ROBERSON v. COMMISSIONER OF SOCIAL SECURITY
OPINION. Signed by Judge Madeline C. Arleo on 7/2/15. (gh, )
NOT FOR PUBLICATION
UNITED STATES DISTRICT COURT
DISTRICT OF NEW JERSEY
Civil Action No. 14-218
July 2, 2015
CAROLYN W. COLYIN,
Acting Commissioner of Social Security,
UNITED STATES DISTRICT JUDGE.
Before this Court is Plaintiff James Roberson’s (“Plaintiff’) request for review, pursuant
to 42 U.S.C.
§ 1383(c)(3), 405(g), of the Commissioner of Social Security Administration’s
(“Commissioner”) denial of Plaintiff’s applications for Disability Insurance Benefits and
Supplemental Security Income Benefits (collectively, “Disability Benefits”).
that the Commissioner’s decision was not supported by substantial evidence, For the reasons set
forth in this Opinion, the Court finds that the Commissioner’s decision is supported by
substantial evidence. Accordingly, the Commissioner’s decision is AFFIRMED.
STANDARD OF REVIEW AND APPLICABLE LAW
A. Standard of Review
This Court has jurisdiction to review the Commissioner’s decision under 42 U.S.C.
§ 405(g). This Court must affirm the Commissioner’s decision if there exists substantial
evidence to support the decision. 42 U.S.C.
§ 405(g); Markie v. Bamhart, 324 F.3d 182, 187 (3d
Cir. 2003). Substantial evidence, in turn, “means such relevant evidence as a reasonable mind
might accept as adequate.”
Ventura v. Shalala, 55 F.3d 900, 901 (3d Cir. 1995).
differently, substantial evidence consists of “more than a mere scintilla of evidence but may be
less than a preponderance.” McCrea v. Comm’r of Soc. Sec., 370 F.3d 357, 360 (3d Cir. 2004).
“[T]he substantial evidence standard is a deferential standard of review.”
Barnhart, 364 F.3d 501, 503 (3d Cir. 2004). Accordingly, the standard places a significant limit
on the district court’s scope of review: it prohibits the reviewing court from “weigh[ing] the
evidence or substitut[ing] its conclusions for those of the fact-finder.” Williams v. Sullivan, 970
F.2d 1178, 1182 (3d Cir. 1992). Therefore, even if this Court would have decided the matter
differently, it is bound by the AU’s findings of fact so long as they are supported by substantial
evidence. Hagans v. Comm’r of Soc. Sec., 694 F.3d 287, 292 (3d Cir. 2012) (quoting Fargnoli v.
Massanarj 247 F.3d 34, 35 (3d Cir. 2001)).
In determining whether there is substantial evidence to support the Commissioner’s
decision, the Court must consider: “(1) the objective medical facts; (2) the diagnoses of expert
opinions of treating and examining physicians on subsidiary questions of fact; (3) subjective
evidence of pain testified to by the claimant and corroborated by family and neighbors; and (4)
the claimant’s educational background, work history, and present age.” Blalock v. Richardson,
483 F.2d 773, 776 (4th Cir. 1973).
B. The Five-Step Disability Test
In order to determine whether a claimant is disabled, the Commissioner must apply a
five-step test. 20 C.F.R.
404.1520(a)(4). First, it must be determined whether the claimant is
currently engaging in “substantial gainful activity.” 20 C.F.R.
404.1 520(a)(4)(i). “Substantial
gainful activity” is defined as work activity, both physical and mental, that is typically performed
for either profit or pay. 20 C.F.R.
§ 404.1572. If it is found that the claimant is engaged in
substantial gainful activity, then he or she is not disabled and the inquiry ends. Jones, 364 F.3d
at 503. If it is determined that the claimant is not engaged in substantial gainful activity, the
analysis moves on to the second step: whether the claimed impairment or combination of
impairments is “severe.”
§ 404.1520(a)(4)(ii). The regulations provide that an
impairment or combination of impairments is severe only when it places a significant limit on
the claimant’s “physical or mental ability to do basic work activities.” 20 C.F.R.
