ELIZABETH M. TIMOTHY, Chief Magistrate Judge.
This case has been referred to the undersigned magistrate judge for disposition pursuant to the authority of 28 U.S.C. § 636(c) and Fed. R. Civ. P. 73, based on the parties' consent to magistrate judge jurisdiction (see docs. 8, 9). It is now before the court pursuant to 42 U.S.C. § 405(g) of the Social Security Act ("the Act"), for review of a final decision of the Commissioner of the Social Security Administration ("the Commissioner of the SSA") denying Plaintiff's application for disability insurance benefits ("DIB") under Title II of the Act, 42 U.S.C. §§ 401-34.
Upon review of the record before this court, it is the opinion of the undersigned that the findings of fact and determinations of the Commissioner are supported by substantial evidence and comport with proper legal principles. Thus, the decision of the Commissioner is affirmed.
On November 29, 2012, Plaintiff filed an application for DIB; she identified her alleged disability onset date as May 1, 2011, but she later amended this date to July 15, 2011 (tr. 32).
In denying Plaintiff's claims, the ALJ made the following findings (see tr. 32-47):
(a) Plaintiff meets the insured status requirements of the Act through June 30, 2017
(b) Plaintiff has not engaged in substantial gainful activity ("SGA") since May 1, 2011, her initial alleged onset date;
(c) Plaintiff has the following severe impairments: cervical degenerative disc disease of C5-6 with radiculopathy and stenosis, cervicalgia, mild lumbar degenerative disc disease, lumbago, carpal tunnel syndrome, and gastroesophageal reflux disease;
(d) Plaintiff does not have an impairment or combination of impairments that meets or medically equals the severity of an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1;
(e) Plaintiff has the residual functional capacity ("RFC") to perform light work as defined in 20 C.F.R. § 404.1567(b), with some exceptions
(f) Plaintiff is capable of performing her past relevant work as a photo clerk (specific vocational preparation ("SVP") level "unskilled"). This work does not require the performance of work-related activities precluded by Plaintiff's RFC.
(g) In the alternative, in light of Plaintiff's age,
(h) Plaintiff has not been under a disability, as defined in the Act, from her initial alleged disability date through the date of the ALJ's decision.
Review of the Commissioner's final decision is limited to determining whether the decision is supported by substantial evidence from the record and was a result of the application of proper legal standards.
The 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 12 months." 42 U.S.C. § 423(d)(1)(A). To qualify as a disability the physical or mental impairment must be so severe that the claimant is not only unable to do her previous work, "but cannot, considering [her] age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy." Id. § 423(d)(2)(A). Pursuant to 20 C.F.R. § 404.1520(a)-(g),
1. If the claimant is performing SGA, she is not disabled.
2. If the claimant is not performing SGA, her impairments must be severe before she can be found disabled.
3. If the claimant is not performing SGA and she has severe impairments that have lasted or are expected to last for a continuous period of at least twelve months, and if her impairments meet or medically equal the criteria of any impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1, the claimant is presumed disabled without further inquiry.
4. If the claimant's impairments do not prevent her from doing her past relevant work, she is not disabled.
5. Even if the claimant's impairments prevent her from performing her past relevant work, if other work exists in significant numbers in the national economy that accommodates her RFC and vocational factors, she is not disabled.
The claimant bears the burden of establishing a severe impairment that keeps her from performing her past work. 20 C.F.R. § 404.1512. If the claimant establishes such an impairment, the burden shifts to the Commissioner at step five to show the existence of other jobs in the national economy which, given the claimant's impairments, the claimant can perform.
Plaintiff completed high school (tr. 46, 62), and she is able to communicate in English (tr. 46). She has past relevant work as a clerk for the United States Postal Service from 1985 to 2009 and as a short order cook and photo clerk in 2010 and 2011 (tr. 211, 235).
