THOMAS E. ROGERS, III, Magistrate Judge.
This is an action brought pursuant to Section 205(g) of the Social Security Act, as amended, 42 U.S.C. Section 405(g), to obtain judicial review of a "final decision" of the Commissioner of Social Security, denying Plaintiff's claim for Disability Insurance Benefits (DIB) and Supplemental Security Income (SSI). The only issues before the Court are whether the findings of fact are supported by substantial evidence and whether proper legal standards have been applied. This case is before the Court pursuant to Local Rule 83.VII.02, D .S.C., concerning the disposition of Social Security cases in this District on consent of the parties. 28 U.S.C. § 636(c).
Plaintiff applied for Disability Insurance Benefits (DIB) and Supplemental Security Income (SSI) on March 13, 2007, alleging that she became disabled on March 5, 2007 (Tr. 23, 131-132, 498). Her claims were denied initially and upon reconsideration (Tr. 76-83). Plaintiff then requested an administrative hearing (Tr. 102-103). On September 16, 2009, the ALJ held a hearing at which Plaintiff, who was represented by counsel, appeared and testified (Tr. 41-74). After the hearing, on November 17, 2009, the ALJ issued a decision finding that Plaintiff was not disabled (Tr. 20-40). On January 6, 2011, the Appeals Council declined to review the ALJ decision, rendering it the final decision of the Commissioner (Tr. 1-5). Plaintiff then appealed this decision to this Court, which issued a decision remanding the case to the Agency for further proceedings (Tr. 603-631). Pursuant to this Court's decision, the Appeals Council remanded Plaintiff's claim to the ALJ, instructing him to hold a new hearing and issue a new decision (Tr. 632-634). The ALJ held a new hearing on April 22, 2013, at which Plaintiff, represented by counsel, appeared and testified (Tr. 529-572). After the hearing, on July 3, 2013, the ALJ issued a new decision finding that Plaintiff was disabled as of January 27, 2010, but not before then (Tr. 495-528).
Plaintiff was born on March 22, 1973 and was 33 years old at the time of the alleged onset. (Tr. 34). Plaintiff has at least a high school and past relevant work experience as a nurse's aide, cleaner, dietary aide, sandwich maker, and waitress. (Tr. 515).
The ALJ provided a detailed summary of the medical evidence, the various physicians' opinions, as well as Plaintiff's testimony, which the Court adopts to the extent that it is consistent with this decision. Additional factual details will be added where necessary to address the issues raised by the parties.
In the decision of July 3, 2013, the ALJ found the following:
(Tr. 498-518).
The Plaintiff argues that the ALJ erred in his decision, and that reversal and an award of benefits are appropriate in this case. Specifically, Plaintiff believes that the ALJ erred (1) in his evaluation of Plaintiff's Listing level mental impairment; (2) in his application of the treating physician rule; (3) in his evaluation of Plaintiff's credibility; and (4) in his formulation of a residual functional capacity for the time period preceding January 27, 2010 which Plaintiff argues is not supported by substantial evidence. (Plaintiff's brief hereinafter "Pl. Br."). The Commissioner argues that the ALJ's decision is supported by substantial evidence and legally correct, and should thus, be affirmed.
The Act provides that disability benefits shall be available to those persons insured for benefits, who are not of retirement age, who properly apply, and who are under a "disability." 42 U.S.C. § 423(a). Section 423(d)(1)(A) defines disability as: the 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 at least 12 consecutive months. 42 U.S.C. § 423(d)(1)(A).
To facilitate a uniform and efficient processing of disability claims, regulations promulgated under the Act have reduced the statutory definition of disability to a series of five sequential questions.
A claimant is not disabled within the meaning of the Act if he can return to PRW as it is customarily performed in the economy or as the claimant actually performed the work. See 20 C.F.R. Subpart P, § 404.1520(a), (b); Social Security Ruling ("SSR") 82-62 (1982). The claimant bears the burden of establishing his inability to work within the meaning of the Act. 42 U.S.C. § 423(d) (5).
