Drevas v. Colvin
Filing
14
MEMORANDUM OPINION regarding Motions for Summary Judgment (D.I. 10 and 12 ). Signed by Judge Richard G. Andrews on 11/25/2015. (nms)
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF DELAWARE
STEPHEN JAMES DREVAS,
Plaintiff,
: Civil Action No. 1:15-194-RGA
v.
CAROLYN COLVIN, Acting
Commissioner of Social Security,
Defendant.
MEMORANDUM OPINION
Oderah C. Nwaeze, Esq., Duane Morris LLP, Wilmington, DE; Eddy Pierre Pierre, Esq., Law
Offices of Harry J. Binder and Charles E. Binder, P.C., New York, NY, Attorneys for Plaintiff.
Nora Koch, Acting Regional Chief Counsel Social Security Administration, Office of the
General Counsel, Philadelphia, PA; Jillian Quick, Assistant Regional Counsel, Office of the
General Counsel, Philadelphia, PA; Charles M. Oberly, III, United States Attorney, Office of the
General Counsel, Philadelphia, PA; Heather Benderson, Special Assistant United States
Attorney, Office of the General Counsel, Philadelphia, PA, Attorneys for Defendant.
November
~2015
AND~
efistrtct udge:
Plaintiff, Stephen James Drevas, appeals the decision of Defendant Carolyn W. Colvin,
Acting Commissioner of Social Security (the "Commissioner"), denying his application for
disability insurance benefits ("DIB") and supplemental security income benefits ("SSI") under
Title II and Title XVI, respectively, of the Social Security Act (the "Act"). 42 U.S.C. §§ 401434, 138l-1383f. This Courthasjurisdictionpursuantto 42 U.S.C. §§ 405(g) and 1383(c)(3).
Presently pending before the Court are cross-motions for summary judgment filed by
Drevas and the Commissioner. (D.I. 10, 12). For the reasons set forth below, the Court denies
Drevas'smotion for summary judgment and grants the Commissioner's motion for summary
judgment.
I.
BACKGROUND
A. Procedural History
Drevas filed an application for DIB on January 26, 2010, and SSI 1 on February 16, 2010,
alleging disability as of January 28, 2009 due to a slip and fall on ice. (D.I. 8 (hereinafter "Tr.")
at 145-53). Drevas's applications were initially denied on August 13, 2010 (Tr. at 86-90) and
were again denied upon reconsideration on August 2, 2011 (Tr. at 92-97). Thereafter, a hearing
took place per Drevas's request before an Administrative Law Judge (the "ALJ") on October 18,
2012. (Tr. at 39-79). The ALJ issued a partially favorable decision on April 26, 2013, finding
Drevas was disabled from January 28, 2009 to October 2, 2011, but his disability ended as of
October 3, 2011. (Tr. at 17-38). Drevas sought review by the Appeals Council (Tr. at 16), but
his request was denied on December 30, 2014, making the ALJ's decision the final decision of
1
Eligibility for SSI is derivative of qualification for DIB. For ease ofreference, the Court will refer only to DIB.
2
the Commissioner. (Tr. at 1-5). On February 27, 2015, Drevas filed the current action for
review of the final decision. (D.I. 1).
B. Plaintiff's Medical History, Condition, and Treatment
i. Medical Evidence
At the onset of his disability, Drevas was thirty-nine years old and possessed a ninth
grade education. (Tr. at 45). Drevas has relevant work experience as a driller, insulation worker,
and supervisor of drilling. (Tr. at 73). Drevas' s detailed medical history is contained in the
record, but the Court will provide a brief summary of the pertinent evidence. The period of
disability !n dispute is from October 3, 2011 to the present; all parties agree that Drevas was
disabled from January 28, 2009 to October 2, 2011.
Subsequent to slipping and falling on ice while at work, Drevas visited the emergency
room for back pain on January 30, 2009, and February 5, 2009. (Tr. at 314-39). As a result of
the fall, Drevas had disc herniation at L4-L5 that caused "significant root compression." (Tr. at
340). For approximately one year, Drevas experienced persistent back and left leg pain, leading
him to visit Dr. Pawan Rastogi on November 17, 2009. (Tr. at 373). Dr. Rastogi diagnosed
Drevas with significant left lumbar radiculopathy that failed to improve with conservative
treatment and recommended that he undergo a microdiscectomy. Id.
On December 7;2009, Drevas underwent the recommended back surgery. (Tr. at 340-42,
357-58). However, the pain persisted, and Drevas reported on March 2, 2010 that he had leg
pain, numbness, and tenderness with a diminished range of motion following his surgery. (Tr. at
348). Dr. Rastogi noted that Drevas's pain had "really not resolved after his microdiscectomy"
and decided to wait and see if the nerve would heal. Id.
3
On April 20, 2010, Dr. Rastogi found that despite participating in physical therapy and
receiving injections, Drevas was still experiencing persistent left leg and lower back pain. (Tr. at .
694). Dr. Rastogi recommended another surgery involving a facetectomy and fusion. Id.
Drevas accepted the advice and underwent a second surgery on his lower back on May 24, 2010.
(Tr. at 694, 552-53). The intraoperative findings of this surgery included "[a] large recurrent
disc herniation with significant root compression[.]" (Tr. at 552).
