KORNECKI v. COMMISSIONER OF SOCIAL SECURITY
Filing
12
OPINION fld. Signed by Judge Claire C. Cecchi on 9/23/14. (sr, )
NOT FOR PUBLICATION
UNITED STATES DISTRICT COURT
DISTRICT OF NEW JERSEY
JOSHUA KORNECKI,
Civil Action No.: 2:1 3-cv-0440 1 (CCC>
Plaintiff.
OPINION
V.
CAROLYN W. COLWN,
Acting Commissioner of Social Security,
Defendant.
CECCHI, District Judge.
1.
INTRODUCTION
Joshua Komecki (“Plaintiff’) appeals the final determination of the commissioner of the
Social Security Administration (“Commissioner” or “Defendant”) denying Plaintiff disability
S
5
benefits under the Social Security Act. The Court has jurisdiction under 42 U.S.C. § 405(g) and
1383(c)(3). This motion has been decided on the written submissions of the parties pursuant to
Federal Rule of Civil Procedure 78.1 For the reasons set forth below, the decision of the
Administrative Law Judge (the “AU”) is affirmed.
II.
BACKGROUND
A.
Procedural History
Plaintiff applied for disability insurance benefits (“DIB’) under Title II from the Social
‘The Court considers any arguments not presented by the parties to be waived. çç
Brennerv. Local 514, United Bhd. of Carpenters & Joiners, 927 F.2d 1283, 1298 (3d Cir. 1991)
(“It is well established that failure to raise an issue in the district court constitutes a waiver of the
argument.”).
Security Administration (“SSA”) on July 27. 2009. (R. 131-139.) Plaintiff alleged disability
beginning on April 1, 2009. (R. 133.) Plaintiff originally claimed that a heart attack, open heart
surgery, post traumatic stress disorder (PTSD”). anxiety, and depression limited his ability to
work. (R. 151.) On appeal, Plaintiff added fatigue, dizziness, and back, neck, chest, and shoulder
pain. (R. 179.) His claim was denied initially on October 21. 2009 (R. 73-77), and denied upon
reconsideration on May 19, 2010. (R. 81-83.) The AU held a hearing in this matter on July 13,
2011. (R. 37.) In a written opinion dated September 20, 2011, the AU determined that Plaintiff
was not disabled, (R. 17-36.) The Appeals Council denied review on April 5, 2013, rendering the
AU’s decision the final judgment of the commissioner. (R. 7-12.) Plaintiff timely filed this
action.
B.
Personal and Employment Background
Plaintiff was 33 years old at the onset of his alleged disability. (R. 133.) He received a
Bachelor of Arts in Accounting at Brooklyn College in May of 1999 and a Juris Doctor at
Hofstra School of Law in June of 2006. (R. 49, 191.) Plaintiff worked as an accountant with
various firms. (R. 50-51, 191-192.) He alleged that he had his heart injury while he was working
as a senior associate at PricewaterhouseCoopers LLP (“PWC”). (R. 51.) He then went on shortterm disability at PWC. but was not able to receive long-term disability. (R. 52.)
The Vocational Expert at Plaintiffs hearing before the AU characterized Plaintiffs past
fifteen years of work as an accountant as sedentary and highly skilled. (R. 64-65.)
C.
Medical Background
Plaintiff alleges that his disability stems from his heart attack when he was 3 i. (R. 53,
62.) He claims that panic attacks, tightness in his chest, shortness of breath, fatigue, dizziness,
and pain in his back, neck, chest, and shoulder limit his ability to work. (R. 151, 179.) He also
2
claims that he is limited by PTSD, anxiety, and depression. (R. 151.) At the hearing before the
AU, Plaintiff testified that if he has any type of pain or breathing issues, he thinks he is having a
heart attack and it is difficult for him to focus. (R. 62.) He then testified that he lacks focus at
times and could not be depended to be at work on time. (R. 53.) Plaintiff also claimed that he can
drive, but he does not drive in busy areas because he does not trust himself to drive while on his
pain medication. (R. 52.)
Plaintiff submitted two self-evaluated function reports. The first—dated in August 2009
indicates that he makes light meals, cleans, that he shops, meets friends, and plays with his
children. (R. 161.) He tries to go out three times a week. (R. 163.) The second, dated three
months later in December 2009, indicates almost none of these activities. (R. 342.)