Once an individual has made a prima facie showing of disability by establishing the inability to return to PRW, the burden shifts to the Commissioner to come forward with evidence that claimant can perform alternative work and that such work exists in the regional economy. To satisfy that burden, the Commissioner may obtain testimony from a VE demonstrating the existence of jobs available in the national economy that claimant can perform despite the existence of impairments that prevent the return to PRW.
The Act permits a claimant to obtain judicial review of "any final decision of the Commissioner [ ] made after a hearing to which he was a party." 42 U.S.C. § 405(g). The scope of that federal court review is narrowly-tailored to determine whether the findings of the Commissioner are supported by substantial evidence and whether the Commissioner applied the proper legal standard in evaluating the claimant's case.
The Court's function is not to "try these cases
One of issues raised by Plaintiff is the ALJ's Listing 12.04 evaluation of her mental impairments. Plaintiff asserts that her treating psychiatrist, Dr. Leah McCartt, found that the Plaintiff met Listing 12.04 for affective disorders for the period 2007-2009. (Tr. 350). Her treatment notes begin on July 30, 2007, which is before the date last insured. Plaintiff indicates that Dr. McCartt clearly states that the she meets Listing 12.04. (Tr. 350, 353) and specifically indicates that she meets the "C" criteria and at least a significant percentage of the time meets the "B" criteria as well.
Plaintiff argues that in his decision the ALJ confuses the "B" and "C" criteria when he allegedly states that the Plaintiff does not meet the "C" criteria because her hospitalization did not last for two weeks or more. Plaintiff also argues that in the alternative, the ALJ fails to provide any meaningful analysis as to the "C" criteria at all.
The Plaintiff bears the burden of showing that her impairment(s) meet a listing.
Medically documented history of a chronic affective disorder of at least 2 years' duration that has caused more than a minimal limitation of ability to do basic work activities, with symptoms or signs currently attenuated by medication or psychosocial support, and one of the following: (1) Repeated episodes of decompensation, each of extended duration; or (2) A residual disease process that has resulted in such marginal adjustment that even a minimal increase in mental demands or change in the environment would be predicted to cause the individual to decompensate; or (3) Current history of 1 or more years' inability to function outside a highly supportive living arrangement, with an indication of continued need for such an arrangement.
20 C.F.R. Part 404, Subpart P, App. 1 § 12.04(C)
Dr. McCartt found that Plaintiff's mental condition resulted in moderate-to-marked restrictions in Plaintiff's ability to perform daily activities; moderate limitations in her ability to maintain concentration, persistence or pace; and marked limitations in her social functioning capacity (Tr. 360). She also found that Plaintiff had experienced one or two episodes of decompensation (Id.), and that her impairments met the paragraph "C" criteria of listing 12.04 as she concluded that Plaintiff has "[a] residual disease process that has resulted in such marginal adjustment that even a minimal increase in mental demands or changes in the environment would be predicted to cause the individual to decompensate." (Tr. 361).
In discussing the "B" criteria, the ALJ found that Plaintiff had moderate restrictions in her ability to perform daily activities; moderate difficulties in maintaining social functioning; moderate difficulties in her ability to maintain concentration, persistence or pace; and no episodes of decompensation of extended duration. (Tr. 503). The ALJ elaborated on his findings as follows:
Next, the ALJ notes that "[t]he claimant's mental impairment(s) does not satisfy the paragraph "C" criteria of the applicable mental disorder listing(s).
A natural reading of this portion of the ALJ's opinion indicates that the ALJ did not confuse the "B" and "C" criteria. Rather the ALJ fully discussed the "B" criteria and his statements with regards to episodes of decompensation was a part of that discussion. Although the ALJ makes a summary statement with regard to the "C" criteria at this juncture of the opinion, the Court finds that his subsequent discussion of Dr. McCartt's opinion adequately explains his findings. In relevant part, the ALJ notes that:
(Tr. 512).
The ALJ appropriately discounted Dr. McCartt's opinion that Plaintiff's mental impairments result in restrictions so severe that they would render her de facto disabled at step three. The ALJ found that this opinion was not entirely reliable because it was inconsistent with other evidence in the record, including Plaintiff's unremarkable mental status examinations and Dr. McCartt's treatment notes which contained high Global Assessment of Functioning (GAF) scores that the doctor herself assessed
Plaintiff also asserts that the ALJ erred in his application of the treating physician rule in relations to the opinions of Plaintiff's treating physicians. Specifically, Plaintiff claims the ALJ improperly discredited the opinions of Drs. James O'Leary, Gurdon Counts, Leah McCartt, James Brennan, Bradley Presnal, and Van Dam. The Commissioner argues that substantial evidence supports the ALJ's analysis of the opinions and/or findings of the Plaintiff's treating physicians.
