JOHN M. BODENHAUSEN, Magistrate Judge.
Paul D. Johnson ("Plaintiff") appeals the decision of the Commissioner of Social Security ("Defendant") denying his application for disability benefits. Because the final decision of the Commissioner is supported by substantial evidence, as discussed below, it is affirmed.
On May 24, 2012, Plaintiff filed an application for disability benefits under Title II of the Social Security Act. 42 U.S.C. § 401 et seq. (Tr. 128)
Plaintiff is a 44 year-old man who has alleged a variety of physical and mental issues, including injuries to both of his knees, a bulging disc in his neck, chronic back pain, and severe anxiety. (Tr. 171) In this appeal, Plaintiff alleges for the first time that he suffers from a severe impairment of depression. (ECF No. 17 at 26-29)
Plaintiff's alleged knee problems began around 2001, as a result of his work as an HVAC technician. (Tr. 407) Plaintiff's alleged back issues and pain appear to be a result of an automobile accident in June of 2006. (Tr. 252) Plaintiff's anxiety issues first appear in the medical record in November of 2010. (Tr. 260) At his hearing, Plaintiff testified concerning these issues, and he also discussed for the first time having carpal tunnel syndrome. (Tr. 38, 40-44) In addition, Plaintiff testified to his daily activities, and how his alleged limitations preclude him from working.
After hearing Plaintiff's testimony, and reviewing the objective medical evidence, the ALJ ultimately found Plaintiff not disabled under the law. (Tr. 22) Consistent with the testimony of a vocational expert ("VE"), the ALJ found that Plaintiff retained the residual functional capacity ("RFC") to perform the requirements of occupations such as a storage facility rental clerk, floor attendant, and information clerk. (
At step one, the ALJ concluded that Plaintiff had not engaged in substantial gainful activity since August 26, 2011. (Tr. 13) At step two, the ALJ found Plaintiff had the following severe impairments: mild carpal tunnel syndrome on the right side; degenerative disc disease of the lumbar and cervical spines; a history of surgery on both knees; and anxiety disorder. (
At step four, the ALJ reviewed the entire record and concluded that Plaintiff retained the RFC to "perform light work as defined in 20 CFR 404.1567(b)" with the additional limitations of "never climbing ladders, ropes, or scaffolds; occasionally climbing ramps and stairs; occasionally stooping, kneeling, crouching, or crawling; and never having repetitive flexion, extension, or rotation of the neck." Additionally, Plaintiff "can only do frequent bilateral fingering (defined as fine manipulation of items no smaller than a paper clip) and frequent bilateral handling (defined as gross manipulation)." Also, Plaintiff must "avoid all use of exposed moving machinery and all exposure to unprotected heights." Finally Plaintiff "is limited to simple work . . ., routine and repetitive tasks and only occasional interaction with coworkers or the general public." (Tr. 15-16)
The ALJ then found Plaintiff unable to perform his past work as a heating and airconditioning technician. (Tr. 21) Then the ALJ proceeded to step five of the analysis. There, as noted above, the ALJ found that jobs exist in the national economy that Plaintiff can still perform, such as a storage facility rental clerk, floor attendant, and information clerk. (Tr. 22) Therefore, the ALJ found that Plaintiff was not disabled under the law. (Tr. 22)
After the ALJ's ruling, Plaintiff submitted additional evidence to the Appeals Council. This evidence included a letter, dated March 7, 2014, from Dr. Nickolas Gillette, D.O., Plaintiff's treating physician, listing Plaintiff's ailments as cervical spondylosis and degenerative disc disease, along with lumbago and bulging disc, causing radiating pain. (Tr. 403) Dr. Gillette concluded that these issues "limit [Plaintiff's] ability to get and keep employment." (
Plaintiff then appealed to this Court under 42 U.S.C. § 405(g). The general issue before the Court is whether the decision of the Commissioner is supported by substantial evidence. More specifically, the parties dispute: (1) the propriety of the ALJ's findings at step two— Plaintiff argues that the ALJ erred by not finding that Plaintiff suffers from the severe impairment of depression, even though he never alleged this impairment in his application for benefits or at his hearing; and (2) whether the ALJ should have ordered an additional consultative examination from Plaintiff's treating psychiatrist to supplement the record relating to Plaintiff's mental impairments.
"To be eligible for [disability] benefits, [Plaintiff] must prove that [he] is disabled. . . ."
