Cordes v. Commissioner of Social Security
REPORT AND RECOMMENDATION re 3 Complaint recommending that the District Court affirm the Commissioner's determination that claimant was not disabled, and enter judgment against claimant and in favor of the Commissioner. Objections to R&R due by 8/14/2017. Signed by Chief Magistrate Judge CJ Williams on 7/31/2017. (skm)
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF IOWA
BRADLEY W. CORDES,
NANCY A. BERRYHILL,
Acting Commissioner of Social Security,
REPORT AND RECOMMENDATION
The claimant, Bradley W. Cordes (claimant), seeks judicial review of a final
decision of the Commissioner of Social Security (the Commissioner) denying his
application for disability insurance benefits under Title II of the Social Security Act, 42
U.S.C. § 401 et seq. (Act). Claimant contends that the Administrative Law Judge (ALJ)
erred in determining that he was not disabled.
For the reasons that follow, I recommend the District Court affirm the
I adopt the facts as set forth in the parties’ Joint Statement of Facts and therefore
only summarize the pertinent facts here. (Doc. 13). Claimant was born in 1978, and
therefore was 30 years old on the date of the alleged onset of disability and 36 years old
at the time of the ALJ’s decision. (AR 23, 65).1 Claimant completed the 11th grade.
(AR 67). Claimant has past relevant work as a shift manager at a restaurant, pizza
“AR” refers to the administrative record below.
delivery driver, produce worker, cabinet assembler, store manager, and construction
laborer. (AR 68-71).
On February 5, 2013, claimant applied for disability insurance benefits, alleging
his disability began on March 1, 2009, due to a bulging disc, hip weakness, bilateral
numbness, and depression. (AR 318, 322).
In 2013, the Social Security Administration denied claimant’s disability application
initially and on reconsideration. (AR 168-171; 173-76).
Claimant requested a hearing and on January 27, 2015, ALJ Jo Ann L. Draper
conducted a hearing on claimant’s application. (AR 58-103). On March 31, 2015, the
ALJ found claimant was not disabled. (AR 12-25). On July 8, 2016, the Appeals Council
denied claimant’s request for review. (AR 1-6). The ALJ’s decision, thus, became the
final decision of the Commissioner. 20 C.F.R. § 404.981.
On September 6, 2016, claimant filed a complaint in this Court.
Between March and April 2017, the parties briefed the issues. (Docs. 14, 15 & 16). On
April 11, 2017, the Court deemed this case fully submitted and ready for decision. (Doc.
17). On the same day, the Honorable Leonard T. Strand, Chief United States District
Court Judge, referred this case to a United States Magistrate Judge for a Report and
DISABILITY DETERMINATIONS AND THE BURDEN OF PROOF
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 12 months.” 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A). An
individual has a disability when, due to his physical or mental impairments, he “is not
only unable to do his previous work but cannot, considering his age, education, and work
experience, engage in any other kind of substantial gainful work which exists . . . in
significant numbers either in the region where such individual lives or in several regions
of the country.” 42 U.S.C. §§ 423(d)(2)(A), 1382c(a)(3)(B). If the claimant is able to
do work which exists in the national economy but is unemployed because of inability to
get work, lack of opportunities in the local area, economic conditions, employer hiring
practices, or other factors, the ALJ will still find the claimant not disabled.
To determine whether a claimant has a disability within the meaning of the Act,
the Commissioner follows the five-step sequential evaluation process outlined in the
Kirby v. Astrue, 500 F.3d 705, 707-08 (8th Cir. 2007).
Commissioner will consider a claimant’s work activity. If the claimant is engaged in
substantial gainful activity, then the claimant is not disabled. “Substantial” work activity
involves physical or mental activities. “Gainful” activity is work done for pay or profit,
even if the claimant did not ultimately receive pay or profit.
Second, if the claimant is not engaged in substantial gainful activity, then the
Commissioner looks to the severity of the claimant’s physical and mental impairments.
If the impairments are not severe, then the claimant is not disabled. An impairment is
not severe if it does not significantly limit a claimant’s physical or mental ability to
perform basic work activities. Kirby, 500 F.3d at 707.
The ability to do basic work activities means the ability and aptitude necessary to
perform most jobs. These include: (1) physical functions such as walking, standing,
sitting, lifting, pushing, pulling, reaching, carrying, or handling; (2) capacities for
seeing, hearing, and speaking; (3) understanding, carrying out, and remembering simple
instructions; (4) use of judgment; (5) responding appropriately to supervision, coworkers, and usual work situations; and (6) dealing with changes in a routine work
setting. Bowen v. Yuckert, 482 U.S. 137, 141 (1987); 20 C.F.R. § 404.1521(b).
