RICHARD L. VOORHEES, District Judge.
On March 2, 2009, Plaintiff's mother, Donna Brown, filed for Title XVI Disability Insurance Benefits ("DIB") on behalf of Plaintiff. (Tr. 150-56). Plaintiff's claim was denied initially on July 31, 2009 (Tr. 127), and upon reconsideration on January 26, 2010 (Tr. 136). Plaintiff also filed for Title II Child Disability Benefits ("CDB") on March 16, 2010. (Tr. 163-69). Plaintiff requested a Hearing regarding the DIB denial upon reconsideration. (Tr. 140-42). Both applications for DIB and CDB were consolidated for one Hearing with Administrative Law Judge ("ALJ") John S. Lamb. (Tr. 89). Plaintiff was not represented by an attorney or a non-attorney representative at the Hearing. (Tr. 35).
After the August 31, 2010 Hearing, both decisions issued from the ALJ were unfavorable to Plaintiff, from which Plaintiff appealed to the Appeals Council. (Tr. 32-50, 21-31, 1-5). Plaintiff's request for review was denied and the Appeals Council affirmed the ALJ's decision, making the ALJ's decision the final decision of the Commissioner of Social Security ("Commissioner"). (Tr. 32-50). Thereafter, Plaintiff timely filed this action for a right to review of the Commissioner's final decision under 42 U.S.C. § 405(g).
It appearing that the ALJ's findings of fact are supported by substantial evidence, the undersigned adopts and incorporates such findings herein as if fully set forth. Such findings are referenced in the discussion which follows.
This Court's review is limited to whether the Commissioner applied the correct legal standards and whether the Commissioner's decision is supported by substantial evidence.
In obtaining disability benefits, the word "disability" is defined by Social Security Administration regulations as the "inability to do any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." 20 C.F.R. § 404.1505(a). Since Plaintiff filed the DIB Application prior to Plaintiff's eighteenth birthday, the ALJ was required to assess Plaintiff under a childhood standard of disability as well as the adult standard. 20 C.F.R. § 416.924. This standard is discussed only to provide background for the ALJ's finding that concerned the mental impairment of depression, since depression was not explicitly mentioned in the decisions evaluating Brown's adult disability claim.
A five-step process, known as "sequential" review, is used by the Commissioner in determining whether a Social Security claimant age eighteen or older is disabled. 20 C.F.R. § 416.920(a). The Commissioner evaluates a disability claim under this adult standard of disability through the following five-step analysis:
20 C.F.R. § 404.1520(b)-(f). In this case, the Commissioner determined Plaintiff's claim failed at the fifth step of the sequential evaluation process for both the DIB and CDB applications. (Tr. 50, 31).
To determine whether a claimant under the age of eighteen is disabled under Title II, the following three-step analysis is used by the Commissioner: (1) whether a claimant is engaging in substantial gainful activity; (2) whether a claimant has a medically determinable "severe" impairment or a combination of impairments that is "severe"; and (3) whether a claimant has an impairment or a combination of impairments that meets or medically equals the criteria of a listing, or that functionally equals the listings.
In determining whether a claimant's impairment functionally equals a listing, a claimant's functioning is assessed in the following six domains: (i) Acquiring and Using Information; (ii) Attending and Completing Tasks; (iii) Interacting and Relating with Others; (iv) Moving About and Manipulating Objects; (v) Caring for Yourself; and (vi) Health and Physical Well-Being. 20 C.F.R. § 416.926(b)(1)(i)-(vi). For a claimant functionally to equal the listing, the impairment or combination of impairments requires a result of a "marked" limitation in at least two domains or an "extreme" limitation in at least one domain. 20 C.F.R. § 416.92a(d). In this case, the Commissioner determined Plaintiff's claim failed at the third step of the evaluation process because Plaintiff's impairments did not meet, medically equal, or functionally equal the listings. (Tr. 48).
The DIB Application Decision, under the adult standard, and the CDB Application Decision share the same process of evaluation and the same findings of fact and conclusions of law in this case. In the pursuit of brevity, this Order will reflect that identical nature by discussing the adult standard of disability under only one of Plaintiff's applications, the CDB Application Decision. The childhood standard discussion will be from the DIB Application Decision, the only application concerned with such a standard.
