R. STEVEN WHALEN, Magistrate Judge.
Plaintiff Anthony J. Simkins ("Plaintiff") brings this action under 42 U.S.C. §405(g) challenging a final decision of Defendant Commissioner denying his application for Disability Insurance Benefits ("DIB") under the Social Security Act. Both parties have filed summary judgment motions which have been referred for a Report and Recommendation pursuant to 28 U.S.C. § 636(b)(1)(B). For the reasons set forth below, I recommend that Plaintiff's Motion for Summary Judgment be GRANTED to the extent that the case is remanded to the administrative level for further administrative proceedings, and that Defendant's Motion for Summary Judgment be DENIED.
On March 28, 2012, Plaintiff filed an application for DIB, alleging disability as of May 10, 2003 (Tr. 150). After the initial denial of the claim, Plaintiff requested an administrative hearing, held on November 26, 2013 in Toledo, Michigan before Administrative Law Judge ("ALJ") Ryan Johannes
On February 23, 2016, Defendant Commissioner filed a motion to dismiss, arguing that Plaintiff's July 27, 2015 filing was outside the 60 days allowed to commence judicial review under 42 U.S.C. 405(g). Docket #12. On June 23, 2016, the Honorable Sean F. Cox adopted my recommendation to deny Defendant's motion for dismissal. Docket #15, 19.
Plaintiff, born August 6, 1967, was 41 on the date last insured ("DLI") of December 31, 2008 and 46 when the ALJ issued his decision (Tr. 31, 150). He completed two years of college and worked previously as a fabricator and mill wright (Tr. 179). He alleges disability due to diabetes, bone spurs of the bilateral feet, right eye blindness, left shoulder rotator cuff damage, right shoulder nerve damage, neuropathy of the feet, arthritis, bladder problems, and lower back and hip ligament damage (Tr. 178).
Plaintiff offered the following testimony.
He lived in Adrian, Michigan, stood 5' 7", and weighed 223 pounds (Tr. 43). He was left-handed (Tr. 44). He lived with his wife and 10-year-old daughter (Tr. 43). He drove himself to the hearing but generally limited his driving to short distances (Tr. 43). He had medical insurance (Tr. 44). Since becoming disabled in May, 2003, he ran "a small hotrod camp" in 2011 for four hours every Saturday (Tr. 44). His last full-time work was as a fabricator in 2003 (Tr. 44). In 2003, his employer let him go due to limitations brought on by neuropathy of the feet, "sugar issues," and injuries from both a workplace accident and an automobile collision (Tr. 45). He received Workers' Compensation benefits (Tr. 45).
The vehicle accident resulted in torn hip and back ligaments and shattered a bone in his back (Tr. 46). He experienced hip pain upon even minimal activity and one leg was shorter than the other (Tr. 46). The right eye blindness caused him to overwork the left eye, resulting in "starbursts" in his vision (Tr. 46). He continued to experience foot pain and stiffness and ankle swelling due to neuropathy (Tr. 46). He also experienced left shoulder pain due to the vehicle accident and right shoulder joint problems (Tr. 47). Due to intestinal damage and diabetes, he experience chronic constipation (Tr. 48). Both wrists tended to "fall asleep" after overuse due to prior wrist fractures (Tr. 48).
The ALJ then directed Plaintiff to discuss his condition prior to the DLI of December 31, 2008 (Tr. 48).
Plaintiff underwent up to 27 steroid injections to the spine in 2004 and 2005 (Tr. 48). At the same time, he treated with a chiropractor on a regular basis (Tr. 48). The right eye blindness, beginning in 1993, was attributable to diabetes (Tr. 49). As of 2003, he was able to stay on his feet for a maximum of two hours a day before experiencing heaviness and numbness (Tr. 49). He underwent October, 2002 arthroscopic surgery to repair the rotator cuff tear sustained in the June, 2002 accident (Tr. 50-51). He had not been treated for depression between May, 2003 and December, 2008 due to "[lack of] funding" (Tr. 52).