Throughout the next five months of follow-up visits with Dr. Rastogi, Drevas complained
of pain. (Tr. at 544-46, 548). On June 22, 2010, Drevas reported new pain in his right buttock
that radiated down his right thigh. (Tr. at 546). On August 24, 2010, Drevas stated that therapy
had not helped his significant back pain accompanied by intermittent pain down his leg. (Tr. at
545). Testing on August 28, 2010 revealed moderate edema and post-operative changes in the
L4-L5 disc space. (Tr. at 550). An MRI on September 24, 2010, reflected mild left epidural
fibrosis and a partial laminectomy defect at the L4-L5 disc space. (Tr. at 548). On November
16, 2010 Dr. Rastogi found that Drevas was "slowly improving[,]" but had a tender back with
diminished range of motion. (Tr. at 544). Drevas again reported intermittent back and leg pain.
Id.
In December 2010, an orthopedic specialist, Dr. Kamali, evaluated Drevas for hip and
back pain and found his clinical exam was "essentially within normal limits and [his]
radiological exam also was normal." (Tr. at 547). However, Dr. Kamali did find that Orevas
slightly favored his left leg when walking and straight leg raising was positive on the left to 65
degrees. Id. Believing no further surgery was necessary because Drevas had "surgical
intervention with no benefit[,]" Dr. Kamali referred Drevas back to Dr. Rastogi. Id.
4
Drevas began seeing internist Dr. Irwin Lifrak on January 5, 2010 for moderate to severe
lower back pain, without pain down either leg, that began again two weeks prior to the visit. (Tr.
at 556). Dr. Lifrak diagnosed acute muscle spasm and muscle sprain/strain and prescribed pain
medication and an exercise program. Id. At a follow-up appointment on February 8, 2010,
Drevas reported intensifi~d pain in numerous joints. (Tr. at 555). Lifrak diagnosed degenerative
joint disease and prescribed pain medication and physical therapy. Id.
Drevas underwent a third and final surgery after an MRI on July 7, 2011 revealed
changes in his lower back including minimal disc protrusion at L4-L5 and bilateral disc
protrusion at L3-L4. (Tr. at 593, 603-606, 615). On August 22, 2011, Dr. Fras performed a
revision of Drevas's lumbar fusion at L4-L5. (Tr. at 593, 603-606). Dr. Fras noted in his
discharge summary that Drevas' s "pain was well controlled[,]" and he was neurologically intact
and stable. (Tr. at 593). Post-operative spine x-rays taken between October 3, 2011 and
December 12, 2011 revealed that Drevas's fusion was intact and reflected stable post-operative
·changes at L4-L5. (Tr. at 608, 610-11).
Dr. Fras wrote on a prescription pad for Drevas on December 7, 2011 that Drevas would
be "unable to work for at least a full year because of chronic back and radicular leg pain." (Tr. at
589). Dr. Fras referred Drevas to pain specialist Dr. Kapur. (Tr. at 724).
On February 2, 2012, Drevas stated to Dr. Kapur that "his back pain [was] much
better[.]" Id. Drevas complained ofleg pain of four to seven on a scale of one to ten, which he
was coping with by taking ibuprofen, but denied weakness in the extremity. Id. Dr. Kapur's
physical examination failed to reveal any muscle spasm or tenderness over Drevas's lower back
joints, but did reflect a positive straight leg raising on the left. Id. However, Drevas's sensation
was intact, and he had full strength in his extremities. Id. Diagnostic testing one week later on
5
February 9, 2012, reflected stable post-operative appearance at the L4-L5 disc space. (Tr. at
607).
Between February 16, 2012 and March 12, 2012, Drevas continued to experience pain in
his legs despite the pain medication prescribed by Dr. Kapur. (Tr. at 719-23). Dr. Kapur
recommended epidural steroid injections in Drevas's spine and stated she was considering
Drevas for participating in her spinal cord stimulator trial. (Tr. at 719-20). On March 12, 2012,
Dr. Kapur administered the lower back injection, and Drevas experienced three to five days of
pain relief. (Tr. 719, 721).
Dr. Fras saw Drevas again in May of 2012 as Drevas reported that he had been
"discharged from Dr. Kapur's pain management practice" because he tested positively for
marijuana and PCP. (Tr. at 736). Drevas stated that he had not experienced much improvement
with injections or physical therapy, but rated his pain as moderate, or six on a scale of one to ten.·
Id. Drevas stated there was no pain running completely down his leg, and he was not
experiencing any tingling, numbness, or weakness. Id. Dr. Fras's physical exam revealed a solid
fusion, negative straight leg raising tests, normal gait, full muscle strength and sensation, and a
lack of any tenderness over joints. Id. Drevas refused Dr. Fras' s recommendations to pursue
physical therapy and to employ another pain management specialist. Id.
The ALJ requested a physical consultative evaluation post-hearing, and on November 9,
2012, Dr. Fink completed a one-time physical examination ofDrevas. (Tr. at 771-82). Dr. Fink
found that Drevas's memory was intact, as well as his lower and upper extremity strength. (Tr.
at 773). Additionally, Drevas had no sensory loss or ataxia of his limbs, gait, or trunk. Id. Dr.