The Social Security Administration's regulations provide that"[r]egardless of its source, we will evaluate every medical opinion we receive." 20 C.F.R. § 404.1527(c). Generally, more weight is given to the opinions of examining physicians than nonexamining physicians. More weight is given to the opinions of treating physicians since they are more likely to be able to provide a detailed, longitudinal picture of a claimant's medical impairment. See 20 C.F.R. §§ 404.1508 and § 404.1527(c)(2). The medical opinion of a treating physician is entitled to controlling weight, i.e. it must be adopted by the ALJ, if it is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in the record. See 20 C.F.R. § 404.1527(c)(2), SSR 96-2p, and
In determining what weight to give the opinions of medical sources, the ALJ must apply all of the factors in 20 C.F.R. § 404.1527(c)(1)-(6), which are: whether the source examined the claimant; whether the source has a treatment relationship with the claimant and, if so, the length of the relationship and the frequency of examination; the nature and extent of the treatment relationship; the supportability and consistency of the source's opinion with respect to all of the evidence of record; whether the source is a specialist; and, other relevant factors. See SSR 96-2p;
Dr. O'Leary, the Plaintiff's treating orthopaedist, treated Plaintiff for
On June 26, 2008 Dr. O'Leary noted that the Plaintiff was using a cane and has an antalgic gait. She had a "mildly positive" straight leg raising test on the left, but negative on the right. Dr. O'Leary noted that the Plaintiff's neuropathy was demonstrated by decreased sensibility and a stocking distribution involving both lower extremities. (Tr. 393)
In August of 2008, Dr. O'Leary filled out a Residual Functional Capacity form in which he stated that the Plaintiff is at the less than sedentary level. He noted that the claimant cannot feel her feet, has poor gait, and uses a cane. (Tr. 363-364).
Dr. O'Leary continued to assess the Plaintiff's gait as slow and shuffling, re-affirming this on November 13, 2008. (Tr. 377).
The ALJ's assessment of Dr. O'Leary opinion reads as follows:
(Tr. 510).
The ALJ considered Dr. O'Leary's opinion, but assigned it little weight because it was inconsistent with other evidence in the record. Despite the disabling limitations Dr. O'Leary assigned Plaintiff, the ALJ notes that the doctor generally found that she exhibited negative or only mildly positive straight leg raise testing, and normal strength and sensation (Tr. 367, 369, 371, 375, 377, 397). The ALJ also considered that objective testing during the period at issue, including MRI and EMG studies, revealed only mild issues (Tr. 510;
Dr. Counts, Plaintiff's primary care source during the relevant period completed an RFC form in June 2007 assigning Plaintiff disabling physical limitations (Tr. 263-265).
With regards to this opinion, the ALJ indicated:
(Tr. 509).
The ALJ appropriately discounted Dr. Counts opinion in finding that it lacked any significant explanation for the limitations identified therein, it was unsupported by Dr. Counts' treatment records, and because Dr. Counts was not an orthopaedist specialist (Tr. 509). Agency regulations indicate that the lack of explanation for an opinion is an appropriate factor for the ALJ to consider. See 20 C.F.R. §§ 404.1527(c)(3), 416.927(c)(3). Also, the ALJ noted that Dr. Counts' opinion was unsupported by his treatment notes, which show that he only met once with Plaintiff close to the time when he completed the opinion at issue, and he did not identify any significant findings during this meeting (Tr. 269). Lastly, the fact that Dr. Counts was not an orthopaedist was also a proper factor for the ALJ to consider.