Plaintiffs documentation of his medical issues begins when he was admitted to the
Staten Island University Hospital (“SIUH”) on December 11, 2007. (R. 214.) Plaintiff was
diaguosed with a myocardial infarction. (R. 195, 214.) He was then sent to the emergency
department for emergent cardiac catheterization.
The cardiac catherization revealed an
anomalous left sinus of Valsalva on the right coronary artery. Id. Plaintiff remained at SIUH
2
until December 14, 2007, when he was transferred to NYU Medical Center. (R. 214-215.) There,
Plaintiff underwent heart surgery on December 19, 2007 (R. 270, 442-444) and was discharged
on December 24. 2007. (R. 552.)
On April 22, 2009, Dr. Elivahu Kopstick evaluated an ?vlRl of Plaintiffs thoracic spine.
(R. 303.) Dr, Kopstick noted postoperative changes related to the prior heart surgery.
The
This was explained by the medical expert at Plaintiffs hearing to mean that Plaintiffs
right coronary artery originated in wrong side ofPlaintifPs heart. (R, 41.) This can cause
myocardial infarction, but can be repaired through operation. (R. 41-42.)
3
physician diagnosed a left paracentral disc herniation at T3-T4 without cord or nerve root
compression or fracture. Id.
Plaintiff visited the Overlook Hospital emergency room for chest pain and anxiety on
April 30, 2010. (R. 610, 612.) He claimed that he felt down all day and became very any and
stressed and started to hyperventilate while on the treadmill. (R. 610.) He was examined by Dr.
Robert D. Slama. (R. 611.) Dr. Slama found atypical chest pain, with negative ck and troponin,
hypokalemia unclear etiology, and stress/anxiety disorder in Plaintiff. Id. Dr. Slama
recommended that Plaintiff may be a candidate for cardiac rehab for Plaintiff’s anxiety disorder
and also be in consideration for behavioral therapy. Id. Plaintiff was discharged on May 1, 2010.
(R. 612.)
On November 18, 2010, Plaintiff had a treadmill stress test administered by Dr. Rama K.
Reddy. (R. 606.) During the test, Dr. Reddy reported that Plaintiff underwent 11.1 minutes of
Bruce Protocol and achieved a METS of 12.9. Id. Dr. Reddy’s impression was that the stress test
was negative for any significant ischemia and Plaintiffs ejection fraction and wall motion were
normal.
The medical expert testified that Dr. Reddy’s report indicated that Plaintiff was
capable of light activity. (R. 42.)
Cardiologist Dr. Duccio Baldari filled out two assessments of Plaintiff’s physical
abilities. (R, 350-401.) On a report dated January 8, 2010, Dr. Baldari diagnosed Plaintiff with
coronary artery disease and s/p coronary artery bypass afting. (R. 350.) He then found that
Plaintiff had no chest discomfort or cardiovascular s’nptorns. (R 352.) He also found Plaintiff
capable of lifting only five pounds. standing or walking fhr less than two hours a day. sitting for
less than six hours a day, and limited pushingpulling as well as hearing, speaking. and traveling.
(R. 353.) Tn his other report. Dr. Baldari filled out a cardiac impairment questionnaire dated
4
January 8. 2010. (R. 395.) He found that Plaintiff had symptoms of chest pain, palpitations. and
angina equivalent pain. Id. Dr. Baldari then indicated that Plaintiff can only sit for one hour and
stand/walk for one hour. (R. 398.) He also listed that Plaintiff can never lift, carry, push, pull,
kneel, or bend in a work situation. (R 398-400.) He wrote that Plaintiff will be absent from work
at least once a month and is incapable of even “low stress.” (R. 399.)
On April 26, 2010, Dr. Rambhai C. Patel completed an internal medical examination of
Plaintiff (R. 478-484.) From the physical examination. Dr. Patel reported that Plaintiff had a
regular sinus rhythm without murmur or gallop. (R. 480.) Dr. Patel then found that Plaintiffs
chest x-ray showed no infiltration or pleural effusion. Id. He also found that there was no
pneumothorax and that Plaintiffs heart size was normal. Id. Dr. Patel’s impression was that
Plaintiffs chest was normal. Id.
