to his right shoulder by Dr. Ahnfeldt." (AR at 464.)
In July 2002, Plaintiff told Dr. Rook that the steroid injection had been "very helpful" and that he had not experienced any bad headaches "over the past month," and while "he still gets daily headaches . . . [t]here has been some improvement . . . overtime." (AR at 463.) Over the next year, Plaintiff continued to see Dr. Rook for his headaches, and neck and low back pain. (AR 454-61.) Over this time, Dr. Rook reviewed Plaintiff's complaints, adjusted his medications, administered Botox injection therapy, and recommended additional treatment including surgery on his shoulder and knee. (Id.) Despite Plaintiff's continuous complaints regarding his headaches, neck pain, back pain, right shoulder pain, and bilateral knee pain, Dr. Rook noted that "nevertheless, he continues to work full-time." (AR at 458.) In 2003, Dr. Rook noted that Plaintiff had undergone arthroscopic surgery on both knees and reported "fairly significant improvement with regards to his knee pain." (AR at 454-56.) During this time, Plaintiff reported that his headaches were responding well to Imitrex (AR at 455), and Zomig (AR at 454).
While Plaintiff experienced particularly severe headaches in August 2003 (AR at 452-53), in September he reported that he did not have "severe headaches over the past three weeks." (AR 451.) In December 2003, Dr. Rook noted that Plaintiff "had been doing a little better over the past few months" and that while "he still has headaches on a daily basis . . ." he had not had a migraine since August. (AR at 450.)
According to Dr. Rook's April 2004 evaluation notes, Plaintiff was hit by a vehicle in a parking lot on January 11, 2004. (AR at 447.) The accident injured "both legs from above the knees to the ankles" and resulted in "extensive bruising" and "swelling in his left knee" but no fractures. (Id.) Dr. Rook's evaluation states that prior to this accident, Plaintiff's "average daily pain was 1-2/10" and that after the accident his average pain was "4-5/10." (AR at 447-49.) Despite this, Dr. Rook opines that there has "been no significant change in his condition since the recent accident," and that he continues to "work[] full-time." (AR at 448.) Additionally, Dr. Rook noted that Plaintiff was in "no apparent distress . . . ambulated normally in the examination room . . . [and] did not demonstrate any chronic pain behaviors." (Id.) Finally, Dr. Rook found that Plaintiff's "lower extremity motor strength was normal" and that "he is reasonably comfortable with the current medications." (AR at 448-49.) Two months later, in June 2004, Dr. Rook noted that while Plaintiff complained of knee pain and was scheduled for surgery with Dr. Ahnfeldt, he continued to work full-time. (AR at 446.) There was no mention of headaches in Dr. Rook's June 2004 notes. (Id.)
Plaintiff's next visit with Dr. Rook was more than a year later on September 15, 2005. (AR at 445.) In his treatment notes, Dr. Rook comments that Plaintiff continues to have knee pain and muscle spasms in his back, but does not mention Plaintiff's headaches. (Id.) Dr. Rook notes that Plaintiff continues to work full-time, although opines that "his job is probably too physically demanding . . . given his current physical problems." (Id.) Plaintiff did not see Dr. Rook again until November 2006. (AR at 240.) During his annual evaluation, Dr. Rook noted that Plaintiff was taking "Robaxin as a muscle relaxant and Vicodan high potency as an analgesic" for "chronic headaches, neck pain, back pain, and knee pain." (AR at 240.) He opined that the medications were "helpful and well tolerated," and that Plaintiff's "condition [was] stable." (Id.) Plaintiff alleges that his condition first interfered with his ability to work (i.e., that "he became unable to work because of his disabling condition") a month after this visit with Dr. Rook. (AR at 117, 143.)
