DAVID D. NOCE, Magistrate Judge.
This action is before the court for judicial review of the final decision of the defendant Commissioner of Social Security denying the application of plaintiff Joyce Castro for disability insurance benefits under Title II of the Social Security Act, 42 U.S.C. §§ 401-434. The parties have consented to the exercise of plenary authority by the undersigned United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). For the reasons set forth below, the final decision of the Commissioner is affirmed.
Plaintiff was born on December 7, 1950 and was 65 years old at the time of her hearing. She filed her application on October 21, 2013, alleging a February 15, 2013 onset date. (Tr. 120, 479, 665.) She alleged disability due to high blood pressure, diabetes, leaking heart valve, high cholesterol, asthma, chronic obstructive pulmonary disease (COPD), depression, laryngitis, and a heart murmur. (Tr. 337.) Her application was denied, and she requested a hearing before an ALJ. (Tr. 239-49.)
On April 13, 2016, following a hearing, an ALJ found that plaintiff was not disabled as defined in the Act. (Tr. 120-29.) She moved the Appeals Council to allow her to present new and material evidence, medical records from Mercy Hospital-Washington from November 12, 2013 to November 5, 2015. (Tr. 9.) On May 19, 2017, the Appeals Council denied her request for review, starting that it found no reason under the rules to review the ALJ's decision. (Tr. 1-5, 295-98.) Thus, the decision of the ALJ stands as the final decision of the Commissioner.
The following is a summary of plaintiff's medical history relevant to this appeal. On October 28, 2013, plaintiff was seen at Mercy Hospital to establish care. She stated that she was applying for disability. Deborah Beste, N.P., examined plaintiff and diagnosed hypertension, diabetes, asthma, mitral valve prolapse, tobacco use disorder, marijuana abuse, depression, gastro esophageal reflux disease (GERD), rib pain, and chronic laryngitis. She had smoked a pack of cigarettes every day for 46 years. She was prescribed Celexa, an antidepressant, and Lisinopril, for high blood pressure, and instructed to return in two weeks. (Tr. 420-34.)
Plaintiff returned to Mercy Hospital on November 14, 2013 for follow-up and complaints of hoarseness. Her blood pressure was elevated and needed better control. A laryngoscopy was ordered. She also complained of headaches and some chest pressure. (Tr. 671-77.) She was seen again on November 20, 2013. She stated that she had stopped taking Celexa because it made her nauseated, that she did not want to take anything more for her depression, and that she did not want to go to counseling. (Tr. 665.) On July 28, 2014, she was seen for an earache. Her blood pressure was elevated. She reported that she had run out of her blood pressure medication months earlier. She was restarted on Atenolol, used to treat high blood pressure. (Tr. 638-49.)
On January 13, 2014, plaintiff underwent a consultative psychological evaluation by Paul Rexroat, Ph.D., a psychologist, for her depression. (Tr. 501-04.) She reported that anxiety was not a problem for her and that she had never received treatment from a mental health professional. She reported feeling sad, lonely, and worthless, as well as being easily irritated even though she still liked being around other people. She described being forgetful and having trouble concentrating. She believed she had been intermittently depressed for fifteen years. (Tr. 502.)
Upon examination, plaintiff was not suspicious, anxious, tense, or weepy. She exhibited a normal range of emotional responsiveness and a normal affect, and was alert and cooperative. She had normal, coherent, and relevant speech, and exhibited adequate social skills. She was well oriented to person, place, time, and situation. She appeared to have normal memory and average intelligence. She was able to solve simple math problems, count backwards, and perform normal abstract verbal reasoning. (Tr. 502-04.)
Dr. Rexroat believed plaintiff had mild limitations in activities of daily living and in social functioning. He indicated that plaintiff was able to sustain concentration, persistence, and pace with simple tasks. Dr. Rexroat diagnosed moderate recurrent major depression and cannabis abuse. He assigned plaintiff a Global Assessment of Functioning (GAF) score of 62, indicating mild symptoms. He concluded her prognosis was "guarded" because of her depression. (Tr. 503-04.)
On January 13, 2014, a carotid duplex study, an ultrasound that looks for blockages in the carotid arteries, showed mild atherosclerosis in the left and right proximal internal carotid arteries. (Tr. 966.) Following an abnormal EKG, additional heart imaging revealed normal systolic function. (Tr. 958.)