Third, if the claimant has a severe impairment, then the Commissioner will
determine the medical severity of the impairment. If the impairment meets or equals one
of the presumptively disabling impairments listed in the regulations, then the claimant is
considered disabled regardless of age, education, and work experience.
Callahan, 133 F.3d 583, 588 (8th Cir. 1998).
Fourth, if the claimant’s impairment is severe, but it does not meet or equal one
of the presumptively disabling impairments, then the Commissioner will assess the
claimant’s residual functional capacity (RFC) and the demands of his past relevant work.
If the claimant can still do his past relevant work, then he is considered not disabled.
Past relevant work is any work the claimant performed within the past fifteen years of
his application that was substantial gainful activity and lasted long enough for the claimant
to learn how to do it. “RFC is a medical question defined wholly in terms of the
claimant’s physical ability to perform exertional tasks or, in other words, what the
claimant can still do despite [ ] her physical or mental limitations.” Lewis v. Barnhart,
353 F.3d 642, 646 (8th Cir. 2003) (citations and internal quotation marks omitted). The
RFC is based on all relevant medical and other evidence. The claimant is responsible for
providing the evidence the Commissioner will use to determine the RFC. (Id.). If a
claimant retains enough RFC to perform past relevant work, then the claimant is not
Fifth, if the claimant’s RFC as determined in Step Four will not allow the claimant
to perform past relevant work, then the burden shifts to the Commissioner to show there
is other work the claimant can do, given the claimant’s RFC, age, education, and work
experience. The Commissioner must show not only that the claimant’s RFC will allow
her to make the adjustment to other work, but also that other work exists in significant
numbers in the national economy. Eichelberger v. Barnhart, 390 F.3d 584, 591 (8th
Cir. 2004). If the claimant can make the adjustment, then the Commissioner will find
the claimant not disabled. At Step Five, the Commissioner has the responsibility of
developing the claimant’s complete medical history before making a determination about
the existence of a disability. The burden of persuasion to prove disability remains on the
claimant. Stormo v. Barnhart, 377 F.3d 801, 806 (8th Cir. 2004).
THE ALJ’S FINDINGS
The ALJ made the following findings at each step.
At Step One, the ALJ found that claimant had not engaged in substantial gainful
activity since March 1, 2009, the alleged onset date of his disability. (AR 14).
At Step Two, the ALJ found that claimant had the severe impairments of
disorder/generalized anxiety disorder.” (Id.).
At Step Three, the ALJ found that none of claimant’s impairments equaled a
presumptively disabling impairment listed in the relevant regulations. (AR 14-15).
At Step Four, the ALJ found claimant had residual functional capacity to perform
sedentary work, with following additional functional limitations that claimant:
[M]ust change postural positions every thirty minutes, rising from seated to
stand or walk for two to three minutes before sitting again, all within the
work area. He could only occasionally climb, balance, stoop or crouch.
He could not kneel or crawl. He could have no more than occasional
exposure to cold and no exposure to hazardous conditions such as heights
or moving machinery. He could never climb ropes, ladders, or scaffolds.
He is limited to tasks learned in thirty days or less, involving no more than
simple work related decisions, requiring little to no judgment and only
occasional workplace changes.
(AR 15-16). Also at Step Four, the ALJ determined that claimant was unable to perform
any past relevant work. (AR 23).
At Step Five, the ALJ determined that based on claimant’s age and limited
education, and with his residual functional capacity, there were jobs that existed in
significant numbers in the national economy that claimant could perform, including order
clerk, assessor, and telephone quote clerk. (AR 24-25). Therefore, the ALJ did not
proceed to Step Five, and found claimant was not disabled. (AR 25).
THE SUBSTANTIAL EVIDENCE STANDARD
The Commissioner’s decision must be affirmed “if it is supported by substantial
evidence on the record as a whole.” Pelkey v. Barnhart, 433 F.3d 575, 577 (8th Cir.
