COOK v. SOCIAL SECURITY ADMINISTRATION COMMISSIONER
REPORT AND RECOMMENDED DECISION re 12 Social Security Statement of Errors/Fact Sheet, 1 Complaint filed by WALLACE F COOK. Objections to R&R due by 11/21/2017. By MAGISTRATE JUDGE JOHN C. NIVISON. (CWP)
UNITED STATES DISTRICT COURT
DISTRICT OF MAINE
WALLACE F. COOK,
NANCY A. BERRYHILL, ACTING
COMMISSIONER, SOCIAL SECURITY
REPORT AND RECOMMENDED DECISION
On Plaintiff Wallace Cook’s application for disability insurance benefits under Title
II and supplemental security income benefits under Title XVI of the Social Security Act,
Defendant, the Social Security Administration Acting Commissioner, found that Plaintiff
has certain medically determinable impairments, but does not have a severe impairment or
combination of impairments. Defendant, therefore, denied Plaintiff’s request for disability
benefits. Plaintiff filed this action for judicial review of Defendant’s final administrative
decision pursuant to 42 U.S.C. § 405(g).
Following a review of the record, and after consideration of the parties’ arguments,
I recommend the Court affirm the administrative decision.
The Administrative Findings
The Commissioner’s final decision is the October 26, 2015, decision of the
Administrative Law Judge (ALJ). (ECF No. 9-2.)1 The ALJ’s decision tracks the familiar
Because the Appeals Council found no reason to review that decision, the Acting Commissioner’s final
five-step sequential evaluation process for analyzing social security disability claims, 20
C.F.R. §§ 404.1520, 416.920.
The ALJ determined that Plaintiff is not disabled at step 2. While the ALJ
recognized medically determinable impairments consisting of status post pituitary tumor,
loss of visual acuity, and degenerative disk disease, the ALJ found that the impairments
are not “severe” for purposes of the disability standard applicable at step 2. (ALJ Decision
¶¶ 3 – 4, R. 16.)
Standard of Review
A court must affirm the administrative decision provided the ALJ applied the correct
legal standards and provided the decision is supported by substantial evidence. This is so
even if the record contains evidence capable of supporting an alternative outcome. MansoPizarro v. Sec’y of HHS, 76 F.3d 15, 16 (1st Cir. 1996) (per curiam); Rodriguez Pagan v.
Sec’y of HHS, 819 F.2d 1, 3 (1st Cir. 1987). Substantial evidence is evidence that a
reasonable mind might accept as adequate to support a finding. Richardson v. Perales, 402
U.S. 389, 401 (1971); Rodriguez v. Sec’y of HHS, 647 F.2d 218, 222 (1st Cir. 1981). “The
ALJ’s findings of fact are conclusive when supported by substantial evidence, but they are
not conclusive when derived by ignoring evidence, misapplying the law, or judging matters
entrusted to experts.” Nguyen v. Chater, 172 F.3d 31, 35 (1st Cir. 1999).
Plaintiff argues that the ALJ erred when he concluded Plaintiff’s impairments were
decision is the ALJ’s decision. (Notice of Appeals Council Action, ECF No. 9-2, R. 1.)
not severe because although the ALJ relied on opinions expressed by Disability
Determination Services consulting physicians in September 2013 (Trumbull, Ex. 1A) and
April 2014 (Lipski, Ex. 5A), after the opinions were issued and before the hearing date,
there were some significant new medical findings. (Statement of Errors at 1 – 2.) In
particular, Plaintiff contends that new findings of venous insufficiency (Ex. 16F) and
polyneuropathy (Ex. 17F), and more recent studies of his degenerative disk disease (Ex.
19F) required additional expert assessment. (Statement of Errors at 3 – 6.) Plaintiff
maintains the ALJ’s error is particularly problematic because a person of his age (61 as of
the October 26, 2015, hearing) and educational background (grade 11), whose skills (selfemployed auto mechanic) do not transfer to other work, is deemed disabled if his residual
functional capacity for substantial gainful activity is limited to light or sedentary work. (Id.
At step 2, although a social security disability claimant must establish that he or she
suffers from a severe condition, the burden is de minimis, designed merely to screen out
groundless claims. McDonald v. Sec’y of HHS, 795 F.2d 1118, 1123 (1st Cir. 1986). The
ALJ may find that an impairment or combination of impairments is not severe only when
the medical evidence “establishes only a slight abnormality or combination of slight
abnormalities which would have no more than a minimal effect on an individual’s ability
to work even if the individual’s age, education, or work experience were specifically
considered.” Id. at 1124 (quoting Social Security Ruling 85–28). In other words, an
impairment is severe if it has more than a minimal impact on the claimant’s ability to
perform basic work activities on a regular and continuing basis. Id. According to
Defendant’s regulations, such activities could include walking or standing for as many as
six hours, while carrying heavy objects, over the course of an eight-hour day, forty hours
per week. 20 C.F.R. §§ 404.1522(a), 404.1545(b); Social Security Ruling 96–8p (“A
‘regular and continuing basis’ means 8 hours a day, for 5 days a week, or an equivalent
work schedule.”). This Court has observed:
There is no hard and fast rule requiring renewed evaluation by a consulting
expert every time a disability claimant experiences new medical events or
obtains new diagnoses in the interval between the initial DDS consultant’s
RFC assessment and the date of the administrative hearing. Particularly
where pain is concerned, an Administrative Law Judge has the unenviable
duty to make a credibility determination, 20 C.F.R. §§ 404.1529(a), (c)(1),
(c)(4), 416.929(a), (c)(1), (c)(4); SSR 96–7p, and the evidence contained in
new medical records may, in some cases, simply dovetail with the credibility
determination. Where the dividing line exists is difficult to determine and
will depend on the particular facts of a case.