Per regulations promulgated by the Commissioner, the ALJ follows a five-step process in determining whether a claimant is disabled. "During this process the ALJ must determine: `1) whether the claimant is currently employed; 2) whether the claimant is severely impaired; 3) whether the impairment is, or is comparable to, a listed impairment; 4) whether the claimant can perform past relevant work; and if not 5) whether the claimant can perform any other kind of work.'"
The Eighth Circuit has repeatedly emphasized that a district court's review of an ALJ's disability determination is intended to be narrow and that courts should "defer heavily to the findings and conclusions of the Social Security Administration."
Despite this deferential stance, a district court's review must be "more than an examination of the record for the existence of substantial evidence in support of the Commissioner's decision."
Finally, a reviewing court should not disturb the ALJ's decision unless it falls outside the available "zone of choice" defined by the evidence of record.
The issues before the Court are noted above. After a careful review of the record, the Court finds that: (1) the ALJ's failure to include depression as a severe impairment is supported by substantial evidence; and (2) the ALJ was not required to obtain a consultative exam regarding Plaintiff's mental health impairments because there was sufficient information in the record to allow him to adjudicate these claims. Therefore, the Court must affirm the decision of the ALJ that Plaintiff is not disabled.
Plaintiff's first argument is that the ALJ erred in failing to find his depression to be a severe impairment. (ECF No. 17 at 26) An impairment is severe if it has more than a minimal impact on an individual's ability to do basic work activities.
Defendant makes several arguments in response. Defendant argues that remand is unnecessary because: (1) it was Plaintiff's burden to prove that he suffered from depression, and yet he did not even allege that he suffered from depression, nor did he proffer evidence in support (either in his initial application or his hearing before the ALJ); (2) the evidence is insufficient to establish that Plaintiff's alleged depression constitutes a severe impairment; and (3) even if Plaintiff did suffer from depression, a failure to list that impairment as severe at step two is not a basis for remand where the ALJ found Plaintiff suffered from a severe impairment (anxiety), continued in the five-step analysis, and accounted for any limitations imposed by the depression in the RFC at step four. (ECF No. 18 at 7-10) Defendant's position is that even if the ALJ had found Plaintiff's depression to be severe, the outcome of the case would not have changed. (
Defendant is correct. As an initial matter, the Court notes that it is Plaintiff's burden to prove the existence of severe impairments.
Furthermore, even if Plaintiff had formally alleged depression as a severe impairment, there is minimal proof in the record to substantiate that claim. As to Plaintiff's purported evidence from Dr. Novinger, his primary care physician in 2011, it is true that the doctor noted Plaintiff had a "depressed mood," but that notation is not a diagnosis. In contrast, there is evidence that Dr. Novinger affirmatively considered whether Plaintiff suffered from depression, and found that he did not. Dr. Novinger screened Plaintiff for depression on February 22, 2011, and the "[r]esult of screening was negative." (Tr. 262) Another such screening on March 22, 2011 similarly came up negative. (Tr. 264) The only mental impairment noted during both of these check-ups was generalized anxiety. (
The records of Dr. Jeffrey Harden, D.O., Plaintiff's treating psychiatrist in 2011, similarly do not support a diagnosis of depression. The ALJ pointed out—and this Court agrees—that it appears Plaintiff was not seeking out Dr. Harden for the purpose of mental health treatment, but instead as a requirement of his terms of probation after he submitted a urine screen that was positive for drug use, indicating that Plaintiff had been using drugs while on probation.
Finally, even Plaintiff's assertion that his subsequent primary care physician—Dr. Gillette—diagnosed him with depression fails to give context. On one occasion, in August of 2013, Dr. Gillette noted that Plaintiff was positive for depression. (Tr. 369) On the other hand, Dr. Gillette never mentioned Plaintiff's purported depression in any other medical records, nor prescribed any medication or course of treatment for depression. As discussed below, Dr. Gillette saw Plaintiff over several months, and never discussed Plaintiff's depression elsewhere.
