JEFFREY L. CURETON, Magistrate Judge.
This case was referred to the United States Magistrate Judge pursuant to the provisions of Title 28, United States Code, Section 636(b). The Findings, Conclusions, and Recommendation of the United States Magistrate Judge are as follows:
Plaintiff Lasonya R. Wilson ("Wilson") filed this action pursuant to Sections 405(g) and 1383(c)(3) of Title 42 of the United States Code for judicial review of a final decision of the Commissioner of Social Security denying her claims for a period of disability and disability insurance benefits ("DIB") under Title II of the Social Security Act ("SSA"). Wilson protectively applied for DIB in February 2011, alleging that her disability began on September 2, 2010. (Transcript ("Tr.") 11, 116-17.) After her application for benefits was denied initially and on reconsideration, Wilson requested a hearing before an administrative law judge ("ALJ"). (Tr. 11, 62-71.) The ALJ held a hearing on June 25, 2012, and she issued an unfavorable decision on July 24, 2012. (Tr. 8-19, 24-57.) On August 26, 2013, the Appeals Council denied Wilson's request for review, leaving the ALJ's decision as the final decision of the Commissioner in her case. (Tr. 1-4.) Wilson subsequently filed this civil action seeking review of the ALJ's decision.
Disability insurance is governed by Title II, 42 U.S.C. § 404 et seq., and numerous regulatory provisions. See 20 C.F.R. Pt. 404. The SSA defines a disability as a medically determinable physical or mental impairment lasting at least twelve months that prevents the claimant from engaging in substantial gainful activity. 42 U.S.C. §§ 423(d), 1382c(a)(3)(A); McQueen v. Apfel, 168 F.3d 152, 154 (5th Cir. 1999). To determine whether a claimant is disabled, and thus entitled to disability benefits, a five-step analysis is employed. 20 C.F.R. § 404.1520. First, the claimant must not be presently working at any substantial gainful activity. Substantial gainful activity is defined as work activity involving the use of significant physical or mental abilities for pay or profit. 20 C.F.R. § 404.1527. Second, the claimant must have an impairment or combination of impairments that is severe. 20 C.F.R. § 404.1520(c); Stone v. Heckler, 752 F.2d 1099, 1101 (5th Cir. 1985), cited in Loza v. Apfel, 219 F.3d 378, 392 (5th Cir. 2000). Third, disability will be found if the impairment or combination of impairments meets or equals an impairment listed in the Listing of Impairments ("Listing"), 20 C.F.R. Pt. 404, Subpt. P, App. 1. 20 C.F.R. §§ 404.1520(d), 416.920(d). Fourth, if disability cannot be found on the basis of the claimant's medical status alone, the impairment or impairments must prevent the claimant from returning to his past relevant work. Id. § 404.1520(e). And fifth, the impairment must prevent the claimant from doing any work, considering the claimant's residual functional capacity, age, education, and past work experience. Id. § 404.1520(f); Crowley v. Apfel, 197 F.3d 194, 197-98 (5th Cir.1999). At steps one through four, the burden of proof rests upon the claimant to show he is disabled. Crowley, 197 F.3d at 198. If the claimant satisfies this responsibility, the burden shifts to the Commissioner to show that there is other gainful employment the claimant is capable of performing in spite of his existing impairments. Id.
A denial of disability benefits is reviewed only to determine whether the Commissioner applied the correct legal standards and whether the decision is supported by substantial evidence in the record as a whole. Leggett v. Chater, 67 F.3d 558, 564 (5th Cir. 1995); Hollis v. Bowen, 837 F.2d 1378, 1382 (5th Cir. 1988). Substantial evidence is such relevant evidence as a responsible mind might accept to support a conclusion. Boyd v. Apfel, 239 F.3d 698, 704 (5th Cir. 2001). It is more than a mere scintilla, but less than a preponderance. Id. A finding of no substantial evidence is appropriate only if no credible evidentiary choices or medical findings support the decision. Id. This Court may neither reweigh the evidence in the record nor substitute its judgment for the Commissioner's, but will carefully scrutinize the record to determine if the evidence is present. Harris v. Apfel, 209 F.3d 413, 417 (5th Cir. 2000); Hollis, 837 F.2d at 1383.
In her brief, Wilson presents the following issues:
(Plaintiff's Brief ("Pl.'s Br.") at 5-17.)