For Plaintiffs mental capacity, Dr. Stephen J. Wakschal provided several reports that the
AU considered. In the record, Dr. Wakschal took progress notes from individual cognitive
behavioral psychotherapy sessions with Plaintiff from December 29, 2008 until August 4, 2009.
(R. 508-544.) These sessions were performed twice per month. (R. 402.) Dr. Wakschal has also
filled out two psychiatric impairment questionnaires of Plaintiff with one dated December 29,
2008 until January 19, 2010 (R. 402) and the other dated May 25, 2011. (R. 621-628.) In
addition, Dr. Wakschal has filled out two medical reports with one dated November 10, 2009 (R.
341) and the other dated August 31. 2010. (R. 507.)
Plaintiff was referred to Dr. Wakschal for psychotherapy sessions by Staten Island Heart
physician Dr. Homayuni and has reported symptoms of PTSD. (R. 510.) From December 29.
2008 until August 4, 2009, Dr. Wakschal provided psychotherapy sessions twice per month to
Plaintiff and wrote a report after each visit. (R. 402, 508-544.) The intake note written by Dr.
Wakschal reported that Plaintiff was experiencing anxiety, depression, flashbacks, irritability,
impaired concentration, pessimistic thinking, and recurrent dreams of trauma. (R. 511.) Dr.
Wakschal then noted that Plaintiff was found well oriented, alert, his affect was blunted, his
mood was empty, his eye contact was poor, and his speech was halting. Id. Dr. Wakschal also
reported that Plaintiff had normal recent memory, psycho-motor retardation, a preoccupation
with his health, and poor frustration tolerance. Id. Plaintiffs treatment during these sessions
focused on Plaintiffs marital problems, family life, and job searching. (R. 508-544.) In Dr.
Wackschal’s last mental status report of Plaintiff on July 21, 2009, he indicated that Plaintiff was
well orientated, alert, had an anxious and depressed mood, had fair eye contact, had logical and
coherent speech, had normal psycho-motor activity, had denied hallucinations, had an open and
cooperative attitude, and was able to verbalize awareness of problems (but was unable to move
from insight to behavioral change). (R. 542.) Dr. Wakschal also reported that Plaintiff was able
to attend and maintain focus, but was volatile and unpredictable. Id.
In a medical report dated November 10, 2009, Dr. Wakschal noted that Plaintiff has
obsessive compulsive disorder (“OCD”) and developed PTSD secondary to his having
undergone open heart surgery. (R. 341.) Dr. Wakschal reported that Plaintiffs symptoms of
hyper-viligilence. irritability, phobic avoidance, and coitive defects will remain intractable for
the foreseeable future due to Plaintiffs enduring stressors. Id. Dr. Wakschai then reported that
Plaintiff is unable to perform any type of work for a period of twelve months. Id.
On August. 3 i. 2010. Dr. Wakschal filed a report that stated Plaintiff was still
participating in sessions and has been in hs office six times since February 201 o. (R. 507.) Dr.
There are no prowess notes for these further sessions in the record.
6
Wakschal then noted that Plaintiff’s symptoms prevent him from improving his mental status
and that Plaintiff remains unable to work. Id.
Dr. Wakschal tilled out a psychiatric impairment questionnaire at some point after
January 19, 2010. (R. 402.) In the questionnaire, Dr. Wakschal diagnosed Plaintiff with PTSD
and OCD. Id. Dr. Wakschal listed many symptoms such as anxiety, anhedonia, excessive
rumination, and social isolation that demonstrated the diagnosis. (R. 404.) He noted that Plaintiff
was markedly limited in performing activities within a schedule, working in coordination with
others, completing a normal workweek without interruptions from psychologically based
symptoms, interacting appropriately with the general public, asking simple questions, accepting
instructions, getting along with co-workers without distracting them, responding appropriately to
changes in the work setting, and setting realistic goals. (R. 405-407.) He felt that from this,
Plaintiff was incapable of even low stress. (R. 408.)
Dr. Wakschal completed the same questionnaire at some point after May 25, 2011. (R.