On July 16, 2011, Plaintiff presented to an emergency room in Ohio after being in a motor vehicle accident (tr. 383-85). Magnetic resonance imaging ("MRI") of Plaintiff's cervical spine obtained on July 27, 2011, showed mild posterior spurring and disc bulging at C3-4 and C4-5, with moderate spurring and disc bulging at C5-6 (tr. 381). There was a mild impression on the ventral cervical cord, which appeared pinched from the anterior and posterior aspects, with marked central canal stenosis down to 7 mm and no cord myelomalacia (id.). The C2-3 level was normal (id.). An MRI of the thoracic spine identified disc space narrowing at T6-T7 and T7-T8, with a small disc protrusion at T7-8, but no central canal or neural foraminal stenosis (tr. 379). A lumbar spine MRI showed stable mild disc space narrowing at L3-L4 with an associated small broad-based disc bulge, but no significant stenosis (tr. 380).
At an August 3, 2011, physical therapy visit, Plaintiff's diagnoses were identified as cervicalgia, neck sprain, lumbago, and lumbar sprain (tr. 357). Her reported pain level was 5 on a scale of 1-10, with 10 being the most severe pain (id.). Plaintiff's discharge assessment dated August 25, 2011, notes that on August 22, 2011, she reported a pain level of 3 to 4 (tr. 337); the assessment opines that Plaintiff's prognosis was "good" with continued therapy and a home exercise program (tr. 338).
Plaintiff presented to Achraf Makki, M.D., a physician with the Brain and Spine Center, on December 13, 2011, with a complaint of severe [8/10] neck pain and back pain (tr. 554). Reviewing Plaintiff's prior medical records, Dr. Makki observed that Plaintiff's cervical spine MRI showed a mild disc bulge at "C3, 4, 5," and central canal stenosis, and her lumbar spine MRI showed mild disc protrusion at L3-4 with mild left lateral stenosis (tr. 557). Dr. Makki prescribed Baclofen and Lortab (id.); later in December, he also administered occipital nerve blocks and trigger point injections for Plaintiff's neck pain (tr. 552-53).
On January 3, 2012, Plaintiff reported to Dr. Makki that she continued to have some pain in her neck secondary to muscle spasms but that the spasms were responding well to treatment (tr. 548). Physical examination was largely normal, other than with respect to the musculoskeletal system, as to which Dr. Makki found multiple trigger points, significant paraspinal muscle tenderness, and decreased range of motion of the cervical spine (tr. 545, 549). Dr. Makki administered additional trigger point injections because they were "giving [Plaintiff a] significant amount of relief," and he prescribed Ambien for Plaintiff's problems with sleeping (tr. 550-51). On January 27, 2012, Plaintiff returned to Dr. Makki and reported continuing neck pain and muscle spasms, symptoms which she described as being moderate in severity and unchanged (tr. 544). Upon examination, Dr. Makki noted significantly decreased spinal range of motion secondary to severe muscle tension, significant muscle tenderness, and taut banding in the form of trigger points in multiple spinal segments (tr. 545). Dr. Makki noted that he had reviewed Plaintiff's cervical spine MRI and the recommendation of a consultant, Dr. Stringer (id.). Dr. Makki stated that he would order facet injections "to help decrease [Plaintiff's] pain, as surgery is not warranted at this point" (id.). He also prescribed the use of Lortab and Baclofen (tr. 546). On February 23, 2012, and March 1, 2012, Plaintiff received additional facet injections for her complaints of neck pain (tr. 542, 543). At her March 27, 2012, visit to Dr. Makki, Plaintiff reported "aching" neck pain which occurred "frequently" and was "moderate in severity and improving" (tr. 539). Dr. Makki advised Plaintiff to use Lortab, Baclofen, and Lyrica and to undergo routine massage therapy (tr. 541).
On June 22, 2012, Plaintiff complained to Dr. Makki of constant, aching pain which was "moderate in severity and worsening" (tr. 536). Her range of motion was described as significantly decreased secondary to severe muscle tension (tr. 538). Dr. Makki prescribed the use of Celebrex, Flexeril, Lyrica, Lortab, and Ambien, and he also advised more physical therapy (id.). Plaintiff attended eighteen physical therapy sessions between July 2012 and September 2012 (tr. 405-09, 411-15, 421-39). In July 2012, Plaintiff was described by a physical therapist as having reduced strength in the upper extremities (tr. 408).
