SUSAN E. SCHWAB, Magistrate Judge.
Plaintiff Leida Iturralde ("Iturralde") asserts that she has been disabled and unable to work since June 16, 2011, due to a number of conditions, including thyroid issues, high blood pressure, carpal tunnel, numbness in arms and hands, right wrist surgery, and right shoulder issues. She brought this action pursuant to 42 U.S.C. §405(g) and 42 U.S.C. §1383(c)(3), seeking review of a final decision of defendant Commissioner of Social Security ("the Commissioner"), who denied Iturralde's claim for disability benefits under Title II of the Social Security Act. For the reasons explained below, we recommend that the final decision of the Commissioner denying Iturralde's claims be AFFIRMED.
The Court refers to the transcripts provided by the Commissioner. See Doc. #10-1 through Doc. #10-15.
When reviewing the Commissioner's final decision denying a claimant's application for benefits, this Court's review is limited to the question of whether the findings of the final decision-maker are supported by substantial evidence in the record. See 42 U.S.C. §405(g); 42 U.S.C. §1383(c)(3); Johnson v. Comm'r of Soc. Sec., 529 F.3d 198, 200 (3d Cir. 2008); Ficca v. Astrue, 901 F.Supp.2d 533, 536 (M.D.Pa. 2012). Substantial evidence "does not mean a large or considerable amount of evidence, but rather such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Pierce v. Underwood, 487 U.S. 552, 565 (1988). Substantial evidence is less than a preponderance of the evidence but more than a mere scintilla. Richardson v. Perales, 402 U.S. 389, 401 (1971). A single piece of evidence is not substantial evidence if the ALJ ignores countervailing evidence or fails to resolve a conflict created by the evidence. Mason v. Shalala, 994 F.2d 1058, 1064 (3d Cir. 1993). But in an adequately developed factual record, substantial evidence may be "something less than the weight of the evidence, and the possibility of drawing two inconsistent conclusions from the evidence does not prevent [the ALJ's decision] from being supported by substantial evidence." Consolo v. Fed. Maritime Comm'n, 383 U.S. 607, 620 (1966). "In determining if the Commissioner's decision is supported by substantial evidence the court must scrutinize the record as a whole." Leslie v. Barnhart, 304 F.Supp.2d 623, 627 (M.D.Pa. 2003). The question before this Court, therefore, is not whether Iturralde is disabled, but whether the Commissioner's finding that she is not disabled is supported by substantial evidence and was reached based upon a correct application of the relevant law. See Arnold v. Colvin, No. 3:12-CV-02417, 2014 WL 940205, at *1 (M.D.Pa. Mar. 11, 2014)("[I]t has been held that an ALJ's errors of law denote a lack of substantial evidence.")(alterations omitted); Burton v. Schweiker, 512 F.Supp. 913, 914 (W.D.Pa. 1981)("The [commissioner]'s determination as to the status of a claim requires the correct application of the law to the facts."); see also Wright v. Sullivan, 900 F.2d 675, 678 (3d Cir. 1990)(noting that the scope of review on legal matters is plenary); Ficca, 901 F.Supp.2d at 536 ("[T]he court has plenary review of all legal issues. . . .").
To receive benefits under the Social Security Act by reason of disability, a claimant must demonstrate an inability to "engage in 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." 42 U.S.C. §423(d)(1)(A); 42 U.S.C. §1382c(a)(3)(A); see also 20 C.F.R. §§404.1505(a), 416.905(a). To satisfy this requirement, a claimant must have a severe physical or mental impairment
In making this determination at the administrative level, the ALJ follows a five-step sequential evaluation process. 20 C.F.R. §§404.1520(a), 416.920(a). Under this process, the ALJ must sequentially determine: (1) whether the claimant is engaged in substantial gainful activity; (2) whether the claimant has a severe impairment; (3) whether the claimant's impairment meets or equals a listed impairment;
Between steps three and four, the ALJ must assess a claimant's RFC. RFC is defined as "that which an individual is still able to do despite the limitations caused by his or her impairment(s)." Burnett v. Comm'r of Soc. Sec., 220 F.3d 112, 121 (3d Cir. 2000) (citations omitted); see also 20 C.F.R. §§404.1520(e), 404.1545(a)(1), 416.920(e), 416.945(a)(1). In making this assessment, the ALJ considers all of the claimant's medically determinable impairments, including any non-severe impairment identified by the ALJ at step two of his or her analysis. 20 C.F.R. §§404.1545(a)(2), 416.945(a)(2).
