WILLIAM M. SKRETNY, District Judge.
1. Plaintiff Todd Robert Strzelczyk 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 disability insurance benefits ("DIB") and Supplemental Security Income ("SSI") 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 November 6, 2013 and December 3, 2013, respectively. (R.
3. On April 12, 2016, ALJ Melissa Jones held a hearing at which Plaintiff— assisted by a non-attorney representative—appeared and testified. (R. at 31-78). Vocational Expert ("VE") Susan Rowe also appeared and testified via telephone.
4. The ALJ considered the case de novo and, on May 9, 2016, issued a written decision denying Plaintiff's applications for benefits. (R. at 10-25). On September 15, 2017, the Appeals Council denied Plaintiff's request to review the ALJ's decision. (R. at 1-6). 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, 12). Plaintiff filed a response on July 31, 2018 (Docket No. 13), 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.
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 May 23, 2013. (R. at 12). At step two, the ALJ found that Plaintiff has the severe impairments of attention deficit hyperactivity disorder/anxiety ("ADHD") and adjustment disorder/anxiety. (R. at 13). At step three, the ALJ found that Plaintiff does not have an impairment or combination of impairments that meets or medically equals any impairment(s) listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. (R. at 13-15).
12. Next, the ALJ found that Plaintiff retained the residual functional capacity ("RFC") to perform work "with only the non-exertional limitations that he is restricted to simple routine and repetitive tasks not at a production rate pace and he can have only occasional interaction with supervisors, coworkers, or the public." (R. at 15).
13. At step four, the ALJ found Plaintiff capable of performing his past relevant work as an assembler. (R. at 23). Accordingly, the ALJ found that Plaintiff is not disabled. (R. at 24).
14. Plaintiff argues that remand is required because the ALJ improperly evaluated medical opinion evidence. (Docket Nos. 8 at 13-19, 13 at 1-3). For the reasons that follow, this argument fails.
15. Plaintiff first argues that the ALJ failed to provide good reasons for rejecting the opinion of Dr. Yap, Plaintiff's treating psychiatrist.
16. Dr. Yap performed an initial psychiatric assessment of Plaintiff on Sept 4, 2013. (R. at 320-22). Plaintiff reported problems with keeping track of time, lack of motivation, anxiety, depression, and decreased memory.
17. On October 8, 2013, Plaintiff reported improvements in mood, depression, and anxiety with medication, but stated that when playing a live video game, "he gets quite anxious and panicky and he gets excited [. . .] to win the game." (R. at 372). Ten days later, Plaintiff—who admitted continued alcohol use—exhibited some significant anxiety and depression symptoms along with some mood lability and complained of difficulty sleeping. (R. at 373). Plaintiff stated that "he cannot work because his sleep schedule is very erratic."
18. Dr. Yap noted that Plaintiff continued to experience anxiety and an erratic sleep pattern on November 15, 2013, following a break-up. (R. at 374). However, progress notes from December 2013 and January 2014 indicate Plaintiff reported improvements in mood, anxiety, and sleep. (R. at 375-76).
19. On March 27, 2014, Plaintiff's mood was fair and he reported having started a new relationship. (R. at 377). Plaintiff described his compliance with prescribed medication as "judicial" and expressed a willingness to participate in vocational rehab.
20. In May, Plaintiff's mood was better, but difficulties with sleep continued. (R. at 378). Dr. Yap increased his mood stabilizer dosage and Plaintiff planned to attend a sleep clinic.
21. On June 27, 2014, Plaintiff reported a "flare up with his anxiety" while helping a friend in his garage. (R. at 379). Plaintiff described the work as "dangerous" because something heavy could have fallen on him and reported feeling shaky while performing the work, but persevered to complete the task.
22. On August 1, 2014, Plaintiff reported an upset stomach and mood swings. (R. at 380). Dr. Yap noted that Plaintiff's medications could cause stomach upset and changed his prescriptions.
23. Plaintiff was more depressed and anxious on September 26, 2014, after his parents told him he must move out in 30 days. (R. at 381). Plaintiff did not know where he would live after that and admitted to drinking three to five times the prior week, consuming six beers each time.
24. On April 1, 2014, Dr. Yap completed a mental functional limitation evaluation form in which he diagnosed Plaintiff with adjustment disorder with anxious and depressed traits and ruled out personality disorder. (R. at 385-87).
25. Dr. Yap opined that Plaintiff would be significantly limited (able to function less than 59% of the time) with respect to most areas of functioning, including any ability to: follow work rules; function independently; maintain attention and concentration; understand, remember, or carry out simple job instructions; maintain personal appearance; and demonstrate reliability.
