LINCOLN D. ALMOND, Magistrate Judge.
This matter is before the Court for judicial review of a final decision of the Commissioner of the Social Security Administration ("Commissioner") denying Disability Insurance Benefits ("DIB") under the Social Security Act (the "Act"), 42 U.S.C. § 405(g). Plaintiff filed his Complaint on April 2, 2018 seeking to reverse the Decision of the Commissioner. On November 5, 2018, Plaintiff filed a Motion for Reversal of the Disability Determination of the Commissioner of Social Security. (ECF Doc. No. 10). On January 4, 2019, the Commissioner filed a Motion for an Order Affirming the Decision of the Commissioner. (ECF Doc. No. 13). Plaintiff filed a Reply on January 17, 2019. (ECF Doc. No. 14).
This matter has been referred to me for preliminary review, findings and recommended disposition. 28 U.S.C. § 636(b)(1)(B); LR Cv 72. Based upon my review of the record, the parties' submissions and independent research, I find that there is substantial evidence in this record to support the Commissioner's decision and findings that Plaintiff is not disabled within the meaning of the Act. Consequently, I recommend that Plaintiff's Motion for Reversal (ECF Doc. No. 10) be DENIED and that the Commissioner's Motion to Affirm (ECF Doc. No. 13) be GRANTED.
Plaintiff filed applications for DIB (Tr. 225-231) and SSI (Tr. 232-240) on October 13, 2015 alleging disability since March 15, 2006. The applications were denied initially on February 28, 2016 (Tr. 88-98, 101-112) and on reconsideration on August 5, 2016. (Tr. 114-128, 130-144). Plaintiff requested an Administrative Hearing. On April 13, 2017, a hearing was held before Administrative Law Judge Barry H. Best (the "ALJ") at which time Plaintiff, represented by counsel, and a Vocational Expert ("VE") appeared and testified. (Tr. 39-65). The ALJ issued an unfavorable decision to Plaintiff on May 31, 2017. (Tr. 17-38). The Appeals Council denied Plaintiff's request for review on February 1, 2018. (Tr. 1-6). Therefore, the ALJ's decision became final. A timely appeal was then filed with this Court.
Plaintiff argues that the ALJ failed to properly evaluate the medical-opinion evidence and erred in his assessment of his and his mother's credibility.
The Commissioner disputes Plaintiff's claims and contends that the ALJ's decision is supported by substantial evidence and must be affirmed.
The Commissioner's findings of fact are conclusive if supported by substantial evidence. 42 U.S.C. § 405(g). Substantial evidence is more than a scintilla —
Where the Commissioner's decision is supported by substantial evidence, the court must affirm, even if the court would have reached a contrary result as finder of fact.
The court must reverse the ALJ's decision on plenary review, however, if the ALJ applies incorrect law, or if the ALJ fails to provide the court with sufficient reasoning to determine that he or she properly applied the law.
The court may remand a case to the Commissioner for a rehearing under sentence four of 42 U.S.C. § 405(g); under sentence six of 42 U.S.C. § 405(g); or under both sentences.
Where the court cannot discern the basis for the Commissioner's decision, a sentence-four remand may be appropriate to allow her to explain the basis for her decision.
In contrast, sentence six of 42 U.S.C. § 405(g) provides:
42 U.S.C. § 405(g). To remand under sentence six, the claimant must establish: (1) that there is new, non-cumulative evidence; (2) that the evidence is material, relevant and probative so that there is a reasonable possibility that it would change the administrative result; and (3) there is good cause for failure to submit the evidence at the administrative level.
A sentence six remand may be warranted, even in the absence of an error by the Commissioner, if new, material evidence becomes available to the claimant.
The law defines disability as 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 twelve months. 42 U.S.C. §§ 416(i), 423(d)(1); 20 C.F.R. § 404.1505. The impairment must be severe, making the claimant unable to do her previous work, or any other substantial gainful activity which exists in the national economy. 42 U.S.C. § 423(d)(2); 20 C.F.R. §§ 404.1505-404.1511.
Substantial weight should be given to the opinion, diagnosis and medical evidence of a treating physician unless there is good cause to do otherwise.
Where a treating physician has merely made conclusory statements, the ALJ may afford them such weight as is supported by clinical or laboratory findings and other consistent evidence of a claimant's impairments.
The ALJ is required to review all of the medical findings and other evidence that support a medical source's statement that a claimant is disabled. However, the ALJ is responsible for making the ultimate determination about whether a claimant meets the statutory definition of disability. 20 C.F.R. § 404.1527(e). The ALJ is not required to give any special significance to the status of a physician as treating or non-treating in weighing an opinion on whether the claimant meets a listed impairment, a claimant's residual functional capacity (
The ALJ has a duty to fully and fairly develop the record.