If the claimed impairment or combination of impairments is not severe, the inquiry ends and
benefits must be denied. Id.; Ortega v. Comm’r of Soc. Sec., 232 F. App’x 194, 196 (3d Cir.
At the third step, the Commissioner must determine whether there is sufficient evidence
showing that the claimant suffers from a listed impairment or its equivalent.
404.1 520(a)(4)(iii). If so, a disability is conclusively established and the claimant is entitled to
benefits. Jones, 364 F.3d at 503. If not, the Commissioner must ask at step four whether the
claimant has residual functional capacity (“RFC”) such that he is capable of performing past
relevant work; if that question is answered in the affirmative, the claim for benefits must be
Ji Finally, if the claimant is unable to engage in past relevant work, the Commissioner
must ask, at step five, “whether work exists in significant numbers in the national economy” that
the claimant is capable of performing in light of “his medical impairments, age, education, past
work experience, and ‘residual functional capacity.”
Jones, 364 F.3d at 503. If so, the claim for benefits must be denied. The claimant bears the
burden of establishing steps one through four, while the burden of proof shifts to the
Commissioner at step five. Bowen v. Yuckert, 482 U.S. 137, 146 n.5 (1987).
Under 42 U.S.C.
§ 405(g) and Third Circuit precedent, this Court is permitted to “affirm,
modify, or reverse the [Commissioner’s] decision with or without a remand to the
[Commissioner] for a rehearing.” Podedwomy v. Harris, 745 F.2d 210, 221 (3d Cir. 1984);
Bordes v. Comm’r of Soc. Sec., 235 F. App’x 853, 865—66 (3d Cir. 2007). While an outright
reversal with an order to award benefits is permissible in the presence of a fully developed record
containing substantial evidence that the claimant is disabled, the Court must order a remand
whenever the record is incomplete or lacks substantial evidence to justify a conclusive finding at
one or more of the five steps in the sequential analysis.
$ Podedworny, 745 F.2d at 22 1—22.
A. Procedural History
This case arises out of Plaintiff’s January 2, 2011, application for disability insurance
benefits and May 1, 2012, application for supplemental security income (with a protective filing
date of January 2, 2011). Tr. 121—32, 144. Plaintiff’s disability insurance benefits claim was
denied initially on April 4, 2011, and upon reconsideration on July 14, 2011. Tr. 64—68, 70—72.
Plaintiff sought review before an administrative law judge, and a hearing was held on May 15,
2012, before the Honorable Richard DeSteno (the “AU”). Tr. 81. On June 12, 2012, the AU
issued a decision denying Plaintiffs claim, finding that he was not disabled because there were
“jobs that exist in significant numbers in the national economy” that Plaintiff could perform. $ç
The Appeals Council denied review on November 6, 2013.
exhausted his administrative remedies, Plaintiff then timely filed this action on January 13, 2014.
Dkt. No. 1, Compl.
B. Factual Background
1. Plaintiff’s Work History
Plaintiff is a 54-year-old male who alleged that he became disabled and unable to work
on October 8, 2009.
Tr. 13, 146.
However, Plaintiff has been unemployed since at least
November 11, 2006, due to his incarceration for assault and forgery. Tr. 146, 325, 331. Prior to
his incarceration and the onset of his alleged disability, Plaintiff worked as a corrections officer
and as a boiler operator for the Newark Board of Education. Tr. 18, 147. As a corrections
officer, Plaintiff mostly oversaw inmates working in the kitchen, loaded and unloaded trucks,
and cleaned the kitchen. Tr. 18, 33. He also assisted with prisoner control and would help lift or
carry prisoners and move furniture. Tr. 158. As a boiler operator, Plaintiff took out trash, swept
halls, and set up the gymnasium and multi-purpose rooms of various schools. Tr. 32. Both jobs
required Plaintiff to frequently lift objects that weighed at least twenty-five pounds and included
extended amounts of walking and standing. Tr. 157—58.