2006); see 42 U.S.C. § 405(g) (“The findings of the Commissioner of Social Security as
to any fact, if supported by substantial evidence, shall be conclusive . . ..”). “Substantial
evidence is less than a preponderance, but enough that a reasonable mind might accept
as adequate to support a conclusion.” Lewis, 353 F.3d at 645 (citations and internal
quotation marks omitted). The Eighth Circuit Court of Appeals explains the standard as
“something less than the weight of the evidence and [that] allows for the possibility of
drawing two inconsistent conclusions, thus it embodies a zone of choice within which the
[Commissioner] may decide to grant or deny benefits without being subject to reversal
on appeal.” Culbertson v. Shalala, 30 F.3d 934, 939 (8th Cir. 1994) (citations and
internal quotation marks omitted).
In determining whether the Commissioner’s decision meets this standard, the court
considers “all of the evidence that was before the ALJ, but we do not re-weigh the
evidence.” Vester v. Barnhart, 416 F.3d 886, 889 (8th Cir. 2005) (citation omitted).
The court considers both evidence that supports the Commissioner’s decision and
evidence that detracts from it. Kluesner v. Astrue, 607 F.3d 533, 536 (8th Cir. 2010).
The court must “search the record for evidence contradicting the [Commissioner’s]
decision and give that evidence appropriate weight when determining whether the overall
evidence in support is substantial.” Baldwin v. Barnhart, 349 F.3d 549, 555 (8th Cir.
2003) (citing Cline v. Sullivan, 939 F.2d 560, 564 (8th Cir. 1991)).
In evaluating the evidence in an appeal of a denial of benefits, the court must apply
a balancing test to assess any contradictory evidence. Sobania v. Sec’y of Health &
Human Servs., 879 F.2d 441, 444 (8th Cir. 1989). The court, however, does not
“reweigh the evidence presented to the ALJ,” Baldwin, 349 F.3d at 555 (citing Bates v.
Chater, 54 F.3d 529, 532 (8th Cir. 1995)), or “review the factual record de novo.” Roe
v. Chater, 92 F.3d 672, 675 (8th Cir. 1996) (quoting Naber v. Shalala, 22 F.3d 186,
188 (8th Cir. 1994)). Instead, if, after reviewing the evidence, the court finds it “possible
to draw two inconsistent positions from the evidence and one of those positions represents
the Commissioner’s findings, [the court] must affirm the [Commissioner’s] denial of
benefits.” Kluesner, 607 F.3d at 536 (quoting Finch v. Astrue, 547 F.3d 933, 935 (8th
Cir. 2008)). This is true even in cases where the court “might have weighed the evidence
differently.” Culbertson, 30 F.3d at 939 (quoting Browning v. Sullivan, 958 F.2d 817,
822 (8th Cir. 1992)). The court may not reverse the Commissioner’s decision “merely
because substantial evidence would have supported an opposite decision.” Baker v.
Heckler, 730 F.2d 1147, 1150 (8th Cir. 1984); see Goff v. Barnhart, 421 F.3d 785, 789
(8th Cir. 2005) (“[A]n administrative decision is not subject to reversal simply because
some evidence may support the opposite conclusion” (citation omitted)).
Claimant argues that the ALJ’s residual functional capacity determination at Step
Four was flawed because: (1) the ALJ failed to evaluate properly the work-related
limitations from treating physician Dr. Meredith Christ (Doc. 16, at 4-14); (2) the ALJ
failed to evaluate properly the work-related limitations from treating psychiatrist Dr.
Muhammad Chowdhry and Advanced Registered Nurse Practitioner (ARNP) Vicki
Boling (Doc. 14, at 15-21); and (3) the ALJ’s residual functional capacity assessment
was not supported by substantial medical evidence from a treating or examining source
(Doc. 14, at 21-22). I will address each of these issues in turn.
The ALJ’s Evaluation of Treating Physician’s Opinion
Claimant argues the ALJ erred in failing to give the work-limitation opinions of
treating physician Dr. Meredith Christ, sufficient weight. (Doc. 14, at 4-14). Claimant
argues that Dr. Christ concluded that claimant had work-related limitations that would
have resulted in a disability finding. (Doc. 14, at 5). Claimant argues that Dr. Christ’s
opinions were entitled to controlling weight because they were well-supported by the
medical evidence and not inconsistent with other substantial evidence. (Doc. 14, at 614).
Dr. Christ treated claimant from April 24, 2014, through the time she rendered
her opinion on January 23, 2015. (AR 616-20). Dr. Christ stated that she saw claimant
every two or three months during that time period for low back pain. (AR 616).2 In a
January 2015 Medical Source Statement, Dr. Christ described claimant’s symptoms as:
Continuous pain, inability to independently tie shoes, depression & anxiety
secondary to pain; in ability to maintain one position due to pain. Pain &
numbness right leg & foot. Fatigue.