At steps one through four, the claimant bears the initial burden of demonstrating the existence of a medically determinable impairment that prevents him or her in engaging in any of his or her past relevant work. 42 U.S.C. §423(d)(5); 20 C.F.R. §§404.1512; Mason, 994 F.2d at 1064.
Once this burden has been met by the claimant, it shifts to the Commissioner at step five to show that jobs exist in significant number in the national economy that the claimant could perform that are consistent with the claimant's age, education, work experience and RFC. 20 C.F.R. §404.1512(f); Mason, 994 F.2d at 1064.
The ALJ's disability determination must also meet certain basic substantive requisites. Most significant among these legal benchmarks is a requirement that the ALJ adequately explain the legal and factual basis for this disability determination. Thus, in order to facilitate review of the decision under the substantial evidence standard, the ALJ's decision must be accompanied by "a clear and satisfactory explication of the basis on which it rests." Cotter v. Harris, 642 F.2d 700, 704 (3d Cir. 1981). Conflicts in the evidence must be resolved and the ALJ must indicate which evidence was accepted, which evidence was rejected, and the reasons for rejecting certain evidence. Id. at 706-707. In addition, "[t]he ALJ must indicate in his decision which evidence he has rejected and which he is relying on as the basis for his finding." Schaudeck v. Comm'r of Soc. Sec., 181 F.3d 429, 433 (3d Cir. 1999).
In his decision dated January 8, 2015, the ALJ held that Iturralde was not disabled within the meaning of the Social Security Act. Tr. 22. At step one, the ALJ determined that Iturralde had not engaged in substantial gainful activity since June 16, 2011, the alleged onset date. Id. at 14. At step two, the ALJ found that Iturralde suffered from the following severe impairments: (1) major depressive disorder, (2) panic disorder with agoraphobia, (3) right wrist injury status post-surgery, and (4) cervical degenerative disc disease. Id.
At step three, the ALJ determined that Iturralde did not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. Id. at 15. In particular, the ALJ considered listings 1.02B, 1.04A, 1.04B, 12.04, and 12.06, and concluded that Iturralde's impairments did not meet the criteria of these listings. Id.
At step four, the ALJ found that Iturralde had "the residual functional capacity to perform light work as defined in 20 C.F.R. 404.1567(b) except she requires no use of the dominant right upper extremity; no ladders; no crawling; and must avoid hazards including machinery that moves about on the job site floor." Id. at 16-17. The ALJ determined that Iturralde "must avoid temperature extremes and vibrations, and is limited to routine, repetitive work in a stable environment." Id. at 17. In making this finding, the ALJ gave significant weight to an opinion by consultative medical examiner Dr. Viral Patel ("Dr. Patel") concerning Iturralde's inability to use her right upper extremity, and the opinion of a state agency psychological consultant Dr. John Gavazzi ("Dr. Gavazzi") finding Iturralde capable of simple, routine, repetitive work in a stable environment. Id. at 20, 21. Little weight was given to treating physician Dr. William Rolle's ("Dr. Rolle") opinion finding Iturralde unable to work because the opinion was "not supported by the longitudinal medical findings, [Iturralde's] improvement with surgery and treatment, her activities of daily living and her ability and desire to travel." Id. at 20.
In formulating the RFC, the ALJ also "considered all symptoms and the extent to which these symptoms can reasonably be accepted as consistent with the objective medical evidence and other evidence" in accordance with 20 C.F.R. 404.1529 and SSRs 96-4p and 96-7p. Id. The ALJ also considered the opinion evidence in accordance with 20 C.F.R. 404.1527 and SSRs 96-2p, 96-5p, 96-6p, and 06-3p. Id. The ALJ found Iturralde's "medically determinable impairments could reasonably be expected to cause the alleged symptoms; however, [Iturralde's] statements concerning the intensity, persistence and limiting effects of these symptoms [were] not entirely credible." Id. at 18. The ALJ drew this conclusion because of various inconsistencies between Iturralde's testimony and her medical records. Id. at 18-21.