In his initial application for disability benefits, Plaintiff claimed to be suffering from
Insulin Dependent Diabetes Mellitus (“IDDM”), kidney dysfunction, high blood pressure,
depression, and panic disorder. Tr. 49. Plaintiff currently lives with his girlfriend and teenage
daughter, and spends most of his time going to the library, to church, or reading the newspaper.
Tr. 160, 164. Although Plaintiff stated that he is able to fold laundry and do the dishes, he
alleges that in his current condition, he is unable to do a vast majority of household chores. Tr.
162. Specifically, Plaintiff states that he can only lift twenty pounds, but infrequently and with
great difficulty, can only walk for about half a mile before needing rest, and has problems
concentrating and remembering to do basic things. Tr. 167, 175. Plaintiff also asserts that he
has trouble sleeping.
$ Tr. 18.
2. Plaintiff’s History of Physical Impairments
Plaintiff has had IDDM for over thirty years, and there is evidence of diabetic neuropathy
resulting in some vision loss.
Tr. 220, 225—26.
On January 18, 2010, Plaintiff was found
unresponsive by his girlfriend and brought to Robert Wood Johnson Hospital where he was
treated for low blood sugar due to “decreased oral intake.” Tr. 206—07. On May 13, 2010,
Plaintiff was brought to Saint Michael’s Medical Center because he had taken insulin but forgot
to eat. Tr. 269. Once he had eaten, however, he denied having any complaints.
8, 2010, Plaintiff was again taken to a hospital because of his low blood sugar after being found
confused on a public bus, Tr. 239; however, after he drank some juice, Plaintiff claimed to feel
better and walked out of the hospital on his own without informing or being examined by
medical staff. Tr. 243. On January 31, 2011, Plaintiff had a “falling out” in front of the library
after taking insulin but forgetting to eat lunch. Tr. 275. Plaintiff had no complaints once he
arrived at the hospital. Id. On both June 20, 2011, and July 12, 2011, Plaintiff was taken to
Saint Michael’s Medical Center because he took more than his normal amount of insulin and
then did not eat anything afterwards. Tr. 422, 429.
Plaintiff also has a history of Chronic Kidney Disease (“CKD”) related to diabetic
nephropathy which has been treated by his nephrologist, Dr. William Chenitz. Tr. 355. A
January 21, 2010, abdominal ultrasound due to an indication of renal insufficiency came back
normal. Tr. 293. It appears, however, that Plaintiff’s CKD has progressively gotten worse: in
August 2010, Plaintiff was noted as having CKD Stage 3 by Dr. Umrana Ahmed. Tr. 248.
August 2011, his disease had progressed to Stage 4. Tr. 48 1—82. Despite renal sonograms
indicating normal or unremarkable findings, Tr. 445, by March 15, 2012, it appeared that
Plaintiff would soon need dialysis access. See Tr. 447, 554. At virtually all consultations with
Dr. Chenitz, Plaintiff either denied having any complaints or reported feeling good or okay. Tr.
466, 470, 481, 494, 501. Plaintiff did complain about back pain in March 2011, but an MRI of
the lumbar spine was unremarkable. Tr. 414.
On April 12, 2010, Dr. Bonito Sanchez wrote a medical assessment letter to the Office of
Disability Adjudication and Review stating that Plaintiff was unable to work due to his IDDM,
hypertensive vascular disease, hyperlipidemia, and diabetic nephropathy and retinopathy. Tr.
Dr. Sanchez did not include any specific limitations in either his letter or in his own
treatment notes. Id. On April 2, 2012, Dr. Teresa Madrid also wrote a letter which was largely
similar to Dr. Sanchez’s; the letter did not include any explanations or specific limitations
resulting from Plaintiff’s condition. Tr. 514. In two separate letters dated March 5, 2012, and
April 2, 2012, Dr. Chenitz stated that Plaintiff’s condition was worsening and that he was being
prepared for renal replacement therapy. Tr. 344, 512.