Between May, 2003 and December 31, 2008 ("relevant period") he experienced hand numbness and gripping problems but did not experience medication side effects other than constipation (Tr. 52). He denied the use of alcohol or marijuana (Tr. 53). During the relevant period, he was able to take care of his personal needs, prepare meals, wash "some dishes," vacuum, and use a computer for about an hour every day (Tr. 54). He was unable to do laundry, grocery shop, or do significant yard work (Tr. 54-55). He spent most of his time caring for his diabetic daughter (Tr. 55). He was unable to walk more than a quarter of a mile, stand for more than two hours, or sit for more than one (Tr. 56). He was unable to lift more than 15 pounds (Tr. 56). He experienced significant weakness when reaching overhead and problems gripping (Tr. 57).
A January, 2003 MRI of the lumbar spine was "fairly unremarkable" (Tr. 330). April, 2003 imaging studies of the right foot showed only minimal degenerative changes of the first toe (Tr. 328). In August, 2003, Plaintiff noted that his vision had been stable in the past year (Tr. 257). In January, 2004, Steven N. Gross, D.O. examined Plaintiff, advising him to avoid "a great deal of bending or lifting (Tr. 396). Plaintiff exhibited full muscle strength with a normal knee and and ankle motion (Tr. 395). In March, 2004, Plaintiff sought treatment for a head cold (Tr. 355)
March, 2005 treating records by Jody Rhames, M.D. note tenderness and a reduced range of right shoulder motion (Tr. 352). May and September, 2005 records state that Plaintiff's health was stable despite lower back pain (Tr. 383-384). Paul Shapiro, M.D. administered epidural injections (Tr. 384). Treating notes for August, 2005 state that Plaintiff planned to resume motocross cycling to stay in shape (Tr. 385). October, 2005 physical therapy records states that Plaintiff experienced increased lower back pain with activity (Tr. 382). He was diagnosed with chronic lower back pain "without radiculopathy" (Tr. 382). Dr. Shapiro administered six steroid injections to the lower back (Tr. 382). December, 2005 physical therapy records state that Plaintiff's lower back condition was "much better" with only "one episode" of sciatica (Tr. 380-381).
January, 2007 records state that Plaintiff completed one month of physical therapy (Tr. 349). In April, 2007, Plaintiff was treated for athlete's foot, and the following month experienced sunburn of the top of the feet while mowing the yard (Tr. 347-348). May, 2007 imaging studies of the right foot showed soft tissue swelling (Tr. 302). July, 2007 chiropractic records state that Plaintiff was a candidate for "intensive" care consisting of three sessions a week for 12 weeks (Tr. 260). Chiropractor Dr. Sullivan observed a "slight right lumbar list" and "slight pelvic unleveling" on the left (Tr. 261). December, 2007 ophthalmological records note Plaintiff's report of good left eye vision without "floaters" (Tr. 254). Examination records (including February, 2009 records) 20/25 vision on the left (Tr. 254, 339, 340). Plaintiff continued to receive intermittent chiropractic treatment until mid-2008 for the conditions of fatigue, neck pain, stiffness, and numbness and tingling of both hands (Tr. 263, 268). An October, 2008 stress test showed an unremarkable ejection fraction (Tr. 270). Ophthalmologist Charles K. Dabbs, M.D. reported that Plaintiff was "doing well" (Tr. 334).
Dr. Rhames' December, 2009 records state that Plaintiff was writing a "screen play" (Tr. 344). In March, 2010, Plaintiff reported that his vision had remained stable since a February, 2009 examination (Tr. 338). Chiropractic records from January, 2014 were negative for recent fractures but the presence of degenerative disc disease (Tr. 417). The records note the symptoms of fatigue of the lower back and hands; hand numbness and pain; and neck, back, and leg pain (Tr. 419).