Plaintiff again presented to Dr. Makki on December 4, 2012 (tr. 529). Plaintiff's reported neck pain was described as aching, constant, and "moderate in severity (5 out of 10) and unchanged" (id.). Dr. Makki noted Plaintiff's previous excellent response to physical therapy and facet injections (tr. 531). Most physical findings were unremarkable, including with respect to upper body strength, which was normal, although some hyperreflexia was noted (tr. 530). Plaintiff's symptom control was "good" (tr. 529).
At a March 4, 2013, visit, Plaintiff reported aching, constant neck pain of moderate severity, or 5/10, and constant lower back pain with a severity of 7/10 (tr. 524). Plaintiff also reported having hand tremors and spasms throughout her body (id.). Other than back pain, a physical examination was largely unremarkable; it was noted that neck pain and stiffness were not present (tr. 525-26), and Plaintiff's symptom control reportedly was good (tr. 524). Dr. Makki noted that if Plaintiff's neck pain increased, repeat cervical facet injections would be administered (id.). Due to the neuropathic features of Plaintiff's complaints, Dr. Makki ordered a nerve conduction study and electromyogram, as well as an MRI of the lumbar spine (id.). A March 18, 2013, nerve conduction study and electromyogram for cervical radiculopathy showed electrophysiologic evidence of mild median neuropathy at the right wrist as seen in carpal tunnel syndrome (tr. 590). Plaintiff was noted to have a history of bilateral carpal tunnel release procedure performed ten years prior (id.). Lower extremity nerve conduction testing for lumbar radiculopathy and piriformis syndrome was normal (tr. 588). A March 12, 2013, lumbar spine MRI report noted mild degenerative disc disease at L2-L3 and L3-L4 (tr. 594).
Plaintiff reported constant, aching neck pain and radiating lower back pain with a severity level of 5/10 on April 4, 2013 (tr. 519). Dr. Makki assessed mild degenerative disc disease of the lumbar spine, mild median neuropathy of the right wrist, and sleep myoclonus (tr. 521). Plaintiff was advised to continue her current prescriptions for pain, given a wrist splint to wear at night for carpal tunnel syndrome, and prescribed medication for sleep myoclonus (id.).
A State agency physician, Edmund Molis, M.D., reviewed Plaintiff's records and prepared a physical RFC for her in April 2013 (tr. 117-19). In Dr. Molis' opinion, Plaintiff was capable of lifting and carrying up to ten pounds frequently and twenty pounds occasionally, sitting for a total of six hours in an eight-hour workday, and standing/walking for a total of six hours in an eight-hour workday (tr. 117). Her ability to push and/or pull (including operating hand and/or foot controls) was unlimited (id.). Plaintiff had no postural limitations but reaching with the left upper extremity was frequently limited. The ability to handle, finger, and feel was unlimited (tr. 118).
In September and October 2013 Plaintiff underwent eight sessions of physical therapy (tr. 614-23). At intake on September 9, 2013, the therapist noted Plaintiff had limited range of motion and reported "significant pain" that was worse while sleeping or lying down (tr. 623). By October 4, 2013, Plaintiff still had pain but it was "somewhat better" (tr. 618), and on October 16, 2013, she reported continued improvement in her symptoms (tr. 616). At discharge on October 21, 2013, Plaintiff's pain had decreased twenty-five percent, and her overall symptoms had decreased by thirty percent (tr. 614, 615), although she continued to report left buttock pain of 5/10 at rest and up to 7/10 with activity. Exacerbating factors included walking, stooping, or standing for more than fifteen minutes (tr. 614). Plaintiff stated that she could perform all of her activities of daily living except cooking and washing dishes, as to which she was limited due to subjective pain and discomfort (tr. 615). According to the therapist, Plaintiff had shown improvement in subjective pain and tolerance to activities of daily living. It also appeared she had reached maximum improvement and would be able to maintain the thirty percent reduction in overall symptoms with home exercises.
