WILLIAM M. SKRETNY, District Judge.
1. Plaintiff Robert Fazzio brings this action pursuant to the Social Security Act ("the Act"), seeking review of the final decision of the Commissioner of Social Security that denied his applications for Supplemental Security Income ("SSI") and disability insurance benefits ("DIB") under Titles II and XVI of the Act. (Docket No. 1). The Court has jurisdiction over this action under 42 U.S.C. § 405(g).
2. Plaintiff protectively filed applications for DIB and SSI with the Social Security Administration ("SSA"), on May 16, 2013, and May 22, 2013, respectively. (R.
3. On June 2, 2015, ALJ Stephen Cordovani held a hearing at which Plaintiff— assisted by counsel—appeared and testified. (R. at 42-86). Vocational Expert ("VE") Josiah Lee Pearson also appeared and testified at the hearing via telephone.
4. The ALJ considered the case de novo and, on August 14, 2015, issued a written decision denying Plaintiff's applications for benefits. (R. at 16-28). On July 31, 2017, the Appeals Council denied Plaintiff's request to review the ALJ's decision. (R. at 1-4). Plaintiff filed the current action, challenging the Commissioner's final decision,
5. Both parties moved for judgment on the pleadings under Rule 12(c) of the Federal Rules of Civil Procedure. (Docket Nos. 8, 13). Plaintiff filed a response on July 27, 2018 (Docket No. 15), at which time this Court took the matter under advisement without oral argument. For the reasons that follow, Plaintiff's motion is denied and Defendant's motion is granted.
6. A court reviewing a denial of disability benefits may not determine de novo whether an individual is disabled.
7. "To determine on appeal whether an ALJ's findings are supported by substantial evidence, a reviewing court considers the whole record, examining the evidence from both sides, because an analysis of the substantiality of the evidence must also include that which detracts from its weight."
8. The Commissioner has established a five-step sequential evaluation process to determine whether an individual is disabled under the Act.
9. The five-step process is as follows:
10. Although the claimant has the burden of proof on the first four steps, the Commissioner has the burden of proof on the fifth and final step.
11. The ALJ analyzed Plaintiff's claim for benefits under the process set forth above. At step one, the ALJ found that Plaintiff has not engaged in substantial gainful activity since January 23, 2007
12. Next, the ALJ found that Plaintiff retained the residual functional capacity ("RFC") to perform light work with the following exceptions: "lift, carry, push and pull limited to no more than 15 pounds; occasional bending and twisting; and alternate sitting and standing every 30 minutes. [Plaintiff] can understand, remember and carry out simple instructions and tasks, with instruction to be provided orally." (R. at 19-26).
13. At step four, the ALJ found that Plaintiff is unable to perform any past relevant work. (R. at 26). At step five, the ALJ found that Plaintiff is capable of performing jobs that exist in significant numbers in the national economy.
14. Plaintiff argues that the ALJ's RFC determination is not supported by substantial evidence because the ALJ improperly relied on "stale" medical opinion evidence. (Docket No. 8 at 9-11; Docket No. 15 at 1-3).
15. "[M]edical source opinions that are conclusory, stale, and based on an incomplete medical record may not be substantial evidence to support an ALJ finding."
16. "However, a medical opinion is not stale simply based on its age. A more dated opinion may constitute substantial evidence if it is consistent with the record as a whole."
17. Here, in evaluating Plaintiff's RFC, the ALJ gave greatest weight to medical opinions from 2007 and 2009
18. In April of 2007, Dr. Mitchell determined that Plaintiff could return to work after being injured on January 22, 2007, but restricted Plaintiff to "no lifting over 20 pounds for 2 weeks." (R. at 372). The ALJ gave this opinion significant weight, noting that "although it is less detailed and less well explained," it is "generally consistent with the opinion of Dr. DenHaese." (R. at 25). The ALJ also noted that Dr. Mitchell's opinion was less relevant to a determination of long-term disability or impairment, because the opinion was rendered proximate to Plaintiff's alleged onset injury.
19. On July 10, 2007, Plaintiff was referred to Dr. Kaplan for consultation of his midthoracic discomfort. (R. at 263). Dr. Kaplan noted that Plaintiff had received no treatment for his January 22, 2007 lumbar injury and diagnosed thoracolumbar sprain and dysfunction.
20. At a follow-up visit on August 21, 2007, Dr. Kaplan noted that Plaintiff had recently returned to work as a roofer, working with restrictions, and recommended physical therapy. (R. at 265). Plaintiff returned to Dr. Kaplan on February 7, 2008. (R. at 266). Plaintiff reported that he had a lot of personal issues that prohibited him from follow-up care.
21. Plaintiff attended 7 physical therapy sessions in 2008 between February 14 and March 11 and, on March 13, 2008, reported a 30-40% improvement in his symptomology and denied pain medication. (R. at 267). Dr. Kaplan ordered an MRI and recommended that Plaintiff continue with physical therapy.
