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 she 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 June 28, 2012, alleging disability beginning November 7, 2010, due to a dislocated disc in her back that causes her pain "all over". (R.pp. 10, 91, 115, 121). Plaintiff's alleged onset date of disability was later amended to September 30, 2012. (R.pp. 10, 21). Plaintiff's claim was denied both initially and upon reconsideration. Plaintiff then requested a hearing before an Administrative Law Judge (ALJ), which was held on October 29, 2013. (R.pp. 19-42). The ALJ thereafter denied Plaintiff's claim in a decision issued January 17, 2014. (R.pp. 10-18). The Appeals Council denied Plaintiff's request for a review of the ALJ's decision, thereby making the determination of the ALJ the final decision of the Commissioner. (R.pp. 1-4).
Plaintiff then filed this action in United States District Court. Plaintiff asserts that the ALJ's decision is not supported by substantial evidence and should be reversed and remanded for an award of benefits or, alternatively, for further consideration. 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 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 fifty-five (55) years old when she alleges she became disabled, has a high school education and has past relevant work experience as a data entry clerk. (R.pp. 17, 23, 25, 91, 116). In order to be considered "disabled" within the meaning of the Social Security Act, Plaintiff must show that she has an impairment or combination of impairments which prevent her from engaging in all substantial gainful activity for which she is qualified by her 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.
After a review of the evidence and testimony in the case, the ALJ determined that, although Plaintiff does suffer from the "severe" impairment
Plaintiff asserts that in reaching this decision, the ALJ erred because she failed to give appropriate weight to Plaintiff's treating source providers and failed to make the necessary credibility findings. However, after a 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 to support the decision of the Commissioner, and that the decision should therefore be affirmed.
On May 20, 2010 (several months before Plaintiff's original, and more than two years prior to her amended, alleged onset date of disability), x-rays of Plaintiff's left shoulder showed soft tissue calcification compatible with calcific tendonitis, but with no fracture, dislocation, or destructive process. (R.p. 190). That same day, x-rays of Plaintiff's cervical spine showed DDD and spondylosis primarily at C5, C6, and C7. (R.p. 191). Thereafter, on June 10, 2010, Dr. Thomas D. Armsey, II, an orthopedist at Midlands Orthopaedics, examined Plaintiff for complaints of bilateral shoulder, neck, and low back pain without radiation to her lower extremities or persistent numbness or weakness. Although Plaintiff complained of "daily" low back pain, she had "full" muscle strength in her cervical spine. (R.pp. 161-163). Dr. T. Daniel Silvester, a radiologist, noted that a cervical spine MRI study taken that day indicated there was no significant spinal canal or neural foraminal stenosis, and no spinal cord or spinal canal nerve root impingement. (R.p. 188). Dr. Armsey stated that Plaintiff had only "mild" disc space narrowing. (R.p. 162).
On June 24, 2010, Plaintiff complained to Dr. Armsey of numbness and tingling in her bilateral upper extremities. He noted that the MRI of her cervical spine revealed C3-C7 mild posterior osteophyte complex without central or foraminal stenosis, no disc herniations, and no bone edema. (R.pp. 163-165). An EMG of Plaintiff's bilateral upper extremities on July 14, 2010, revealed only very mild right carpal tunnel syndrome, no sign of left carpal tunnel syndrome, and no evidence of left or right cervical radiculopathy. (R.pp. 166-167). On July 27, 2010, Dr. Armsey noted that Plaintiff was still complaining of pain that he could not explain, and that her EMG and other diagnostic studies showed no acute pathology that would explain her pain. (R.pp. 168-169).
On August 10, 2010, Plaintiff complained to Dr. Armsey about cervical, low back, and bilateral shoulder pain. Examination of her lumbar spine revealed only mild paraspinal tenderness, full strength to flexion/extension/rotation/lateral bending, no midline tenderness, and negative straight leg raising test bilaterally. Plaintiff's bilateral lower extremities were neurovascularly intact, her gait was non-antalgic, and there was no atrophy of her bilateral lower extremities. Examination of Plaintiff's cervical spine revealed only mild paraspinal tenderness, with no lesions, erythema, midline tenderness, crepitus, or masses. There was also no atrophy of her bilateral upper extremities, her muscle strength was full, her deep tendon reflexes were full and equal, and her sensation was intact. Dr. Armsey noted that Plaintiff was showing improvement with her recent walking program, and he prescribed a physical therapy program. His assessment was chronic low back pain, obesity, and cervical spine pain-spondylosis. (R.pp. 170-171).
