JOHN M. BODENHAUSEN, Magistrate Judge.
This action is before the Court, pursuant to the Social Security Act ("the Act"), 42 U.S.C. §§ 401, et seq., authorizing judicial review of the final decision of the Commissioner of Social Security (the "Commissioner ") denying Plaintiff Rebecca Hovis' Title II application for Disability Insurance Benefits ("DIB"). All matters are pending before the undersigned United States Magistrate Judge with consent of the parties, pursuant to 28 U.S.C. § 636(c). The matter is fully briefed, and for the reasons discussed below, the Commissioner's decision is affirmed.
Sometime between 2002 and 2005, the exact date being unknown,
The ALJ concluded that Plaintiff had not met her burden of demonstrating that she suffered from a severe impairment. (Tr. 14) Accordingly, the ALJ held that Plaintiff was not under any disability during the relevant time period — November 8, 2005, her alleged onset date, to June 30, 2007, her date last insured. (Tr. 16)
In her brief to this Court, Plaintiff nominally raises two issues, although these issues require the Court to consider several subsidiary matters. First, Plaintiff argues that the ALJ erred in concluding that none of her impairments were "severe" at step two of the sequential evaluation process. [ECF No. 12 at 7-12] Second, Plaintiff argues that the ALJ erred in discounting her credibility in evaluating her pain and subjective complaints. (
As explained below, the Court has considered the entire record in this matter. Because the decision of the Commissioner is supported by substantial evidence, it will be affirmed. The undersigned will first summarize the decision of the ALJ and the administrative record. Next, the undersigned will address each of the issues Plaintiff raises in this Court.
In a decision dated November 20, 2013, the ALJ determined that Plaintiff was not disabled under the Social Security Act. (Tr. 11-16) The ALJ acknowledged that the administrative framework required him to follow a five-step, sequential process in evaluating Plaintiff's claim. (Tr. 12-13) At step one, the ALJ concluded that Plaintiff had not engaged in any substantial gainful activity from November 8, 2005 (her alleged disability onset date), to June 30, 2007 (the date on which Plaintiff last met the insured status requirements of the Act). (Tr. 13) At step two, the ALJ found Plaintiff had the following determinable impairments during the relevant time period: diabetes, degenerative disc disease, and obesity. (
In making his determination, the ALJ declined to consider evidence regarding Plaintiff's condition after her date last insured.
(Tr. 15) The ALJ further noted that, although the evidence after Plaintiff's last date insured showed an increase in her pain, gastrointestinal discomfort, seizure activity, and migraine headaches, such evidence was not relevant to Plaintiff's claim. (
The administrative record in this matter and includes extensive medical records. The Court has reviewed the entire record, including the evidence covering the relevant time period. The following is a summary of pertinent portions of the record.
The ALJ conducted a hearing on November 12, 2013. Plaintiff was present and represented by an attorney. Also present was a vocational expert ("VE"), Darrell W. Taylor, Ph.D. At the outset of the hearing, the ALJ and Plaintiff's attorney noted that the matter appeared to be a "step five case." (Tr. 25) Also, Plaintiff's attorney confirmed that Plaintiff's date of last insured was June 30, 2007. (
Although the VE testified at the hearing, the ALJ ultimately found Plaintiff not disabled at step two. No party has identified any aspect of the VE's testimony as being relevant to any of the issues in the present matter. Accordingly, only Plaintiff's testimony is summarized herein.
