JOEL H. SLOMSKY, District Judge.
Before the Court are the Objections of Plaintiff Franklin Dale Browner to the Report and Recommendation of United States Magistrate Judge Timothy R. Rice. (Doc. No. 16.) On December 2, 2016, Plaintiff filed a Complaint against Defendant Nancy A. Berryhill, acting Commissioner of Social Security Administration ("SSA"), seeking review of the final decision of Defendant, which denied Plaintiff's claim for disability insurance benefits ("DIB") under Title II of the Social Security Act ("Act"), 42 U.S.C. §§ 401-434. (Doc. No. 3.) On July 30, 2017, the Court referred this matter to Magistrate Judge Rice for a Report and Recommendation ("R&R"). (Doc. No. 14.) On October 18, 2017, Magistrate Judge Rice issued the R&R, recommending that Plaintiff's request for review be denied. (Doc. No. 15.) On October 31, 2017, Plaintiff timely filed Objections to the R&R. (Doc. No. 16.) On November 13, 2017, Defendant filed a Response to Plaintiff's Objections (Doc. No. 18), and on November 21, 2017, Plaintiff filed a Reply to Defendant's Response. (Doc. No. 19.) On December 1, 2017, Defendant filed a Corrected Response to Plaintiff's Objections. (Doc. No. 23.)
Pursuant to 28 U.S.C. § 636(b)(1), the Court has conducted a
Plaintiff Franklin Dale Browner was born on August 3, 1963
On April 11, 2012, Plaintiff applied for DIB, alleging a disability beginning on December 15, 2010. (R. at 11.) It was based upon fibromyalgia
Plaintiff testified at the hearing that he stopped working in December 2010 because his father, who took him to work, got sick and Plaintiff had no way of getting to his job. (R. at 35, 41.) He claimed that he suffers from severe pain, particularly on the left side of his body, running from his neck down to his legs. (R. at 49.) He has trouble sitting and standing for over ten minutes, and can only walk for approximately ten minutes. (R. at 45.) At the time of his hearing, Plaintiff had been using a cane for approximately four months without a doctor's prescription or recommendation. (
(R. at 46.)
Plaintiff testified that he typically sleeps for approximately forty-five minutes to one hour because of his pain. (R. at 53.) He frequently takes a brief nap during the day because of the minimal rest he has. (
When asked how his symptoms were progressing, Plaintiff stated they were worsening:
(R. at 53-54.)
The VE testified that Plaintiff's past work as a nurse's assistant and a furniture assembler were both classified as semi-skilled and heavy work in the
On October 21, 2013, the ALJ denied Plaintiff's claim for DIB. (R. at 121, 127.) On February 11, 2015, the SSA's Appeals Council remanded the decision back to the ALJ with instructions to evaluate the fibromyalgia in accordance with Social Security Ruling ("SSR") 12-2P
On June 18, 2015, Plaintiff appeared before ALJ Lash for a second hearing. (R. at 67.) Since the 2013 hearing, Plaintiff had not received additional education or obtained employment. (R. at 70-72.) Once more, he testified to the pain he experienced, complaining of "fibromyalgia and a little bit of arthritis in [his] back and . . . widespread pain going through [his] body." (R. at 73.) When asked how long Plaintiff had suffered from this pain, he stated:
(R. at 73.)
He again complained about his physical limitations as a result of his pain, such as the discomfort he experiences while sitting and standing for several minutes. (R. at 74, 82.) He also described the same side effects from his medications that he testified about in 2013. (R. at 78.) He identified Dr. Lawrence Brent again as his rheumatologist and Dr. Azra Qureshi as his primary care physician. (R. at 76.) Plaintiff additionally told the ALJ that he experienced mood changes, specifically feelings of hostility and depression. (R. at 79.)
Another VE, Nancy Harter, was also present at Plaintiff's 2015 hearing, and responded to the following questions from Plaintiff's counsel and the ALJ:
(R. at 94.)