(AR 616). Dr. Christ described claimant’s pain thus:
Main area of pain is low back & down right leg. Leg will give out randomly
causing difficulty w/ ambulation. Pain rates 9-10/10 majority of the time.
Sitting, standing, & walking increases pain.
(Id.). Dr. Christ also indicated that claimant had neuro-anatomic distribution of pain.
(Id.). Dr. Christ identified reduced range of motion (indicating claimant could not flex
his low back far enough to reach his feet, even from a sitting position), positive supine
straight leg raising on his right leg at 30° and left leg at 45°, positive seated straight leg
The medical records, however, show that she saw claimant only three times: April 24, 2014,
June 9, 2014, and August 11, 2014. (AR 534-39). An MRI was performed on August 20, 2014.
raising test, abnormal gait, mild sensory loss on the right side, reflex loss on the right
side, and motor loss. (AR 617). Dr. Christ indicated that claimant’s medication caused
claimant fatigue, impaired his mental clarity, and caused mild urinary retention issues.
With regard to work-related limitations, Dr. Christ opined that claimant could only
walk ½ city block without rest or severe pain, could sit for only 15 minutes and stand
for only 20 minutes at one time. (AR 617). Dr. Christ opined that claimant could stand
or walk less than 2 hours and sit for about 2 hours in an eight-hour workday. (Id.). Dr.
Christ further opined that claimant needed a job that permitted him to shift positions at
will, needed periods when he could walk around during work, and would need a cane
when standing or walking. (AR 618). Dr. Christ also opined that claimant would need
unscheduled 20- to 30-minute breaks every ten minutes. (Id.). Dr. Christ opined that
claimant could rarely lift 10 pounds and never any more, and could never twist, stoop
(bend), crouch or squat, or climb ladders or stairs. (Id.). Dr. Christ opined that claimant
would be “off task” more than 25% of the time, is incapable of even “low stress” work,
and would need to be absent from work more than four days per month as the result of
impairments or treatment. (AR 619).
The ALJ noted that Dr. Christ treated claimant for less than a year before
rendering her opinion. (AR 21). The ALJ accurately summarized Dr. Christ’s opinion
as set forth above. (Id.). The ALJ gave “[l]imited weight” to Dr. Christ’s opinions,
however, because they were “not consistent with the medical records as a whole” and
were not supported by Dr. Christ’s “own attached objective imaging.” (Id.). The ALJ
then described in some detail the results of an MRI of claimant’s lumbar spine taken in
August 2014 that Dr. Christ attached to her opinion. (Id.). In short, the ALJ noted that
the MRI showed only “mild narrowing of interspace” between two discs, and that the
imaging “appeared much the same as it did at the time of the prior examinations.” (AR
21-22). It is important to note that in her decision the ALJ did not arrive at her own
interpretation of the MRI, but, rather, was quoting from the MRI report signed by Dr.
Greg E. Raeckar DO and Dr. Christ. (AR 621).
An ALJ must determine a claimant’s residual functional capacity based on “all of
the relevant evidence, including the medical records, observations of treating physicians
and others, and an individual’s own description of [his] limitations,” but “there is no
requirement that an RFC finding be supported by a specific medical opinion.” Hensley
v. Colvin, 829 F.3d 926, 931-32 (8th Cir. 2016) (alterations in original) (citation and
internal quotation marks omitted).
In determining a claimant’s residual functional
capacity, it is the ALJ’s function to weigh conflicting evidence and to resolve
disagreements among physicians. See Estes v. Barnhart, 275 F.3d 722, 725 (8th Cir.
2002). A treating physician’s medical opinions are given controlling weight if they are
“well-supported by medically acceptable clinical and laboratory diagnostic techniques
and [are] not inconsistent with the other substantial evidence.” See Choate v. Barnhart,
457 F.3d 865, 869 (8th Cir. 2006) (internal citation and quotation marks omitted). A
treating physician’s opinion may be disregarded if it is unsupported by clinical or other
data or is contrary to the weight of the remaining evidence in the record. See Myers v.
Colvin, 721 F.3d 521, 525 (8th Cir. 2013) (“We conclude that substantial evidence
supports the ALJ’s determination that [the doctor’s] opinion was inconsistent with the
treatment record and thus not entitled to controlling weight.”); Anderson v. Astrue, 696
F.3d 790, 793-94 (8th Cir. 2012).