Fink concluded that Drevas had two medical limitations: severe, lower back pain and pain down
the left leg, and significant muscle spasm in the left paraspinal muscle area. Id. In an eight hour
6
work day, Dr. Fink felt that Drevas could only walk for one of the hours and stand for one-half
of an hour. (Tr. at 778).
i. Mental Health Evidence
In July and August 2010, Drevas was hospitalized due to suicidal ideation subsequent to
his fall in January of 2009. (Tr. at 520-27). Upon Drevas's first visit to the hospital on July 27,
2010, he was diagnosed with major depression and chronic pain syndrome. (Tr. at 525). At
Drevas's second visit to the hospital on August 24, 2010, he was diagnosed with bipolar
affective disorder, depressed phase, opiate dependence, and chronic pain. (Tr. at 524). At the
time ofDrevas's discharge from hospital stays, his Global Assessment of Functioning ("GAF")
was 50 and 30, respectively. (Tr. at 523). During both says, his affect was des<:;ribed as
anhedonic, flat, blunted, and restricted. (Tr. 521, 525).
Drevas began treatment with Dr. Patricia Lifrak one month later and continued seeing Dr.
Lifrak until September 24, 2012. (Tr. at 766-68). At Drevas's first visit on September 30, 2010,
Dr. Lifrak described his mood and affect as depressed and anxious, and she diagnosed Drevas
with mood disorder and depression. Id. Dr. Lifrak also noted that Drevas was suffering from
decreased short and long term mernory, decreased concentration, angry outbursts, difficulty
sleeping and social withdrawal. Id. Dr. Lifrak found that Drevas's GAF was 60 at that time.
(Tr. at 768).
Starting April 12, 2011, Drevas started to show improvement in his mental state, albeit
experiencing some documented ups and downs. (Tr. 751-65) .. On April 12, 2011, Dr. Lifrak
noted that Drevas "denie [d] depression" and noted that his mood and appetite had improved.
(Tr. at 761) .. On July 11, 2011 and July 18, 2011, Drevas was "doing well[,]" and was less
depressed, denying manic symptoms, and getting better sleep. (Tr. at 758-59). After his third
7
and final surgery, Drevas's improvement waned as Dr. Lifrak noted that he recently had back
surgery and "[felt] down sometimes" about his pain and how he could not work. (Tr. at 757).
Between January 13, 2012 and September 24, 2012, Dr. Lifrak noted that Drevas was still
depressed, but less so than before. (Tr. at 751-55) .. At his last visit with Dr. Lifrak, Drevas was
"doing better still depressed but less than before. Mood is stable .... Sleep is good." (Tr. at
751).
Drevas also received treatment from psychologist Dr. Silberman between December 23,
2011 and January 24, 2012. (Tr. at 728-34). On December 23, 2011, Dr. Silberman noted that
Drevas had been "chronically depressed as a result of major depressive disorder." (Tr. at 732).
At his last visit with Dr. Silberman, Drevas, while still depressed and crying easily, appeared less
depressed, with clear, goal-directed speech. (Tr. at 728).
The ALJ requested a mental consultative evaluation post-hearing, and four months after
Dr. Fink's physical consultative evaluation, on March 18, 2013, Dr. Kurz completed a one-time
mental health evaluation ofDrevas. (Tr. at 783-91). Dr. Kurz noted that Drevas stated that "the
chronic pain[,]" and not emotional or psychological issues, "was the primary reason that he was
unable to work" but ''there was no evidence that pain affected his performance during this
evaluation." (Tr. at 786). Further, Dr. Kurz found that Drevas exhibited no indications of
depression or anxiey and at no time was he teary. (Tr. at 785). Further, Drevas's eyes were
clear, his gait steady, and his cognitive skills, including working and long-term memory, were
also intact. (Tr. at 785-86). Dr. Kurz diagnosed Drevas with depression and generalized anxiety
disorder, but found that the estimated degree of impairment from these disorders ranged from
moderate to none. (Tr. at 787-90). Dr. Kurz stated that Drevas's GAF was 63 at the time of the
evaluation. (Tr. at 786).
8
C. ALJ Decision
In his April 26, 2013 decision, the ALJ found that Drevas had the severe impairments of
history of back trauma, status post three back surgeries, depression, anxiety, and history of
substance abuse, currently in remission. (Tr. at 25). The ALJ also found that from January 28,
2009 through October 2, 2011, Drevas had the residual functional capacity ("RFC") to perform
sedentary work, except that due to pain, depression and the need for multiple back surgeries,
Drevas ''would have had limited productivity and reliability so that he was off task 20% or more
of the workday." (Tr. at 26). Thus, a vocational expert testified that, after considering Drevas's
age, education, work experience, and RFC, Drevas was unable to perform any work existing in
the national economy in significant numbers from January 28, 2009 through October 2, 2011.
(Tr. at 29-30).
As of October 3, 2011, the ALJ determined that Drevas did not have an impairment or
combination of impairments that met or medically equaled one of the listed impairments in 20
C.F.R. Part 404, Subpart P, Appendix 1. (Tr. at 32). Further, the ALJ concluded that Drevas
experienced medical improvement beginning October 3, 2011. Id. The ALJ relied upon the
evidence that Drevas had no additional surgeries scheduled, his fusion was solid, and there were
no neurological abnormalities. Id. Additionally, the ALJ found that Drevas reported significant
relief in low back pain, and Dr. Patricia Lifrak and Dr. Silberman both had progress notes
documenting Drevas's "improvement in his depressive symptoms with medication and
treatment." (Tr. at 33).