621-628.) Here, Plaintiff was diagnosed with PTSD. (R. 621.) There were some clinical findings
4
that demonstrated this diagnosis, but less than the earlier questionnaire. (R. 622.) Dr. Wakschal
found that Plaintiff was capable of low stress work, but likely to be absent from work more than
three times a month as a result of the impairments. (R. 627-628.)
Dr. Joan F. Joynson, a non-examining state agency psychologist, completed a mental
residual functional capacity assessment on October 14, 2009. (R. 337-340.) in this assessment,
Plaintiff was found to have not significant or only’ minor limitations on cognition. (R, 337-338.)
Poor memory, personality change, recurrent panic attacks, anhedonia, and illogical
thinking were not found, unlike in the first questionnaire. (R. 622.)
7
Dr. Joynson then explained that Dr. Wakschal’s progress notes and Plaintiff’s own reports lead
her to the conclusion that Plaintiff can follow complex directions, respond adequately to
supervision, and adapt to workplace changes for simple work. (R. 339.)
Dr. Vasudev Makhija evaluated Plaintiff at the request of the Social Security
Administration on April 13. 2OlC. (R. 473.) Dr. Makhija noted that Plaintiff claimed to have had
lost interest in everything. (R. 473-474.) Dr. Makhija also reported that Plaintiff claims he is
constantly afraid that he is going to have another heart attack, even though doctors told him that
his corrective surgery made another attack unlikely. (R. 474.) Dr. Makhija observed that Plaintiff
appeared to be withdrawn, his mood was anxious and depressed, but he had no thoughts of
suicide. (R. 476.) Dr. Makhija then reported that Plaintiff was alert and oriented, but had
difficulty with serial seven subtractions and could not spell the word “world” backwards after
two attempts. Id. The doctor diagnosed Plaintiff with major depressive disorder, generalized
anxiety disorder, and cognitive disorder (not otherwise specified). Id.
Dr. Jane Shapiro, a non-examining state agency psychologist, completed a mental
residual functional capacity assessment on May 18, 2010. (R. 500-503.) In this assessment,
Plaintiff was only listed as markedly limited in the ability to interact appropriately with the
general public. (R. 501.) Dr. Shapiro considered Dr. Wakschal’s notes from December of 2008
until August of 2009, Dr. Wakschal’s assessment from January 2010, and Dr. Makhija’s mental
status examination in order to fill out the assessment. (R. 502.) Dr. Shapiro noted that Plaintiff is
able to manage only simple instructions, concentrate sufficiently to complete only simple tasks.
respond appropriately to supervision (hut not to the general public), and would do best in a
setting
with minimal need to coordinate with others. Id.
IlL
LEGAL STANDARDS
8
A.
Standard of Review
This court has jurisdiction to review the Commissioner’s decision under 42 U.S.C.
§
405(g) and 1383(c)(3). Courts are not “permitted to re-weigh the evidence or impose their own
factual determinations,” but must give deference to the administrative findings. Chandler v.
Comm’r Soc. Sec., 667 F.3d 356, 359 (3d Cir. 2011); see also 42 U.S.C.
§ 405(g).
Nevertheless,
the Court must “scrutinize the record as a whole to determine whether the conclusions reached
are rational” and supported by substantial evidence. Gober v. Matthews, 574 F.2d 772, 776 (3d
Cir. 1978) (citations omitted). Substantial evidence is more than a mere scintilla, and is “such
relevant evidence as a reasonable mind might accept as adequate to support a conclusion.”
Chandler, 667 F.3d at 359 (citing Richardson v. Perales. 402 U.S. 389, 401 (1971)). If the factual
record is adequately developed, substantial evidence “may be ‘something less than the weight of
the evidence, and the possibility of drawing two inconsistent conclusions from the evidence does
not prevent an administrative agency’s finding from being supported by substantial evidence.”
Daniels v. Astrue, No. 4:08-1676, 2009 WL 1011587, at *2 (M.D. Pa. Apr. 15, 2009) (quoting
Consolo v. Fed. Mar. Comm’n, 383 U.S. 607, 620 (1966)). In other words, under this deferential
standard of review, the Court may not set aside the AU’s decision merely because it would have
come to a different conclusion. Cruz v. Cornm’r of Soc. Sec., 244 F.App’x 475, 479 (3d Cir.