After issuance of the ALJ's decision on December 6, 2013, Plaintiff submitted records to the AC which documented a January 2014 office visit with Dr. Makki (tr. 637-42). At that visit, Plaintiff reported constant, aching neck pain of moderate severity, or 6/10, and worsening (tr. 637). She also reported headaches and upper extremity weakness (id.). Dr. Makki's findings with respect to the musculoskeletal system included moderate tenderness to palpation of the cervical spine, evidence of cervical paravertebral muscle spasm, moderate bilateral tenderness to palpation of the occipital nerve, moderate tenderness to palpation of the facet joints with severe tenderness at C4-5, C5-6, and C6-7. Under the section of his report titled "Today's Impression," Dr. Makki noted that he had discussed with Plaintiff that the "natural pathology of the disease [is that it] is expected to progress rather than improve[ ]" and that Plaintiff "has had an increase in neck pain associated with headaches" (tr. 640). Dr. Makki recommended more physical therapy and referred Plaintiff for a functional capacity evaluation ("FCE") (id.). In light of the "significant" axial pain Plaintiff was reporting and his findings of facet tenderness, Dr. Makki also decided to proceed with joint facet injections (id., tr. 641), and he ordered a repeat MRI of the cervical spine (tr. 641). The report of this MRI states there are "mild degenerative disc and joint changes in the cervical spine which contribute to mild central canal stenosis at C3-4 and C5-6 and neural foraminal narrowing of varying degrees at several levels in the cervical spine including the right side at C3-4 and bilaterally at C5-6" (tr. 643). Compared with a previous examination dated December 26, 2012, it was noted there was little change (tr. 643-44).
The FCE ordered by Dr. Makki was completed by physical therapist Mohamed Hussein
Plaintiff testified at the administrative hearing that several conditions prevent her from working, including a bulging disc in her neck that her physician told her pressed into her spinal cord (tr. 67). She also has arthritis in her shoulder, problems with her upper and lower back, and carpal tunnel disease (id.). Her main problems are with her neck and hands, which worsened after her July 2011 automobile accident and have not improved (tr. 79). Plaintiff stated that her neck condition causes sharp, shooting pain that travels to her head, as well as causes numbness and tingling in her arms and hands (tr. 68). She also has sharp, shooting pain in her upper and lower back and numbness and tingling in her legs (id.). "With medication, [she] could keep [her pain level] at a four or a five. Without, it's seven or eight" (id.; see also tr. 69). The more severe pain lasts for about "an hour or two" and occurs every day when it is time for her to take her medication again (id.). Lifting, stooping, and bending and excessive walking, sitting, or standing worsen her pain (tr. 69). Plaintiff also has difficulty, bilaterally, with gross manipulation of items approximately one-third of each day (id.); with gripping approximately two-thirds of each day (tr. 70); and with fine manipulation approximately three-fourths of each day (id.). Plaintiff thought she could lift five to ten pounds while seated (id.), and carry ten to fifteen pounds occasionally (tr. 72-73). She drops things frequently (tr. 77). Plaintiff could stand for fifteen to twenty minutes at a time for a total of two hours per workday (tr. 72-73), sit for fifteen to twenty minutes at a time for a total of two hours per workday (tr. 72), and walk for fifteen to twenty minutes for a total of one hour per workday (id.). On an average day, during an eight-hour period Plaintiff needs to lie down and use a heating pad about two to three hours due to pain and poor sleep (tr. 73, 80). A home traction device for her neck, which she uses several times per week, helps to reduce her pain for several days at a time (tr. 80-81). Her husband performs most of the household chores, although Plaintiff can do some things around the house and goes shopping with her husband about once per week (tr. 73-74). Plaintiff watches television approximately six to seven hours per day (tr. 74).
