JEROME B. SIMANDLE, District Judge.
This matter comes before the Court pursuant to 42 U.S.C § 405(g) for review of the final decision of the Commissioner of the Social Security Administration ("SSA") denying the application of Plaintiff Donna Lynn Kalb ("Plaintiff") for Social Security Disability Benefits and Supplemental Security Income under Title II and XVI of the Social Security Act, 42 U.S.C. § 401
In the pending appeal, Plaintiff contends that the ALJ's decision must be reversed and remanded on three grounds. To that end, Plaintiff contends that the ALJ erred by: (1) failing to properly evaluate and weigh the medical evidence of record, including the opinions of Plaintiff's treating physician; (2) failing to make a finding of disability based on the existence of a listing level impairment consistent with Listing 1.04 in the Listings of Impairments; and (3) failing to consider all of Plaintiff's impairments in assessing her Residual Function Capacity ("RFC"). For the reasons that follow, the Court will affirm the ALJ's decision.
Plaintiff filed an application for Social Security Disability Benefits on April 16, 2013 (R. at 240-44), and an application for Supplemental Security Income on April 24, 2013 (R. at 245-50), alleging a disability onset date of March 20, 2013. Plaintiff's claim was denied by the SSA on July 15, 2013. (R. at 175-80). Her claim was again denied upon reconsideration on December 16, 2013. (R. at 185-90.) A hearing was held before ALJ Karen Shelton on November 24, 2015. (R. at 48-118.) The ALJ issued her opinion on January 15, 2016, denying benefits. (R. at 23-47.) On May 17, 2017, the Appeals Counsel denied Plaintiff's request for review. (R. at 3-8.) This appeal timely follows.
Plaintiff was 50 years old on the alleged disability onset date and 52 years old at the time of her hearing before the ALJ. (R. at 61.) She graduated from high school and subsequently earned a degree in office automation. (R. at 65.) Plaintiff subsequently worked for several years at various law firms, before spending ten years as a foreclosure coordinator at a mortgage company. (R. at 66-67.) In late 2012, Plaintiff left the mortgage company to work at a mortgage foreclosure law firm that laid her off in March 2013. (R. at 69-70, 73-74.) She then reapplied to work at the mortgage company she had previously left, but the mortgage company decided not to hire her back. (R. at 74.) Plaintiff then collected unemployment benefits while looking for other jobs. (R. at 75-76.) She has not worked since.
Plaintiff was diagnosed with lupus in 1993 (R. at 406), which was in remission until sometime in 2012. (R. at 433.) She was also diagnosed with diabetes mellitus in November 2012. (
On March 22, 2013, Plaintiff visited Dr. Vincent Savarese, M.D., an endocrinologist, for a follow up relating to poor glycemic control. (R. at 421.) Dr. Savarese observed that Plaintiff's blood glucose control was improving and that she had been working hard on diet and exercise. (
On April 12, 2013, Dr. Savarese observed that Plaintiff had full muscle strength in her upper and lower extremities with no atrophy noted. (R. at 437.) He also assessed Plaintiff with having diabetic peripheral neuropathy and prescribed her with 60mg Cymbalta per day. (R. at 438.) The following month, Plaintiff returned to Dr. Savarese who observed that Cymbalta improved her symptoms, though her neuropathic pain remained present. (R. at 433.) Dr. Savarese also noted that Plaintiff's lupus was no longer in remission. (
A September 6, 2013 MRI of Plaintiff's
From November 15, 2013 through July 15, 2015, Plaintiff attended pain management with RA Pain Services of Cherry Hill, consistently complaining of neck, lower back, and generalized joint pain. (R. at 702-58, 799-895.) On several occasions, she was noted as using a cane to ambulate. (R. at 705, 715, 721, 727, 738, 744, 750, 756, 802, 808, 815, 821, 827, 834, 841, 848, 862, 868, 874, 880, 886, 892.) On examination, Plaintiff had normal muscle strength and tone, and she was able to walk on her heels and toes. (
On March 5, 2014, Dr. Savarese prepared a physical residual functional capacity assessment wherein he opined that Plaintiff's symptoms would frequently interfere with her attention and concentration required to perform simple workrelated tasks; she would not be required to lie down during a workday in excess of her normal breaks or lunch; she could walk a half a block before needing to rest; she could sit and stand/walk for five minutes each at one time; she would need a job which permits shifting positions from sitting, standing, or walking; she would need to take two or three unscheduled breaks during an eight-hour workday; she could occasionally lift less than 10 pounds; and she would likely be absent once or twice a month. (R. at 976-78.) Ultimately, Dr. Savarese opined that Plaintiff was capable of working an eight-hour workday, five days a week with the limitations noted. (R. at 977.)
