REGGIE B. WALTON, District Judge.
Mary Clark, the plaintiff in this civil lawsuit, seeks a judgment reversing the defendant Social Security Administration's (the "Administration") denial of her application for social security disability insurance benefits and supplemental security income benefits. Complaint ("Compl.") ¶ 4. Currently before the Court is the plaintiff's motion for a judgment of reversal or remand and the defendant's motion for a judgment of affirmance, which were filed pursuant to 42 U.S.C. § 405(g) (2006). After careful review of the plaintiff's complaint, the administrative record, the parties' motions, and all memoranda of law and exhibits related to those motions,
Except where otherwise noted, the following facts are part of the administrative record submitted to the Court. The plaintiff is a former "customer service representative for a telephone company ... and... hair dresser" who, in 1992, "was diagnosed with mild carpal tunnel syndrome." Administrative Record ("A.R.") at 16. She sought treatment for her ailment and was given cortisone injections, which helped improve her condition. Id. Approximately ten years later, the plaintiff met with Garcia DeSousa, a neurologist, regarding "numbness and pain in the fingers [of] both hands[,] with the right hand being worse than the left hand." Id. Dr. DeSousa preformed "EMG and nerve conduction studies of [the plaintiff's] upper extremities,"
On March 25, 2002, the plaintiff "underwent [a] right carpal tunnel release." Id. Despite this surgical procedure, as well as subsequent medication and therapy, the plaintiff continued to experience pain in her right hand. Id. The plaintiff then "underwent EMG and nerve conduction studies of her right upper extremity" on July 25, 2002, which revealed "marked improvement in the distal latencies for the median curve." Id. Dr. DeSousa concluded
On April 24, 2003, the plaintiff visited Frederic Guerrier, M.D., at the Roser Park Medical Center, who she has seen "on an[d] off since June 25, 1998[,] for yearly checkups and for her complaints of hand pain, itchy skin[,] and hypertension." Id. at 16-17. On this particular visit, the plaintiff visited Dr. Guerrier regarding "pain in her joints" and to have "her medication refilled." Id. at 16. Dr. Guerrier referred the plaintiff for additional laboratory tests, which "revealed [an] elevated glucose ... and cholesterol reading." Id. at 17. Then, on June 26, 2003, the plaintiff "reported to Dr. Guerrier" that she had experienced a fall "at work and was having right[-]sided pain in her chest, arm, shoulder, back[,] and hip." Id. The plaintiff also informed Dr. Guerrier "that she sought help at Johnnie Ruth Clark Clinic," and that the clinician at that facility had "restricted her from work" for approximately one week. Id. A physical examination was subsequently conducted on the plaintiff (presumably by Dr. Guerrier), which revealed "no acute distress." Id.
The plaintiff did not return to the Roser Park Medical Center for further examination by Dr. Gurrier until October 6, 2003, when she claimed to have been experiencing body pain as a result of another fall two weeks prior to the visit. Id. Although she received "a cortisone shot in her shoulder" which relieved some of the pain, the plaintiff indicated to Dr. Guerrier that the problem was "not totally resolved." Id. Furthermore, she "reported having neck spasms." Id. An examination of the plaintiff revealed "tenderness to palpation in her right shoulder." Id.
As alluded to above, the plaintiff had been diagnosed with having elevated blood pressure. Id. On May 18, 2003, the plaintiff visited the St. Petersburg Free Clinic (the "Free Clinic") "for [a] blood pressure check and medication refills." Id. "Her blood pressure was noted to be 150/98 in the left arm and 130/80 in the right arm."
The plaintiff suffered from yet another ailment on March 18, 2004, when she visited a hospital emergency room "after injuring her left finger." Id. The plaintiff underwent an x-ray examination, which revealed "an acute fracture" on her left hand. Id. The finger was placed on a splint, "and she was given a prescription for anti-inflammatory medication and pain medicine." Id.
