DRZAL v. COMMISSIONER OF SOCIAL SECURITY
Filing
18
OPINION filed. Signed by Chief Judge Freda L. Wolfson on 03/31/2020. (jmh)
UNITED STATES DISTRICT COURT
DISTRICT OF NEW JERSEY
JOANNE DRZAL,
:
:
:
: Civil Action No. 18-10316 (FLW)
:
: OPINION
:
:
:
:
:
Plaintiff,
v.
ANDREW SAUL,
Acting Commissioner of Social Security,
Defendant.
WOLFSON, United States District Judge:
Joanne Drzal (“Plaintiff”), appeals from the final decision of the Acting Commissioner of
Social Security, Andrew Saul (“Defendant”) denying Plaintiff disability benefits under Tile II
and Title XVI of the Social Security Act (the “Act”). After reviewing the Administrative Record,
the Court finds that the Administrative Law Judge’s (“ALJ”) decision was based on substantial
evidence and, accordingly, it is affirmed.
I.
FACTUAL BACKGROUND AND PROCEDURAL HISTORY
Plaintiff was born on January 10, 1967 and was 46 years old1 on the alleged disability
onset date of November 17, 2013. Administrative Record 16, 25 (hereinafter “A.R.”). Plaintiff
graduated from high school and completed two years of college. A.R. 39. Prior to her alleged
disability, Plaintiff worked as a legal clerk and secretary. A.R. 43
On January 3, 2014 and July 2, 2014, Plaintiff applied for disability insurance benefits
and supplemental security income, respectively, alleging disability beginning on November 17,
1
The regulations of the Social Security Administration state that “[t]he term younger
individual is used to denote an individual 18 through 49.” 20 C.F.R., Part 404, Subpart P,
Appendix 2, § 201(h)(1). As such, at the time of her application, Plaintiff was considered a
younger individual.
1
2013, on the basis of her mental ailments, including post-traumatic stress disorder, depression,
and anxiety. A.R. 16. Plaintiff’s claims were denied on December 8, 2014, and again upon
reconsideration on February 28, 2015. A.R. 16. Thereafter, Plaintiff requested a hearing, which
was held on June 6, 2017, before ALJ Meryl L. Lissek. A.R. 34. The ALJ determined that
Plaintiff was not disabled, and denied her claims for disability insurance benefits and
supplemental security income. A.R. 26-27. Plaintiff requested review by the Appeals Council,
which was denied on April 9, 2018. A.R. 1-4. Thereafter, on June 8, 2018, Plaintiff filed the
instant appeal.
A.
Review of the Medical Evidence2
In a Social Security Disability Psychiatric Report, dated July 7, 2014, Florence Ruth
(“Ms. Ruth”), a licensed clinical social worker (“LCSW”), indicated that she treated Plaintiff on
a weekly basis from February 6, 2013 to July 3, 2014. A.R. 575. Therein, she summarized the
results of a mental status examination from Plaintiff’s last visit, during which Plaintiff was alert
and oriented in all spheres; well-groomed; cooperative; had normal speech, and “good”
concentration, memory, intellect, and judgment; denied suicidal or homicidal ideations; did not
suffer from hallucinations or delusions; and exhibited a neutral mood and anxious affect. A.R.
576.
Ms. Ruth noted that Plaintiff was able to recall three out of three words immediately, and
once again five minutes later; she performed serial fives “well”; she spelled the word “world”
forward and backward; she counted numbers forward and backwards; and she tracked a
conversation. A.R. 576. But, according to Ms. Ruth, Plaintiff’s understanding, memory,
sustained concentration, persistence, social interaction, and abilities to adapt to changes in the
2
The Court notes that numerous pages of the medical record consist of handwritten and
poorly photocopied notes.
2
work setting were all “limited” “due to [her] condition.” A.R. 578. Ms. Ruth diagnosed Plaintiff
with post-traumatic stress disorder, anxiety, depression, and documented symptoms including
fearfulness, chronic fatigue, and panic attacks lasting from 15 to 20 minutes in length. A.R. 57577. Despite these limitations, Ms. Ruth found that, “with considerable effort,” [Plaintiff] takes
care of 8-year-old-son and home, manages money, drives a car, prepares meals and does
shopping.” A.R. 579.
On June 5, 2014, Ashwini Neelgund, M.D., performed an initial psychological evaluation
on Plaintiff, assessing calm and cooperative behavior; fair appearance and grooming; normal
orientation and psychomotor functioning; rapid and pressured speech; anxious mood; appropriate
affect; logical, coherent, circumstantial, and tangential thought processes; and poor insight and
judgment with no delusions, hallucinations, and suicidal/homicidal thoughts. A.R. 581-82. Dr.
Neelgund diagnosed general anxiety disorder, depressive order, “other psychosocial and
environmental problems,” and he rendered a GAF3 score of 45-50. A.R. 582. Notwithstanding
his findings, Dr. Neelgund noted that Plaintiff was not interested in taking “psychiatric
[medication] at this time” or an intensive outpatient treatment, as “she feels that she does not
need higher level of care.” A.R. 583.
On June 24, 2014, Ms. Roth wrote a letter to an unspecified recipient and explained that
she had treated Plaintiff since February of 2013 for “tremendous emotional stress, anxiety,
depression & fatigue[,]” and that “it seems that [Plaintiff] may need ongoing psychotherapy” for
an indefinite period of time. A.R. 633-34. Ms. Roth listed Plaintiff’s “traumatic” experiences,
3
GAF is an acronym that refers to an individual’s score on the Global Assessment of
Functioning Scale. AM. PSYCHIATRIC ASS’N, DIAGNOSTIC AND STATISTICAL
MANUAL OF MENTAL DISORDERS 32 (4th ed. Text Revision 2000). In that connection, the
scale is used as a tool which reflects the “clinician’s judgment of [an] individual’s overall level
of functioning,” in light of a patient’s overall impairments in psychological, social, and
occupational functioning. Id.
3
which included “being a domestic abuse victim,” “a violent crime victim,” “an incest victim,”
and a “Hurricane Sandy/Irene victim.” A.R. 633. As a result, Ms. Roth concluded that Plaintiff
required a one-year leave of absence from her work “to resolve, cope and deal with her personal
life issues,” and she noted that, because Plaintiff “is a newly single parent with an eight-year-old
son,” Plaintiff “has been unable to meet the demands of her personal life with her work life.”