In her July 24, 2012 decision, the ALJ found that Wilson met the insured status requirements of the SSA through December 31, 2015 and had not engaged in any substantial gainful activity since September 2, 2010, the alleged date of Wilson's onset of her disability. (Tr. 13.) The ALJ further found that Wilson suffered from the severe impairments of multiple sclerosis and seizure disorder. (Tr. 13.) In making such a determination, the ALJ stated:
(Tr. 13-14 (internal citations omitted) (emphasis omitted).)
Next, the ALJ held that none of Wilson's impairments, or combination of impairments, met or equaled the severity of any impairments in the Listing. (Tr. 14, 17.) As to Wilson's RFC, the ALJ stated:
(Tr. 14 (emphasis omitted).) Next, the ALJ found that Wilson was able to perform her past relevant work as a data entry clerk and administrative assistant. (Tr. 18.) Consequently, the ALJ concluded that Wilson was not disabled. (Tr. 18-19.)
Wilson first complains that the AU "misstated the evidence and failed to adhere to the `de minimis' standard imposed by the Fifth Circuit and by controlling Social Security law in finding no severe back impairment." (Pl.'s Br. at 5.) Wilson argues that this was, inter alia, "legally erroneous." (Pl.'s Br. at 7.) To evaluate whether a claimant's medical condition qualifies as a "severe impairment" at Step Two of the analysis, the Commissioner has issued regulations that define a "severe impairment" as one that "significantly limits [a claimant's] physical or mental ability to do basic work activities." 20 C.F.R. §§ 404.1520(c), 416.920(c); cf. id. §§ 404.1521(a), 416.921(a) ("An impairment or combination of impairments is not severe if it does not significantly limit your physical or mental ability to do basic work activities."). The Fifth Circuit, however, has held that a literal application of that definition is inconsistent with the statutory language and legislative history of the SSA. See Stone, 752 F.2d at 1104-05. Instead, the Fifth Circuit has established the following standard for determining whether a claimant's impairment is severe: An impairment is not severe only when it is a "slight abnormality" having "such minimal effect on the individual that it would not be expected to interfere with the individual's ability to work, irrespective of age, education or work experience." Id. at 1101 (emphasis added).
In this case, it is clear that the ALJ applied the correct legal standard as she specifically cited to Stone. (Tr. 14.) As set forth above, the ALJ, in analyzing whether Wilson's back impairment was severe, stated, "I therefore find that this condition is not severe according to the standard enunciated in Stone v. Heckler, 752 F.2d 1099 (5th Cir. 1985) and Social Security Ruling 85-28." (Tr. 14 (emphasis omitted).) Thus, the ALJ did not err in setting forth and applying the correct legal standard at Step Two.
Wilson also argues that substantial evidence does not support the ALJ's finding that Wilson's back impairment was not severe. (Pl.'s Br. at 8-9.) Wilson argues that the ALJ's statement that the imaging has shown "no more than mild arthritic changes in [Ms. Wilson's] spine" is erroneous. (Pl.'s Br. at 8.) Wilson claims that the clinical findings in the records as well as an August 2010 MRI and January 2011 x-ray show that Wilson's back impairment was severe. (Pl.'s Br. at 8.) Defendant, on the other hand, argues that the medical evidence of record supports the ALJ's finding that Wilson's back impairment was not severe.
As stated above, the ALJ specifically found at Step Two, inter alia, that Wilson's back impairment was not a severe impairment. In this case, it is clear that the ALJ was aware of and considered Wilson's back impairment throughout her decision. (See, e.g., Tr. 13, 15-16, 18.) Based on all the evidence in the record, however, the ALJ determined that Wilson's back impairment was not a severe impairment. While the ALJ may have erred in not discussing all the evidence in the record relating to Wilson's back impairment, any error is harmless. See Murrell v. Colvin, No. 3:12-CV-3757-G (BN), 2013 WL 4623549, at *5 (N.D. Tex. Aug. 29, 2013) ("[E]ven if the ALJ's determination that Plaintiffs borderline intellectual functioning was not a severe impairment was error, Plaintiff cannot show the prejudice required for remand."). Wilson, although pointing to other evidence indicating that her back impairment caused her some leg weakness, decreased sensation reflexes, and muscle strength, has not presented any nonconclusory evidence showing how her back impairment impacted her ability to work in a manner not already accounted for in the ALJ's finding that her multiple sclerosis was severe (and caused some back issues) and in the RFC determination. See Martinez v. Astrue, No. 2:10-CV-0102, 2011 WL 4128837, at *9 (N.D. Tex. Sept. 9, 2011). The mere presence or diagnosis of some impairment is not disabling per se. See Hames v. Heckler, 707 F.2d 162, 165 (5th Cir. 1983).