3. Plaintiff’s History of Mental Impairments
In addition to his physical impairments, Plaintiff also has sought medical treatment for
mental impairments at the Bayonne Community Mental Health Center from April 2010 through
April 2012. Tr. 516. In his initial walk-in visit on April 19, 2010, Plaintiff stated that he was
“depressed all the time” and discouraged as a result of his incarceration which cost him his
careers and tarnished his reputation. Tr. 323, 325. Plaintiff also denied suffering from any
chronic pain or physical/developmental disability. Tr. 324. Plaintiff had no prior psychiatric
treatment and stated that, despite attempts to receive such treatment during his incarceration, he
was never provided mental health services because there were others with “more severe
problems.” Tr. 334. Plaintiff’s prison records do not indicate, however, any attempts to seek
mental health treatment. Tr. 517—49. It was noted that Plaintiff had mild to transient symptoms.
Plaintiff was diagnosed with panic attacks with agoraphobia—first episode—and a major
depressive episode by Raquel Rahim, A.P.N. at his initial psychiatric evaluation.
Plaintiff again was noted as having mild to transient symptoms. Id. Plaintiff had nine total visits
with Ms. Rahim, whose notes are based on Plaintiff’s self-reporting. See Tr. 338—40, 552—54.
At his initial psychiatric evaluation on June 9, 2010, Plaintiff reported “fleeting suicidal
ideation,” Tr. 334, but previously denied having suicidal thoughts at emergency room visits for
his diabetes that occurred during the course of his mental health treatment. Tr. 270, 422, 429.
Plaintiff reported that his condition gradually improved during the course of his mental health
treatment. On August 20, 2010, Plaintiff stated that when he took his medication, he would not
go into “full blown” panic and that he was sleeping better. Tr. 340. On August 3, 2011, Plaintiff
stated that his depression was better but that he still suffered from some anxiety. Tr. 552. On
September 14, 2011, Plaintiff reported that his panic attacks were occurring further apart, that his
sleep was better, and that his depression was okay. Tr. 553. On January 10, 2012, it was also
noted by Ms. Rahim that Plaintiff was in a good mood, positive, and eloquent. Tr. 554. In his
last visit with Ms. Rahim on April 10, 2012, she noted that Plaintiff was mildly anxious but
“overall in good spirits and positive.”
III. THE AU’s DECISION
Following a hearing on May 15, 2012, Tr. 27—43, the AU issued his decision on June 12,
2012, in which he found that Plaintiff was not disabled.
The AU first noted that
Plaintiff had not been engaged in any substantial gainful activity since the alleged onset date of
October 8, 2009. Tr. 15. At step two, the AU found that Plaintiff suffered from the following
medically determinable severe impairments: (I) diabetes; and (2) renal disease.
At step three of the sequential analysis, the AU found that Plaintiff did not have a
medically determinable impairment or combination of impairments that met or medically
equaled a listed impairment in 20 C.F.R. Part 404, Subpart P, Appendix 1 (“Appendix 1”). Tr.
Specifically, the AU measured Plaintiff’s diabetes against the listed requirements for
endocrine disorders in Listing 9.00 and his renal disease against Listings 6.02 and 6.06. Id.
concluding that Plaintiff’s diabetes did not meet or medically equal a listed impairment, the AU
found that the evidence in the record did not make the required showing of long-term
complications associated with his diabetes or establish any “end organ damages rising to listing
The AU concluded that Plaintiff’s renal disease also did not meet the listing
requirements because “the evidence [did] not document the need for dialysis, kidney transplant,
or other requisite findings on testing as required by listings 6.02 or 6.06.”
The AU then determined Plaintiff’s RFC. The AU found that Plaintiff was capable of
performing the full range of light work as defined at 20 C.F.R. 404.1567(b) and 416.967(b),
including: (1) lifting and carrying objects weighing up to twenty pounds; (2) frequently lifting
and carrying objects weighing up to ten pounds; (3) standing, walking, and sitting up to six hours
in an eight-hour day; and (4) pushing and pulling arm and leg controls.
14± Additionally, the
AU found that Plaintiff had no significant non-exertional limitations.