The ALJ found that this medical improvement increased Drevas' s RFC and, ultimately,
ended Drevas's disability. In determining Drevas's RFC, the ALJ found his testimony regarding
the intensity, limiting effects, and persistence of his symptoms to be not entirely credible. (Tr. at
9
34). Thus, the ALJ opined that Drevas had the RFC to perform sedentary work, except that any
jobs would consist of simple, routine tasks and could be performed in either a sitting or standing
position. (Tr. at 33). Therefore, the ALJ concluded that Drevas's disability ended October 3,
2011, as there were jobs that exist in significant numbers in the national economy that Drevas
could perform. (Tr. at 36-37).
II.·
LEGAL STANDARD
A. Standard of Review
This Court must uphold the Commissioner's factual decisions if they are supported by
"substantial evidence." See 42 U.S.C. § 405(g); Monsour Medical Ctr. v. Heckler, 806 F.2d
1185, 1190 (3d Cir. 1986). "Substantial evidence" means less than a preponderance of the
evidence but more than a mere scintilla of evidence:" See Rutherford v. Barnhart, 399 F.3d 546,
552 (3d Cir. 2005). As the United States Supreme Court has noted, substantial evidence (does
not mean a large or significant amount of evidence, but rather such relevant evidence as a
reasonable mind might accept as adequate to support a conclusion." Pierce v. Underwood, 487
U.S. 552, 565 (1988) (citing Consol. Edison Co. v. NLRB, 305 U.S. 197, 229 (1938)).
In determining whether substantial evidence supports the Commissioner's findings, the
Court may not undertake a de novo review of the Commissioner's decision and may not re-weigh
the evidence of record. See Monsour, 806 F .2d at 1190. The Court's review is limited to the
evidence that was actually presented to the ALJ. See Matthews v, Apfel, 239 F.3d 589, 593-95
(3d Cir. 2011). "Credibility determinations are the province of the ALJ and only should be
disturbed on review if not supported by substantial evidence." Pysher v. Apfel, 2001 WL
793305, at *3 (E.D. Pa. July 11, 2001) (citations omitted).
The Third Circuit has explained that a:
10
single piece of evidence will not satisfy the substantiality test if the
[Commissioner] ignores or fails to resolve, a conflict created by countervailing
evidence. Nor is evidence substantial if it is overwhelmed by other evidence particularly certain types of evidence (e.g. evidence offered by treating
physicians) - or if it really constitutes not evidence but mere conclusion.
Kent v. Schweiker, 710 F.2d 110, 143 (3d Cir. 1983). Even ifthe reviewing Court would have
decided the case differently, it must give deference to the ALJ and affirm the Commissioner's
decision ifit is supported by substantial evidence. See Monsour, 806 F.2d at 1190-91.
B. Disability Determination Process
Title II of the Act, 42 U.S.C. § 423(a)(l)(D), "provides for the payment of insurance
benefits to persons who have contributed to the program and who suffer from a physical or
mental disability." Bowen v. Yuckert, 482 U.S. 137, 140 (1987). To qualify for DIB, the
claimant must establish that he or she was disabled prior to the date he or she was last insured.
See 20 C.F.R. § 404.131; Matullo v. Bowen, 926 F.2d 240, 244 (3d Cir. 1990). A "disability" is
defined 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 a continuous period of not less than twelve months. See
42 U.S.C. § 423(d)(l)(A). A claimant is disabled "only if [the individual's] physical or mental
impairment or impairments are of such severity" that the individual is precluded from
performing previous work or "any other kind of substantial gainful work which exists in the
national economy." 42 U.S.C. § 423(d)(2)(A); Barnhart v. Thomas, 520 U.S. 20, 21-22 (2003).
To determine whether an individual is disabled, the Commissioner must employ a fivestep sequential analysis. See 20 C.F.R. § 404.1520; Plummer v. Apfel, 186 F.3d 422, 427-28 (3d
Cir. 1999). If a finding of disability or non-disability can be made at any point in the sequential
process, the Commissioner will not review the claim further. 20 C.F.R. § 404.1520(a)(4).
11
At step one, the Commissioner must determine whether the claimant is engaged in any
substantial gainful activity. 20 C.F.R. § 404.1520(a)(4)(i). If the claimant is engaged in
substantial gainful activity, the claimant is not disabled. Id. If the claimant is not engaged in
substantial gainful activity, step two requires the Commissioner to determine whether the
claimant is suffering from a severe impairment or a severe combination of impairments. 20
C.F.R. § 404.l520(a)(4)(ii). If the claimant is not suffering from·a severe impairment or a
combination of impairments that is severe, the claimant is not disabled. Id.
If the claimant's impairments are severe, step three requires the Commissioner to
compare the claimant's impairments to a list of impairments (the "listings") that are presumed
severe enough to preclude ~y gainful work. 20 C.F.R. § 404.1520(a)(4)(iii); Plummer, 186 F.3d
at 428. When a claimant's impairment or its equivalent matches an impairment in the listings,
the claimant is presumed disabled. 20 C.F.R. § 404.1520(a)(4)(iii). If the claimant's
impairments or impairment combination are not listed or medically equivalent to any listing, then
the analysis continues to steps four and five. 20 C.F.R. § 404.1520(e).
