NANCY A. VECCHIARELLI, Magistrate Judge.
Plaintiff, Arthur Dailey ("Plaintiff"), challenges the final decision of Defendant, Carolyn W. Colvin, Acting Commissioner of Social Security ("Commissioner"), denying his application for Period of Disability ("POD") and Disability Insurance Benefits ("DIB") under Title II of the Social Security Act ("Act"),
On April 4, 2012, Plaintiff filed his application for POD and DIB and alleged a disability onset date of March 23, 2012. (Transcript ("Tr.") 10.) The application was denied initially and upon reconsideration, and Plaintiff requested a hearing before an administrative law judge ("ALJ"). (Id.) On June 5, 2013, an ALJ held Plaintiff's hearing. (Id.) Plaintiff participated in the hearing, was represented by counsel, and testified. (Id.) A vocational expert ("VE") also participated and testified. (Id.) On June 13, 2013, the ALJ found Plaintiff not disabled. (Tr. 7.) On July 22, 2013, the Appeals Council declined to review the ALJ's decision, making it the Commissioner's final decision. (Tr. 1.)
On August 12, 2013, Plaintiff filed his complaint to challenge the Commissioner's final decision. (Doc. No. 1.) The parties have completed briefing in this case. (Doc. Nos. 10, 11.)
Plaintiff asserts the following assignments of error: (1) The ALJ erred in evaluating the opinions of Plaintiff's treating physicians; (2) the ALJ erred in assigning great weight to the opinions of non-examining state agency physicians; and (3) the ALJ's residual functional capacity (RFC) determination is not supported by substantial evidence.
Plaintiff was born in February 1964 and was 48-years-old on the alleged disability onset date. (Tr. 16.) He had a limited education and was able to communicate in English. (Tr. 17.) He had past relevant work as a furnace operator and foundry worker. (Tr. 16.)
Plaintiff was diagnosed with multiple sclerosis in 2000. (Tr. 15.) An MRI of Plaintiff's brain from May 31, 2012, showed stable white matter changes and no new lesions. (Tr. 1015, 1045.) On June 27, 2012, Plaintiff saw Darshan Mahajan, M.D., with complaints of increased tingling and burning on his right side, arm, and leg, as well as neck pain. (Tr. 1015.) Plaintiff also complained of "feeling somewhat jittery inside." (Id.) Dr. Mahajan listed Plaintiff's active diagnoses as dizziness and giddiness; unspecified essential hypertension; type II or unspecified type diabetes mellitus without mention of complication, not stated as uncontrolled; and multiple sclerosis. (Tr. 1016.) On examination, Plaintiff's strength was well maintained, his balance was good, and he was ambulating well. (Tr. 1017.) Treatment records show that Plaintiff has done relatively well with his multiple sclerosis but has experienced some exacerbations over the years which affect the right side of his body. (Tr. 277-308, 341-372, 390-392, 394-396, 463-466, 468-471, 985-988, 1015-1018, 1032-1046, 1199-1207, 1209-1212, 1251-1254, 1310-1365, 1467-1470.)
From January 31, 2012, to at least October 22, 2012, Bharat C. Shah, M.D., often observed that Plaintiff had normal strength, sensation, and/or reflexes in his arms and legs. (Tr. 867, 869-870, 1258, 1260-1261, 1264, 1267, 1270.) On April 26, 2013, Dr. Mahajan observed that Plaintiff was "ambulating better now" and was using a cane to stabilize himself. (Tr. 1470.) On examination, Plaintiff's strength was wellmaintained and his balance was good. (Tr. 1469.) At a May 20, 2013, examination, Plaintiff displayed a normal gait and station. (Tr. 1444.)
Records from Dr. Shah note that Plaintiff received treatment for cervicalgia, lumbago, and sacroiliitis. Plaintiff underwent a lumbar spine x-ray on February 4, 2012, which showed mild multi-level discogenic degenerative changes. (Tr. 1379.) An x-ray of Plaintiff's cervical spine from June 20, 2012, showed right C3-4 neuroforaminal compromise from facet arthropathy. (Tr. 1013.) Plaintiff's cervical vertebral bodies remained normally aligned and preserved in height. (Id.) His disc space heights were also maintained. (Tr. 1013.) Furthermore, MRIs of the thoracic and lumbar spines performed on April 8, 2012, were normal, and an MRI of the cervical spine performed on August 21, 2012, was unremarkable. (Tr. 842, 1204-1205.) As noted previously, from January 31, 2012, to at least October 22, 2012, physical examinations have noted normal muscle strength, normal sensation, and normal reflexes. (Tr. 277-308, 341-372, 390-392, 394-396, 463-466, 468-471, 985-988, 1015-1018, 1032-1046, 1199-1207, 1209-1212, 1251-1254, 1310-1365, 1467-1470.)