4± In making that
determination, the AU first evaluated Plaintiff’s testimony regarding his subjective feelings of
pain in light of the medical evidence in the record. Tr. 18—19. The AU found, however, that
Plaintiff’s statements concerning the “intensity, persistence, and limiting effects” of his
symptoms were not credible. Tr. 19. The AU noted that MRIs of Plaintiffs lumbar spine were
normal, that abdominal ultrasounds from 2010 “due to indication of renal insufficiency” were
unremarkable, that Plaintiffs nephrologist, Dr. William Chenitz, did not indicate any exertional
limitations in his treatment notes, and that Plaintiffs diabetes related symptoms appeared to stem
from his “history of medical noncompliance.” Id.. Finally, based on Plaintiffs own statements,
the AU concluded that Plaintiffs lack of work appeared to be caused by his incarceration rather
than his medical impairments. j
In so finding, the AU
accorded the opinions of Plaintiffs treating physicians Dr.
Sanchez and Dr. Madrid no weight due to their letters’ insufficient explanation and lack of
support found in the objective medical evidence. Tr. 20. Specifically, the AU rejected Dr.
Sanchez’s opinion because it was “not sufficiently explained” and because it conflicted with the
reports of Dr. Ahmed which indicated that Plaintiff was “feel[ing] OK.” Id. Similarly, the AU
rejected Dr. Madrid’s “declaration of disability” because it was “not supported by more recent
treatment records of Dr. Chenitz.” Id.
Next, the AU considered whether Plaintiff was capable of performing any of his past
relevant work in light of his RFC. The AU concluded that both of Plaintiffs previous jobs, as a
corrections officer and a boiler operator/head custodian required a medium exertional level of
work. j Accordingly, the AU found that Plaintiff could not perform those jobs. j4 At step
five, however, the AU found that in light of Plaintiffs “age, education, work experience, and
RFC, there [were] jobs that exist in significant numbers in the national economy” that he could
perform and that therefore, Plaintiff was not disabled. Tr. 20—21. In reaching that conclusion,
the AU relied heavily upon the Medical-Vocational Guidelines, 20 C.F.R. Part 404, Subpart P,
Appendix 2 (“Appendix 2”) and Social Security Ruling 83-11. Tr. 20. The AU found that
Appendix 2 directed a finding of “not disabled” because Plaintiff was capable of performing
substantially all of the exertional demands of light work, with no non-exertional limitations. Id.
Plaintiff argues that the AU’s decisions at steps two and three, as well as his RFC
assessment, were not supported by substantial evidence. The Court will address each argument
A. The AU’s Step Two Finding
At step two, the AU found that Plaintiffs mental impairments were not severe. Tr. 17.
So long as the AU rules in Plaintiffs favor by finding that any single impairment meets the
severity threshold required at step two, however, any error the AU made in this determination
was harmless. Salles v. Conim’r of Soc. Sec., 229 F. App’x 140, 145 (3d Cir. 2007). Here, the
AU found that Plaintiff had severe impairments involving both diabetes and renal disease. Tr.
15. Therefore, any error that may have been made regarding the severity of Plaintiffs mental
impairments at step two was harmless and is thus not reversible error.
B. The AU’s Step Three Finding
Plaintiff also challenges the AU’s finding at step three that none of Plaintiffs conditions,
either individually or in combination, met or medically equaled a listed impairment.
Specifically, Plaintiff challenges the AU’s determination that Plaintiff did not suffer from renal
disease or nephrotic syndrome as defined in Listings 6.02 or 6.06, respectively. Plaintiff argues
that the AU ignored the letters from Dr. Chenitz stating that Plaintiff would soon need dialysis
and points to the fact that he has recently undergone surgery to receive a shunt necessary for
dialysis treatments as evidence that his conditions meet or medically equal a listed impairment.
The Court disagrees.
The Court camiot reverse or remand an AU’s decision on the basis of additional
evidence that was not before the AU unless such evidence is new, material, and Plaintiff can
show good cause for why it was withheld from the AU initially. Matthews v. Apfel, 239 F.3d
589, 594 (3d Cir. 2001). For evidence to satisfy the materiality requirement, it must not merely
concern evidence of the “subsequent deterioration of [a] previously non-disabling condition.”
Szubak v. Sec. of Health & Human Servs., 745 F.2d 831, 834 (3d Cir. 1984).