At step four, the Commissioner determines whether the claimant retains the RFC to
perform past relevant work. See 20 C.F.R. § 404.1520(a)(4)(iv); Plummer, 186 F.3d at 428. A
claimant's RFC is "that which an individual is still able to do despite the limitations caused by
his or.her impairment[s]." Fargnoli v. Massanari, 247 F.3d 34, 40 (3d Cir. 2001) (quoting
Burnett v. Commissioner ofSoc. Sec. Admin., 220 F.3d 112, 131 (3d Cir. 2000)). "The claimant
bears the burden of demonstrating an inability to return to [his or] her past relevant work."
Plummer, 186 F.3d at 428. If the claimant is able to return to his or her past relevant work, the
claimant is not disabled. See id.
12
If the claimant is unable to return to her past relevant work, step five requires the
Commissioner to determine whether the impairments preclude the claimant from adjusting to any
other available work. See 20 C.F .R. § 404.1520(g) (mandating "not disabled" finding if claimant
can adjust to other work); Plummer, 186 F.3d at 428. At this last step, the burden is on the
Commissioner to show that the claimant is capable of performing other available work before
denying disability benefits. 2 See Plummer, 186 F.3d at 428. In other words, the Commissioner
must prove that ''there are other jobs existing in significant numbers in the national economy
which the claimant can perform, consistent with her medical impairments, age, education, past
work experience, and [RFC]." Id. . In making this determination, the Commissioner must
analyze the cumulative effect of all of the claimant's impairments. See id. At this step, the
assistance of a vocational expert is often sought. See id.
III.
DISCUSSION
Drevas makes three primary objections. (D.I. 11 at 2). First, Drevas argues that the ALJ
failed to properly weigh the medical evidence and erred in finding that Drevas experienced
medical improvement. Id. Second, Drevas contends that the ALJ failed to properly evaluate his
credibility. Id. Third, Drevas argues that the ALJ relied on flawed vocational expert testimony.
Id. After reviewing the decision of the ALJ in the light of the relevant standard of review and
applicable legal principles, this Court finds that the ALJ' s decision is supported by substantial
evidence for the reasons discussed below.
A. ALJ's Weighing of Medical Evidence and Finding of Medical Improvement
Drevas argues that the ALJ erred in discrediting the opinions of treating physician Dr.
Fras and consultative examiner Dr. Fink and finding that Drevas experienced medical
2
The claimant bears the burden of proof at steps one through four, and the Commissioner bears the burden of proof
at step five. Smith v. Commissioner of Soc. Sec., 631F.3d632, 634 (3d Cir. 2010).
13
improvement as of October 3, 2011. Id. at 13-14. This Court finds that the ALJ properly
considered the opinions and medical evidence contained in the record in order to conclude
Drevas experienced medical improvement.
The ALJ is required to weigh all of the evidence in the medical record to resolve any
material conflicts. See Richardson v. Perales, 402 U.S. 389, 399 (1971) (clarifying that when
the record contains conflicting medical evidence, it is the ALJ' s duty to weigh that evidence and
resolve the conflict); Brown v. Astrue, 649 F.3d 193, 196 (3d Cir. 2011) (discussing when "there
[is] record evidence from a treating [physician] suggesting a contrary conclusion, the ALJ is
entitled to weigh all evidence in making its finding"); Fargnoli, 247 F3d at 43 (citations
omitted) (explaining that ALJ may weigh credibility of the evidence); 20 C.F.R. § 404.1527(b),
416.927(b) ("In determining whether you are disabled, we will always consider the medical
opinions in your case record together with the rest of the relevant evidence we receive."). While
the ALJ is instructed to generally give controlling weight to treating physician opinions, the ALJ
can discount a treating physician's opinion if it is not consistent "with the other substantial
evidence in [the claimant's] record." 20 C.F.R. § 404.1527(c)(2), 416.927(c)(2); see also
Fargnoli, 247 F.3d at 42. However, the ALJ must "give good reasons" for discounting medical
evidence in the record. 20 C.F.R. § 404.1527(c)(2), 416.927(c)(2); Fargnoli, 247 F.3d at 43
("Although the ALJ may weigh the credibility of the evidence, he must give some indication of
the evidence that he rejects and his reason(s) for discounting that evidence,"). Additionally,
"[a]lthough a treating physician's opinion is entitled to great weight, a treating physician's
statement that a plaintiff is unable to work or is disabled is not dispositive." Peny v. Astrue, 515
F. Supp. 2d 453, 462 (D. Del. 2007).
14
When an ALJ deems an opinion :unwort4y of controlling ~eight, the ALJ must then
evaluate the weight to give to the opinion according to specific factors. 3 See 20 C.F .R. §
404.1527(c)(l)-(6), 416.927(c)(l)-(6); Gonzales v. Astrue, 537 F. Supp. 2d 644, 660 (D. Del
2008) ("Even where there is contradictory medical evidence, ... and an ALJ decides not to give
a treating physician's opinion controlling weight, the ALJ must still carefully evaluate how much
weight to give the treating physician's opinion."). The ALJ's determination must be clear
enough to allow a reviewing court to determine what weight was given to an opinion and the
reasons for that weight determination. SSR 96-2p, 1996 WL 374188, at *5 (July 2, 1996)
(clarifying that "the notice of the determination or decision ... must be sufficiently specific to
make clear to any subsequent reviewers the weight the adjudicator gave to the treating source's
medical opinion and the reasons for that weight").