A.R. 633-34.
On July 17, 2014, more than six weeks after her last visit, Dr. Neelgund treated Plaintiff,
but he declined to sign her disability papers, because, as his medical progress notes indicate,
Plaintiff “ha[d] been non-complaint with her treatment recommendations.” A.R. 584. Upon
examination, Plaintiff denied feeling anxious, depressed, manic, having difficulties with
sleeping, obsessive thoughts, changes in her appetite and weight, problems with her memory and
speech, and suffering from headaches, delusions, hallucinations, and suicidal/homicidal thoughts
or ideations. A.R. 584-55. In addition, Plaintiff’s mental status evaluation revealed the following
results: fair appearance; good grooming; cooperative behavior; normal psychomotor functioning;
responsive, talkative, and pressured speech; euthymic mood; appropriate affect; coherent and
circumstantial thought processes; oriented cognition; and poor insight and judgment. A.R. 58485.
In November 2014, Christopher Williamson, Psy.D., performed a mental status
evaluation on Plaintiff at the request of the Administration. A.R. 600. During the evaluation,
Plaintiff reported “ongoing issues of chronic depression and post-traumatic stress disorder,” “a
“longstanding history [of] domestic violence[,]” “issues of incest,” and “panic attacks” resulting
in “heart palpitations, difficulty breathing, and chest tightness,” but she was not taking
4
medication for these issues. A.R. 600. Upon examination, Dr. Williamson rendered the following
observations:
She arrived on time as scheduled. She was casually dressed and
groomed, appearing her stated age. She was cooperative
throughout. She was noticeably guarded. She appeared physically
and emotionally uncomfortable. She was noticeably verbose to the
point where she had pressured speech. . . . There was no evidence
of a formal thought disorder. There was no noted compulsions or
thinking and/or behavior. Her overall mood appeared depressed
and anxious.
A.R. 601. He continued:
She has a history of suicidal ideation but denies any current plan or
intent. . . . She could repeat up to 7 digits forward and 4 digits
backwards. She could complete simple mathematical calculations
of addition and subtraction. Her overall fund of knowledge
appeared to be in the average range. Abstract reasoning appeared
to be intact. She was well oriented to time, place, and person, as
well as recent current events. She could recall 0 out of 3 objects at
5- and 10-minute intervals.
A.R. 602. Based on his evaluation, Dr. Williamson diagnosed Plaintiff with post-traumatic stress
disorder, bipolar disorder (mixed type), and generalized anxiety disorder with panic attacks. A.R.
602. In his concluding remarks, Dr. Williamson noted that Plaintiff is “competent to handle her
own funds[.]” A.R. 602.
On December 2014, Dr. Joan F. Joynson, a State agency medical consultant, conducted
an independent examination of Plaintiff’s medical records. A.R. 84. Dr. Joynson began with a
formal assessment of Plaintiff’s functional limitations, documenting the following observations:
mild difficulties in maintaining social functioning and performing activities of daily living;
moderate difficulties in maintaining concentration, persistence, or pace; no episodes of
decompensation for an extended duration of time. A.R. 84. Dr. Joynson also examined Plaintiff’s
ability to perform mental activities over the course of a normal workday and workweek.
5
According to Dr. Joynson, Plaintiff had no limitations with respect to her understanding or
memory, interacting with coworkers and authorities in the workplace, and adapting to workplace
changes. A.R. 85.
Dr. Joynson also found that Plaintiff was not significantly limited in her capacity to
perform the following tasks: carry out very short and simple instructions; carry out detailed
instructions; maintain attention and concentration for extended periods; perform activities within
a schedule, maintain regular attendance, and be punctual; sustain an ordinary routine without
special supervision; work in coordination with or proximity to others without being distracted by
them; and make simple work-related decisions. On the other hand, Dr. Johnson noted that
Plaintiff was moderately limited in her capacity to perform the following tasks: complete a
normal workday and workweek without interruptions from psychologically-based symptoms and
to perform at a consistent pace without an unreasonable number and length of rest periods. A.R.
86.
In her concluding remarks, Dr. Joynson noted: “[Plaintiff] denies panic attacks or severe
[symptoms] of [post-traumatic stress disorder] and does not want [psychiatric] medications. . . .
[Plaintiff] has a high level of functioning, cares for her 10 year old, pays for someone to mow her
lawn, she shops, manages finances, uses the computer, she is very high functioning. . . .
[Plaintiff] is able to sustain [concentration, persistence, and pace] for simple work functions.”
A.R. 86.
On February 20, 2015, Sharon Flaherty, Ph.D., a second State Agency medical
consultant, conducted an independent review of Plaintiff’s medical records and rendered the
following assessment of Plaintiff’s functional limitations: mild difficulties in performing
activities of daily living; moderate restrictions in maintaining social functioning and maintaining
6
concentration, persistence, or pace; no episodes of decompensation for an extended duration of
time. A.R. 111.
On February 10, 2015, Pauline Nelson, Psy.D., completed a Social Security Disability
Psychiatric Report, wherein she indicated that she treated Plaintiff on three separate occasions.
A.R. 589. The report included the results of Plaintiff’s last mental status examination that Dr.
Nelson performed on November 10, 2014, during which Plaintiff was alert; oriented in all three
spheres; in touch with reality; her mood was euthymic; her affect was anxious and depressed; she
was neatly groomed but fidgeted nervously; her speech was normal; she had “normal to above”
intellect; and she exhibited good judgment. A.R. 590. Dr. Nelson also examined Plaintiff’s
ability to perform certain work related mental activities, and she rendered the following
conclusions: no limitations in adapting to changes in the work place, recognizing hazards,
traveling/using public transportation, setting realistic goals, and making independent plans; and
some limitations in understanding and memory, sustained concentration and persistence, and
engaging in social interactions because of her “worried thoughts.” A.R. 592. Dr. Nelson
diagnosed Plaintiff with generalized anxiety disorder and post-traumatic stress disorder, and she
noted that Plaintiff suffered from “period panic attacks” that could interfere with her functioning,
occurred “when [her] safety is threatened,” and lasted between five and thirty minutes. A.R. 589,
591.