In this case, the AU
compared Plaintiffs condition to Listings 6.02 and 6.06 in
To meet Listing 6.02, Plaintiff must have been on dialysis for at least twelve
months or currently be receiving dialysis that is expected to last at least twelve months. 20
C.F.R. Part 404, Subpart P, Appendix 1. Although Dr. Chenitz did indicate in both of his letters
that Plaintiff would eventually need dialysis, at the time the AU rendered his decision Plaintiff
had not received any kind of dialysis treatment, nor did the objective medical evidence reveal an
immediate need for such treatment. See Tr. 36, 302—03, 334, 344, 443, 512, 554. Any future
need for dialysis resulting from the further deterioration of Plaintiffs kidneys could potentially
be grounds for a new disability claim but cannot serve as a basis for finding that the AU’s
decision to deny benefits was not supported by substantial evidence. Similarly, Listing 6.06 for
nephrotic syndrome requires Plaintiff to suffer from anasarca—a general swelling of the body.
20 C.F.R. Part 404, Subpart P, Appendix 1.
As the AU acknowledged, however, there is
nothing in the record that suggests Plaintiff was diagnosed with or complained of symptoms
commonly associated with such a condition. See Tr. 17, 438—5 10.
The AU also found that none of Plaintiffs impairments considered individually or in
combination medically equaled the severity of a listed impairment. Tr. 17. Plaintiff fails to
demonstrate otherwise. Although Plaintiff has been diagnosed with Stage Four CKD, there is no
evidence that Plaintiff has suffered from renal failure or end-organ damage. Tr. 17, 438—510.
At the hearing, the only symptoms Plaintiff claimed to suffer from as a result of his CKD were
shortness of breath and excessive urination. Tr. 36. Although Plaintiff did complain to his
nephrologist of back pain, a subsequent MRI of his lumbar spine was unremarkable. Tr. 414,
Plaintiff has failed to demonstrate how these symptoms match the severity of the
requirements in the listings. Plaintiff has not been hospitalized as a result of his CKD, nor has he
complained of any severe bone pain, high blood pressure or any other physical symptoms
corroborated by objective medical evidence which would medically equal the listing
requirements. The objective medical evidence reveals no complications or symptoms Plaintiff
suffers from that would equal the severity of the conditions required by the listings. Thus, the
Court finds substantial evidence in the record to support the AU’s finding at step three that
Plaintiff’s condition did not meet or medically equal a listed impairment in Appendix 1.
C. The AU’s RFC Determination
As noted above, the AU determined that Plaintiff was capable of performing the full
range of light work with no non-exertional limitations. Tr. 17. Plaintiff argues that the AU’s
RFC assessment was not supported by substantial evidence because the AU failed to consider or
explain the basis for rejecting contrary evidence in the record. The Court disagrees.
An AU must consider all pertinent evidence. Burnett v. Comm’r of Soc. Sec., 220 F.3d
112, 121 (3d Cir. 2000).
While the AU does not need to discuss every piece of evidence
included in the record, he must explain his reasons for discounting contradictory evidence. j4 at
1. Plaintiff’s Subjective Complaints of Pain
Plaintiff argues that the AU failed to properly evaluate his subjective complaints of
pain.’ Again, the Court disagrees.
In assessing whether Plaintiff was disabled, the AU is required to consider Plaintiff’s
subjective complaints of pain. 20 C.F.R.
404.1529, 416.929; Dorfv. Bowen, 794 F.2d 896,
901 (3d Cir. 1986). Plaintiff’s subjective complaints without more, however, are not enough to
establish that Plaintiff is disabled.
Dorf, 794 F.2d at 901.
Plaintiff retains “the burden of
demonstrating that h[is] subjective complaints were supported by medical evidence.” Alexander
v. Shalala, 637 F,2d 968, 972 (3d Cir. 1981). Furthermore, once it has been established by
medical evidence that Plaintiff’s symptoms were caused by a medically determinable
impairment, in order to determine the symptoms’ “intensity, persistence and functionally limiting
effects,” the AU must “make a finding about the credibility of [Plaintiff’s] statements about the
symptom(s) and its functional effects.” SSR 96-’7p, 61 Fed. Reg. 34483, 34484 (July 2, 1996).
