BRISTOW MARCHANT, Magistrate Judge.
The Plaintiff filed the Complaint in this action pursuant to 42 U.S.C. § 405(g), seeking judicial review of the final decision of the Commissioner wherein he was denied disability benefits. This case was referred to the undersigned for a report and recommendation pursuant to Local Civil Rule 73.02(B)(2)(a), (D.S.C.).
Plaintiff applied for Disability Insurance Benefits (DIB) on November 1, 2010, alleging disability beginning October 6, 2008 due to back problems and arthritis. (R.pp. 37, 175).
Plaintiff then filed this action in this United States District Court, asserting that there is not substantial evidence to support the ALJ's decision, and that the decision should be reversed and remanded for further consideration, or for an outright award of benefits. The Commissioner contends that the decision to deny benefits is supported by substantial evidence, and that Plaintiff was properly found not to be disabled.
Under 42 U.S.C. § 405(g), the Court's scope of review is generally limited to (1) whether the Commissioner's decision is supported by substantial evidence, and (2) whether the ultimate conclusions reached by the Commissioner are legally correct under controlling law.
The Court lacks the authority to substitute its own judgment for that of the Commissioner.
A review of the record shows that Plaintiff, who was thirty-eight (38) years old on his amended alleged disability onset date, has a high school education and past relevant work experience as a truck driver. (R.p. 42). In order to be considered "disabled" within the meaning of the Social Security Act, Plaintiff must show that he has an impairment or combination of impairments which prevent him from engaging in all substantial gainful activity for which he is qualified by his age, education, experience and functional capacity, and which has lasted or could reasonably be expected to last for a continuous period of not less than twelve (12) months. Further, the record shows that Plaintiff's eligibility for DIB expired on December 31, 2009. (R.p. 39). Therefore, in order to be entitled to disability benefits, Plaintiff must show that his impairments became disabling by no later than that date.
After a review of the evidence and testimony in this case, the ALJ determined that, although Plaintiff does suffer from the "severe" impairments
Plaintiff asserts that in reaching his decision, the ALJ erred by failing to give proper weight to the opinion of Plaintiff's treating physician, Dr. Steven Cremer, and by improperly evaluating Plaintiff's subjective testimony as to the extent of his pain and limitations and finding that Plaintiff could perform a significant number of jobs in the national economy with his impairments. However, after careful review and consideration of the evidence and arguments presented, the undersigned finds and concludes for the reasons set forth hereinbelow that there is substantial evidence in the case record to support the decision of the Commissioner, and that the decision should therefore be affirmed.
Plaintiff's medical records reflect that he ruptured a disc on January 12, 2001 while picking up a 40 pound water bottle. He underwent a laminectomy on February 27, 2001, but as his back pain continued he underwent a second fusion surgery at L4 and S1 on August 14, 2001. Post operatively he had no significant problems. (R.pp. 261-262, 522-524). On September 10, 2002 Plaintiff was seen at Winchester Musculoskeletal Medicine by Dr. Kimberly Salata, still complaining of significant pain. On examination Plaintiff was found to be well developed, well nourished, and in no acute distress. Plaintiff's ambulation was significant for a step-to-gait with the left leg, and he was only briefly able to stand on his heels and toes. However, straight leg raising and FABER maneuver
While the record reflects that Plaintiff remained out of work for a period of time as a result of this injury and resulting surgeries, after a further period of recovery he returned to work full time as a tractor trailer driver in 2003. (R.pp. 193, 236). Plaintiff also continued to be seen by Dr. Salata, with an "interim history" entry from May 28, 2003 noting that she had had a "lengthy discussion [with Plaintiff] regarding the results of his [functional capacity evaluation] and the inconsistencies as well was the demonstration of submaximal efforts and magnified illness behavior. [Plaintiff] indicated that his attorneys had also informed him that the results [of his FCE] were indicative of inconsistencies". (R.p. 254). An entry from November 20, 2003 notes that Plaintiff was approximately halfway through his real estate license preparation, and that he had done some hunting. (R.p. 252).