The next day, the plaintiff returned to the Free Clinic to seek treatment for her various medical conditions. Id. During that visit, the plaintiff's blood pressure was measured at 120/70, and she was advised
On July 14, 2005, the plaintiff visited the Free Clinic and reported having "pain in both hands." Id. at 18. She again "reported pain in both hands and wrists" during a visit several weeks later on August 9, 2005, but an examination conducted at that time revealed "no clinical signs of carpal tunnel syndrome in the claimant's hands [or] wrists," although "[s]he did have tenderness of the right lateral epicondyle." Id. The plaintiff was then referred "for a course of physical therapy." Id. The plaintiff made another visit to the clinic on August 17, 2005, when she "was diagnosed with diabetes mellitus" and "was noted to be overweight." Id. She was given, inter alia, "class information re[garding] diet and cooking." Id.
While the plaintiff was seeking medical treatment for her various ailments, she filed an application with the Administration on April 27, 2004, for disability insurance benefits and supplemental security income benefits that she claimed she was entitled to receive as of March 15, 2004. Id. at 13. In her application, the plaintiff alleged that she had been "unable to work due to carpal tunnel syndrome and [a] broken little finger on the left [hand]." Id. at 16. As part of the agency's assessment of her claims, the plaintiff "was examined by Christopher M. Davey, M.D., on November 12, 2004." Id. at 18. Dr. Davey concluded that while the plaintiff was approximately seventy "pounds overweight for" someone of "her height," the plaintiff was not suffering from any "acute distress." Id. Furthermore, he found that "[a]ll" of the plaintiff's "joints were normal and had full range of motion." Id. In other words, he found that "[t]here were no [signs of] deformity, heat, redness, tenderness, swelling[,] or signs of inflammation." Id. The examination also revealed that the plaintiff "had full range of motion of her spine and was able to bend over easily," and that she was able to straighten and raise her leg normally. Id. As for her left wrist, which had previously caused her problems, Dr. Davey observed that "[h]er grip was 5/5, strong and equal bilaterally," and that "she easily handled the pages of a magazine." Id. Indeed, the examination showed that her "[m]otor strength was 5/5 in all four extremities," and that "[h]er gait was also normal." Id.
The Administration initially denied her claim on August 11, 2004, id. at 13, as well as her request for reconsideration on November 24, 2004, id. at 32-39. The plaintiff sought a hearing for review of her application, which was granted and held on November 29, 2006. Pl.'s Mem. at 2. At the hearing, the Administrative Law Judge (the "ALJ") heard testimony from the plaintiff, and exhibits previously identified during the initial review were received into evidence and made part of the administrative record. A.R. at 227-40. In her testimony, the plaintiff indicated that she had
The ALJ ruled against the plaintiff on December 28, 2006. Id. at 13-19. The ALJ used a five-step sequential evaluation process (discussed in detail below) and found that while the plaintiff's carpal tunnel syndrome and obesity were "severe" in nature, "[n]o treating or examining physician of record has reported any of the necessary clinical, laboratory, or radiographic findings to meet or equal the criteria" set forth in 20 C.F.R. § 404.1520(a)(4)(iii). Id. at 15. Furthermore, the ALJ found that the plaintiff's testimony "concerning the intensity, persistence[,] and limiting effects of [her] symptoms [was] not entirely credible," since her testimony was inconsistent with the other evidence in the record. Id. at 18-19. The ALJ also found that the plaintiff could "return to [her past] jobs" as a customer service representative or hair dresser "given her residual functional capacity for medium work activity." Id. at 19; see also supra p.2 (noting that the plaintiff is a former "customer service representative for a telephone company ... and ... hair dresser"). The plaintiff then appealed the ALJ's decision to the Social Security Administration Appeals Council (the "Appeals Council") on February 8, 2007, which denied the review request because it found "no reason under [its] rules to review the [ALJ's] decision." A.R. at 2.
