Mains v. SSA
Filing
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MEMORANDUM OPINION AND ORDER: It is ORDERED that Pla's 13 Motion for Summary Judgment be DENIED, Dft's 20 Motion for Summary Judgment be GRANTED, and that Judgment be entered affirming the final decision of the Commissioner. Signed by Magistrate Judge Edward B. Atkins on June 10, 2014. (AWD) cc: COR
UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF KENTUCKY
CENTRAL DIVISION at LEXINGTON
CIVIL ACTION NO. 5:13-CV-437-EBA
VALERIE ELAINE MAINS,
V.
PLAINTIFF,
MEMORANDUM OPINION
AND ORDER
CAROLYN W. COLVIN,
Commissioner of Social Security Administration,
DEFENDANT.
I. INTRODUCTION
Plaintiff, Valerie Elaine Mains, brings this action under 42 U.S.C. § 405(g) to challenge the
Defendant Commissioner’s final decision denying her application for Supplemental Security Income
(SSI). [Record No. 13-1]. Upon consent of the parties, this matter has been referred to the
undersigned to conduct all proceedings and order the entry of final judgment in accordance with 28
U.S.C. § 636(c) and Fed.R.Civ.P. 73. [Record No. 19]. Now ripe for decision on the parties’ crossmotions for summary judgment, and for the reasons set forth herein, the Plaintiff’s Motion for
Summary Judgment [Record No. 13] shall be denied, the Defendant’s Motion for Summary
Judgment [Record No. 20] shall be granted, and Judgment will be entered affirming the
Commissioner’s final decision.
II. FACTUAL BACKGROUND & PROCEDURAL HISTORY
On March 31, 2010, the Plaintiff filed an application for supplemental security income. [Tr.
132-135]. In this application, the Plaintiff alleged disability since March 29, 2010. Id. In her
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Disability Report, Form SSA-3368, the Plaintiff claimed her work ability was limited due to
rheumatoid arthritis, migraines and bursitis. [Tr. 161-167]. Her claim was denied initially [Tr. 8386], and on reconsideration [Tr. 69]. After denial of her claim, Plaintiff requested a hearing in front
of an Administrative Law Judge (“ALJ”). [Tr. 91].
On July 17, 2012, a hearing was held before ALJ Greg Holsclaw. [Tr. 27-67]. The Plaintiff
testified at the hearing, and was represented by Terry Minser. [Tr. 27-67]. The ALJ also heard
testimony from vocational expert Dr. Jackie Rogers. [Tr. 27-67]. ALJ Holsclaw denied Plaintiff’s
claim for benefits in a written decision dated August 31, 2012. [Tr. 11-20]. In evaluating Plaintiff’s
claim, the ALJ applied the five-step sequential evaluation process to determine that she was not
disabled. See 20 C.F.R. §§ 404.1520; 416.920. At the first step, the ALJ found that Plaintiff had
not engaged in substantial gainful activity since the date of her application for benefits. [Tr. 13].
Next, the ALJ found that the Plaintiff has the following severe impairments: degenerative disc
disease of the cervical and lumbar spine; osteoarthritis; headaches; depression; and post-traumatic
stress disorder (PTSD). [Tr. 13].
At step three, the ALJ found that Plaintiff’s medically
determinable impairments did not meet or medically equal one of the listed impairments in 20 C.F.R.
Part 404, Subpart P, Appendix 1. [Tr. 13-14].
Before proceeding to the fourth step, the ALJ found that Plaintiff’s impairments left her with
the residual functional capacity (“RFC”) to perform sedentary work as defined by the Regulations.
[Tr. 14-15]. Specifically, the ALJ described Plaintiff’s exertional and non-exertional limitations:
No lifting/carrying more than ten pounds occasionally; no standing/walking more
than two hours out of an eight hour day and for no more than 45 minutes at one time;
can perform unlimited pushing/pulling up to the exertional limitations; no more than
frequent balancing; no more than occasional stooping, kneeling, crouching, crawling,
or climbing ramps or stairs; no climbing of ladders, ropes, or scaffolds; no work
around dangerous moving machinery or unprotected heights; no work around
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concentrated exposure to vibration; no driving or operating heaving machinery; no
more than simple routine work; no more than occasional, if any, work that requires
independent decision making, use of judgment or work outside a set schedule; and
no more than occasional, if any, changes in the workplace setting.