The VE testified that Plaintiff has past work as a short order cook, photo clerk, and postal carrier (tr. 85). These jobs, as performed by Plaintiff, were generally consistent with the descriptions for the positions in the Dictionary of Occupational Titles ("DOT") (tr. 86). The "semi skills" Plaintiff acquired working as a postal carrier were transferrable only to the position of file clerk, which is classified as light work (tr. 85).
The ALJ first asked the VE to assume that Plaintiff's testimony was fully credible. If Plaintiff's testimony were taken as true, the VE testified, Plaintiff could not perform any of her past work or any other work due to her allegations of severe pain up to three hours per day, need to use a traction device, and sleep problems (tr. 87). Next, the ALJ asked the VE to assume an individual who could perform light work, with the following restrictions (tr. 88-89). The individual could occasionally use her hands for simple grasping and for pushing/pulling of arm controls, and she could frequently use her hands for fine manipulation. The individual could occasionally use her feet for pushing/pulling leg controls, and she could occasionally stoop, crouch, kneel, and crawl. She could never climb ropes, scaffolds, and ladders. The hypothetical individual could occasionally climb stairs and ramps, balance, reach overhead, work around unprotected heights, be around moving machinery, be exposed to marked changes in temperature and humidity, and drive automotive equipment. The individual experienced a moderate degree of pain which occasionally interfered with concentration, persistence, and pace but did not require her to abandon her work station. The individual could respond appropriately to supervisors, co-workers, and the public. She could use judgment in completing simple one and two-step work-related decisions and could occasionally use judgment in complex or detailed work-related decisions. She could deal with changes in the routine work setting. She could understand, remember, and carry out simple one and two-step instructions and could occasionally do so with respect to detailed or complex instructions. She could maintain concentration, attention, and pace for at least two hours, with breaks. She could maintain activities of daily living and did not experience any episodes of decompensation of extended duration. The VE responded that an individual of this description could perform Plaintiff's past work of photo clerk (tr. 89). The individual could also, taking into consideration transferrable skills from the position of postal carrier, work as a file clerk (tr. 90). There were also unskilled jobs the individual could perform, including storage facility rental clerk and ticket seller (id.).
The ALJ then changed one element of the hypothetical question: the individual's moderate degree of pain interfered with concentration, persistence, and pace for one to two hours daily and required her to abandon her work station. The VE testified that such an individual could not perform any of Plaintiff's past work or any other work (tr. 91).
The court addresses Plaintiff's grounds for reversal and remand of this case in the following order: (1) the ALJ erred in making his credibility determination; (2) the ALJ erred at step four because Plaintiff's past work as a photo clerk was not SGA and her RFC precludes the performance of that position. Also, the ALJ erred at step five because Plaintiff's RFC precludes performance of the file clerk, storage facility rental clerk, and ticket seller jobs; and (3) the AC erred in denying Plaintiff's request for review. The Commissioner responds that substantial evidence supports her final decision, and thus it should be affirmed.
A claimant may establish that she has a disability through her own testimony regarding her pain or other subjective symptoms.
In this case, the ALJ concluded that Plaintiff had an underlying medically determinable impairment that reasonably could be expected to cause the pain alleged but that Plaintiff's statements concerning the intensity, persistence, and limiting effects of her pain were not entirely credible (tr. 38). In other words, Plaintiff's impairment reasonably could cause pain, but not the severe level of pain alleged by Plaintiff (tr. 44). According to the ALJ, the record evidence was "indicative of moderate pain[,] not severe pain" (tr. 45).
In support of her claim that the ALJ erred in making his credibility finding, Plaintiff points to clinical and/or physical therapy notes from December 2011, June 2012, and October 2013 (doc. 20 at 11, citing tr. 536, 538, 554, 614, in reference to reported pain levels); December 2012 (id., citing tr. 531, in reference to a prescription for narcotic pain medication); and August and December 2012 (id. at 12, citing tr. 531, 535, in reference to Plaintiff's receipt of treatment and therapy due to continuing pain). She also points to medical records concerning reduced upper extremity strength, limited range of motion, and muscle spasms (id. at 12, citing tr. 408, 531, 545). In addition, Plaintiff contends that her restricted activities of daily living are not inconsistent with her allegations of severe pain and limitations.