Applying the childhood standard of evaluation, the ALJ determined that Plaintiff had not engaged in "substantial gainful activity" since March 2, 2009, the date of the application. (Tr. 40, Finding 2). Furthermore, the ALJ determined that Plaintiff, prior to turning eighteen years old, suffered from the severe impairments of impaired breathing, scoliosis of the thoracolumbar spine, history of one functioning kidney, and Klippel-Feil syndrome. (Tr. 40, Finding 3). However, the ALJ found that these impairments or combination of impairments did not meet or medically equal the criteria of an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1, Part A or B. (Tr. 40, Finding 4) (noting 20 C.F.R §§ 416.920(d), 416.924, 416.925, and 416.926). The ALJ also found that Plaintiff did not functionally equal the listings as allowed by 20 C.F.R. § 416.926a. (Tr. 40, Finding 5). This is so because the ALJ found that Plaintiff only had one marked limitation in the six domains, that of Health and Physical Well-Being, and did not have any extreme limitations. (Tr. 43-48). Other than the domain of Health and Physical Well-Being, Plaintiff was found to have no limitations. (Tr. 43-48).
The ALJ's application of the adult standard for disability started with a finding that Plaintiff had not engaged in "substantial gainful activity" since her date of birth, April 23, 1992. (Tr. 26, Finding 2). At the next step of sequential review, the ALJ found that the claimant had the severe impairments of impaired breathing, scoliosis of the thoracolumbar spine, history of one functioning kidney, and Klippel-Feil syndrome. (Tr. 26, Finding 3). However, the ALJ found that the impairments or combination of impairments did not meet or medically equal the criteria of an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. (Tr. 27, Finding 4) (noting 20 C.F.R. §§ 404.1520(d), 404.1525, 404.1526, 416.920(d), 416.925, and 416.926).
Next, the ALJ determined that Plaintiff had the RFC to perform sedentary work as defined by 20 C.F.R. §§ 404.1567(a) and 416.967(a), but also that Plaintiff can lift or carry a maximum of ten pounds occasionally and five pounds frequently. (Tr. 27). This RFC determination is challenged by Plaintiff as not being supported by substantial evidence. (Doc. 15, p. 1). Upon determining the RFC, the ALJ found that Plaintiff did not have past relevant work. (Tr. 30, Finding 6). In the final step, the ALJ found that a significant number of jobs existed that Plaintiff could perform. (Tr. 30, Finding 10).
Plaintiff has made the following assignments of error: the ALJ (1) did not fulfill the duty of developing a full and fair record, (2) did not correctly assess the Residual Functioning Capacity ("RFC") by not finding Plaintiff's testimony to be credible regarding neck pain, headaches, and mental impairments, and (3) did not give enough weight to the opinion of Plaintiff's mother concerning Plaintiff's condition. Determining the RFC at the fourth step of the ALJ's sequential review is the essential focal point of this appeal.
"[T]he ALJ has a duty to explore all relevant facts and inquire into the issues necessary for adequate development of the record, and cannot rely only on the evidence submitted by the claimant when that evidence is inadequate."
Plaintiff maintains that the ALJ failed the duty of developing a full and fair record by: (1) not requesting medical records available after March 26, 2010, and (2) not ordering a consultative physical or psychological evaluation to properly determine and assess Plaintiff's limitations after Plaintiff was eighteen years old.
Plaintiff incorrectly asserts that the ALJ never requested records dated subsequent to March 26, 2010. (Doc. 15, p. 11). Plaintiff indicated on an undated Recent Medical Treatment Form, supplied by the Social Security Administration, that Carolina Spine & Neurosurgery Center ("CSNC") treated or examined her after March 26, 2010. (Tr. 238). On July 21, 2010, the ALJ requested the Plaintiff's medical records from CSNC dated September 25, 2009-forward. (Tr. 392-93). CSNC responded to the request on August 6, 2010, with records spanning from November 12, 2009 to March 18, 2010. (Tr. 384-91). Therefore, contrary to Plaintiff's assertion, the last date of medical evidence in the Hearing file is subsequent to January 7, 2010. (Doc. 15, p. 15). In fact, the ALJ cited the March 18, 2010 visit to CSNC in the decision.
Furthermore, this Court finds favor with the reasoning that "any error on the part of the ALJ [is] harmless" when a plaintiff makes no showing of prejudice.
In this case, Plaintiff has not provided any additional records not already given by CNSC to the ALJ. Plaintiff has not cited medical evidence that suggests her condition changed in any significant way since the June 2009 physical examination and the 2010 CSNC visits. Although Plaintiff indicated on the Recent Medical Treatment Form that she was treated or examined by CSNC after March 26, 2010, she has not submitted evidence or argued that such a visit took place. The ALJ requested the CSNC medical records from September 25, 2009-forward, to which CSNC responded. (Tr. 392-93, 384-91). Therefore, Plaintiff has not made a showing of prejudice in this matter.