Plaintiff again complained of daily cervical, bilateral shoulder, and low back pain on September 3, 2010. Dr. Armsey noted that x-rays of Plaintiff's lumbar spine showed DDD at L3-L4 with end plate sclerosis, and mild DDD at L4-L5 and L5-S1. He recommended an MRI to rule out L4 nerve root entrapment. (R.pp. 172-173). A September 2010 MRI of Plaintiff's lumbar spine showed mild DDD of her lumbar spine without any significant compressive sequelae. (R.p. 186). On September 17, 2010, Dr. Armsey noted that the MRI showed mild central canal stenosis and bi-foraminal stenosis at L3-L4, and left-sided disc bulge without stenosis. He planed to administer a diagnostic and therapeutic lumbar epidural steroidal injection (LESI). (R.p. 175).
Dr. Armsey administered a LESI on September 28, 2010. (R.p. 176). On October 5, 2010, Plaintiff reported improvement in her pain and function. Dr. Armsey noted that Plaintiff's neck and back improved with the injection as well as formal physical therapy, that she had started a walking program for weight loss and aerobic fitness, and was motivated to improve her core strength. He opined that, from a functional standpoint, Plaintiff could perform no overhead work or lift in excess of ten pounds. (R.pp. 178-179).
When Plaintiff returned on January 7, 2011, Dr. Armsey noted that she was clinically improving with a home exercise program and intermittent pain medications. (R.p. 180-181). On April 21, 2011, Dr. Armsey noted that Plaintiff was doing well with regard to her neck, back, and, leg pain. He prescribed Ibuprofen, an anti-inflammatory medication. (R.pp. 182-183). During her July 19, 2011 appointment with Dr. Armsey, Plaintiff reported intermittent neck and back pain, but denied radicular pain in her arms and legs, reported she was walking a bit for exercise and had lost four pounds, and that she was performing exercises at home with improvement. (R.pp. 184-185).
At Plaintiff's next appointment with Dr. Armsey on December 9, 2011, she complained of low back pain with occasional right lower leg radiculopathy that was tolerable. Examination revealed that Plaintiff had a normal gait, no limp, 5/5 (full) motor strength, and negative straight leg raise testing. Plaintiff told Dr. Armsey that she was not interested in aggressive management and wanted to advance her activities as instructed and follow up in three months. (R.pp. 193-194).
Plaintiff was examined on February 21, 2012, by Dr. Vijaya Korrapati, an oncologist, for follow-up of her cutaneous T-cell lymphoma,
In March 2012, Plaintiff reported to Dr. Armsey that her pain (which she described as 6/10) was being alleviated with medication that was "helping a lot". She ambulated with a normal gait, her range of motion was normal, her motor strength was 5/5, and straight leg raise testing was negative. (R.pp. 195-197). On April 12, 2012, Plaintiff was referred to Dr. Ivan E. Lamotta, an orthopedic surgeon also with Midlands Orthopaedics, to discuss surgical options because she had not responded to conservative management. Plaintiff complained of low back pain that had persisted for over a year, described her pain as moderate, and denied any radicular symptoms. Physical examination revealed a normal gait, 5/5 motor strength, and negative straight leg raise testing. Dr. Lamotta recommended an updated MRI. (R.pp. 198-201). An April 19, 2012 MRI of Plaintiff's lumbar spine showed disc space loss and mild disc bulging at L3-L4. (R.pp. 211-212, 243-244). On May 3, 2012, Plaintiff reported 8/10 pain in her back and 4-7/10 in her right leg (posterior), but also stated that her medication (Lortab) was helping a lot. Even so, Dr. Lamotta opined that conservative management had been unsuccessful in controlling Plaintiff's symptoms. (R.pp. 202-205).
At her May 2012 appointment with Dr. Korrapati, it was noted that Plaintiff's lab work looked good, and that her last CT scans in December 2011 had showed no lymphadenopathy.