The record reflects that Plaintiff frequently reported to her health care providers—and also testified at the administrative hearing—that medication and other treatment generally maintained her pain at a moderate level of approximately 5/10 (tr. 68, 531, 535; see also tr. 45, 524, 529, 533, 548). It appears that, in the records that were before the ALJ, Plaintiff reported more intense levels of pain only on an intermittent basis to her health care providers (see, e.g., tr. 554 [pain level of 8/10 constantly in neck], 614 [pain level of 7/10 in left buttock with activity]). Also, Plaintiff does not identify where, if at all, the medical record reflects that she reported to Dr. Makki or others that she experienced severe pain daily for one to two hours prior to taking her medications, as she testified at the hearing, and the court is not aware of any such references.
As Plaintiff contends, in July 2012 her physical therapist noted that her upper extremity strength was slightly reduced (tr. 408). On at least three subsequent occasions, however—December 2012, March 2013, and April 2013—Dr. Makki reported that Plaintiff's upper extremity strength was normal (tr. 521, 526, 530).
In addition, the objective evidence documents that Plaintiff's conditions were found, at most, to be mild to moderate in degree, not severe. Her July 2011 MRIs of the cervical, thoracic, and lumbar spine mostly revealed mild to moderate changes (tr. 379-381), as did a March 2013 MRI of the lumbar spine (tr. 594). A March 2013 nerve conduction study and electromyogram for cervical radiculopathy showed mild neuropathy (tr. 590), and lower extremity nerve conduction testing was normal (tr. 588). In April 2013, Dr. Makki's assessments included mild degenerative disc disease of the lumbar spine and mild median neuropathy of the right wrist (tr. 521). Also, although these results were not before the ALJ, it is noteworthy that the report of an MRI of the cervical spine conducted in January 2014 showed mild changes and was described as being unchanged from December 2012 (tr. 643-44).
The foregoing medical records support the ALJ's finding that Plaintiff's testimony concerning the level of pain she experiences is not entirely credible. Similarly, as the ALJ found, Plaintiff's acknowledged ability to bathe, feed, and use the toilet without assistance; prepare simple meals; occasionally perform light household chores; shop once a week; watch television up to seven hours per day; and provide some care for her ill husband (tr. 35, 223, 224, 225, 226, 612) suggests that the nature and effects of Plaintiff's symptoms are not as severe as she contends. In short, the court concludes that there is substantial evidence of record in support of the ALJ's conclusion that Plaintiff's statements concerning the intensity, persistence, and limiting effects of her pain and other symptoms are not entirely credible. Accordingly, the ALJ's credibility determination should not be disturbed.
Plaintiff argues that the ALJ's finding at step four that she could perform her past work as a photo clerk is erroneous because, given her limited annual earnings of only $2,623.16 from the position (see tr. 199), it did not constitute SGA. The Commissioner does not directly address Plaintiff's argument, instead contending that even if the ALJ erred at step four the error was harmless because his finding at step five is supported by substantial evidence.
Past relevant work is work that the claimant (1) performed within the last fifteen years, (2) lasted long enough for the claimant to learn how to do the work, and (3) was performed at the level of substantial gainful activity. 20 C.F.R. § 416.965(a). "Substantial work activity" is work that involves doing significant physical or mental activities and includes part-time work. 20 C.F.R. §§ 404.1572(a), 416.972(a). "Gainful work activity" is work activity done for pay or profit. 20 C.F.R. §§ 404.1572(b), 416.972(a). To determine whether a claimant performed substantial gainful activity, the ALJ ordinarily will consider whether wages derived from the work activity exceed minimum thresholds. 20 C.F.R. §§ 404.1574(b), 416.974(b). "If a claimant receives wages exceeding those set out in an earnings guidelines table, a presumption arises that she was engaged in substantial gainful activity during that period."