The same month, Dr. Dabbs noted the left eye had a Posterior Chamber Intraocular Lens Implantation ("PCIOL") with "limited visual fields secondary to diabetic retinal ischemic and laser treatment" (Tr. 421). He noted that Plaintiff "best-corrected vision" was 20/30 (Tr. 421). He noted that Plaintiff also experienced Charles Bonnet syndrome of the left eye
In May, 2012, Saada Abbas, M.D. performed a non-examining review of the treating and consultative records on behalf of the SSA, finding insufficient evidence through December 31, 2008 to make a disability finding (Tr. 75-80).
In December, 2013, R. Scott Lazzara, M.D. performed a consultative examination on behalf of the SSA, noting Plaintiff's report of disability due to uncontrolled diabetes, lower back and hip problems, right eye blindness, bilateral shoulder problems, neuropathy of the feet, and arthritis (Tr. 369, 404). Plaintiff reported that he sustained injuries in a 1991 motorcycle accident and was again injured in a 2002 accident resulting in right shoulder and lower back problems (Tr. 369). He admitted that he was able to drive, do household chores, and spend time "filming with a friend" (Tr. 370). He reported that he could stand or sit for around one hour, walk a mile, and lift 40 pounds "to the waist but [not] overhead" (Tr. 370). He exhibited a slightly reduced range of bilateral shoulder, knee and lumbar spine motion (Tr. 371, 373). Dr. Lazzara found that Plaintiff did not require the use of a cane (Tr. 373).
Dr. Lazzara also completed an assessment of Plaintiff's work-related abilities, finding that he could lift up to 20 pounds occasionally (up to 50 on the right); sit for six hours in an eight-hour workday and stand, or walk for four hours (Tr. 364). He found that Plaintiff would need to change position once an hour (Tr. 364). He limited Plaintiff to occasional reaching overhead and push/pulling (Tr. 365). He also found that Plaintiff could climb, balance, stoop, knee, and crouch on an occasional basis (Tr. 366). Dr. Lazarra precluded all crawling (Tr. 366). He found that due to right-eye blindness, Plaintiff was unable to read small print (Tr. 366). Dr. Lazarra precluded all exposure to unprotected heights, extreme cold, and moving mechanical parts (Tr. 367). He limited Plaintiff to occasional driving, exposure to extreme heat, operating a motor vehicle, and vibration (Tr. 367). He found no limitation in activities of daily living (Tr. 368, 403).
VE McGee classified Plaintiff's past relevant work as a stock-parts fabricator as semiskilled and exertionally medium
Based on the above restrictions, VE testified that the hypothetical individual would be unable to perform Plaintiff's past relevant work but could perform the light, unskilled jobs of a palletizer (1,500 positions in the regional economy); bagger of garments (2,000); and shipping and receiving weigher (1,500-2,000) (Tr. 62). The VE testified that if the same individual were limited to sedentary rather than exertionally light work, he could perform the work of a telephone quotation clerk (1,500-2,000); table worker (1,000); and document preparer (10,000) (Tr. 62-63). The VE stated that the need for a sit/stand "at will" option would not change the sedentary job numbers (Tr. 63). He testified that the need to be off task for 20 percent or more of the workday, or, more than one absence each month would preclude all work (Tr. 64).
The VE stated that his testimony was consistent with the information found in the Dictionary of Occupational Titles except for his finding regarding a sit/stand option which was based on his own professional experience (Tr. 61, 63).
Citing Plaintiff's treating records, ALJ Johannes found that Plaintiff experienced the severe impairments of "lumbar degenerative disc disease, cervical degenerative disc disease, right eye blindness, diabetes mellitus, and residuals of right shoulder injury" but that none of the impairments met or equaled a listed impairment under 20 C.F.R. Part 404, Subpart P, Appendix 1 (Tr. 24-25). The VE found that on or before the date last insured of December 31, 2008, Plaintiff retained the Residual Functional Capacity ("RFC") for exertionally light work with the following additional limitations:
Citing the VE's findings, the ALJ found that while Plaintiff was unable to perform his past relevant work, he could perform the exertionally light, unskilled work of a palletizer, bagger of garments, and shipping and receiving weigher (Tr. 30, 62).