Plaintiff has been diagnosed with coronary artery disease. (Tr. 1015.) In April 2008, physicians implanted a drug-eluting stent in Plaintiff's circumflex artery due to a myocardial infarction. (Tr. 374, 382, 390, 394, 398-399, 402, 522.) After complaining of angina, Plaintiff underwent a cardiac catheterization on February 24, 2012, which showed two-vessel non-obstructive coronary disease with good ventricular function. (Tr. 484.) From May 7 to May 9, 2013, Plaintiff sought treatment at EMH Healthcare after sustaining a non-ST elevated myocardial infarction. (Tr. 1427-1434.) He underwent another catheterization. (Tr. 1433.) Following this procedure, Plaintiff maintained an ejection fraction of 55% with moderate ventricular hypertrophy. (Id.) Two weeks later, Plaintiff reported that he was doing well and no longer had chest pain or shortness of breath. (Tr. 1451.)
Plaintiff underwent a sleep study on December 14, 2012, which demonstrated moderate sleep apnea. (Tr. 1350-1351.) Plaintiff was prescribed a CPAP mask, which he reported helped him to feel more awake in the daytime. (Tr. 1442.)
In May 2012, an electromyogram ("EMG") test was conducted in response to Plaintiff's complaints of numbness in his hands. (Tr. 913.) The EMG showed moderate bilateral median nerve compression neuropathy at the wrist consistent with a diagnosis of moderate bilateral carpal tunnel syndrome. (Id.) On June 8, 2012, Plaintiff underwent right median nerve decompression surgery. (Tr. 999-1000.) On December 5, 2012, he underwent left median nerve decompression surgery. (Tr. 1464-1465.) A month after surgery, Mario M. Sertich, M.D., noted that Plaintiff's incision "healed beautifully," and Plaintiff indicated that he had no significant pain and was very happy with his results. (Tr. 1457.)
On August 29, 2012, Dr. Mahajan opined that Plaintiff "cannot return to his job. He needs to apply for Disability." (Tr. 1212.) Dr. Mahajan added, "[w]e shall see how he does in the next five to six months. I asked him to try to build up his endurance." (Id.) He gave Plaintiff a return to work date of January 3, 2013. (Id.)
On April 4, 2013, a physical therapist at Mercy Medical Center completed a Functional Capacities Evaluation, which Dr. Shah signed. (Tr. 1397-1400.) The evaluation recorded significantly decreased grip and pinch strength bilaterally and decreased coordination in the upper extremities. (Tr. 1445-1446.) According to the report, Plaintiff could lift five pounds occasionally and had decreased coordination/dexterity and grip/pinch strength. (Tr. 1398-1399.) The report further indicated that Plaintiff could stand for two hours in an eight-hour workday and sit for two hours in an eight-hour workday. (Tr. 1400.)
On September 24, 2012, Leon D. Hughes, M.D., a state agency physician, completed a residual functional capacity (RFC) assessment. (Tr. 88-89.) After reviewing the record evidence, Dr. Hughes opined that Plaintiff could perform light work that involved occasional pushing/pulling with the right leg; no climbing of ladders, ropes, or scaffolds; frequent climbing of ramps and stairs; unlimited balancing; occasional stooping, crouching, and crawling; frequent kneeling; and no concentrated exposure to hazards. (Tr. 88-89.) On November 29, 2012, Malika Haque, M.D., another state agency physician, affirmed Dr. Hughes' findings, but further limited Plaintiff to work avoiding all exposure to hazards. (Tr. 108-109.)
Plaintiff worked as a furnace operator and/or metal clean-up worker until 2012. (Tr. 32, 54.) He testified that in 2012, he visited his employer's doctor, who informed him that he could no longer work for the company due to his multiple sclerosis and angina. (Tr. 32-35.)
Plaintiff was diagnosed with multiple sclerosis, which was treated with steroids but still caused burning and numbness on the right side of his body. (Tr. 83-84.) He also had difficulty digesting food and experienced frequent nausea. (Tr. 84.) Plaintiff had sleep apnea, for which he was prescribed a CPAP machine. (Tr. 41.) He testified that the machine has helped him. (Id.) At the time of his hearing, Plaintiff was on about 26 or 27 medications. (Tr. 39.) His wife helped him to remember when to take his medications. (Tr. 42.) He also experienced vertigo, which caused him to feel dizzy and nauseous. (Tr. 49.) Plaintiff had frequent urinary tract infections and was expected to have to self-catheterize if his antibiotics became ineffective. (Tr. 96-97.)