On January 15, 2015, Beth Maguire, LCSW, performed a mental status evaluation on
Plaintiff, during which she exhibited a normal or labile mood; appropriate or sad affect; fair
insight; fair judgment; normal orientation; normal or remote memory; alertness; unremarkable
posture; normal gait; normal motor activities; normal or loose thought processes with normal
thought content; cooperative behavior; spontaneous and verbose speech; and appropriate attire.
7
A.R. 608. Ms. Maguire diagnosed Plaintiff with anxiety, adjustment disorder, and post-traumatic
stress disorder and fatigue. A.R. 611. Plaintiff also agreed to attend weekly group therapy
sessions and indicated that she was “open to possibility of medication and will consult with
psychiatrist.” A.R. 610.
On June 5, 2017, Russell Holstein Ed.D. drafted a letter summarizing his treatment of
Plaintiff stating: “[i]n my treatment of [Plaintiff], she continues to speak about her husband who
has, on more than one occasion, abused her, such that she has gotten a restraining order against
him. However, she is very much against terminating the marriage, in part because [of] her
situation as a single mother with very limited opinion, and without disability money, is
struggling to maintain a household for herself and her son. . . . . The focus on our therapy is on
the damned if you do, and damned if you don’t situation involving her husband . . . . A.R. 642.
Dr. Holstein also noted that, although Plaintiff was experiencing a “difficult psychological
situation” which could result in “prolonged and difficult suffering,” she “was not eager to take
psychoactive medication, as she does not necessarily feel that the medications would help her.”
A.R. 642
In another correspondence, dated June 12, 2017, Dr. Holstein provided the following
explanation: “[i]n [a] previous note, I described the psychological dilemma behind [Plaintiff’s]
current situation involving both anxiety and depression. A.R. 646. “The tension behind the
situation is such that Ms. Drzal is currently unable to work.” A.R. 646. Indeed, according to Dr.
Holstein, “[a]t the present time, [Plaintiff’s] commitment as a single parent to her son, as well as
her desire to try to keep the possibility of a marriage with a very impaired man, prevents her
from really being able to devote her energies to a job. Her sense of preoccupation about her
personal life and her personal situation would preclude her ability to maintain a substantial,
8
gainful employment at the present time.” A.R. 646. However, Dr. Holstein concluded his
correspondence with the following remarks: “[i]t would be my expectation that is she could
achieve some greater stability in life, and when her son is more independent, that a return to
work would certainly not only be possible, but desirable.” A.R. 646.
B.
Review of Testimonial Record
Plaintiff appeared and testified at a hearing in this matter, held on June 6, 2017, before
the ALJ. A.R. 34-62. Plaintiff testified that she was 50 years old, and that she had worked for the
IRS for 25 years, performing clerical, legal assistant, and secretarial work. A.R. 39-40. Plaintiff
alleged that her work consisted of assisting attorneys with “typing assignments, filing, closing
case files, opening case files, working on a computer,” and “assisting analysts.” A.R. 40-42.
Plaintiff stated that, at times, she acted as a supervisor and assigned work to other employees.
A.R. 42.
Plaintiff testified that she would not be able to sustain a job, because she would be
“distracted, unable to concentrate,” and could “complete tasks on occasion” because of her
anxiety and the “thoughts that creep up from [her] past [that] continue to be part of [her] life,”
including her troublesome marriage. A.R. 44. Plaintiff stated that she “need[ed] to take a break.”
A.R. 44.
Plaintiff stated that, starting in February 2017, she received treatment from Dr. Holstein
once a week. A.R. 45. Plaintiff acknowledged that the record did not contain Dr. Holstein’s
treatment notes, and testified that she, instead, submitted a recent “dictated letter [from Dr.
Holstein” that summarized her “situation.” A.R. 45. Plaintiff also admitted that she could not
provide treatment notes from her sessions with Dr. Ganzon in 2013, another provider from whom
9
she sought medical treatment, because those documents were destroyed during Hurricane Sandy.
A.R. 46.
Plaintiff also explained that, before she had found Dr. Holstein, she was “trying to find a
therapist and [she] wasn’t able to find one who took Medicaid who [she] had a good enough
rapport[.]”A.R. As a result, Plaintiff stated that she stopped seeking treatment and, instead, “did
sort of my own type of self-therapy by trying to get support online[.]” A.R .47. In addition to her
treatment for mental health, Plaintiff testified that she sees her “breast surgeon periodically
because [she] was diagnosed with breast cancer and also the hematologist for blood work.” A.R.
47. Plaintiff, nonetheless, clarified that she was “not claiming any exertional limitations.” A.R.
50.
When asked how she felt, Plaintiff stated that she was “better.” A.R. 54. Plaintiff
explained that she was “less afraid” and less anxious. A.R. 55. Plaintiff testified that, although
she suffers from chronic fatigue, she was capable of preparing breakfast for herself and her son,
driving her son to school, food shopping, cleaning the house, doing laundry, spending time on
the computer, and handling her bills A.R. 55-56. Plaintiff alleged that she takes “tamoxifen,” but
no medications for her mental health. A.R. 55. Plaintiff mentioned that she had never been
hospitalized for psychiatric reasons. A.R. 55-56.
C.
ALJ’s Findings
The ALJ issued a written decision, following the hearing, on September 11, 2017, and
applied the standard five-step process to determine if Plaintiff had satisfied her burden of
establishing disability. A.R. 16-32. First, the ALJ found that Plaintiff had not engaged in
substantial gainful activity since November 17, 2013, the alleged onset date, and throughout the
relevant period. A.R. 19.
10
Second, the ALJ found that Plaintiff had the following severe impairments: “posttraumatic stress disorder (domestic violence survivor, violent crime survivor, and hurricane
Sandy victim survivor), anxiety, depression and fatigue. A.R. 19. Third, the ALJ determined that
Plaintiff did not have an impairment or combination of impairments that met or medically
equaled one of the listed impairments in 20 C.F.R. part 404, subpart P, app. 1. A.R. 26-27.
Moreover, in this step, the ALJ considered Plaintiff’s medical impairments under listings 12.04,
12.06, and 12.15, and found that the paragraph B and C criteria for those listings were
unsatisfied. A.R. 19.