The plaintiff then filed her complaint in this Court on October 24, 2007, alleging that the defendant's "final administrative decision ... [wa]s not based upon substantial evidence," Compl. ¶ 6, and, on April 29, 2008, she moved by motion for reversal of the agency's decision. In support of her motion, the plaintiff argues that the ALJ (1) failed to properly assess the plaintiff's residual functional capacity at step 4 of the sequential evaluation process as required by Social Security Ruling 96-8p, Pl's Mem. at 3-7, (2) failed to properly consider the plaintiff's obesity during the evaluation of her claims, id. at 8-12, and (3) failed in his duty to properly develop the administrative record because pertinent medical records were not obtained, id. at 13-17.
In response to the plaintiff's motion for a judgment of reversal, the defendant filed a cross-motion for judgment of affirmance on July 21, 2008. In support of this cross-motion, the defendant argues that (1) the ALJ appropriately considered the plaintiff's obesity at step three based on the record evidence, Def.'s Mem. at 13, (2) the ALJ performed a proper residual functional capacity assessment by reviewing the record as a whole, id. at 14-20, and (3) the ALJ properly developed the record since the burden was on the plaintiff to provide additional information, and she has presented
As noted above, both parties seek relief pursuant to 42 U.S.C. § 405(g). Under that statute, a court reviewing a benefits determination by the Administration is "confined to determining whether the [Administration's] decision ... [was] supported by substantial evidence in the record." Brown v. Bowen, 794 F.2d 703, 705 (D.C.Cir.1986). With respect to the Administration's factual determinations, the "substantial evidence" requirement mandates that the Administration's findings be supported by "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 401, 91 S.Ct. 1420, 28 L.Ed.2d 842 (1971) (internal citation and quotation marks omitted). The standard requires "more than a scintilla, but less than a preponderance of the evidence." Evans Fin. Corp. v. Director, 161 F.3d 30, 34 (D.C.Cir.1998) (internal quotation marks omitted).
With respect to the Administration's legal rulings, "the [district] court shall review only the question of conformity" by the Administration to its own regulations as well as "the validity of such regulations." 42 U.S.C. § 405(g). Thus, the reviewing court must uphold the Administration's legal "determination if it ... is not tainted by an error of law." Smith v. Bowen, 826 F.2d 1120, 1121 (D.C.Cir. 1987). However, a court may only consider the grounds proffered by the agency in its decision, as post hoc rationalizations will not suffice. Butler v. Barnhart, 353 F.3d 992, 1003 n. 5 (D.C.Cir.2004).
The plaintiff must establish, inter alia, that she qualifies as "disabled" within the meaning of the Social Security Act to recover disability benefits or supplemental security income benefits. 42 U.S.C. § 423(a)(1)(E) (providing social security benefits for claimants "under a disability"); see also id. § 1382(a) (providing supplemental security income benefits to disabled claimants who meet statutory criteria); Wells v. Astrue, Civil Action No. 02-1357(RBW), 2009 WL 2338047, at *3 (D.D.C. July 30, 2009) (explaining the requirements for a claimant to recover disability insurance benefits or supplemental security income benefits). A claimant is considered "disabled" if she can demonstrate 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. § 416(i)(1); see also id. § 1382c(a)(3)(A) (same).
To evaluate whether an individual meets the standard of an inability to engage in substantial gainful activity for either disability insurance benefits or supplemental security income benefits, the Administration engages in a five-step sequential evaluation of the individual's disability claim. 20 C.F.R. § 404.1520; see also id. § 416.905. Under this analysis, the claimant must first show that she is not presently engaged in "substantial gainful activity." Id. § 404.1520(a)(4)(i); see also id. § 416.920(b). Second, the claimant must have a "severe impairment" that "significantly limits [her] ... ability to do basic work activities." Id. § § 416.920(c); see
The parties in this case do not dispute that the first two steps in the analysis are satisfied. A.R. 15. The Court's inquiry is thus confined to whether the ALJ erred in steps three through five of the evaluation process and whether the ALJ adequately developed the administrative record. As set forth in greater detail below, because the record reveals substantial evidence to support the ALJ's findings in steps three through five of the evaluation process, and that the ALJ fulfilled his duty to adequately develop the record, the Court must affirm the ALJ's decision and grant the defendant's motion for affirmance.