In addition, if Plaintiff’s symptoms can effectively be controlled through treatment or
medication, his condition cannot be found disabling. Dearth v. Bamhart, 34 F. App’x 874, 875
(3d. Cir. 2002) (citing Gross v. Heckler, 785 F.2d 1163, 1165-66 (4th Cir. 1986)).
In this case, the AU considered Plaintiff’s subjective complaints and found that although
Plaintiff suffered from impairments that could reasonably be expected to cause his symptoms,
Plaintiff’s complaints regarding their intensity, persistence, and limiting effects were not
The Court finds absolutely no basis upon which to sustain Plaintiff’s claim of bias
against the AU. Plaintiff has alleged no level of misconduct on behalf of the AU but merely
states a disagreement with the AU’s determination of Plaintiffs credibility. Specifically, the
AU’s conclusion that Plaintiff’s lack of work was primarily caused by his incarceration is
supported at numerous points in the record and Plaintiff’s self-reporting, Tr.146, 325, 331, and
there is no evidence to suggest or reason to conclude that the AU’s determination was even
remotely grounded in some level of bias against claimants who have served time in prison or are
substantiated by the objective medical evidence. Tr. 19. This determination is supported by
The medical evidence reveals Plaintiffs complaints of weakness and
passing out from diabetes complications were caused by Plaintiff’s own medical non-compliance
in failing to eat after taking his prescribed medication. See Tr. 206—07, 239—243, 269, 275, 422,
Plaintiffs complaints regarding his CKD are also unsupported by the medical
evidence and Plaintiffs own prior reporting. Although Plaintiff testified at the hearing that his
CKD causes shortness of breath and excessive urination, Tr. 36, the record is devoid of any
documents substantiating Plaintiff’s claim. Tr. 438—5 10. Plaintiff complained of back pain on
one occasion, Tr. 468, but an MRI of his lumbar spine was normal, Tr. 414; at every other
consultation with Dr. Chenitz, Plaintiff reported feeling well. See Tr. 439, 466, 470, 481, 494.
Likewise, Plaintiffs complaints regarding his panic disorder and depression are
inconsistent with the objective medical evidence and Plaintiffs previous statements.
assessing Plaintiffs RFC, the AU clearly considered Plaintiffs mental impairments and found
that those impairments did not create any exertional or non-exertional limitations. Tr. 17. On
two separate occasions, Plaintiff was diagnosed as having only mild to transient symptoms. Tr.
328, 336. Although Plaintiff indicated that he attempted to receive mental health services during
his incarceration, Tr. 334, Plaintiffs prison records do not contain any information on or
indication of Plaintiffs need for mental health services during that time.
Additionally, Plaintiff reported that, while on his prescribed medication, he would not go into
“full blown” panic and was sleeping better. Tr. 340. Furthermore, the most recent records of
Ms. Rahim, who treated Plaintiff at Bayonne, clearly indicate that Plaintiffs depression was
improving and that his panic attacks were less frequent. $çç Tr. 552—54.
2. Treating Physician Opinions
As part of his analysis, the AU must consider Plaintiff’s treating physicians’ opinions.
Adorno v. Shalala, 40 F.3d 43, 47 (3d Cir. 1994). The opinions of treating physicians are given
substantial, and sometimes even controlling, weight. 20 C.F.R. §404.1 527(d)(2); Cotter, 642 F.
2d at 704. The opinions of treating physicians may be rejected outright only if there is clear
contradictory medical evidence. Fouch v. Barnhart, 80 F. App’x 181, 185 (3d Cir. 2003) (citing
Morales v. Apfel, 225 F.3d 310, 317 (3d Cir. 2000)). Such opinions also “may be accorded more
or less weight depending upon the extent to which explanations are provided..
v. Comm’r of Soc. Sec., 507 F. App’x 111, 118 (3d Cir. 2012) (citing Plummer v. Apfel, 186
F.3d 422, 429 (3d Cir. 1999) (quotation omitted)). If there is conflicting medical evidence, the
AU is allowed to choose which source to credit so long as he considers all of the evidence and
provides some reason for discounting the evidence rejected. Fouch, 225 F.3d at 317. Moreover,
the diagnosis of a condition, without more, is not enough to establish disability.