Fourth, the ALJ determined that Plaintiff retained the residual function capacity to
perform a full range of work at all exertional levels but with the following nonexertional
limitations: “she can have occasional contact with supervisors and minimal contact with the
general public. She can work in proximity of co-workers but not together with them. She can
work in jobs that do not involve many work related decisions. Based on psychiatric symptoms
and fatigue, the claimant will be off task 5% of an eight hour day and absent one time per
month.” A.R. 20-21.
Fifth, the ALJ found that, taking into consideration Plaintiff’s age, education, work
experience, and residual functional capacity, “there are jobs that exist in significant numbers in
the national economy that the claimant can perform.” A.R. 25. In reaching this determination,
the ALJ relied on the testimony of a vocational expert that an individual with Plaintiff’s age,
education, past relevant work experience, and residual functional capacity could perform the
following representative occupations: Garment Folder DOT# 789.687-066; Labeler DOT#
920.687-126; and Ticket Tagger DOT# 652.685-094, which the vocational expert testified
existed in the regional economy and national economy in the aggregate amount of 280,000. A.R.
11
26.
II.
STANDARD OF REVIEW
On a review of a final decision of the Commissioner of the Social Security
Administration, a district court “shall have power to enter, upon the pleadings and transcript of
the record, a judgment affirming, modifying, or reversing the decision of the Commissioner of
Social Security, with or without remanding the cause for a rehearing.” 42 U.S.C. § 405(g); see
Matthews v. Apfel, 239 F.3d 589, 592 (3d Cir. 2001). The Commissioner’s decisions regarding
questions of fact are deemed conclusive on a reviewing court if supported by “substantial
evidence in the record.” 42 U.S.C. § 405(g); see Knepp v. Apfel, 204 F.3d 78, 83 (3d Cir. 2000).
While the court must examine the record in its entirety for purposes of determining whether the
Commissioner’s findings are supported by substantial evidence, Gober v. Matthews, 574 F.2d
772, 776 (3d Cir. 1978), the standard is highly deferential. Jones v. Barnhart, 364 F.3d 501, 503
(3d Cir. 2004). Indeed, “substantial evidence” is defined as “more than a mere scintilla,” but less
than a preponderance. McCrea v. Comm’r of Soc. Sec., 370 F.3d 357, 360 (3d Cir. 2004). “It
means such relevant evidence as a reasonable mind might accept as adequate.” Plummer v. Apfel,
186 F.3d 422, 427 (3d Cir. 1999). A reviewing court is not “empowered to weigh the evidence
or substitute its conclusions for those of the fact-finder.” Williams v. Sullivan, 970 F.2d 1178,
1182 (3d Cir. 1992), cert. denied, 507 U.S. 924 (1993). Accordingly, even if there is contrary
evidence in the record that would justify the opposite conclusion, the Commissioner’s decision
will be upheld if it is supported by the evidence. See Simmonds v. Heckler, 807 F.2d 54, 58 (3d
Cir. 1986).
Disability insurance benefits may not be paid under the Act unless Plaintiff first meets the
statutory insured status requirements. See 42 U.S.C. § 423(c). Plaintiff must also demonstrate
12
the “inability 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 12 months. . . .” 42
U.S.C. § 423(d)(1)(A); see Plummer, 186 F.3d at 427. An individual is not disabled unless “his
physical or mental impairment or impairments are 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.” 42 U.S.C. §
423(d)(2)(A).
Eligibility for supplemental security income requires the same showing of
disability. Id. at § 1382c (a)(3)(A)-(B).
The Act establishes a five-step sequential process for evaluation by the ALJ to determine
whether an individual is disabled. See 20 C.F.R. § 404.1520. First, the ALJ determines whether
the claimant has shown that he or she is not currently engaged in “substantial gainful activity.”
Id. at § 404.1520(a); see Bowen v. Yuckert, 482 U.S. 137, 146-47 n.5 (1987). If a claimant is
presently engaged in any form of substantial gainful activity, he or she is automatically denied
disability benefits. See 20 C.F.R. § 404.1520(b); see also Bowen, 482 U.S. at 140. Second, the
ALJ determines whether the claimant has demonstrated a “severe impairment” or “combination
of impairments” that significantly limits his physical or mental ability to do basic work activities.
20 C.F.R. § 404.1520(c); see Bowen, 482 U.S. at 146-47 n.5. Basic work activities are defined
as “the abilities and aptitudes necessary to do most jobs.” 20 C.F.R. § 404.1521(b). These
activities include physical functions such as “walking, standing, sitting, lifting, pushing, pulling,
reaching, carrying or handling.” Id. A claimant who does not have a severe impairment is not
considered disabled. Id. at § 404.1520(c); see Plummer, 186 F.3d at 428.
Third, if the impairment is found to be severe, the ALJ then determines whether the
13
impairment meets or is equal to the impairments listed in 20 C.F.R. Pt. 404, Subpt. P., App. 1
(the “Impairment List”). 20 C.F.R. § 404.1520(a)(4)(iii). If the claimant demonstrates that his
or her impairments are equal in severity to, or meet those on the Impairment List, the claimant
has satisfied his or her burden of proof and is automatically entitled to benefits. See id. at §
404.1520(d); see also Bowen, 482 U.S. at 146-47 n.5. If the specific impairment is not listed, the
ALJ will consider in his or her decision the impairment that most closely satisfies those listed for
purposes of deciding whether the impairment is medically equivalent.
See 20 C.F.R. §
404.1526(a). If there is more than one impairment, the ALJ then must consider whether the
combination of impairments is equal to any listed impairment.
Id.
An impairment or
combination of impairments is basically equivalent to a listed impairment if there are medical
findings equal in severity to all the criteria for the one most similar. Williams, 970 F.2d at 1186.