On January 14, 2014, plaintiff underwent a laryngoscopy for excision of a bilateral cord polyp. (Tr. 945, 948-49, 951.)
On January 25, 2014, plaintiff saw Raymond Leung, M.D., an internist. Dr. Leung diagnosed hypertension, diabetes, heart murmur, neck and back pain with decreased range of motion in the cervical and lumbar spines, and asthma and COPD. Dr. Leung did not provide an opinion regarding plaintiff's physical abilities. (Tr. 507-10.)
Cervical spine imaging on March 19, 2014, showed mild to moderate multilevel degenerative change, and mild reversal of the normal cervical lordosis. Lumbar imaging revealed mild multilevel degenerative change. (Tr. 515-16.)
On March 21, 2014, state-agency medical consultant, Kyle W. Devore, Ph.D., a clinical psychologist, reviewed the record. He opined that plaintiff had mild restrictions in activities of daily living; no difficulties maintaining social functioning; mild difficulties maintaining concentration, persistence, or pace; and no repeated episodes of decompensation. Dr. Devore concluded that plaintiff did not have a severe mental impairment because she had no more than mild limitations in any functional area. (Tr. 228-30.)
On September 2, 2014, plaintiff saw Arjun Singh, M.D., an internist, for anxiety and back pain. Plaintiff described her anxiety as an 8/10 with medication and 10/10 without medicine. Dr. Singh prescribed Xanax, a short acting drug used to treat anxiety, and recommended that she obtain counseling and treatment with a psychiatrist. Plaintiff saw Dr. Singh every two weeks during September and October 2014 for anxiety. (Tr. 538-543.)
A coronary angiography on September 5, 2014, demonstrated severe two vessel coronary artery disease. She received percutaneous coronary intervention, a non-surgical procedure used to treat narrowing of the coronary arteries of the heart found in coronary artery disease, with excellent results. (Tr. 912, 925.)
Plaintiff sought emergency treatment on October 20, 2014, for chest pain, anemia, and gastrointestinal bleeding. (Tr. 852.) An upper G.I. endoscopy confirmed iron deficiency anemia secondary to chronic blood loss. She received a transfusion and intravenous Protonix, used to treat heartburn. She was diagnosed with GERD. (Tr. 772, 777, 815.)
On November 24, 2014, plaintiff reported having anxiety spells every few days for several months. Dr. Singh continued her on Xanax and saw plaintiff on a monthly basis through October 23, 2015. (Tr. 519-22, 526-37.)
An echocardiogram administered on September 16, 2015, revealed, among other things, normal left ventricle size and function, with an estimated ejection fraction, a measurement of the percentage of blood leaving the heart each time it contracts, of 60%, which is considered normal; impaired relaxation; mild left atrial enlargement; and thickened aortic valve with severe stenosis or narrowing. (Tr. 754.)
A heart catheterization on September 25, 2015, demonstrated moderate aortic stenosis or narrowing; patient stents, systemic hypertension; mildly elevated filling pressures; and anemia. (Tr. 721.)
On November 5, 2015, a small intestinal endoscopy confirmed iron deficiency anemia and gastrointestinal hemorrhage. (Tr. at 710, 714.) A heart catheterization of March 24, 2016, revealed moderate to severe aortic stenosis, normal cardiac output, one vessel coronary artery disease, hypertension, and hyperlipidemia. (Tr. 142.)
On January 19, 2016, x-rays showed minimal carpal metacarpal joint degenerative disease, osteopenia of the left hand, and moderate thumb carpal metacarpal joint degenerative disease and osteopenia on the right hand. (Tr. 986-87.)
On December 22, 2015, plaintiff appeared and testified to the following at a hearing before an ALJ. (Tr. 183-222.) She is unable to work due to uncontrolled blood pressure, shortness of breath, dizziness, neck and back pain, and legs giving out when standing for more than 15 to 20 minutes and when walking without support. She is also unable to work due to difficulties with heart stents, diabetes, and asthma. She experiences anxiety and stress, and has taken Xanax three or four times per day for the past one to two years. She cares for her brother who is in home hospice, causing anxiety and stress. Her medications make her tired and dizzy. (Tr. 197-207.)
A vocational expert also testified at the hearing. The VE testified that plaintiff's past work included administrative assistant, which is sedentary and skilled; receptionist, which is sedentary and semi-skilled; and secretary, which is sedentary and semi-skilled. (Tr. 190-191.)