2007) (citing
B.
anflyfel. 181 F.3d 358, 360 (3d Cir. 1999)).
Determining Disability
Pursuant to the Social Security Act, to receive DIB, a claimant must satisfi the insured
status requirements of 42 U.S.C. s 423(c). In order to be eligible for Benefits, a claimant must
show that he is disabled by demonstrating that he is unable to “engage in any substantial gainful
activity by reason of any medically determinable physical or mental impairment which can be
9
expected to result in death or which has lasted or can be expected to last for a continuous period
of not less than twelve months.” 42 U.S.C.
§ 423(d)(1)(A), 1382c(a)(3)(A). Taking into account
the claimant’s age, education, and work experience, disability will be evaluated by the claimant’s
ability to engage in his previous work or any other form of substantial gainful activity existing in
the national economy. 42 U.S.C.
423(d)(2)(A), 1382c(a)(3)(B). Thus, the claimant’s physical
or mental impairments must be “of such severity that 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 the national economy
.
.
.
.“
Id
§ 423(d)(2)(A),
1382c(a)(3)(B). Decisions regarding disability will be made individually and will be “based on
evidence adduced at a hearing.” Sykes v. Apfel, 228 F.3d 259, 262 (3d Cir. 2000) (citing Heckler
v. Campbell, 461 U.S. 458, 467 (1983)). Congress has established the type of evidence necessary
to prove the existence of a disabling impairment by defining a physical or mental impairment as
“an impairment that results from anatomical, physiological, or psychological abnormalities
which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques.”
42 U.S.C.
§ 423(d)(3), l382(a)(3)(D).
The SSA follows a five-step sequential evaluation to determine whether a claimant is
disabled within the meaning of the statute. 20 C.F.R.
§ 404.1520. First, the AU must determine
whether the claimant is currently engaged in gainful activity. Sykes, 228 F3d at 262. Second, if
he is not, the AU determines whether the claimant has a severe impairment that limits his ability
to work. Id. Third, if he has such an impairment, the AU considers the medical evidence to
determine whether the impairment is listed in 20 C.F.R. Part 404. Subpart P. Appendix I (the
“Listings”). If it is. this results in a presumption of disability. Id. If the impairment is not in the
Listings, the AU must determine how much residual functional capacity (“RFC”) the applicant
10
retains in spite of his impairment. Id. at 263. Fourth, the AU must consider whether the
claimant’s RFC is enough to perform his past relevant work. Id. Fifth, if his RFC is not enough,
the AU must determine whether there is other work in the national economy that the claimant
can perform. Id.
The evaluation will continue through each step unless it can be determined at any point
that the claimant is or is not disabled. 20 C.F.R.
§ 404.1 520(a)(4). The claimant bears the burden
of proof at steps one, two, and four, upon which the burden shifts to the Commissioner at step
five. Sykes, 228 F.3d at 263. Neither party bears the burden at step three.
IV.
at 262 n.2.
DISCUSSION
A.
The AU’s RFC Determination Is Supported By Substantial Evidence
When determining Plaintiff’s RFC the AU found that Plaintiff could “lift or carry 20
pounds occasionally and 10 pounds frequently; stand or walk for 6 hours in an eight hour work
day; sit for 6 hours in an eight hour work day; and perform unlimited pushing or pulling within
the weight restriction given.” (R. 24.) Moreover, the AU found that Plaintiff is able to perform
jobs that require no use of ladders, ropes, or scaffolds; that require frequent use of ramps or
stairs; that require occasional balancing, stooping, kneeling, crouching, and/or crawling; and that
require no exposure to unprotected heights, hazards or dangerous machinery, Id. Furthermore.
the AU found that “as to the mental demands of work,
claimant is able to pertbrm jobs: that
are unskilled, and repetitive; that permit at least three breaks during the workdayeach of at least
1 5 minutes duration: that are low stress . .; that require no work in close proximity (closer than
35 feet) to others to avoid distraction; and that require occasional contact with supervisors, co
workers, and no contact with the general pub1ic” (R. 24-25.)
