ROBERT S. BALLOU, Magistrate Judge.
Plaintiff Cheryl Withers filed this action challenging the final decision of the Commissioner of Social Security ("Commissioner") finding her not disabled and therefore ineligible for supplemental security income ("SSI"), and disability insurance benefits ("DIB") under the Social Security Act ("Act").
This court limits its review to a determination of whether substantial evidence exists to support the Commissioner's conclusion that Withers failed to demonstrate that she was disabled under the Act.
Withers protectively filed for SSI and DIB on March 19, 2013, claiming disability due to depression, tendonitis, anemia, sleep apnea, and carpal tunnel.
On December 11, 2015, the ALJ entered his decision analyzing Withers's claims under the familiar five-step process
Withers alleges that the ALJ erred by failing to: (1) find that Withers had one or more severe impairments; (2) give adequate weight to the opinion of a Dr. Jadali
In April 2014, Withers was hospitalized due to a bowel obstruction that required a colectomy. R. 467-93. In June 2014, she complained of excess bowel movements, and at the hearing Withers testified that she suffers from frequent and urgent bowel movements. R. 70-72, 564. A colonoscopy in November 2014 showed mild acute and chronic inflammation and tubular adenoma. R. 733. Withers complained of epigastric (abdominal) pain in March 2015, but had no blood and "okay" bowel movements. R. 570. In July 2015, she presented to the hospital with rectal bleeding and was advised to follow up with her gastroenterologist. R. 587-94. At the hearing she complained of excess bowel movements, however, there are no further records of treatment for bowel obstruction.
Regarding her carpal tunnel and trigger finger, Withers complained of tingling in her hands in January 2013 during an office visit at the Free Clinic of Central Virginia. R. 681. In January 2014, Withers complained of worsening right hand pain, and indicated that medication and using a brace at night helps. R. 558, 562. In March 2014, Withers presented for a follow-up for her trigger finger, and reported excellent pain relief from her cortisone shot, but continuing weakness. R. 563. She had no digit locking and negative Tinel's signs, and was diagnosed with resolving trigger finger.
Withers was diagnosed with mild obstructive sleep apnea in May 2013, and the doctor noted that "this degree of sleep disordered breathing is of unclear clinical significance. If felt to be contributing to patient symptomology, therapeutic considerations include CPAP, weight loss, intraoral devices and upper airway surgery." R. 398.
Regarding her psychological health, Withers had been diagnosed with depression prior to her alleged onset date of March 1, 2014. R. 683, 558. In January 2014, Withers complained of getting "very emotional about things" during her visit to the Free Clinic of Central Virginia. R. 558. In June 2014, she was placed on a trial of Trazadone for depression; in August 2014, the notes indicate a diagnosis of chronic depression and anxiety, instruct her to continue the Trazadone, while noting that she was not taking it regularly, and increase her Paxil dosage. R. 659, 686.
Regarding her back pain, in July 2014, Withers complained of muscle spasms in her back which were helped by medication, and was diagnosed with mild sciatica in August 2015. R. 565, 576.
In September 2013, Dr. Jadali performed a consultative examination. R. 439-43. Physical examination findings were normal, including normal extremities, normal joints, and normal range of motion. R. 443. Dr. Jadali diagnosed Withers with carpal tunnel syndrome in her right hand and depression.
In October 2013 and July 2014 state agency psychological consultants Sreeja Kadakkal, M.D. and Jo McClain, Psy.D., performed a records review and found that Withers mental impairments caused mild restriction of activities of daily living, no difficulties in maintaining social functioning, concentration, persistence, or pace, and no episodes of decompensation of extended duration. R. 107, 133. The state agency doctors found that Withers had no severe mental impairment.
In July 2014, state agency physician R.S. Kadian, M.D. reviewed the updated record and found that Withers had no severe impairments. R. 132.
Withers argues that the ALJ incorrectly found that she suffers from no severe impairments. Withers asserts that her gastrointestinal condition, carpal tunnel syndrome, trigger finger, obstructive sleep apnea, depression and anxiety, hip bursitis, back pain, and obesity amount to one or more severe impairments under the standard in
An impairment is non-severe when it causes no significant limitations in the claimant's ability to work. 20 C.F.R. §§ 404.1521(a), 416.921(a). "[A]n impairment can be considered as `not severe' only if it is a slight abnormality which has such a 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."
Here, substantial evidence supports the ALJ's conclusion that Withers's impairments were non-severe, and indicates that the ALJ did not err by ending his inquiry at step two. Significantly, Withers has not identified any medical records or opinions that the ALJ failed to consider, but rather asks the court to reweigh the evidence, which I am not permitted to do. In his opinion, the ALJ provided a detailed history of Withers's medical treatment and testimony at the hearing. R. 25-30. He broadly concluded, "In terms of [Withers's] alleged physical and mental impairments, she had few signs on exam and had positive response to limited and conservative treatment that was mainly limited to Free Clinic and emergency room visits." R. 30. In support of this statement, the ALJ specifically addressed her impairments, and how they responded to treatment.