At Dr. Lamotta's recommendation, a lumbar discography was performed on May 25, 2012, and it showed findings consistent with Plaintiff's typical pain at the L3-L4 level. It was also noted that there was narrowing, degeneration, and fissuring at this disc space. (R.pp. 241-242). On June 28, 2012, Dr. Lamotta recommended Plaintiff undergo a lateral interbody fusion at L3-L4, but Plaintiff stated that she did not feel quite ready for surgery and wanted to think about it. (R.pp. 206-209).
On August 6, 2012, state agency physician Dr. Hugh Wilson completed a physical RFC assessment and opined that Plaintiff had the RFC for light work
Plaintiff was examined by Dr. Tanya Seawright, a primary care physician, for complaints of back pain on August 21, 2012. Plaintiff reported that she was filing for disability; was scheduled for a LESI later in the week, was considering back surgery, and needed to decide whether to pursue surgery as she had been denied disability benefits two weeks earlier, had not worked since 2010, and had been receiving unemployment benefits for two years that were due to end that week. (R.p. 427). Thereafter, Dr. Guillermo E. Pineda, a cardiologist, saw Plaintiff on August 28, 2012, at which time Plaintiff reported that she was able to perform her day-to-day physical activities around the house with no limitations. Dr. Pineda opined that Plaintiff was stable from a cardiovascular standpoint. (R.pp. 237-240).
As previously noted, Plaintiff does not herself contend that her impairment was of a disabling severity during the period of time covered by the medical records cited and discussed hereinabove. (R.pp. 10, 21). Therefore, in order to obtain DIB, Plaintiff must have evidence to show that her condition significantly worsened after September 30, 2012 (her alleged disability onset date) from what it had been as shown by these medical records.
The record reflects that Dr. Ellen Humphries, a state agency medical consultant, completed a physical RFC assessment on October 11, 2012 (which was now after Plaintiff alleges her condition had become disabling), in which she opined that Plaintiff had the same limitations (i.e., that Plaintiff was capable of performing a range of light work) as was previously assessed by Dr. Wilson. (R.pp. 53-55,
At an appointment prior to her February 2013 colonoscopy, Plaintiff denied back pain, arthralgias, stiffness, and myalgias. (R.pp. 320-322). When Plaintiff returned on April 11, 2013, Dr. Lamotta noted that surgery had not been approved by Plaintiff's insurance company, that she would proceed to obtain a second surgical opinion, and that she "may" be a candidate for surgery in the future. (R.pp. 431-433). On examination Dr. Lamotta found that Plaintiff had only mildly limited range of motion in her spine, that she ambulated without need of any assistive devices, that her lower extremity strength was full (5/5) and had no deficits, and that she had intact sensation in all major dermatomes. (R.p. 434).
Plaintiff returned to Dr. Korrapati in May 2013, and reported feeling well overall, except for slight fatigue and pain in her lower back. Plaintiff's rashes were noted to be stable and her labs looked good. The plan was to monitor Plaintiff clinically with no indication that a CT scan was needed at that time. (R.pp. 334-337). On June 19, 2013, Dr. Steven C. Poletti of Southeastern Spine Institute recommended that Plaintiff undergo interbody fusion. Plaintiff said she would follow up with Dr. Lamotta for surgical approval. (R.p. 402).
On June 21, 2013, Dr. Seawright performed a well adult examination. Plaintiff described her general health as good, and Dr. Seawright noted that Plaintiff was stable on her current diabetes medications without complications and that she was tolerating her cholesterol medications well. Examination revealed that Plaintiff had a supple and non-tender neck, no carotid bruit or thryromegaly, normal range of motion, a normal gait, and normal sensation. (R.pp. 404-407).
On June 27, 2013, Plaintiff returned to Dr. Lamotta with complaints of lower back pain. Examination revealed mildly limited range of motion, an ability to ambulate without an assistive device, no deficits in Plaintiff's lower extremity strength (5/5), and intact sensation in all dermatones. Dr. Lamotta noted he would seek surgical approval from Plaintiff's insurance company for surgery (L3-L4 interbody fusion). (R.pp. 428-430).
Plaintiff initially argues that the ALJ's RFC determination that she could perform a range of sedentary work is not supported by substantial evidence, in particular that the ALJ failed to give appropriate weight to the opinion of her treating source providers. Plaintiff's argument is essentially that the ALJ should not have given great weight to treating orthopedist Dr. Armsey's October 2010 opinion, and should instead have given greater weight to later evidence indicating a worsening in her condition.