Bachelder v. SSA Comm’r, No. 1:09-CV-436-JAW, 2010 WL 2942689, at *6 (July 19,
2010), report and recommendation adopted, 2010 WL 3155151 (D. Me. Aug. 9, 2010).
See also Rose v. Shalala, 34 F.3d 13, 18 (1st Cir. 1994) (“[T]he amount of weight that can
properly be given the conclusions of non-testifying, non-examining physicians will vary
with the circumstances, including the nature of the illness and the information provided the
expert. In some cases, written reports submitted by non-testifying, non-examining
physicians cannot alone constitute substantial evidence, although this is not an ironclad
rule.” (citations and internal quotation marks omitted)).
In this case, Donald Trumbull, M.D., and Marcia Lipski, M.D., determined that
Plaintiff’s impairments are not severe. In forming their opinions, they considered medical
evidence related to Plaintiff’s tumor removal/visual acuity, degenerative disk disease, and
headaches. (Ex. 1A, R. 70; Ex. 5A, R. 87.) Dr. Lipski also considered a lumbar x-ray
report of “mild” degenerative changes, dated April 16, 2014. (R. 88.) Both consultants
reviewed the September 2013 examination findings of David Axelman, M.D. (Ex. 6F),
who assessed severe limitations impacting Plaintiff’s ability to engage in prolonged sitting
or standing, bending, and bearing weight, but they found Dr. Axelman’s assessment to be
Following the assessments by Drs. Lipski and Trumbull, Plaintiff obtained an
evaluation of bilateral foot pain and numbness. In a report dated August 26, 2014, Mona
Li, M.D., found deep venous insufficiency bilaterally and “great saphenous vein venous
insufficiency” on the left. (Ex. 16F, R. 447.) Dr. Li’s plan included “conservative
measures such as rest, elevation, compression stockings, maintenance of weight, exercise,
and avoidance of prolonged standing and sitting.” (Id.) An EMG study was ordered to
explore the possible connection between dysesthesias over the plantar surfaces of both feet
and lumbar degenerative disk disease. (Ex. 17F, R. 454.) On October 1, 2014, Peter
Arabadjis, M.D., reported an abnormal study, which noted that Plaintiff is experiencing
sensorimotor demyelinating and axonal polyneuropathy, most likely due to toxic or
metabolic etiology, with no electrodiagnostic evidence of left lumbosacral plexopathy or
radiculopathy. (R. 455.)
Upon review of an MRI study of Plaintiff’s lumbar spine conducted on December
17, 2014, Mark Piccirillo, M.D., reported that “[m]oderate relative narrowing of the L5-S1
disc is seen in association with erosive endplate bony changes and adjacent reactive
marrow signal abnormalities,” and provided his impression that Plaintiff suffered from
“[m]oderately advanced disc and endplate degenerative changes at L5-S1,” but “[n]o signs
of significant neural encroachment.” (R. 502 – 503.)
According to the ALJ, the medical records generated after the assessments
performed by Drs. Lipski and Trumbull “do not reflect any significant findings that would
support a different decision” than the one endorsed by Dr. Lipski. (R. 18.) In support of
his determination, the ALJ cited chiropractic records from May 2014, in which Plaintiff
reported that one month of treatments had improved his lower back pain by 90 percent (Ex.
21F, R. 564); a provider progress note from December 2014, which note reflected that
Plaintiff is on his knees “a lot” due to his work (Ex. 20F, R. 531); a report of 0 pain in a
treatment note associated with Plaintiff’s presentation for care of pneumonia symptoms
(Ex. 20F, R. 538); and Plaintiff’s testimony that lower extremity neuropathy is pronounced
at night, but not at work; that he had not thrown out his back in two years and has not
returned to the chiropractor; that he is not undergoing active medical treatment for these
conditions; and that his strength is not diminished. Defendant contends the ALJ’s findings
are supported by substantial evidence because none of the diagnostic studies provide
reliable evidence of any degree of functional impairment. (Response at 9 – 11, ECF No.