When asked about his daily activities, Plaintiff reiterated that he has trouble sitting and standing for extended periods of time. (R. at 84.) With respect to his daily activities, he testified that he rarely leaves the house except to smoke a cigarette or to go shopping with his family. (R. at 87.) Plaintiff also stated that he goes for a walk twice a week for approximately a quarter of a mile before his stiffness sets in. (
On August 24, 2015, the ALJ denied Plaintiff's claim. (R. at 12.) The ALJ determined that Plaintiff had four severe impairments: severe fibromyalgia; degenerative disc disease
On December 2, 2016, Plaintiff requested judicial review of the ALJ's decision pursuant to 42 U.S.C. § 405(g). (Doc. No. 3.) He alleges that the ALJ erred by failing to: (1) properly weigh the medical opinion of his treating physician; (2) fully credit his allegations of disabling pain; (3) adequately develop the medical record; and (4) support the RFC assessment with substantial evidence. (Doc. No. 11 at 7-11; Doc. No. 15 at 1.)
As previously noted, on July 14, 2017, the Court referred the matter to United States Magistrate Judge Timothy R. Rice for an R&R (Doc. No. 14), and on October 18, 2017, Magistrate Judge Rice issued the R&R recommending that Plaintiff's Request for Review be denied. (Doc. No. 15.) On October 31, 2017, Plaintiff timely filed the Objections that are now before this Court for consideration. (Doc. No. 16.)
To prove a "disability," a claimant must demonstrate "the inability to do any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." 20 C.F.R. § 404.1505(a). The claimant has the burden of proving the existence of a disability and can satisfy this burden by showing an inability to return to former work.
When evaluating a disability, the SSA uses a five-step process, which is followed in a set order:
§ 404.1520(a)(4)(i)-(v).
Between the third and fourth steps, the SSA assesses a claimant's residual functional capacity, which is "the most [a claimant] can do despite [their] limitations." § 404.1545(a)(1). The SSA uses the RFC assessment at Step Four to determine if the claimant is able to do their "past relevant work." § 404.1545(a)(5)(i). "Past relevant work" is "work that you have done within the past 15 years, that was substantial gainful activity, and that lasted long enough for you to learn to do it." § 404.1560(b)(1).
When reviewing a final decision of the Commissioner, the Court must determine whether the record demonstrates substantial evidence to support the Commissioner's decision. 42 U.S.C. §§ 405(g), 1383(c)(3). Substantial evidence is "more than a mere scintilla . . . [and includes] such relevant evidence as a reasonable mind might accept as adequate to support a conclusion."
Because the Commissioner adopts an ALJ's decision as his findings of fact, the ALJ must set out a specific factual basis for each finding.
At the hearing on July 3, 2013, the ALJ heard testimony from Plaintiff and VE Sherry Pistone-Tiversi (R. at 27) and at the hearing on June 18, 2015, the ALJ heard testimony from Plaintiff and VE Nancy Harter. (R. at 65.) Additionally, the ALJ considered the medical opinions of Plaintiff's treating rheumatologist, Dr. Lawrence Brent, and Plaintiff's primary care physician, Dr. Azra Qureshi, as well as various other medical records and evaluations. (R. at 11.) After reviewing the evidence in the Record, and proceeding through the five-step evaluation process, the ALJ concluded that Plaintiff was not disabled within the meaning of the Social Security Act. (R. at 12.)
First, at step one, the ALJ determined Plaintiff had not engaged in any substantial gainful activity since the alleged onset date. (R. at 13.) At step two, the ALJ determined that Plaintiff suffered from the following severe impairments: fibromyalgia; degenerative disc disease of the lumbar and thoracic spines; and de Quervain's disease. (R. at 14.) She found that the dog bite injury to Plaintiff's left hand was non-severe for the purposes of the DIB determination because it resulted in less than minimal work-related limitations. (
At step four, the ALJ concluded that Plaintiff had the RFC to perform light work that is limited to jobs with routine, repetitive tasks that do not require climbing ladders, ropes, or scaffolds, constant reaching, handling, fingering, or feeling with the left-non-dominant upper extremity. (R. at 16.) The jobs should not require Plaintiff to be exposed to hazards, including moving machinery and unprotected heights and should be limited to those that require only occasional interaction with co-workers and supervisors. (
At step five, the ALJ concluded that jobs exist in significant numbers in the national economy that Plaintiff could perform. (
On June 5, 2017, Plaintiff filed a Brief and Statement of Issues in Support of Request for Review ("Request for Review"). (Doc. No. 11.) In his Request for Review, Plaintiff raised the following seven issues:
(
Upon review of these seven issues, four overarching points emerge from Plaintiff's Request for Review: (1) that the ALJ failed to treat Dr. Brent's testimony with controlling weight; (2) that the ALJ failed to fully credit Plaintiff's allegations of pain; (3) that the ALJ failed to adequately develop the medical record; and (4) the ALJ's RFC assessment was unsupported by substantial evidence.