Additionally, in July of 2009 Dr. Counts indicated that Plaintiff was totally and permanently disabled, with such disability beginning in August 2007. (Tr. 333). Dr. Counts stated on another occasion that the Plaintiff is disabled and "unable to be gainfully employed." (Tr. 337). The ALJ appropriately gave these opinions minimal weight as they spoke to an issue reserved to the Commissioner. Determinations of disability are ultimately "an issue reserved to the Commissioner" (Tr. 543). More fully, pursuant to SSR 96-5p, available at 1996 WL 374183, at *2, "treating source opinions on issues that are reserved to the Commissioner are never entitled to . . . special significance. Giving controlling weight to such opinions . . . would be an abdication of the Commissioner's statutory responsibility to determine whether an individual is disabled" (emphasis added). That said, opinions from any medical source on issues reserved to the Commissioner must never be ignored. The adjudicator is required to evaluate all evidence in the case record that may have a bearing on the determination or decision of disability, including opinions from medical sources about issues reserved to the Commissioner. If the case record contains an opinion from a medical source on an issue reserved to the Commissioner, the adjudicator must evaluate all the evidence in the case record to determine the extent to which the opinion is supported by the record.
For the reasons noted supra in the Court's discussion of the Listing 12.04 analysis, the Court concludes that the ALJ appropriately considered Dr. McCartt's opinions under the treating physician and the ALJ's findings with regards to this opinion are supported by substantial evidence.
Dr. Brennan treated Plaintiff regularly for her diabetes at Laurel Endocrine Associates. Dr. Brennan did not complete an assessment of Plaintiff's RFC; nonetheless, Plaintiff relies on the information contained in the doctor's treatment notes to argue that a more restrictive RFC was warranted. (Pl. Br. at 8-10). Plaintiff cites treatment notes from various appointment dates which note that her diabetes was "uncontrolled" during the period at issue.
Plaintiff briefly cites records from Drs. Presnal and Van Dam. She indicates that on July 13, 2006, Dr. Presnal at the Moore Clinic found diabetic neuropathy. (Tr. 233). Plaintiff also notes that on February 14, 2007, Dr. Van Dam diagnosed the Plaintiff with lumbar spondylosis and performed an epidural steroid injection. However, other than these notations, the Plaintiff does not explain how these records warrant a more restrictive RFC finding for the period pre-January 2010. Neither of these doctors identifies any specific RFC limitations affecting Plaintiff.
Plaintiff also alleges that the ALJ's pre-January 2010 RFC finding, which determined that Plaintiff retained the capacity to perform a limited range of sedentary work, is not supported by substantial evidence. As part of her argument the Plaintiff indicates that the ALJ's pre-January 2010 RFC finding is unsupported because the ALJ did not identify any reason for finding that Plaintiff's RFC was more restrictive as of January 27, 2010, the ALJ's determined date of disability. The Commissioner disagrees with Plaintiff's position.
An adjudicator is solely responsible for assessing a claimant's RFC. 20 C.F.R. §§ 404.1546(c), 416.946(c). In making that assessment, he must consider the functional limitations resulting from the claimant's medically determinable impairments. Social Security Ruling ("SSR") 96-8p, available at 1996 WL 374184, at *2. It is the claimant's burden, however, to establish how her impairments impact her functioning. See 20 C.F.R. §§ 404.1512(c), 416.946(c);
In the instant case, substantial evidence supports the ALJ's assessment of Plaintiff's RFC prior to January 2010.
In concluding that Plaintiff's condition deteriorated starting in January 2010, the ALJ found as follows:
Plaintiff asserts that "continuous use of a walker" in 2010 does not suggest that her condition worsened because her gait before January 2010 was also noted to be problematic (Pl. Br. at 4). However, reference to her slow and shuffling gait prior to 2010 is markedly different from a gait requiring continuous use of a walker in 2010, and this finding supports the conclusion that her condition deteriorated as of January 2010. As noted by the Commissioner, in around mid-2007, Plaintiff reported walking one mile daily, which suggests her gait was much more functional at the time (Tr. 249, 250, 256). Also, before 2010, Plaintiff reported using a cane due to gait problems, but not a walker (Tr. 305, 338, 368, 393). Significantly, as late as July 2009, Plaintiff's doctor observed that "[s]he [was] able to walk unassisted, but [did] better with a walking stick" (Tr. 338).