Also at step four, the ALJ concluded that Iturralde was unable to perform any of her past relevant work as a cashier II, general merchandise salesperson, store laborer, or general clerk and material handler. Id. at 21. At step five, after considering Iturralde's age, education, work experience and RFC, the ALJ concluded that there are jobs that exist in significant numbers in the national economy that Iturralde could perform. Id. This finding relied on the testimony of vocational expert Michael J. Kibler ("the VE"). Id. at 22. The VE testified at the administrative hearing that an individual with Iturralde's RFC and limitations, as determined by the ALJ, could perform the requirements of representative occupations such as a conveyor line bakery worker, an usher, and a surveillance system monitor. Id. The ALJ ultimately found that Iturralde was not disabled under sections 216(i) and 223(d) of the Social Security Act. Id.
Iturralde raises three issues on appeal: (1) Does substantial evidence support the ALJ's evaluation of treating physician Dr. Rolle's opinion evidence? (2) Does substantial evidence support the ALJ's RFC assessment? and (3) Is the ALJ's finding on Iturralde's credibility supported by substantial evidence? We shall address each argument seriatim.
Iturralde asserts that the ALJ improperly weighed the opinion evidence from treating physician Dr. Rolle in formulating his RFC. Doc. 11 p. 12. The pertinent case law establishes that "[t]he ALJ must consider all of the relevant evidence and give a clear explanation to support his or her findings when determining the residual functional capacity." Isaac v. Colvin, Civil No. 3:12-1120, 2014 WL 1942555, at * 5 (M.D. Pa. May 14, 2014) (citing Burnett v. Comm'r, 220 F.3d 112, 121 (3d Cir. 2000)). When evaluating opinions by a treating source, the ALJ should accord treating physician's reports great weight, especially when such opinions reflect expert judgment based on continuous observation of the patient's health over an extended period of time. See Morales v. Apfel, 225 F.3d 310, 317 (3d Cir. 2000); Plummer v. Apfel, 186 F.3d 422, 429 (3d Cir. 1999) (quoting Rocco v. Heckler, 826 F.2d 1348, 1350 (3d Cir.1987)). This preference for treating source opinions is recognized in the regulations, which state that:
20 C.F.R. §404.1527(c)(2);
When a treating source's medical opinion is not given controlling weight, the ALJ must evaluate all of the non-controlling opinions based on several factors listed in 20 C.F.R. §404.1527(c). These factors include (1) the length of the treatment and frequency of examination; (2) the nature and extent of the treatment relationship; (3) the opinion's support by medical evidence; (4) the opinion's consistency with the record as a whole; and (5) the treating physician's specialization. 20 C.F.R. §404.1527(c). Also, the ALJ will consider other factors brought to the ALJ's attention or of which the ALJ is aware, that tend to support or contradict a medical opinion. 20 C.F.R. §404.1527(c)(6).
In the Third Circuit case Morales v. Apfel, the Court established a standard for weighing treating, non-treating, and non-examining physician opinions stating that:
Relying on the language from Morales and the evaluation standards in 20 C.F.R. §404.1527(c) recited in the preceding paragraphs, Iturralde argues that the ALJ erred by assigning little weight to treating physician Dr. Rolle's opinion that Iturralde is unable to work. Doc 11 p. 10-11. Iturralde also stresses that the ALJ must explain why he rejected a medical opinion. Id. at 11. In response, the Commissioner asserts that this is an impermissible request for the Court to reweigh evidence because the ALJ has the exclusive authority of evaluating medical opinions in the record and determining disability under 20 CFR §404.1527(c), (e) and (d)(1)(3), and Perales, 402 U.S. at 399. Doc. 12 p. 10, 11.
Dr. Rolle is the rehabilitation and physical medicine specialist who treated Iturralde for her right arm and hand pain from February 15, 2013 to March 27 2013.
Doc. 10-2 p. 20.