When he began seeing Plaintiff in December of 2012, Dr. Gillette noted that Plaintiff presented with issues of back pain, and noticed that his past medical history included diagnoses of anxiety, herniated disc, and knee issues. (Tr. 322) In his review of Plaintiff's symptoms, Dr. Gillette noted Plaintiff was positive for back pain and neck pain, but negative for depression and other mental health issues. (Tr. 323) Two weeks later, Dr. Gillette noted that Plaintiff presented with anxiety issues. Dr. Gillette noted that the symptoms were "fairly controlled," and in another review of Plaintiff's symptoms, noted that he was positive for back pain, neck pain, and anxiety, but negative for depression and other psychiatric symptoms. (Tr. 336-37) During a follow-up appointment in February, 2013, Plaintiff only complained about his back pain, not anxiety or depression, and Dr. Gillette noted that Plaintiff "states that his Anxiety has been well controlled with the Xanax." (Tr. 343)
Even in July of 2013, Plaintiff presented with anxiety, back pain, and chest pain, not depression. Plaintiff presented with a "depressed mood," but denied "diminished interest or pleasure, hallucinations or thoughts of death or suicide." (Tr. 357) Dr. Gillette thought the anxiety was "associated with chronic pain and headache," as opposed to depression. (
It appears that—taken as a whole—Dr. Gillette did not consider Plaintiff to be suffering from depression. Even after the single instance that he noted Plaintiff positive for depression, in August of 2013, Dr. Gillette then subsequently issued a medical source statement on September 25, 2013, in which he listed Plaintiff's diagnoses as cervicalgia, lumbago, and bulging disc. (Tr. 390) Dr. Gillette did not list depression as a diagnosis. Furthermore, in a follow-up letter from March of 2014, Dr. Gillette opined that Plaintiff suffered from "cervical spondylosis and degenerative disc disease, along with lumbago and bulging disc." (Tr. 403) Dr. Gillette made no mention of depression, or any mental health impairment. This omission is significant.
The Court also finds it relevant that Plaintiff did not allege any issues with depression in his function report. (Tr. 199-206) In that report, Plaintiff discussed how his back and neck pain prevented him from engaging in certain activities. Plaintiff discussed how anxiety precluded him from certain activities, but he made no mention of any issues with depression. Similarly, Plaintiff's wife filled out a third party function report. (Tr. 178-85) In that report, (which substantially repeats everything said in Plaintiff's function report) Plaintiff's wife does not mention depression at all. She mentions how neck and back pain limit Plaintiff, but does not discuss any impact that depression may have on Plaintiff's activities.
Additionally, and at a broader level, the evidence contained in the third party function report does not indicate activities consistent with disability. For example, the third party report shows that Plaintiff: (1) has no problems with issues of personal care; (Tr. 179) (2) does yard work, including watering the garden for an hour or two every other day; (Tr. 180) (3) goes outside daily; (Tr. 181) (4) is able to pay bills, count change, handle a savings account, and use a checkbook or money orders; (
Finally, there was one specific diagnosis of depression in the medical records—that of APN Cindy Mayberry. APN Mayberry diagnosed Plaintiff with PTSD, generalized anxiety disorder, and said that "major depression is recurrent." (Tr. 349) However, the ALJ was right to reject this information as an official diagnosis, because APNs are not acceptable medical sources for diagnosing claimants under the Social Security regulations.
Therefore, it is clear that the weight of the medical and other evidence in this case demonstrates that: (1) Plaintiff did not allege depression as a severe impairment until his appeal to this Court; (2) Plaintiff did not affirmatively offer evidence in support of his assertion, even though it is his burden to prove severity; and (3) the weight of the medical and other evidence demonstrates that Plaintiff's depression does not meet the requirements for a finding of severity. Although "severity is not an onerous requirement for the claimant to meet . . . it is also not a toothless standard."
Alternatively, a further problem for Plaintiff is that even if the ALJ should have noted depression as a severe impairment, his failure to do so would not be sufficient cause for remand because it is the functional limitations imposed by a severe impairment that are dispositive, not the fact of diagnosis.
For example, Plaintiff reported to Dr. Gillette that his anxiety symptoms were aggravated by "conflict, or stress and social interactions." (Tr. 336) The ALJ accepted this evidence, and accounted for this shortcoming in functional ability by limiting Plaintiff to simple work, and work involving "only occasional interaction with coworkers or the general public." (Tr. 15-16) This limitation is consistent with the ALJ's findings regarding Plaintiff's activities of daily living, social functioning, and concentration, persistence, and pace.
