LOUISE W. FLANAGAN, District Judge.
This matter is before the court on cross-motions for judgment on the pleadings. (DE 17, 21). Pursuant to 28 U.S.C. § 636(b)(1) and Federal Rule of Civil Procedure 72(b), United States Magistrate Judge Robert T. Numbers, II, entered a memorandum and recommendation ("M&R"), wherein it is recommended that the court deny plaintiff's motion, grant defendant's motion, and affirm defendant's decision. (DE 23). Plaintiff timely objected to the M&R, (DE 24), and defendant made no response. Therefore, the issues raised are ripe for ruling. For the reasons that follow, the court adopts in part the M&R, rejects it in part, and remands to defendant for further proceedings.
Plaintiff protectively filed two applications for disability benefits July 12, 2013, alleging disability beginning April 16, 2012. Both applications were denied initially and upon reconsideration. Thereafter, plaintiff requested hearing before an administrative law judge ("ALJ"), who, after hearing held May 29, 2015, denied plaintiff's claims June 25, 2015. Following the ALJ's denial of his application, plaintiff timely requested review before the Appeals Council. The Appeals Council denied plaintiff's request for review August 11, 2016, leaving the ALJ's decision as defendant's final decision. Plaintiff then filed a complaint in this court seeking judicial review.
The court has jurisdiction under 42 U.S.C. § 405(g) to review defendant's final decision denying benefits. The court must uphold the factual findings of the ALJ "if they are supported by substantial evidence and were reached through application of the correct legal standard."
"A necessary predicate to engaging in substantial evidence review is a record of the basis for the ALJ's ruling," including "a discussion of which evidence the ALJ found credible and why, and specific application of the pertinent legal requirements to the record evidence."
To assist in its review of defendant's denial of benefits, the court may "designate a magistrate judge to conduct hearings . . . and to submit . . . proposed findings of fact and recommendations for the disposition [of the motions for judgment on the pleadings]."
The ALJ's determination of eligibility for Social Security benefits involves a five-step sequential evaluation process, which asks whether:
In the instant matter, the ALJ performed the sequential evaluation. At step one, the ALJ found that plaintiff had not engaged in substantial gainful activity since April 16, 2012. At step two, the ALJ found that plaintiff had the following severe impairments: degenerative disc disease of the cervical and lumbar spine; soft tissue injuries, status-post motor vehicle accident; history of right femur fracture; obesity; and an affective disorder. At step three, the ALJ determined that these impairments were not severe enough, either individually or in combination, to meet or medically equal one of the listed impairments in the regulations.
Before proceeding to step four, the ALJ determined that during the relevant time period plaintiff had the residual functional capacity ("RFC") to perform sedentary work, with the following limitations: has the capacity to lift and carry, push and pull up to ten pounds frequently and 20 pounds occasionally, and to stand and walk for up to two hours in an eight-hour workday, and to sit for six hours in an eight-hour workday; could never climb ladders, scaffolds, or ropes, occasionally climb ramps and would need to avoid concentrated exposure to hazards such as unprotected heights and dangerous machinery; would need the flexibility to use a hand held assistive device such as a cane while walking; could understand, remember, and carry out simple instructions, which is defined to mean activity that is consistent with a reasoning level of "two" or "three" as defined in the Dictionary of Occupational Titles; could sustain attention and concentration sufficient to carry out those simple instructions over the course of an eight-hour workday; could work in occupations that require occasional contact with co-workers, supervisors, and the general public; and would be limited to low stress work, which is specifically defined to mean: no fast paced production, only simple work related decisions, and few or no changes in the work setting.
At step four, the ALJ concluded plaintiff was unable to perform his past relevant work as a construction worker, dump truck driver, or power shovel operator. At step five, the ALJ determined that jobs exist in the national economy in significant numbers that plaintiff can perform. Thus, the ALJ concluded that plaintiff was not disabled under the terms of the Social Security Act.
In his objections, plaintiff argues that the ALJ's RFC determination pertaining to plaintiff's physical and mental capacity was not supported by substantial evidence and was not adequately explained. In support of this argument, plaintiff relies upon medical records assessing plaintiff's physical and mental capacity, including records of psychological diagnoses generated between the date of the ALJ's decision and the Appeals Council's denial of review.
The court addresses first plaintiff's argument that his medical records demonstrate inability to work due to chronic pain. In assessing credibility of plaintiff's pain allegations, the ALJ must follow a two-step process: (1) the ALJ must determine whether the claimant's medically determinable impairments could reasonably cause the alleged symptoms, including pain, and (2) the ALJ must evaluate the credibility of the statements regarding those symptoms.
At step one, the ALJ found that plaintiff's medically determinable impairments could reasonably cause the alleged symptoms, including pain. (Tr. 248). At step two, the ALJ found that plaintiff's testimony regarding the intensity of pain was not entirely credible. (Tr. 252). In support of this finding, the ALJ discussed several medical sources indicating that plaintiff's pain was not as severe as claimed. In particular, the ALJ considered medical evaluations authored by Dr. Anjali Gupta, M.D. ("Gupta"), Roger Ordronneau, PA-C ("Ordronneau"), Dr. David Musante, M.D. ("Musante"), Dr. Constant Masere, M.D. ("Masere"), Dr. Haresh Kathard, M.D. ("Kathard"), and Dr. Edwin Swann, M.D. ("Swann"). Each of the foregoing sources assessed plaintiff's pain at various levels of intensity causing corresponding levels of functional impairment.