In addition, “[a] treating physician’s own
inconsistency may also undermine his opinion and diminish or eliminate the weight given
his opinions,” such as when the opinion is inconsistent with contemporaneous treatment
Hacker v. Barnhart, 459 F.3d 934, 937 (8th Cir. 2006) (citation omitted).
Similarly, an ALJ may discount the weight given to a treating physician’s opinion if the
treatment notes simply do not support the limitations endorsed in the opinion. See Cline
v. Colvin, 771 F.3d 1098, 1104 (8th Cir. 2014) (holding that a treating physician’s
opinion is entitled to less weight if it is unsupported by the physician’s own records).
In this case, the ALJ correctly found the treating doctor’s medical records simply
did not support the limitations she imposed on the checklist form. Dr. Christ’s treatment
notes provide no basis to support the extreme limitations she endorsed on the checkbox
form. Indeed, the MRI report she attached reflected only mild narrowing of interspace
that “imping[ed] upon the proximal right S1 nerve root sleeve,” but with “[n]o worrisome
marrow signal changes,” “[n]o vertebral compression,” and “no remarkable change since
the prior MR examination in January last year.” (AR 621).3 In assessing the weight to
be given to Dr. Christ’s opinion, the ALJ also properly considered that Dr. Christ saw
claimant for less than a year. See Whitman v. Colvin, 762 F.3d 701, 706 (8th Cir. 2014)
(“In considering how much weight to give a treating physician’s opinion, an ALJ must
also consider the length of the treatment relationship and the frequency of examinations.”
(internal citation and quotation marks omitted)).
Claimant argues that the medical records support the limitations endorsed by Dr.
Christ, citing to reports of Dr. Christ and other physicians from 2011 to 2014. (Doc.
14, at 8-13). These records do not support claimant’s argument. The records show that
claimant underwent back surgery in 2011 and follow-up treatment. (AR 443, 457, 461).
Claimant had a neurosurgical evaluation on February 26, 2013, with Dr. Jackson at
Dr. Jackson’s impression was that claimant had “mild L5 and severe S1
radiculopathy.” (AR 494). Lumbar MRI ordered and reviewed by Dr. Jackson on
February 26, 2013, showed “postoperative changes at L5-S1 with residual disc herniation
at this level.” (AR 493). As noted, however, in 2014, the lumbar MRI showed only
Claimant is simply wrong when he alleges that “the ALJ relied on a bare allegation [of
inconsistency] with no citation to the record.” (Doc. 14, at 13). The ALJ cited the MRI report
Dr. Christ attached to her opinion. (AR 21).
“mild spinal canal narrowing at L4-5” and at L5-S1 disc protrusion and epidural scarring
that impinged on the S1 nerve root sleeve. (AR 621). Dr. Christ’s very limited medical
records from the three times she saw claimant (AR 532-39) reflect largely nothing more
than claimant’s subjective complaints and the single MRI already discussed. Indeed, on
June 9, 2014, Dr. Christ noted that she thought claimant’s “most recent bout of back pain
is more muscular than anything else.” There are no tests or other objective basis in Dr.
Christ’s notes to support the extreme work-related limitations she noted in her opinion.
Although Dr. Christ referenced positive leg raising in her opinion (AR 617), there is no
reference to conducting such tests in her treatment notes. (AR 532-39). Although Dr.
Christ referenced “abnormal gait” in her opinion (AR 617), her treatment notes are
inconsistent, noting a limp in April 2014 (AR 539), a “pretty normal gait” in June 2014
(AR 536), and a reference that claimant “walks fairly well once he gets going” in August
2014. (AR 534). In Dr. Christ’s Medical Source Statement she noted reflex loss (AR
617), but her notes make no reference to claimant’s reflexes. (AR 532-39). Although
claimant saw a number of other doctors in 2013 and 2014 regarding complaints about
back and leg pain, none of those medical records reflect work-related limitations endorsed
by any other physician. (AR 511-28, 541-44, 547-48, 550-53).
The ALJ also considered and gave “partial weight” to state agency physicians
Matthew Byrnes, D.O., and Tracey Larrison, D.O. (AR 23). Both doctors concluded
claimant could carry 20 pounds occasionally and ten pounds frequently, could stand and
walk for two hours and sit for about six hours in an eight-hour workday, and could
occasionally push, pull, balance, stoop, crouch, and climb ramps and stairs. (AR 13033, 144-48). The only other relevant limitations these doctors found appropriate were
that claimant never kneel, crawl, or climb ladders, ropes, or scaffolds. (Id.).
