PATRICIA L. COHEN, Magistrate Judge.
Plaintiff Danny McDaniel seeks review of the decision by Defendant Social Security Commissioner Andrew Saul denying his application for a period of disability and Disability Insurance Benefits (DIB) under the Social Security Act. For the reasons set forth below, the Court affirms the Commissioner's denial of Plaintiff's application.
In February 2015, Plaintiff, who was born in August 1952, filed an application for DIB alleging that he became disabled on November 5, 2014 as a result of "bladder cancer stage 1 waiting for treatment." (Tr. 110-11, 140) The Social Security Administration (SSA) denied Plaintiff's claim, and he filed a timely request for a hearing before an administrative law judge (ALJ). (Tr. 87)
In February 2017, the ALJ conducted a hearing at which Plaintiff and a vocational expert testified. (Tr. 24-42) In a decision dated July 2017, the ALJ found that Plaintiff "has not been under a disability, as defined in the Social Security Act, from November 7, 2014, through the date of this decision[.]" (Tr. 10-17) Plaintiff filed a request for review of the ALJ's decision with the SSA Appeals Council, which denied review. (Tr. 3-5) Plaintiff has exhausted all administrative remedies, and the ALJ's decision stands as the SSA's final decision.
Plaintiff testified that he was sixty-four years old and a "career tow motor driver." (Tr. 28) Plaintiff most recently worked for fifteen years for the same company, where he "drove a forklift . . . in the shipping department." (Tr. 29) Plaintiff's job required him to lift "probably . . . 100 pounds at a time." (
Plaintiff testified that he underwent surgery for bladder cancer. (Tr. 30) When the ALJ asked Plaintiff "what kind of trouble" prevented him from working, Plaintiff testified that, since his surgery, "the biggest thing is running to the bathroom . . . when it hits me I got to go. And it might be a dozen times a day where it never done that before." (Tr. 31-32) Plaintiff was able to control his bladder "[n]ot every time, most of the time" and he generally wore adult incontinence undergarments, or Depends. (Tr. 32) Plaintiff explained that the incontinence was "not just leakage," but a full bladder void. (
Plaintiff stated that pain and lack of strength in his left hand also prevented him from returning to work after the bladder surgery. (Tr. 34) Despite undergoing surgery in his left wrist, his left hand was about half as strong as his right hand and he could not hold anything with that hand for more than "a minute or two[.]" (
Finally, Plaintiff testified that back and right knee pain prevented him from working. (Tr. 36) Plaintiff stated that he last received treatment for his back in 2008 or 2010. (
The vocational expert testified that Plaintiff's past relevant work as a forklift driver, as performed, was classified as "heavy." (Tr. 41) When the ALJ asked the Plaintiff whether a hypothetical person "who has bladder difficulty and . . . needs a bathroom inside of two hours frequently" could maintain employment, the vocational expert answered: "No, he would need to be accommodated and that would not allow him to work competitively." (
With respect to Plaintiff's medical treatment records, the Court adopts the facts provided by Plaintiff in his statement of uncontroverted facts and admitted by the Commissioner. [ECF Nos. 19-1, 24-1] The Court also adopts the additional facts set forth in the Commissioner's "response to Plaintiff's statement of facts with additional material facts" because Plaintiff does not refute them. [ECF No. 24-1]
To be eligible for benefits under the Social Security Act, a claimant must prove he or she is disabled. 42 U.S.C. § 423(a)(1);
To determine whether a claimant is disabled, the Commissioner engages in a five-step evaluation process.
Prior to step four, the Commissioner must assess the claimant's residual functional capacity (RFC), which is "the most a claimant can do despite [his or her] limitations."