On October 18, 2017, after considering the ALJ's Decision and the Administrative Record, Magistrate Judge Rice issued an R&R finding that there was substantial evidence to support the ALJ's denial of benefits and recommending that the Court affirm the ALJ's decision to deny Plaintiff's claim for DIB under Title II of the Social Security Act. (Doc. No. 15.)
Plaintiff has made three objections to Magistrate Judge Rice's R&R. (Doc. No. 16.) First, he asserts that the ALJ improperly concluded that Plaintiff's fibromyalgia did not constitute an impairment either by itself or in combination with other impairments that meets or medically equals the severity of one of the listed impairments as recognized by Appendix 1 of 20 C.F.R. § 404.1520(d). (
In concluding that Plaintiff's fibromyalgia was not an impairment or medically equals the severity of a listed impairment in 20 C.F.R. § 404.1520(d), the ALJ did not commit error because her decision was supported by sufficient evidence in the record and she sufficiently explained her findings.
"An ALJ need not `use particular language or adhere to a particular format in conducting [her] analysis,' as long as `there is sufficient development of the record and explanation of findings to permit meaningful review.'"
In this case, Plaintiff asserts: "It is the belief of the Plaintiff that the administrative decision and the Report and Recommendation demonstrate that nobody involved in this matter has a satisfactory understanding of the disease process and symptoms of fibromyalgia necessary to properly evaluate this plaintiff's case." (Doc. No. 16 at 1.) Put another way, Plaintiff challenges the ALJ's conclusion that Plaintiff's fibromyalgia did not medically equal a listing either by itself or in combination with another medically determinable impairment.
The ALJ relied on the guidance of SSR 12-2P for how to evaluate fibromyalgia at step 3 of SSA's five-step sequential process. SSR 12-2P instructs that to determine whether fibromyalgia medically equals a listed impairment, an ALJ must evaluate whether it "medically equals a listing (
Though the ALJ could have considered whether other impairments are medically equal to the fibromyalgia in addition to inflammatory arthritis, the fact that she did not does not constitute error here. Plaintiff has not shown that the analysis of the ALJ under the listing of inflammatory arthritis was improper, nor does he provide other "specific avenues for meeting or equaling specific listings that the ALJ should have considered but did not."
Accordingly, the ALJ did not commit error in determining Plaintiff's fibromyalgia was not an impairment, or was part of a combination of impairments, that met or medically equaled the severity of a listed impairment in 20 C.F.R. § 404.1520(d).
Plaintiff argues that the ALJ incorrectly afforded little weight to Dr. Brent's opinion and that this finding was improperly upheld by Magistrate Judge Rice in the R&R. (Doc. No. 16 at 2.) Plaintiff asserts that Dr. Brent's medical opinion was consistent with the medical evidence on the record and Plaintiff's own testimony before the ALJ. (
Generally, an ALJ must give great weight to a claimant's treating physician; however, an ALJ may discredit the treating physician's opinion if contradictory evidence appears in the record.
Here, the ALJ reviewed records from Dr. Brent and Dr. Qureshi as well as Plaintiff's testimony and letters received from Plaintiff's mother. In a fibromyalgia medical source statement dated November 2, 2012, Dr. Brent indicated that he was awaiting lab tests to determine the exclusion of other disorders that could cause repeated manifestations of symptoms that present as fibromyalgia. (R. at 494.) The medical source statement also shows that Dr. Brent examined Plaintiff twice by that time: once on March 18, 2012 and a second time on August 30, 2012. (
On July 24, 2012, Dr. Brent sent a letter to Dr. Qureshi stating that he examined Plaintiff again on that day. (R. at 509). Based upon the information contained in the letter, however, it appears that the primary reason for the examination was the dog bite injury Plaintiff suffered on his left hand and not his fibromyalgia. (
Plaintiff argues that Dr. Brent's opinion was supported because no laboratory or x-ray study provided an alternative cause for Plaintiff's symptoms other than fibromyalgia. (Doc. No. 11 at 8.) He further notes that there is "no objective study, such as a lab test or an x-ray to establish the diagnosis." (
The ALJ also considered that Dr. Brent did "not perform [a] function assessment" with respect to Plaintiff's manipulative—i.e., related to the hand—limitations. (R. at 544-45.) Additionally, in analyzing Plaintiff's impairments under the SSA framework for "inflammatory arthritis" (R. at 16), the ALJ noted that a radiology exam dated January 30, 2012 reported fair results: "[Plaintiff's] bones are normally mineralized. There is no fracture or dislocation. No arthritic changes are identified. No soft tissue abnormalities are seen." (R. at 443.) On the same day, a thoracic exam confirmed that Plaintiff's "vertebra are normal in statute and contour . . . The findings are all compatible with mild degenerative arthritis in otherwise normal thoracic spine." (R. at 445.) Thus, the ALJ properly evaluated Plaintiff's fibromyalgia in accordance with SSR 12-2P to determine whether it medically equals a listing either by itself or in combination with another medically determinable impairment.