In summary, I find there is substantial evidence in the record as a whole for the
ALJ to have afforded Dr. Christ’s opinion limited evidentiary weight. Therefore, I find
the ALJ did not err when she declined to include Dr. Christ’s work-related limitations in
claimant’s residual functional capacity assessment.
The ALJ’s Evaluation of Examining Psychiatrist’s Opinion
Claimant argues that the ALJ’s residual functional capacity assessment was flawed
because it did not incorporate limitations found by examining psychiatrist Dr. Muhammad
Chowdhry and Vicki Boling, ARNP. (Doc. 15, at 15-21). Claimant argues that Dr.
Chowdhry and Ms. Boling provided opinions regarding claimant’s mental limitations that
were supported by the medical records, but the ALJ did not include those limitations in
her residual functional capacity assessment. Claimant argues that the ALJ failed to
provide an adequate explanation for discounting those limitations. (Id.).
Claimant was seen at the Black Hawk-Grundy Mental Health Center, Inc. (the
Center), from February 3, 2014, through October 14, 2014.
December 10, 2014, the Center provided a Mental Medical Source Statement signed by
Dr. Chowdhry and Ms. Boling. (AR 608-613). Claimant was first seen on February 3,
2014, by social worker Joyce Andresen and the records indicate claimant was diagnosed
with Depressive Disorder, Panic Disorder, and Generalized Anxiety Disorder. (AR 55758). The notes indicated that claimant stated his wife referred him to the Center, but
indicated that “[h]is attorney also wanted him to get evaluated, because he is applying
for disability.” (AR 557). Over the course of the following eight months, social worker
Richard Anfinson saw claimant a dozen times and Ms. Boling saw claimant on seven
occasions. (AR 559-606). The appointments with Mr. Anfinson lasted approximately
one hour, while the appointments with Ms. Boling lasted approximately twenty minutes.
(Id.). Dr. Chowdhry never saw claimant. By the time of the last appointment in October
2014, claimant’s examination showed normal thought process, normal associations, good
judgment and insight, no abnormal thoughts, normal orientation, adequate memory,
normal attention/concentration, normal language, adequate fund of knowledge,
appropriate and “better” mood, and increased sleep. (AR 605). The notes indicate that
claimant’s status was improving. (Id.).
The Mental Medical Source Statement indicated that claimant would find speed,
precision, complexity, deadlines, making decisions, completing tasks, dealing with the
public, being criticized by supervisors, remaining at work for a full day, and fear of
failure at work stressful. (AR 609). It indicated that claimant would miss more than
four days per month as a result of claimant’s impairments and treatment. (Id.). The
statement noted that, in addition to his mental issues, claimant’s pain and the effect of
psychiatric medication would make it difficult for claimant to work on a sustained basis.
(Id.). The statement also listed a number of symptoms, including decreased energy,
suicidal ideations, anxiety, difficulty concentrating, and short-term memory impairment.
(AR 610). Regarding mental abilities and aptitudes needed for unskilled work, the
statement indicated that claimant would be seriously limited in his ability to maintain
regular attendance. The statement also indicated that claimant would be unable to meet
competitive standards for completing a normal workday without interruptions from his
symptoms and for dealing with stress, and no ability to perform at a consistent pace
without an unreasonable number of rest periods. (AR 611). As for semi-skilled or skilled
work, the statement indicated claimant would be seriously limited in his ability to deal
with the stress of such work. (AR 612).
The ALJ summarized claimant’s mental health history.
The ALJ noted that
claimant was examined by a licenses psychologist, Dr. Carroll Roland, in March 2013,
who found that claimant’s memory was intact, his thoughts were goal directed, he did
not exhibit any thought abnormalities, and reported “fleeting passive suicidal ideation.”
(AR 19). The ALJ noted that the psychologist found claimant had become increasingly
depressed secondary to mounting financial pressures, but that any limitations on his
ability to work would be pain-related and not due to mental health issues. (AR 20). Dr.
Roland assessed claimant with a Global Assessment of Functioning (GAF) of 70,
reflecting mild symptoms. (Id.). The ALJ then summarized the records and treatment
that claimant received at Black Hawk-Grundy Mental Health Center. (Id.). The ALJ
also summarized the Medical Source Statement submitted by Dr. Chowdhry and Ms.