Plaintiff also assigns, as error, the ALJ's failure to order examinations after she turned eighteen years old to evaluate her limitations. (Doc. 15, p. 11). While a consultative physical or psychological evaluation was not given after Plaintiff turned eighteen years old to properly determine and assess Plaintiff's physical or psychological limitations and functional limitations, a physical examination was conducted on June 19, 2009, a date subsequent to Plaintiff's May 23, 2009 car accident. (Tr. 326-30, 314-25). The physical examination was conducted approximately ten months prior to Plaintiff's eighteenth birthday (April 23, 2010).
Plaintiff's argument is without merit for three reasons. First, the ALJ is not required to order a consultative psychological or physical examination. 20 C.F.R. § 416.919a(b) ("We may purchase a consultative examination to try to resolve an inconsistency in the evidence, or when the evidence as a whole is insufficient to allow us to make a determination or decision on your claim."). Dr. Timothy Johnston ("Dr. Johnston") performed the physical examination of Plaintiff ten months prior to her eighteenth birthday. (Tr. 326). Further, the examination took place approximately one month after Plaintiff's car accident, which allegedly made her condition worse. (Tr. 326-30, 219).
Second, no evidence suggests that Plaintiff's condition deteriorated in any significant way since the June 2009 physical examination. (Doc. 15, p. 14-15). Plaintiff correctly acknowledges that the ALJ is required to "make every reasonable effort to ensure that the file contains sufficient evidence to assess the RFC." (SSR 96-8p). However, sufficient evidence did exist for the ALJ to assess the RFC without ordering a second physical examination in a little over a year. None of Plaintiff's subsequent medical visits since the June 2009 physical examination, ranging from July 2009 to March 2010, indicate that Plaintiff's condition deviated substantially since the physical examination. (Tr. 370-76 (Sept. 24, 2009), 377 (Sept. 24, 2009), 384-85 (Nov. 12, 2009), 386 (Nov. 18, 2009), 387-88 (Jan. 7, 2010), 389-90 (March 18, 2010)). The examination, in combination with the on-record subsequent medical visits leading up until March 18, 2010, constitutes substantial evidence that a second physical examination was not required.
Third, the ALJ did not order a psychological examination because the ALJ found Plaintiff to be not credible regarding mental impairments based on the inconsistency between Plaintiff's testimony and the objective medical evidence. (Tr. 47). Plaintiff contends that the failure of a consultative psychological examination was a failure in developing the record. (Doc. 15, p. 11). That finding will be discussed in "Section V-A-2" of this Order concerning the ALJ's determination of Plaintiff's RFC. Again, regulations do not require an ALJ to order psychological examinations, as shown by the following:
20 C.F.R. § 404.1519a.
The record shows that (1) Dr. Johnston noted Plaintiff's mood and affect were appropriate during the June 2009 physical examination and (2) Plaintiff failed to check any of the three boxes located under "Psychological" on a Health Questionnaire such as depression, anxiety, or insomnia on September 24, 2009. (Tr. 375-76). Although the ALJ did not specifically refer to this section of the Health Questionnaire, specific references are not always required.
The ALJ found that Plaintiff has the RFC to perform sedentary work
A repetitive criticism of the ALJ's decision by Plaintiff is that the ALJ did not have medical records of Plaintiff after she reached eighteen years old. (Doc. 15, p. 10-11, 14-15). While it is true that the ALJ erroneously noted that medical opinions rendered after Plaintiff turned eighteen years old were in the record (Tr. 48) (citing Tr. 243, 244, 326-29, 378-83), this is harmless error in the
Plaintiff's argument that the ALJ's RFC determination is in error is without merit. Specifically, Plaintiff asserts error from the ALJ for not finding credible her claims of neck pain, headaches, and mental impairments. Each claim was decided with substantial evidence and followed appropriate legal standards as the following discussion will show.
To determine the credibility of subjective complaints, the ALJ is to follow the two-step process laid out in
In the first step, the ALJ is to determine whether there is objective medical evidence showing "the existence of a medical impairment(s) which results from anatomical, physiological, or psychological abnormalities and which could reasonably be expected to produce the pain or other symptoms alleged."
If such an impairment is found at the first step, the second step calls for the ALJ to evaluate "the intensity and persistence of the claimant's pain, and the extent to which it affects her ability to work. . . ."
The ALJ properly followed the
Plaintiff argues that she was entitled to rely exclusively on subjective medical evidence during the second step of
Plaintiff's statements regarding the intensity, persistence, and limiting effects of her neck pain were found not credible. (Tr. 28). The level of review from this Court is simply whether or not substantial evidence supports that determination. 42 U.S.C. § 405(g). Substantial evidence, as defined by the Fourth Circuit, supports this finding of Plaintiff not being credible.