The ALJ discounted Plaintiff's allegations of limitation. He noted that a January, 2003 MRI of the lumbar spine was unremarkable and that May, 2008 treatment notes showed only mild lumbar spine abnormalities (Tr. 27). The ALJ observed "a break in chiropractic treatment from May, 2008 to January, 2014" and that the recent records showed only "routine and conservative treatment" (Tr. 27). He commented that Plaintiff had "relatively little medical treatment for the allegedly disabling impairments" despite having health insurance for the past 18 years (Tr. 29). He noted that while Plaintiff experienced right eye blindness, the left eye vision was "good" (Tr. 27). He cited Plaintiff's admission to Dr. Lazzara that he could lift up to 40 pounds, drive, and perform activities of daily living (Tr. 28). The ALJ noted that while Dr. Lazzara conducted the examination in December, 2013 (five years after the expiration of benefits) Plaintiff [did] not assert that his physical abilities [had] improved since the date last insured" (Tr. 28).
The district court reviews the final decision of the Commissioner to determine whether it is supported by substantial evidence. 42 U.S.C. §405(g); Sherrill v. Secretary of Health and Human Services, 757 F.2d 803, 804 (6
Disability is defined in the Social Security Act as the "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). In evaluating whether a claimant is disabled, the Commissioner is to consider, in sequence, whether the claimant: 1) worked during the alleged period of disability; 2) has a severe impairment; 3) has an impairment that meets or equals the requirements of an impairment listed in the regulations; 4) can return to past relevant work; and 5) if not, whether he or she can perform other work in the national economy. 20 C.F.R. §416.920(a). The Plaintiff has the burden of proof at steps one through four, but the burden shifts to the Commissioner at step five to demonstrate that, "notwithstanding the claimant's impairment, he retains the residual functional capacity to perform specific jobs existing in the national economy." Richardson v. Secretary of Health & Human Services, 735 F.2d 962, 964 (6th Cir.1984).
Plaintiff argues first that the ALJ erred by rejecting Dr. Dibbs' January, 2014 finding of permanent disability due to vision problems. Plaintiff's Brief, 16-18, Docket #24, Pg ID 581 (citing Tr. 28, 421). He contends that instead of simply discounting the disability opinion, the ALJ was required to recontact Dr. Dibbs' for "clarification" of the treating findings. Id.
"[I]f the opinion of the claimant's treating physician is supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in [the] case record, it must be given controlling weight." Hensley v. Astrue, 573 F.3d 263, 266 (6th Cir. 2009)(internal quotation marks omitted) (citing Wilson, 378 F.3d 541, 544 (6th Cir. 2004); 20 C.F.R. § 404.1527(c)(2)). However, in the presence of contradicting substantial evidence, the ALJ may reject all or a portion of the treating source's findings, see Warner v. Commissioner of Social Sec., 375 F.3d 387, 391-392 (6th Cir. 2004), provided that he supplies "good reasons" for doing so. Wilson, at 547; 20 C.F.R. § 404.1527(c)(2))
In support of the rejection of the "disability" opinion, the ALJ cited Dr. Dibbs' February, 2009 records that Plaintiff's left eye vision was "good" approximately one month following the DLI of December 31, 2008 (Tr. 27). The ALJ then addressed Dr. Dibbs' January, 2014 that Plaintiff was disabled as a result of vision problems:
In the RFC, the ALJ included a restriction to "work that does not require bilateral depth perception, or visual acuity, or accommodation due to single eye vision" (Tr. 25).