If the claimant is not conclusively disabled under the criteria set forth in the Impairment
List, step three is not satisfied, and the claimant must prove at step four whether he or she retains
the “residual functional capacity” (“RFC”) to perform his or her past relevant work. 20 C.F.R. §
404.1520(e); Bowen, 482 U.S. at 141. If the claimant is able to perform previous work, the
claimant is determined to not be disabled. 20 C.F.R. §§ 404.1520(e), 416.920(e); Bowen, 482
U.S. at 141-42. The claimant bears the burden of demonstrating an inability to return to the past
relevant work. Plummer, 186 F.3d at 428. Finally, if it is determined that the claimant is no
longer able to perform his or her previous work, the burden of production then shifts to the
Commissioner to show, at step five, that the “claimant is able to perform work available in the
national economy.” Bowen, 482 U.S. at 146-47 n.5; Plummer, 186 F.3d at 428. This step
requires the ALJ to consider the claimant’s residual functional capacity, age, education, and past
work experience. 20 C.F.R. § 404.1520(f). The ALJ must analyze the cumulative effect of all
14
the claimant’s impairments in determining whether the claimant is capable of performing work
and not disabled. Id.
III. PLAINTIFF’S CLAIMS ON APPEAL
Plaintiff makes four arguments on appeal as to why the ALJ’s disability determinations
were unsupported by substantial credible evidence. First, Plaintiff argues that the ALJ erred by
failing to accord adequate weight to the opinions of her treating physicians. Second, Plaintiff
contends the ALJ erred in evaluating her credibility. Third, Plaintiff avers that the ALJ erred in
assigning “little weight” to an IRS award of disability benefits to Plaintiff. Fourth, Plaintiff
maintains that the ALJ failed to evaluate her nonexertional limitations in accordance with
SSR96-9P. Each argument is addressed in turn.
A.
Opinion Evidence
First, Plaintiff argues that the ALJ failed to accord adequate weight to the opinions of her
treating providers, including Dr. Holstein, Dr. Nelson, and Ms. Florence. Plaintiff’s Brief, at 10.
I disagree.
At step four, the ALJ is required to formulate a claimant’s RFC. See Chandler v. Comm’r
of Soc. Sec., 667 F.3d 356, 361 (3d Cir. 2011) (“The ALJ—not treating or examining physicians
or State agency consultants—must make the ultimate disability and RFC determinations.”). In
performing this inquiry, “the ALJ must consider all evidence before him,” and, while the ALJ
may weigh the credibility of the evidence, the ALJ must also provide “some indication of the
evidence which he rejects and his reason(s) for discounting such evidence.” Burnett v. Comm’r
of Social Sec. Admin., 220 F.3d 112, 121 (3d. Cir. 2000); Cotter v. Harris, 642 F.2d 700, 704 (3d
Cir. 1981); Goldberg v. Colvin, No. 13-6055, 2015 U.S. Dist. LEXIS 31012, at *24-25 (D.N.J.
Mar. 13, 2015).
In “the absence of such an indication, the reviewing court cannot tell if significant
15
probative evidence was not credited or simply ignored.” Cotter, 642 F.2d at 705. Thus, the
failure to indicate whether contradicting evidence was considered, or to also provide a basis for
rejecting such evidence warrants remand; however, the ALJ need not examine “every relevant
treatment note” in rendering a decision. Schaudeck v. Comm’r of Soc. Sec. Admin., 181 F.3d 429,
435 (3d Cir. 1999); Fargnoli v. Halter, 247 F.3d 34, 42 (3d Cir. 2001). “Where the ALJ’s
findings of fact are supported by substantial evidence, [courts] are bound by those findings, even
if [one] would have decided the factual inquiry differently.” Hagans v. Comm’r of Soc. Sec., 694
F.3d 287, 292 (3d Cir. 2012).
With respect to opinion evidence, a determinable impairment must be established by
“acceptable medical sources, defined to only include licensed physicians, psychologists,
optometrists, podiatrists, and qualified speech-language pathologists. See 20 CFR 404.1513; 20
CFR 416.913. That is, licensed clinical social workers, such as Ms. Ruth in this case, are not
acceptable medical sources, but are instead classified as “other sources” pursuant to the
regulations. As such, findings from other sources may be used for the limited purpose of
demonstrating “the severity of [a claimant’s] impairment,” and, if applicable, their opinions
should be evaluated pursuant to those factors which are used to weigh opinion evidence.4 Indeed,
the ALJ “generally should explain the weight given to opinions from these ‘other sources’ in a
manner which “allows a claimant or subsequent reviewer to follow the adjudicator’s
reasoning[.]” See SSR 06-03(p).
4
These factors include: “[h]ow long the source has known and how frequently the source
has seen the individual; [h]ow consistent the opinion is with other evidence; [t]he degree to
which the source presents relevant evidence to support an opinion; [h]ow well the source
explains the opinion; [w]hether the source has a specialty or area of expertise related to the
individual’s impairment(s), and; [a]ny other factors that tend to support or refute the opinion. See
SSR 06-03(p).
16
Moreover, under the regulations, a treating source’s opinion will be given controlling
weight if the opinion “is well-supported by medically acceptable clinical and laboratory
diagnostic techniques and is not inconsistent with the other substantial evidence in [the] case
record.” 20 C.F.R. § 404.1527(c)(2). Several factors may also be used to determine the weight
given to a medical opinion, including: length of treatment relationship, the nature and extent of
the treatment relationship, supportability by medical evidence, and consistency with the record as
a whole. Id. When a treating source’s opinion conflicts with that of a non-treating source, “the
ALJ may choose whom to credit but cannot reject evidence for no reason or for the wrong
reasons.” Morales v. Apfel, 225 F.3d 310, 317 (3d Cir. 2000). Indeed, the ALJ must rely only on
“contradictory medical evidence” in rejecting the treating source’s opinion, and, as another
requirement, provide “an explanation of the reasoning behind [her] conclusions,” including
“reason(s) for discounting rejected evidence.” Fargnoli v. Halter, 247 F.3d 34, 43 (3d Cir. 2001);
Morales, 225 F.3d at 317.
Here, the ALJ complied with the pertinent social security regulations in attributing
minimal weight to Ms. Ruth’s opinions, a LCSW, who provided a Social Security Disability
Psychiatric Report, dated May 1, 2014, on behalf of Plaintiff. In the report, Ms. Ruth indicated
that, because of her “condition,” Plaintiff would be limited in her abilities to perform various
work-related activities, including understanding, interacting with others, maintaining adaptive
functioning, and sustaining concentration and persistence. A.R. 578. However, the ALJ assigned
little weight to these findings, noting that Ms. Ruth is an “unacceptable medical source,” such
that her opinion cannot establish a medically determinable impairment. A.R. 23. The ALJ also
held that the report was “vague,” “unsupported by more than a general explanation[,]” and
inconsistent with her findings that Plaintiff was capable of managing her own benefits. A.R. 23.