[Tr. 14-15].
The fourth step of the analysis is to determine whether the Plaintiff’s residual functional
capacity would allow her to perform the requirements of her past relevant work. The ALJ
determined that the Plaintiff was unable to perform any past relevant work, See 20 C.F.R. §§
404.1565, 416.965. [Tr. 19]. At the fifth and final step, relying on the testimony of the Vocational
Expert (“VE”) and taking into consideration Plaintiff’s age, educational background, past relevant
work experience, and residual functional capacity, the ALJ must determine whether the Plaintiff is
capable of making a successful adjustment to work existing in significant numbers in the national
economy. See 20 C.F.R. §§ 404.159(a); 416.969(a). Based on the testimony of the Vocational
Expert, the ALJ held that, “[c]onsidering the claimant’s age, education, work experience, and
residual functional capacity, the claimant is capable of making a successful adjustment to other work
that exists in significant numbers in the national economy . . . .” [Tr. 19]. Based on these findings,
the ALJ determined that the Plaintiff was not under a “disability” as defined by the Social Security
Act, See 20 C.F.R. §§ 404.1520(g) and 416.920(g). [Tr. 20].
Following the ALJ’s adverse decision, the Plaintiff properly exhausted her administrative
remedies by appealing to the Social Security Appeals Council. [Tr. 6-7]. On October 31, 2013, the
Council denied Mains’ request for review. [Tr. 1-5]. On December 19, 2013, Plaintiff initiated the
present action by filing her Complaint in the United States District Court for the Eastern District of
Kentucky. [Record No. 1]. In her Motion for Summary Judgment, the Plaintiff asserts two grounds
for relief: (1) that the ALJ’s step three finding that Mains’ spinal impairments did not rise to the
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level of a disability under the regulations was unsupported by substantial evidence; and (2) that the
ALJ failed to properly apply the treating physician rule set forth in 20 C.F.R. § 404.1527 when he
discounted the opinion of treating physician Dr. Arnold. [Record No. 13-1]. The Commissioner
responds that the ALJ’s decision should be affirmed, as he applied the proper standards and
supported his decision with substantial evidence. [Record No. 20]. Following briefing, this matter
was referred to the undersigned, upon consent of the parties for all proceedings. [Record No. 19].
III . ANALYSIS
Pursuant to 42 U.S.C. § 405(g), a reviewing court “must affirm the Commissioner’s
conclusions absent a determination that the Commissioner has failed to apply the correct legal
standard or has made findings of fact unsupported by substantial evidence in the record.”
Longworth v. Comm’r Soc. Sec., 402 F.3d 591, 595 (6th Cir. 2005) (citations omitted). The scope
of judicial review is limited to the record itself, and the reviewing court “may not try the case de
novo, nor resolve conflicts in evidence, nor decide questions of credibility.” Hogg v. Sullivan, 987
F.2d 328, 331 (6th Cir. 1993) (citations omitted).
A.
The ALJ’s finding that Mains’ spinal impairments did not meet or equal a listed
impairment under Listing 1.04 was supported by substantial evidence.
In her motion for summary judgment, the Plaintiff claims that the ALJ’s finding in regard
to her claims of spinal impairment was not supported by substantial evidence. [Record No. 13-1 at
9]. The Plaintiff claims that the ALJ failed to sufficiently articulate how he reached his conclusion
that Mains’ spinal impairment did not meet or equal a listed impairment under Listing 1.04. Id. at
11. This claim fails upon review of the record.
The Sixth Circuit has held that “substantial evidence exists when a reasonable mind might
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accept the relevant evidence as adequate to support a conclusion.” Warner v. Comm’r of Soc. Sec.,
375 F.3d 387, 390 (6th Cir. 2004) (citations omitted). The limited nature of substantial evidence
review prevents the reviewing court from substituting its judgment for that of the ALJ. Rather, so
long as substantial evidence exists, the reviewing court should affirm the ALJ’s decision “even if
there is substantial evidence in the record that would have supported an opposite conclusion.”