The ALJ's rationale for rejecting Dr. Dibbs' January, 2014 disability opinion is well supported and explained. The Commissioner, not a treating source, is responsible for deciding whether a claimant meets "the statutory definition of disability." 20 C.F.R. § 404.1527(d)(1). While a treating source opinion regarding a claimant's medical condition is entitled to deference, the SSA "will not give any special significance to the source of an opinion on issues reserved to the Commissioner." § 404.1527(d)(3)(emphasis added). The ALJ noted that in contrast to Dr. Dibbs' disability opinion, his treating records for the relevant period showed "good" left eye vision (Tr. 27). Plaintiff cites a number Dr. Dibbs records for the relevant period. Plaintiff's Brief at 17 (citing Tr. 254-257, 331-340, 420-421). However, these records generally undermine rather support the allegations of disabling vision problems: (Tr. 254)(denied "flashers" or "floaters" in left eye vision), (Tr. 255)(rare or occasional floaters), (Tr. 256)(no floaters), (Tr. 256)(no ocular pain or floaters), and approximately one month after the DLI (Tr. 234)(doing well).
Plaintiff's argument that the ALJ was required to recontact Dr. Dibbs for "clarification" of the treating opinion is not well taken. To be sure, "after weighing the evidence," the ALJ may seek "additional evidence or clarification" if s/he "cannot reach a conclusion about whether" the claimant is disabled. 20 C.F.R. § 404.1520b(c)(1). However, recontacting a medical source is appropriate "only if the evidence received from that source is inadequate for a disability determination," DeBoard v. CSS, 2006 WL 3690637, *5 (6th Cir. December 15, 2006); § 404.1512(e) and that "[a]bsent a gap in the record, the ALJ has no duty to recontact the physician." Starkey v. CSS, 2008 WL 828861, *4 (W.D. Mich. March 26, 2008)(citing Johnson v. Barnhart, 138 Fed. Appx. 186, 189, 2005 WL 1414406, *3 (11th Cir. June 17, 2005)). Dr. Dibbs' treating records for the relevant period amply support the finding that visual problems did not preclude all work. As such, the ALJ was not obliged to recontact Dr. Dibbs.
For overlapping reasons, Plaintiff's contention that the ALJ misquoted Dr. Rhames' findings regarding the vision problems does not provide grounds for remand. Plaintiff takes issue with the ALJ's statement that Dr. Rhames diagnosed Plaintiff "as legally blind in his right eye." Plaintiff's Brief at 17 (citing Tr. 27, 341). While Dr. Rhames, a general practitioner, listed "legally blind" among Plaintiff's "active problems" at a December, 2011 examination, the "legally blind" statement is followed by "right eye prosthesis" (Tr. 341). Dr. Rhames' findings do not mention left eye vision problems much less suggest that Plaintiff experienced legal blindness in both eyes. Moreover, Dr. Dibbs' records for the relevant period showing 20/30 vision in the left eye do not meet the statutory definition of blindness which requires 20/200 central visual acuity "or less of the better eye." See Williams v. Comm'r of Soc. Sec., 93 F. App'x 34, 36, 2004 WL 445184 (6th Cir. March 9, 2004)(citing 42 U.S.C. § 416(i)(1)(B); 20 C.F.R. § 404.1581). More obviously, Plaintiff's ability to drive, mow the lawn, run a hotrod camp, and care for his daughter during the relevant period belies his claim that the treating physician found him legally blind in both eyes.
As such, the ALJ's statement that Dr. Rhames found Plaintiff "legally blind" in only the right eye does not constitute a misstatement of the record.
In his second argument, Plaintiff argues that the ALJ's credibility determination is tainted by the ALJ's failure to consider the limiting effects of Charles Bonnet syndrome, bilateral neuropathy of the feet, and obesity. Plaintiff's Brief at 19-20. In his third argument, Plaintiff revisits his claim that the ALJ did not adequately consider the same conditions in crafting the RFC. Plaintiff's Brief at 20-22. He contends that as a result, the RFC does not reflect his full degree of limitation. Id.
The credibility determination, currently guided by SSR 96-7p, describes the process for evaluating symptoms.
