JANET F. KING, Magistrate Judge.
Plaintiff in the above-styled case brings this action pursuant to 205(g) of the Social Security Act, 42 U.S.C. § 405(g), to obtain judicial review of the final decision of the Commissioner of the Social Security Administration which denied her disability claims. For the reasons set forth below, the court finds that the Commissioner's decision should be affirmed.
Plaintiff Kistina Beck-Easley filed applications for a period of disability, disability insurance benefits, and supplemental security income on November 17, 2009, alleging a disability onset date of July 5, 2007. [Record ("R.") at 164-68]. After her applications were denied initially and on reconsideration, Plaintiff requested an administrative hearing which was held on January 12, 2012. [R. at 40-86]. On March 30, 2012, the Administrative Law Judge ("ALJ") issued a decision denying Plaintiff's applications. [R. at 20-39]. Plaintiff requested and the Appeals Council granted review of the ALJ's decision. On June 25, 2013, the Appeals Council adopted the ALJ's findings in part and found Plaintiff not disabled. [R. at 1-18]. Having exhausted her administrative remedies, Plaintiff filed a complaint on August 29, 2013, seeking judicial review of the Commissioner's final decision. [Doc. 3]. The parties have consented to proceed before the undersigned Magistrate Judge.
Plaintiff was born on August 6, 1970, and was thirty-six years old at the time of her alleged onset of disability and forty-one years old at the time of the administrative hearing. [R. at 5, 31]. Plaintiff meets the insured status requirements of the Social Security Act through September 30, 2011, and the ALJ found that Plaintiff has not engaged in substantial gainful activity since July 5, 2007, the alleged onset date. [R. at 25].
The ALJ found that Plaintiff has the following impairments which are considered "severe" impairments within the meaning of the Social Security Regulations: chronic multiple sclerosis pain, fibromyalgia, cervical spine pain, chronic opioid usage and obesity. [R. at 25-26]. The ALJ found that Plaintiff does not have a mental or physical impairment or combination of impairments that meets or medically equals one of the relevant listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1, and made specific findings that Plaintiff's mental impairment does not meet or medically equal the criteria of listings 12.04 (affective disorders) and 12.09 (substance addiction disorders).
The ALJ found that Plaintiff has the residual functional capacity ("RFC") to perform a reduced range of sedentary work with the following limitations. Plaintiff can lift 10 pounds occasionally and 5 pounds frequently. She can stand for 2 hours in an 8-hour workday and sit for 6 hours in an 8-hour workday. And she can perform frequent push and pull and foot controls. Plaintiff requires a one-hour interval sit/stand option and a hand held assistive device for uneven terrain and prolonged ambulation. She can climb stairs occasionally but is unable to climb ladders. Plaintiff can occasionally balance, kneel, crawl, stoop and crouch. She is able to handle and finger frequently. Plaintiff cannot work around hazardous machinery, at unprotected heights or on vibrating surfaces. And Plaintiff is limited to work that involves simple, routine and repetitive work tasks or instructions, that does not require close coordination or interaction with co-workers or the general public, and that is low stress (requiring only occasional decision making and occasional changes in work setting), does not require confrontational involvement with a supervisor and not production pace. [R. at 27].
The ALJ found that a person with Plaintiff's RFC would not be able to perform her past relevant work as a home health provider, companion care person or server. [R. at 31]. Plaintiff is considered a younger individual and has at least a high school education and can speak English. The ALJ found that transferability of skills is not material to the determination of disability because using the Medical-Vocational Rules as a framework supports a finding that Plaintiff is "not disabled" regardless of her transferable skills. [
The ALJ's decision [R. at 15-27] states the relevant facts of this case as modified herein as follows:
The claimant testified that she is 5 feet 7 inches tall and weighs between 175 and 185 pounds. She lives with her husband, three boys and her granddaughter. She completed college. She testified that she is disabled due to her mental capacity, pain, swelling, stress, lack of ability to cope, hands swelling up and experiencing numbness of her hand. She tries to do small things for herself and her children and can wash dishes for 5 to 10 minutes.