The next year, in 2007, Dr. Rook opined that Plaintiff's condition was "about the same," and that "he continues to experience chronic neck pain and headaches." (AR at 239.) Dr. Rook additionally noted that Plaintiff had been seeing a chiropractor and that "his condition has been improving with the chiropractic treatment." (Id.) In Dr. Rook's treatment notes from Plaintiff's 2008 annual evaluation, Dr. Rook noted that Plaintiff's condition was stable, but that he "continues to complain of bilateral knee pain, neck pain, and headaches." (AR at 238.) Dr. Rook opined that Plaintiff's medications are helpful and well tolerated and that Plaintiff has "good days and bad days." (Id.) In May 2009, Dr. Rook noted that Plaintiff "continues to complain about headaches, neck pain, and back pain," and that Plaintiff was "developing a tolerance to the high potency Vicodin." (AR at 237.) Dr. Rook prescribed a "low-dose Methadone . . . as a long-acting agent . . . with Vicodin as the rescue agent." (Id.) The following month, in June 2009, Dr. Rook noted that Plaintiff is "much more comfortable with the addition of Methadone," and that the Methadone "has been very well tolerated." (AR at 236.) Dr. Rook added that Plaintiff's biggest problem at that time "is intermittent severe headaches." (Id.) In April 2010, Dr. Rook noted that Plaintiff enjoyed an "overall improvement in his condition," that he is "almost back to a baseline level, where he was prior to the recent motor vehicle accident [in December 2009]," and that he is "stable with the current pharmacologic regimen." (AR at 443.) Six weeks later, in May 2010, Dr. Rook noted that Plaintiff experienced a slight "increase in upper and lower back pain since the accident . . . on December 15, 2009," but that "he is now at maximum medical improvement related to injuries sustained" in that accident. (AR at 442.) There was no mention of Plaintiff's headaches in Dr. Rook's May 2010 notes. (Id.) In his most recent treatment notes dated November 4, 2010, Dr. Rook noted that Plaintiff was "doing well with the current pharmacologic regimen," and that Plaintiff's condition was "stable" with improvements in Plaintiff's "cervical range of motion" and "some decrease in [Plaintiff's] headaches." (AR at 441.)
In his treatment notes from 2006 through November 4, 2010, Dr. Rook consistently opined that Plaintiff had no pain behaviors, was not under distress, ambulated normally, was "well groomed," and had been mentally alert with normal thought and mood. (AR 236-40; 441-44.)
The Court's role is not to reweigh the evidence or substitute its judgment for that of the Commissioner, Salazar, 468 F.3d at 621, and finds that the ALJ's decision not to give Dr. Rook's opinion controlling or significant weight was supported by substantial evidence (i.e., the treatment notes discussed supra, the findings and opinion of Dr. Baca and Plaintiff's own testimony, as discussed in the ALJ's opinion (AR at 25-27)).
Additionally, the Court finds that the ALJ did, in fact, consider Plaintiff's nonexertional impairments. The ALJ discussed Plaintiff's chronic headaches and pain at length in her opinion, and factored them into her analysis. (AR at 21-29.) While Plaintiff argues that he should be found disabled because his headaches interfere with his ability to work on a consistent basis (Doc. # 17 at 19), the evidence discussed above demonstrates that Plaintiff's condition had been stable and that he was improving with chiropractic care.
Plaintiff next argues that the ALJ erred by failing to consider a two-page written statement (AR 174-75) submitted by his mother, Gloria Lindsey, in which she describes her observations of Plaintiff's limitations. (Doc. # 17 at 27.) In her statement, Ms. Lindsey states, in part, that at times she had seen Plaintiff "have pain to where he could not lift his head or think" and that he "could barely speak" on the telephone. (AR at 174-75.) She adds that Plaintiff has "days when he cannot get out of bed" and that "he is always in pain." (Id.) The regulations state that the Commissioner will consider "descriptions and observations of [a claimant's] impairment(s), including limitations that result from [a claimant's] symptoms, such as pain, provided by . . . [claimant's] family, or other persons." 20 C.F.R. §§ 404.1545(a)(3), 416.945(a)(3). However, the ALJ is not required to make a specific written finding as to a lay witness's credibility.
Plaintiff alleges that the ALJ erred by failing to follow the framework set out in Luna v. Bowen, 834 F.2d 161, 163-4 (10th Cir. 1987) for analyzing disabling pain. (Doc. # 17 at 27-28.) Luna requires the ALJ to consider: (1) whether there is objective medical evidence of a pain-producing impairment; (2) whether there is a "loose nexus" between the pain-producing impairment and the subjective allegations of pain; and (3) whether the pain is in fact disabling, considering all of the objective and subjective evidence. Luna, 834 F.2d at 163-4.
In her opinion, the ALJ found that there was objective medical evidence of a pain-producing impairment, and that there is a nexus between the impairment and the allegations of pain. (AR at 25.) However, after her consideration of the record, the ALJ concluded that Plaintiff's statements regarding "the intensity, persistence and limiting effects of these symptoms" were not credible to the extent that "they are inconsistent with the" RFC assessment. (Id.) The ALJ then concluded that Plaintiff's pain levels would allow him to do light work. (AR at 23-27.) Despite Plaintiff's assertion to the contrary, the Court finds that the ALJ satisfied the analysis required by Luna v. Bowen and, therefore, does not find a basis to reverse on this issue.
For the foregoing reasons, it is ORDERED that the ALJ's decision is AFFIRMED. Each party shall bear its own costs and attorney's fees.