Plaintiff argues that Dr. Armsey's October 2010 opinion was based on only on the diagnoses that had been made at that time (bilateral upper extremity radiculopathy, cervical spinal pain with spondylosis, and chronic back pain) and objective medical evidence which included x-rays and MRI of her cervical spine that showed mild DDD and a lumbar MRI that revealed mild DDD without an significant compressive sequelae identified, but that by 2012 her diagnoses included lumbago, spinal stenosis, disc degeneration, sciatica, and cervicaligia, while an April 2012 MRI indicated a worsening of her lumbar condition including disc space loss and bulging at L3-4. Plaintiff asserts that she has moderate to severe osteoarthritis in her lumbar and cervical spine with pain radiating to her upper and lower extremities which precludes her from performing sedentary work, and that the ALJ erred in finding that she had the RFC to perform a range of sedentary work.
RFC is defined as "the most [a claimant] can still do despite [the claimant's] limitations." 20 C.F.R. § 404.1545(a)(1). In SSR 96-8p, RFC is defined as a function-by-function assessment of an individual's physical and mental capacities to do sustained, work-related physical and mental activities in a work setting on a regular and continuing basis of eight hours per day, five days per week, or the equivalent. SSR 96-8p, 1996 WL 374184. An RFC "assessment must include a narrative discussion describing how the evidence supports each conclusion, citing specific medical facts (e.g., laboratory findings) and nonmedical evidence (e.g., daily activities, observations);"
Here, however, the ALJ properly evaluated Plaintiff's RFC by including in her decision a narrative discussion of the medical and nonmedical evidence to conclude that Plaintiff had the RFC to perform a range of sedentary work. (R.pp. 14-17). The ALJ specifically stated that the RFC:
(R.p. 17).
Objective medical evidence supports the ALJ's conclusion that although Plaintiff's DDD limited her to sedentary work, her combination of severe and non-severe impairments did not prevent her from performing all work.
Plaintiff's June 2010 cervical spine MRI revealed minimal to mild posterior disc/osteophyte formation at C3-4 through C6-7 without any spinal canal or neural foraminal stenosis and no spinal cord or spinal nerve root impingement, and nerve conduction studies in July 2010 showed no left or right cervical radiculopathy. (R.pp. 15, 166-167, 188). A lumbar spine MRI in September 2010 showed only mild degenerative disc disease without significant compressive sequelae. At L3-4 there was mild symmetrical diffuse disc bulge, mild central stenosis, and mild bilateral foraminal stenosis; at L4-5 there was a diffuse disc bulge slightly asymmetric to the left, mild left and no significant right foraminal stenosis, no significant central canal stenosis, and mild bilateral facet arthropathy; and at L5-S1 there was mild symmetrical diffuse disc bulge, no significant central stenosis, and no more than mild bilateral foraminal stenosis. (R.pp. 16, 186). Similarly, a lumbar MRI in May 2012 revealed that at L3-4 there was some mild annular disc bulging without significant deformity to the thecal sac, no spinal stenosis, and patent lateral recesses and neural foramina; at L4-5 there was no focal disc deformity and no spinal stenosis; and at L5-S1 there was no focal disc deformity, no spinal stenosis, and only some mild degenerative change involving the facet joints. (R.p.16, 211). Discography was positive for Plaintiff's typical pain at the L3-L4 level. (R.p. 242). Additionally, musculoskeletal examinations consistently indicated normal range of motion, normal gait, full strength, and normal sensory findings. (R.pp. 16-17, 196-197, 194, 344, 406).
These clinical findings extended into Plaintiff's purported period of disability, as in the latest treatment note of record (June 2013 — more than eight months after her amended onset date), clinical findings from Dr. Lamotta indicated that Plaintiff had only mildly limited range of motion, she ambulated without an assistive device, she had no deficits in lower extremity strength, and her sensation was intact. (R.p. 17, 430).
Hence, the ALJ's decision to give great weight to the 2010 opinion of treating orthopedist Dr. Armsey (that Plaintiff was limited to no overhead work and no lifting more than ten pounds) is supported by substantial evidence, as it is consistent with the overall evidence of record from throughout the relevant time period.
Additionally, the ALJ's determination that Plaintiff could perform a reduced range of sedentary work is also supported by the opinions of the state agency physicians, who actually found that Plaintiff could perform a higher level of light work.