Regarding her carpal tunnel syndrome and trigger finger, the ALJ wrote, "The medical evidence reveals that [Withers] admitted a positive response to bracing and naproxen for CTS symptoms in June 2013." R. 30. And further,
R. 31. The ALJ specifically referenced that opinion of the state agency doctor Dr. Kadian, who found that Withers's carpal tunnel syndrome was non-severe, giving his opinion "great weight" because it was "supported by [Withers] few abnormalities on exam, positive response to limited and conservative treatment, and continued work and daily activities through the date of the decision." R. 32, 132.
Regarding Withers's gastrointestinal condition, the ALJ wrote, "Though she required a brief hospitalization the next month for a perforated cecum, she responded well to surgery." R. 31. The ALJ also referenced Withers's "BMI of 33.69 in October 2014" and noted that she "had normal colonoscopy results [in November 2014]." He wrote that "she was alert with normal memory and bowel sounds at her August 2015 gastroenterology visit . . . and her September 2015 endoscopy was normal." R. 31.
Regarding Withers's back and hip pain, the ALJ specifically referenced the October 2013 consultative exam, writing that she "had normal strength, gait, reflexes, sensation, coordination, grip strength, straight leg raise testing and range of motion in all extremities." R. 31. He further wrote:
R. 31.
The ALJ also discussed Withers's mental health, noting that she "reported doing well at her June 2014 check-up; she was alert and oriented on exam; she was assessed with stable anxiety and depression; and she was prescribed medication refills for Vitamin D deficiency and mental symptoms." R. 31. He noted that Withers was "assessed with controlled anxiety and insomnia in early August 2015." R. 31. The ALJ also referenced the opinions of the state agency psychologists who found that Withers's affective disorder was a non-severe impairment, giving these opinions "great weight" because they were "consistent with the lack of mental abnormalities on the claimant's exams, her positive response to limited and conservative treatment of medications as prescribed by her primary care provider, and her reported work and daily activities." R. 32.
The ALJ concluded that, "In sum, all of [Withers] medically determinable impairments, either had symptoms that did not last for 12 months or more, or they did not cause symptoms or signs on exam that would have even minimally affected [Withers] ability to carry out basic, work-related activities because they were adequately treated with conservative measures." R. 31. The ALJ also noted that Withers's "wide-range of daily activities, current work activity, and admission that she was not working full-time for her current client because of non-physical reasons, all support that her impairments did not even minimally affect her ability to carry out basic, work-related activities." R. 31. Specifically, the ALJ referred to Withers's admission at the hearing that she worked for three hours in the morning, five days a week, including assisting her client with dressing and performing light chores, and did not work a full day because of personality conflicts with her employer's relative, did her own grocery shopping, cooked meals, shopped, cared for pets and her own personal needs, attended church, and handled her finances. R. 31.
Withers simply has not met her burden of establishing that her impairments are severe, including the requirement that an impairment be expected to last for at least 12 months.
Withers argues the ALJ should have afforded greater weight to Dr. Jadali's opinion that she was limited to light work. In support, Withers emphasizes that Dr. Jadali performed a physical examination as part of his consultative examination, and points to a medical record from Lynchburg Hematology Clinic indicating that Withers should not engage in physically strenuous activity.
First, the ultimate decision on whether Withers meets the statutory definition for disability is always reserved to the Commissioner, and thus Dr. Jadali's opinion on Withers's disability was entitled to no special weight.
Here, the ALJ adequately discussed the findings and opinions of Dr. Jadali and explained why he did not adopt Dr. Jadali's finding that Withers was limited to light work. Regarding Dr. Jadali, the ALJ wrote:
R. 32. Accordingly, the ALJ did not err in his evaluation and weighing of Dr. Jadali's consultative examination and remand is not warranted on these grounds.
Withers argues that the ALJ should have obtained a psychological consultative examination to determine the extent that her depression and anxiety limit her ability to work, as well as x-rays of her lower back and hips. Withers emphasizes that her mental health medication has doubled and states that she "reports such severe stress that it, alone, would prevent her from maintaining full time work." Pl.'s Br. at 16. She also states that, because the record contains evidence of back and thigh pain, as well as a "positive straight leg raise at 70 degrees" and "visible knotting on her thigh," the ALJ should have ordered an X-ray or consultative examination.
Under the regulations, an ALJ has discretion in deciding whether to order a consultative examination.
Here, the ALJ did not have a duty to obtain additional medical evidence because the medical records were not "inadequate" for purposes of determining whether plaintiff was disabled.
The ALJ's analysis shows that he considered multiple sources of psychological evidence, as well as evidence of her back and hip impairments, in reaching his decision and substantial evidence supports the ALJ's decision not to order a consultative psychological evaluation or x-rays of her back and hips.
For the foregoing reasons, Withers's Motion for Summary Judgment is