The plaintiff alleges that obesity was not properly considered by the ALJ during steps three through five of the sequential evaluation process. Pl.'s Mem. at 9. Obesity is a relevant factor to be considered by the agency in conducting the five-step sequential evaluation process. See SSR 02-1p, 2000 WL 628049, at *3 (Sept. 12, 2002) (declaring that the Administration should consider obesity under step three as to whether or not obesity combined with another impairment would meet a listing under the disability regulations); id. at *6 (noting that obesity is also considered in steps four and five since obesity "can cause limitation of function" and "the effects of obesity may not be obvious"). An in-depth review of obesity is not required, however, when a detailed discussion of obesity would not affect the case. See, e.g., Rivera v. Comm'r of Social Sec., 320 Fed.Appx. 128, 130 (3d Cir.2009) (noting that "[w]hen the ALJ determines that obesity, either alone or in concert with other conditions, is not a relevant factor, there is no requirement that an ALJ repeat this determination throughout each step of the sequential analysis"); Rutherford v. Barnhart, 399 F.3d 546, 553 (3d Cir.2005) (citing Skarbek v. Barnhart, 390 F.3d 500, 504 (7th Cir.2004)) (following the Seventh Circuit's decision that when the plaintiff has not indicated how obesity has contributed to an inability to work, an ALJ's failure to thoroughly discuss obesity in the analysis does not require a remand).
Here, the plaintiff has failed to present any persuasive argument that the ALJ's determination was not based on the evidence of obesity already provided to the agency, nor has she made any showing that any new evidence of obesity would alter the ruling. The plaintiff's sole dispute is that the ALJ "failed to consider the impact of the [p]laintiff's obesity upon basic work activities," without going into any detail about the complained-of impact. Pl.'s Mem. at 12; but see Rutherford, 399 F.3d at 553 (noting that the mere assertion that "her weight makes it more difficult for her to stand, walk and manipulate her hands and fingers" was insufficient grounds for remand when it was clear that
The plaintiff additionally argues that the ALJ failed to properly assess her functional limitations, Pl.'s Mem. at 3, by failing "to perform a function-by-function assessment of the [p]laintiff's abilities to perform work-related activities" and failing to "set forth a narrative discussion describing how the evidence supported each conclusion, citing specific material facts," id. at 5. Before engaging in steps four and five of the five-step sequential evaluation, the ALJ must determine the claimant's residual functional capacity. 20 C.F.R. § 404.1520; see also id. § 416.920. The analysis must include how the ALJ considered the evidence and any ambiguities in the record. Butler, 353 F.3d at 1000. The residual functional capacity determines what a person "can do in a work setting" despite any impairments or limitations "based on all the relevant evidence in [a claimant's] case." 20 C.F.R. § 404.1545(a); see also id. § 416.945(a). In conducting a residual functional capacity analysis, an ALJ must perform an individual or function-by-function assessment of the following capacities: "[s]itting, standing, walking, lifting, carrying, pushing, and pulling." SSR 96-8p, 1996 WL 374184, at *5 (July 2, 1996). In addition, the ALJ must provide a narrative discussion of how the evidence supported the ALJ's decision regarding the claimant's residual functional capacity, referencing medical facts and nonmedical evidence. Id. at *7. When, however,
Hartline v. Astrue, 605 F.Supp.2d 194, 204 (D.D.C.2009) (citing SSR 96-8p, 1996 WL 374184, at *1) (internal quotations removed). The undersigned member of the Court has found that "an articulation of the function-by-function analysis is not required, particularly for capacities for which no limitation is alleged." Banks v. Astrue, 537 F.Supp.2d 75, 84 (D.D.C.2008).
Here, the Court finds that the ALJ performed a sufficient function-by-function assessment of the plaintiff's capacities. There is no allegation in this
A.R. 16-19. Based on these findings by the ALJ, the Court finds that the ALJ's decision was supported by the record evidence and that the ALJ sufficiently explained how he arrived at his conclusion based on the medical assessments performed on the plaintiff.