We also find it important to note that Iturralde does not point to any other medical opinions in the record that conclude Iturralde's impairments currently render her unable to work. Because the ALJ is free to give weight and reject opinions at his discretion, and because the ALJ explained his rejection, we find that the ALJ did not err in weighing Dr. Rolle's opinion concerning this matter. 20 C.F.R. §404.1527(c)(2).
Iturralde also asserts that the ALJ was required to contact Dr. Rolle, if the ALJ had any doubt about Dr. Rolle's opinion. Doc. 11 p. 12. In support, Iturralde relies on SSR 96-5p and Brown v. Astrue, 590 F.Supp.2d 669 (D.Del. 2008) (there is a duty to contact a doctor if the ALJ felt that additional information was required from the opining doctor), and Smith v. Astrue, 843 F.Supp.2d 486, 489 (D.Del. 2012) (instructs the ALJ to contact opining doctors when there are internal inconsistencies with multiple medical opinions in the record). Id. Contrary to Iturralde's assertions, we find that the ALJ was not required to recontact Dr. Rolle.
It is well-established in the Third Circuit that "an administrative law judge will need to recontact a treating physician . . . only where the evidence is insufficient or inadequate for the ALJ to make a determination regarding the claimant's disability." Morales v. Colvin, No. 3:14-CV-2330, 2016 WL 907743, at *11 (M.D. Pa. Mar. 2, 2016) (citing Johnson v. Commissioner of Social Security, 529 F.3d 198, 204-205 (3d Cir. 2008)). It is true, as Iturralde asserts, that SSR 96-5p does require that the ALJ "make every reasonable effort to recontact" treating sources for clarification of an opinion with a basis that is unclear to the ALJ; however, this Court notes in Langston v. Colvin that the codification of 20 C.F.R. §404.1520b in March 26, 2012 "rendered recontact permissive." Langston v. Colvin, No. 1:15-CV-1117, 2012 WL 4523843, at *1 n.1 (M.D. Pa. Aug. 30, 2016) (citing Morales, 2016 WL 907743, at *11)). 20 C.F.R. §404.1520b establishes that the ALJ "may recontact" a treating physician, and that it is the ALJ's choice to seek additional evidence or clarification. 20 C.F.R. §404.1520b (c)(1). If an ALJ has enough evidence to make a determination of disability without the one inconsistent medical opinion, he or she is allowed to do so. 20 C.F.R. §404.1520b (b).
Here, Dr. Rolle's opinion that Iturralde is unable to work is the one opinion that is inconsistent with the other medical opinions in the record, which found that Iturralde can perform light work. Tr. 20. Under 20 C.F.R. §404.1520b, it is within the ALJ's discretion to decide whether he needed explanation from Dr. Rolle in order to make his decision. In light of 20 C.F.R. §404.1520b and the foregoing case law, we find that the ALJ did not err in deciding to not contact Dr. Rolle. The ALJ sufficiently explains why he discounted Dr. Rolle's opinion, and the record shows there are other credible medical opinions that support the ALJ's decision; therefore, his allotment of weight to Dr. Rolle's opinion is supported by substantial evidence.
In sum, because the ALJ is not required to give a treating physician controlling weight, and because he explained and supported his reasoning in according Dr. Rolle's opinion little weight with substantial evidence in the record, we find that the ALJ did not err in his evaluation of Dr. Rolle's opinion.
Iturralde argues that the ALJ did not properly assess her impairments when determining her RFC. Doc. 11 p. 13. Specifically, she alleges that the ALJ failed to address the impairment of Iturralde's left upper extremity in August 2012. Id. at 14. She further argues that when the ALJ limited her to "routine, repetitive work in a stable environment," such limitations did not account for her moderate difficulty in maintaining concentration, persistence, and pace. Id. at 15. In response, the Commissioner argues that the ALJ discussed relevant evidence that satisfies the ALJ's duty to clearly explain how he reached the RFC finding. Doc. 12 p. 15.