In January 2010, the claimant completed a report in which she stated that she was able to dress, bathe, shave and feed herself and was going to church. (Exhibit 6E). Six months later, the claimant completed a report stating that she does not have any activities of daily living. (Exhibit 12E). The claimant's friend, Sandra Bell, also completed a report in June 2010. (Exhibit 11E). Ms. Bell reported that she talked on the telephone or saw the claimant at least 4 to 5 times per week and that the claimant was able to feed herself and prepare light meals, do laundry with assistance, fold clothes, dust and lift baskets of clothes and was able to drive a car and go shopping for groceries and personal items.
The claimant's medical records from Comprehensive Pain Management Center, Cobb Medical Associates, the Humber Parkerson Clinic, Wellstar Kennestone Hospital, Wellstar Cobb Hospital and the Pain Solution Treatment Center reflect the following treatment and opinions. (Exhibits 1F-33F). Dr. Dexter Tooman
Dr. Steven Gary Berger, a licensed consultative psychologist, examined the claimant on January 14, 2010. Although the claimant appeared anxious, Dr. Berger found that the claimant's thoughts were linked in a logical manner and no delusions were reported. The claimant had a Global Assessment of Functioning ("GAF") score of 55 indicating moderate symptoms. And Dr. Berger opined that the claimant could understand instructions although she would be slow in her task performance. (Exhibit 4F). In February 2010, Dr. William Meneese, a State agency psychologist, reviewed the claimant's records and completed a Psychiatric Review Technique form and found the claimant not disabled, and Dr. Cassandra Comer, a State agency physician, completed a Physical RFC Assessment and found the claimant not disabled. (Exhibits 6F, 7F).
Between July 2, 2010, and September 1, 2010, the claimant was treated at Austell Comprehensive Pain Management for neck and back pain. (Exhibit 12F). The claimant reported pain as 10/10 on a scale of 1-10 on July 2, 2010, but Dr. Preteesh Patel observed that the claimant was able to sit comfortably on the examination table without difficulty or any evidence of pain and that her gait was normal and that she reported that heat, ice and medication lessen her pain. And, on September 1, 2010, Dr. Patel noted that the claimant had normal curvature of the lumbar spine, hypertonic muscles and no trigger points. [R. at 442-43].
The claimant was evaluated by Dr. Carol Glover, a psychiatrist at Wellstar Cobb Hospital and Medical Center, on August 17, 2010, and seen a second time on September 14, 2010. Although the claimant presented with an anxious mood, Dr. Glover opined that the claimant's thought process was coherent, memory grossly intact and mood congruent. And the claimant reported that Xanax makes life more tolerable and helps to lessen the symptoms of her anxiety. (Exhibit 13F).
Dr. Paul Lance Walker, a consultative physician, examined the claimant on October 5, 2010, and found normal range of motion of her back including flexion, extension, lateral bending and lateral rotation and that she did not have any limitation with the functional use of her upper extremities. X-rays of the lumbar and cervical spine [R. at 460] show maintained vertebral body heights and alignment and no acute fracture or dislocation of the lumbar and cervical spine. Dr. Walker observed that the claimant walked slowly with a cane in her right hand but that she could walk in the room without a cane. (Exhibits 14F, 15F and 16F). And Dr. Willis Callins, a State agency medical consultant, opined on November 18, 2010, that the claimant could frequently lift and/or carry 25 pounds and occasionally lift 50 pounds as well as sit, stand and walk for 6 hours out of an 8-hour workday. (Exhibit 20F).
On March 16, 2011, at Dallas Comprehensive Pain Management, Dr. Anantha Kamath noted normal curvature of the claimant's spine, and Dr. Kamath was unable to identify any trigger points on deep palpation of the para-vertebral muscles. (Exhibit 21F). The claimant stated that her average pain was a 7/10, and Dr. Kamath noted that the claimant reported good pain relief with her medication with little to no side effects and that her ability to function was improved due to the effective pain control. [R. at 553-56]. And, in April 2011, Dr. Kamath noted that the claimant did not have any decreased lateral bending of the lumbar spine, that her heel and toe walk were normal, that reflexes were equal and symmetric and that her toes were "down-going." (Exhibit 24F).