Longworth, 402 F.3d at 595 (citations omitted). Substantial evidence is “more than a scintilla of
evidence but less than a preponderance; it is such relevant evidence as a reasonable mind might
accept as adequate to support a conclusion.” Rogers v. Comm’r of Soc. Sec., 486 F.3d 234, 241 (6th
Cir. 2007) (citations omitted). “The substantial evidence standard presupposes that there is a ‘zone
of choice’ within which the [Commissioner] may proceed without interference from the courts.”
Felisky v. Bowen, 35 F.3d 1027, 1035 (6th Cir.1994) (citations omitted).
In this case, the ALJ properly supported his findings in the record with substantial evidence.
Listing 1.04A requires, “[e]vidence of nerve root compression characterized by neuro-anatomic
distribution of pain, limitation of motion of the spine, motor loss (atrophy with associated muscle
weakness) accompanied by sensory or reflex loss and, if there is involvement of the lower back,
positive straight-leg raising test (sitting and supine).” 20 C.F.R. Part 404, Subpart P, App. 1. In this
case, the ALJ found that the record was devoid of evidence showing nerve root compression as
required under the listing. [Tr. 13]. In her response, the Commissioner correctly contends that the
record does not reflect nerve root compression. [Record No. 20 at 5]. An August 2007 emergency
room note shows that a CT of Mains’ lumbar spine was, “negative for any disc problems or
compression.” [Tr. 301]. In addition, a February 2009 MRI revealed that Mains’ nerve roots
“appeared symmetrical.” [Tr. 505].
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In regard to the claimant’s alleged spinal impairments, the ALJ also reviewed the record as
a whole, including the testimony given at the hearing. The ALJ found that:
Multiple radiographic studies including plain film, computed tomography (CT), and
magnetic resonance imagining (MRI) confirm the presence of cervical and
degenerative disk disease, partially corroborating the claimant’s allegations (Exhibits
22F, 23F and 30F). However, the remaining findings are generally unremarkable
and do not correspond to the level of severity presented by the claimant. Treatment
records document a history of back problems and clinical findings show limited
ranges of motion and paraspinal tenderness with a consistent diagnosis of multilevel
degenerative changes with disk bulges, but there is no evidence of nerve root
impingement. Office notes from Dr. Mitchell Simmons, Dr. John Gilbert, Dr.
William Beers, Dr. John O’Connell, and Dr. Richard Arnold (Exhibits 6F-12F, 15F,
20F, 22F-24F, 29F, 32F and 33F) document conservative treatment for complaints
of neck and back plain. Pain management records from Dr. Alan Rison also
document routine conservative treatment (Exhibits 31F and 35F). However, despite
all of this documentation, there is not a lot of diagnostic expertise being applied at
these visits, nor is there any significant therapeutic decision-making at these
evaluations. More or less, every visit looks the same, in terms of documentation and
medical care, and no significant changes are introduced. Treatment records show the
claimant has been tried on multiple medications including Lortab, Percocet, and
more recently, Morphine, but the changes have occurred due to her chronic use of
medications and the lessening effectiveness of the medications as a result, not due
to an increase in symptoms.
[Tr. 15-16]
Further, the ALJ found that the claimant was not entirely credible in regard to the frequency
and severity of her limitations and overall disability. [Tr. 16]. The ALJ noted that the objective
findings documented on the record were insufficient to show that she was precluded from
preforming a range of light work and that the description of the symptoms and limitations provided
throughout the record were unpersuasive. Id. Moreover, the medical evidence of record did not
support a finding of severe limitations on her physical abilities and the claimant’s own testimony
regarding her daily activities did not clearly support a level of limitation that would be wholly
consistent with being disabled. Id. Specifically, the ALJ found that during the hearing, the claimant
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did not answer questions in a forthright manner and instead would talk around questions. Id. The
ALJ also noted that Mains was able to perform self-grooming and personal hygiene activities with
some assistance, complete household chores, prepare meals, wash dishes and do laundry. [Tr. 17].