17
And, although Ms. Ruth’s Report indicated that she had treated Plaintiff since February 2013, the
ALJ explained that “no records of those appointments” existed. A.R. 23.
Tellingly, Plaintiff does not raise a specific argument as to the ALJ’s assessment of Mr.
Ruth’s findings, but rather contends that the ALJ’s decision fails to provide an adequate basis for
review. However, in contrast to Plaintiff’s position, the Court finds that the ALJ rendered a
decision in which she provided an adequate explanation for discrediting Ms. Ruth’s
determinations. Indeed, after appropriately noting that Ms. Ruth was not an acceptable medical
source, the ALJ provided additional reasons for discrediting her findings. In that regard, the ALJ
determined that Ms. Ruth’s conclusions were inconsistent, unclear, and unsupported, as the
record did not contain a single treatment note from her sessions with Plaintiff. Wimberly v.
Barnhart, 128 Fed. Appx. 861, 863 (3d Cir. 2005) (holding that the ALJ did not err by refusing
to accord controlling weight to an opinion which “was itself internally inconsistent.”). Therefore,
based on these reasons, the ALJ’s assessment of Ms. Ruth’s source opinion does not warrant
remand.
In addition, Plaintiff argues that the ALJ erred in assigning “some weight” and “little
weight” to the opinions of Plaintiff’s treating physicians, including Dr. Nelson’s Social Security
Disability Psychiatric Report, dated February 10, 2015, and Dr. Holstein’s letters from June
2017. Plaintiff’s Brief, at 13-14. However, I find that the ALJ complied with the pertinent social
security regulations in attributing minimal weight to the opinions of Plaintiff’s treating
physicians.
First, Dr. Nelson’s Social Security Disability Psychiatric Report indicated that she had
treated Plaintiff on no more than three separate occasions, and she opined that Plaintiff suffered
from no more than “some” limitations with respect to her abilities to engage in work related
18
mental activities, including understanding, sustaining concentration and persistence, and
interacting with others. A.R. 592. Moreover, according to Dr. Nelson, Plaintiff exhibited no
limitations in adapting to changes in the work place, recognizing hazards, traveling/using public
transportation, setting realistic goals, and making independent plans. A.R. 592. However, while
the ALJ assigned “some weight” to these findings, she concluded that she could not accord them
more weight, based on the short length of Dr. Nelson’s treatment relationship with Plaintiff, and
her “vague” determinations, which were supported with no more than a “cursory explanation.”
A.R. 24.
Second, in his letters, Dr. Holstein opined that Plaintiff was unable to work at the time of
treatment because of Plaintiff’s preoccupation with her personal life, but that, if she were able to
achieve a greater degree of stability, “a return to work would certainly not only be desirable, but
quite possible.” A.R. 646. However, in assigning little weight to Dr. Holstein’s opinion, the ALJ
noted that it was inconsistent with the testimony that Plaintiff provided at her hearing, during
which she stated that her therapist was encouraging her to attempt to work part-time. A.R. 24. In
addition, the ALJ explained that Dr. Holstein’s statement presented an assessment of the
Plaintiff’s current functioning, instead of a long-term assessment of the her work-related
functional limitations, and that he was opining on an issue which was reserved for the
Commissioner. A.R. 24.
Here, the ALJ appropriately discounted Dr. Nelson’s medical findings. As to Dr.
Nelson’s determinations with respect to Plaintiff’s concentration, attention, and persistence
capabilities, the ALJ explained that there was no evidence to support that she had reported these
problems on a consistent basis, as the record revealed large gaps in treatment. In fact, the ALJ
noted that these findings were in conflict with Plaintiff’s own statements to Dr. Nelson, as she
19
had reported that she “rarely” felt unable to concentrate. A.R. 597. And, the ALJ also referenced
certain mental status exams, during which Plaintiff’s concentration was “intact,” and she
performed simple mathematical calculations and other related cognitive tasks. To the extent that
Plaintiff disagrees with the reasons for discrediting the opinion of Dr. Nelson, it is axiomatic that
such grounds fail to provide an appropriate basis for appeal, because reviewing “courts are not
permitted to re-weigh the evidence or impose their own factual determinations.” Chandler., 667
F.3d at 359.
In addition, the ALJ did not err in assigning little weight to Dr. Holstein’s opinion. As the
ALJ noted, Dr. Holstein did not provide, for example, a functional assessment of Plaintiff’s
abilities to perform specific work related tasks, on the basis of clinical diagnostic medical
techniques. Rather, Dr. Holstein opined on Plaintiff’s overall inability to work; but, as the
applicable regulations provide, “[s]tatements by a physician that a claimant is or was ‘unable to
work,’ . . . are not ‘medical opinions’ but instead are ‘opinions on issues reserved to the
Commissioner[.]’” Roberts v. Comm’r of Soc. Sec., No. 09-2211, 2010 U.S. Dist. LEXIS 47132,
at *35 (D.N.J. 2010) (quoting 20 C.F.R. § 404.1527(e)(1)). Therefore, because this determination
was within the province of the ALJ, she was not required to accept Dr. Holstein’s assessment of
Plaintiff’s overall ability to work. Indeed, opinions of that nature are “not the sort of treating
source medical opinion[s] entitled to any kind of weight.” Johnson v. Comm’r of Soc. Sec., 529
F.3d 198, 203 n. 2 (3d Cir. 2008); Taylor v. Barnhart, 474 F. Supp. 2d 650, 662 (D. Del. 2007)
(“It is within the ALJ’s lone discretion to determine whether an individual is disabled or ‘unable
to work’ under the statutory definition.”); see also Roberts, 2010 U.S. Dist. LEXIS 47132, at
*35.
