AVERN COHN, District Judge.
This is a Social Security case. Plaintiff Jeffrey P. Lundby (Lundby) appeals the final decision of the Commissioner of Social Security (Commissioner) denying his application for Disability Insurance Benefits (DIB) and Supplemental Security Income (SSI). Lundby claims that he has been disabled since August 3, 2009, due to stomach problems, depression, and back, shoulder, elbow, and hand pain.
The parties filed cross motions for summary judgment. (Docs. 19, 22). The motions were referred to a magistrate judge (MJ) for a report and recommendation (MJRR). After the MJRR recommended that Lundby's motion be denied and the Commissioner's motion be granted, Lundby filed timely objections. For the reasons that follow, the Court overrules Lundby's objections, adopts the MJRR, denies Lundby's motion for summary judgment, grants the Commissioner's motion, and affirms the administrative law judge's (ALJ) decision denying benefits.
As the parties have not objected to the MJ's recitation of the procedural history and administrative record, the Court adopts that portion of the MJRR as if fully set forth herein. A brief history of the procedural posture follows.
Lundby applied for DIB and SSI on August 28, 2013. He alleged disability as of August 3, 2009.
When the Commissioner denied the claims, Lundby requested a hearing. On January 27, 2015, Lundby appeared with counsel before an ALJ. At the hearing, Lundby testified on his own behalf. Following the hearing, Lundby submitted additional medical evidence, including reports from additional consultative physical and psychological examinations ordered by the ALJ. All additional evidence was entered into the record.
The ALJ issued a written decision denying Lundby's claims, finding that Lundby was not disabled. Lundby's date last insured (DLI) is December 31, 2014.
The Appeals Council denied Lundby's request for review, rendering the decision of the Commissioner final. Lundby appeals from that decision.
The MJRR summarized the ALJ's decision denying benefits:
(Doc. 23 at 3-5).
Lundby made three arguments to show that the ALJ's decision was not supported by substantial evidence. First, Lundby said that the ALJ failed to properly apply the treating medical source rule and give controlling weight, rather than "limited weight," to the opinions of Lundby's treating physicians Dr. Smith and Dr. Billies. Lundby said the ALJ should have given controlling weight to the two treating opinions because they were consistent with one another and with all other medical evidence, and they imposed limitations that were far in excess of those in the RFC.
Second, Lundby said that the ALJ failed to account for his limitations on fine and gross manipulation, and reaching overhead. Lundby said that even though every physician offered an opinion that Lundby had limited use of his upper extremities, the RFC neither acknowledged those limitations nor incorporated them.
Finally, Lundby said that the ALJ's decision regarding his mental limitations was unsupported by substantial evidence because the opinion of his treating therapist, Lisa Wilmot, was improperly afforded "limited weight," while the opinion of a consulting examiner, Dr. Kirzner, was afforded "significant weight." Further, Lundby said that despite assigning Dr. Kirzner's opinion "significant weight," the ALJ improperly assumed the role of doctor by "adjust[ing]" it to find that "the claimant's limitations [we]re moderate, rather than marked in nature."
In his motion, the Commissioner said that the decision denying benefits was supported by substantial evidence. First, the Commissioner said that the ALJ properly offered "limited weight" to the treating opinions of Dr. Smith and Dr. Billies because they were inconsistent with unremarkable physical examinations, mild objective evidence, Lundby's testimony, and the consulting opinion of internist Dr. Wood.
Second, the Commissioner asserted that the ALJ did not err in omitting Lundby's limitations on fine and gross manipulation and reaching overhead because the ALJ noted that physical examinations were largely unremarkable, and Dr. Wood found that Lundby had a full range of gross and fine motor activities.
Finally, the Commissioner said that the ALJ properly afforded treating therapist Wilmot's opinion "limited weight" because it was vague and inconsistent with Lundby's own testimony about his limitations. The Commissioner also said that the ALJ did not improperly assume the role of doctor by scaling back Dr. Kirzner's consulting opinion because in light of Lundby's own admissions, moderate limitations were more reasonable than marked limitations.