22. A May 5, 2008 magnetic resonance imaging scan ("MRI") of Plaintiff's lumbar spine showed no disc herniations or stenosis, but did show "a small degree of bony hypertrophy [. . .] with minimal borderline appearing disc bulges at L3-4 and L4-5" and a "small area of edema along a portion of the L4 vertebral body." (R. at 22, 269).
23. In an addendum to a report from February 23, 2009, Dr. DenHaese opined that Plaintiff had a mild to moderate level of disability and imposed work restrictions limiting Plaintiff to "no lifting greater than 15 lb., no repetitive bending, twisting motions, and no repetitive pulling motions." (R. at 366). The ALJ gave this opinion great weight because it was expressed in functional terms and consistent with the record as a whole, as well as consistent with Plaintiff's own testimony. (R. at 24-25).
24. On March 11, 2009, Plaintiff saw Dr. Pilly for consultation for low back pain. (R. at 362). Physical exam showed 5/5 strength throughout both upper and lower extremities, normal range of motion of the lumbar spine with no kyphotic or scoliotic deformity, and normal gait and station. (R. at 364). Dr. Pilly noted that Plaintiff was on temporary total disability and recommended physical therapy and epidural steroid injections. (R. at 365).
25. On September 29, 2009, Dr. Pilly opined that Plaintiff had L5-S1 disc herniation causing a bilateral S1 radiculopathy and thoracic disc herniation causing a thoracic radiculopathy. (R. at 303). Dr. Pilly noted that Plaintiff "is classified as a mild disability" and scheduled Plaintiff for epidural steroid injections. (R. at 303-04).
26. Dr. Pilly re-evaluated Plaintiff on March 9, 2010. (R. at 299). He noted that Plaintiff had failed to keep appointments for epidural steroid injections and now "adamantly declines" to undergo that form of treatment. (R. at 299-300). Dr. Pilly asked Plaintiff to undergo an electromyogram (EMG) and nerve conduction study, and indicated that depending on the results of the study, he might refer Plaintiff to neurosurgery for consideration of a minimally invasive decompressive surgery. (R. at 300).
27. The EMG on May 27, 2010 revealed no abnormal findings and no evidence of acute bilateral lumbar radiculopathy. (R. at 294-296). However, the ALJ noted that the EMG "did not rule out a small fiber sensory radiculopathy" in the lower extremities. (R. at 23).
28. Plaintiff was re-evaluated on June 9, 2010, following the EMG study. (R. at 290). Plaintiff reported some improvement in symptoms with physical therapy, but refused chiropractic care.
29. On June 15, 2010, Plaintiff's MRI showed no significant changes from the 2008 scan. (R. at 23, 292). Once again, Plaintiff had no disc herniations or stenosis, though he had "a tiny degree of edema [. . .] which is similar to the previous exam," as well as "a minimal degree of some bony hypertrophy [. . .] similar to the previous exam," and "borderline tiny bulges [. . .] unchanged compared to the previous exam." (R. at 292).
30. On July 22, 2010, Plaintiff was evaluated by Dr. Siddiqui for complaints of back pain. Plaintiff stated that he continued to go to physical therapy, but that he had not attended in several weeks. (R. at 305). Plaintiff also claimed that "[h]e recently went to Virginia Beach and had been participating in physical activities there."
31. Between 2010 and 2013, Plaintiff received no treatment for his allegedly disabling condition. (R. at 332). On June 6, 2013, Plaintiff presented to Dr. Vigna with complaints of low back pain, which he rated at a level of 7/10 that day.
32. Plaintiff reported that he "does not drive long distances and does not know how far he could drive with his low back pain."
33. Dr. Vigna noted that x-rays taken that day—June 6, 2013—showed normal thoracic and lumbosacral spines with "well-preserved disc heights and no instability." (R. at 325-28). Dr. Vigna ordered updated MRI and EMG studies, recommended chiropractic treatment, and indicated that Plaintiff had a 66.66% temporary impairment for workers' compensation purposes. (R. at 334).
34. On July 25, 2013, Dr. Vigna noted that Plaintiff's recent MRI demonstrated a "small degree of early osteophyte development and edema involving [. . .] the L3 and L4 vertebral bodies," and that (R. at 343) Plaintiff's June 27, 2013 EMG study had found no evidence of active denervation, but was "highly suggestive of a chronic right L5 radiculopathy." (R. at 340). Dr. Vigna also noted that Plaintiff had not attended chiropractic treatment because his truck had broken down and referred him to a chiropractor located nearer Plaintiff's home. (R. at 342-43). Dr. Vigna again opined that Plaintiff had a 66.66% temporary impairment. (R. at 343).
35. The ALJ discussed the opinions of Drs. Pilly, Siddiqui, and Vigna, but noted they were rendered for Plaintiff's workers' compensation case. (R. at 21-25). The ALJ gave these opinions little weight because "they are not well explained nor expressed in functional terms," and because they were based on rules inapplicable to Social Security disability determinations. (R. at 25).
36. It is well settled that "a treating physician's opinion that an individual is disabled is not entitled to controlling weight, because the ultimate issue of disability is reserved for the Commissioner."
37. Furthermore, "the ALJ correctly noted that the determination of disability in the context of a workers' compensation claim uses a different standard than the Social Security Act."