As an additional basis to reject the opinions of Plaintiff’s treating physicians, the ALJ
20
referenced the state medical agency consultants’ findings, both of whom determined that
Plaintiff was able to sustain concentration, persistence, and pace for simply work functions, and
that she could understand and follow moderately complex instructions. Significantly, the medical
determinations of the state agency consultants with respect to Plaintiff’s abilities are consistent
with the ALJ’s RFC, which limits her to jobs that do not require her to perform “many work
related decisions.”5 Therefore, based on these circumstances, in total, the Court holds that the
ALJ did not err in discrediting the opinions of Plaintiff’s treating physicians. See Craig v.
Comm’r of Soc. Sec., No. 13-4454, 2014 U.S. Dist. LEXIS 164064, at *30 (D.N.J. Nov. 21,
2014) (“If, however, a treating physician’s opinion is contradicted by other medical evidence in
the record, including the opinion of a non-treating physician, the ALJ may accept the most
credible medical opinion.”) (citing Plummer, 186 F.3d at 429); see also Schmits v. Astrue, No.
08-1971, 2009 U.S. Dist. LEXIS 48182, at *23 (D.N.J. June 9, 2009) (“Furthermore, given the
well-delineated contradictory medical evidence identified by the ALJ in her opinion, the Court
finds that the ALJ was entitled to accept the most credible medical opinion, even if provided by .
. . a non-treating physician”).
B.
Plaintiff’s Credibility
Second, Plaintiff argues that the ALJ failed to appropriately evaluate her subjective
complaints as to the severity of her impairments. Plaintiff’s Brief, at 14-17. Plaintiff’s position
lacks merit.
5
I note that, although the State agency consultants rendered their opinions before Dr.
Holstein treated Plaintiff, Plaintiff does not contend that their determinations were unreliable for
this reason. Nonetheless, the ALJ was not required to accept Dr. Holstein’s opinion, as explained
supra. Also, Plaintiff did not provide any medical evidence to show that her mental impairments
significantly changed between the time the State agency consultants reviewed Plaintiff’s medical
condition and when Dr. Holstein treated Plaintiff. In fact, based on the record, Plaintiff’s mental
condition remained relatively consistent.
21
The Third Circuit has held that credibility determinations are entitled to a significant
amount of deference on appeal. See Hoyman v. Colvin, 606 Fed. Appx. 678 (3d Cir. 2015) (“The
credibility determinations of an administrative judge are virtually unreviewable on appeal.”)
(citation omitted); see also Reefer v. Barnhart, 326 F.3d 376, 380 (3d Cir. 2003) (stating that
courts “ordinarily defer to an ALJ’s credibility determination because he or she has the
opportunity at a hearing to assess a witness’ demeanor.”); see also Izzo v. Comm’r of Soc. Sec.,
186 Fed. Appx. 280, 286 (3d Cir. 2006) (finding that “a reviewing court typically defers to an
ALJ’s credibility determination so long as there is a sufficient basis for the ALJ’s decision to
discredit a witness.”).
A claimant’s subjective symptoms must be corroborated by objective medical evidence;
i.e., evidence of a medically determinable impairment that can reasonably be expected to
produce the claimant’s underlying symptoms. See Hartranft v. Apfel, 181 F.3d 358, 362 (3d Cir.
1999) (citing 20 C.F.R. § 404.1529). The most recent Social Security Ruling within this context,
SSR 16-3p, 2016 SSR LEXIS 4, effective March 28, 2016, describes a two-step process that
ALJs are required to follow in evaluating a claimant’s statements about symptoms. SSR 16-3p,
2016 SSR LEXIS 4 at *3; Hopper v. Saul, No. 18-1799, 2019 U.S. Dist. LEXIS 119889, at *40
(D.N.J. July 16, 2019).
First, the ALJ “must consider whether there is an underlying medically determinable
physical or mental impairment(s) that could reasonably be expected to produce an individual’s
symptoms, such as pain.” SSR 16-3p, 2016 SSR LEXIS 4 at *3. “Second, once an underlying
physical or mental impairment(s) that could reasonably be expected to produce an individual’s
symptoms is established, [the ALJ] evaluate[s] the intensity and persistence of those symptoms
to determine the extent to which the symptoms limit an individual’s ability to perform work-
22
related activities. . .” Id.; see also Mirza v. Saul, No. 18-0185, 2019 U.S. Dist. LEXIS 109748, at
*27 (D.N.J. June 28, 2019).
If the ALJ finds that the objective medical evidence does not substantiate the claimant’s
testimony about his or her symptoms, then the ALJ is required to make a determination on the
basis of the entire record by considering: (1) The claimant’s daily activities; (2) the location,
duration, frequency and intensity of the claimant’s pain or other symptoms; (3) precipitating or
aggravating factors; (4) the type, dosage, effectiveness, and side effects of any medication the
claimant takes or has taken to alleviate pain or other symptoms; (5) treatment, other than
medication, the claimant receives or has received for relief of pain or other symptoms; (6) any
measures the claimant uses or has used to relieve pain or other symptoms; and (7) other factors
concerning the claimant’s functional limitations and restrictions due to pain or other symptoms.
20 C.F.R. §§ 416.929(c)(3)(i)-(vii).
Here, in accordance with the applicable regulations, and based on the medical evidence,
the ALJ determined that Plaintiff’s “medically determinable impairments could reasonably be
expected to cause the . . . alleged symptoms.” A.R. 22. However, the ALJ concluded that
Plaintiff’s “statements concerning the intensity, persistence and limiting effects of these
symptoms are not entirely consistent with the medical evidence and other evidence in record.”
A.R. 22. In rendering that determination, the ALJ first explained that Plaintiff’s “limited medical
treatment” was inconsistent with her complaints of “debilitating impairment.” A.R. 22. Indeed,
the ALJ emphasized that the medical evidence failed to show that Plaintiff “regularly engaged in
treatment until February 2017[,]” prior to which she declined to seek outpatient treatment,
because, in Plaintiff’s view, she did not require a “higher level of care.” A.R. 22. Moreover, the
ALJ referenced multiple occasions on which Plaintiff stopped seeing a provider altogether, or
23
failed to return for a follow-up visit. A.R. 22. These considerations, which were set forth in the
ALJ’s decision, constituted an appropriate basis to discredit Plaintiff’s subjective complaints. See
SSR 16-3p, 2016 SSR LEXIS 4 (“[I]f the frequency or extent of the treatment sought by an
individual is not comparable with the degree of the individual’s subjective complaints, or if the
individual fails to follow prescribed treatment that might improve symptoms, we may find the
alleged intensity and persistence of an individual’s symptoms are inconsistent with the overall
evidence of record.”).