Plaintiff testified primarily in response to questions posed by her attorney, with additional questions interjected by the ALJ. At the time of her hearing, Plaintiff was thirty-nine years old. (Tr. 26) Plaintiff last worked in 2002 as a phlebotomist for a hospital in Cape Girardeau, Missouri. Plaintiff lost her job due to absenteeism allegedly caused by a seizure disorder. (Tr. 27) According to Plaintiff, in July 2001, she began to suffer from a seizure disorder that resulted in the loss of her driver's license and the ability to travel to and from work. (Tr. 27-28) Plaintiff testified that she has not worked since she lost her phlebotomist job in 2002. When asked to identify the biggest problems that prevented her from returning to work, Plaintiff listed her limited driving ability, her back issues, anxiety, and depression. (Tr. 28)
Plaintiff indicated that between 2002 and 2005, her currently alleged disability onset date, she had a prior disability claim pending. That claim was denied in or around 2008. (Tr. 26) Plaintiff explained that she did not apply for benefits again until 2012 because she had "just given up." (Tr. 26-27)
Plaintiff testified that, although she was taking medications, she still experienced seizures in 2005, 2006, and 2007. (Tr. 29) Plaintiff described her seizures during that time period as being "non-convulsive," and that she would have a "staring spell." (
Plaintiff also testified that, since 1997, she has experienced hip and lower back pain. Plaintiff stated that she originally injured her back at work, and that "it just has progressively gotten worse over the years." (Tr. 31) During the 2005-2007 timeframe, Plaintiff indicated that she was on pain medication and received injections for her back pain. According to Plaintiff, her treatment only helped her for short periods of time. (Tr. 32-33)
Plaintiff was also asked about her weight. She indicated that her weight fluctuated a lot. (Tr. 35) The ALJ asked Plaintiff about a doctor's report that she was walking one and a half miles, three times weekly, riding a bike, and working out on a treadmill. Plaintiff claimed that she only tried to do those activities and was not actually able to do so. (
Plaintiff also described problems with controlling her blood sugar, and that she was diagnosed with diabetes in December 2005. (Tr. 36)
Plaintiff further testified that she was diagnosed with various stomach-related conditions, including irritable bowel syndrome and gastroesophageal reflux disease ("GERD"). According to Plaintiff, she had her gallbladder removed in 1996, and her stomach issues started in 1997. Plaintiff acknowledged that, despite the onset of her stomach problems, she was able to continue working as a phlebotomist. After Plaintiff stopped working, her stomach problems were better at times and worse at times. (Tr. 37) Plaintiff related, however, that her stomach problems resulted in her needing to use the restroom six to eight times on an average day, and up to fifteen times on her worst days. (Tr. 38)
Plaintiff reported that she has suffered from hypertension and heart palpitations since around 2000 and that her symptoms could occur daily, sometimes lasting for fifteen to twenty minutes. Plaintiff stated that she could control her palpitations by holding ice chips in her mouth, but in severe cases, her husband took her to the hospital. (Tr. 40-41)
Plaintiff also received treatment for ovarian cysts. According to Plaintiff, she has suffered from this condition since she was a young adult. (Tr. 41)
Plaintiff described her daily activities and limitations during the 2005-2007 timeframe. She reported that she could not lift anything over twenty pounds, but was able to do some household work, including cooking and cleaning, and she was able to go shopping. Plaintiff indicated, however, that she had some difficulty performing her household chores and sometimes her husband handled shopping and other household duties. (Tr. 34) Plaintiff indicated that she could make her own bed, dress herself, and do some light cooking, but she also had to sit down frequently. Plaintiff stated that she would spend two or three hours to clean a room, because she had to sit down frequently. Plaintiff was able to take care of most of her basic hygiene matters. Plaintiff also occupied her time by watching television and reading. (Tr. 41-44) Plaintiff testified that she was most comfortable reclined, with her feet elevated and that walking or standing too long caused her legs to swell. (Tr. 43-44)
In her Disability Report — Appeal, Plaintiff reported that she is not able to drive "due to the side effects of my medications nor do I have a drivers [sic] license, I do not feel safe being a driver of a licensed vehicle." (Tr. 227)
The medical evidence in the record shows that Plaintiff has a history of diverticulitis, hypertension, diabetes mellitus, seizures, hip pain, obesity, back pain, gastroesophageal reflux disease, and polycystic ovarian syndrome.