Plaintiff contends that the AU erred in its determination of Plaintiffs RFC by (1) not
11
following the treating physician rule and (2) not properly evaluating Plaintiff’s credibility. (P1.
Br. 17-22, 22-26.) The court addresses each in turn.
1.
The Treating Physician Rule
The so-called ‘treating physician rule’ states that the AU
should give a treating
physician’s opinion regarding the severity of an alleged impairment “controlling weight” if the
opinion “is well-supported by medically acceptable clinical and laboratory diagnostic techniques
and is not inconsistent with other substantial evidence.” 20 C.F.R.
§ 404.1527(c)(2)(2012); see
also Fargnoli v. Massanari, 247 F.3d 34, 43 (3d Cir. 2001).
Plaintiff sets forth two arguments for why the AU failed to properly follow the treating
physician rule. First, Plaintiff alleges that the AU erred by not giving treating psychologist Dr.
WakschaFs opinions controlling weight. (P1. Br. 21.) Second, Plaintiff argues that the AU erred
by not evaluating Dr. Wakschal’s opinion according to the factors set forth in 20 CFR
§*
404.1527(c)(2)-(6) and SSR 96-2p. (P1. Br. 21-22.) The Court finds neither argument persuasive.
a)
The AU Properly Found that Dr. Wakschal’s Opinion Is Not
Controlling
Plaintiff argues that because the opinions from treating psychologist Dr. Wakschal are
supported by appropriate findings and are uncontradicted by substantial evidence, then these
opinions should have been controlling. (P1. Br, 21.) Defendant disagrees, arguing that Dr.
Wakschal’s determination was contradicted by other substantial evidence in the administrative
record. Defendant argues that the AUJ’s reliance on this substantial evidence should not be
disturbed by this Court. The Court agrees.
First, the AU found Dr. Wakschal’s opinions are contradicted by the Plaintiff’s reported
activities of daily living. (R. 29.) it is proper for an AU to consider whether daily activities
12
contradict a treating physician’s opinion. See 20 C.F.R.
§ 404.1529(c)(3); see
Russo v.
Astrue, 421 F.App’x 184. 191 (3d Cir. 2011) (finding that the AU’s decision to not apply
controlling weight to the treating physician’s opinion appropriate where the opinion was
inconsistent with plaintiff’s reported daily activities), Here, the AU
pointed out that Dr.
Wakschal reported Plaintiff had anxiety. anhedonia, excessive rumination, and social isolation.
(R. 27.) However, Plaintiff reported to Dr. Wakschal that his daily activities included driving
long distances, attending social functions, and visiting relatives. (R. 29; 541) Further, the AU
correctly notes that Plaintiff’s first function report indicates relatively normal day to day
activities, including interacting with friends online, shopping, light cleaning and cooking, and
attending synagogue services twice a week. (R. 161-176). Thus, Dr. Wakschal’s opinion is
inconsistent with the reported daily activities of Plaintiff.
The AU’s opinion also contrasts Dr. Wakschal’s opinion with the opinion of state
agency psychologist, Dr. Shapiro. (R. 29.) The opinion notes that while Dr. Shapiro’s
conclusions are well supported, Dr. Wakschal’s “are not supported by the record.” (Id.) When
examining the record, an AU is not foreclosed from relying upon a non-examining physicians
opinion. Moody v. Barnhart, 114 F. App’x 495, 501 (3d. Cir 2004) (citing 20 C.F.R.
§
404.1527(d)). ‘The Regulations allow the AU to rely upon medical opinions and specifically
provide that all evidence from nonexamining sources [is] opinion evidence.” Id. (quoting 20
C.F.R.
§ 404.1 527(f) (reclassified as 20 C.F.R. § 404.1527(e)). When the opinion of a treating
physician conflicts with that of a non-treating. non-examining physician, the AU may choose
whom to credit but “cannot reject evidence for no reason or for the wrong reason.” Morales v.
Apfcl, 225 F.3d 310, 317 (3d Cir. 2000) (citing Plummer y_pfq, 186 F.3d 422, 429 (3d
Cir.l999)). If there are conflicting opinions of psychiatrists dealing with a plaintiffs mental
13
impairment, the non-treating psychiatrist’s opinion may be used as substantial evidence if it
conflicts the treating psychiatrist’s opinion. Brown v. Astrue, 649 F.3d 193, 196-97 (3d Cir.