Wilson also argues that the ALJ erred at Step Two by completely ignoring Wilson's chest pain even though she had been treated at the emergency room on at least four occasions for such pain. (Pl.'s Br. at 9.) However, as noted by Wilson, Robert Capper, M.D., a cardiologist, "ruled out myocardial ischemia as a possible etiology of [Wilson's] discomfort and . . . reassured her that her heart is normal" in February 2012. (Tr. 376; see Pl.'s Br. at 9.) Moreover, Wilson does not point to any evidence in the record indicating that her chest pain caused any work-related limitations beyond those already found by the ALT in her RFC determination. Thus, remand is not required.
In addition, Wilson argues that the ALJ erred in not considering her chest pain and musculoskeletal impairments in combination with her obesity. (Pl.'s Br. at 9.) Contrary to Wilson's claims, however, the ALJ specifically considered and analyzed her obesity and ultimately found that "in this particular instance the claimant has failed to demonstrate specific limitations of any kind related to obesity." (Tr. 18.) In addition, the ALJ stated:
(Tr. 18 (emphasis omitted).) Based on the foregoing, it is clear that the ALJ considered Wilson's obesity in conjunction with her other impairments. Thus, the ALJ did not err, and remand is not required.
Next, Wilson argues that the ALJ erred in failing to properly explain her finding in the RFC determination that Wilson required the use of an assistive device while standing and walking. (Pl.'s Br. at 9-11.) Wilson claims that the ALJ failed to specify whether this assistive device was a one-hand or a two-hand device and this distinction is critical for two reasons. (Pl.'s Br. at 9.) To begin with, Wilson argues that if she is required to use a two-hand assistive device, then she would have an inability to ambulate as defined in 20 C.F.R. Pt. 404, Subpt. P, App. 1, § 1.00(B)(2)(b) and would have met section 11.09 of the Listing. (Pl.'s Br. at 9-10.) Specifically, Wilson states:
(Pl.'s Br. at 10.)
Second, Wilson argues that "the question of whether [she] required a one or two-hand assistive device is essential to evaluating her ability to perform her past relevant work." (Pl.'s Br. at 10.) Specifically, Wilson states:
(Pl.'s Br. at 10.)
As to the first issue, section 11.09 of the Listing states:
As noted by Wilson, the ALT also stated:
(Tr. 17.) While such a statement does refer to Wilson's ability to ambulate, it does not state that this was the sole reason the ALJ found that Wilson did not meet section 11.09 of the Listing. Instead, the majority of the ALJ's reason for her finding was that there was no non-conclusory
Moreover, with respect to the ALJ's finding in the RFC determination that Wilson needs to use an assistive device while standing or walking, the ALJ was obviously aware that Wilson used various assistive devices, including a walker, cane, and wheelchair. (See, e.g., Tr. 14, 15.) In addition, the ALJ, regardless of her RFC determination that Wilson could perform light work with various limitations, ultimately determined at Step Four that Wilson was capable of performing her past relevant work as a data entry clerk and administrative assistant. (Tr. 18.) In making such a determination, the ALJ relied on the testimony of a vocational expert ("YE"). (Tr. 18.)
At the hearing before the ALJ, the ALJ asked the VE to assume the following: "a person has a light functional capacity and would need to use—stand and walk no more than four hours—but can stand and walk no more than four hours out of an eight-hour day, and would need to use an assistive device when standing and walking." (Tr. 51.) The VE testified that such a person would be able to perform Wilson's past relevant work as a data entry clerk and administrative assistant and that both jobs were sedentary in nature. (Tr. 52.) When the ALJ asked if a person with that vocational profile would be able to do other jobs, the VE responded, "Yes. Well, you—the RFC says light with four hours. I would be comfortable naming sedentary jobs in that as light with an assistive device, a cane and/or walker." (Tr. 52.)