Plaintiff's October, 2008 BMI of 32.7 places him in the obese range
The lack of reference to obesity in the RFC discussion is coupled with other errors. For example, while Dr. Lazzara limited Plaintiff to walking or standing for four hours in an eight-hour workday with a sit/stand option, the ALJ provided no rationale for his finding that Plaintiff was capable of walking or standing for six hours in eight (Tr. 25, 28, 364). The question of whether Plaintiff can walk four (with a sit/stand option) or six hours a day is particularly critical, given that exertionally light work as found in the RFC requires walking up to six hours a day. In performing light work, "the weight lifted may be very little," so long as a "good deal of walking or standing" is involved. 20 C.F.R. § 404.1567(b). None of the medical records or Plaintiff's description of his own activities can be interpreted to state that he is capable of walking up to six hours in an eight-hour workday.
Likewise, while Dr. Lazarra found that Plaintiff was limited to occasional overhead reaching due to shoulder problems, the ALJ failed to provide an explanation for the RFC for frequent rather than occasional overhead reaching (Tr. 25, 28, 365). While I am mindful that the VE testified that an individual of Plaintiff's education, age, and work experience would be capable of a range of sedentary work with a sit/stand option (Tr. 62-63), an additional limitation to occasional overhead reaching (as found by Dr. Lazzara) raises the question of whether a significant number of sedentary jobs exist for an individual with some degree of manipulative limitation. See SSR 96-9p, 1996 WL 374185,*8 (July 2, 1996) "Any significant manipulative limitation of an individual's ability to handle and work with small objects with both hands will result in a significant erosion of the unskilled sedentary occupational base." (Emphasis added). Although the ALJ was not required to adopt Dr. Lazzara's consultative opinion, none of the other medical records or testimony supports the finding that Plaintiff could reach overhead for up to two-thirds of an eight-hour workday (Tr. 365). Moreover, while the ALJ accorded only "partial weight" to Dr. Lazzara's findings, it appears that the ALJ discounted those findings only to the extent that they were a "current" assessment rather than an evaluation of Plaintiff's limitations during the relevant period (Tr. 28). The ALJ did not provide any rationale for his alternative finding that Plaintiff was capable of walking six hours a day and performing frequent overhead reaching.
Although the ALJ concluded that Dr. Lazzara's opinion supported an RFC for light work, it is unclear that Dr. Lazzara's findings of the inability to walk for more than four hours, a sit/stand option, and a limitation in manipulative abilities allows for either light or sedentary work. Accordingly, a remand for further administrative proceedings is appropriate on this basis as well.
While a remand to the administrative level is warranted for the above-discussed reasons, I decline to recommend a remand for an award of benefits. An award of benefits is appropriate "only if all essential factual issues have been resolved and the record adequately establishes a plaintiff's entitlement to benefits." Faucher v. HHS, 17 F.3d 171, 176 (6th Cir. 1994). While the transcript shows that Plaintiff experiences multiple, significant conditions, a remand for benefits prior to the resolution of the unresolved factual issues would be premature. As such, I recommend a remand for further administrative proceedings consistent with the above discussion.
For the reasons stated above, I recommend that Plaintiff's Motion for Summary Judgment be GRANTED to the extent that the case is remanded to the administrative level for further administrative proceedings, and that Defendant's Motion for Summary Judgment be DENIED.
Any objections to this Report and Recommendation must be filed within 14 days of service of a copy hereof as provided for in 28 U.S.C. §636(b)(1) and E.D. Mich. LR 72.1(d)(2). Issue first raised in objections to a magistrate judge's report and recommendation are deemed waived. U.S. v. Waters, 158 F.3d 933, 936 (6
Within 14 days of service of any objecting party's timely filed objections, the opposing party may file a response. The response shall be not more than 20 pages in length unless by motion and order such page limit is extended by the court. The response shall address specifically, and in the same order raised, each issue contained within the objections.