The ALJ noted four points in the record after the May 2009 car accident: (1) a record from Murphy Medical Center, on the day of the accident, showed Plaintiff's neck was non-tender, had painless range of motion, and trachea was midline (Tr. 29) (citing Tr. 315); (2) a record from CSNC showed that Dr. Mark Moody ("Dr. Moody") diagnosed Plaintiff with resolving cervical sprain or strain (Tr. 29) (citing Tr. 387); (3) a record from CSNC on March 18, 2010, showed Dr. Moody's physical examination of Plaintiff resulted in Dr. Moody concluding that "[Plaintiff] has normal strength and sensation in all motor groups and dermatomes of the upper extremities" (Tr. 29) (citing Tr. 389); and (4) a record of Dr. Johnston's musculoskeletal examination of Plaintiff on June 19, 2009, in which Dr. Johnston found that while Plaintiff had limitations with the normal excursion of the thoracic spine, Plaintiff also had "normal range of motion to side bending, flexion, and rotation of the cervical spine in all planes." (Tr. 29) (citing Tr. 328). This is substantial evidence to support the ALJ's determination that Plaintiff's testimony concerning neck pain was not credible.
Plaintiff's statements regarding the intensity, persistence, and limiting effects of her headaches were found not credible. (Tr. 28). Substantial evidence supports the ALJ's determination, with references to the record before and after the May 2009 car accident that show an inconsistency with the objective medical evidence and Plaintiff's statements. The following four citations to the record by the ALJ satisfies substantial evidence: (1) a record from Dr. Guram on July 29, 2008, showing that Plaintiff's headaches had resolved since the earlier complaints of intermittent headaches (Tr. 28) (citing 308); (2) a record from Dr. Johnston's June 2009 physical examination showing that Plaintiff denied having problems with headaches (Tr. 29) (citing 327); (3) an initial Physical Therapy Evaluation form from November 18, 2009, showing no complaint of headaches from Plaintiff (Tr. 29) (citing Tr. 386); and (4) a record from Dr. Moody on January 7, 2010, showing that Plaintiff took pain medication on an infrequent basis and Plaintiff's problems section did not have headaches listed. (Tr. 29) (citing Tr. 387).
Plaintiff's testimony regarding the intensity, persistence, and limiting effects of depression and anxiety were found not credible. (Tr. 28). Plaintiff's updated Disability Report Form 3441, the exact date of which is uncertain
Plaintiff asserts that depression is also a cause of Plaintiff not caring for her personal needs. (Tr. 232). Although the ALJ does not discuss depression in the CDB Application Decision, this is harmless error since the ALJ evaluated the mental impairment in the DIB Application Decision. (Tr. 47) (citing Tr. 232). In this decision, the ALJ found Plaintiff's testimony concerning depression to be not credible. (Tr. 47). The ALJ references the January 25, 2010 Childhood Disability Evaluation Form from Dr. Val Sokolev ("Dr. Sokolev") that found no limitation in the domain of "Caring for Yourself."
As discussed prior, Plaintiff must show how Plaintiff was prejudiced by an alleged error from the ALJ.
Further, an ALJ is not tasked with the "impossible burden of mentioning every piece of evidence" that may be placed into the Administrative Record.
Regulations also provide for a claimant's daily activities to be considered in the ALJ's evaluation of credibility.
The ALJ cited the record on many occasions to show an inconsistency between Plaintiff's daily activities and the subjective complaints of neck pain, headaches, and mental impairments. First, the ALJ referenced an undated Child Function Report in which Plaintiff admitted being able to dance, swim, drive a car, throw a ball, and work video game controls. (Tr. 28) (citing Tr. 205). Second, the ALJ cited the July 2008 visit with Dr. Guram's release of Plaintiff to continue cheerleading. (Tr. 28) (citing Tr. 308). Third, the ALJ cited Dr. Justin Field's October 25, 2004 report that "[Plaintiff] is quite active and has no limitations at this point except for contact sports." (Tr. 29) (citing and quoting Tr. 312). These references constitute substantial evidence to show an inconsistency with Plaintiff's testimony that the symptoms and pain are not as persistent and intense as claimed.
An ALJ discrediting lay witness testimony from family members of a plaintiff when the testimony is largely corroborative of a plaintiff's own testimony has found support in this District.
The testimony of Plaintiff's mother in this case is lay witness opinion that "does little more than corroborate a plaintiff's own testimony."
The undersigned has carefully reviewed the decision of the ALJ, the transcript of proceedings, Plaintiff's Motion and Brief, the Commissioner's Responsive Pleading, and Plaintiff's assignments of error. Review of the entire record reveals that the ALJ Decision is supported by substantial evidence.