Social Security regulations set an average monthly-earnings threshold for SGA. 20 C.F.R. §§ 404.1574(b)(3)(i); 416.974(b)(3)(I). In 2010, the year Plaintiff worked as a photo clerk, the average-monthly-earnings threshold for SGA activity was $1,000. See http://
The court finds the record to be sufficient, however, to support by other means the ALJ's finding that Plaintiff's work as a photo clerk in 2010 constituted SGA. During the hearing, the ALJ asked Plaintiff about the amount of standing required and the amount of weight she had to lift and carry in her past work as a photo clerk (tr. 65). Also, the ALJ asked the VE if she had reviewed the record in the case and if Plaintiff had performed her past work in a manner that was consistent with the requirements of the DOT; the VE responded affirmatively to both questions (tr. 84, 86). The DOT outlines the strength, reasoning, math, language, writing, speaking, and specific vocational preparation demands required of the photo clerk position. See
Plaintiff also contends that the Commissioner's decision should be reversed because the ALJ failed to resolve a conflict between the VE's testimony and the DOT, as required by Social Security Ruling ("SSR") 00-4p.
Plaintiff contends that the ALJ failed to ask the VE if there was any conflict between her testimony and the DOT (doc. 20 at 16). As noted previously, however, at the administrative hearing in this case, the ALJ asked the VE if Plaintiff had performed her past work in a manner that was consistent with the requirements of the DOT (tr. 86), and the VE responded affirmatively (id.). The actual exchange, as recorded in the transcript, reflects that the ALJ posed the following question to the VE:
(tr. 86).
The court finds that a reasonable reading of this exchange encompasses the question of whether there is any conflict between the VE's testimony and the DOT. The VE's testimony, essentially, was that the demands of Plaintiff's prior jobs—which included the photo clerk position—were consistent with the requirements of the DOT; that being the VE's opinion, there obviously was no conflict between her testimony and the DOT. As Plaintiff's hearing counsel raised no challenge or objection to the VE's testimony, although given the opportunity to question the VE, there was no apparent conflict for the ALJ to resolve concerning Plaintiff's past work and thus no error.
Even if there was an actual conflict between the VE's testimony and the DOT, in the Eleventh Circuit the VE's testimony trumps the DOT because "the DOT is not the sole source of admissible information concerning jobs."
For all of the foregoing reasons, the court finds no reversible error in the ALJ's step four finding that Plaintiff could perform her past work as a photo clerk. On this basis alone, adequate evidence supports the ALJ's decision that Plaintiff is not disabled. Moreover, the court can assign no reversible error to the ALJ's step five finding—which also relied on the VE's testimony— that Plaintiff could work as a file clerk, storage facility rental clerk, and ticket seller.
Plaintiff contends that the "new and material evidence [she submitted to the AC] merits remand for further consideration by the ALJ, and demonstrates that the Commissioner's decision is unsupported by substantial evidence" (doc. 20 at 9). According to Plaintiff, the AC wrongly rejected Mr. Hussein's FCE on the basis it was "about a later time" than the ALJ's decision, because Plaintiff's medical condition did not significantly deteriorate in the less than two-month period between the issuance of the ALJ's decision on December 6, 2013, and Mr. Hussein's evaluation on January 28, 2014. In support, Plaintiff cites the January 2014 cervical spine MRI that indicates "little interval change" between 2012 and 2014, Dr. Makki's relatively unchanged treatment for several years, and Plaintiff's consistent reports of pain in Dr. Makki's records. Plaintiff contends the AC's action is also contrary to the ALJ's decision in that the ALJ afforded significant weight to the medical records and assessments of Dr. Makki, who ordered the FCE and provided the only examining source opinion of record, whereas the ALJ only gave partial weight to the opinion of State examiner Dr. Molis. The AC's failure to consider the FCE, Plaintiff maintains, resulted in harmful error, as the VE testified that an individual who could only sustain work activity for five or six hours daily—which is more than the FCE indicates Plaintiff could do—would be unemployable. The Commissioner responds that Plaintiff's argument fails because the evidence submitted to the AC would not have changed the ALJ's decision.