Additional facts will be set forth as necessary during discussion of Plaintiff Beck-Easley's arguments.
An individual is considered to be disabled if she is unable "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). The impairment or impairments must result from anatomical, psychological, or physiological abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques and must be of such severity that the claimant is not only unable to do her previous work but cannot, considering age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy.
"We review the Commissioner's decision to determine if it is supported by substantial evidence and based upon proper legal standards."
"The burden is primarily on the claimant to prove that [she] is disabled, and therefore entitled to receive Social Security disability benefits."
At step one, the claimant must prove that she is not engaged in substantial gainful activity.
"If the claimant cannot prove the existence of a listed impairment, [she] must prove at step four that [her] impairment prevents him from performing [her] past relevant work."
The ALJ made the following findings of fact:
1. The claimant meets the insured status requirements of the Social Security Act through September 30, 2011.
2. The claimant has not engaged in substantial gainful activity since July 5, 2007, the alleged onset date. (20 C.F.R. §§ 404.1571, et seq., and 416.971, et seq.).
3. The claimant has the following severe impairments: chronic multiple sclerosis pain, fibromyalgia, cervical spine pain, chronic opioid usage and obesity. (20 C.F.R. §§ 404.1520(c) and 416.920(c)).
4. The claimant does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (20 C.F.R. §§ 404.1520(d), 404.1525, 404.1526, 416.920(d), 416.925, and 416.926).
5. The claimant has the residual functional capacity to perform sedentary work as defined in 20 C.F.R. §§ 404.1567(a) and 416.967(a). The claimant is able to lift 10 pounds occasionally and 5 pounds frequently, stand for 2 hours in an 8-hour workday, sit for 6 hours in an 8-hour workday and can perform frequent pushing and pulling and foot controls. The claimant requires a one-hour interval sit/stand option and a hand held assistive device for uneven terrain and prolonged ambulation. The claimant is able to climb stairs occasionally but is unable to climb ladders. The claimant is able to balance, kneel, crawl, stoop and crouch occasionally. The claimant is able to handle and finger frequently. The claimant is restricted to work that does not require working around hazardous machinery, at unprotected heights or on vibrating surfaces and to work that is limited to simple, routine and repetitive work tasks or instructions, that does not require close coordination or interaction with co-workers or the general public, and that is low stress (only occasional decision making and changes in work setting), nonconfrontational involvement with supervisor and is not production pace.
6. The claimant is unable to perform any past relevant work. (20 C.F.R. §§ 404.1565 and 416.965).
7. The claimant was born on August 6, 1970, and was 36 years old, which is defined as a younger individual age 18-44, on the alleged disability onset date. (20 C.F.R. §§ 404.1563 and 416.963).
8. The claimant has at least a high school education and is able to communicate in English. (20 C.F.R. §§ 404.1564 and 416.964).
9. Transferability of job skills is not material to the determination of disability because using the Medical-Vocational Rules as a framework supports a finding that the claimant is not disabled, whether or not the claimant has transferable job skills. (
10. Considering the claimant's age, education, work experience, and residual functional capacity, there are jobs that exist in significant numbers in the national economy that the claimant can perform. (20 C.F.R. §§ 404.1569, 404.1569(a), 416.969 and 416.969(a)).
11. The claimant has not been under a disability, as defined in the Social Security Act, from July 5, 2007, through March 30, 2012. (20 C.F.R. §§ 404.1520(f) and 416.920(f)).
[R. at 23-33].