Comm’r of Soc. Sec., 349 F. App’x 805, 808 (3d Cir. 2009) (citing Petition of Sullivan, 904 F.2d
826, 845 (3d Cir. 1990)).
Additionally, disability determinations are reserved to the
Commissioner of the Social Security Administration; statements by doctors or medical experts
that Plaintiff is disabled do not override the conclusions the Commissioner is legally authorized
to make nor do they guarantee or necessitate a finding of disability. 20 C.F.R.
As noted previously, the AU does not need to consider every piece of evidence, and needs only
to provide explanations for why contradictory evidence was rejected. Burnett, 220 F.3d at 122.
Plaintiff argues that the AU ignored the opinions of his treating physicians. The Court
disagrees. The AU did not ignore the opinions of Plaintiff’s treating physicians, but instead
chose to accord them no weight because they were insufficiently explained.
decision is supported by substantial evidence. First, both of the letters from Dr. Sanchez and Dr.
Madrid concerning Plaintiff’s IDDM simply state Plaintiff’s condition and the kinds of doctors
he regularly visits. Neither letter, however, explains the functional effects this condition has on
Plaintiff that could reasonably support the conclusion that Plaintiff is disabled. Tr. 220, 514. In
addition, the conclusions made by Plaintiff’s treating physicians are themselves inconsistent with
the objective medical evidence which shows Plaintiff’s condition could reasonably be controlled
by treatment and medication. See Tr. 206—07, 269, 239—243, 275, 422, 429, 529. Similarly, the
conclusions of Plaintiff’s nephrologist, Dr. Chenitz, are also unsupported by the objective
medical evidence and insufficiently explained. Tr. 344, 512. As the AU noted, Dr. Chenitz’s
own records do not indicate that Plaintiff suffered from any complaints relating to his CKD—
indeed they consistently indicate that Plaintiff was feeling well and had no complaints. Tr. 466,
470, 481, 494, 501. Dr. Chenitz’ s letters simply restate Plaintiff’s diagnosis and mention that
Plaintiff may soon need dialysis, Tr. 344, 512; but, as noted previously, Plaintiff had not
received, nor had he been fitted to receive, any dialysis treatment at the time the AU rendered
his decision. See Tr. 36 (Plaintiff stating that he was being prepared for surgery for shunt to
receive dialysis), 554 (notes from Raquel Rahim dated April 10, 2012, reporting that Plaintiff
stated he may need dialysis in the near future).
Although Plaintiff is correct that the AU did not explicitly consider the statements of Ms.
Rahim, Plaintiff’s treating nurse at Bayonne, Ms. Rahim’s letter cannot fairly be characterized as
contradictory evidence. Ms. Rahim’s letter simply states Plaintiff’s diagnosis, the medication he
was prescribed, and Plaintiff’s need to continue treatment. Tr. 516. Ms. Rahim’s letter does not
contain any conclusions about Plaintiff’s functionality, but instead seems to suggest that
Plaintiff’s symptoms can be controlled through continued treatment.
$ Tr. 516. The letter also
does not mention Ms. Rahim’s own notes which clearly show that Plaintiff’s condition was
improving. See Tr. 340, 516, 553—54. The AU found that the record did not establish any non
exertional limitations caused by Plaintiffs mental impairments and there is nothing in the record
that contradicts this finding. Tr. 20; see Tr. 323—339, 552—54. Because the AU considered
Plaintiff’s mental impairments in his RFC assessment and reached a conclusion that is supported
by the objective medical evidence and Plaintiffs own reporting, the Court declines to disturb the
Because the Court finds that the AU’s decision is supported by substantial evidence, the
Commissioner’s disability determination is AFFIRMED. An appropriate order will follow.
Is Madeline Cox Arleo
HON. MADELINE COX ARLEO
UNITED STATES DISTRICT JUDGE
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