Similarly, the ALJ was correct in noting that Plaintiff's objective physical exam findings show more severe problems in 2010. For example, while the ALJ observes that Plaintiff's treatment records from Dr. Ogburu-Ogbonnaya, the pain specialist Plaintiff began seeing in January 2010, show,
Although Plaintiff argues that her diabetes was described as uncontrolled before 2010 (Pl. Br. at 8), as noted
Additionally, the Court notes that the medical opinions of the reviewing agency doctors support the ALJ's pre-January 2010 RFC finding. Agency regulations state that expert opinions of medical reviewers may amount to substantial evidence where, as here, they represent a reasonable reading of the relevant medical evidence.
From a physical standpoint, the ALJ relied on the opinions of Drs. Ellen Humphries and Rebecca Merriweather (Tr. 507-508). Dr. Humphries opined that Plaintiff retained the physical RFC to perform a limited range of light work, which exceeds the ALJ's RFC finding of less than sedentary work (Tr. 296-303). Dr. Merriweather, in turn, found that Plaintiff was restricted to a limited range of sedentary work, as the ALJ found (compare Tr. 905-912 with Tr. 504). The ALJ found Dr. Merriweather's opinion more consistent with the record and noted that she had reviewed more of Plaintiff's records than Dr. Humphries had the opportunity to consider; accordingly, he assigned greater weight to Dr. Merriweather's opinion (Tr. 508). Substantial evidence supports the ALJ's reliance on these opinions for the period preceding January 2010.
Regarding, Plaintiff's mental impairments, the opinions of reviewing Drs. Edward Waller and Philip Michel, and consultative psychiatrist Dr. John Bradley, substantially support the ALJ's RFC determination. Both Drs. Waller and Bradley opined that Plaintiff retained an RFC consistent with the ALJ's finding (
Additionally, Plaintiff's essentially normal mental status findings throughout the period at issue and the high GAF scores her mental health providers assigned her suggest that she retains the capacity to perform simple work with certain additional restrictions, as the ALJ and the reviewing doctors concluded.
For the reasons discussed, and having concluded that the opinion evidence of Plaintiff's treating physicians was appropriately considered and evaluated, the Court finds that the ALJ's conclusion that Plaintiff's symptoms deteriorated as of January 2010, resulting in a more limited RFC finding, is supported by substantial evidence.
Plaintiff alleges also that the ALJ failed to properly evaluate and make adequate findings regarding Plaintiff's credibility. The undersigned disagrees. The ALJ must make a credibility determination based upon all the evidence in the record. Where an ALJ decides not to credit a claimant's testimony, the ALJ must articulate specific and adequate reasons for doing so, or the record must be obvious as to the credibility finding.
It is not sufficient to make a conclusory statement that "the individual's allegations have been considered" or that "the allegations are (or are not) credible." It is also not enough for the adjudicator simply to recite the factors that are described in the regulations for evaluating symptoms. The determination or decision must contain specific reasons for the finding on credibility, supported by the evidence in the case record, and must be sufficiently specific to make clear to the individual and to any subsequent reviewers the weight the adjudicator gave to the individual's statements and the reasons for that weight. This documentation is necessary in order to give the individual a full and fair review of his or her claim, and in order to ensure a well-reasoned determination or decision. SSR 96-7p.
Under
When assessing the credibility of Plaintiff's subjective complaints, the ALJ must analyze such complaints in view of the following factors: (1) the nature, location, onset, duration, frequency, radiation and intensity of any pain; (2) precipitating and aggravating factors; (3) type, dosage, effectiveness and adverse side-effects of any pain medication; (4) treatment, other than medication, for relief of pain; (5) functional restrictions; and, (6) Plaintiff's daily activities. Craig v. Chater, 76 F.3d 585, 593 (4th Cir. 1996) (citing 20 C.F.R. §§ 404.1529(c)(3), 416.929(c)(3)). In addition to these factors, the ALJ must consider all of the relevant evidence in assessing the claimant's credibility concerning the intensity and persistence of the pain and its limiting effects. 20 C.F.R. § 404.1529(c). A claimant's allegations of pain "need not be accepted to the extent they are inconsistent with the available evidence, including objective evidence of the underlying impairment, and the extent to which that impairment can reasonably be expected to cause the pain the claimant alleges she suffers."