With respect to the opinion of Gupta, the ALJ did not rest final determination upon that opinion, because Gupta's temporary assessment addressed plaintiff's condition only for the days following a vehicle accident taking place April 16, 2012. (
Next, the ALJ considered the opinion of Masere, which was formed on the basis of a consultative examination conducted August 24, 2013. (
Finally, the ALJ considered the opinion of Swann, the conclusions of which the ALJ adopted in determining plaintiff's RFC, except insofar as Swann assessed that plaintiff suffered visual limitations, which limitations the ALJ found entirely unsupported by the record. (Tr. 250-51). The ALJ gave substantial weight to Swann's opinion on the grounds that Swann is an expert well-versed in "program rules and the expected limitations of impairments" and "had the opportunity to review a substantial portion of the medical evidence of record." (Tr. 251).
The foregoing assignments of weight to opinion evidence evaluating plaintiff's pain are supported by substantial evidence and adequately explained where the ALJ accurately described the conclusions set forth in each source of evidence and explained that the opinion of Swann was credited over other opinions because it was grounded in expertise, set forth in specific terms, and based upon a larger universe of data than other opinion evidence in the record. (
Furthermore, based upon Swann's evaluation, the fact that plaintiff's overall treatment for pain was conservative in nature, and that plaintiff was able to sit through hearing held May 29, 2015, which lasted over an hour despite plaintiff's testimony that he could sit no more than 15 minutes due to pain, the ALJ found that plaintiff's subjective reports of extreme, debilitating pain were unsupported by the record. (Tr. 252). Where this conclusion is indeed consistent with numerous sources of medical evidence and with the ALJ's observations at hearing, the ALJ's finding that plaintiff's pain was not debilitating is supported by substantial evidence and adequately explained.
Plaintiff argues that the ALJ erred in reaching the foregoing conclusion. However, where the ALJ's relied upon medical evidence that supported factual filings announced in the decision, and where the ALJ explained why other medical and plaintiff's subjective allegations of pain were not credited as strongly as the opinion of Swann, the ALJ's decision was permissible under the standards set forth in
Plaintiff also objects to the M&R on the ground that the ALJ's determination pertaining to plaintiff's mental impairments was unsupported by substantial evidence. In assessing plaintiff's mental impairments, the ALJ considered plaintiff's subjective reports of depression given at hearing, a clinical assessment by Jessica Drennen, MSW, LCSWA ("Drennen"), a February 25, 2015, psychiatric evaluation by Victoria Payne, M.D. ("Payne"), and a report based upon a follow-up with Payne on April 28, 2015.
Plaintiff also notes additional evidence that was submitted to the Appeals Council, which evidence was generated after the ALJ announced decision on plaintiff's claim. (Tr. 2). Such additional evidence includes: 1) treatment notes from several providers of psychological services dated from July 6, 2015, to April 1, 2016; 2) additional medical records dated between July 10, 2015, and November 11, 2015; 3) a medical source statement from Payne dated November 25, 2015, opining that plaintiff hears voices, sees visions, and that two hospitalizations due to depression and suicidal ideation indicate the severity of plaintiff's condition; 4) a medical source statement from Dr. Godfried Arthur, M.D. ("Arthur"), dated December 15, 2015, opining that plaintiff's major depression, suicidal thoughts, and auditory hallucinations significantly affect plaintiff's functioning; and 5) a Medicaid decision from North Carolina Department of Health and Human Services ("NCDHS") dated December 22, 2015, by which decision NCDHS found plaintiff disabled under standards relevant in an action of that nature. (
"[Defendant] must consider evidence submitted with [a] request for review in deciding whether to grant review if the additional evidence is (a) new, (b) material, and (c) relates to the period on or before the date of the ALJ's decision."
In this case, the evidence post-dating the ALJ's decision submitted to the Appeals Council is "new" because where it accounts for plaintiff's hospitalizations and diagnoses based thereon, the evidence is neither duplicative nor cumulative of other evidence in the record.
On remand, the ALJ must account for evidence generated after June 25, 2015, to the extent such evidence may affect plaintiff's RFC determination prior to that time. Specifically, evidence submitted to the Appeals Council may suggest that plaintiff's mental impairments started degenerating following the April 28, 2015, follow-up evaluation conducted by Payne, where such evidence includes hospitalizations and diagnoses of severe depression, anxiety, suicidal ideation, homicidal ideation, and auditory hallucinations. (
Defendant argues, and the magistrate judge agreed, that the ALJ properly considered all evidence of record pertaining to plaintiff's mental condition prior to the date of the ALJ's decision June 25, 2015. The ALJ indeed considered medical evidence existing as of the date of Payne's April 28, 2015, follow-up examination and plaintiff's reports of psychological symptoms existing in the record and reaffirmed at hearing May 29, 2015, and explained that such evidence was not found determinative in light of the conservative nature of treatment provided to plaintiff and in light of the "relatively mild" nature of plaintiff's psychotic symptoms as noted by Payne. (Tr. 709). However, defendant's argument fails where evidence of plaintiff's mental health status following the date of decision suggest deterioration with onset date prior to June 25, 2015, with a reasonable possibility that such evidence supports a finding of disability prior to that time.
Based on the foregoing, the court ADOPTS the recommendation in the M&R in part, REJECTS it in part, GRANTS plaintiff's motion (DE 17), DENIES defendant's motion (DE 21), and REMANDS to defendant for further proceedings consistent with this opinion, pursuant to sentence four of 42 U.S.C. § 405(g).
SO ORDERED.