To be sure, the record does contain evidence that conflicted with the ALJ's conclusion; specifically, the plaintiff's testimony at the hearing about the "intensity, persistence and limiting effects of the[] symptoms." Id. at 18. This evidence, however, was judged by the ALJ to be "not entirely credible." Id. The ALJ evaluated all of the relevant evidence and concluded that the "severity of symptoms alleged is not consistent with the total medical and nonmedical evidence." Id. Moreover, the ALJ found that the plaintiff's testimony was not supported by the numerous medical evaluations conducted as part of the agency's assessment of her claims. Id. Thus, the plaintiff's testimony does not cause the Court to conclude that the ALJ's decision was unsupported by substantial evidence.
Lastly, the plaintiff claims that the ALJ failed to properly develop the administrative record by failing to "obtain pertinent medical records," Pl.'s Mem. at 13, failing to "recontact any of the [p]laintiff's medical sources to obtain additional evidence," id. at 14, and "fail[ing] to make any `attempt to arrange for a consultative examination,'" id. These arguments fail to merit reversal of the ALJ's ruling.
In developing the record, it is the plaintiff's responsibility to "provide medical evidence showing that [she has] an impairment and how severe it is during the time that [she is] disabled." 20 C.F.R. § 404.1512(c); see also id. § 416.912(c). However, it is the duty of the ALJ to "investigate fully all matters at issue and to develop the comprehensive record requisite for a fair determination of disability." Poulin v. Bowen, 817 F.2d 865, 870 (D.C.Cir.1987). The Administration is generally required to "develop" a claimant's medical records for the twelve-month period prior to the filing of a claim. 20 C.F.R. § 404.1512(d); see also id. § 416.912(d).
Here, the plaintiff did not provide the ALJ with any additional records, nor did she direct the ALJ to the existence of any such record. Moreover, the record evidence was sufficient for the ALJ to render his ruling. The ALJ relied heavily on various medical sources, as well as the assessments of the plaintiff's functional limitations. A.R. 16-19. While the plaintiff indicated that she had continued to go to the Free Clinic for medical services through October 2006, and that the ALJ failed to obtain any records from that facility, Pl.'s Mem. at 13, the ALJ was nonetheless able to consider the plaintiff's own testimony presented during the hearing he conducted regarding her treatment at the clinic, A.R. 237-40, and the fact that the plaintiff acknowledged obtaining some relief from her ailments as a result of the medication provided to her by the clinic, id. at 237. In any event, reversal for "failure to develop the record is only warranted where such failure is unfair or prejudicial." Smith v. Astrue, 534 F.Supp.2d 121, 134 (D.D.C.2008) (Huvelle, J.) (internal citations omitted). As the plaintiff does not argue that the ALJ overlooked any material evidence, but rather has merely alleged that the ALJ simply erred in his decision, her challenge based on the ALJ's failure to obtain the Free Clinic's medical records must be rejected.
The Court must also reject the plaintiff's second claim regarding the development of the record because an ALJ is required to recontact medical sources only "[w]hen the evidence [the agency] receive[s] from [the plaintiff's] ... medical source is inadequate for [it] to determine whether [the plaintiff is] disabled." 20 C.F.R. § 404.1512(e); see Smith, 534 F.Supp.2d at 134 (holding that "[w]here the majority of the objective evidence in the record shows normal findings and other physicians have not found [the] plaintiff unable to work, a single, unsupported finding does not establish a need for additional evidence"); see also 20 C.F.R. § 416.912(e). Here, there is no ambiguity in the record, and the sole piece of evidence that conflicts with the medical evidence in the record was plaintiff's hearing testimony regarding the severity of her symptoms, which the ALJ considered and rejected. A.R. at 18, 232-40. Like the situation in Smith, this single unsupported part of the record does not show that there was a need for the ALJ to recontact the medical sources identified in the record and considered by the ALJ.
For the foregoing reasons, the Court concludes that the ALJ's rejection of the plaintiff's application for benefits was supported by substantial record evidence, and, accordingly, the agency's decision must be affirmed by the Court.