Based on this testimony, it is clear that the ALJ's reference in the RFC to the use of an assistive device referred to a cane and/ or walker. In addition, any error relating to the ALJ's RFC determination limiting Wilson to light work (as opposed to sedentary work) is harmless as the ALJ, relying on the testimony of the VE, ultimately found that Wilson could perform her past relevant work as a data entry clerk or administrative assistance, which were both sedentary in nature, with the use of either a cane and/or walker. See Audler v. Astrue, 501 F.3d 446, 448 (5th Cir. 2007) (stating that ALJ's omission does not require remand unless it affected claimant's substantial rights); Mays v. Bowen, 837 F.2d 1362, 1364 (5th Cir. 1988) ("Procedural perfection in administrative proceedings is not required" as long as the "substantial rights of a party have [not] been affected.").
Next, Wilson argues that the ALJ erred in rejecting the opinion of "[a]nother physician (name illegible)." (Tr. 17.) Specifically, Wilson states:
(Pl.'s Br. at 11-13 (internal citations omitted).)
Controlling weight is assigned to the opinions of a treating physician if it is wellsupported by medically acceptable clinical and laboratory diagnostic techniques and not inconsistent with other substantial evidence in the record. 20 C.F.R. § 404.1527(c)(2); Martinez v. Chater, 64 F.3d 172, 176 (5th Cir. 1995); Bowman v. Heckler, 706 F.2d 564,568 (5th Cir. 1983). However, the determination of disability always remains the province of the ALJ, and the ALJ can decrease the weight assigned to a treating physician's opinion for good cause, which includes disregarding statements that are brief and conclusory, unsupported by acceptable diagnostic techniques, or otherwise unsupported by the evidence. Leggett, 67 F.3d at 566; Greenspan v. Shalala, 38 F.3d 232, 237 (5th Cir. 1994); Muse v. Sullivan, 925 F.2d 785, 790 (5th Cir. 1991). Conclusory statements to the effect that the claimant is disabled or unable to work are legal conclusions, not medical opinions, and are not entitled to any special significance. See 20 C.F.R. § 404.1527(d); see also Frank v. Barnhart, 326 F.3d 618, 620 (5th Cir. 2003).
In a partially filled out one-page document signed on November 29, 2011, Dr. Willett opined that Wilson's disability is permanent and Wilson has seizures frequently. (Tr. 319.) In addition, Dr. Willett diagnosed Wilson with multiple sclerosis and seizures. (Tr. 319.) While the ALJ erred in stating that such document was signed by a physician whose name is illegible, any error is harmless. To begin with, as to Dr. Willett's opinion that Wilson is permanently disabled, the determination of disability is an issue reserved for the Commissioner. See 20 C.F.R. § 404.1527(d); Moore v. Sullivan, 919 F.2d 901, 905 (5th Cir. 1990) ("Mlle ALJ has sole responsibility for determining a claimant's disability status."). As to Dr. Willet's statement that Wilson has seizures frequently and diagnosis of multiple sclerosis and seizures, the ALJ incorporated such statements by finding that Wilson suffered from the severe impairments of multiple sclerosis and seizure disorder and included limitations in the RFC determination to account for such impairments. (Tr. 13, 16.)
Moreover, while the ALJ may have erred in failing to properly consider the opinion of Dr. Willett, substantial evidence supports the ALJ's determination. In making her RFC determination, the ALJ relied, inter alia, on the following evidence in the record: (1) a June 16, 2011 consultative examination performed by Dr. Nwankwo (Tr. 15, 17; see Tr. 220-24); (2) a January 6, 2011 examination by Candice Winful, M.D. (Tr. 15; see Tr. 310); (3) a Physical Residual Functional Capacity Assessment dated September 20, 2011 from State Agency Medical Consultant Robin Rosenstock, M.D. ("SAMC Rosenstock").
