PATRICIA L. COHEN, Magistrate Judge.
Angela York ("Plaintiff") seeks review of the decision of the Social Security Commissioner, Carolyn Colvin, denying her applications for Disability Insurance Benefits under the Social Security Act.
On July 3, 2012, Plaintiff filed an application for Disability Insurance Benefits alleging she was disabled as of May 1, 2012
The SSA granted Plaintiff's request for review, and an ALJ conducted a hearing on December 12, 2013. (Tr. 30-57, 96-116). At the hearing, Plaintiff testified that she was thirty-one years of age, five feet and seven inches tall, and weighed 290 pounds. (Tr. 23, 50). She explained that she was unable to work because she suffered "fibromyalgia and it affects my back and my hips. I have a history of blood clots, which I have lot of swelling in my leg when I sit or stand for very long periods. I just found out not too long ago I have hepatitis C. I have diabetes.. . . I'm just tired a lot. . . ." (Tr. 36). Plaintiff explained that "standing or sitting for very long periods of time" caused her leg to swell, and she had to "get up and move it around" or "sit down and take breaks." (Tr. 37-38). Plaintiff stated she generally elevated her leg "probably three to four hours" between the hours of 9:00 a.m. and 5:00 p.m. (Tr. 39). Plaintiff testified that she experienced pain, numbness, and tingling in her hands for about four hours every morning. (Tr. 40-41).
Plaintiff stated that she controlled her diabetes with "four shots a day," Metformin, and "the diabetes diet." (Tr. 42). Plaintiff also took Oxycodone, Savella, Lasix, and Xanax for her other conditions. (Tr. 44-45). Plaintiff believed the diabetes caused her fatigue, and she usually took two forty-five-minute naps per day. (Tr. 43-44). Plaintiff testified that she was capable of: sitting or standing for forty to forty-five minutes; walking approximately one block; and lifting or carrying ten to fifteen pounds. (Tr. 46). Plaintiff stated that she was able to do buttons and zippers, but she could not reach or bend over. (Tr. 46-47). Plaintiff helped her mother with cooking and cleaning, but needed assistance grocery shopping and, occasionally, getting in and out of the bath tub. (Tr. 49).
A vocational expert (VE) also testified at the hearing. (Tr. 50-56). The ALJ asked the VE to consider a hypothetical individual of Plaintiff's age, education, and work experience, and the ability to "lift, carry, push and pull 20 pounds occasionally and 10 pounds frequently; could stand and walk a total of six hours out of an eight-hour day; sit six hours out of an eight-hour day; cannot climb ladders, ropes or scaffolds; cannot work at unprotected heights or around hazards. All other postural activities can be performed on an occasional basis." (Tr. 51). The VE testified that such a person could perform Plaintiff's previous jobs as a fast food worker, cashier, and short-order cook, but not as a home healthcare aide. (Tr. 52). When the ALJ asked the VE "what other kinds of jobs might be available?," the VE identified the jobs of cashier II, wire wrapping machine operator, and bench assembler. (Tr. 52).
In a decision dated January 30, 2014, the ALJ applied the five-step evaluation process set forth in 20 C.F.R. § 404.1520
After reviewing Plaintiff's testimony and medical records, the ALJ determined that "the claimant's statements concerning the intensity, persistence and limiting effects of these symptoms are not entirely credible[.]" (Tr. 23). The ALJ found that Plaintiff had the residual functional capacity (RFC) to
(Tr. 21-22). Based on the testimony of a vocational expert, the ALJ concluded that Plaintiff was capable of performing past relevant work as a convenience store cashier and fast food worker. (Tr. 24). The ALJ further stated: "Although the claimant is capable of performing past relevant work, there are other jobs existing in the national economy that she is also able to perform." (
Plaintiff filed a request for review of the ALJ's decision with the SSA Appeals Council, which denied review on April 15, 2015. (Tr. 7-14, 1-6). Plaintiff has exhausted all administrative remedies, and the ALJ's decision stands as the SSA's final decision.
A court must affirm an ALJ's decision if it is supported by substantial evidence. 42 U.S.C. § 405(g). "Substantial evidence `is less than a preponderance, but enough so that a reasonable mind might find it adequate to support the conclusion.'"