The ALJ is required to order additional medical tests and exams only when a claimant's medical sources do not give sufficient medical evidence about an impairment to determine whether the claimant is disabled. 20 C.F.R. § 416.917;
The ALJ must follow five steps in evaluating a claim of disability.
In determining whether a claimant's physical and mental impairments are sufficiently severe, the ALJ must consider the combined effect of all of the claimant's impairments, and must consider any medically severe combination of impairments throughout the disability determination process. 42 U.S.C. § 423(d)(2)(B). Accordingly, the ALJ must make specific and well-articulated findings as to the effect of a combination of impairments when determining whether an individual is disabled.
The claimant bears the ultimate burden of proving the existence of a disability as defined by the Social Security Act.
Once the ALJ finds that a claimant cannot return to her prior work, the burden of proof shifts to the Commissioner to establish that the claimant could perform other work that exists in the national economy.
Exclusive reliance is not appropriate when a claimant is unable to perform a full range of work at a given residual functional level or when a claimant has a non-exertional impairment that significantly limits basic work skills.
"Pain can constitute a significant non-exertional impairment."
Where an ALJ decides not to credit a claimant's testimony about pain, the ALJ must articulate specific and adequate reasons for doing so, or the record must be obvious as to the credibility finding.
A lack of a sufficiently explicit credibility finding becomes a ground for remand when credibility is critical to the outcome of the case.
The ALJ decided this case adverse to Plaintiff at Step 5. At Step 2, the ALJ found that Plaintiff's depression, anxiety and ADD were "severe" impairments. (Tr. 22). The ALJ assessed an RFC for a full range of work at all exertional levels but subject to substantial non-exertional limitations related to Plaintiff's mental impairments. (Tr. 25). At Step 4, the ALJ determined that Plaintiff had no past relevant work. (Tr. 31). Ultimately, at Step 5, the ALJ concluded that Plaintiff was not disabled because he was able to perform unskilled work available in the economy. (Tr. 32).
Plaintiff challenges the ALJ's evaluation of the various treating and consulting medical opinions of record. He argues that the ALJ's RFC determination is not supported by substantial evidence and does not adequately account for Plaintiff's "off task" limitations and likely absenteeism.
In his Reply Memorandum, Plaintiff highlights his argument that the ALJ's failure to consider the treating source opinion of Dr. Debra Roberts requires reversal and remand. (ECF Doc. No. 14 at p. 2). Plaintiff asserts that the Commissioner "reluctantly conceded" this error in her Memorandum and "tried to hide it in the middle of [her] overarching argument."
The "opinion" in question is dated February 13, 2009 and was included in the medical records reviewed by the state agency reviewing psychologists, Dr. Kleinman and Dr. Killenberg. (Tr. 104, 118, 350). The document is titled "medical report" and relates diagnoses of ADHD and anxiety. (Tr. 350). The form asks the physician to include "sufficient Details of History, Physical and Diagnostic Findings, Clinical Course, Therapy and Response."
As an initial matter, it is questionable whether this is an "opinion." It is on a form entitled "medical report" which seeks information such as diagnoses, history, treatment and response. It does not solicit an opinion or seek any assessment of functional limitations. Plaintiff also fails to persuasively explain how the ALJ's RFC assessment fails to reasonably account for Dr. Roberts' comments. The ALJ significantly limited Plaintiff to uncomplicated, unskilled work with short breaks every two hours, no significant exercise of independent judgment, only occasional changes in job setting, and interaction with co-workers, supervisors and the public significantly limited in both frequency and subject matter. (Tr. 25-26). Finally, although Plaintiff's counsel brought the opinion of Ms. Crandall (Exh. 19F) to the ALJ's attention at the hearing, (Tr. 45), he did not mention Dr. Roberts' "opinion." Plaintiff's counsel also did not raise the issue of failure to consider Dr. Roberts' "opinion" to the Appeals Council in his letter brief dated August 18, 2017. (Exh. B18E).
Plaintiff also challenges the ALJ's evaluation of the competing medical opinions of record. However, he fails to establish that the ALJ committed any reversible error in evaluating such opinions and essentially asks this Court to reweigh the conflicting medical opinions which is not this Court's role on review.
In determining Plaintiff's RFC, the ALJ gave "great weight" to the January 2016 opinion of Dr. McKinsey, an examining psychologist, and "significant weight" to the opinions of Drs. Kleinman and Killenberg, the consulting psychologists. (Tr. 28-31). The ALJ also afforded "partial weight" to the March 2017 opinion of Ms. Crandall, a treating psychiatric nurse and the September 2015 report of Dr. D'Amico, an evaluating psychologist. (Tr. 29).