The MJRR rejected Lundby's arguments. First, the MJRR determined that the ALJ gave good reasons for affording limited weight to the assessments done by treating physicians Dr. Billies and Dr. Smith. Specifically, the MJRR explained that the ALJ adequately considered and analyzed the treating opinions, and correctly found that they imposed extreme limitations that were inconsistent with other substantial evidence in the record, including multiple unremarkable physical examinations, mild objective evidence such as x-rays and MRI scans, and Lundby's own statements regarding his capabilities. For example, Lundby testified that he could walk four to five blocks at a time, walk or stand up to three hours a day, and sit for extended periods in a comfortable chair. Lundby also testified that his daily activities included shopping, fishing, driving, fixing meals, cleaning, walking his dog, taking pontoon rides, playing cards, and occasionally lifting between 30 and 40 pounds. Further, the ALJ considered that consultative examiner Dr. Guiboux declined Lundby's request to assist him in obtaining disability in 2009 because he had only "some minor arthritis." The MJRR's analysis supported the ALJ's determination that the record contradicted Dr. Billies' and Dr. Smith's findings.
Second, the MJRR determined that substantial evidence supported the ALJ's finding that Lundby was capable of performing light work with a sit/stand option. Specifically, the MJRR explained that the ALJ did not err in omitting limitations of fine and gross manipulations and reaching overhead from his RFC assessment. The MJ explained that because the ALJ gave limited weight to Dr. Billies' and Dr. Smith's treating opinions, limited weight was appropriately extended to include their limitations on Lundby's use of his upper extremities. The ALJ also relied on the consultative physical and neurological examinations done by internist Dr. Wood, who found that Lundby could push and pull, and had essentially a full range of motion in his shoulders and hands.
Third, the MJRR determined that the ALJ gave good reasons for affording limited weight to the mental assessment done by treating therapist Ms. Wilmot, and appropriately detracted from the significant weight given to the mental assessment done by consultative psychologist Dr. Kirzner. Specifically, the MJRR explained that the ALJ was not required to give controlling weight to Ms. Wilmot's treating opinion, and after giving it "serious consideration," he appropriately disagreed with her extreme limitations because they were vague, conclusory, and inconsistent with Lundby's own testimony. Further, the MJRR explained that the ALJ properly gave Dr. Kirzner's opinion significant weight, even though the ALJ found Lundby's mental limitations to be moderate rather than marked, because Lundby stated that he gets along well with authoritative figures, and Dr. Kirzner found that Lundby retained the ability to understand instructions and pay attention. The ALJ also relied on the consultative opinion of mental health provider Erin Crow, who found that Lundby "ha[d] normal perception, unremarkable thought processes, exhibited fair judgment, fair impulse control, and good insight."
Thus, the MJRR recommended granting the Commissioner's motion, denying Lundby's motion, and affirming the ALJ's decision denying benefits.
Lundby has three objections to the MJRR. First, Lundby says the MJ improperly excused the ALJ's erroneous application of the treating source rule, allowing him to "play doctor," and render his own independent medical opinion. Lundby further says that even if his admissions regarding his capabilities and daily activities are true, they do not permit the ALJ's RFC finding of light work for forty hours per week. Finally, Lundby says a consultative opinion by Dr. Wood did not justify the ALJ's decision to disregard the treating source rule because it was inconsistent with two treating opinions, and even the ALJ did not adopt it.
Second, Lundby says the MJ improperly excused the ALJ's failure to account for Lundby's limitations on fine and gross manipulation and reaching overhead in his RFC assessment. Lundby says that although every physician offered an opinion limiting the use of his upper extremities, the MJ excused the ALJ's failure to acknowledge or incorporate them in his RFC assessment. Instead, Lundby says the MJ "provided the analysis the ALJ did not[,]" which the Court is precluded from doing. Finally, Lundby says the MJ erred in finding that limitations on his upper extremities were never alleged, and in ignoring those imposed by Dr. Wood, namely that Lundby was "limited . . . to occasional pushing and pulling bilaterally, and only frequent handling, fingering, and feeling."