In addition, the ALJ reasoned that the limiting effects of Plaintiff’s complaints were
inconsistent with her activities of daily living. Indeed, as the ALJ found, Plaintiff’s allegations
were undermined by those activities, which included caring for herself and son without
assistance from others, handling the bills, preparing breakfast for herself and her son, driving her
son to school, cleaning the house, doing laundry, food shopping, and spending time on the
computer to research potential support groups. A.R. 20. Moreover, the ALJ noted that multiple
examinations characterized Plaintiff as neatly groomed, further supporting that she could care for
herself. A.R. 20. These grounds, too, constituted an appropriate basis to discredit the extent of
Plaintiff’s complaints. Schmidt v. Comm’r Soc. Sec., 465 Fed. Appx. 193, 198 (3d Cir. 2012)
(finding that the plaintiff's activities of daily living were inconsistent with his subjective
complaints of disabling pain); Morel v. Colvin, No. 14-2934, 2016 U.S. Dist. LEXIS 44347, at
*13 (D.N.J. April 1, 2016) (concluding that the record supported the ALJ’s decision to discredit
the plaintiff’s subjective complaints, where the plaintiff was “able to independently care for her
personal needs, “serve[] as the primary caregiver for her teenaged son,” prepare meals, and clean
the house.).
24
As another basis to discredit the Plaintiff’s complaints, the ALJ explained that Plaintiff
was not on medication other than medication for her breast cancer, which did not cause her side
effects. A.R. 22. In addition, the ALJ, again, referenced the determinations of the state agency
consultants, both of whom, as explained above, concluded that Plaintiff could, in contrast to
Plaintiff’s testimony, sustain concentration, persistence or pace for simple work functions.
Therefore, in discounting Plaintiff’s subjective complaints, the record indicates that the ALJ
considered them in light of the available medical evidence, and the applicable regulations and
factors that govern such a decision. As such, the ALJ’s decision to discount Plaintiff’s own
subjective complaints was based on substantial evidence.
C.
IRS Benefits
Third, Plaintiff contends that the ALJ committed error in failing to assign substantial
weight to the IRS’s determination that Plaintiff was disabled from a prior employment position
as a legal assistant. Plaintiff’s Brief, at 17-19. However, Plaintiff’s argument fails to persuade
me.
While the Third Circuit has found that “a determination by another governmental agency
is entitled to substantial weight[,] Kane v. Heckler, 776 F.2d 1130, 1135 (3d Cir. 1985), that
agencies’ decision is, nevertheless, not binding on the ALJ. See 20 C.F.R. §§404.1504, 416.904;
see also Pratts v. Comm’r of Soc. Sec., No. 13-2372, 2015 U.S. Dist. LEXIS 116452 at *40
(D.N.J. Sept. 1, 2015); Alston v. Astrue, No. 10-839, 2011 U.S. Dist. LEXIS 115031, at *5 (W.D.
Pa. Oct. 5, 2011). Therefore, an ALJ can accord less weight to another governmental agencies’
decision, as long as the ALJ “sets forth specific and valid reasons for doing so and that those
reasons are supported by substantial evidence of record.” Solomon v. Saul, No. 18-1443, 2020
U.S. Dist. LEXIS 14420, at *6 (W.D. Pa. Jan. 29, 2020); Scott v. Astrue, No. 06-2541, 2007 U.S.
25
Dist. LEXIS 42928, at *22 (E.D. Pa. June 13, 2007) (“[T]he ALJ may properly reject another
agency’s findings if he/she explains his/her decision.”); see also Pratts, 2015 U.S. Dist. LEXIS
116452 at *40.
Here, in assigning little weight to the IRS’s determination, the ALJ provided two specific
reasons for discounting the award of benefits, explaining: “[f]indings of other federal agencies
are non binding upon the Social Security Administration and there is no function-by-function
assessment of the claimant’s work related limitations.” See §§ 404.1504, 416.904 (holding that
“a decision by any other governmental agency about whether [a claimant is] disabled . . . or
entitled to any benefits is based on its [own] rules, [and] it is not binding on” the Social Security
Administration). Significantly, an award of benefits from other governmental agencies that do
not include a function-by-function assessment is sufficient to discount those agencies disability
determinations. Solomon, 2020 U.S. Dist. LEXIS 14420, at *6 (holding that the ALJ
appropriately discounted another agencies’ disability determination that “did not contain
function-by-function limitations.”). Thus, the ALJ did not commit error in discounting the IRS’s
disability determination.
D.
SSR96-9P
Fourth, Plaintiff argues that the ALJ failed to act in accordance with SSR96-9P, because
she did not evaluate her nonexertional impairments. Specifically, SSR96-9P addresses a
claimant’s ability to do less than a full range of sedentary work, and provides that the individual
must be able to remain in a seated position for approximately six hours of an eight-hour workday
in order to perform a full range of sedentary work. SSR 96-9p, 1996 SSR LEXIS 6. Here,
because the ALJ found that Plaintiff was capable to perform to a “full range of work at all
exertional levels,” SSR 96-9p is inapplicable to the case at hand. See Hans v. Astrue, No. 11-374,
26
2011 U.S. Dist. LEXIS 149208, at *29 (E.D. Pa. Nov. 29, 2011) (“SSR 96-9p applies only when
a claimant is limited to sedentary work.”); Johnson v. Astrue, No. 10-30169, 2011 U.S. Dist.
LEXIS 131217, at *18 (D. Mass Nov. 9, 2011) (“SSR 96-9p . . . applies only to sedentary
work.”) Therefore, this ground fails to provide a basis for remand.
IV.
CONCLUSION
For the reasons set forth above, the Court finds that the ALJ’s decision was supported by
substantial evidence in the record. Accordingly, the ALJ’s decision is affirmed. An appropriate
Order shall follow.
/s/ Freda L. Wolfson
Freda L. Wolfson
U.S. Chief District Judge
27
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