Bala v. SSA
MEMORANDUM OPINION & ORDER: (1) The decision of the Commissioner is found to be supported by substantial evidence and is hereby AFFIRMED; (2) Plaintiff's Motion for Summary Judgment (Doc. # 13 ) is hereby DENIED; (3) Defendant's Motion for Summary Judgment (Doc. # 15 ) is hereby GRANTED; and (4) A Judgment in favor of Defendant Commissioner will be entered contemporaneously herewith. Signed by Judge David L. Bunning on 5/11/2017.(RBB)cc: COR
UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF KENTUCKY
CIVIL ACTION NO. 16-129-DLB
RAYMOND LEONARD BALA
MEMORANDUM OPINION & ORDER
NANCY A. BERRYHILL, Acting
Commissioner of Social Security
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Plaintiff brought this action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3) to
obtain judicial review of an administrative decision of the Commissioner of Social
Security. The Court, having reviewed the record and for the reasons set forth herein, will
affirm the Commissioner’s decision.
FACTUAL AND PROCEDURAL BACKGROUND
Plaintiff filed an application for Disability Insurance Benefits (DIB) on July 22, 2013,
alleging disability beginning May 25, 2013. (Tr. 10). Plaintiff’s application for DIB was
denied on October 22, 2013. Id. Plaintiff appealed, and his Request for Reconsideration
was denied on January 22, 2014. Id. Plaintiff then filed a Request for Hearing by
Administrative Law Judge. Id. On April 14, 2015, Administrative Law Judge (ALJ) Don
C. Paris ruled that Plaintiff was not entitled to DIB. Id. The decision became final on May
14, 2016, when the Appeals Council denied review of Plaintiff’s claim. (Tr. 3-6). On June
28, 2016, Plaintiff filed suit in this Court. (Doc. # 2). The parties then filed Cross-Motions
for Summary Judgment, which are now ripe for review. (Docs. # 13 & 15).
Overview of the Process
Judicial review of the Commissioner’s decision is restricted to determining whether
it is supported by substantial evidence and was made pursuant to proper legal standards.
See Colvin v. Barnhart, 475 F.3d 727, 729 (6th Cir. 2007). “Substantial evidence” is
defined as “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.” Cutlip v. Sec’y of Health & Human Servs., 25 F.3d 284, 286 (6th Cir. 1994).
Courts are not to conduct a de novo review, resolve conflicts in the evidence, or make
credibility determinations. Id. Rather, the Court must affirm the Commissioner’s decision
if it is supported by substantial evidence even if the Court might have decided the case
differently, Her v. Comm’r of Soc. Sec., 203 F.3d 388, 389-90 (6th Cir. 1999), and even if
there is evidence favoring Plaintiff’s side, Listenbee v. Sec’y of Health & Human Servs.,
846 F.2d 345, 349 (6th Cir. 1988). Similarly, an administrative decision is not subject to
reversal merely because substantial evidence would have supported the opposite
conclusion. Smith v. Chater, 99 F.3d 780, 781-82 (6th Cir. 1996).
To determine disability, the ALJ conducts a five-step analysis. Step One considers
whether the claimant can still perform substantial gainful activity; Step Two, whether any
of the claimant’s impairments, alone or in combination, are “severe”; Step Three, whether
the impairments meet or equal a listing in the Listing of Impairments; Step Four, whether
the claimant can still perform past relevant work; and Step Five, whether a significant
number of other jobs exist in the national economy that the claimant can perform. For the
last step, the burden of proof shifts from the claimant to the Commissioner to identify “jobs
in the economy that accommodate [Plaintiff’s] residual functional capacity.” See Jones v.
Comm’r of Soc. Sec., 336 F.3d 469, 474 (6th Cir. 2003); see also Preslar v. Sec’y of
Health & Human Servs., 14 F.3d 1107, 1110 (6th Cir. 1994).
The ALJ’s Determination
At Step One, the ALJ found that Plaintiff has not engaged in substantial gainful
activity since May 25, 2013, the alleged onset date. (Tr. 12). At Step Two, the ALJ
determined that Plaintiff has the following severe impairments: history of compression
fractures of the thoracic and lumbar spine, and degenerative disc disease of the lumbar
spine. Id. At Step Three, the ALJ concluded that Plaintiff does not have an impairment
or combination of impairments that meets or medically equals one of the listed
impairments in 20 C.F.R. § 404, Subpart P, Appendix 1. (Tr. 14).