Third, Lundby says the MJ improperly permitted the ALJ to "play doctor" in establishing Lundby's mental limitations because after noting that he gave psychologist Dr. Kirzner's consultative opinion "significant weight[,]" the ALJ adjusted Dr. Kirzner's opinion, which imposed mostly "marked" limitations, to only "moderate" limitations. Further, Lundby says the MJ erred in allowing the ALJ to merely review Dr. Kirzner's findings and ascribe his own significance and weight to them.
A district court must conduct a de novo review of the parts of a MJRR to which a party objects. 28 U.S.C. § 636(b)(1). "A judge of the court may accept, reject, or modify, in whole or in part, the findings or recommendations made by the magistrate judge. The judge may also receive further evidence or recommit the matter to the magistrate judge with instructions."
Judicial review of a Social Security disability benefits application is limited to determining whether "the commissioner has failed to apply the correct legal standards or has made findings of fact unsupported by substantial evidence in the record."
When determining whether the Commissioner's decision is supported by substantial evidence, the reviewing court must consider the entire record as a whole.
Lundby's objections to the MJRR are without merit. Lundby's first objection is that the MJ erred in excusing the ALJ's application of the treating source rule because the ALJ did not adopt largely similar opinions by two treating sources, gave greater weight to a consultative opinion, and did not actually adopt the findings of any of the three physicians. The Court addresses each of these three arguments in turn.
An ALJ is required to give controlling weight to treating source opinions if they are "supported by medically acceptable clinical and laboratory diagnostic techniques and . . . not inconsistent with the other substantial evidence in [the] case record."
First, the MJ correctly found that the ALJ's decision to give less than controlling weight to the treating opinions of Dr. Billies and Dr. Smith was appropriate. The ALJ properly applied the treating source rule by discounting the treating opinions because they were unsupported by the medical record and inconsistent with other substantial evidence. For example, the ALJ explicitly stated that he afforded the treating opinions limited weight because their extreme limitations were not supported by Lundby's unremarkable physical examinations, nor by mostly mild objective evidence, such as x-rays and MRI scans. Further, the ALJ noted that the treating opinions were inconsistent with Lundby's own statements regarding his capabilities, including that he could walk or stand up to three hours in a day and was able to sit for extended periods in a comfortable chair. The ALJ also cited Lundby's testimony that he could go fishing, play cards, walk his dogs, take pontoon rides, and lift up to 40 pounds occasionally. The ALJ utilized these daily activities in tailoring Lundby's work limitations and crafting his credibility determination, stating that they "[we]re consistent with basic work functions," and undermined his claim that he "ha[d] problems using his hands because of arthritis." (Doc. 12 at 17, 20).
Second, the MJ correctly found that the ALJ provided good reasons for affording limited weight to Dr. Billies' and Dr. Smith's treating opinions, and significant weight to Dr. Wood's consultative opinion. In addition to the reasons described above, the ALJ discounted the treating opinions because they were inconsistent with two opinions rendered by consultative examiner Dr. Wood, who imposed significantly fewer limitations after performing two physical examinations that were normal.
Finally, the ALJ explained why his RFC limitations did not correlate identically to those imposed by the three physicians. As a preliminary matter, the RFC determination is one exclusively reserved to the ALJ. Further, simply because the RFC did not adopt the exact limitations of any opining physician does not mean that it was impermissibly based on the ALJ's own independent evaluation of the evidence. As previously stated, the ALJ cited objective medical evidence, contradictory testimony by Lundby, and an inconsistent opinion by Dr. Wood, as reasons why the treating opinions' limitations were given little weight. Further, in explaining his handling of the limitations imposed by Dr. Wood's opinion, the ALJ explained that he "g[ave] additional consideration to [Lundby's] testimony regarding his abilities to stand or walk for up to three hours, and regarding his ability to sit, as well as [his] subjective pain complaints." (MJRR at 15). Thus, the ALJ explained the limitations in his RFC by citing to substantial evidence in the record, and it should not be disturbed merely because the same evidence could have supported a different decision.