Between January 19, 2005, and October 8, 2007, Dr. Robert Dodson treated Plaintiff for gastrointestinal symptoms, headaches, and leg pain. (Tr. 242-51)
On January 19, 2005, Plaintiff received follow-up treatment for her gastrointestinal symptoms and intermittent headaches. (Tr. 251) A physical examination showed Plaintiff to be obese with no acute distress. Dr. Dodson found Plaintiff to have metabolic syndrome, reactive airway disease, IBS/GERD, hypertension, and elevated transaminases, and treated Plaintiff by prescribing a medication regimen. (
On May 11, 2005, Plaintiff returned for treatment, and Dr. Dodson noted that her scheduled appointment had been two months earlier. (Tr. 250) Plaintiff reported her main complaint was an increased frequency of headaches. (
Dr. Dodson reviewed the CT studies with Plaintiff on June 8, 2005. Plaintiff reported "a significant decrease in the frequency and intensity of her headaches and [was] very pleased with this med[ication]" Topamax. (Tr. 249) Dr. Dodson noted that Plaintiff's migraine headaches had a good response on Topamax and increased her dosage. (Tr. 248-49) Dr. Dodson diagnosed Plaintiff with elevated transminases, hypertension with palpitations, migraine headaches, and obesity. (
In the routine follow-up visit on November 4, 2005, Plaintiff reported she had been "walking 1.5 miles three times per week with a friend" and "walking like crazy." (Tr. 248)
On June 20, 2006, Plaintiff reported that she had continued with her walking regimen until she started experiencing recent, sudden right leg swelling and pain. (Tr. 247) Dr. Dodson counseled Plaintiff to diet and exercise and found her migraine headaches to be stable. (
On December 19, 2006, Plaintiff reported that she had tried to make some diet and exercise changes but her low back and right hip discomfort limited her walking exercise. (
On October 4, 2007, Plaintiff received follow-up after treatment in the emergency room for symptoms of gastroenteritis.
The relevant medical evidence will be discussed in more detail below, as part of the Court's analysis of the arguments raised by Plaintiff herein.
In a disability insurance benefits ("DIB") case, the burden is on the claimant to prove that he or she has a disability.
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.
In her brief, Plaintiff contends that the ALJ committed reversible error when: (1) the ALJ assessed Plaintiff's credibility and ignored third-party statements; and (2) the ALJ found none of Plaintiff's impairments to be severe. As explained below, the Court finds substantial evidence in the record as a whole supports the ALJ's decision that Plaintiff is not disabled within the meaning of the Act.
The Court first addresses the ALJ's adverse credibility determination. An evaluation of Plaintiff's credibility is necessary to a full consideration of the ALJ's conclusion that none of Plaintiff's impairments amounted to a severe impairment. The Eighth Circuit has instructed that the ALJ is to consider the credibility of a plaintiff's subjective complaints in light of the factors set forth in
This Court reviews the ALJ's credibility determination with deference and may not substitute its own judgment for that of the ALJ. "The ALJ is in a better position to evaluate credibility, and therefore we defer to her determinations as they are supported by sufficient reasons and substantial evidence on the record as a whole."
Plaintiff contends that the ALJ failed to perform a proper credibility analysis because the ALJ failed to give sufficient reasons for the adverse credibility finding. Although the ALJ did not specifically mention
In this case, the ALJ concluded that Plaintiff's "statements concerning the intensity, persistence and limiting effects of these symptoms are not entirely credible. . .," and noted that he must consider the factors listed in addition to the objective medical evidence, when assessing Plaintiff's credibility. (Tr. 14-15) In evaluating Plaintiff's credibility, the ALJ determined that Plaintiff was not fully credible because the objective medical record is inconsistent with her allegations of the severity of her impairments.
One reason given by the ALJ focused on the inconsistencies between Plaintiff's treatment history and the alleged severity of her impairments. The ALJ noted that Plaintiff's treatment history is inconsistent with her allegations of the severity of her impairments inasmuch as the record shows "only a handful of clinic visits between November 2005 and June 2007." (Tr. 15) The few treatment records that exist do not indicate a worsening of Plaintiff's conditions.
The lack of supporting objective medical evidence to corroborate Plaintiff's subjective complaints is also an important factor an ALJ should consider when evaluating those complaints.
The ALJ's decision shows that he explicitly considered the instant record, including Plaintiff's limited treatment record. In so doing, the ALJ articulated the inconsistencies between the record and Plaintiff's subjective statements.