Boling. (AR 21). The ALJ gave “some weight” to the opinions reflected in that statement
as it pertained to claimant’s mental health issues, but “little weight” to limitations based
on claimant’s complaints of physical pain because “this was not the primary purpose of
their treatment interaction with the claimant and not within their treating specialty.” (Id.).
In her residual functional capacity assessment, the ALJ included the following mental
[Claimant] is limited to tasks learned in thirty days or less, involving no
more than simple work related decisions, requiring little to no judgment
and only occasional workplace changes.
Although an ALJ must consider medical opinion evidence in formulating a
claimant’s residual functional capacity, the ALJ has a duty to formulate the RFC based
on all of the relevant and credible evidence of record. Cox v. Astrue, 495 F.3d 614, 619
(8th Cir. 2007); Dykes v. Apfel, 223 F.3d 865, 866 (8th Cir. 2000) (per curiam). This
evidence includes a claimant’s daily activities. Owen v. Astrue, 551 F.3d 792, 799 (8th
Cir. 2008) (finding an ALJ properly discounted the opinions of a medical source because
claimant’s activities of daily living did not reflect the physical limitations found). Thus,
an “ALJ may reject the conclusions of any medical expert, whether hired by the claimant
or the government, if they are inconsistent with the record as a whole.’” Wagner v.
Astrue, 499 F.3d 842, 848 (8th Cir. 2007) (quoting Pearsall v. Massanari, 274 F.3d
1211, 1219 (8th Cir. 2001)). When determining the RFC, “‘[t]he opinion of a consulting
physician who examines a claimant once or not at all does not generally constitute
substantial evidence.’” Singh v. Apfel, 222 F.3d 448, 452 (8th Cir. 2000) (quoting Kelley
v. Callahan, 133 F.3d 583, 589 (8th Cir. 1998)). Regardless of the source of the opinion,
however, an ALJ must explain and give good reasons for the weight accorded to the
various opinions. 20 C.F.R. § 404.1527(c)(2).
I find that substantial evidence supported the ALJ’s decision to afford the opinions
reflected in the Mental Medical Source Statement some weight with respect to mental
health limitations and little weight as to opinions based on claimant’s pain complaints.
First, the ALJ was fully justified in giving little weight due to the fact that Dr. Chowdhry
signed off on the Mental Medical Source Statement when the records show Dr. Chowdhry
did not treat claimant. Additionally, there is no indication of what, if any, review of the
records he made prior to signing the statements. That Dr. Chowdhry’s signature is simply
a formality is reflected in the handwritten note indicating that a co-signature from an MD
was needed on the form. (AR 613).
Moreover, the ALJ was justified in assigning different weight to mental health
issues versus medical issues, given the specialty and treatment provided at the Center.
As for claimant’s mental health, the statement reflects that claimant’s therapy and
medication had been a “good combination” and that claimant’s mental impairments were,
as a result of this treatment, “under better control.” (AR 21, 608). Ms. Boling’s notes
reflected that claimant’s presentation on each of the visits was unremarkable other than
symptoms of depression. (AR 563-64, 571, 578, 585, 595, 600, 605). Ms. Boling’s
notes reflected on each occasion that claimant’s condition was either stable, unchanged,
or improving.” (AR 571, 578, 585, 595, 600, 605). These notes contrast sharply with
the severe work-related limitations endorsed in the Mental Medical Source Statement.
See Hogan v. Apfel, 239 F.3d 958, 961 (8th Cir. 2001) (noting an ALJ may discount
treating physician's opinion if she has offered inconsistent opinions). The ALJ could
properly conclude that the work-related impairments identified in the statement were tied
more to claimant’s physical pain than to claimant’s mental health. (AR 609).
The ALJ could also give little weight to the Center’s Mental Medical Source
Statement because it was inconsistent with the opinions of other mental health
professionals. Consultative psychologist Carrol Roland, Ph.D., examined claimant on
March 28, 2013. (AR 497-501). Dr. Roland diagnosed claimant with “Major Depressive
Disorder, single episode with moderate to severe intensity.” (AR 501). Dr. Roland
assessed claimant with a GAF score of 70, and determined that any “deterrent to full time
competitive employment appears to be chronic pain and physical limitations” and not to
mental illness. (Id.). State agency psychological consultants Myrna Tashner, Ed.D. and
Dee Wright, Ph.D., concluded that claimant’s mental impairments resulted in only mild
restrictions of activities in daily living, social functioning, and maintaining concentration,
persistence, and pace. (AR 129-30, 142-43).