Wilson also argues that the ALJ erred in rejecting the opinion of Dr. Gowdagere, Wilson's treating neurologist, without analyzing the factors set forth in 20 C.F.R. 1527(c). (Pl.'s Br. at 13-15.) In Newton v. Apfel, the Fifth Circuit Court of Appeals held that "absent reliable medical evidence from a treating or examining specialist, an ALJ may reject the opinion of the treating physician only if the ALJ performs a detailed analysis of the treating physician's views under the criteria set forth in 20 C.F.R. § 404.1527." 209 F.3d 448, 453 (5th Cir. 2000). Under the statutory analysis of 20 C.F.R. § 404.1527(c), the ALJ must evaluate the following: (1) examining relationship; (2) treatment relationship, including the length, nature, and extent of the treatment relationship, as well as the frequency of the examination(s); (3) supportability; (4) consistency; (5) specialization; and (6) other factors which "tend to support or contradict the opinion." 20 C.F.R. § 404.1527(c); see also SSR 96-6p, 1996 WL 374180, at *3 (S.S.A., July 2, 1996); SSR 96-2p, 1996 WL 374188, at *4 (S.S.A. July 2, 1996).
Pursuant to Newton, the ALJ is required to perform a detailed analysis of the treating physician's views under the factors set forth in 20 C.F.R. § 404.1527(c) only if there is no reliable medical evidence from another treating or examining physician that controverts the treating specialist. See Newton, 209 F.3d at 455-57. An ALJ does not have to perform a detailed analysis under the factors in the regulation "where there is competing first-hand medical evidence and the ALJ finds as a factual matter that one doctor's opinion is more well-founded than the another," as well as in cases in which "the ALJ weighs the treating physician's opinion on disability against the medical opinion of other physicians who have treated or examined the claimant and have specific medical bases for a contrary opinion." Id. at 458; see Alejandro v. Barnhart, 291 F.Supp.2d 497, 507-11 (S.D. Tex. 2003); Contreras v. Massanari, No. 1:00-C242-C, 2001 WL 520815, at *4 (N.D. Tex. May 14, 2001) ("The Court's decision in Newton is limited to circumstances where the administrative law judge summarily rejects the opinions of a claimant's treating physician, based only on the testimony of a non-specialty medical expert who had not examined the claimant.")
As to Dr. Gowdagere's January 5, 2012 form, the ALJ did reject such opinion, stating that he could not give such opinion "more than minimal evidentiary weight." (Tr. 17; see Tr. 327-30.) However, the Court concludes that the ALJ did properly analyze his opinion pursuant to the factors set forth in 20 C.F.R. § 404.1527(c) before rejecting such opinion. As to factor one, the ALJ indicated that he had "reviewed [Dr. Gowdagere's] treatment records in great detail" (Tr. 17) and referenced such treatment records in the ALJ decision (Tr. 16 (referring to Exhibit 9F p. 9) and Tr. 17.) As to factor two, the ALJ was obviously aware that Dr. Gowdagere was a treating physician as she set forth the law regarding rejecting the opinion of a treating source immediately prior to stating that she was giving Dr. Gowdagere's January 2012 opinion no more than minimal evidentiary weight. (Tr. 17.) As to factors three, four, and six, the ALJ set forth much of the other medical evidence in the record and explained that she was rejecting Dr. Gowdagere's opinions because they were "unsupported by the objective evidence" and "fail[ed] to assign a sufficient rationale for an opinion." (Tr. 17.) As to factor five, although the ALJ did not specifically mention that Dr. Gowdagere was a neurologist, it is clear that she, at least implicitly, knew this fact as Dr. Gowdagere's records which were referenced by the ALJ in his decision clearly indicate that Dr. Gowdagere is a neurologist.
Wilson, citing to Social Security Ruling ("SSR") 82-62, also claims that the ALJ erred in failing to perform a step-by-step analysis of the physical and mental demands of Wilson's past relevant work. (Pl.'s Br. at 16-17.) Specifically, Wilson states:
(Pl.'s Br. at 16-17 (internal citations omitted).)
Once the ALJ has made the RFC determination, the ALJ moves on to Step 4 of the disability analysis. At Step 4, the claimant bears the burden of showing that she cannot perform her past relevant work. See Leggett, 67 F.3d at 564. Past relevant work "is work that you have done within the past 15 years, that was substantial gainful activity, and that lasted long enough for you to learn to do it." 20 C.F.R. § 404.1560(b)(1). When determining at Step Four whether the claimant could perform his past relevant work, the ALJ is permitted to consult a VE. See, e.g., Adams v. Astrue, No. 08-0135, 2009 WL 774845, at *7 (W.D. La. Mar. 24, 2009) ("At Step Four of the sequential evaluation process, the ALT employed a [VE] to find that [the claimant] was able to return to her past relevant work."); Pierce v. Astrue, No. 07-1294, 2008 WL 4373036, at *13 (E.D. La. Sept.22, 2008) ("Although a vocational expert is not required to make a step 4 determination, an ALJ may utilize such expert testimony.") "The value of a vocational expert is that he is familiar with the specific requirements of a particular occupation, including working conditions and the attributes and skills needed." Vaughan v. Shalala, 58 F.3d 129, 132 (5th Cir. 1995).