At the first step of the sequential evaluation, the ALJ found that Plaintiff Beck-Easley has not engaged in substantial gainful activity since July 5, 2007, her alleged date of disability onset. [R. at 25]. At the second step, the ALJ found that Plaintiff has chronic multiple sclerosis pain, fibromyalgia, cervical spine pain, chronic opioid usage and obesity which are "severe" impairments within the meaning of the Social Security Regulations. [
At step four, the ALJ found that Plaintiff has the RFC to perform a reduced range of sedentary work with the following limitations. She can lift 10 pounds occasionally and 5 pounds frequently, stand for 2 hours in an 8-hour workday, sit for 6 hours in an 8-hour workday and perform frequent push and pull and foot controls. Plaintiff requires a one-hour interval sit/stand option and a hand held assistive device for uneven terrain and prolonged ambulation. Plaintiff can climb stairs occasionally but not ladders. She can balance, kneel, crawl, stoop and crouch occasionally. She cannot work around hazardous machinery, at unprotected heights or on vibrating surfaces. She is able is able to handle and finger frequently. She is limited to work that involves simple, routine and repetitive work tasks or instructions, that does not require close coordination or interaction with co-workers or the general public and that is low stress (requiring only occasional decision making and occasional changes in work setting), not production pace and that does not require confrontational involvement with a supervisor. [R. at 27]. The ALJ found that Plaintiff is not able to perform her past relevant work but that there are other jobs that exist in significant numbers that an individual with the same age, education, work experience and RFC as Plaintiff can perform. [R. at 32]. The ALJ therefore found that Plaintiff is not disabled as defined by the Social Security Act. [
Plaintiff contends that the ALJ committed several errors and that the ALJ's decision should be reversed. Plaintiff's first argument is that the ALJ failed to follow the "slight abnormality" standard in finding that Plaintiff's depression, anxiety and post traumatic stress disorder ("PTSD") are non-severe impairments. Plaintiff's next argument is that the ALJ failed to properly apply the pain standard. Plaintiff's third argument is that the ALJ made inaccurate statements with regard to the evidence cited as supporting Plaintiff's ability to work. And Plaintiff contends that the ALJ committed reversible error by failing to give great weight to the 2007 opinion of Dr. Dexter Tooman in an Attending Physician's Statement of Disability. [Doc. 13]. The Commissioner contends that the ALJ correctly applied the proper standards, that the ALJ's error at step five in describing the jobs identified by the VE was corrected by the Appeals Council and that substantial evidence supports the Commissioner's decision that Plaintiff is not disabled. [Doc. 14].
At step two of the sequential evaluation process, the claimant has the burden of showing that she has a severe impairment.
At step two, the ALJ found that Plaintiff has several severe physical impairments. [R. at 25]. The ALJ did not discuss Plaintiff's alleged mental impairments until step three when evaluating whether Plaintiff has a mental or physical impairment or combination of impairments that meets or equals a listed impairment. [R. at 26]. "Nothing requires that the ALJ must identify, at step two, all of the impairments that should be considered severe."
Plaintiff argues that the ALJ nonetheless erred by not including more severe limitations in her RFC assessment based on her depression, anxiety and PTSD. [Doc. 13 at 9]. The ALJ found, in relevant part, that Plaintiff has the RFC to perform sedentary work which "is limited to simple, routine and repetitive work tasks or instructions[,] that does not require close coordination or interactions with co-workers or the general public, and that is low stress (only occasional decision making and changes in work setting), nonconfrontational involvement with supervisor and not production pace." [R. at 27]. Plaintiff contends that, given the medical record evidence of her mental impairments and medications and her testimony of panic attacks, nausea and PTSD and that she has difficulty remembering and concentrating and poor sleep due to anxiety, nightmares and PTSD, the ALJ should have included more severe limitations in her RFC such as limiting her to "less than simple, routine and repetitive work tasks or instructions." [Doc. 13 at 9-10, citing R. at 49-50, 55, 64, 280-82, 288, 351-69, 374, 447-59, 721-27, 810, 1019-20].
In support, Plaintiff discusses one of the medical records which she cites: Dr. Berger's psychological evaluation. [Doc. 13 at 9-10]. Plaintiff points out that Dr. Berger diagnosed her condition as "major depression, recurrent, mild and PTSD" with a GAF score of 55 in January 2010 and that Dr. Berger opined that Plaintiff is "able to understand instructions, but is significant (sic) limited in her ability to carry out tasks, likely able to sustain attention for short periods of time if given breaks, her task performance would be expected to be slow, likely to decompensate under highly stressful conditions, and likely to get along well with others." [Doc. 13 at 9, quoting R. at 321-22 (internal quotation marks omitted)].