In the present case, the ALJ adequately explained why certain portions of the medical
evidence were rejected or given less weight in accordance with the applicable law described
above. Mason v. Shala/a, 994 F.2d 1058, 1067 (3d Cir. 1993). Drevas contends that the ALJ
improperly discredited the December 7, 2011 opinion written on a prescription pad by Dr. Fras,
his treating physician, that Drevas was "unable to work for at least a full year because of chronic
back and radicular leg pain." (D.I. 11 at 15-16); (Tr. 36, 589). Further, Drevas argues that the
ALJ failed to indicate what weight was given to Dr. Fras's opinion, as well as reasons for that
weight. (D.I. 11 at 16).
3
The six factors the ALJ must consider are: (1) whether there is an examining relationship; (2) the treatment
relationship, including the length and nature of the relationship; (3) supportability of the opinion, as in the better the
explanation offered for an opinion, the more weight will be given to the opinion; (4) consistency, meaning more
weight is given to opinions that are consistent with the medical record as a whole; (5) specialization; and (6) other
factors. See 20 C.F.R. § 404.1527(c)(l)-(6), 416.927(c)(l)-(6).
15 .
This Court finds that it is clear from the ALJ' s determination what weight was given to
Dr. Fras's finding ofDrevas's inability to work until at least December 7, 2012, and the ALJ
explicitly listed reasons for discrediting Dr. Fras's opinion. (Tr. at 35-36). The ALJ recognized
that Dr. Fras was a treating source, but did "not give his opinion controlling weight" as it was not
supported by medical signs and laboratory findings, conflicted with treatment records, and was
not supported by the medical evidence or consistent with the record as a whole. Id. Ultimately,
the ALJ found that Drevas was no longer disabled as of October 3, 2011, which rejects Dr. Fras's
opinion that Drevas could not work until at least December 7, 2012. Id. The ALJ listed specific
evidence from the record which was in direct conflict with Dr. Fras's opinion regarding when
Drevas could work. 4 Thus, it is clear to this Court that the ALJ gave little or no weight to Dr.
Fras's opinion. The ALJ did not have to take Dr. Fras's opinion as to when Drevas would be
able to work as dispositive, because that decision is reserved to the Commissioner. See Perry,·
515 F. Supp. 2d at 462.
Drevas also argues that the ALJ erred in discrediting consultative examiner, Dr. Fink,
because the ALJ did not give any appropriate reason for according "little weight" to Dr. Fink's
opinions. (D.I. 11 at 16-17). Yet, the ALJ applied the requisite factors in determining how much
weight to give Dr. Fink's opinion and gave "good reasons" for the weight determination as
required by the regulations. (Tr. at 36); see 20 C.F.R. § 404.1527 ("We will always give good
reasons in our notice of determination or decision for the weight we give your treating source's
opinion."). The ALJ found that Dr. Fink's opinion was inconsistent with the medical record as a
whole and listed specific evidence of such. Id. Specifically, the ALJ found Dr. Fink's opinion
4
Specifically, the ALJ found that"[ o]bjective studies have demonstrated a solid fusion. The claimant has not
required any further surgeries. The record shows that the claimant has been discharged from pain management due
to non-compliance and he informed Dr. Fras that he has not yet contacted another pain management specialist." (Tr.
at 36).
16
was in conflict with the record's reflection ofDrevas's improvement in "lumbar spine pain
following the third and final revision surgery and the benign findings on physical examinations
since October 3, 2011." Id. The ALJ also explicitly considered the short length of Dr. Fink's
treatment relationship. Id. Thus, this Court finds that the ALJ correctly applied the law in
discrediting Dr. Fink's opinion.
Finally, Drevas contends that the ALJ erred in finding that he experienced medical
improvement. (Tr. at 14-15). In making a finding of medical improvement, the ALJ must
determine ifthere has been any improvement in the claimant's impairments and then assess
whether the improvement is related to the claimant's ability to work. See 20 C.F.R. §
404.1594(a);416.994(a). Medical improvement is defined as any "decrease in the medical
severity" of a claimant's impairment(s) and "must be based on changes (improvement) in the
symptoms, signs and/or laboratory findings associated with [a claimant's] impairment(s)." 20
C.F.R. § 404.1594(b)(i), 416.994(b)(i).
The ALJ summarized medical evidence, incl~ding diagnostic testing and clinical
findings, that showed Drevas experienced improvement. 5 The ALJ then went on to state that the
medical improvement was related to Drevas's ability to work, because it resulted in an increase
in his residual functional capacity. (Tr. at 33-35). Thus, this Court finds that the ALJ applied the
appropriate law in findin~ medical improvement and weighing the medical evidence such that
substantial evidence supports the ALJ' s conclusion.
5
The ALJ found that the record showed Drevas experienced improvement in his back and with his depression. (Tr.
at 31-33). As for Drevas's back, the ALJ noted that he "ha[d] not had any further surgeries since August 2011 and
no surgeries ha[d] been scheduled." Id. at 32. "Objective studies subsequent to [Drevas's] final revision surgery on
his back in August 2011 document[ ed] that the fusion [was] solid[,]" Drevas "reported significant relief in low back
pain[,]" and "there were no neurological abnormalities." Id. Mentally, the ALJ summarized that "[p]rogress notes
from Dr. [Patricia] Lifrak and Allen Silberman, Ed.D., document[ed] that [Drevas] ... experienced improvement in
his depressive symptoms with medications and treatment[.]" Id. at 33.