Generally, a claimant is allowed to present new evidence at each stage of the administrative review process "[s]ubject to the limitations [in 20 C.F.R. §§] 404.970(b) and 404.976(b)." 20 C.F.R. § 404.900(b). The AC has discretion not to review the ALJ's denial of benefits. 20 C.F.R. § 404.967. Nevertheless, the AC must consider "new and material evidence" that "relates to the period on or before the date of [the ALJ's] hearing decision" and must review the case if the ALJ's "action, findings, or conclusion is contrary to the weight of the evidence currently of record." 20 C.F.R. § 404.970(b). The evidence must be "chronologically relevant" to the time period considered by the ALJ in order to be considered by the AC.
Here, the court concludes that Plaintiff has not made the requisite showing to warrant a sentence four remand based on the additional evidence she presented to the AC. The January 18, 2014, office note and January 24, 2014, MRI report from Dr. Makki, and Mr. Hussein's January 28, 2014, FCE were completed after the date of the ALJ's decision on December 6, 2013; thus, on their face, these documents do not relate to the chronically relevant period, i.e., the period on or before the decision date. As noted, however, Plaintiff submits that the new documents do relate to the relevant period because they show her condition was the same in late January 2014, when those records were created, as it was in early December 2013, when the ALJ issued his decision.
In late January 2014, Plaintiff reported severe symptoms to Dr. Makki, including increased pain, headaches, and upper extremity weakness (tr. 640). In light of Plaintiff's report and his physical findings at that time, Dr. Makki ordered additional physical therapy sessions, an FCE, facet injections, and a new MRI of the cervical spine (id.). He also advised Plaintiff that the "natural pathology" of her conditions would likely result in their becoming progressively worse (id.). Dr. Makki's January 18, 2014, report—including its mention of Plaintiff's subjective complaint of increased pain, his physical findings, his treatment and diagnostic recommendations, and his advice to Plaintiff about the expected prognosis of her conditions—seems to suggest a possible recent deterioration in Plaintiff's spinal conditions. The report does not implicitly or explicitly relate its findings to the period prior to December 6, 2013, the date of the ALJ's decision, thus establishing the necessary chronological relevance. See
The January 2014 cervical spine MRI ordered by Dr. Makki reflects mild changes, with "little interval change" since the last examination in December 2012 (tr. 643-44). Notably, the cervical spine MRI taken in July 2011 also revealed only mild to moderate changes (tr. 381).
As to the January 28, 2014, FCE, even if Mr. Hussein's findings were accepted, the court concludes that the FCE does not establish the necessary chronological relevance to the time period before December 6, 2013. The findings are significantly more severe than Plaintiff's previous records indicate, including that Plaintiff's "current functional abilities and musculoskeletal findings demonstrate that she
In short, the court concludes that Plaintiff has failed to show that—in light of the new evidence she submitted to the AC and relies on in this appeal (specifically, Dr. Makki's January 2014 office note, the January 2014 cervical MRI report, and Mr. Hussein's January 2014 FEC)—the ALJ's unfavorable decision is not supported by substantial evidence or that the new evidence renders the denial of benefits erroneous.
For the foregoing reasons, the Commissioner's decision is supported by substantial evidence and should not be disturbed. 42 U.S.C. § 405(g);
Accordingly, it is
(tr. 37).
The court has augmented the parties' references to the record and factual information, where deemed appropriate, for clarity and completeness. It has not outlined the entire record, including the evidence of Plaintiff's mental health records that was before the ALJ and the AC (although Plaintiff cites some of them). A discussion of these records is not needed here because, as the Commissioner notes, Plaintiff does not challenge any findings pertaining to her alleged mental limitations. Accordingly, the court outlines and discusses only the medical evidence pertaining to Plaintiff's alleged physical limitations, although it includes the mental restrictions imposed by the ALJ in his decision and hypothetical questions posed to the VE.
Nevertheless, as discussed above, the court is not bound by SSR 00-4p and instead must follow Eleventh Circuit precedent, which here provides that a VE's testimony "trumps" an inconsistent provision of the DOT. See