However, based on the records cited by the parties in their briefs and the record as a whole, the court finds that substantial record evidence supports the limitations in the ALJ's RFC assessment. The record shows that Plaintiff was experiencing some anxiety in 2007. [R. at 280-82, 288]. But, as the ALJ found, in February 2008, Dr. Michaele Brown with Pain Solution Treatment Center noted that Plaintiff's mood and affect were normal and appropriate, and the record shows that Plaintiff had normal recent, immediate and remote memory and normal language functions. [Exhibit 1F; R. at 30, 269]. Plaintiff cites records showing that she experienced some anxiety in July and November 2008 and in October and December 2009. [
Dr. Meneese found that, although Plaintiff's alleged limits could arise from her depression, anxiety and PTSD, the medical record evidence through February 2010 including Dr. Berger's evaluation and Plaintiff's ADLs "did not reflect signs/sxs of markedly disabling mental illness." [R. at 334]. And Dr. Meneese opined that Plaintiff's allegations of mental disability were only partially credible. [
The ALJ found that Dr. Kamath, who treated Plaintiff at Comprehensive Pain Management between July 2010 and March 2011, reported that Plaintiff's medication was providing good pain relief with little to no side effects, and the record reflects that Dr. Kamath reported that Plaintiff's ability to function was improved as a result of her effective pain control. [R. at 29, citing Exhibit 21F; R. at 553 ("able to perform more activities")]. Dr. Kamath noted that Plaintiff did not have any decreased lateral bending of the lumbar spine on April 15, 2011, and that her heel and toe walk were normal, reflexes equal and symmetric, and toes "down-going." [R. at 29; Exhibit 24F]. And Dr. Kamath noted in May, June and July 2011 that Plaintiff's mood and affect were normal. [
For the above reasons, the court finds that substantial medical record evidence supported the limitations that the ALJ included in Plaintiff's RFC to account for her mental impairments, that is, limiting Plaintiff to "simple, routine, and repetitive work tasks or instructions, that does not require close coordination or interaction with co-workers or the general public, and that is low stress (requiring only occasional decision making and occasional changes in work setting), nonconfrontational involvement with a supervisor, and not production pace." [R. at 27]. The court finds that, as stated in the decision, the ALJ "account[ed] for all of [Plaintiff's mental] limitations . . . even to an extent greater than the limitations which were demonstrated in the record." [R. at 31]. Plaintiff has not shown that the ALJ's decision should be reversed because more severe mental-function limitations should have been included in Plaintiff's RFC.
Plaintiff's second argument is that the ALJ did not properly apply the pain standard. When a claimant seeks to establish disability through subjective testimony of her pain or other symptoms, a three (3) part "pain standard" established by the Eleventh Circuit applies.
The ALJ found that Plaintiff Beck-Easley suffers from several underlying chronic medical conditions. [Doc. 13 at 11]. Therefore, Plaintiff met the first requirement of the pain standard.
The ALJ then had to consider whether there was either objective medical evidence confirming the severity of Plaintiff's alleged symptoms or whether the objectively determined medical condition underlying her alleged symptoms was of such severity that it could be reasonably expected to give rise to her alleged pain or symptoms.
Plaintiff argues that the ALJ nonetheless failed to properly apply the pain standard when he stated that Plaintiff's "`statements concerning the intensity, persistence and limiting effects of these symptoms are not credible to the extent they are inconsistent with'" the ALJ's RFC assessment. [Doc. 13 at 13, quoting R. at 28, and citing
As in
Plaintiff argues that the ALJ made inaccurate statements regarding the evidence in evaluating Plaintiff's ability to work. [Doc. 13 at 13]. Plaintiff gives just one example of the ALJ inaccurately stating the evidence — a mistake in describing the occupations identified by the VE for a person with Plaintiff's age, education, work experience and RFC — and argues that "[this] misstatement taken as a whole, reveal[s] an inaccurate review of the record and inadequate support in the record for the ALJ's decision." [Doc. 13 at 14, citing R. at 32]. Plaintiff's argument fails for several reasons.