The ALJ was also permitted to consider Plaintiff's own testimony during his hearings. At the 2015 hearing, Plaintiff stated that he was able to walk briefly, for approximately a quarter of a mile. (R. at 85.) He also informed the ALJ that he was able to take public transportation. (R. at 91.) His statements about his use of transportation supported a Function Report dated May 6, 2012 completed by Plaintiff. (R. at 363.) In the Report, Plaintiff states that he uses public transportation to go to doctors' appointments and shop for food. (
In sum, ALJ Lash considered Dr. Brent's medical opinion and weighed that against any contradictory evidence. In analyzing Plaintiff's fibromyalgia under the listing of inflammatory arthritis, she reasonably looked at medical records describing any pain or inflammation in Plaintiff's joints and musculoskeletal system. The ALJ also noted the contradictory evidence Plaintiff himself provided with respect to his abilities, acknowledging in her findings that Plaintiff was able to engage in light chores, walk short distances, and take public transportation. (R. at 15, 17, 18.) Upon consideration of Plaintiff's actual abilities, the ALJ reasonably concluded that his pain was not as severe as reported. Given the lack of lab reports with diagnoses that would exclude alternate causes of Plaintiff's pain, contradicting medical records, and conflicting testimony by the Plaintiff, the ALJ acted within her authority to give less weight to Dr. Brent's opinion.
The ALJ properly found that Plaintiff had RFC. Her findings were supported by substantial evidence which included Plaintiff's testimony and submissions that he was able to engage in light activity.
In determining RFC, an ALJ must consider all the evidence before her.
Plaintiff argues that the ALJ failed to abide by SSR 96-8P, which sets forth the policy interpreting ruling on assessments of residual functional capacity in initial claims for disability benefits under SSA.
At the 2013 hearing, although Plaintiff purportedly had been suffering from fibromyalgia since the 1980s (R. at 31), he stated that he had stopped working because his father could no longer transport him to his job. (R. at 41.) Thus, the ALJ reasonably inferred that Plaintiff's "impairment(s) would not prevent the performance of that job, since it was being performed adequately at the time [Plaintiff] stopped working for unrelated reasons." (R. at 18.) The ALJ also considered the fact that Plaintiff testified that he was able to engage in "daily activities including taking public transportation, caring for personal needs, socializing with family members, performing household chores, shopping, and leaving the house regularly to smoke and take walks." (
Furthermore, as discussed previously, the ALJ was proper to accord less weight to Dr. Brent's opinion because there was contradictory evidence in the record. The ALJ reviewed Plaintiff's evidentiary record and noted that there was a lack of "persistent attempts to seek treatment from specialists since the alleged onset date" of December 15, 2010. (R. at 18.) With respect to the medical records, the ALJ noted that Dr. Brent had not completed a complete function assessment of Plaintiff's abilities, nor did he list any specific work-related limitations. (
Finally, SSR 96-8P includes the following instruction:
1996 WL 374184, at *3 (July 2, 1996).
Thus, the ALJ properly found that Plaintiff had an RFC to perform light work
Plaintiff's objections to the R&R filed by Magistrate Judge Rice will be overruled. The Court will approve and adopt the R&R of Magistrate Judge Rice in its entirety. An appropriate Order follows.
(R. at 380). On June 2, 2015, Ms. Browner submitted a second message stating:
(R. at 406.)
42 U.S.C. § 405(b)(1).
2012 WL 3104869, at *6 (July 25, 2012).