Plaintiff lived in a house with his wife and mentally challenged son. (Tr. 44.) Plaintiff made sure his son took his pills, used the restroom properly, and ate lunch. (Tr. 46.) At home, Plaintiff tried to keep his house clean by sweeping and doing dishes. (Tr. 47.) He could mow part of his one acre lawn with a tractor before having to stop due to back pain. (Tr. 48.) He socialized with others by sitting around a fire pit in his driveway. (Tr. 48-49.) Plaintiff testified that he could probably stand for about a half hour at a time and sit for about 45-50 minutes before having to stand up and walk around. (Tr. 46.)
Thomas Heiman, a vocational expert, testified at Plaintiff's hearing. The ALJ asked the VE to assume a hypothetical individual of Plaintiff's age, education, and work history who was right-handed and had an eleventh grade education. (Tr. 54.) The individual could engage in light exertion work and could occasionally push/pull with the right, lower extremity; could never climb ladders, ropes, or scaffolds; could occasionally stoop; could frequently climb stairs and ramps; was unlimited in balancing; could frequently kneel; and could occasionally crouch and crawl. (Tr. 54-55.) The VE testified that the hypothetical individual could perform work as a cashier II, photocopying machine operator; and a small products assembler. (Tr. 55-56.)
The ALJ asked the VE to assume a second hypothetical individual with the same limitations as described previously except that the individual could perform work at the sedentary exertion level rather than at the light level. (Tr. 56.) The ALJ testified that the individual could perform such jobs as a document scanner or document preparer, a final assembler, and a food and beverage order clerk. (Tr. 57.)
The ALJ asked the VE whether his opinion would change with regard to the two aforementioned hypothetical questions if the individual used a cane for ambulating. (Tr. 58.) The VE testified that he would eliminate the jobs mentioned in the light category and the final assembler and food and beverage order clerk jobs. (Id.)
A claimant is entitled to receive benefits under the Social Security Act when he establishes disability within the meaning of the Act. 20 C.F.R. § 416.905;
The Commissioner reaches a determination as to whether a claimant is disabled by way of a five-stage process.
The ALJ made the following findings of fact and conclusions of law:
(Tr. 12-18.)
Judicial review of the Commissioner's decision is limited to determining whether the Commissioner's decision is supported by substantial evidence and was made pursuant to proper legal standards.
The Commissioner's conclusions must be affirmed absent a determination that the ALJ failed to apply the correct legal standards or made findings of fact unsupported by substantial evidence in the record.
Plaintiff argues that the ALJ erred by failing to give controlling weight to the opinions of two of Plaintiff's treating physicians, Drs. Mahajan and Shah. "An ALJ must give the opinion of a treating source controlling weight if he finds the opinion `well-supported by medically acceptable clinical and laboratory diagnostic techniques' and `not inconsistent with the other substantial evidence in the case record."
Dr. Mahajan did not provide a report regarding Plaintiff's RFC. On August 29, 2012, however, Dr. Mahajan opined that Plaintiff "cannot return to his job. He needs to apply for Disability." (Tr. 1212.) Dr. Mahajan added, "[w]e shall see how he does in the next five to six months. I asked him to try to build up his endurance." (Id.) He gave Plaintiff a return to work date of January 3, 2013. (Id.) Plaintiff maintains that the ALJ erred by failing to acknowledged Dr. Mahajan's statement in her hearing decision, arguing that "[t]he ALJ is not free to simply ignore the opinion of a treating physician and must articulate good reasons when she fails to accord the opinion substantial weight." (Plaintiff's Brief ("Pl.'s Br.") 12.)
The ALJ did not err in failing to acknowledge or assign weight to Dr. Mahajan's statement that Plaintiff could not return to his job until January 3, 2012, as Dr. Mahajan's opinion is not an opinion of a medical condition, but rather is an opinion of disability that is reserved for the ALJ. It is well established that certain issues are reserved to the Commissioner for determination. See
On April 4, 2013, Dr. Shah, through a physical therapist, opined that Plaintiff: had decreased coordination/dexterity and grip/pinch strength; could lift five pounds occasionally; could stand for a total of two hours in an eight-hour workday; and could sit for a total of two hours in an eight-hour workday. (Tr. 1397-1400.) Dr. Shah concluded that Plaintiff was unable to work. (Tr. 1400.)