On or before March 19, 2014, Plaintiff started treating with Dr. James Dwyer, D.O., a rheumatologist. (R. at 966-68). On October 22, 2014, Plaintiff reported to Dr. Dwyer that "since last seen, she is doing somewhat better," but that she remains uncomfortable and fatigued. (R. at 961.) On examination, Dr. Dwyer noted that Plaintiff walked with a normal gait, had no swelling, warmth, or erythema in her joints, had a full range of motion in all joints with the exception of generalized tenderness in her upper and lower extremities with some light touch sensation changes in her lower extremity consistent with known diabetic neuropathy. (R. at 961.)
On February 9, 2015, Plaintiff revisited Dr. Dwyer, who this time noted that Plaintiff was taken off steroids because of problems with her diabetes and recent laboratory studies, which demonstrated improvement in her inflammatory markers. (R. at 959.) Plaintiff also reported to Dr. Dwyer that her depression had improved with Cymbalta. (
A June 3, 2015 MRI of Plaintiff's
On August 10, 2015, Dr. Dwyer observed on physical examination that Plaintiff had a normal gait with no swelling, warmth, or erythema in any joints and full range of motion of all joints except for diffuse tenderness without localization. (R. 956.) Additionally, Dr. Dwyer noted that recent laboratory studies showed her lupus at the present time was negative. (
On June 25, 2013, Plaintiff visited Dr. Jonathan Wahl, M.D., for a consultative examination. (R. at 525-27.) During this examination, Plaintiff was "comfortable, anxiety free, and in no apparent distress." (R. at 525.) Plaintiff reported burning neuropathy in her lower extremities, hip pain, and dizziness caused by Type I diabetes, as well as depression with decreased sleep and increased appetite. (
On July 17, 2013, Dr. Wahl prepared an addendum, wherein he noted that, while Plaintiff had somewhat decreased range of motion in her elbows, she had full range of motion of both shoulders and wrists, and unimpaired functioning of both hands. (R. at 532.) Dr. Wahl observed that Plaintiff had no swelling, effusion, tenderness, heat, or deformity in her wrists or hands, and full range of motion in her knees, hips, and ankles. (
Dr. Jyorthsna Shastry, M.D., a State agency medical consultant, reviewed Plaintiff's medical records and assessed her physical residual functional capacity. (R. at 134-35.) Dr. Shastry opined that Plaintiff could perform light work with occasional stooping, kneeling, crouching, crawling, and climbing ramps, stairs, ladders, ropes, or scaffolds. (
In an April 2013 Adult Function Report, Plaintiff reported that she lived alone, cared for pets, tended to personal care, prepared simple meals, washed laundry, cleaned when she could, drove a car, shopped in stores, handled her personal finances, watched television, and visited with friends and family at their homes. (R. at 285-89.)
During a hearing held by the ALJ on November 24, 2015, Plaintiff testified that she drove a car, prepared meals, dressed herself, read books and magazines, played with her pets, and shopped in stores. (R. at 285-89.) She also testified that she has "extreme chronic pain" due to her lupus (R. at 77), which she experiences 24 hours per day, 7 days per week. (R. at 114.) According to Plaintiff, she has flare ups of lupus that occur four to five times per month, lasting anywhere from one to three days. (R. at 85.) Since she was hospitalized in January 2013, Plaintiff reported that she has had "one flare after another." (R. at 80, 89.) Plaintiff testified that she could probably return to her prior job at the mortgage company, subject to certain limitations. (R. at 106-07) (Q: Do you think that if you got the job back at the mortgage place, that you'd be able to do it? A: As long as they could deal with me getting up and moving around all the time. Q: How often would that be? A: Probably every hour.).
During Plaintiff's hearing in front of the ALJ, the ALJ also heard testimony from William Slaven, a vocational expert. (R. at 110-113.) Based on Plaintiff's testimony, the vocational expert classified her past work as a Delinquent Account Clerk, DOT 241.357-010, which is skilled work that is sedentary. (R. at 111.) The vocational expert opined that a person with Plaintiff's RFC could perform work as a Delinquent Account Clerk, both as listed in the DOT, and as it was actually performed by Plaintiff. (R. at 112-13.)
In a written decision dated January 15, 2016, the ALJ found that Plaintiff was not disabled within the meaning of the Social Security Act at any time between the alleged onset date of disability and the date of the ALJ's written decision because, consistent with Plaintiff's age, education, work experience, and RFC, she was capable of working in her past job as a delinquent account clerk. (R. at 39.)
