MICHAEL A. TELESCA, District Judge.
Represented by counsel, Richard Pintagro ("Plaintiff") instituted this action pursuant to Title XVI of the Social Security Act ("the Act"), seeking review of the final decision of the Acting Commissioner of Social Security ("the Commissioner")
On September 10, 2012, Plaintiff protectively filed an SSI application, alleging a disability onset date of November 7, 2002, due to a traumatic ruptured disc, hypertension, dyslipidemia, obstructive sleep apnea, and chronic low back pain. (T.172-78, 194).
Before the Court are the parties' cross-motions for judgment on the pleadings. The Court will discuss the record evidence further below, as necessary to the resolution of the parties' contentions. For the reasons discussed below, the Commissioner's decision is affirmed.
Plaintiff argues that the ALJ erred in his weighing of the RFC questionnaire completed by State agency medical consultant Dr. Walter Cobbs on February 15, 2013. (T.262-69). Plaintiff further contends that the RFC assessment is not supported by substantial evidence.
On February 15, 2013, State agency medical consultant Dr. Walter Cobbs provided an opinion based on his review of the available medical records. (T.262-69). With regard to Plaintiff' exertional limitations, Dr. Cobbs opined that Plaintiff could occasionally lift and/or carry (including upward pulling) 20 pounds, frequently lift and/or carry (including upward pulling) 10 pounds, stand and/or walk (with normal breaks) at least 2 hours in an 8-hour day, sit (with normal breaks) about 6 hours in an 8-hour day, and had an unlimited ability to push and/or pull (including operation of hand/foot controls). (T.263). Dr. Cobbs cited the following evidence in support of these limitations: MRI dated October 6, 2008, showing mild to moderate degenerative disc disease ("DDD") without spinal stenosis or nerve root compression; a lumbar spine x-ray dated November 27, 2012, showing mild to moderate DDD; and office notes from J.G. Dahlie, M.D. (to whom Plaintiff apparently was referred by Dr. Erika Connor) showing "limitation of lumbar forward flexion to 20 deg[rees], but in multiple exams, DTR [deep tendon reflexes], SLR [straight-leg raising], sensory intact; toe and heel walk limited by back pain, gait slow, not antalgic, no aid to ambulation, no limitation upper extremities; may walk up to 4 hrs/8 hr day, unscheduled rest approximately 10 min[utes] hourly, sit [sic]. Sit may take 5 min[ute] break to stretch, 1/hr." (T.263-64).
The ALJ found that Plaintiff has the RFC to perform sedentary work,
(T.14). The ALJ did not include any unscheduled rest breaks in the RFC.
The ALJ stated in his decision that Dr. Cobbs' RFC questionnaire deserved "substantial weight" "except for the limits regarding standing/walking." (T.18). According to Plaintiff, the ALJ failed to reconcile Dr. Cobbs' report with the RFC by failing to include unscheduled rest breaks. Plaintiff interprets Dr. Cobbs' report as stating that he needs "unscheduled rest approximately ten minutes hourly" to sit, and, when sitting, needs one five-minute break every hour to stretch. This is a misreading of the record.
The section in which these rest breaks were mentioned were not part of Dr. Cobbs' opinion regarding Plaintiff's exertional limitations. Rather, Dr. Cobbs' reference to "unscheduled rest" was made in response to question 6 of the RFC form which asked Dr. Cobbs to "[c]ite the specific facts upon which [his] conclusions [in questions 1 through 5] are based." (T.263).
On August 8, 2011, Plaintiff's primary care physician Dr. Erika Connor wrote a letter stating that she was currently treating Plaintiff for chronic low back pain secondary to traumatic ruptured discs, hypertension, dyslipidemia, and obstructive sleep apnea. (T.254). She asserted that he "has been incapacitated since 2002 because of his back pain" and "is not able to work both because of his chronic pain but also secondary to the nature of treatment for his back pain." (
The ALJ assigned "partial weight" to Dr. Connor's August 8, 2011 letter because, as the ALJ correctly noted, it was on an issue reserved to the Commissioner. (T.18). An opinion that a claimant is totally or partially "disabled" or is under a "disability", even from an acceptable medical source such as a treating physician, is not entitled to any particular weight.