Indeed, the ALJ discussed at length the allegations of Plaintiff's mental impairments. The ALJ discussed how, in relation to Plaintiff's anxiety, Plaintiff's lack of consistent treatment tended to support the idea that this mental limitation was not so debilitating as to preclude all work. (Tr. 19) This is a permissible inference by the ALJ.
More explicitly, the ALJ specifically said that he considered Ms. Mayberry's diagnoses that Plaintiff suffered from depression, even though she was not an appropriate medical source. (Tr. 19) Finally, the ALJ noted that during Plaintiff's orthopedic evaluations in August and September of 2013, he was "alert, oriented, [and] had an appropriate affect." (Tr. 19, 394, 398) It is clear, therefore, that the ALJ took into account Plaintiff's mental impairments, and analyzed that evidence in some detail. In light of that finding, it is inappropriate to remand this case even if the ALJ should have formally labelled Plaintiff's depression "severe," because the ALJ addressed the dispositive inquiry—Plaintiff's functional limitations.
Plaintiff's second argument is that the ALJ erred in failing to request that the "treating psychiatrist" perform a consultative examination.
Defendant, on the other hand, argues that the ALJ had sufficient medical evidence before him to fashion an RFC. (ECF No. 18 at 11-13) Defendant points out that the ALJ discussed the medical evidence from Dr. Harden as well as the portions of Dr. Gillette's treatment notes that dealt with anxiety and other mental impairments. Additionally, Defendant points out that the POMS that Plaintiff alludes to is not binding upon the Commissioner, and that "nothing barred Plaintiff from obtaining this evaluation and opinion on his own, if he felt it would be beneficial to his claim." (ECF No. 18 at 13)
The Court agrees with Defendant. An ALJ is only required to obtain additional medical examinations where the medical records and evidence before him is not sufficient to determine whether Plaintiff is disabled.
Here, the Court finds that there was sufficient evidence before the ALJ to formulate an RFC, and additional psychological testing was unnecessary. The ALJ had Dr. Harden's notes and diagnoses before him when evaluating Plaintiffs' RFC. Also, the ALJ had Dr. Gillette's notes before him when making his RFC. Furthermore, the ALJ had APN Mayberry's analysis of Plaintiff's anxiety and depression issues. (Tr. 19) The ALJ therefore had before him multiple different pieces of probative medical evidence along with Plaintiff's own function report and third party reports. Also, it is clear that the ALJ articulated the logical link between that evidence and the RFC that he ultimately found. (
The Court also agrees that Plaintiff's reliance upon the POMS is misplaced, because nothing in that manual required the ALJ to seek additional medical evidence where he had enough evidence before him to make a decision. The legal duty to seek additional evidence is based on the case law and regulatory provisions cited above, not POMS. But even if the POMS had directed the ALJ to seek additional evidence, the ALJ would not be bound by that provision.
For all of the foregoing reasons, Plaintiff's arguments that the ALJ erred are unavailing. The ALJ thoroughly evaluated the evidence in this case, and gave Plaintiff a full and fair hearing. The ALJ's conclusions in this matter are supported by substantial evidence.
Accordingly,
A separate Judgment shall be entered this day.
Also in his Reply brief, Plaintiff points to evidence from two orthopedists, Drs. Andrew Volgas, M.D., to whom Plaintiff was referred for evaluation of his carpal tunnel syndrome, and Mark Drymalski, M.D., to whom Plaintiff was referred for evaluation of his neck and back pain.
Dr. Volgas found that Plaintiff was positive for, inter alia, depression. (Tr. 394) However, Dr. Vargas' assessment is inconsistent, because he also notes that Plaintiff's mood is normal, and he did not diagnose Plaintiff with any psychological issues, and did not include any corresponding treatment in his treatment plan.
In completing Plaintiff's social history, Dr. Drymalski, who is an orthopedist, as opposed to a psychiatrist, noted that Plaintiff "has poor sleep and depression as well as suicide attempt/ideation." (Tr. 398) Dr. Drymalski was evaluating Plaintiff's only complaint that day— "Neck pain, arm numbness and pain." (Tr. 396) There is no indication that Dr. Drymalski was attempting to make a psychiatric diagnosis. Furthermore, Dr. Drymalski's treatment plan included "pain management," relating to Plaintiff's neck pain, not depression treatment. (Tr. 399) Also, neither doctor referred Plaintiff to a psychiatric specialist or suggested any follow up psychiatric care.