On June 1, 2004, which was now after Plaintiff had returned to working full time as a tractor trailer driver in December 2003, Plaintiff stated that he was "doing about the same" but that he did have some exacerbation of his pain while on a camping trip and trying to start a fire. On examination Dr. Salata found that Plaintiff had some left lumbar paraspinal spasm, but his reflexes were symmetric, his ambulation was normal, and he had full strength (5/5). (R.p. 251). On July 14, 2005, Dr. Salata noted that Plaintiff felt better since returning to work, and that he was doing more yard work and was remaining active, although prolonged standing or sitting increased his back pain. On examination Plaintiff was again found to have full strength with no muscle atrophy and normal ambulation. (R.p. 250). On January 11, 2007, Dr. Salata found some general weakness to resistence in Plaintiff's left lower extremity diffusely, but he had negative straight leg raising, his reflexes were symmetric, his sensation was intact, and he had a normal ambulation. Plaintiff exhibited decreased lumbar flexion, and there was a "slight" prominence to the left lumbar paraspinal musculature. Plaintiff indicated during this visit that "overall he has been doing fairly well". (R.p. 249). Again, Plaintiff does not contend that his medical problems were disabling during this period of time. Plaintiff apparently began seeing Dr. Cremer in 2008. (R.p. 349).
The record reflects that Plaintiff continued to work full time as a truck driver until October 6, 2008. (R.pp. 53, 175). This is when Plaintiff originally claimed that he became disabled and was no longer able to work;
With respect to Plaintiff's medical records, there is one encounter note from September 18, 2009 (which would be within the relevant time frame for establishing disability), where Plaintiff was seen by Dr. Cremer's practice for a complaint of chest congestion and "intermittent" leg pain. (R.p. 346). There is nothing to indicate any significant worsening of Plaintiff's condition or that he had a disabling impairment in this office note. To the contrary, Dr. Cremer noted that Plaintiff's diagnosis (illegible)
Shortly after having this MRI performed, Plaintiff went to a hospital on January 31, 2010 complaining of chronic back pain, which he described as "severe", "sharp", and "burning". On examination Plaintiff was found to have a well healed scar over his lower lumbar spine (from his previous surgeries) with no overlying erythema or redness, he had normal range of motion in his extremities with no lower extremity edema, he had no calf tenderness, no motor deficit, and no sensory deficit. Plaintiff was noted to be ambulatory, he was assessed with right sided sciatica, and advised to continue with his current medications. (R.pp. 284-285). These findings are consistent with those as far back as the treating records of Dr. Salata, and fail to show or document any significant worsening of Plaintiff's condition.
Plaintiff was seen by Dr. Cremer on March 5, 2010 (now over two months after his eligibility for DIB had expired) for complaints of back pain and (apparently) for review of his January MRI, but there are few notations on the treatment form of any objective findings. (R.p. 342). Plaintiff returned to see Dr. Cremer on March 19, 2010, where he was noted to be complaining of pain and stiffness. Most of the hand written notes from this visit are illegible, although apparently Plaintiff did refuse some kind of procedure or medication. (R.p. 341). On April 9, 2010, Plaintiff was seen at MUSC Health on referral from Dr. Cremer, where Plaintiff advised that he was currently partially disabled from work as a machinist, but that he was seeking employment as a truck driver. Plaintiff advised the physician (unidentified) that he was suffering from pain at a level of 10 on a 10 point scale, but on examination Plaintiff was noted to move his arms and legs, that he had full (5/5) strength in both his arms and his legs, normal sensation across with light touch and position sense X4 in his extremities, and a normal symmetric gait. (R.p. 291).
On April 30, 2010, Plaintiff had an x-ray of his lumbar spine which showed bilateral pedicle screws from his surgeries at L4-L5 and S1 with vertical stabilizer bars, the two inferior screws being non-intact. Plaintiff had normal height and alignment from T12 through S1, there was no scoliosis, no spondylolysis, no instability, and no subluxation. No compression fracture or instability was noted, and he had normal motion. (R.p. 318). An office note from Dr. Cremer's practice on May 5, 2010 again indicates that Plaintiff presented complaining of pain and stiffness, and Plaintiff's medications were reviewed. (R.p. 340). A medical entry from May 28, 2010 notes that Plaintiff was starting a new job and wanted an increase in his oxycodone. (R.p. 339).
Plaintiff returned to see Dr. Cremer on June 23, 2010 as a follow-up to complaints of chronic back pain and for a review of his medication regimen. (R.p. 338). This was now six months after his eligibility for DIB had expired. Plaintiff was seen on July 20, 2010 by Judith Hughes, a nurse practitioner in Dr. Cremer's office, who noted that Plaintiff was complaining of back pain, that his Fentanyl prescription was helping with his pain, and that he was "now back to work part-time".
On October 10, 2010 (almost ten months after Plaintiff's eligibility for DIB had expired), Dr. Cremer completed a medical questionnaire (physical) in which he opined that Plaintiff suffered from chronic low back pain and nerve pain, that Plaintiff was able to walk less than one hour in an eight hour work day, stand less than one hour, and sit less than one hour. He further opined that Plaintiff would only occasionally be able to lift up to ten pounds, and never lift over that amount, that he was restricted from climbing stairs or ladders, although he was not restricted from bending, and that Plaintiff was unable to work an hour eight hour day five days a week. Dr. Cremer opined that he did not expect Plaintiff's condition to improve, and that he could perform less than the full range of sedentary work. (R.pp. 329-331).