At Step Four, the ALJ found that Plaintiff possesses the residual functional capacity
(RFC) to perform medium work, as defined in 20 C.F.R. § 404.1567(c), with the following
[Plaintiff] can lift and carry 50 pounds occasionally and 25 pounds
frequently. He can stand/walk six hours, and walk six hours, out of an eighthour workday. He can climb ramps, stairs, ladders, ropes, or scaffolds no
more often than frequently. He should avoid concentrated exposure to fullbody vibration.
(Tr. 14-20). Based upon this RFC and relying on the testimony of a vocational expert
(VE), the ALJ concluded that Plaintiff was unable to perform his past relevant work as a
maintenance worker/janitor or construction worker. (Tr. 20).
The ALJ proceeded to Step 5 and found that there were a significant number of
jobs in the national economy that Plaintiff could perform. (Tr. 20-21). In making this
conclusion, the ALJ asked the VE whether jobs existed in the national economy for an
individual of claimant’s age, education, work experience, and RFC. Id. The VE testified
that Plaintiff could find work at the medium exertional level as a laundry worker (1,000
jobs in Kentucky, 60,000 nationally), hand packer (15,000 jobs in Kentucky, 1,165,000
nationally), or bagger (2,000 jobs in the state, 160,000 nationally). Id. Based on these
findings, the ALJ concluded that Plaintiff was capable of adjusting to other work and
therefore has not been under a disability, as defined in the Social Security Act, from May
25, 2013 through the date of the decision. (Tr. 21).
Plaintiff alleges two errors in the hearing decision and asks this Court to reverse
the disability determination and remand for immediate payment of benefits or for a new
administrative hearing before a different ALJ. (Doc. # 13-1). Specifically, Plaintiff argues
that the ALJ “improperly failed to assign greater weight to the opinion of [his] treating
physician, Dr. April Hall,” and that “the ALJ’s determination that the Plaintiff is not disabled
is not supported by substantial evidence.” (Doc. # 13-1 at 12-16) (capitalization altered).
Each of Plaintiff’s arguments are targeted at Step 4 of the ALJ’s analysis and can be
characterized as follows: (1) the ALJ erred in weighing the medical opinion testimony,
and (2) the ALJ’s RFC of limited medium work is not supported by the record. These
arguments will be addressed in turn.
The ALJ did not err in weighing the medical opinion testimony.
In social security disability cases, medical evidence may come from treating
sources, non-treating sources, and non-examining sources. 20 C.F.R. § 404.1502. A
treating source is the claimant’s “own physician, psychologist, or other acceptable
medical source who provides [claimant], or has provided [claimant], with medical
treatment or evaluation and who has, or has had, an ongoing treatment relationship with
[claimant].” Id. A non-treating source is an acceptable medical source who has examined
the claimant but does not have an ongoing treatment relationship with him or her, while a
non-examining source has not examined the claimant but provided medical or other
opinion evidence in the case. Id. Plaintiff takes issue with the ALJ’s alleged failure to
accord sufficient weight to the medical opinion testimony provided by Dr. Hall, a treating
A treating source’s opinion is entitled to controlling weight if it is “‘well supported
by medically acceptable clinical and laboratory diagnostic techniques’ and ‘not
inconsistent with the other substantial evidence in the case record.’” Wilson v. Comm’r
of Soc. Sec., 378 F.3d 541, 544 (6th Cir. 2004) (quoting 20 C.F.R. § 404.1527(d)(2)). If
a treating source’s opinion is not entitled to controlling weight, the ALJ must consider the
following factors in order to determine how much weight to give the opinion: (1) the length
of the treatment relationship and the frequency of the examination; (2) the nature and
extent of the treatment relationship; (3) the supportability of the opinion; (4) the
consistency of the opinion with the record as a whole; and (5) the specialization of the
treating source. Id. The ALJ must provide “good reasons” for giving less than controlling
weight to a treating source’s opinion.
20 C.F.R. § 404.1527(d)(2).
decision denying benefits ‘must contain specific reasons for the weight given to the
treating source’s medical opinion, 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.’”