"If, after reviewing the record, the court finds it is possible to draw two inconsistent positions from the evidence and one of those positions represents the ALJ's findings, the court must affirm the ALJ's decision."
Plaintiff claims that substantial evidence does not support the ALJ's determination that she is not disabled. Plaintiff asserts that the ALJ erred in: (1) finding that Plaintiff performed past relevant work at the substantial gainful activity level; (2) improperly weighing the medical opinion evidence when formulating Plaintiff's RFC; and (3) finding that Plaintiff's allegations of disability were not entirely credible. (ECF No. 16). The Commissioner counters that the ALJ properly evaluated the medical opinion evidence and Plaintiff's credibility and found that Plaintiff could perform jobs existing in significant number in the national economy. (ECF No. 17).
Plaintiff first argues that the ALJ's decision at step four was not supported by substantial evidence because Plaintiff's earnings records "do not show [she] performed the identified past work at the substantial gainful activity level" and, as a result, those jobs do not constitute "past relevant work" as defined by 20 CFR. § 404.1560(b)(1). (ECF No. 16 at 7). In response, the Commissioner asserts that "[e]ven if those jobs did not amount to past relevant work,...the ALJ found in the alternative that Plaintiff could perform other jobs existing in significant numbers in the national economy." (ECF No. 17 at 14).
The Commissioner has established a five-step sequential evaluation process to determine whether claimants are eligible for Social Security disability benefits.
In this case, Plaintiff reported that she worked as an in-home healthcare aide for her parents from November 2006 through December 2011 and as a cook at McDonalds from October 2011 through December 2011. (Tr. 159-66). In 2005, Plaintiff worked as a cashier and made pizzas at Casey's. (Tr. 35, 144). At the hearing, the VE testified that an individual with Plaintiff's RFC could perform Plaintiff's past work as a fast food worker, cashier, and shortorder cook, but not as a home healthcare aide. (Tr. 52). When the ALJ asked the VE "what other kinds of jobs might be available?," the VE identified the jobs of cashier II, wire wrapping machine operator, and bench assembler. (Tr. 52).
In his decision, the ALJ found at step four of the sequential evaluation process that Plaintiff could perform her past relevant work as a fast food worker, convenience store cashier, and short-order cook. (Tr. 24). The ALJ did not refer to the applicable guidelines for determining whether Plaintiff's past work constituted substantial gainful activity. However, the ALJ did not end his analysis at step four, but rather proceeded to step five to consider whether Plaintiff was capable of performing other jobs. (
The Court need not determine whether Plaintiff's past work as a fast food worker, cashier, or short-order cook constituted "past relevant work" for purposes of 20 CFR § 404.1565(a). Even if Plaintiff's earnings were below the guidelines, any error in considering those jobs past relevant work was harmless. Because the record showed and the ALJ found that Plaintiff was capable of performing other jobs in the national economy, the ALJ properly determined that Plaintiff was not disabled.
In her second argument, Plaintiff asserts that the ALJ's RFC determination is not supported by substantial evidence because the ALJ improperly weighed the medical opinion evidence. (ECF No. 16). More specifically, Plaintiff claims the ALJ assigned too little weight to the opinion of Plaintiff's treating physician and too much weight to that of the consulting physicians. The Commissioner counters that the ALJ properly weighed the medical opinion evidence when determining Plaintiff's RFC. (ECF No. 17).
In determining a claimant's RFC, the ALJ is required to consider the medical opinion evidence of record together with the other relevant evidence. 20 C.F.R. § 404.1527(b). A treating source's opinion is entitled to 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 [a claimant's] case record."
Unless the ALJ assigns controlling weight to a treating physician's opinion, the ALJ must explain the weight given to every medical opinion of record, regardless of its source.