At the first stage of the five-step sequential evaluation process, the ALJ determined that Plaintiff had not engaged in substantial gainful activity since March 20, 2013, which was on or around the date she stopped working. (R. at 28.) The ALJ also noted that "the claimant applied for and received unemployment benefits after the alleged onset date," which "shows that the claimant was actively applying for work, claimed to be available for work and held themselves out [to] another agency to be able and willing to work during the adjudicative period." (R. at 28-29.) "While acceptance of unemployment benefits in no way impacts a medical determination of disability," the ALJ stated, "such acceptance . . . impacts the claimant's overall credibility regarding self-reported information." (R. at 29.)
Next, at step two, the ALJ determined that Plaintiff had the following "severe" impairments: systemic lupus erythematous; diabetes mellitus; and degenerative disc disease of the cervical and lumbar spine. (
At step three, the ALJ concluded that none of Plaintiff's impairments or combination of impairments met or medically equaled the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1, including those set forth in Listings 1.04, 11.14, and 14.02. (R. at 31.)
Between step three and step four, the ALJ determined that Plaintiff possessed the RFC to perform "sedentary work," as defined in C.F.R. §§ 404.1567(a) and 416.967(a), except that:
(R. at 31.)
In determining Plaintiff's RFC, the ALJ considered "all symptoms and the extent to which these symptoms can reasonably be accepted as consistent with the objective medical evidence and other evidence." (R. at 32.) Although the ALJ found that Plaintiff's impairments "could reasonably be expected to cause the alleged symptoms," she concluded that Plaintiff's statements "concerning the intensity, persistence and limiting effects of these symptoms are not entirely credible for the reasons explained in this decision." (R. at 33.) In doing so, the ALJ analyzed the medical evidence in the record with respect to each of Plaintiff's impairments, as well as the opinions of various treating physicians and State agency medical consultants. (R. at 31-39.)
In crafting the RFC, the ALJ assigned "little weight" to the March 2014 Physical RFC Assessment prepared by Plaintiff's treating endocrinologist, Dr. Savarese, after finding "it is a gross overstatement of [Plaintiff's] mental health limitations, the limiting effect(s) of her experience of pain/other symptoms and her physical limitations," and, according to the ALJ, "[t]he record simply does not corroborate Dr. Saverese's opinion and does not reveal the amount or frequency of positional changes that would have been observed in office visits if [Plaintiff] were limited as suggested in this opinion." (R. at 38.) The ALJ also assigned "little weight" to the May 2013 Residual Functional Capacity Questionnaire Jamie Strause prepared on Plaintiff's behalf, because:
(R. at 37.) With respect to Ms. Strause, the ALJ further noted that "as an advanced practice nurse, [she] is not an acceptable medical source," and her opinion thus carries "no weight." (
Based on Plaintiff's RFC and the vocational expert's testimony from the November 24, 2015 hearing, the ALJ found, at step four, that Plaintiff was able to perform her past relevant work as a delinquent account clerk. (R. at 39.) Accordingly, the ALJ found that Plaintiff was not under a disability, as defined in the Social Security Act, from March 20, 2013 through the date of the decision. (
This Court reviews the Commissioner's decision pursuant to 42 U.S.C. § 405(g). The Court's review is deferential to the Commissioner's decision, and the Court must uphold the Commissioner's factual findings where they are supported by "substantial evidence." 42 U.S.C. § 405(g);
In order to establish a disability for the purpose of disability insurance benefits, a claimant must demonstrate a "medically determinable basis for an impairment that prevents him from engaging in any `substantial gainful activity' for a statutory twelve-month period."
The Commissioner reviews claims of disability in accordance with the sequential five-step process set forth in 20 C.F.R. § 404.1520. In step one, the Commissioner determines whether the claimant currently engages in "substantial gainful activity." 20 C.F.R. § 1520(b). Present engagement in substantial activity precludes an award of disability benefits.
Plaintiff argues that the ALJ erred by: (1) failing to properly evaluate and weigh the medical evidence of record, including the opinions of Plaintiff's treating physician; (2) failing to make a finding of disability based on the existence of a listing level impairment consistent with Listing 1.04 in the Listings of Impairments; and (3) failing to consider all of Plaintiff's impairments in assessing her RFC. The Court addresses each argument in turn.