Though the ALJ states that Mains may not be “symptom free,” a review of the medical evidence
along with observations made and the testimony given at the hearing are “persuasive in regards that
the complaints of pain are not fully credible.” Id.
Therefore, the ALJ supported his findings with substantial evidence that Mains was not
disabled, based on the symptoms she was experiencing from spinal impairments. In regard to this
claim, the ALJ took into consideration Mains’ testimony at the hearing, along with the reports,
statements, and medical records of both examining and treating physicians before making his
decision. [Tr. 11-20]. Upon this review, the ALJ found that Plaintiff’s statements concerning the
intensity, persistence, and limiting effects of her symptoms were not credible, to the extent they were
inconsistent with her residual functional capacity assessment, and that the objective medical
evidence did not support her claims. [Tr. 11-20]. In his written decision, the ALJ noted conflicting
objective medical evidence, considered Mains’ testimony at the hearing, and reviewed the record
in a light most favorable to the Plaintiff. [Tr. 11-20]. The Plaintiff’s claim that there is no evidence
provided at this stage to the contrary are without merit.
B.
The ALJ properly weighed the opinion of the treating physicians.
In her Motion for Summary Judgment, Mains argues that the ALJ erred by discounting the
medical opinion of her treating physician Dr. Arnold. [Record No. 13-1]. According to the Plaintiff,
the ALJ fails to provide any “good reasons” for refusing to give treating physician Dr. Arnold’s
opinion controlling weight and that abject failure suggests that the authoring ALJ failed to properly
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apply the treating physician rule set forth in 20 C.F.R. §404.1527. Id. at 15. In opposition, the
Commissioner correctly maintains that the ALJ complied with the treating physician rule and that
the decision to give less weight to Dr. Arnold’s opinion was supported by substantial evidence.
[Record No. 20].
Throughout the five-step disability evaluation process, the ALJ is charged with the duty to
weigh evidence, resolve material conflicts in testimony, and determine the case accordingly. See
Richardson v. Perales, 402 U.S. 389, 399 (1971). “The Commissioner has elected to impose certain
standards on the treatment of medical source evidence.” Gayheart v. Comm'r of Soc. Sec., 710 F.3d
365, 375-381 (6th Cir. 2013)(quoting Cole v. Astrue, 661 F.3d 931, 937 (6th Cir. 2011)). Set forth
in administrative regulations, these standards describe “(1) the various types of evidence that the
Commissioner will consider, 20 C.F.R. § 404.1512; (2) who can provide evidence to establish an
impairment, 20 C.F.R. § 404.1513; and (3) how that evidence will be evaluated, 20 C.F.R. §
404.1520b.” Gayheart, 710 F.3d at 375. Medical opinions are to be weighed by the process set forth
in 20 C.F.R. § 404.1527(c).
Generally, under the treating physician rule, the ALJ “will” give a treating source’s opinion
controlling weight if it “is well-supported by medically acceptable clinical and laboratory diagnostic
techniques and is not inconsistent with the other substantial evidence in [the] case record.” 20 C.F.R.
§ 404.1527(d)(2). Even so, “[i]t is an error to give an opinion controlling weight simply because
it is the opinion of a treating source if it is not well supported by medically acceptable clinical and
laboratory diagnostic techniques or if it is inconsistent with the other substantial evidence in the case
record.” SSR 96-2p, “Policy Interpretation Ruling Titles II and XVI: Giving Controlling Weight to
Treating Source Medical Opinions,”1996 WL 374188 at *2, 1996 SSR LEXIS 9 at *5 (SSR 1996).
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The Sixth Circuit “has consistently stated that the Secretary is not bound by the treating physician's
opinions, and that such opinions receive great weight only if they are supported by sufficient clinical
findings and are consistent with the evidence.” Bogle v. Sullivan, 998 F.2d 342, 347-48 (6th Cir.