In this case, Dr. Alex Dymek, Plaintiff's primary care physician completed four RFC questionnaires. (Tr. 359-65, 375-76, 416-17, 496-97). In all of the RFC questionnaires, Dr. Dymek stated that Plaintiff suffered back and leg pain, fatigue, and edema and needed to "recline or lie down during a hypothetical 8-hour workday in excess of the typical 15-minute break in the morning, the 30-60 minute lunch, and the typical 15-minute break in the afternoon." (
In an RFC questionnaire dated January 22, 2013, Dr. Dymek opined that Plaintiff could sit sixty minutes at a time and four hours in an eight-hour workday; stand or walk thirty minutes at a time and four hours in an eight-hour workday; required fifteen-minute breaks hourly; could use her hands 50% and her fingers and arms 10% of the time during an eight-hour workday; and would likely be absent from work once or twice a month. (Tr. 375-76). On April 23, 2013, Dr. Dymek completed another RFC questionnaire in which he stated that Plaintiff: could not walk one city block; could sit, stand or walk five minutes at a time and zero hours in an eight-hour workday; and would likely be absent from work once or twice a month. (Tr. 416-17). In an RFC dated October 30, 2013, Dr. Dymek wrote that Plaintiff could sit sixty minutes at a time and four hours in an eight-hour workday and stand or walk thirty minutes at a time or four hours in an eight-hour workday. (Tr. 496-97).
In his decision, the ALJ gave "little weight to the opinion of Dr. Dymek in multiple RFC questionnaires[.]" (
(
Plaintiff acknowledges that Dr. Dymek "provided multiple opinions expressing varying degrees of exertional and non-exertional limitations." (ECF No. 16 at 12). However, Plaintiff maintains the ALJ erred to the extent he disregarded Dr. Dymek's opinion that Plaintiff required a sit/stand requirement and/or leg elevation limitations because this limitation was consistent with his treatment notes and consistently included in the RFC questionnaires.
Although Dr. Dymek consistently included sit/stand and leg elevation requirements in the RFC questionnaires, these limitations are not consistent with his treatment notes.
Plaintiff reported difficulties with leg swelling to Dr. Dymek on October 13 and 25, 2012, and he prescribed Lasix for water retention. (Tr. 393-94). On November 12, 2012, when Plaintiff visited Dr. Dymek for an upper respiratory infection, he noted leg edema and refilled her Lasix prescription. (Tr. 386-87). Dr. Dymek noted no edema in his treatment notes of: January 12, 2013; April 18, 2013; July 10, 2013; July 30, 2013; and September 9, 2013. (Tr. 378-79, 486-87, 483-85, 481-82, 470-72). Dr. Dymek's notes of September 30, 2013 and October 8, 2013 contained no reference to swelling or edema. (Tr. 464-65, 461-62).
Having reviewed the record and the ALJ's reasoning, the Court cannot say that the ALJ's decision to assign Dr. Dymek's opinion little weight lies outside the "available zone of choice."
Plaintiff next argues that the ALJ erred in weighing the medical opinions of Drs. Trowbridge and Velez. Dr. Denise Trowbridge, a state agency consultant, reviewed Plaintiff's medical records and completed a physical RFC assessment for Plaintiff on November 17, 2012. (Tr. 63-67). Dr. Trowbridge found that Plaintiff had the following exertional limitations: occasionally lift and/or carry twenty pounds; frequently lift and/or carry ten pounds; stand and/or walk about six hours in an eight-hour workday; and sit about six hours in an eight-hour workday. (Tr. 64). Dr. Trowbridge explained that, although Dr. Dymek attributed Plaintiff's back pain to fibromyalgia, "[i]t does not appear she has the other symptoms associated with full [fibromyalgia] syndrome." (
Dr. Trowbridge disagreed with Dr. Dymek's RFC assessment of August 2012. (Tr. 65-66). She explained: "[T]he need to alternate positions, limit use of the [upper extremities] and limit sitting time are not supported by his notes. His notes indicate the claimant was in no distress on his exam. There is no mention of difficulty sitting in his file. He does not describe full [fibromyalgia] syndrome in his notes, just pain + trigger points." (Tr. 65). Dr. Trowbridge believed that Dr. Dymek's opinion was more restrictive than her findings because he "relie[d] heavily on the subjective report of symptoms and limitations provided by the individual[.]" (Tr. 66).
Dr. Dennis Velez, reviewed Plaintiff's medical records and completed a consultative examination for Plaintiff on August 25, 2012. (Tr. 361-65). Dr. Velez observed that Plaintiff's heart and lungs were normal, her stance and gait were normal, and she had "full strength in both the upper and lower extremities," normal sensory examination, and negative straight leg raise in both the supine and sitting positions. (Tr. 362-63). In regard to Plaintiff's musculoskeletal condition, Dr. Velez wrote:
(Tr. 363).