The ALJ also found that Dr. Connor's opinion that Plaintiff was "incapacitated" was inconsistent with the physician's own treatment notes. (T.18). This finding is based on substantial evidence in the record. The notes from early 2012
Plaintiff argues that the ALJ was required to recontacting Dr. Connor to request clarification or a more detailed opinion regarding Plaintiff's RFC. "[W]here there are no obvious gaps in the administrative record, and where the ALJ already possesses a complete medical history, the ALJ is under no obligation to seek additional information in advance of rejecting a benefits claim."
Here, the ALJ possessed a complete medical record containing multiple medical opinions, including the reports of Dr. Cobbs and consultative physician Dr. Joseph Prezio. Under the circumstances of this case, where the record is sufficient to make an informed decision on the question of disability, remand solely to recontact Dr. Conner is not required.
The ALJ found Plaintiff's subjective complaints less than fully credible in light of Plaintiff's daily activities, including his performance of community service, "lack of support in the objective evidence for the level of impairment alleged," "extensive polysubstance abuse," and "treatment non-compliance." Plaintiff argues that the ALJ's credibility analysis was not based on substantial evidence. Plaintiff only challenges the ALJ's consideration of his "polysubstance abuse."
Generally speaking, it is the function of the ALJ "to resolve evidentiary conflicts and to appraise the credibility of witnesses, including the claimant."
While the Regulations provide that the Commissioner "will not reject [a claimant's] statements about the intensity and persistence of [his] pain or other symptoms or about the effect [his] symptoms have on [his] ability to work . . . solely because the available objective medical evidence does not substantiate [his] statements[,]" 20 C.F.R. §§ 404.1529(c)(2), 416.929(c)(2), the ALJ nevertheless must determine credibility "in light of medical findings and other evidence[] regarding the true extent of the pain alleged by the claimant."
Here, Dr. Connor routinely observed normal ambulation and negative straight leg raising tests. (T.16, 282-305, 362-420). In fact, Dr. Connor "really emphasized [illegible] reg[ular] exercise [and] wt [sic] loss." (T.293). Consultative physician Dr. Prezio observed that Plaintiff displayed minimal lumbar tenderness despite his significantly decreased lumbar range of motion; SLR also was negative, with no muscle atrophy, and no neurological deficits. (T.274-75). Although Plaintiff did everything in "slow motion" as if he were "asleep during the entire evaluation" with Dr. Prezio, the consultative psychologist that same day did not describe Plaintiff as somnolent; instead, he was alert and oriented.
The ALJ was permitted to consider Plaintiff's treatment noncompliance, which was documented in the record. Plaintiff's primary care physician, Dr. Connor, repeatedly advised him to stop smoking marijuana, which he did not do. (T.285, 293, 329, 332). Plaintiff admitted to Dr. Connor on April 26, 2012, that he was "smoking marijuana and not using his sleep apnea ventilator as directed." (T.16). SSR 96-7p states, in pertinent part, that "the individual's statements may be less credible . . . if the medical reports or records show that the individual is not following the treatment as prescribed and there are no good reasons for this failure." SSR 96-7P, 1996 WL 374186, at *7 (S.S.A. July 2, 1996);
With regard to Plaintiff's alleged "polysubstance abuse," the ALJ used a term suggesting that Plaintiff was abusing more than one substance.
However, substantial evidence does support a finding that Plaintiff was illegally using marijuana, against his doctor's express instructions. There are also multiple instances in the record where Plaintiff falsely denied using marijuana. For instance, Plaintiff told consultative physician Dr. Prezio that he "does not . . . use street drugs and has never smoked." (T.273). While Plaintiff has pointed out an apparent inaccuracy in the ALJ's decision, the Court finds that any error was harmless, because the ALJ's ultimate conclusion with respect to Plaintiff's credibility was supported by substantial evidence. Therefore, the Court declines to overturn the Commissioner's decision on this basis.
For the foregoing reasons, the Court finds that the Commissioner's decision is not legally erroneous and is supported by substantial evidence. Accordingly, the Commissioner's decision is affirmed. Defendant's motion for judgment on the pleadings is granted, and Plaintiff's motion for judgment on the pleadings is denied.
The Clerk of Court is directed to close this case.