The ALJ also discussed how Plaintiff's hearing testimony was inconsistent with, and in some instances contradicted by, the objective treatment records. In her hearing testimony, Plaintiff testified that she had seizures, low back pain, migraine headaches, and GERD. The ALJ noted that although Plaintiff testified about having severe low back pain and seizures, the medical record was devoid of any treatment notes or opinion statements to confirm her pain or seizure complaints prior to the date of last insured. Regarding Plaintiff GERD, the ALJ noted that, during the relevant time period, the medical record showed Plaintiff had been successfully treated by Dr. Dodson. Thus, the medical record during the relevant time period would not corroborate the severity and frequency of symptoms as reported by Plaintiff. Dr. Dodson's treatment notes indicated that Plaintiff's headaches were effectively treated with medication, namely Topamax. (Tr. 249)
Further, the ALJ noted that Plaintiff "testified to gastroesophageal reflux disease with severe cramping, diarrhea and irritable bowel. However, the evidence reflected only a handful of clinic visits between November 2005 and June 2007, and no hospital stays for bowel function or pain issues during that time." (Tr. 15) The ALJ noted that "the only medically determinable impairments that are established by the medical records prior to the date of last insured were polycystic ovarian syndrome, alleged right hip pain and some gastrointestinal symptoms to include cramping and diarrhea. The [Plaintiff] was given no restrictions and was treated effectively with hydrations [sic] and medications."
Additionally, at the hearing, the ALJ asked Plaintiff about a doctor's report that she was walking one and a half miles, three times weekly, riding a bike, and working out on a treadmill. Plaintiff claimed that she only tried to do those activities and was not actually able to do so. (Tr. 35) Her hearing testimony is refuted by the November 4, 2005, treatment note wherein Plaintiff reported she had been "walking 1.5 miles three times per week with a friend" and the June 20, 2006, treatment note when Plaintiff reported that she had continued with her walking regimen until she started experiencing her recent, sudden right leg swelling and pain. (Tr. 247-48) There are no medical records during the relevant time period supporting Plaintiff's testimony.
These inconsistencies between Plaintiff's sworn testimony and the objective medical evidence are significant. The ALJ was justified in discrediting Plaintiff's credibility in this regard.
Next, the ALJ noted that no treating or examining source ever indicated that Plaintiff was disabled or unable to work or imposed functional limitations on Plaintiff's capacity for work.
Finally, the ALJ noted that Plaintiff was treated effectively with hydration and medications, and such treatment had controlled Plaintiff's gastrointestinal impairments.
Although the observations of third-parties may support a Plaintiff's credibility, the letters provided by the third parties in this case generally echoed and corroborated the hearing testimony of Plaintiff regarding her alleged symptoms and their effects. The ALJ may discount corroborating testimony on the same basis used to discredit a plaintiff s testimony. In
Based on the foregoing, substantial evidence in the record as a whole supports the ALJ's adverse credibility finding in this case.
Plaintiff contends that the ALJ committed reversible error when the ALJ found none of her impairments to be severe at step two of the evaluation process.
The ALJ found Plaintiff had the medically determinable impairments of diabetes, degenerative disc disease, and obesity, and concluded that the impairments, alone or in combination, are not of listing level. At step two of the sequential evaluation, the ALJ determined Plaintiff's impairments not to be severe, finding that there was no evidence that her symptoms and limitations were of sufficient severity to prevent the performance of all sustained work activity.
"An impairment . . . is not severe if it does not significantly limit [the claimant's] physical or mental ability to do basic work activities." 20 C.F.R. § 416.921(a). Basic work activities "mean the abilities and aptitudes necessary to do most jobs," including physical functions; capacities for seeing, hearing, and speaking; understanding, carrying out, and remembering simple instructions; use of judgment; responding appropriately to supervision, co-workers and usual work situations; and dealing with changes in a routine work setting. 20 C.F.R. § 416.921(b). The burden of showing a severe impairment at step two of the sequential evaluation rests with the claimant, and the burden is not great.
A review of the record shows that the ALJ found Plaintiff's impairments did not significantly limit her ability to perform basic work-related activities and, therefore, the ALJ determined that Plaintiff did not have any severe impairments.
The ALJ found that "the only medically determinable impairments that are established by the medical records prior to the date of last insured were polycystic ovarian syndrome, alleged right hip pain and some gastrointestinal symptoms to include cramping and diarrhea. The claimant was given no restrictions and was treated effectively with hydrations and medications." (Tr. 15) Accordingly, the ALJ denied Plaintiff benefits at step two, finding that Plaintiff's impairments "did not significantly limit[] her ability to perform basic work activities is supported by the medical evidence of record." (Tr. 16)
Plaintiff focuses primarily on two specific areas of impairment — obesity and migraine headaches. The Court will address each of these areas. The Court will also address Plaintiff's contention that the ALJ failed in his burden to develop the record in this matter.