Plaintiff first avers that the ALJ erred in formulating her RFC between steps three and four by assigning "little weight" to the opinion of Plaintiff's treating endocrinologist, Dr. Savarese. (Pl.'s Br. at 7-10.) Specifically, Plaintiff argues that the ALJ improperly discounted Dr. Savarese's March 5, 2014 opinion that, because of her symptoms, Plaintiff would need to take unscheduled breaks, possibly two to three times per day and lasting up to thirty minutes at a time, and that Plaintiff would also likely miss one or two days of work per month. (
SSR 96-8p dictates that the RFC assessment be a "functionby-function assessment based upon all of the relevant evidence of an individual's ability to do work-related activities." In order to meet the requirements of SSR 96-8p, the ALJ "must specify the evidence that he relied upon to support his conclusion."
"[T]he ALJ — not treating or examining physicians or State agency consultants — must make the ultimate disability and RFC determinations."
In determining Plaintiff's RFC, the ALJ carefully considered and thoroughly discussed all available medical records and the opinions of several doctors who examined Plaintiff, including Dr. Savarese. (R. at 31-39.) Ultimately, the ALJ assigned "little weight" to Dr. Savarese's opinion after finding "it is a gross overstatement of [Plaintiff's] mental health limitations, the limiting effect(s) of her experience of pain/other symptoms and her physical limitations," and because "[t]he record simply does not corroborate Dr. Saverese's opinion and does not reveal the amount or frequency of positional changes that would have been observed in office visits if [Plaintiff] were limited as suggested in this opinion." (R. at 38.)
Substantial evidence supports the ALJ's decision to discount Dr. Savarese's opinion. For example, Dr. Savarese's opinion was inconsistent with treatment notes from Plaintiff's pain management physicians showing she had normal muscle strength and was able to walk on her heels and toes (R. at 705, 715, 721, 727, 738, 744, 750, 756, 802, 827, 834-35, 841-42, 848-49, 855-56, 862, 868, 874, 880, 886, 892), as well as Dr. Dwyer's treatment notes indicating that Plaintiff walked with a normal gait, had no swelling, warmth, or erythema in her joints, and had full range of motion in all joints with the exception of generalized tenderness in her upper and lower extremities with some light touch sensation changes in her lower extremity consistent with known diabetic neuropathy. (R. at 956, 959, 961.) Dr. Savarese's opinion was also inconsistent with Dr. Wahl's examination (R. at 532), and the opinions of the State agency medical consultants. (R. at 134-35, 164-66.) On this record, the ALJ did not err.
Plaintiff next argues that the ALJ failed to make a finding that Plaintiff meets or equals a level impairment consistent with Listing 1.04A. (Pl. Br. at 10-13.) To that end, Plaintiff maintains "there is sufficient evidence in the record that meets or equals a Listing level impairment consistent with 1.04(A)." Listing 1.04A. (
20 C.F.R. §§ 404.1512(g), 404.1560(c). The ALJ found:
(R. at 31) (emphasis added). The ALJ's finding is consistent with the notes of several physicians that concluded Plaintiff had full strength with no evidence of atrophy. (R. at 434, 437, 532, 705, 715, 721, 727, 738, 744, 750, 745, 802, 808, 815, 821, 827, 834-35, 841-42, 848-49, 855-56, 862, 868, 874, 880, 886, 892.) Accordingly, substantial evidence supports the ALJ's findings regarding Listing 1.04.
Finally, Plaintiff argues that the ALJ failed to properly consider all of Plaintiff's "severe" and "non-severe" impairments in formulating her RFC. (Pl. Br. at 13-18.) Specifically, Plaintiff avers that the ALJ overlooked, ignored, or improperly evaluated Plaintiff's cervical and lumbar radiculopathy, mental impairments, lupus, and peripheral neuropathy. To the contrary, the Court finds that substantial evidence supports the ALJ's determination that, notwithstanding these conditions, Plaintiff could perform a range of sedentary work.
Between steps three and four, the ALJ is required to assess all of the claimant's impairments — even ones that are not "severe" — in combination, when making the RFC determination.
SSR 96-8p (emphasis added);
Here, the ALJ accounted for all of Plaintiff's "severe" (R. at 32-39) and "non-severe" impairments (R. at 29-31), before finding that she possessed the RFC to perform "sedentary work," except that:
(R. at 31.) As the ALJ explained:
(R. at 39.) The Court finds that the ALJ fully considered all of Plaintiff's severe and non-severe impairments, including her cervical and lumbar radiculopathy, mental impairments, lupus, and peripheral neuropathy, and reasonably determined that Plaintiff could perform sedentary work with the limitations set forth in the RFC. Accordingly, substantial evidence supports the ALJ's treatment of Plaintiff's impairments in the formulation of her RFC.
For the foregoing reasons, the ALJ's decision will be affirmed. An accompanying order will be entered.