Plaintiff is correct that the ALJ mistakenly listed the occupations of potato chip sorter, small products assembler and basket filler as examples of jobs that the VE testified a person with Plaintiff's age, education, experience and RFC could perform. [
Also, Plaintiff's reliance on
Appeals Council. While the court has an obligation to "scrutinize the record as a whole . . . to determine if the decision reached is reasonable . . . and supported by substantial evidence . . . [,]"
Plaintiff Beck-Easley's argument that the ALJ made inaccurate statements with regard to her ability to work is also not supported by her alleged back condition. [
The clinical observations by Plaintiff's treating physician, Dr. Kamath, in 2011, are consistent with Dr. Callins' and Dr. Walker's opinions. As the ALJ noted, Dr. Kamath observed on March 16, 2011, that no trigger points could be identified on deep palpation of the para-vertebral muscles and that Plaintiff reported an improved ability to function on her pain control medication. [R. at 29; Exhibit 21F; R. at 553 ("reports she is able to perform more activities because of her current medication regimen"; "admits to taking more [pain meds] than rx'd"), 554 ("She is moderately active.")]. And, in April 2011, Dr. Kamath found that Plaintiff did not have "any decreased lateral bending of the lumbar spine, that her heel and toe walk were normal, and that reflexes were equal and symmetric. . . ." [R. at 29; Exhibit 24F]. For the above reasons and authority, the court finds that Plaintiff's third argument — that the ALJ misstated the record evidence — is not a basis for reversing the Commissioner's final decision that Plaintiff is not disabled.
Plaintiff's last argument is that the Commissioner's decision should be reversed because the ALJ failed to give great weight to the opinion of Dr. Dexter Tooman. [Doc. 13 at 16]. The record contains a single, one page Attending Physician's Statement of Disability that Dr. Tooman completed on September 26, 2008, with a section at the bottom of the page for Plaintiff's employer to complete. (Exhibit 26F). Dr. Tooman reported that Plaintiff had been seen monthly from July 12, 2007, through September 5, 2008, after an accident on July 5, 2007, for complaints of severe neck pain and mid back and low back pain. [R. at 718]. Under objective findings, Dr. Tooman noted "positive orthopedic test" and "[undecipherable] findings of myospasms." [
Because the determination about whether a claimant has met the statutory definition of disability is reserved to the Commissioner, a medical source's opinion that a claimant is disabled is not controlling.
20 C.F.R. §§ 404.1527(c)(2), 416.927(c)(2).
A treating medical source's opinion is given controlling weight if it is "well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence" in the record. 20 C.F.R. §§ 404.1527(c)(2), 416.927(c)(2) If the treating source's opinion is not given controlling weight, then the Commissioner is required to consider the following six factors in determining the weight to give the opinion: (1) length of the treatment relationship and the frequency of examination; (2) nature and extent of the treatment relationship; (3) supportability; (4) consistency; (5) specialization; and (6) any other relevant factors.
Plaintiff argues that Dr. Tooman's treating opinion was entitled to more weight than the ALJ gave to the opinion of Dr. Lance Walker who was a consulting examining physician. [Doc. 13 at 18].
The Eleventh Circuit has consistently held that the opinions of treating physicians must be accorded substantial or considerable weight by the Commissioner unless good cause exists to discredit these opinions.
In determining the weight to give to Dr. Tooman's opinion, the ALJ was not required to address each of the above factors listed in the regulations, 20 C.F.R. §§ 404.1527(c), 416.927(c), "as long as the ALJ provide[d] `good cause' for rejecting the treating source's medical opinion."
For the above reasons, the court finds that the ALJ "articulated specific reasons for declining to give the treating physician's opinion controlling weight, and [that the ALJ's] reasons [are] supported by substantial evidence."
For the foregoing reasons and cited authority, the court finds that the Commissioner's final decision is supported by substantial evidence and based upon proper legal standards. It is, therefore,
The Clerk is