Obesity is considered severe "when alone or in combination with another medically determinable physical or mental impairment(s), it significantly limits an individual's physical or mental ability to do basic work activities." S.S.R. 02-1p, 2000 WL 628049, *4 (S.S.A. Sept. 12, 2002). "There is no specific level of weight or [Body Mass Index] that equates with a `severe' or a `not severe' impairment."
20 C.F.R. Pt.404, Subpart P, Appx. 1, §1.00(Q).
There is no evidence that Plaintiff's obesity was a severe impairment affecting her ability to work during the relevant time frame. When examined by Dr. Dodson, Plaintiff's weight ranged from 246 to 269 pounds, and Dr. Dodson diagnosed her with morbid obesity. Plaintiff did not testify at the hearing that her obesity limited her ability to function in any manner. In fact, Plaintiff failed to list obesity as an impairment in her application.
At the hearing, Plaintiff did not testify that her obesity affects her ability to function or limits her ability to work, only that her weight fluctuates, and Plaintiff never alleged any limitation in function as result of her obesity.
The fact that Plaintiff herself did not report her obesity as a severe impairment in her application cannot be overlooked. In this case, the ALJ found Plaintiff's obesity to be a non-severe impairment. Substantial evidence in the record as a whole supports the ALJ's determination in this regard.
The ALJ expressly considered Plaintiff s testimony regarding her migraine headaches and found the evidence showed that her migraine headaches did not worsen until after the expiration of Plaintiff's insured status on June 30, 2007. (Tr. 15)
A review of the treatment record during the relevant time showed after Plaintiff reported increased frequency of headaches on May 11, 2005, and Dr. Dodson prescribed Topamax. In follow-up treatment on June 8, 2005, Plaintiff reported "a significant decrease in the frequency and intensity of her headaches and [was] very pleased with this med[ication]," and Dr. Dodson noted that Plaintiff's migraine headaches had a good response on Topamax and increased her dosage. (Tr. 249) During treatment on June 20, October 17, and December 19, 2006, Plaintiff did not complain of migraine headaches, and Dr. Dodson found her migraine headaches to be stable on June 20, 2006. (Tr. 245-47)
The objective medical record for the relevant time period shows therefore that Plaintiff's migraine headaches were controlled through treatment and stabilized by medications.
Based on the medical evidence from the relevant time period, the record supports the ALJ's conclusion that Plaintiff did not have a medically severe impairment as a result of migraine headaches. The only medical evidence during the relevant time period, Dr. Dodson's treatment notes, shows that Plaintiff's migraine headaches improved after treatment and starting a medication regimen of Topamax. Thus, it was proper for the ALJ to find Plaintiff's impairment to be controllable or amenable to treatment and thus do not support a finding of total disability.
There is no objective medical evidence suggesting that Plaintiff's impairments or a combination of the impairments are significant enough to cause a disability precluding the performance of any substantial gainful activity. The record supports the determination of the ALJ that Plaintiff is capable of engaging in substantial gainful activity. The substantial evidence on the record as a whole supports the ALJ's decision.
Plaintiff also contends the ALJ failed to fully and fairly develop the record. Plaintiff argues that the ALJ should have solicited a medical opinion evaluating the severity and limiting effects of her impairments. As explained below, the lack of a medical opinion evaluating the severity and limiting effects of Plaintiff's impairments does not, in this case, necessitate a finding that the ALJ failed to properly develop the record.
Although it is an ALJ's duty to develop the record; it is the plaintiff's responsibility to provide medical evidence to show that she is disabled.
In the instant case, there was sufficient medical evidence for the ALJ to determine whether Plaintiff is disabled and therefore no need for the ALJ to further develop the record.
Although the record may very well show that Plaintiff's condition deteriorated after her date of last insured, June 30, 2007, the relevant time period at issue in this case is quite narrow— November 8, 2005, through June 30, 2007. Thus, Plaintiff did not satisfy her burden of proof before the Commissioner.
The undersigned concludes that the ALJ's decision is supported by substantial evidence on the record as a whole. An ALJ's decision is not to be disturbed "`so long as the . . . decision falls within the available zone of choice. An ALJ's decision is not outside the zone of choice simply because [the Court] might have reached a different conclusion had [the Court] been the initial finder of fact.'"
Accordingly,
(Tr. 11)