Applying the foregoing five-step analysis, the ALJ found that Plaintiff: (1) had not engaged in substantial gainful activity since November 7, 2014; and (2) had the severe impairments of "status post surgical removal of a malignant tumor from bladder, Bacuillus Calmette-Geurin therapy, and degenerative joint disease of the left hand" and non-severe impairments of vision problems and knee and back pain. (Tr. 12-13) At step three, the ALJ found that Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (Tr. 13)
The ALJ reviewed Plaintiff's testimony and medical records and determined that, while his "medically determinable impairments could reasonably be expected to produce" the alleged symptoms, Plaintiff's "statements concerning the intensity, persistence, and limiting effects of these symptoms are not entirely consistent with the medical evidence and other evidence in the record[.]" (Tr. 14) In regard to Plaintiff's urinary frequency and incontinence, the ALJ acknowledged that Plaintiff's testimony opinion of his treating urologist were "consistent with each other but inconsistent with the treatment record." (Tr. 15) The ALJ also found that Plaintiff could wear adult incontinence undergarments in the employment setting for his "occasional urinary incontinence."
The ALJ determined that Plaintiff had the RFC to perform "the full range of medium work as defined in 20 CFR 404.1567(c)." (Tr. 13) At step four of the sequential evaluation, the ALJ found that Plaintiff was able to perform his past relevant work as a fork lift driver. (Tr. 16) In the alternative, Plaintiff could perform other jobs that exist in significant numbers in the national economy." (Tr. 17) The ALJ therefore concluded that Plaintiff was not disabled. (
Plaintiff claims that substantial evidence does not support the ALJ's RFC determination because the RFC is conclusory and not supported by medical evidence. More specifically, Plaintiff argues that the record contains no medical evidence supporting the LJ's finding that Plaintiff could perform a full range of medium with no restrictions such as proximity to the bathroom or frequent bathroom breaks. [ECF No. 19] Additionally, Plaintiff argues that the ALJ "ignored [his] testimony without adequate explanation." [
RFC is the most a claimant can still do in a work setting despite that claimant's physical or mental limitations.
Although the ALJ bears the primary responsibility for assessing a claimant's RFC based on all relevant evidence, "a claimant's residual functional capacity is a medical question."
Plaintiff's medical records establish that, in November 2014, Plaintiff's urologist Dr. Bryan performed a "cystoscopy, transurethral resection of bladder tumor" and "[l]eft extracorporeal shockwave lithotripsy." (Tr. 189) At his post-operative follow-up appointments, Plaintiff complained to Dr. Bryan of urgency, frequency, and burning when he urinated. (Tr. 356, 350)
In January 2015, Dr. Bryan performed a "[r]estaging transurethral resection of bladder tumor." (Tr. 183-84) Approximately two weeks later, Plaintiff followed up with Dr. Bryan and reported occasional urgency and bladder spasm. (Tr. 347) In March 2016, Plaintiff presented to Dr. Bryan's office for Bacillus Calmette-Guerin (BCG) therapy.
Plaintiff received his last two BCG treatments in April 2015, and Dr. Bryan noted at both appointments that Plaintiff was "doing well." (Tr. 322, 326) In May 2015, Dr. Bryan performed a "surveillance cystoscopy and bladder biopsy." (Tr. 179) The surgical pathology report diagnosed: "urinary bladder, right later wall biopsy; acute and chronic inflammation." (Tr. 181)
In September 2015, Dr. Bryan noted that Plaintiff noted that Plaintiff was "doing well has no urinary complaints" and performed another surveillance cystoscopy. (Tr. 205) Results revealed that Plaintiff's urine was nitrate positive and appeared infected. (Tr. 207) Dr. Bryan prescribed ciprofloxacin and instructed Plaintiff to return in two weeks. (
When Plaintiff followed up with Dr. Bryan in January 2016, Dr. Bryan noted that Plaintiff was "doing well." (Tr. 199) In May 2016, Plaintiff had a negative urinalysis and negative cystoscopy. (Tr. 197) At Plaintiff's next follow-up appointment in December 2016, Dr. Bryan noted that Plaintiff: completed BCG therapy one and half years ago; he was "doing well and has no urinary complaints today"; and continued to take tamsulosin. (Tr. 152) Dr. Bryan performed a cystoscopy, which revealed no abnormalities. (Tr. 154)
Although Plaintiff's last treatment records from Dr. Bryan are dated December 2016, Dr. Bryan wrote a letter in April 2017 stating he was currently treating Plaintiff "for several urological issues including frequency, urge incontinence and urgency." (Tr. 147) Dr. Bryan explained that, as a result of Plaintiff "extensive resection of a high-grade bladder tumor" and bladder cancer treatment, Plaintiff developed "significant lower urinary tract symptoms of voiding small amounts regularly which requires excessive trips to the bathroom." (
The ALJ reviewed Plaintiff's treatment records and noted that Plaintiff was "doing well without urinary complaints within a year" of completing the BCG treatments. (Tr. 15) In regard to Dr. Bryan's medical opinion, the ALJ determined that it was "inconsistent with the treatment record" and "falls short of opining that the claimant is unable to work due to this condition." (Tr. 16) The ALJ concluded: "[T]here is no question that the claimant has these issues, but he manages this problem by wearing adult incontinency garments and this strategy would also be effective in the workplace." (
Plaintiff argues that the ALJ's finding that Plaintiff could maintain full-time employment wearing adult incontinency garments was not supported by medical evidence. However, Plaintiff's treatment records reflected significant improvement in Plaintiff's bladder problems over time. Indeed, Dr. Bryan last noted "occasional urgency and bladder spasm" in February 2015. Similarly, Plaintiff's most recent mention of bladder or related sleep problems to his primary care physician appear in his treatment records of March 2015. Dr. Bryan's treatment notes after February 2015 stated only that Plaintiff: was "doing well" (March 2015, April 2015, January 2016); had "no complaints" (October 2015); and had "no urinary complaints" (September 2015, December 2015, January 2016). Accordingly, the Court finds that "some medical evidence" supported the ALJ's finding that Plaintiff's urinary frequency and incontinence did not affect his ability to function in the workplace or require restrictions to his RFC.
While Plaintiff is correct Dr. Bryan's treatment notes contained no reference to adult incontinence undergarments, Plaintiff testified about them at the hearing. More specifically, Plaintiff stated that he made it to the bathroom "most of the time" and generally wore adult incontinence undergarments, so that his incontinence did not require him to change clothes. In light of this testimony and the evidence that Plaintiff had not complained of urinary urgency or incontinence to his treating physicians in almost two years, the ALJ did not err in omitting from the RFC any limitations for Plaintiff's use of the bathroom.
Next, Plaintiff claims that ALJ erred in discounting his subjective complaints. If a claimant makes statements about the intensity, persistence, and limiting effects of his symptoms, the ALJ must determine whether the statements are consistent with the medical and other evidence of record.
When evaluating a claimant's subjective statements about symptoms, the ALJ must "give full consideration to all of the evidence presented relating to subjective complaints," including a claimant's work history and observations by third parties and physicians regarding: "(1) the claimant's daily activities; (2) the duration, frequency and intensity of the pain; (3) precipitating and aggravating factors; (4) dosage, effectiveness and side effects of medication; and (5) functional restrictions."
In this case, the ALJ found that, while Plaintiff's "medically determinable impairments could reasonably be expected to produce" the symptoms he alleged, Plaintiff's statements "concerning the intensity, persistence, and limiting effects" of those symptoms was not consistent with the medical evidence and other evidence in the record. As previously discussed in regard to Plaintiff's urinary incontinence, Plaintiff's treatment records did not reflect any complaints since after March 2015. As to the degenerative joint disease in Plaintiff's left hand, the ALJ discounted those complaints because his recent examinations showed "full nonrestrictive range of motion of the wrist" and "good resolution from the majority of the symptoms." (Tr. 15)
"`If an ALJ expressly discredits the claimant's testimony and gives good reason for doing so, [the Court] will normally defer to the ALJ's credibility determination.'"
For the foregoing reasons, the Court finds there is substantial evidence in the record to support the ALJ's decision. Accordingly,
A separate judgment in accordance with this Memorandum and Order is entered this date.