On April 13, 2016, the ALJ issued a decision finding that plaintiff was not disabled under the Act. (Tr. at 120-29.) At Step One, the ALJ found that plaintiff had not engaged in substantial gainful activity since February 15, 2013, her alleged onset date. At Step Two, the ALJ found that plaintiff had the following severe impairments: mitral valve prolapse; coronary artery disease (CAD); asthma; anemia; and COPD. The ALJ also found that plaintiff had the non-severe impairments of depression, anxiety, diabetes, hypertension, hyperlipidemia, and degenerative changes in her spine and thumbs. At Step Three, the ALJ found that plaintiff's impairments did not meet or medically equal the severity of any impairment listed in 20 C.F.R. part 404, subpart P, appendix 1. (Tr. 122-25.)
The ALJ determined that plaintiff had the residual functional capacity (RFC) to perform sedentary work as defined in 20 C.F.R. section 404.1567(a) except that she was limited to frequent reaching, handling, and fingering bilaterally. At Step Four, the ALJ concluded that plaintiff could perform her past relevant work as an administrative assistant, receptionist, and secretary. Accordingly, the ALJ determined that plaintiff was not disabled under the Act. (Tr. 124-29.)
The court's role on judicial review of the Commissioner's decision is to determine whether the Commissioner's findings apply the relevant legal standards to facts that are supported by substantial evidence in the record as a whole.
To be entitled to disability benefits, a claimant must prove she is unable to perform any substantial gainful activity due to a medically determinable physical or mental impairment that would either result in death or which has lasted or could be expected to last for at least twelve continuous months. 42 U.S.C. §§ 423(a)(1)(D), (d)(1)(A), 1382c(a)(3)(A);
Steps One through Three require the claimant to prove: (1) she is not currently engaged in substantial gainful activity; (2) she suffers from a severe impairment; and (3) her condition meets or equals a listed impairment. 20 C.F.R. § 404.1520(a)(4)(i)-(iii). If the claimant does not suffer from a listed impairment or its equivalent, the Commissioner's analysis proceeds to Steps Four and Five. Step Four requires the Commissioner to consider whether the claimant retains the RFC to perform past relevant work (PRW).
Plaintiff argues the ALJ erred (1) in concluding that her depression and anxiety were non-severe medically determinable impairments at Step Two and (2) in failing to explain her finding that she could perform sedentary work. She argues that even assuming that her impairments were not severe, the ALJ erred in failing to include any limitation for her mental impairments in his RFC. This court disagrees.
At Step Two of the evaluation process, the ALJ must determine if a claimant suffers from a severe impairment.
A severe impairment is an impairment or combination of impairments that significantly limits a claimant's physical or mental ability to perform basic work activities.
The regulations set forth a technique for an ALJ to determine whether a claimant's mental impairments are severe. See 20 C.F.R. § 404.1520a. The ALJ considers the following four functional areas: (1) activities of daily living; (2) social functioning; (3) concentration, persistence, or pace; and (4) episodes of decompensation.
Here, the ALJ found that plaintiff had no limitations in activities of daily living. (Tr. 122.) "Activities of daily living" include activities such as cleaning, shopping, cooking, taking public transportation, paying bills, maintaining a residence, caring appropriately for grooming and hygiene, using telephones and directories, and using a post office. 20 C.F.R. Pt. 404, Subpt. P, App. 1, § 12.00C. Here, plaintiff handled her own personal care, cooked, drove, read, socialized with others, went out alone, shopped, cleaned her house, washed laundry, and cared for her seriously ill brother. (Tr. 122, 205, 325-29, 503.) That evidence supports the finding that plaintiff had no limitations in activities of daily living.
The ALJ next found that plaintiff had no limitations in social functioning. (Tr. 123.) Social functioning includes the ability to get along with others; an individual might demonstrate impaired social functioning by a history of altercations, evictions, firings, fear of strangers, avoidance of interpersonal relationships, or social isolation.
With respect to concentration, persistence, or pace, the ALJ found that plaintiff had no limitations. (Tr. 123.) Concentration, persistence, or pace refers to the ability to sustain focused attention and concentration sufficiently long to permit the timely and appropriate completion of tasks commonly found in work settings.