Dr. Velez wrote that, because Plaintiff "had tender points at 9 out of the 18 points," her diagnosis of fibromyalgia "could not be substantiated." (Tr. 364). Although Plaintiff informed him that she suffered a Factor V Leiden deficiency, Dr. Velez's examination revealed "no lower or upper extremity swelling and had a negative Homan's sign." (
In his decision, the ALJ assigned "some weight to the opinions of the consultative physician [Dr. Velez] and the State agency physician [Dr. Trowbridge] because they are consistent with the claimant's treatment notes, the physical examination of record, and the objective testing in the record." (Tr. 23). Plaintiff contends that Dr. Velez's opinion did not support the ALJ's RFC and that the ALJ relied too heavily upon Dr. Trowbridge's opinion.
The opinion of a consulting doctor alone generally does not constitute substantial evidence.
Notably, the ALJ gave "some weight" to the opinions of Drs. Velez and Trowbridge. He did not rely solely upon the opinions of the consulting doctors when determining the severity of Plaintiff's impairments and formulating the RFC. Rather, the ALJ considered the record as a whole, including those portions of Dr. Dymek's opinions that were consistent with the opinions of these consulting sources.
The ALJ did not, as Plaintiff argues, simply adopt Dr. Trowbridge's RFC determination. An RFC determination "is based on all the evidence in the record, including `the medical records, observations of treating physicians and others, and an individual's own description of his limitations.'"
In her final argument, Plaintiff claims the ALJ's credibility determination is not supported by substantial evidence. (ECF No. 16). More specifically, Plaintiff asserts the ALJ improperly considered evidence of her work history, noncompliance with doctors' recommendations, and activities of daily living. In response, the Commissioner argues that substantial evidence supported the ALJ's credibility determination.
Before determining a claimant's RFC, the ALJ must evaluate the credibility of the claimant's subjective complaints.
The ALJ cited the results of objective medical testing, as well as the clinical signs and findings, as grounds for discrediting Plaintiff's subjective allegations. (Tr. 22-23). A lack of objective medical findings to support the degree of subjective complaints is an important factor in evaluating a claimant's credibility.
In assessing Plaintiff's credibility, the ALJ also found that Plaintiff's "fair work history" suggested that she had "low motivation to work" and undermined her credibility. (Tr. 22). "A lack of work history may indicate a lack of motivation to work rather than a lack of ability."
Additionally, the ALJ considered Plaintiff's noncompliance with her healthcare providers' recommendations to follow the recommended diet, exercise, lose weight, and cease smoking. (Tr. 23). "A failure to follow a recommended course of treatment...weighs against a claimant's credibility."
The ALJ noted that Plaintiff was noncompliant with her treatment for diabetes. (Tr. 23). Additionally, he wrote: "[H]er doctor has advised her to quit smoking, to exercise regularly and to watch her diet, yet the evidence does not indicate that the claimant has followed her doctor's advice." (
Plaintiff argues the ALJ erred in discounting her credibility based on her failure to follow recommendations for smoking cessation, diet, or exercise because this advice did not constitute treatment. (ECF No. 16 at 14). In support of her argument, Plaintiff cites an SSA ruling relating to consideration of obesity as an impairment in the five-step sequential evaluation.
Finally, the ALJ found that Plaintiff's daily activities, as reported in her adult function report, undermined her testimony that she required assistance in cooking, cleaning, and shopping. (Tr. 23). The ALJ stated that, in her function report, Plaintiff wrote "that she fixes meals, cares for her personal hygiene, cares for her two children [ages 15 and 10], does laundry daily, drives, shops for food and clothes, and goes fishing on a weekly basis." (
The court finds that the ALJ considered Plaintiff's subjective complaints on the basis of the entire record and set out a number of inconsistencies that detracted from her credibility. Because the ALJ's determination not to credit Plaintiff's subjective complaints is supported by "good reasons and substantial evidence," the Court defers to his determination.
For the reasons discussed above, the Court finds that substantial evidence in the record as a whole supports the Commissioner's decision that Plaintiff is not disabled. Accordingly,
A separate judgment in accordance with this Memorandum and Order is entered this date.