On December 29, 2010, consultative physician Dr. Cleve Hutson reviewed Plaintiff's medical records from before, during, and after Plaintiff's alleged disability onset date and expiration of eligibility, and gave little to no weight to Dr. Cremer's October 2010 assessment that Plaintiff could perform less than the full range of sedentary work because it was "based on the absence of objective findings from this physician". (R.pp. 324-325). On March 17, 2011, a second consultative physician, Dr. Joseph Gonzales, also reviewed Plaintiff's medical records and came to the same conclusion. (R.pp. 394-395). Further, a psychiatric review form completed that same date by state agency physician Dr. Lisa Warner found insufficient evidence to assess Plaintiff's self report of anxiety and depression. (R.pp. 396-408).
On May 4, 2011 (well over a year after Plaintiff's eligibility for DIB had expired), Plaintiff had an MRI of his sacrum/SI joints and pelvis which revealed no focal abnormalities, and that his post surgical changes remained stable from his previous MRI of January 28, 2010. This report noted that there was "[n]o apparent explanation for the [Plaintiff's] current symptoms with no defined acute fractures. (R.pp. 490-491). On May 11, 2011, Plaintiff had another MRI of his lumbar spine, which determined that Plaintiff's lumbar spine was stable when compared with the MRI from January 28, 2010, with no evidence of recurrent disc herniations or fragmentation. (R.pp. 488-489).
On August 16, 2011 Dr. Cremer wrote a letter stating that Plaintiff suffered from chronic back pain with radiculopathy and a history of ruptured disc since January 11, 2001, for which he had undergone surgery, that he requires extensive medications for pain, that he has to lay down three to four times a day to help relieve pain, that he uses a cane to walk, and that on September 1, 2009 Plaintiff was "reevaluated and diagnosed as fully disabled". Dr. Cremer further stated in this letter that Plaintiff has "massive amounts of scar tissue around the nerves and internal hardware as well as degenerative disc disease", and that he has "failed back syndrome".
On February 15, 2012, Plaintiff presented to the Waccamaw Community Hospital Emergency room complaining of "burning low back pain radiating to left leg". Examination reveal that Plaintiff's strength in all of his extremities was "strong". Plaintiff was administered medications and released. (R.p. 507, 512).
After a review of the record and evidence in this case, the ALJ determined that Plaintiff had the RFC to perform light work, restricted to no climbing of stairs/ropes/scaffolds, only occasionally performing other postural activities, with a further limitation to simple, routine, repetitive tasks. (R.p. 40). Plaintiff argues that in reaching his RFC findings, the ALJ committed reversible error by failing to give controlling weight to the opinion of Dr. Cremer that Plaintiff was incapable of performing even sedentary work.
In rejecting Dr. Cremer's opinion that Plaintiff was as limited as he indicated in his October 10, 2010 questionnaire and October 16, 2011 letter, the ALJ noted Dr. Cremer's own records showing that when Plaintiff was seen on September 18, 2009 (the only record from within the applicable time period for obtaining disability), there was no indication of any significant worsening of his condition and that Plaintiff's only complaint was of congestion and "intermittent" leg pain. The ALJ further noted that Dr. Cremer records after that time reflected conservative treatment of Plaintiff's condition with medications and that Plaintiff was even exercising (including swimming) and had returned to part time work. (R.pp. 41-42, 337, 342, 346).
As previously noted, Plaintiff had all of the impairments shown in his medical records prior to his alleged disability onset date, and there is no indication in Dr. Cremer's records of any significant worsening of his condition after that date, or indeed anytime prior to December 31, 2009, when his edibility for DIB expired.
Further, in addition to the paucity of evidence from Dr. Cremer's own practice to support the degree of limitation claimed by Plaintiff and opined to by Dr. Cremer, the ALJ also cited to the contrary medical findings of the Waccamaw Community Hospital, Plaintiff's MRI's and x-rays, as well as the functional capacity assessments of the state agency physicians, showing that examinations of Plaintiff's lower extremities revealed normal bulk, tone and strength with equal reflexes and pulses, objective evidence of only mild disc degeneration and annular bulging of the lumbar spine and scarring (which the ALJ accounted for in his RFC finding), and that there was an "absence of objective findings" to support Dr. Cremer's opinion. (R.p. 42);
After a review of the evidence, the ALJ determined that Plaintiff could perform at least light work restricted by the limitations noted in the decision, and that these restrictions would accommodate Plaintiff's condition consistent with the medical evidence documenting his impairments, while also giving Plaintiff every benefit of the doubt (including considerations of Plaintiff's complaints of associated pain) in determining an appropriate RFC.