38. The ALJ also gave little weight to the opinion of Dr. Latona-Brzezinski, a chiropractor who opined that Plaintiff was 100% disabled. (R. at 25). Between January and April of 2014, Dr. Latona-Brzezinski completed various workers' compensation forms related to Plaintiff's chiropractic care and massage therapy. (R. at 393-415). Dr. Latona-Brzezinski's initial report, dated January 6, 2014, indicated that Plaintiff was currently working (R. at 399) and that Plaintiff had "severe muscle spasms in his mid/lower back and would greatly benefit from massage therapy in conjunction with chiropractic [care]." (R. at 401).
39. A progress report dated February 3, 2014 indicated there had been no changes in Plaintiff's injury, subjective complaints, or objective findings; nor were there any changes to the current treatment plan, which consisted of massage therapy that day. (R. at 409). The form also indicated Dr. Latona-Brzezinski's opinion that Plaintiff had a 100% temporary impairment, would not benefit from vocational rehabilitation, and was unable to return to work.
40. On February 5, 2014, Dr. Latona-Brzezinski requested authorization for six weeks of massage therapy, stating "[Plaintiff] has been progressing well with the combination of massage therapy and chiropractic treatment. It would be in the best interest of the patient to continue with this treatment plan." (R. at 411).
41. On February 28, 2014, Dr. Latona-Brzezinski indicated there had been no changes in Plaintiff's injury status or treatment plan and again opined—without explanation or support—that Plaintiff had a 100% temporary impairment and could not return to work because "pain preventing." (R. at 412). Questions on the workers' compensation form that asked about Plaintiff's work status and whether he would benefit from vocational rehabilitation were left unanswered.
42. The ALJ noted that "a chiropractor is not considered an acceptable [medical] source," and that Dr. Latona-Brzezinski's opinion was "conclusory and unexplained," "not expressed in functional terms," and was based on workers' compensation rules. (R. at 25). In addition, the ALJ found that Dr. Latona-Brzezinski's treatment notes were internally inconsistent, pointing out that the first report, which indicated Plaintiff was currently working (R. at 399-401), was "not substantially different" from subsequent reports that alleged Plaintiff was 100% disabled (R. at 409, 412). (R. at 25). For these reasons, the ALJ properly discounted Dr. Latona-Brzezinski's opinions.
43. The ALJ also considered Plaintiff's testimony regarding cessation of treatment for his allegedly disabling condition and Plaintiff's recent full-time work experience. (R. at 24-25). In addition to receiving no treatment between 2010 and 2013 (R. at 332), at the hearing on June 1, 2015, Plaintiff testified that he had not seen a doctor nor had he sought any form of treatment since the end of summer, 2014. (R. at 65-66). Since then, Plaintiff had managed his pain by using a heating pad, taking hot baths, and taking over-the-counter Ibuprofen. (R. at 64-65).
44. Plaintiff testified that he was hired through a temp agency as a parts inspector for fuel injection systems in 2014. (R. at 56-58). He stopped attending his massage therapy sessions after that, stating he "couldn't make it [to massage therapy] because [he] was working those days." (R. at 65). Hired on March 24, 2014 (R. at 193), Plaintiff worked full-time—four days a week, 10 hours each day—for approximately four months, performing a job that required him to stand at a machine for 2-3 hours at a time without breaks. (R. at 57-58, 62, 66-67). Plaintiff lost this job when the hiring company stopped working with his temp agency. (R. at 56-57).
45. In determining Plaintiff's RFC, the ALJ considered the entire record, including Plaintiff's treatment history, recent full-time work experience, and opinion evidence. (R. at 19-26). Nothing in the record indicates that the ALJ relied on opinions that were inconsistent with the record or that the ALJ erred in giving little weight to opinions rendered for workers' compensation purposes.
46. Moreover, despite Plaintiff's claim that "the record does support some evidence that [Plaintiff's] condition worsened since March of 2009," there is no indication that Plaintiff suffered from a clearly deteriorating condition at the time of the ALJ's decision. If anything, evidence that Plaintiff's allegedly disabling condition went untreated for years, together with Plaintiff's return to full-time work for several months in 2014 supports the opposite conclusion. Therefore, Plaintiff's contention that the ALJ relied on stale evidence is unpersuasive.
47. Having reviewed the ALJ's decision in light of Plaintiff's arguments, this Court finds no error in the ALJ's determination. The decision contains an adequate discussion of the medical and opinion evidence supporting the ALJ's determination that Plaintiff is not disabled, and Plaintiff's aforementioned arguments are unavailing. Plaintiff's Motion for Judgment on the Pleadings is therefore denied, and Defendant's motion seeking the same relief is granted.
IT HEREBY IS ORDERED, that Plaintiff's Motion for Judgment on the Pleadings (Docket No. 8) is DENIED.
FURTHER, that Defendant's Motion for Judgment on the Pleadings (Docket No. 13) is GRANTED.
FURTHER, that the Clerk of Court is directed to CLOSE this case.
SO ORDERED.