17
Here, the ALJ applied the correct law and provided detailed explanations of his reasons
for discrediting medical opinions, weighing the evidence, and finding medical improvement.
According to the relevant standard ofreview, this Court cannot undertake a re-weighing of the
evidence. The Court therefore rejects Drevas's arguments regarding the ALJ's supposed errors
in weighing medical evidence and finding medical improvement.
B. Drevas's Credibility
Drevas contends that the ALJ erred in evaluating his credibility. (D.1. 11 at 18).
Specifically, Drevas argues that the ALJ's determination that Drevas's statements were "not
entirely credible" was boilerplate language that provides no explanation for why Drevas's
testimony about his symptoms were discredited. Id. at 19.
In evaluating a claimant's credibility, the ALJ must follow a two-step process. See 20
C.F .R. § 404.1529. First, the ALJ must "consider whether there is an underlying medically
determinable physical or mental impairment(s) ... that could reasonably be expected to produce
the individual's pain or other symptoms:" SSR 96-7p, 1996 WL 374186, at *2 (July 2, 1996).
Second, the ALJ "must evaluate the intensity, persistence, and limiting effects of the individual's
symptoms to determine the extent to which the symptoms limit the individual's ability to do basic
work activities." Id. Specifically, the ALJ's determination must reflect "specific reasons for the
finding on credibility, supported by the evidence in the case record," and must make clear to
subsequent reviewers the weight given to the individual's statements. Id. at *4.
Here, the ALJ applied the requisite two-step credibility procedure. (Tr. at 33-36). The
ALJ found that Drevas's "medically determinable impairments could reasonably be expected to
produce the alleged symptoms; however, [Drevas's] statements concerning the intensity,
persistence and limiting effects of these symptoms are not entirely credible for the reasons
18
explained in the decision:" Id. at 34. The ALJ then extensively discussed the medical record to
give reasons for discrediting Drevas's credibility. Id. at 34-36. Finding that Drevas's statements
about the preclusive nature of his symptoms were inconsistent with other evidence in his medical
record, the ALJ determined that he was "not entirely credible." 6 Id. It is clear to this subsequent
reviewing Court what weight was given to Drevas' s statements through the ALJ' s discussion of
the relevant medical evidence as contrasted with Drevas's opinions about the preclusive nature
of his pain. 7 There was boilerplate. More importantly, though, there was also analysis specific
to Drevas. Thus, after examining the ALJ' s decision with respect to the relevant standard of
review, this Court finds the ALJ appropriately evaluated Drevas's credibility.
C. Vocational Expert Testimony
Drevas argues that the ALJ failed to accurately describe Drevas' s mental limitations to
the vocational expert in his hypothetical. (D.I. 11 at 20). Specifically, Drevas argues that the
ALJ did not convey Drevas's moderate difficulties with concentration, persistence, or pace to the
vocational expert, and instead only limited Drevas to simple, routine tasks. Id.
In steps four and five of a disability determination, "a vocational expert ... may offer
expert opinion testimony in response to a hypothetical question about whether a person with the
physical and mental limitations imposed by the claimant's medical impairment(s) can meet the
demands of the claimant's previous work, either as the claimant actually performed it or as
6
Evidence of this includes Drevas's testimony 'that he lay in bed "[a]ll day long,' [but] he had no atrophy and full
strength in his legs ... ; he admitted improvement in his back following his last surgery, which successfully
remained fused ... ; [and] during a psychological examination in March 2013, [Drevas] displayed 'no evidence that
pain affected his performance[.]'" (D.I. 13 at 17).
7
For instance, Drevas's testified that his pain required him to lie in bed all day, but the ALJ limited Drevas to
sedentary work. (Tr. at 33, 37). Additionally, the ALJ is not required to use any particular language in conveying to
any subsequent reviewing court what weight was given to the claimant's statements; the weight given is only
required to be clear to the reviewing court. See Wright v. Comm'r ofSoc. Sec., 386 F. App'x 105, 109 (3d Cir. 2010)
(affirming that the claimant's statements were "not entirely credible" because "the record lack[ed] objective medical
evidence supporting [the claimant's] subjective complaints" and therefore "substantial evidence in the record
support[ed] the ALJ's credibility assessment").
19
generally performed in the national economy." 20 C.F.R. § 404.1560(b)(2). "[T]he ALJ must
accurately convey to the vocational expert all of a claimant's credibly established limitations" in
order to rely upon the vocational expert's testimony as substantial evidence. Rutheiford, 399
F.3d at 554 (citing Plummer, 186 F.3d at 431). The ALJ is :free to reject limitations "ifthere is
conflicting evidence in the record." Id. The purpose of posing a hypothetical is to determine
whether a claimant has the residual functional capacity to perform either the claimant's previous
work or any work that exists in the national economy. 8 Ramirez v. Barnhart, 372 F.3d 546, 549
(3d Cir. 2004) (explaining that purpose of hypothetical is to determine whether the claimant had
a residual functional capacity to perform any work in the national economy).