Soc. Sec. Rul. 96-2p, 1996 WL 374188 at *5 (1996).
The “treating physician rule” only applies to medical opinions. While a medical
expert may opine “on issues such as whether [claimant’s] impairment(s) meets or equals
the requirements of any impairment(s) in the Listing of Impairments,” as well as claimant’s
residual functional capacity or the application of vocational factors, such opinions are not
entitled to controlling weight.
See 20 CFR § 404.1527(d)(2) (stating that “the final
responsibility for deciding these issues is reserved to the Commissioner”). “Although the
ALJ may not entirely ignore such an opinion, his decision need only explain the
consideration given to the treating source’s opinion.” Turner v. Comm’r of Soc. Sec., 381
F. App’x 488, 493 (6th Cir. 2010) (citation and internal quotation marks omitted).
Plaintiff argues that the ALJ erred by failing to give Dr. Hall’s opinion, as a treating
source, controlling weight. Dr. Hall opined that Plaintiff “can lift [a] maximum of 20 pounds
at any given time, and 10 pounds frequently,” that he “can stand or walk for a total of two
hours and without interruption for thirty minutes,” that he “can only sit for [a] total of two
hours in an 8 hour day and without interruption for thirty minutes,” that he should “never
climb, balance, stoop, crouch, kneel, [or] crawl,” and that he is “limited in his ability to
reach, push, and pull due to limited range of motion, [paresthesia], pain, and spasms.”
(Doc. # 13-1 at 13-14; Tr. 456-57).
Plaintiff argues that Dr. Hall’s restrictions are
consistent with the medical evidence of record, that Dr. Hall is in the “be[st] position to
make this call,” that she is “very thorough,” and her “records are not cookie cutter.” Id. at
13-14. As a result, Plaintiff asserts, the Commissioner erred as a matter of law in
discounting her opinion. Id.
Contrary to Plaintiff’s claims, the ALJ did not impermissibly reject Dr. Hall’s opinion.
The RFC does not incorporate Dr. Hall’s limitations because the ALJ determined that her
opinion “[wa]s not consistent with the bulk of the objective medical evidence” and
therefore accorded it only limited weight. (Tr. 19-20). By contrast, the ALJ gave greater
weight to the opinion of non-treating consultative examiner Dr. Hill, who observed the
claimant just three months after his accident, and whose opinion was “supported by the
objective medical evidence as a whole.” (Tr. 19).
Indeed, Dr. Hall’s opinion is not consistent with objective evidence in the medical
record. In August 2013, three months after the fall that caused his alleged disability, a
consultative examination by Dr. Hill revealed that Plaintiff had normal posture and gait,
could get up and down off the examination table, had 5/5 strength in his upper and lower
extremities, and could perform activities involving sitting, standing, moving about, and
handling objects. (Tr. 306-08). Dr. Hill opined that “strenuous physical activity such as
lifting, climbing, [and] carrying heavy loads” would be limited due to Plaintiff’s range of
motion, but did not impose limitations as significant as those suggested by Dr. Hall. Id.
Plaintiff rated his pain as a two or three on a one-to-ten scale. Id. Dr. Muffly, an
orthopedic surgeon who saw Plaintiff at his attorney’s request, noted in November of 2013
that Plaintiff had good balance on a single leg, could fully squat and rise, and walked
without a limp despite constant mild back pain and limited range of motion in his lumbar
spine. (Tr. 419-20). He also had normal strength in his arms and legs. Id. The state
agency reviewing physician, Dr. Back, opined that Plaintiff could occasionally lift 50
pounds and frequently lift 25 pounds, could stand, walk, or sit for 6 hours in an 8 hour
workday, and could climb ramps, stairs, ladders, ropes, or scaffolds no more than
frequently. (Tr. 78-80). An MRI in April 2014 also revealed no significant canal stenosis
at Plaintiff’s T12 vertebra and mild degenerative changes at L4-5. (Tr. 427-28).
Dr. Hall’s opinion was also not well-supported by her treatment notes. See 20
C.F.R. § 404.1527(c)(2) (weight given a medical opinion depends upon whether it is “wellsupported by medically acceptable clinical and laboratory diagnostic techniques”). For
example, in August and October 2014, Dr. Hall documented a reduced range of motion,
back pain, and muscle weakness, but included no objective medical support for the
extreme functional limitations she later suggested. (Tr. 446-47, 452; see also Tr. 430
(reduced range of motion in spine and hip in July 2014)).1
In short, the ALJ specifically stated that Dr. Hall’s opinion was not entitled to
controlling weight. (Tr. 19-20). Although Dr. Hall was a treating source, the ALJ found
that her “opinion is not consistent with the bulk of the objective medical evidence.” Id.
Because the ALJ summarized the objective medical evidence, revealing several
inconsistencies between Dr. Hall’s opinions and the overall record, and considered the
factors required by 20 C.F.R. §§ 404.1527(c), he has satisfied the “treating physician”
rule and its “good reasons” requirement. Accordingly, the ALJ engaged in the proper
analysis and reached a conclusion that is supported by substantial evidence, and the
Court finds no error in his treatment of Dr. Hall’s opinion.
The ALJ’s RFC assessment is supported by substantial
A RFC is “an administrative assessment of the extent to which an individual’s
medically determinable impairment(s), including any related symptoms, such as pain,
Plaintiff attempts to bolster Dr. Hall’s opinion by arguing that her notes were typed and
straightforward and that she ordered testing. (Doc. # 13-1 at 13-14). That is not enough
to overturn the ALJ’s decision to accord less weight to a medical opinion where, as here,
the opinion is inconsistent with other record evidence and is not well-supported by the
treatment notes. “Even if the evidence could also support another conclusion, the decision
of the Administrative Law Judge must stand if the evidence could reasonably support the
conclusion reached.” Her v. Comm’r of Soc. Sec., 203 F.3d 388, 389-90 (6th Cir. 1999).
may cause physical or mental limitations or restrictions that may affect his or her capacity
to do work-related physical and mental activities.” Soc. Sec. Rul. 96-8p, 61 Fed. Reg.
34,474, 34,475 (Jul. 2, 1996). Put another way, the RFC is “what an individual can still
do despite his or her limitations.” Id. “In assessing the total limiting effects of [the
claimant’s] impairment(s) and any related symptoms, [the ALJ] will consider all of the
medical and nonmedical evidence” in the record. 20 C.F.R. § 404.1545(e). The ALJ is
only required to incorporate those limitations that she finds credible in the RFC
assessment. Irvin v. Social Sec. Admin., 573 F. App’x 498, 502 (6th Cir. 2014) (citing
Casey v. Sec’y of Health & Human Servs., 987 F.2d 1230, 1235 (6th Cir. 1993)).
Plaintiff broadly alleges that the ALJ erred by failing to find him disabled because
there is not substantial evidence for the ALJ’s RFC determination, and because “the
combined effects of [Plaintiff’s] physical and mental impairments reflect that he could not
perform a wide range of even sedentary work on a regular and sustained basis.” (Doc. #
13-1 at 14-15). Plaintiff also argues that the ALJ did not “consider the totality of evidence
in the record.” Id. That argument, a conclusory assertion of disability, fails.
At Step Four of the analysis, the ALJ carefully reviewed the entire record and found
that Plaintiff was capable of doing medium work with the limitations specified. (Tr. 1420). The ALJ went through the objective medical evidence and explained why he gave
great weight to the opinions of the consultative examiners, some weight to the opinion of
the orthopedic surgeon, and little weight to the opinion of the treating physician Dr. Hall.
The ALJ also properly discounted Plaintiff’s subjective symptoms to the extent they lacked
credibility. Because the ALJ incorporated the limitations that he found credible into the
RFC and properly weighed the medical opinion testimony, there is no error. Accordingly,
substantial evidence supports the ALJ’s determination that Plaintiff was not disabled.
For the reasons stated herein, IT IS ORDERED as follows:
The decision of the Commissioner is found to be supported by substantial
evidence and is hereby AFFIRMED;
Plaintiff’s Motion for Summary Judgment (Doc. # 13) is hereby DENIED;
Defendant’s Motion for Summary Judgment (Doc. # 15) is hereby
A Judgment in favor of Defendant Commissioner will be entered
This 11th day of May, 2017.
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