Finally, the ALJ considered the low GAF scores Ms. Boling found applicable to
claimant, but properly discounted the importance of these subjective assessments. (AR
20-21). See Nowling v. Colvin, 813 F.3d 1110, 1123 (8th Cir. 2016) (noting that GAF
scores have limited importance).
In summary, I find there is substantial evidence in the record as a whole for the
ALJ to have afforded the Mental Medical Source Statement with “some weight” in
relation to mental health opinions and “little weight” in relation to opinions based on
claimant’s subjective complaints of physical pain. Therefore, I find the ALJ did not err
when she declined to include the Mental Medical Source Statement’s work-related
limitations in claimant’s residual functional capacity assessment.
The ALJ’s Residual Functional Capacity Assessment
Claimant argues that the ALJ’s residual functional capacity assessment was flawed
because “it is not supported by substantial medical evidence from a treating or examining
source.” (Doc. 14, at 21-22). Here, claimant argues that the ALJ’s residual functional
capacity assessment lacked medical support because the ALJ “did not rely on the
opinions” of Dr. Christ, Dr. Chwodhry/Ms. Boling [sic], Dr. Byrnes, or Dr. Larrison,”.
(Id.). Claimant demands the Court reverse the ALJ’s decision and remand the case “for
further development of the record.” (Doc. 14, at 22).
A claimant has the burden of proving his disability. Stormo, 377 F.3d at 806. It
is the claimant’s burden to prove his residual functional capacity. Baldwin v. Barnhart,
349 F.3d 549, 556 (8th Cir. 2001). Where a claimant argues that an ALJ failed to
develop the record, the claimant carries the burden of showing he was prejudiced or
treated unfairly by the ALJ’s development of the record. Lacroix v. Barnhart, 465 F.3d
881, 886 (8th Cir. 2006). Here, claimant has failed to carry his burdens.
First, claimant overstates the record when he asserts the ALJ did not consider the
opinions of Dr. Christ, Dr. Chowdhry, Ms. Boling, Dr. Byrnes, and Dr. Larrison. The
ALJ considered the opinions of all of these sources; the ALJ gave “some,” “limited,”
“partial,” and “little” weight to these opinions in light of the medical records and the
record as a whole. Second, claimant ignores the ALJ’s reliance on Dr. Delbridge as a
treating source. (AR 21-22). Finally, the ALJ relied, as she may, upon non-examining
consultants. Smith v. Colvin, 756 F.3d 621, 626 (8th Cir. 2014).
Ultimately, the ALJ’s residual functional capacity “must be supported by some
medical evidence,” but “there is no requirement that an RFC finding be supported by a
specific medical opinion.” Hensley, 829 F.3d at 932. The ALJ must determine a
claimant’s residual functional capacity assessment based on all of the relevant medical
and non-medical evidence. Boyd v. Colvin, 831 F.3d 1015, 1020 (8th Cir. 2016). Courts
will not reverse an ALJ’s residual functional capacity assessment where, as here, the
record was reasonably complete and contained sufficient evidence from which the ALJ
could make the assessment. Haley v. Massanari, 258 F.3d 742, 748 (8th Cir. 2001).
Accordingly, I find the ALJ did not err and that there was substantial evidence in
the record as a whole to support her residual functional capacity assessment.
For the reasons set forth herein, I find the ALJ acted well within the zone of choice
within which the Commissioner may act. Culbertson, 30 F.3d at 939. Therefore, I
respectfully recommend the District Court affirm the Commissioner’s determination that
claimant was not disabled, and enter judgment against claimant and in favor of the
Parties must file objections to this Report and Recommendation within fourteen
(14) days of the service of a copy of this Report and Recommendation, in accordance
with 28 U.S.C. § 636(b)(1) and FED. R. CIV. P. 72(b). Objections must specify the parts
of the Report and Recommendation to which objections are made, as well as the parts of
the record forming the basis for the objections. See FED. R. CIV. P. 72. Failure to object
to the Report and Recommendation waives the right to de novo review by the District
Court of any portion of the Report and Recommendation as well as the right to appeal
from the findings of fact contained therein. United States v. Wise, 588 F.3d 531, 537
n.5 (8th Cir. 2009).
IT IS SO ORDERED this 31st day of July, 2017.
Chief United States Magistrate Judge
Northern District of Iowa
Disclaimer: Justia Dockets & Filings provides public litigation records from the federal appellate and district courts. These filings and docket sheets should not be considered findings of fact or liability, nor do they necessarily reflect the view of Justia.
Why Is My Information Online?