In sum, the Court finds that the weight the ALJ assigned to the treating source and consultative opinions is supported by substantial evidence, and Lundby's first objection lacks merit.
Lundby's second objection is that the ALJ failed to acknowledge and incorporate upper extremities restrictions imposed by three medical opinions in his RFC. However, the MJ properly concluded that the ALJ did not err in omitting limitations on fine and gross manipulation and reaching overhead from Lundby's RFC assessment. "Although a function-by-function analysis is desirable, SSR 96-8p does not require ALJs to produce such a detailed statement in writing."
The ALJ addressed the treating source opinions on Lundby's upper extremities and provided good reasons for rejecting them. As indicated above, the ALJ properly discounted Dr. Billies' and Dr. Smith's opinions, which included their limitations on Lundby's upper extremities. For example, the ALJ cited "unremarkable objective evidence," including x-rays showing only minimal osteoarthritis in Lundby's upper extremities. (MJRR at 14). In addition, the ALJ cited 2014 x-rays showing that Lundby's left shoulder had only minimal joint irregularity.
Further, both the MJ and the ALJ recognized the limitations Dr. Wood imposed on Lundby's upper extremities, and the MJ properly found that the ALJ considered them in crafting his RFC. The MJ noted that Dr. Wood limited Lundby to occasional pushing and pulling bilaterally, and frequent handling, fingering, and feeling. (MJRR at 17-18). The ALJ also explicitly cited these upper extremities restrictions when he explained why he gave significant weight to Dr. Woods' opinion. (Doc. 12 at 20). Finally, the ALJ asked the Vocational Expert to list jobs Lundby would be capable of doing if he "was limited to occasional handling and fingering." (Doc. 19 at 14). While this Court's role is limited to the review of agency action, it may consider all evidence in the record and before the ALJ,
Lundby's third objection, that the ALJ "simply reviewed Dr. Kirzner's examination findings and ascribed different weight or significance to them than had the doctor," is also without merit.
The MJ correctly found that the ALJ did not "play doctor" in establishing Lundby's mental limitations. The ALJ properly discounted Dr. Kirzner's "marked" conclusions because they were inconsistent with his (Dr. Kirzner's) own examination findings, Lundby's statements, and another medical source's findings. Dr. Kirzner found that Lundby had moderate to marked difficulties carrying out instructions because he had difficulties understanding and remembering. However, in discounting this limitation to moderate, the ALJ cited Dr. Kirzner's own examination findings that Lundby could still manage his own resources, drive, understand instructions, and pay attention.
Dr. Kirzner found that Lundby had marked difficulties in interacting appropriately with the public because he had impaired social activities. However, in discounting this limitation to moderate, the ALJ cited Lundby's function report, where Lundby stated that he gets along well with family, friends, and neighbors, and has no problems getting along with authority figures. Further, the ALJ cited a mental status examination conducted by mental health provider Erin Crow. Although Crow found that Lundby was emotionally distressed, anxious, and depressed, she also found that he was cooperative, had normal perception and unremarkable thought processes, exhibited fair judgment and impulse control, and had good insight. Thus, the ALJ based his determination of Lundby's mental limitations on Dr. Kirzner's opinion, discounted by substantial contradictory evidence in the record, and not on his own independent evaluation of the evidence.
For the reasons stated above, the MJRR is ADOPTED, Lundby's objections are OVERRULED, Lundby's motion for summary judgment is DENIED, the Commissioner's motion for summary judgment is GRANTED, and the ALJ's decision denying benefits is AFFIRMED. The ALJ's decision is supported by substantial evidence and will not be disturbed.
SO ORDERED.