1993).
Importantly, in cases where the ALJ declines to give a treating source’s opinion controlling
weight, however, he must balance the following factors to determine what weight to give it: “the
length of the treatment relationship and the frequency of examination, the nature and extent of the
treatment relationship, supportability of the opinion, consistency of the opinion with the record as
a whole, and specialization of the treating source.” Wilson v. Comm’r of Soc. Sec., 378 F.3d 541,
544 (6th Cir. 2004) citing 20 C.F.R. § 404.1527(d). In addition, the ALJ has a duty to provide good
reasons in the decision for the weight given to a treating source’s opinion. 20 C.F.R. §
404.1527(d)(2). “Those good reasons must be ‘supported by the evidence in the case record, and
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.’” Cole, 661 F.3d at
938 quoting SSR 96-2p, 1996 SSR LEXIS 9 at *11-12, 1996 WL 374188 at *5.
In this case, the ALJ’s decision regarding the weight given to the opinion of Dr. Arnold was
supported by substantial evidence. Dr. Arnold opined that the Plaintiff could lift less than 10
pounds; could sit for fifteen minutes at a time and for less than two hours of an eight hour day; and
could stand/walk for five minutes at a time and less than two hours of an eight hour day. [Tr. 738].
The ALJ, however, attributed less weight to these findings based on a review of various factors. The
ALJ found that, “little weight [should be] accorded to the opinion of Dr. Richard Arnold at Exhibit
32F, that the claimant is essentially precluded from full time work activity as inconsistent with the
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overall objective evidence of the record and the claimant’s testimony regarding her activities.” [Tr.
18]. The ALJ also noted, as cited above, that Dr. Arnold documented conservative treatment for
complaints of neck and back pain, but despite all of this documentation, there was not “a lot of
diagnostic expertise being applied at these visit, nor [was] there any significant therapeutic decisionmaking at these evaluations.” [Tr. 16]. The ALJ found that, “every visit look[ed] the same, in terms
of documentation and medical care, and no significant changes were introduced.” Id.
Instead, the ALJ chose to accord greater weight to the State physical consultants’ findings
that the claimant was limited to a range of light work. [Tr. 18]. The ALJ found that these findings
were, “generally supported by the narrative explanation and citation to the evidence of record.” Id.
The ALJ also noted that he granted some benefit of the doubt to the Plaintiff in regard to her
subjective allegations, but overall found that the State agency consultants conducted “a thorough
evaluation of the evidence and offered limitations consistent with the preponderance of the
evidence.” Id. Although these State agency consultants were not examining physicians, “their
opinions [were] not entitled to controlling weight, but must be considered and weighed as those of
highly qualified physicians and psychologists who are experts in the evaluation of the medical issues
in disability claims under the Social Security Act (SSR 96-6p).” Id.
Thus, when viewing the entire record, this Court finds that substantial evidence supported
the ALJ’s decision to assign little weight to Dr. Arnold’s findings. Substantial medical evidence
exists indicating that Mains was not physically impaired as Dr. Arnold’s determination indicated.
The substantial evidence was provided for in the record and reflects that Mains has been able to
handle her own hygiene and do light household work. The ALJ noted the claimant’s unreliable
testimony and the fact that other evaluating physicians did not share Dr. Arnold’s conclusions before
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making his final decision. Put simply, there was sufficient evidence upon which a reasonable person
could accept as adequate the decision to discount the opinion of Dr. Arnold. As the Plaintiff has
failed in her burden of presenting colorful claims of error, the undersigned finds that her motion for
summary judgment be denied.
IV. CONCLUSION
For the foregoing reasons, it is ORDERED that the Plaintiff’s Motion for Summary
Judgment [Record No. 13] be DENIED, the Defendant Commissioner’s Motion for Summary
Judgment [Record No. 20] be GRANTED, and that Judgment be entered affirming the final decision
of the Commissioner.
Signed June 10, 2014.
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