The regulations state that when a claimant has a medically determinable severe impairment, that does not meet the criteria of a listing, the ALJ will consider the impairment and related symptoms in the RFC. 20 C.F.R. § 404.1529(d)(4). The evidence used to assess the RFC is all "relevant medical and other evidence." 20 C.F.R. § 404.1545(a)(3). SSR 96-8p clarifies that "in assessing RFC, the adjudicator must consider only limitations and restrictions attributable to medically determinable impairments." Iturralde asserts the ALJ failed to address her August 2012 complaint about the impairment of her left upper extremity, and further argues that this alleged failure renders the RFC assessment improper. Doc. 11 p. 14.
The ALJ clearly references the alleged impairment of Iturralde's left upper extremity in the RFC when he states that "[a]lthough the claimant presented in August 2012 with complaints of left-sided neck and arm pain, she demonstrated intact circulation, sensation and motor function of both hands, and exhibited full strength of the major muscle groups of the left upper extremity." Tr. 18. We find that this is a sufficient discussion of Iturralde's issue with her left arm because, as the Commisioner states in his brief: (1) there is only one medical record in the whole record evidencing that Iturralde had pain in her left upper extremity in August 2012; (2) in March 2013 she admitted to Dr. Rolle that the pain had "significantly resolved;" and (3) she reported in her disability paperwork that she was using her left hand to do her daily tasks. Doc. 12 p. 15-16 (internal quotations omitted). Further Iturralde does not point to any evidence of her left upper extremity being an impairment except the one medical record evaluating the initial injury.
Due to the lack of evidence of severe or continuous impairment, and her own admission that her problems with her left upper extremity had significantly resolved, the ALJ's decision to not classify Iturralde's left upper extremity issue as a medically established impairment; and his decision not to give the issue the same weight as her medically established severe and non-severe impairments is supported by substantial evidence. SSR 96-8p. The ALJ considered the evidence that Iturralde had asserted as relevant in accordance with SSR 96-8p, and did not err in his assessment of the RFC with respect to this matter.
Iturralde further asserts that "the ALJ did not engage in an individualized inquiry of Iturralde's limitations" when the ALJ limited her to "routine, repetitive work in a stable environment" as a result of her having moderate restrictions in concentration, persistence, or pace. Doc. 11 p. 15-16. Iturralde argues that based on Ramirez v. Barnhart, 372 F.3d 546, 554 (3d Cir. 2002), and several other cases following Ramirez, such limitations do not account for Iturralde's deficiencies in concentration, persistence, or pace Id. at 15. Iturralde however, never sets forth why the ALJ's limitation is insufficient. Rather, Iturralde merely lists citations with language from these decisions and circles back to her initial assertion Id. at. 15-16. This tactic is ineffective in that "[m]erely identifying the ALJ's finding that the Plaintiff has moderate limitation in concentration, persistence, and pace and then citing Ramirez is insufficient." Walck v. Colvin, No. 1:15-CV-01265, 2017 WL 3405115, at *15 (M.D. Pa. Mar. 17, 2017). It is not the job of the Court to construct or develop arguments for a party; therefore, we will not address this part of the second issue. See Loewen v. Berryhill, No. 16-35174, 2017 WL 6525196, at *1(9th Cir. 2017) (citing Carmickle v. Commissioner, Social Sec. Admin., 533 F.3d 1155, 1161 n.2 (9
Thus, we find that the ALJ did not err in his assessment of the RFC for Iturralde.
Iturralde also argues that the ALJ's determination regarding her credibility pertaining to the severity of her symptoms was not supported by substantial evidence, and that "[t]he ALJ failed to provide clear and convincing reasoning as to why he rejected [her] credibility." Doc. 11 p. 16; 21. It is established law that ALJ credibility determinations are "virtually unreviewable on appeal" Bieber v. Dep't of Army, 287 F.3d 1358, 1364 (Fed. Cir. 2002), and that such determinations are entitled to "`great deference.'" Horodenski v. Comm'r of Soc. Sec., 215 F. App'x 183, 189 (3d Cir. 2007) (quoting Atl. Limo, Inc. v. NLRB, 243 F.3d 711, 718 (3d Cir. 2001)). "`ALJ's findings based on the credibility of the applicant are to be accorded great weight and deference, particularly since an ALJ is charged with the duty of observing a witness's demeanor and credibility.'" Frazier v. Apfel, No. 99-CV-715, 2000 WL 288246, at *9 (E.D. Pa. Mar. 7, 2000) (quoting Walters v. Comm'r of Soc. Sec., 127 F.3d 525, 531 (6th Cir. 1997)).