In sum, after careful review of the record, the undersigned can find no reversible error in the ALJ's treatment of the findings of Plaintiff's treating sources or as to her RFC findings. The ALJ did not rely solely on evidence from prior to Plaintiff's amended onset date (including Dr. Armsey's October 2010 opinion) in finding that Plaintiff was not disabled, but considered all of the medical evidence of record from both prior to and after that date. Additionally, Dr. Armsey, as well as an orthopedic surgeon in the same practice (Dr. Lamotta), continued to treat Plaintiff thereafter (including after Plaintiff's amended onset date), and the ALJ properly noted that no additional or greater limitations were placed on Plaintiff by her treating orthopedist or by any other evaluating orthopedist. (R.p. 17). Further, no treating physician determined that Plaintiff was disabled. (R.p. 17).
The ALJ adequately explained the rationale behind her decision, which is supported by substantial evidence in the case record.
Plaintiff also asserts that the ALJ erred in failing to properly analyze her credibility. She argues that her testimony that her lumbar problem kept her "from doing a lot of stuff because I'm not able to sit this long, use my hands regularly . . . It's just really uncomfortable for me to work because I'm in such pain-severe pain most of the time" (R.p. 29), as well as her reports to physicians that medications and changing positions were the only ways she could alleviate the pain, support her credibility. Plaintiff also contends that opinions of her physicians that she had a "dynamic instability at the level of L3-L4" and had "failed extensive conservative care in the form of medication, physical therapy and epidural steroid injections" support her testimony as credible.
However, while concluding that Plaintiff did have medically determinable impairments that could reasonably be expected to cause the symptoms she alleged, the ALJ found that Plaintiff's statements concerning the intensity, persistence and limiting effects of these symptoms were not credible to the extent inconsistent with the RFC set forth in the decision. (R.p. 15). In reaching this conclusion, the ALJ discussed and evaluated both the medical records and Plaintiff's testimony. (R.pp. 14-17). That is exactly what the ALJ is supposed to have done;
In finding that the medical evidence and Plaintiff's activities of daily living did not support her allegations, the ALJ noted that Plaintiff's treating orthopedist (Dr. Armsey) wrote in July 2010 that the extent of pain complained of was "unexplained" because Plaintiff's nerve conduction and other diagnostic studies revealed no acute pathology to explain Plaintiff's pain. Dr. Armsey only limited Plaintiff to no overhead work and no lifting more than ten pounds in October 2010. Thereafter, Plaintiff's May 2012 lumbar MRI did not show significant deformity of the thecal sac and showed no spinal stenosis, while her June 2013 clinical findings continued to show only mildly limited range of motion, that she was able to ambulate without an assistive device, and that she had no deficits in lower extremity strength and intact sensation. (R.pp. 15-16). Plaintiff's examinations continued to reveal throughout her period of alleged disability that, notwithstanding her reports of 9/10 pain, she was consistently found to have full (5/5) strength and essentially normal range of motion. (R.pp. 434-436).
The ALJ's credibility determination is also supported by Plaintiff's activities of daily living, which included grocery shopping once a week for about thirty minutes, doing laundry once a week, attending church each Sunday, washing dishes, making up her bed, using a microwave to prepare food, and heating up food. (R.pp. 14-15, 27-28);
The ALJ's determination is also supported by Plaintiff's own reports concerning her condition to her medical providers, which indicate that Plaintiff reported improvement with a recent walking program in August 2010; clinical improvement with her home exercise program and intermittent pain medications in January 2011; that she was doing well with regard to her neck, back, and leg pain in April 2011; had only intermittent pain in her neck and back pain without radicular pain in July 2011; only occasional tolerable right lower leg radiculopathy in December 2011; and that she was not quite ready for fusion surgery in June 2011. (R.pp. 15-16, 171, 181, 183, 185, 194). Plaintiff also reported to her cardiologist in August 2012 that she was able to perform her day-to-day activities around the house with no limitations. (R.p. 15, 237).
Finally, Plaintiff also argues that she should be found credible based on the VE's testimony that, if Plaintiff's assertions as to her limitations were considered to be credible, she would not be able to perform her past relevant work or any other substantial work in the competitive labor market.
As previously noted, this Court may not overturn a decision that is supported by substantial evidence just because the record may contain conflicting 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 affirmed.
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.'"
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);
(R.pp. 39-40).