JOI ELIZABETH PEAKE, Magistrate Judge.
Plaintiff Donna Michailo ("Plaintiff") brought this action pursuant to Section 205(g) of the Social Security Act (the "Act"), as amended (42 U.S.C. § 405(g)), to obtain judicial review of a final decision of the Commissioner of Social Security denying her claim for Disability Insurance Benefits under Title II of the Act. The parties have filed cross-motions for judgment, and the administrative record has been certified to the Court for review.
Plaintiff filed her application for Disability Insurance Benefits on September 23, 2009, alleging a disability onset date of September 9, 2009. (Tr. at 218-19.)
Federal law "authorizes judicial review of the Social Security Commissioner's denial of social security benefits."
"Substantial evidence means `such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.'"
"In reviewing for substantial evidence, the court should not undertake to re-weigh conflicting evidence, make credibility determinations, or substitute its judgment for that of the [ALJ]."
In undertaking this limited review, the Court notes that in administrative proceedings, "[a] claimant for disability benefits bears the burden of proving a disability."
"The Commissioner uses a five-step process to evaluate disability claims."
A finding adverse to the claimant at any of several points in this five-step sequence forecloses a disability designation and ends the inquiry. For example, "[t]he first step determines whether the claimant is engaged in `substantial gainful activity.' If the claimant is working, benefits are denied. The second step determines if the claimant is `severely' disabled. If not, benefits are denied."
On the other hand, if a claimant carries his or her burden at each of the first two steps, and establishes at step three that the impairment "equals or exceeds in severity one or more of the impairments listed in Appendix I of the regulations," then "the claimant is disabled."
In the present case, the ALJ found that Plaintiff has not engaged in substantial gainful activity since her alleged onset date. She therefore met her burden at step one of the sequential evaluation process. At step two, the ALJ further determined that Plaintiff suffered from the following severe impairments: degenerative disc disease of the lumbar spine, anxiety, depression, and chemical dependence. (Tr. at 27.) The ALJ found at step three that none of these impairments, singly or in combination, met or equaled a disability listing. (Tr. at 27-28.) Therefore, the ALJ assessed Plaintiff's RFC and determined that she could perform medium work with further limitations to unskilled, simple, routine, repetitive tasks, only occasional social interaction, and stable work hours and location. (Tr. at 28-29.)
At step four, the ALJ determined that the mental demands of Plaintiff's past relevant work exceeded her RFC. (Tr. at 35.) However, he concluded at step five that, given Plaintiff's age, education, work experience, and RFC, along with the testimony of the vocational expert regarding those factors, she could perform other jobs available in the national economy and therefore was not disabled. (Tr. at 35-37.)
Plaintiff now raises three challenges to the ALJ's decision. Specifically, she argues that the ALJ failed to (1) properly weigh the opinion of Dr. Stanley Schaeffer, Plaintiff's primary care physician, (2) consider all of Plaintiff's medically determinable impairments and their combined effect, and (3) properly assess Plaintiff's credibility. Ultimately, none of these contentions merit remand.
Plaintiff first contends that the ALJ failed to analyze Dr. Schaeffer's opinion in accordance with Social Security Ruling ("SSR") 96-2p and 20 C.F.R. § 404.1527(c), better known as the "treating physician rule." The treating physician rule generally requires an ALJ to give controlling weight to the well-supported opinion of a treating source as to the nature and severity of a claimant's impairment, based on the ability of treating sources to
20 C.F.R. § 404.1527(c). However, if a treating source's opinion is not "well-supported by medically acceptable clinical and laboratory diagnostic techniques or is inconsistent with other substantial evidence in the case record," it is not entitled to controlling weight.
Where an ALJ declines to give controlling weight to a treating source opinion, he must "give good reasons in [his] . . . decision for the weight" assigned, taking the above factors into account. 20 C.F.R. § 404.1527(c)(2). "This requires the ALJ to provide sufficient explanation for `meaningful review' by the courts."
Opinions by physicians regarding the ultimate issue of whether a plaintiff is disabled within the meaning of the Act are never accorded controlling weight because the decision on that issue is reserved for the Commissioner alone. 20 C.F.R. § 404.1527(d).
In the present case, Dr. Schaeffer completed a three-page form, dated August 1, 2011, assessing Plaintiff's "physical abilities and limitations for Social Security disability claim" purposes. (Tr. at 548-50.) On this form, Dr. Schaeffer indicated that, due to back pain and anxiety, Plaintiff could perform no physical activities whatsoever, with the exception of occasionally driving and occasionally using her hands and arms. (Tr. at 548-49.) He opined, for example, that Plaintiff could never sit or stand for any length of time or lift any amount of weight. (Tr. at 548.) He further opined that she could never tolerate cold or heat and could never tolerate noise exposure. (Tr. at 549.) He further asserted that Plaintiff's back pain has persisted with these restrictions since her alleged onset date, and that the pain continues to render her unable to work. (Tr. at 550.)
The ALJ assigned no weight to Dr. Schaeffer's opinions, explaining that "Dr. Schaeffer reported that the claimant had extremely severe physical functional limitations" and "essentially opined that the claimant could do absolutely nothing of a physical nature." (Tr. at 35.) The ALJ further explained that "[d]espite the extreme restrictions described by Dr. Schaeffer, the results of his own examinations of the claimant from August 1, 2011, through June 26, 2012, did not reveal any apparent musculoskeletal deficits or physical limitations," and that Dr. Schaeffer's opinions "are not supported by the totality of the objective medical evidence of record, including his own examinations of the claimant, which apparently did not show any significant musculoskeletal deficits." (Tr. at 31, 35.) In addition, the ALJ further noted that "none of the claimant's treating physicians, with the exception of Dr. Schaeffer . . ., reported any significant physical functional limitations for her from November of 2009 through October 23, 2012." (Tr. at 33.)
Although Plaintiff now contends that "the ALJ rejected Dr. Schaeffer's opinion without citing `persuasive contradictory evidence,' and without assessing the factors contained in 20 CFR § 404.1527" (Pl.'s Br. [Doc. #7] at 10), the decision itself belies her claim. In accordance with 20 C.F.R. 404.1527(c), the ALJ recognized that Dr. Schaeffer served as Plaintiff's treating family practice physician throughout the time period at issue (Tr. at 31), but found that his treatment records failed to support his opinion of total disability (Tr. at 31, 33, 34, 35). As noted above, the ALJ also recognized significant inconsistencies between Dr. Schaeffer's opinion and other record evidence. While recognizing that "imaging studies do show lumbar degenerative disk disease," the ALJ found that "with the exception of an occasional limping gait, the results of many physical examinations did not show any markedly severe difficulties with ambulation, moving about, with sitting, or with the use of upper extremities." (Tr. at 33;
(Tr. at 34) (citations omitted). In light of the above, the Court concludes that the ALJ gave good reasons in his decision for discounting Dr. Schaeffer's opinions and provided a "sufficient explanation for `meaningful review' by the courts."
Plaintiff next contends that the ALJ erred in failing to include partial sacralization, pain disorder, and osteoarthritis of the knees among her severe impairments at step two of the sequential analysis. (Pl.'s Br. at 11-13, 18-19.) "However, even assuming these impairments were severe, such error does not necessitate remand. As long as the ALJ determines that the claimant has at least one severe impairment and proceeds to discuss all of the medical evidence, any error regarding failure to list a specific impairment as severe at step two is harmless."
In terms of physical impairments, the ALJ included degenerative disc disease of the lumbar spine among Plaintiff's severe impairments (Tr. at 27) and, after discussing and weighing the medical evidence of this impairment at great length, limited Plaintiff to medium work in light of her back pain (Tr. at 28-35). Plaintiff now points to an x-ray taken in 2007, two years prior to the alleged onset date, as evidence of partial sacralization of her lumbar spine. (Tr. at 482.) However, Plaintiff herself never suggests what limitations, if any, her partial sacralization might require. Instead, she theorizes that this condition "may well have been" the source of her allegedly disabling pain. (Pl.'s Br. at 12.) However, no medical source, including Dr. Spivey who reviewed the 2007 x-ray noting partial sacralization and who ordered and reviewed multiple additional images from 2009 and 2011, opined that this condition played any role, let alone the principal role, in Plaintiff's back pain. (See, e.g., Tr. at 466, 481-82.) The ALJ considered and discussed all of the medical evidence, including Dr. Spivey's treatment notes, and Plaintiff fails to show that the ALJ erred by omitting from his decision a specific mention of partial sacralization.
Plaintiff's challenge regarding her pain disorder fails for similar reasons. As the ALJ noted, Plaintiff's consultative psychiatric examiner, Dr. Richard Spencer, included pain disorder among his diagnoses, along with adjustment disorder, generalized anxiety disorder, and chronic alcoholism. (Tr. at 32, 402.) Even with these diagnoses, Dr. Spencer concluded that Plaintiff had adequate social functioning and could understand instructions, although he noted that "adjustments in occupational areas appear poor." (Tr. at 32, 402.) Significantly, neither Dr. Spencer nor any other medical source specified which, if any, of Plaintiff's recommended functional limitations could be attributed to pain disorder.
State agency psychological consultant Dr. Jonathan Mayhew subsequently gave Dr. Spencer's evaluation significant weight when undertaking his mental RFC assessment of Plaintiff. (Tr. at 428.) Dr. Mayhew found that Plaintiff seemed dysphoric, which Plaintiff blamed on reported spinal pain, but Dr. Mayhew opined that, "from a mental standpoint, she does not present with limitations which would preclude performance of at least SRRTs in a stable, low social work setting." (Tr. at 34, 428.) The ALJ explicitly considered and incorporated both Drs. Spencer and Mayhew's opinions in concluding that Plaintiff can perform "only unskilled simple, routine, repetitive tasks . . . but should only engage in occasional interaction with others [in] a work environment with stable hours and locations." (Tr. at 29.) As neither the record nor Plaintiff herself identify any omitted medical evidence relating to Plaintiff's pain disorder or suggest any additional RFC limitations as a result of that disorder, substantial evidence supports the ALJ's determination regardless of the omission of pain disorder as a severe impairment at step two.
Plaintiff's final step two challenge regarding bilateral osteoarthritis of the knees merits the same result. Plaintiff contends that "[t]he ALJ erred by failing to consider . . . osteoarthritis a severe impairment at step two of the sequential evaluation, and by failing to sufficiently consider that impairment in combination with pain disorder when determining [Plaintiff's] RFC." (Pl.'s Br. at 19.) The ALJ explicitly acknowledged Plaintiff's complaints of bilateral knee pain, but also noted that x-rays revealed "only `mild' joint space narrowing of the medial tibia and femur compartments bilaterally." (Tr. at 32) (citing Tr. at 557). Although Plaintiff argues that, after receiving Synvisc injections to treat this condition, she "had increased pain, reduced range of motion[,] and crepitus" (Pl.'s Br. at 19), thereby suggesting that her knee impairment was more severe or limiting than acknowledged by the ALJ, the record itself reveals just the opposite. Following Dr. Schaeffer's observation of "somewhat mild crepitus to range of motion" bilaterally, he injected Synvisc into Plaintiff's left knee. "She had good results in about 5-10 minutes with much less pain. Better range of motion. No more clicking noted." (Tr. at 556.) Dr. Schaeffer further advised that he could inject the other knee on a return visit (
Finally, Plaintiff argues that the ALJ failed to properly assess her pain allegations under the framework set out in
Notably, while the ALJ must consider Plaintiff's statements and other subjective evidence at step two, he need not credit them "to the extent they are inconsistent with the available evidence, including objective evidence of the underlying impairment, and the extent to which that impairment can reasonably be expected to cause the pain the claimant alleges she suffers."
Where the ALJ has considered these factors and has heard Plaintiff's testimony and observed her demeanor, the ALJ's credibility determination is entitled to deference.
In the present case, the ALJ determined at step one of the
To refute the first of these justifications, Plaintiff cites the opinion of Dr. Alan Rosenbloom, who performed a one-time consultative physical examination of Plaintiff on November 3, 2009. Dr. Rosenbloom opined that Plaintiff's condition "affects her ability to sit, stand, move about, [and] lift and carry, all related to her back pain." (Pl.'s Br. at 17) (citing Tr. at 379). Dr. Rosenbloom also found that Plaintiff "can handle light objects[,] hear[,] and speak," but that "[t]raveling is quite problematic [because] sitting . . . for any length of time [causes Plaintiff] increasing back and leg pain." (Tr. At 379.)
The ALJ assigned only "some weight" to these opinions. The ALJ acknowledged that Plaintiff's impairments "affected her ability to perform exertional activities," but the ALJ further emphasized Dr. Rosenbloom's failure to "quantify his assessment" of Plaintiff's abilities. (Tr. at 34.) Plaintiff fails to show that Dr. Rosenbloom's opinions do, in fact, conflict with the finding of no "markedly severe difficulties" in the exertional activities specified by the ALJ. In the circumstances, Dr. Rosenbloom's opinion does not provide a basis for overturning the ALJ's credibility findings.
Plaintiff next alleges that the ALJ improperly relied on Plaintiff's chemical dependence as a basis for rejecting her allegations of disabling pain. However, the ALJ did not "`discount [claimant's] subjective complaints simply because of [her] dependence on narcotic pain medications.'" (Pl.'s Br. at 14) (quoting
IT IS THEREFORE RECOMMENDED that the Commissioner's decision finding no disability be AFFIRMED, that Plaintiff's Motion for Judgment on the Pleadings [Doc. #6] be DENIED, that Defendant's Motion for Judgment on the Pleadings [Doc. #9] be GRANTED, and that this action be DISMISSED with prejudice.