Plaintiff has shown no error in the ALJ's evaluation of the opinions of Drs. Kleinman and Killenberg.
Based on their review, Dr. Kleinman and Dr. Killenberg opined that Plaintiff could carry out only simple tasks and would be restricted to limited public contact. (Tr. 109, 125). Dr. Killenberg observed that, while Plaintiff reports he is "ok" interacting with authority and able to perform public tasks, she found that his history of depression and anxiety made him "poorly suited to work that requires sustained public interaction, or intensive group work with co-workers." (Tr. 125). She also found him "able to sustain adequate interactions in a work setting with minimal interpersonal demands."
Plaintiff has also shown no error in the ALJ's decision to give only "partial weight" to the opinions of Ms. Crandall. While it is undisputed that Ms. Crandall does not qualify as an "acceptable" medical source, the ALJ thoroughly evaluated her opinions in a manner consistent with SSR 06-3p. (Tr. 29). The ALJ ultimately assigned "partial weight" to Ms. Crandall's statements in light of the factors set forth in 20 C.F.R. § 416.927. The ALJ accurately observed that Ms. Crandall failed to support her opinions with any explanation or any objective medical evidence or findings.
Plaintiff argues that the ALJ's determinations as to his and his mother's credibility are not supported by substantial evidence "because they fail to identify any evidence
The ALJ made reasonable credibility determinations in the context of the record as a whole. Plaintiff has not shown that the ALJ committed any error, and, again, essentially asks this Court to reweigh the evidence and reach an alternate finding. While reasonable minds may disagree as to how to interpret the varied and competing pieces of evidence presented in this case, the ALJ's conclusion is reasonably supported by the record as a whole and thus is entitled to deference.
Plaintiff argues that the ALJ made an "impermissible medical judgment" at Step 3 that he did not meet any of the Listings and should have obtained medical expert testimony to assist in that finding. Here, neither Dr. Kleinman nor Dr. Killenberg opined that Plaintiff met any of the potentially applicable mental health Listings. (Tr. 106-107, 121). However, as explained by the ALJ in his decision, the applicable Listings were amended after their review. The ALJ applied the revised "Part B" and "Part C" criteria and found at Step 3 that they were not satisfied by Plaintiff. (Tr. 23-25). The ALJ found no basis to undertake a "readjudication of the initial or reconsideration determinations" and reasonably concluded that a Step 3 determination could be "reliably made on the basis of the current record." (Tr. 23).
In applying the "Part B" criteria, the ALJ reasonably concluded that Plaintiff had only mild or moderate limitations and Plaintiff does not identify any specific error in this regard. Rather, Plaintiff focuses on the "Part C" criteria requiring a showing that he has "achieved only marginal adjustment."
The ALJ found that the evidence failed to satisfy the "Part C" criteria. He noted that the record showed that Plaintiff "moved from one home to another during the relevant period, which strongly suggests that he has retained significant ability to adapt to changes in his environment." (Tr. 25). Plaintiff disputes this finding and argues that the evidence cited by the ALJ "actually showed just the opposite." (ECF Doc. No. 10-1 at pp. 33-34). The Commissioner counters that the record actually reflects that Plaintiff "adjusted to a difficult move and did not experience the necessary deterioration in functioning to satisfy the C criteria." (ECF Doc. No. 13-1 at p. 30).
The move took place in late 2016 due to a foreclosure, and the record reflects it was stressful. However, there is sufficient support in the record for the ALJ's finding that Plaintiff was able to adjust and adapt to the changes. Thus, the ALJ's Step 3 finding that Plaintiff failed to satisfy the "Part C" criteria is supported by substantial evidence and must be affirmed. For instance, a treatment note from January 9, 2017 reported a "difficult adjustment after the move" but noted that Plaintiff was "calmer today," "doing better with celexa," "thoughts are more organized, less racing," "mildly" anxious and depressed, sleeping well and a normal appetite. (Tr. 783). A January 10, 2017 treatment note also reflected a relatively positive adjustment to the move. (Tr. 750). He indicated that the move was to a quiet neighborhood away from triggers and "shady characters" he used to run into.
For the reasons discussed herein, I recommend that Plaintiff's Motion for Reversal (ECF Doc. No. 10) be DENIED and that the Commissioner's Motion to Affirm (ECF Doc. No. 13) be GRANTED. I further recommend that Final Judgment enter in favor of Defendant.
Any objection to this Report and Recommendation must be specific and must be filed with the Clerk of the Court within fourteen days of its receipt.