Limitations in broad functional areas are used at a number of steps in the disability
determination process for different reasons. See SSR 96-8p, 1996 WL 374184, at *4 (July 2,
1996) (explaining "the limitations identified in the 'paragraph B' and 'paragraph C' criteria are
not an RFC assessment but are used to rate the severity of mental impairment( s) at steps 2 and 3
of the sequential evaluation process"); Ramirez, 3 72 F .3d at 555 (explaining that while
limitations in broad functional area ":findings are 'not an RFC assessment' and that step four
requires a 'more detailed assessment,"' these limitations still play a role in steps four and five).
At steps two and three, limitations in broad functional areas are used to determine the severity of
a claimant's mental impairment. See SSR 96-8p, 1996 WL 374184, at *4. In the work capacity
assessment at steps four and five, these limitations need to be accounted for through specific
physical functions that adequately convey what a claimant is able to do at work. 20 C.F.R. §
8
The residual functional capacity of a claimant is what the ALJ will use to determine if the claimant can adjust to
any work that exists in the national economy and is defined as the most a claimant can do despite his or her physical
or mental limitations. 20 C.F.R. § 404.1545(a)(l) ("Your residual functional capacity is the most you can still do
despite yourlimitations."); 20 C.F.R. § 404.1560(c)(l) ("We will look at your ability to adjust to other work by
considering your residual functional capacity and the vocational factors of age, education, and work experience[.]").
20
404.1545(c), 416.945(c) (describing process by which an ALJ "first assess[ es] the nature and
extent of [claimant's] mental limitations and restrictions and then determine[ s] [claimant's]
residual functional capacity for work activity on a regular and continuing basis. A limited ability
to carry out certain mental activities, such as limitations in understanding, remembering, and
carrying out instructions, and in responding appropriately to supervision, co-workers, and work
pressures in a work setting, may reduce your ability to do past work and other work.").
However, the regulations do not require the exact language of a claimant's limitations in broad
functional areas to be explicitly stated in a work capacity assessment. Id.
Drevas cites Ramirez v. Barnhart as controlling Third Circuit precedent with respect to
whether a hypothetical in which a claimant is limited to simple, routine tasks adequately conveys
that claimant's moderate difficulties with concentration, persistence, or pace. (D.I. 11 at 20); see
Ramirez, 372 F.3d at 554. The Third Circuit held in Ramirez that an ALJ's hypothetical limiting
a claimant that often suffered from deficiencies in concentration, persistence, or pace to simple
one or two-step tasks failed to adequately convey that claimant's limitations. Ramirez, 372 F.3d
at 554. Drevas concedes that "[ s]ince Ramirez was decided, the Commissioner replaced the term
'often' with 'moderate."' (D.I. 11 at 20). The language used in the present case is different
from Ramirez, as "moderate" does not have the same meaning as "often." Consequently,
Ramirez is not controlling in the case at hand. See McDonald v. Astrue, 293 F. App'x 941, 946
(3d Cir. 2008) (accepting an ALJ's hypothetical when the ALJ made a "finding that [claimant]
only had 'moderate limitations with his ability to maintain concentration, persistence, and pace,'
[and] the ALJ included in her hypothetical that the individual be limited to 'simple, routine
tasks"'); Menkes v. Astrue, 262 F. App'x 410, 412 (3d Cir. 2008) ("Having previously
acknowledged that [claimant] suffered moderate limitations in concentration, persistence and
21
pace, the ALJ also accounted for these mental limitations in the hypothetical question by
restricting the type of work to 'simple routine tasks."'); Steppi v. Colvin, No. CV 10-954-SLR
(SRF), 2014 WL 794573, at *13 (D. Del. Feb. 27, 2014), report and recommendation adopted,
No. CV 10-954-SLR (SRF), 2014WL1339071 (D. Del. Mar. 31, 2014) ("The Third Circuit has
explained that when the ALJ limits a claimant's employment to simple or routine work, it
accounts for the claimant's moderate limitations in concentration, persistence, and pace.").
Here, the ALJ accounted for Drevas's broad functional limitations in concentration,
persistence, or pace by limiting Drevas to "simple, routine tasks." (Tr. at 31, 36-37). Drevas has
not asserted any further mental limitations that would preclude him from such work, and
evidence supports the ALJ's limitation to simple, routine tasks. For instance, the Commissioner
highlights that "by October 2011, [Drevas] required only conservative psychiatric treatment; he
reported that medication was helping with depressive symptoms[,]" "his cognitive skills were
intact[,]" "and a psychological examiner found no evidence of mood, thought, or personality
disorder and thus assessed only mild symptoms[.]" (D.I. 13 at 19). Additionally, "[n]o medical
source identified any work-preclusive mental limitations." Id. Thus, as Drevas's limitations in
concentration, persistence, or pace were adequately conveyed by limiting him to simple, routine
tasks, the ALJ did not present a flawed hypothetical to the vocational expert. Consequently, the
ALJ was justified in relying on the vocational expert's testimony as substantial evidence.
IV.
CONCLUSION
For the reasons discussed above, Drevas's motion for summary judgment (D.I. 11) is
denied, and the Commissioner's cross-motion for summary judgment (D.I. 13) is granted.
A separate order will be entered.
22
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