Plaintiff must demonstrate that the impairments are severe, and must provide
medical evidence regarding the limiting effects of the impairments on which the step 2
challenge is based. LaBonte v. Astrue, No. 2:09-cv-00058-GZS, 2010 WL 2024895, at *2
(D. Me. May 18, 2010). Failure to do so not only undermines a step 2 challenge, but
renders harmless any supposed error. Beaulieu v. Colvin, No. 1:14-CV-00335-DBH, 2015
WL 4276242, at *2 & n.5 (D. Me. July 14, 2015). In other words, even if Plaintiff
establishes that the ALJ erred at step 2, remand is only appropriate if Plaintiff also
demonstrates that had the ALJ not erred, the result would have been different. Bolduc v.
Astrue, No. 09-220-B-W, 2010 WL 276280, at * 4 n.3 (D. Me. Jan. 19, 2010).
Plaintiff relies in part on the findings and assessment of Dr. Axelman (Ex. 6F).2 Dr.
Axelman opined that Plaintiff has difficulty with sitting for 30 minutes, standing and
walking. Additionally, Dr. Axelman found that Plaintiff has difficulty bending and “lifting
very small amounts of weight.” (R. 335.) Dr. Axelman’s medical opinion is consistent
with a residual functional capacity for a subset of light work or sedentary work. Dr. Lipski,
however, reviewed Dr. Axelman’s assessment, noted that the assessment “relies heavily on
the subjective report of symptom and limitations provided” by Plaintiff, and concluded that
Dr. Axelman’s assessment did not support a finding that Plaintiff suffered from a severe
physical limitation. (Ex. 5A., R. 90.) Consistent with Dr. Lipski’s opinion, the ALJ gave
“little weight” to Dr. Axelman’s opinion, and found that “Dr. Axelman seemed to have
simply reiterated the claimant’s subjective complaints and the limitations described by the
claimant were not supported by the findings on examination.” (R. 20.)
circumstances, Dr. Lipski’s conclusion constitutes substantial evidence to support the
ALJ’s determination that despite Dr. Axelman’s assessment, Plaintiff did not suffer from
a severe impairment. The issue, therefore, is whether the subsequent reports related to
Plaintiff also cited the treatment records of Richard Bruns, D.C. (Ex. 21F.) Although Dr. Bruns assessed
a 21% disability, he also reported significant improvement with treatment. (Id.) The ALJ’s finding that
Dr. Bruns’s records were not probative of a severe functional limitation (R. 20) was not error.
venous insufficiency, polyneuropathy, and progressive disc disease required the ALJ to
find a severe impairment regardless of Dr. Lipski’s assessment.
The MRI report regarding Plaintiff’s lumbar spine degenerative disk disease does
not provide evidence of limiting effects. In fact, Dr. Piccirillo’s impression could be
regarded as supportive of the ALJ’s finding insofar as Dr. Piccirillo indicated there were
“no signs of significant neural encroachment.” (Ex. 19F, R. 503.) Furthermore, while the
EMG study of Plaintiff’s lower extremities was “abnormal,” Dr. Arabadjis found no
evidence that the lower extremity symptoms were in any way connected to Plaintiff’s
lumbosacral condition. (Ex. 17F, R. 455.) As to Plaintiff’s lower extremities, the EMG
report does not contain an opinion regarding the limiting effects of the findings. Finally,
in the report prepared following her vascular consultation (Ex. 16F), Dr. Li characterized
varicosities as “essentially asymptomatic” (R. 447), denied the presence of symptoms
consistent with venous insufficiency (Id.), and stated that, overall, Plaintiff “is relatively
Given the assessment and given Dr. Li’s conservative
recommendations regarding treatment, the mere fact that she advised against “prolonged
standing and sitting” (R. 447) would not require a different conclusion by or a reassessment
by the ALJ.
In addition, the ALJ reviewed the treatment records generated after Dr. Lipski’s
assessment and reasonably determined that the records did not support an alternative
finding. The ALJ noted, among other evidence, the absence of “any significant findings”
subsequent to Dr. Lipski’s review, that findings in the medical record do not reflect a loss
of strength on muscle testing, the significant improvement of Plaintiff’s symptoms as the
result of a course of chiropractic treatment, and the lack of ongoing active treatment, in
support of his conclusion that Plaintiff did not suffer from a severe impairment. (R. 18 –
20.) The ALJ’s assessment of the medical evidence was reasonable.
In short, the ALJ’s step 2 determination is supported by substantial evidence on the
record. Plaintiff, therefore, cannot prevail on his claim of error.
Based on the foregoing analysis, I recommend the Court affirm the administrative
A party may file objections to those specified portions of a magistrate
judge’s report or proposed findings or recommended decisions entered
pursuant to 28 U.S.C. § 636(b)(1)(B) for which de novo review by the district
court is sought, together with a supporting memorandum, and request for oral
argument before the district judge, if any is sought, within fourteen (14) days
of being served with a copy thereof. A responsive memorandum and any
request for oral argument before the district judge shall be filed within
fourteen (14) days after the filing of the objection.
Failure to file a timely objection shall constitute a waiver of the right to
de novo review by the district court and to appeal the district court’s order.
/s/ John C. Nivison
U.S. Magistrate Judge
Dated this 7th day of November, 2017
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