The ALJ then found that plaintiff had no episodes of decompensation of extended duration. (Tr. 123.) Because the ALJ found no limitations in the first three functional areas, and no episodes of decompensation, the ALJ properly determined that plaintiff's mental impairments were non-severe.
The fact that plaintiff received only conservative and sporadic treatment also supports the determination that her mental impairments were not severe. (Tr. 126.) The ALJ noted plaintiff stopped taking Celexa, an antidepressant, after only one month and declined to try another medication or receive counseling. (Tr. 126, 665.) She did not seek further treatment until September 2014, nearly one year later. (Tr. 126, 543.) Thereafter, her treatment consisted only of anxiety management with Xanax by her primary care doctor, Arjun Singh, M.D. (Tr. 126, 519-43.) Plaintiff did not seek care from a psychiatrist despite Dr. Singh's recommendation to do so. (Tr. 126, 543.)
It was reasonable for the ALJ to conclude that plaintiff would have received treatment from a mental-health professional if her conditions were truly severe.
In sum, the ALJ properly found that plaintiff's anxiety and depression were nonsevere impairments based upon plaintiff's daily activities, including caring for her ill brother, the clinical findings from her mental-status examinations, her conservative course of treatment, and the opinion of Dr. DeVore.
Plaintiff also argues that the ALJ failed to consider her continued need for prescription medication. Plaintiff is incorrect. The ALJ acknowledged that plaintiff was prescribed Xanax by Dr. Singh. (Tr. 126.) However, the mere fact that plaintiff took medication does not mandate a finding of severity. Courts have affirmed an ALJ's finding that a claimant's mental impairment was non-severe despite the fact that a claimant took medication.
As discussed above, plaintiff's daily activities and conservative course of treatment undermined her allegations. (Tr. 126.) The ALJ noted that plaintiff stopped working for reasons unrelated to her health and sought employment during the period she claimed to be disabled, belying her allegations of disabling symptoms. (Tr. 126, 191-92, 338, 479.) Accordingly, the ALJ was not required to credit plaintiff's subjective statements.
Plaintiff also argues the ALJ erred in citing her lack of inpatient psychiatric treatment because inpatient hospitalization is not a requirement of disabling mental impairments. However, the ALJ did not require that plaintiff have a history of hospitalizations or inpatient treatment, rather the ALJ simply found it significant that plaintiff had received only conservative treatment. The ALJ also noted that plaintiff stopped taking antidepressant medication after a very short period, that she had gaps in treatment, and that she had not received care from a specialist. (Tr. 126.)
Here, plaintiff, who bears the burden of proving a severe impairment, cites no credible evidence that she had more than mild limitations in any area of functioning or any episodes of decompensation. This Court concludes the ALJ properly found plaintiff's mental impairments were not severe.
Plaintiff next argues that even if the ALJ was correct in concluding that her impairments were not severe, the ALJ erred in failing to include any limitation for her mental impairments in his RFC. She argues that the ALJ's RFC was inconsistent with the opinion of Dr. Rexroat, consultative psychological examiner, whose opinion was given great weight by the ALJ.
RFC is a medical question and the ALJ's determination of RFC must be supported by substantial evidence in the record.
In this case, the ALJ determined that plaintiff had the RFC to perform sedentary work as defined in 20 C.F.R. section 404.1567(a) except that she was limited to frequent reaching, handling, and fingering bilaterally. (Tr. 124.)
Dr. Rexroat opined that plaintiff had mild limitations in activities of daily living and in social functioning. He believed that plaintiff was able to sustain concentration, persistence, and pace with simple tasks. He assigned a GAF score of 62, indicating mild symptoms. (Tr. 503-04.) The ALJ gave "great," but not controlling weight, to Dr. Rexroat's opinion. (Tr. 127.)
Plaintiff does not assert the ALJ erred in giving significant weight to Dr. Rexroat's opinion. Rather, she argues that the ALJ erred in not adopting his opinion that she was limited to simple tasks or in explaining why she rejected that limitation.
Even assuming arguendo that Dr. Rexroat intended to limit plaintiff to only simple tasks, the ALJ did not err. An ALJ is not required to adopt all the limitations of any medical opinion.