Therefore, this claim is without merit.
With respect to Plaintiff's contention that the ALJ committed reversible error in his evaluation of Plaintiff's subjective testimony and credibility, this argument was also without merit. The ALJ specifically discussed Plaintiff's testimony, but while concluding that Plaintiff did have a medically determinable impairment that could reasonably be expected to cause the symptoms Plaintiff alleged, he found that Plaintiff's statements concerning the intensity, persistence and limiting effects of these symptoms was not credible to the extent inconsistent with the RFC set forth in the decision. (R.pp. 40-41). In reaching this conclusion, the ALJ noted that he had considered Plaintiff's testimony including that he had continued to seek employment, as well as the medical records and evidence previously discussed. That is exactly what he is supposed to have done.
Further, when objective evidence conflicts with a claimant's subjective statements, an ALJ is allowed to give the statements less weight;
With respect to Plaintiff's testimony, the ALJ noted Plaintiff's statements that he had "constant back pain" which required daily medications, that he engages in very little physical activity, and is even unable to do any household chores, and evaluated and contrasted that testimony with the objective medical evidence of generally mild findings, normal range of motion in his extremities, that Plaintiff himself had reported that he was exercising including swimming and had even returned to part time work, as well as that he continued to seek employment and held himself out as being able to work during the relevant time period. (R.pp. 40-42).
In sum, the ALJ did not conduct an improper credibility analysis, nor does his decision otherwise reflect a failure to properly consider the affect Plaintiff's impairments had on his ability to work. Rather, the record and evidence cited by the ALJ provides substantial evidence to support the ALJ's findings as to the extent of Plaintiff's limitations, and the undersigned can therefore find no reversible error in the ALJ's evaluation of Plaintiff's subjective testimony.
While Plaintiff seeks to have this Court give precedence to his testimony as opposed to the other evidence of record and substitute its own judgment for that of the ALJ, that is not the proper standard for review in a Social Security case. This Court may not overturn a decision that is supported by substantial evidence just because the record may contain conflicting evidence.
Plaintiff's final claim of error is that the ALJ relied on VE testimony to determine that he could perform jobs that existed in significant numbers in the national economy with his impairments, but that this testimony and opinion was given in response to an incomplete hypothetical. This argument is without merit.
The record reflects that in determining whether Plaintiff could perform gainful employment with the degree of impairment set forth in the decision, the ALJ obtained testimony from a Vocational Expert who testified that an individual of Plaintiff's age, education, and work experience could perform several jobs that exist in the national economy with his limitations. (R.pp. 40, 66-68). Plaintiff's claim of error is that it was improper for the ALJ to rely on the VE's testimony based on this hypothetical because it did not take into account all of Plaintiff's impairments as established by the record. However, the ALJ's hypothetical did account for all credibly established medical findings in the record as determined by the ALJ's RFC finding, which the undersigned has previously found is supported by substantial evidence.
The ALJ was not required to include limitations in his hypothetical that he did not find were warranted or shown in the evidence.
Substantial evidence is defined as ". . . evidence which a reasoning mind would accept as sufficient to support a particular conclusion."
Under this standard, the record contains substantial evidence to support the conclusion of the Commissioner that the Plaintiff was not disabled within the meaning of the Social Security Act during the relevant time period. Therefore, it is recommended that the decision of the Commissioner be
The parties are referred to the notice page attached hereto.
The parties are advised that they may file specific written objections to this Report and Recommendation with the District Judge. Objections must specifically identify the portions of the Report and Recommendation to which objections are made and the basis for such objections. "[I]n the absence of a timely filed objection, a district court need not conduct a de novo review, but instead must `only satisfy itself that there is no clear error on the face of the record in order to accept the recommendation.'" Diamond v. Colonial Life & Acc. Ins. Co., 416 F.3d 310 (4th Cir. 2005) (quoting Fed. R. Civ. P. 72 advisory committee's note).
Specific written objections must be filed within fourteen (14) days of the date of service of this Report and Recommendation. 28 U.S.C. § 636(b)(1); Fed. R. Civ. P. 72(b); see Fed. R. Civ. P. 6(a), (d). Filing by mail pursuant to Federal Rule of Civil Procedure 5 may be accomplished by mailing objections to: