Claymon v. Commissioner of Social Security
Filing
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MEMORANDUM OPINION AND ORDER by Magistrate Judge H. Brent Brennenstuhl on 9/6/2019. IT IS HEREBY ORDERED that the final decision of the Commissioner is AFFIRMED. IT IS FURTHER ORDERED that judgment is GRANTED for the Commissioner. cc: Counsel (CDF)
UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF KENTUCKY
LOUISVILLE DIVISION
CIVIL ACTION NO 3:17-CV-00554-HBB
DANIEL STEVEN CLAYMON
PLAINTIFF
VS.
ANDREW SAUL, COMMISSIONER
SOCIAL SECURITY ADMINISTRATION1
DEFENDANT
MEMORANDUM OPINION
AND ORDER
BACKGROUND
Before the Court is the complaint (DN 1) of Daniel Steven Claymon (APlaintiff@) seeking
judicial review of the final decision of the Commissioner pursuant to 42 U.S.C. § 405(g). Both
the Plaintiff (DN 20) and Defendant (DN 26) have filed a Fact and Law Summary. For the
reasons that follow, the final decision of the Commissioner is AFFIRMED, and judgment is
GRANTED for the Commissioner.
Pursuant to 28 U.S.C. § 636(c) and Fed.R.Civ.P. 73, the parties have consented to the
undersigned United States Magistrate Judge conducting all further proceedings in this case,
including issuance of a memorandum opinion and entry of judgment, with direct review by the
Sixth Circuit Court of Appeals in the event an appeal is filed (DN 17). By Order entered July 17,
1 Andrew Saul is now the Commissioner of Social Security and is automatically substituted as a party pursuant to
Fed.R.Civ.P. 25(d). See also Section 205(g) of the Social Security Act, 42 U.S.C. § 405(g) (action survives
regardless of any change in the person occupying the office of Commissioner of Social Security).
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2018 (DN 18), the parties were notified that oral arguments would not be held unless a written
request therefor was filed and granted. No such request was filed.
FINDINGS OF FACT
Plaintiff protectively filed an application for Disability Insurance Benefits on November 4,
2014 (Tr. 16, 163-69). Plaintiff alleged that he became disabled on November 20, 2012, because
of a heart problem and degenerative disc disease (Tr. 16, 182). Administrative Law Judge Gloria
B. York (AALJ@) conducted a video hearing from Lexington, Kentucky on March 2, 2017 (Tr. 16,
37-39). Plaintiff and her attorney, Ross Ahern, participated from Louisville, Kentucky (Id.).
Christopher Rymond, an impartial vocational expert, also testified during the hearing (Id.).
In a decision dated May 23, 2017, the ALJ evaluated this adult disability claim pursuant to
the five-step sequential evaluation process promulgated by the Commissioner (Tr. 16-30). At the
first step, the ALJ found Plaintiff has not engaged in substantial gainful activity since November
20, 2012, the alleged onset date (Tr. 19). At the second step, the ALJ determined that Plaintiff
has the following severe impairments: a history of cardiomyopathy with Class II congestive heart
failure status post pacemaker placement; neck and low back pain with degenerative disc disease;
and a mild cognitive disorder (Id.). Additionally, the ALJ concluded that Plaintiff=s history of
hernia repair times two, purported seizure disorder, and alcohol use disorder are Anon-severe@
impairments (Tr. 19-20). At the third step, 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 Appendix 1 (Tr. 20).
At the fourth step, the ALJ found Plaintiff has the residual functional capacity (RFC) to
perform a limited range of light work as defined in 20 C.F.R. § 404.1567(b) because he can lift
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and carry twenty pounds occasionally and ten pounds frequently; stand and walk six hours out of
and eight-hour day; sit six hours out of an eight-hour day; and is limited to routine, repetitive tasks
which require only occasional interaction with supervisors and coworkers and no interaction with
the general public in a job which is not fast paced (Tr. 22). Relying on testimony from the
vocational expert, the ALJ found that Plaintiff is unable to perform any of his past relevant work
(Tr. 28).
The ALJ proceeded to the fifth step where he considered Plaintiff=s RFC, age, education,
and past work experience as well as testimony from the vocational expert (Tr. 28-29). The ALJ
found that Plaintiff can perform a significant number of jobs that exist in the national economy
(Id.). Therefore, the ALJ concluded that Plaintiff has not been under a Adisability,@ as defined in
the Social Security Act, from November 20, 2012 through the date of the decision (Tr. 30).
Plaintiff timely filed a request for the Appeals Council to review the ALJ=s decision (Tr.
161-62). The Appeals Council denied Plaintiff=s request for review (Tr. 1-4).
CONCLUSIONS OF LAW
Standard of Review
Review by the Court is limited to determining whether the findings set forth in the final
decision of the Commissioner are supported by Asubstantial evidence,@ 42 U.S.C. § 405(g); Cotton
v. Sullivan, 2 F.3d 692, 695 (6th Cir. 1993); Wyatt v. Sec’y of Health & Human Servs., 974 F.2d
680, 683 (6th Cir. 1992), and whether the correct legal standards were applied. Landsaw v. Sec’y
of Health & Human Servs., 803 F.2d 211, 213 (6th Cir. 1986). ASubstantial evidence exists when
a reasonable mind could accept the evidence as adequate to support the challenged conclusion,
even if that evidence could support a decision the other way.@ Cotton, 2 F.3d at 695 (quoting
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Casey v. Sec’y of Health & Human Servs., 987 F.2d 1230, 1233 (6th Cir. 1993)). In reviewing
a case for substantial evidence, the Court Amay not try the case de novo, nor resolve conflicts in
evidence, nor decide questions of credibility.@ Cohen v. Sec’y of Health & Human Servs., 964
F.2d 524, 528 (6th Cir. 1992) (quoting Garner v. Heckler, 745 F.2d 383, 387 (6th Cir. 1984)).
As previously mentioned, the Appeals Council denied Plaintiff=s request for review of the
ALJ=s decision (Tr. 1-4). At that point, the ALJ=s decision became the final decision of the
Commissioner. 20 C.F.R. §§ 404.955(b), 404.981, 422.210(a); see 42 U.S.C. § 405(h) (finality
of the Commissioner’s decision). Thus, the Court will be reviewing the decision of the ALJ, not
the Appeals Council, and the evidence that was in the administrative record when the ALJ rendered
the decision. 42 U.S.C. § 405(g); 20 C.F.R. § 404.981; Cline v. Comm’r of Soc. Sec., 96 F.3d
146, 148 (6th Cir. 1996); Cotton v. Sullivan, 2 F.3d 692, 695-696 (6th Cir. 1993).
The Commissioner’s Sequential Evaluation Process
The Social Security Act authorizes payment of Disability Insurance Benefits and
Supplemental Security Income to persons with disabilities. 42 U.S.C. §§ 401 et seq. (Title II
Disability Insurance Benefits), 1381 et seq. (Title XVI Supplemental Security Income). The term
Adisability@ is defined as an
[I]nability 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 (12)
months.
42 U.S.C. §§ 423(d)(1)(A) (Title II), 1382c(a)(3)(A) (Title XVI); 20 C.F.R. §§ 404.1505(a),
416.905(a); Barnhart v. Walton, 535 U.S. 212, 214 (2002); Abbott v. Sullivan, 905 F.2d 918, 923
(6th Cir. 1990).
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The Commissioner has promulgated regulations setting forth a five-step sequential
evaluation process for evaluating a disability claim. See AEvaluation of disability in general,@ 20
C.F.R. §§ 404.1520, 416.920. In summary, the evaluation proceeds as follows:
1)
Is the claimant engaged in substantial gainful activity?
2)
Does the claimant have a medically determinable
impairment or combination of impairments that satisfies the
duration requirement and significantly limits his or her
ability to do basic work activities?
3)
Does the claimant have an impairment that meets or
medically equals the criteria of a listed impairment within
Appendix 1?
4)
Does the claimant have the residual functional capacity to
return to his or her past relevant work?
5)
Does the claimant’s residual functional capacity, age,
education, and past work experience allow him or her to
perform a significant number of jobs in the national
economy?
Here, the ALJ denied Plaintiff=s claim at the fifth step.
Plaintiff challenges Finding No. 5 by arguing the RFC determination is not supported by
substantial evidence (DN 20 PageID # 1341-46). Plaintiff explains the ALJ failed to adequately
develop the record with medical opinions addressing his physical/mental limitations and, as a
result, she formulated the RFC based upon her own lay interpretation of the raw medical data (Id.).
Defendant asserts the RFC determination in Finding No. 5 is supported by substantial
evidence in the record and comports with applicable law (DN 26 PageID #1360-64). Defendant
argues the ALJ carefully and thoroughly analyzed the evidence in the record and gave proper
weight to the medical/psychological opinions in the record (Id.).
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The residual functional capacity finding is the Administrative Law Judge=s ultimate
determination of what a claimant can still do despite his or her physical and mental limitations.
20 C.F.R. §§ 404.1545(a), 404.1546. The Administrative Law Judge makes this finding based
on a consideration of medical source statements and all other evidence in the case record. 20
C.F.R. §§ 404.1529, 404.1545(a), 404.1546. Thus, in making the residual functional capacity
finding the Administrative Law Judge must necessarily assign weight to the medical source
statements in the record and assess the claimant’s subjective allegations.
20 C.F.R. §§
404.1527(c), 404.1529.
The Court will first address Plaintiff’s claim that the ALJ failed to fully develop the record
regarding his purported mental impairment and lapses in memory.
At the second step,
notwithstanding medical evidence in the record to the contrary (Tr. 260-68), the ALJ gave Plaintiff
the benefit of the doubt and found he had a mild cognitive disorder that caused more than minimal
limitations in his ability to perform basic work activities (Tr. 19). The ALJ also noted Plaintiff
had been diagnosed with alcohol use disorder but found the impairment not severe (Tr. 20). At
the third step, the ALJ noted neurocognitive testing by Joanne M. Schroeder, Psy.D., revealed
normal attention, memory, concentration, and processing speed despite Plaintiff’s complaints (Id.
citing Tr. 21, 264-66). At the fourth step, the ALJ accurately summarized the reports discussing
the May 2014 psychological examination and June 2014 neuropsychological evaluation by Dr.
Schroeder (Tr. 24, 111-130, 260-68). These reports and evidence regarding Plaintiff’s alcohol
use disorder provide substantial evidence to support the ALJ’s RFC determination that Plaintiff is
“limited to routine, repetitive tasks which require only occasional interaction with supervisors and
coworkers and no interaction with the general public in a job which is not fast paced” (Tr. 22).
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What little medical evidence Plaintiff has cited to substantiate his assertions (see Tr. 330, 355,
375) is misguided because for the most part he is relying on his own subjective statements in the
medical records. What the medical records do indicate is a diagnosis of “Alcohol Use Disorder,
mild,” and it imposes a mild limitation on his occupational and social functioning (Tr. 353, 355).
The medical records also show Plaintiff was not diagnosed with Generalized Anxiety Disorder,
Dysthymia, or a cognitive disorder (see Tr. 353-54). Notably, Plaintiff has not cited, and the
Court has not found, any objective medical evidence in the record supporting Plaintiff’s subjective
complaints of ongoing lapses in memory.
Further, Plaintiff acknowledges Dr. Schroeder’s
conclusion that there was no neurocognitive disorder and the current findings of normal cognition
suggest if there was a prior diagnosis of mild cognitive disorder it was related to temporary factors
(DN 20 PageID # 1342 citing Tr. 266). Additionally, in March 2017, the ALJ agreed to hold the
record open to permit Plaintiff to submit the report from a recent neuropsychological evaluation
(Tr. 68). While Plaintiff did not submit a report, he provided February 2017 notes concerning
the neuropsychological evaluation with clinical findings that substantiate the ALJ’s RFC
determination (see Tr. 25, 1248-55). Viewing the totality of the medical evidence in the record,
there are clinical findings, diagnostic opinions, and functional opinions from examining sources
addressing Plaintiff’s mental impairments, including his purported lapses in memory. In sum,
the ALJ’s findings regarding the limitations imposed by Plaintiff’s purported mental impairment
and lapses in memory are supported by substantial evidence in the record and comport with
applicable law.
The Court will next address Plaintiff’s claim that the ALJ failed to fully develop the record
regarding his physical limitations before making the RFC determination. Plaintiff asserts that
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State Agency medical consultant Dr. Irlandez prepared the only physical assessment in the record.
Plaintiff contends the ALJ inappropriately relied on this assessment because Dr. Irlandez did not
review all the medical evidence in the record and the ALJ failed to indicate she considered this
before assigning weight to his opinion (Id.). For this reason, Plaintiff argues Dr. Irlandez’s
opinion does not constitute substantial evidence to support the ALJ’s RFC determination that he
can perform light work (Id.).
At the second step, the ALJ thoroughly reviewed the evidence in the record and determined
that Plaintiff’s history of cardiomyopathy with Class II congestive heart failure status post
pacemaker placement and his neck and back pain with degenerative disc disease are severe
impairments (Tr. 19). The ALJ also found Plaintiff’s history of hernia repair times two did not
constitute a severe impairment because the condition imposed no more than a slight or minimal
limitation in his ability to perform basic work activities (Id.).
The ALJ also indicated he
considered this condition in assessing Plaintiff’s RFC (Tr. 20). At the third step, the ALJ again
considered the evidence in the record and concluded Plaintiff’s impairments did not meet or equal
Listing 1.04 (disorders of the spine) and Listing 4.02 (chronic heart failure) (Tr. 20). At the fourth
step, the ALJ accurately summarized the evidence in the record regarding these physical
impairments, including Plaintiff’s subjective complaints regarding his symptoms and pain (Tr. 2327). The ALJ noted that treating specialists classified Plaintiff’s heart condition as New York
Heart Association (NYHA) Functional Classification Class III from September 2014 through
January 2015 and no more than NYHA Class II from April 2015 through at least February 2017
(Tr. 23). The ALJ observed that NYHA Class II indicates only mild symptoms with slight
limitation during ordinary activities (Id.). The ALJ also recognized that Plaintiff’s subjective
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complaints about his back and neck conditions were inconsistent with the objective imaging and
clinical findings by treating sources (Tr. 25-26).
The regulations provide that Administrative Law Judges “must consider” the medical
findings of State Agency medical and psychological consultants because they “are highly
qualified” physicians and psychologists as well as “experts in Social Security disability
evaluation.” 20 C.F.R. § 404.1527(e)(2). When a State Agency medical consultant renders an
opinion without having the opportunity to review the complete case record, the Administrative
Law Judge must consider the subsequently submitted evidence in assessing how much weight to
give that source’s opinion. See Kepke v. Comm’r of Soc. Sec., 636 F. App’x 625, 632-33 (6th
Cir. 2016); Blakely v. Comm’r of Soc. Sec., 581 F.3d 399, 409 (6th Cir. 2009).
Plaintiff is correct, Dr. Irlandez’s opinion of March 3, 2015 is the only medical opinion in
the record addressing Plaintiff’s physical limitations (Tr. 90-95).
The ALJ accurately
summarized Dr. Irlandez’s opinion and explained that she gave it “some weight as it is generally
consistent with the record as a whole, such as NYHA Class II classification and largely normal
examination findings” (Tr. 27 citing 249-388 and 1243-57). Notably, the ALJ’s explanation cited
medical evidence received after Dr. Irlandez gave his opinion (see Tr. 1243-57). Thus, the ALJ
indicated that she did consider the subsequently submitted evidence in assessing how much weight
to give Dr. Irlandez’s opinion.
Plaintiff also accuses the ALJ of impermissibly interpreting raw medical data in functional
terms when she made her RFC findings. Certainly, an Administrative Law Judge is not qualified
to interpret raw medical data in functional terms. See Lennon v. Apfel, 191 F.Supp.2d 968, 977
(W.D. Tenn. 2001) (Administrative Law Judge made functional findings based on his own
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interpretation of the treating physician’s findings). But that is not what occurred here. The
ALJ’s decision indicates she had the benefit of Dr. Irlandez’s medical opinion as well as the
opinions of the treating cardiac specialists indicating Plaintiff’s NYHA classification from
September 2014 through January 2015 was Class III and from April 2015 through at least February
2017 it was Class II. In sum, the ALJ’s RFC determination is supported by substantial evidence
in the record and comports with applicable law.
ORDER
IT IS HEREBY ORDERED that the final decision of the Commissioner is AFFIRMED.
IT IS FURTHER ORDERED that judgment is GRANTED for the Commissioner.
September 6, 2019
Copies:
Counsel
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