As noted above, the ALT found at Step Four that Wilson could perform her past relevant work as a data entry clerk and administrative assistant. (Tr. 18.) Specifically, the ALJ stated:
(Tr. 18-19.) At the hearing before the ALT, the VE listened to Wilson's testimony regarding what she did in her past jobs, inter alia, as a residential home manager, administrative assistant, computer lab assistant, home health care aid, and sales associate (Tr. 34-38.) The VE then went through the various jobs that Wilson had described, trying to classify them and pinpoint the DOT numbers associated with each. (Tr. 48-51.)
SSR 82-62 requires that when the ALT has determined that a claimant retains the RFC to perform a past relevant job, the decision must contain the following specific findings: (1) a finding of fact as to the individual's RFC; (2) a finding of fact as to the physical and mental demands of the past job or occupation; and (3) a finding of fact that the individual's RFC would permit a return to his or her past job or occupation. SSR 82-62, 1982 WL 31386, at *4 (S.S.A. 1982). When determining whether a claimant retains the RFC to perform her past relevant work, the ALJ can look to either (1) the job duties peculiar to an individual job as the claimant actually performed it or (2) the functional demands and job duties of the occupation as generally required by employees throughout the national economy. SSR 82-61, 1982 WL 31387, at *1-2 (S.S.A. 1982).
In this case, the Court concludes that the ALJ, based on her "treatment of the record in its entirely and the VE's testimony at the administrative hearing," did comply with SSR 82-62. See Pierce v. Astrue, No. 07-1294, 2008 WL 4373036, at *11 (E.D. La. Sept. 22, 2008). Moreover, the Court does not need to determine whether the ALJ erred in relying on the VE's testimony that Wilson could perform her past relevant work as an administrative assistance because the ALJ also determined that she could perform her past relevant work as a data entry clerk. Thus, even assuming that the ALJ erred at Step Four in relying on the VE's testimony that she could perform her past relevant work as an administrative assistance, any error is harmless because the ALJ also found that Wilson could perform another job. See Halley v. Astrue, No. 5:09-CV-135-BG, 2010 WL 2605214, at *3 (N.D. Tex. May 27, 2010) ("[E]ven if the court were to assume, arguendo, that the ALJ's determination that [the claimant] could perform past work as a cashier was reached in error, any error must be considered harmless because the ALJ determined that she could perform another job she worked at in the past.") Thus, remand is not required.
It is recommended that the Commissioner's decision be affirmed.
Under 28 U.S.C. § 636(b)(1), each party to this action has the right to serve and file specific written objections in the United States District Court to the United States Magistrate Judge's proposed findings, conclusions, and recommendation within fourteen (14) days after the party has been served with a copy of this document. The United States District Judge need only make a de novo determination of those portions of the United States Magistrate Judge's proposed findings, conclusions, and recommendation to which specific objection is timely made. See 28 U.S.C. § 636(b)(1). Failure to file by the date stated above a specific written objection to a proposed factual finding or legal conclusion will bar a party, except upon grounds of plain error or manifest injustice, from attacking on appeal any such proposed factual findings and legal conclusions accepted by the United States District Judge. See Douglass v. United Servs. Auto Ass'n, 79 F.3d 1415, 1428-29 (5th Cir. 1996) (en banc).
Under 28 U.S.C. § 636, it is hereby
It is further
20 C.F.R. Pt. 404. Subpt. P, App. 1, § 11.00E.
(Tr. 220.)
Contrary to Wilson's assertions, this statement does state that Wilson reported she can walk about 85% of the time without any device. Albeit confusing, the 90% statement appears to refer to the fifteen days of the month when she is using a device. Even assuming Dr. Nwanwko recorded the statement in error, the ALJ is bound by the evidence that appears in the record.