2011) (“Although there was record evidence from a treating psychiatrist suggesting a contrary
conclusion, the AU is entitled to weigh all evidence in making its finding”).
Here, the AU reported that Dr. Shapiro’s conclusions are consistent with the residual
functional capacity while Dr. Wakschal’s opinions are not. (R. 29.) Dr. Shapiro noted that
Plaintiff is able to manage only simple instructions, concentrate sufficiently to complete only
simple tasks, respond appropriately to supervision (but not to the general public), and would do
best in a setting with minimal need to coordinate with others. (R. 502.)
Plaintiff notes that Dr. Shapiro’s evaluation of the record excluded a medical report and
second questionnaire submitted by Dr. Wakschal. (P1. Br. 17). Plaintiff argues that this renders
Dr. Shapiro’s opinion unreliable. (Id.) However, as noted by Plaintiff, the medical report and
second questionnaire “were not significantly changed from those detailed in the earlier
questionnaire.” (P1. Br. 8). This did not add significant information which would render Dr.
Shapiro’s opinion unreliable. The relevant differences are that the second questionnaire had less
clinical findings for the diagnosis, indicated that the Plaintiff was capable of low stress (as
opposed to the first questionnaire which stated Plaintiff was “incapable of even low stress”), and
specified that Plaintiff was likely to be absent from work more than three times a month as a
result of the impairments. (R. 402-409. 621-628) Thus, Dr. Shapiro’s opinion was based on a
sufficient prior review of the records and the AU was correct in considering and crediting the
findings of Dr. Shapiro. (R. 29.)
Accordingly, the record supports the AU’s holding that Dr. Wakschal’s opinions were
not controlling pursuant to 20 C.F.R. § 404.1527.
14
b)
The AU
Properly Considered the 20 C.F.R.
Factors In Weighing Dr. Wakschal’s
§ 404.1527
Opinion
If the treating physician’s opinion is not given controlling weight, the AU applies the
factors listed in 20 C.F.R.
§ 404.1527(c)(l)-(6) to determine the appropriate weight to give a
medical opinion. The court finds that the AU properly considered these factors in weighing Dr.
5
Wakschal’ s opinion.
The AU
must consider all of the evidence and may weigh the credibility of that
evidence, but must give some indication of the evidence that was rejected and the reasoning for
rejecting it. See Burnett v. Commissioner of Soc. Sec. Admin., 220 F.3d 112, 121 (3d Cir. 2000);
see also Fargnoli, 247 F.3d at 42-44 (remanding the AU’s decision for failure to explain the
weight given to evidence from claimant’s treating physicians). In regards to weighing a nontreating source over a treating source, an AU may reject a treating physician’s opinion on the
basis of contradictory medical evidence, or may accord it more or less weight depending on the
extent to which supporting explanations are provided. Santiago v. Barnhart, 367 F.Supp.2d 728,
736 (E.D. Pa. 2005) (quoting Plummer, 186 F.3d at 429).
The AU’s decision to not accord Dr. Wakschal’s opinions controlling weight was
supported. As set forth in the preceding section, the AU’s found that Dr. Wakschal’s opinions
were inconsistent with the record. The AU specifically noted that Dr. Wakschal’s opinions were
inconsistent with the Plaintiffs reported activities of daily living. visit to the emergency room in
These factors include: (1) examining relationship; (2)(i) length of treatment relationship
and frequency of examination; (2)(ii) nature and extent of the treatment relationship: (3)
supportabillt\ (4) Lons1stenc ot the record (5) specialization of the physician and (6) other
factors, such as any other information which would tend to support or contradict the medical
opinion.
20 C.F.R. § 404.1 527(d)(l)-(6).
15
2010, and Dr. Shapiro’s opinion. (R. 29.) Thus, AU followed the standard set forth in Burnett
and properly supported her decision to give Dr. Wakschal’s opinions little weight. Accordingly,
the AU properly weighed the factors, and her decision is supported by substantial evidence.
2.
The AU Properly Evaluated Plaintiffs Credibility
Plaintiffs final contention is that the AU failed to properly credit Plaintiffs testimony.