26. The ALJ gave little weight to Dr. Yap's April 2014 opinion of Plaintiff's functional limitations, finding the opinion inconsistent with Dr. Yap's own treatment notes that indicate Plaintiff reported improvements and an ability to complete tasks, and because Dr. Yap indicated the limitations would not persist if Plaintiff ceased to use drugs and/or alcohol. (R. at 20). The Court finds no error in this evaluation.
27. "[A claimant's] drug and alcohol abuse do not preclude a grant of Social Security disability benefits" where other severe impairments are found "independently disabling."
28. Because Dr. Yap opined that Plaintiff's functional limitations would not persist independent of his drug and/or alcohol use, Plaintiff has not met this burden.
29. Plaintiff also argues that the ALJ erred in evaluating the opinion of another treating psychiatrist, Dr. Hak Ko. (Docket No. 8 at 17-19). A mental functional limitation evaluation form signed by Dr. Ko on March 14, 2016 indicates diagnoses of unspecified anxiety and ADHD and ruled out alcohol abuse. (R. at 395-97).
30. Here, Dr. Ko opined that Plaintiff is incapable of performing appropriately, effectively, and on a sustained basis even 60% of the time in any area of functioning (occupational, performance, or personal-social).
31. Handwritten notes describe Plaintiff's difficulties with stress management, focus, and concentration as well as his poor hygiene and time management.
32. Dr. Ko indicated that Plaintiff's described functional limitations would persist "to a degree" if he stopped using alcohol and/or drugs, and explained:
33. The ALJ gave little weight to this opinion because it was "formed based upon an examination [where Plaintiff] was observed to be under the influence of alcohol" and "appear[ed] to rest largely on [Plaintiff's] subjective complaints and history, which are not supported by the medical evidence of record." (R. at 20).
34. The Court finds no error in this evaluation. The relevant inquiry before the ALJ is whether Plaintiff would be disabled if he stopped using drugs or alcohol. Dr. Ko's opinion describes Plaintiff's symptoms and limitations only as exacerbated by his drug or alcohol use. (R. at 395-97). As such, this opinion provides little insight into the effect or severity of any impairments that would persist in the absence of Plaintiff's drinking. Thus, the ALJ did not err in giving Dr. Ko's opinion little weight.
35. Plaintiff argues in the alternative that even though the ALJ had good reasons to give little weight to this opinion, she should have "recontacted Dr. Ko for the basis of his opinion." (Docket No. 8 at 19). This argument is unavailing.
36. The duty to seek clarification of a medical opinion arises only when the medical record is incomplete or otherwise insufficient to allow the ALJ to determine whether a claimant is disabled.
37. Here, the record—which is not alleged to be incomplete—contains other medical opinions that are not restricted to an examination of symptoms or limitations made more severe by alcohol or drug use. The ALJ gave great weight to three of these opinions. (R. at 21-22).
38. The ALJ gave great weight to the opinion of consulting examiner Dr. Santarpia, who performed a psychiatric evaluation on February 20, 2014. (R. 336-39). Dr. Santarpia's mental status examination found Plaintiff well-groomed, with appropriate eye contact, speech and affect, and euthymic mood. (R. at 337). Plaintiff's attention, concentration, and memory skills were all intact, and he exhibited average cognitive function with fair insight and judgment. (R. at 338).
39. Dr. Santarpia opined that Plaintiff is mildly impaired with respect to performing complex tasks independently and that he has some difficulties due to distractibility, but that he could "follow and understand simple directions and instructions, perform simple tasks independently, maintain attention and concentration, maintain a regular schedule, learn new tasks, make appropriate decisions, relate adequately with others, and appropriately deal with stress within normal limits."
40. The ALJ also gave great weight to the opinions of treating physician Dr. Gullickson, and consulting examiner Dr. Liu. (R. at 22). Dr. Gullickson opined that Plaintiff did not have a marked restriction in his daily activities and could perform heavy work. (R. at 370-71). Results of Dr. Liu's physical examination of Plaintiff were unremarkable, and he opined that Plaintiff has no limitation for routine activities. (R. at 341-44). The ALJ found these opinions to be consistent with clinical findings and the medical record, and so afforded each opinion great weight. Plaintiff does not point to any insufficiency in this evidence, nor to any missing records, so this Court finds that the ALJ was not under an obligation to recontact Dr. Ko.
41. In this case, the ALJ has given good reasons for her evaluation of the medical opinion evidence and there is no indication the record is inadequate as a basis for a disability determination. In fact, the very opinions Plaintiff would see the ALJ bound to adopt support only that Plaintiff's functional limitations would not persist if he stopped drinking. For the foregoing reasons, the Court finds that the ALJ's determination that Plaintiff is not disabled is supported by substantial evidence.
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. 12) is GRANTED.
FURTHER, that the Clerk of Court is directed to CLOSE this case.
SO ORDERED.