The Third Circuit is clear that "[a]llegations of pain and other subjective symptoms must be supported by objective medical evidence." Hantraft v. Apfel, 181 F.3d 358, 362 (3d Cir. 1999) (referring to 20 C.F.R. §404.1529). "Inconsistencies in a claimant's testimony or daily activities permit an ALJ to conclude that some or all of the claimant's testimony about her limitations or symptoms is less than fully credible." Garret v. Comm'r of Soc. Sec., 274 Fed. Appx. 159, 164 (3d Cir.2008) (citing Burns v. Barnhart, 312 F.3d 113, 129-30 (3d Cir.2002)).
There is also guidance on credibility in SSR 96-7p,
SSR 96-7p.
The Social Security Rulings and Regulations provide a further framework under which a claimant's subjective complaints are to be considered. 20 C.F.R. § 404.1529; SSR 96-4p; SSR 96-7p. Symptoms such as pain, fatigue, weakness, or nervousness will only be considered to affect a claimant's ability to perform work activities, if such symptoms result from an underlying physical or mental impairment that has been demonstrated to exist by medical signs or laboratory findings. 20 C.F.R. § 404.1529(b). Once a medically determinable impairment that results in such symptoms is found to exist, the Commissioner must evaluate the intensity and persistence of such symptoms to determine their impact on the claimant's ability to work. Id. In so doing, the medical evidence of record is considered along with the claimant's statements. Id.
Guided by the foregoing legal requirements and benchmarks, we find that Iturralde's subjective complaints were not borne out by the record, and thus, we are satisfied that the ALJ's evaluation of Iturralde's credibility was supported by substantial evidence. The ALJ found that the intensity, persistence, and limiting effects of Iturralde's alleged symptoms were "not entirely credible" due to various inconsistencies between her testimony and medical records, and in his decision the ALJ points to various, specific inconsistencies that cause him to doubt the intensity and persistence of Iturralde's symptoms. Tr. 18-21.
One inconsistency to which the ALJ refers is Iturralde's claim that her symptoms of depression, anxiety and panic affect her ability to carry out her daily needs and socialize; however, she denied having any symptoms of depression and anxiety in December 2012, April 2013, and June 2014. Tr. 19. Another inconsistency articulated by the ALJ in support of his finding was that Iturralde testified at the ALJ hearing about suffering from headaches and experiencing pain from brushing her hair; yet there is nothing in the record showing that she reported these symptoms to her treating physicians. Id. The ALJ also explains that it is hard to find Iturralde's complaints entirely credible because "despite [Iturralde]'s alleged symptoms and limitations, [Iturralde] requires only conservative treatment measures and has not required inpatient psychiatric treatment or hospitalization." Id. The inconsistencies between Iturralde's testimony and the evidence in the record that the ALJ discusses are specific enough and sufficient to meet his duty in evaluating symptoms as required by SSR 96-7p.
Because the ALJ articulated specific reasons as to why he found Iturralde's allegations concerning the intensity, persistence, and limiting effects of her alleged symptoms lacked credibility, and because the ALJ's determination of credibility is entitled to great deference, we shall defer to the ALJ's evaluation of Iturralde's subjective complaints.
In sum, the ALJ's allotment of little weight to Dr. Rolle's opinion, his RFC assessment, and his evaluation of Iturralde's credibility are sufficiently explained and supported by substantial evidence in the record; therefore, the ALJ did not err in his decision on these bases.
Accordingly, because we find that the ALJ's decision is supported by substantial evidence, IT IS RECOMMENDED that Iturralde's request for a new administrative hearing should be DENIED, and the Commisioner's final decision denying Iturralde's applications for Social Security Benefits under Title II of the Social Security Act should be AFFIRMED. IT IS FURTHER RECOMMENDED that final judgment should be entered in favor of the Commissioner of Social Security and against Iturralde, and the Clerk of Court should close this case.
The parties are further placed on notice that pursuant to Local Rule 72.3:
Failure to file timely Objections to the foregoing Report and Recommendation may constitute a waiver of any appellate rights.