(Pa. Br. 22-26.) Plaintiff alleges that the AU did not consider the factors enumerated in SSR 967p prior to making the RFC determination. (P1. Br. 25-26.) Plaintiff claims that ‘[tjhe regulations
at 20 C.F.R.
§ 404.1529(c)(4) instruct the AU to evaluate the consistency of a claimant’s
statements not against the adjudicator’s own RFC finding, as the AU did here, but rather instruct
the AU to compare the claimant’s testimony against the evidence of the record.” (P1. Br. 20.)
In evaluating a claimant’s testimony regarding symptoms and pain, an AL.J must first
determine whether there is a medically determinable impairment that could reasonably be
expected to produce the alleged pain or symptoms. 20 C.F.R.
§ 404.1529. When impairment is
found, a claimant’s statements about their pain and symptoms do not alone establish disability.
20 C.F.R.
§ 404.1529(a); see Bembery v. Barnhart, 142 F.App’x 588, 591 (3d Cir. 2005). The
AU must evaluate a claimant’s subjective statements in relation to the objective evidence and
other evidence. 20 C.F.R.
§* 404.1529(c)(4): Bailey v. Comm’r of Soc. Sec.,
618 (3d Cir. 2009) (“[A]n individual’s statements about symptoms
..
354 F.App’x 613,
must be corroborated by
medical evidence”). When performing this evaluation, in addition to the objective medical
evidence, the AU must assess (1) the individual’s daily activities; (2) the location, duration,
frequency, and intensity of the individual’s pain or other symptoms; (3) factors that precipitate
and agavate the symptoms; (4) medications, treatments, or other measures the claimant takes to
alleviate the symptoms; and (5) any other relevant factors. SSR 96-7p. In making this
16
determination, the AU
is given great discretion and judicial deference. See Bembery, 142
F.App’x at 591. The court finds the AU properly conducted this analysis.
Here, the AU first found that Plaintiffs medically determinable impairments could be
expected to cause the alleged symptoms. (R. 26.) The AU then found that “the claimant’s
statements concerning the intensity, persistence, and limiting effects of these symptoms are not
credible to the extent that they are inconsistent with the above residual capacity assessment.” j4,
In the AU’s examination of the evidence, she found that Plaintiffs reported activity is
inconsistent with his follow-up visits with Dr. Wakschal. (R. 29.) The AU
did not find
Plaintiffs inability to perform concentration exercises with Dr. Makhija indicative of Plaintiffs
functioning. (R. 29.) The AU supported this finding by reporting that Plaintiff was listed to have
intact memory and concentration by Dr. Wakschal’s mental status examination (R. 542),
6
Plaintiff reported a far greater activity level at the hearing, and that Plaintiff was reporting some
alleviation of his symptoms due to the medicine he was taking. (R. 29, 53.) The AU also noted
that plaintiff visited the emergency room for anxiety, but there was no evidence of anxiety by the
time Plaintiff was examined. (R. 29, 610.) Additionally, the AU
examined Dr. Baldari’s
assessments (R. 350-401), Plaintiffs back MRI (R. 303), Plaintiffs tread mill stress test (R.
606), and the internal medical examination performed by Dr. Patel (R. 478-484.)
After
examining the record evidence, the AU determined that “the claimant would certainly have
some degree of limitations in work related social functioning and maintaining persistence and
pace; as a result. I have limited the amount of time he could spend interacting with others, and
The AU stated the mental status examination listing Plaintiff with intact memory and
concentration was in August of 2009, but—in fact—the examination occurred in July of 2009.
(R. 29, 542.)
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_______________________________
also allowed for concentration deficits in his residual functional capacity
assessment.” (R. 29.)
Thus.
the AU
compared the claimant’s testimony against the evidence of the record
and
comported with the applicable standards in determining the credibility of
Plaintiffs testimony as
to his symptoms and pain.
V.
CONCLUSION
For the foregoing reasons, the ALYs decision that Plaintiff is not disabled within the
meaning of the Social Security Act is hereby affirmed. An appropriate order accompanies this
Opinion.
DATED:
—‘—
?-:2
CLAIRE C. CECCHI, U.S.D.J.
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