Moreover, other portions of the ALJ's decision explain why she found that plaintiff was not limited to performing only simple tasks. The ALJ noted that plaintiff drove, cared for her seriously ill brother, read, used a computer, and handled her own finances. (Tr. 123, 205, 325-29, 503.) During Dr. Rexroat's examination, plaintiff displayed normal memory and average intelligence, quickly solved simple problems, and counted backwards. (Tr. 503.) Moreover, objective findings from Dr. Singh's treatment notes do not reflect any deficiencies in concentration, persistence, or pace. (Tr. 518-43.) Plaintiff also displayed intact memory, and normal thought content and fund of knowledge at other examinations. (Tr. 508, 561.) The record evidence supported the finding that plaintiff was not limited to performing only simple tasks. Accordingly, the ALJ properly declined to limit plaintiff to performing only simple tasks.
As noted above, Dr. DeVore, a state-agency medical consultant, found that plaintiff did not have a severe mental impairment because she had no more than mild limitations in any functional area. Specifically, Dr. DeVore believed that plaintiff had mild restrictions in activities of daily living; no difficulties maintaining social functioning; mild difficulties maintaining concentration, persistence, or pace; and no repeated episodes of decompensation. (Tr. 228-30.) The ALJ gave great weight to Dr. DeVore's opinion because it was consistent with the evidence as a whole. (Tr. 127.)
Plaintiff contends the ALJ erred in failing to include any work-related restrictions to account for Dr. DeVore's opinion that she was mildly limited in her activities of daily living and in maintaining concentration. The court disagrees.
The Commissioner's rulings recognize that, although "a `not severe' impairment(s) standing alone may not significantly limit an individual's ability to do basic work activities," it might impose limitations when considered with a claimant's other impairments.
Moreover, the ALJ's finding was consistent with the majority of courts in this Circuit, which have generally held that a mild limitation in an area of mental functioning requires no corresponding limitation in the RFC.
In sum, the ALJ properly considered all of plaintiff's impairments in formulating her RFC but did not believe that plaintiff's mild mental health symptoms imposed any work-related limitations of functioning.
The ALJ found that plaintiff had various severe and non-severe physical impairments, including mitral valve prolapse, coronary artery disease (CAD), asthma, anemia, COPD, hypertension, hyperlipidemia, and degenerative changes in her spine and thumbs. (Tr. 122, 125.) Plaintiff argues that the ALJ did not rely upon any medical evidence to support her RFC finding as to her limitations because there was no supporting medical opinion.
Although an ALJ must rely upon "some medical evidence" to formulate a claimant's RFC, "some medical evidence" is not limited to a medical opinion.
Here, even without a supporting medical opinion, the ALJ had sufficient evidence to determine plaintiff's RFC. The ALJ's RFC assessment was supported by "some medical evidence," as detailed above. This court concludes the record evidence provided a sufficient medical basis for the ALJ to determine plaintiff's RFC.
Moreover, it is plaintiff's burden to prove RFC.
Finally, the Court on its own motion addresses whether new evidence submitted to the Appeals Council warrants remand.
Plaintiff submitted post-hearing medical records from Mercy Hospital dated June 17 to July 5, 2016. Plaintiff was seen in the emergency room and admitted to Mercy Hospital June 17-18, 2016 after feeling light headed and faint. She reported that she had had a pacemaker placed on May 13, 2016, and began experiencing lightheadedness and weakness about two to three weeks after. She was diagnosed with chronic anemia, hypokalemia or low blood potassium levels, chest pain, and dizziness. She improved and was discharged home. (Tr. 48-54.)
On July 5, 2018, plaintiff was seen in the emergency room of Mercy Hospital with complaints of back pain. Imaging showed minimal compressive deformities in the lower thoracic spine which were most likely chronic. She was diagnosed with a compression deformity of the vertebra, most likely chronic, and osteoarthritis of the spine. She was prescribed oxycodone and valium and discharged that day. (Tr. 10-40.)
The Appeals Council must consider additional evidence if it is new, material, and relates to a time period before the ALJ's decision.
Here, the Appeals Council noted the ALJ decided plaintiff's case through April 13, 2016. The Council stated the additional evidence did not relate to the period at issue and therefore did not affect the decision about whether she was disabled on or before that date. (Tr. 2.) This Court agrees that the new evidence does not warrant remand here.
For the reasons set forth above, the final decision of the Commissioner of Social Security is affirmed. An appropriate Judgment Order is filed herewith.