The ALJ assigned little weight to Dr. Shah's opinion, finding that the assessment was not supported by the objective evidence "including Dr. Shah's own patient notes which indicate normal reflexes, normal sensation, and normal muscle strength." (Tr. 16.) If this were all the ALJ had said about the evidence, the case would require remand.
In this case, the ALJ provided a lengthy discussion of the medical evidence before evaluating the opinions of the treating physicians and the other medical opinions contained in Plaintiff's record. (Tr. 12-16.) The ALJ's discussion of the medical evidence was not merely a rote recitation of Plaintiff's longitudinal history; rather, the ALJ analyzed the medical evidence and explained how it supported her ultimate RFC determination. (Id.) For example, the ALJ discussed the following evidence, which implicitly rejects Dr. Shah's opinion regarding Plaintiff's physical limitations:
Had the ALJ discussed the aforementioned evidence immediately after stating that she was assigning only limited weight to Dr. Shah's opinion, there would be no question that the ALJ provided "good reasons" for giving Dr. Shah's opinion less than controlling weight. The fact that the ALJ did not analyze the medical evidence for a second time (or refer to her previous analysis) when rejecting Dr. Shah's opinion does not necessitate remand of Plaintiff's case. "No principle of administrative law or common sense requires us to remand a case in quest of a perfect opinion unless there is reason to believe that the remand might lead to a different result."
On September 24, 2012, state agency physician Dr. Hughes opined that Plaintiff could perform light work that involved occasional pushing/pulling with the right leg; no climbing of ladders, ropes, or scaffolds; frequent climbing of ramps and stairs; unlimited balancing; occasional stooping, crouching, and crawling; frequent kneeling, and no concentrated exposure to hazards. (Tr. 88-89.) On November 29, 2012, Dr. Haque, another state agency physician, affirmed Dr. Hughes' findings, but further limited Plaintiff to work avoiding all exposure to hazards. (Tr. 108-109.) The ALJ assigned great weight to the aforementioned opinions, finding that they were consistent with the objective evidence in the record. (Tr. 16.)
Plaintiff maintains that the ALJ erred in assigning great weight to the opinions of state agency physicians Drs. Hughes and Haque. According to Plaintiff, the opinions of Drs. Hughes and Haque are not supported by substantial evidence, because the record was not complete at the time they rendered their opinions. Specifically, Plaintiff argues that the state agency physicians did not consider Dr. Mahajan's August 29, 2012, opinion that Plaintiff could not work, nor did they "have the benefit of the functional capacity assessment, the records from the pulmonologist, or the hospitalization records for April and May 2013 for another multiple sclerosis exacerbation and another heart attack, respectively."
Plaintiff has provided no legal support for his argument that the ALJ could not properly rely on the opinions of Drs. Hughes and Haque because the record was not complete at the time they rendered their opinions.
Plaintiff argues that, other than the reports from Drs. Hughes and Haque, there is no evidence in the record to support the ALJ's RFC determination. Specifically, Plaintiff contends that the ALJ failed to account for Plaintiff's difficulty in using his upper extremities as a result of bilateral carpal tunnel syndrome surgeries; his need to use a cane for stability; and his need to take unscheduled naps during the day. The Commissioner responds that substantial evidence supports the ALJ's RFC determination. For the following reasons, Plaintiff's argument is without merit.
RFC is an indication of a claimant's work related abilities despite his limitations. See 20 C.F.R. § 416.945(a). A claimant's RFC is not a medical opinion, but an administrative determination reserved to the Commissioner. See 20 C.F.R. § 416.945(e). As such, the ALJ bears the responsibility for assessing a claimant's RFC based on all of the relevant evidence, 20 C.F.R. § 416.945(a), and must consider all of a claimant's medically determinable impairments, both individually and in combination, S.S.R. 96-8p.
Here, the ALJ considered Plaintiff's record as a whole and concluded that despite his impairments, he had the RFC to perform a range of light work
Thus, the ALJ properly considered Plaintiff's carpal tunnel syndrome, sleep apnea, and use of a cane, and nonetheless concluded that-based on the medical and opinion evidence of record-he was capable of performing a limited range of light work. Plaintiff may be correct that evidence in the record supports the conclusion that he is impaired in the use of his upper extremities, that he uses a cane for stability, and that he needs to take unscheduled naps during the day; however, this is not the appropriate standard to apply to the ALJ's decision. An ALJ's decision that is supported by substantial evidence will not be overturned even though substantial evidence supports the opposite conclusion.
For the foregoing reasons, the Commissioner's final decision is AFFIRMED.