The ALJ may choose to reject a claimant's testimony regarding his pain or physical condition, but he must explain the basis for such rejection to ensure that the decision is sufficiently supported by substantial evidence.
Here, the ALJ accepted that Plaintiff had medically determinable impairments that could reasonably be expected to cause the alleged symptoms, but cited both objective and subjective evidence detracting from Plaintiff's statements regarding the extent of her limitations in a lengthy section of his opinion entitled "evaluation of the credibility of claimant's allegations."
With regards to claimant's allegations related to her anxiety and depression, with problems being around people, inability to perform complicated tasks, and inability to stay on task, the ALJ noted in relevant part:
Additionally, in evaluating Plaintiff's credibility as to both her mental and physical limitations, the ALJ expressly considered Plaintiff's daily activities. He found that Plaintiff reported that she drove, did household chores, cared for a child, took her child to school, and prepared meals in December of 2007. She was also noted to walk a mile every day in April of 2007, capable of lifting up to 10 pounds in October of 2007, and able to shop for her family's needs in stores. She also attended church.
The ALJ's consideration of these factors indicates that he adequately considered how Plaintiff's impairments affected his daily routine. Courts have generally found that evidence of similar levels of activity tends to weigh against a finding of disability.
Additionally, the ALJ also considered other evidence of record, including
Plaintiff asserts certain specific issues with regards to her position that the ALJ erred in evaluating her credibility, specifically as to how it changed in January of 2010. Plaintiff takes issue with the ALJ's statement that she had no difficulty sitting by March 2010 (Tr. 506), which she claims does not support the ALJ's determination that her impairments deteriorated in January 2010 and rendered her disabled as of that time. (Pl. Br. at 16). In reviewing the ALJ's credibility determination in its entirety as well as the ALJ's RFC determinations pre and post January 2010, the Court does not find Plaintiff's position to be persuasive. The ALJ did not rely on the fact that Plaintiff's ability to sit degraded after January 2010 to find her disabled, nor did he indicate that Plaintiff's ability to sit was any different after January 2010 (
Plaintiff also asserts that the ALJ's credibility analysis is deficient because the ALJ erred in finding that she did not need a cane. (Pl. Br. at 16). The ALJ stated that Plaintiff did not "necessarily" need a cane (Tr. 507), and, in doing so, cited substantial evidence in the record supporting that conclusion:
The ALJ reasonably concluded that Plaintiff did not necessarily need a cane.
Finally, Plaintiff disputes the ALJ's finding that she modified her testimony a number of times during the hearing. (Pl. Br. at 17). A review of the administrative hearing transcript, however, supports the ALJ's finding. (Tr. 544, 545 (Plaintiff testified at her second administrative hearing that she had not performed household chores since 2006, which ALJ observes is inconsistent with her testimony at the first hearing); Tr. 58-59, 556 (during her first hearing, Plaintiff stated she started using a cane in 2009, but, during her second hearing, she testified she began using a cane in 2004)). Moreover, even if the ALJ erred as to his factual finding regarding testimony modification, the error is harmless as substantial evidence in this case otherwise supports the ALJ's adverse credibility assessment.
The ALJ is responsible for assessing a claimant's credibility and resolving conflicts in the evidence,
Finally, Plaintiff argues that "there is no rational reason" for the ALJ to find that she has difficulty interacting with the public, but not with supervisors or co-workers. (Pl. Br. at 18-19). Other than a citation to "logic," Plaintiff provides no support for this contention. After review, the Court concludes that the ALJ reasonably found that Plaintiff's RFC included restrictions in her ability to deal with the public only. Although Dr. Waller (state agency physician) found that Plaintiff would perform better in a low stress job setting that does not require ongoing interaction with the public, he did not impose any restrictions on her interaction with co-workers or supervisors. (Tr. 325, 895) Dr. Michel (also a state agency physician) found that Plaintiff had the ability to work in coordination with or proximity to others without being distracted by them. (Tr. 1022). The ALJ reasonably relied on the opinions of these doctors and Plaintiff's position is without merit.
This Court is charged with reviewing the case only to determine whether the findings of the Commissioner were based on substantial evidence.