Mayes v. Colvin
Filing
10
MEMORANDUM OF DECISION AND ORDER denying 5 Pltf's Motion for Summary Judgment; granting 8 Deft's Motion for Summary Judgment; and affirming and dismissing decision of the Commissioner. Signed by District Judge Martin Reidinger on 9/23/14. (ejb)
THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF NORTH CAROLINA
ASHEVILLE DIVISION
CIVIL CASE NO. 1:13-cv-00085-MR-DLH
LINDA H. MAYES,
)
)
Plaintiff,
)
)
vs.
)
)
CAROLYN W. COLVIN,
)
Commissioner of Social Security
)
Administration,
)
)
Defendant.
)
_______________________________ )
MEMORANDUM OF
DECISION AND ORDER
THIS MATTER is before the Court on the Plaintiff’s Motion for
Summary Judgment [Doc. 5] and the Defendant’s Motion for Summary
Judgment [Doc. 8].
I.
PROCEDURAL HISTORY
The Plaintiff Linda H. Mayes filed an application for disability
insurance benefits on October 7, 2005, alleging that she had become
disabled as of March 1, 2003. [Transcript (“T.”) 129-133, 150, 182]. The
Plaintiff’s
application
was
denied
initially
[T.
102-107]
and
on
reconsideration [T. 110-116]. The Plaintiff requested a hearing before an
Administrative Law Judge (“ALJ”) which occurred on June 30, 2009. [T.
30-62]. On July 24, 2009, ALJ Avots issued an unfavorable decision. [T.
13-29].
On July 30, 2010, the Appeals Council denied the Plaintiff’s
request for review, thereby making the ALJ’s decision the final decision of
the Commissioner. [T. 7-11]. The Plaintiff then brought this action in this
Court.
The Commissioner moved for remand of the Plaintiff’s case according
to 42 U.S.C. § 405(g). [T. 617-19]. This Court remanded the case to the
Appeals
Council
[T.
620-22],
instructing
that
upon
remand,
the
Commissioner was to:
evaluate the severity of the Plaintiff’s cervical and
lumbar degenerative disc disease, and reassess
Plaintiff’s physical residual functional capacity in
light of all of the medical evidence of record,
obtaining input from the medical staff or a State
Agency medical consultant, [and] if necessary, hold
a new hearing at which Plaintiff will be able to testify
and present evidence.
[T. 620-22]. The Appeals Council then remanded this matter to ALJ Riley
for further hearing. [T. 558-89]. The Plaintiff amended her alleged onset
date to June 20, 2007 at her hearing with ALJ Riley via video conference
on July 23, 2012. [T. 562]. On August 14, 2012, ALJ Riley issued an
unfavorable decision. On January 29, 2013, the Appeals Council denied
the Plaintiff’s request for review, thereby making the ALJ’s decision the final
decision of the Commissioner. [T. 516-18]. The Plaintiff has exhausted all
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available administrative remedies, and this case is now ripe for review
pursuant to 42 U.S.C. § 405(g).
II.
STANDARD OF REVIEW
The Court’s review of a final decision of the Commissioner is limited
to (1) whether substantial evidence supports the Commissioner’s decision,
Richardson v. Perales, 402 U.S. 389, 401 (1971), and (2) whether the
Commissioner applied the correct legal standards, Hays v. Sullivan, 907
F.2d 1453, 1456 (4th Cir. 1990). The Court does not review a final decision
of the Commissioner de novo. See Smith v. Schweiker, 795 F.2d 343, 345
(4th Cir. 1986).
The Social Security Act provides that “[t]he findings of the
Commissioner of Social Security as to any fact, if supported by substantial
evidence, shall be conclusive. . . .” 42 U.S.C. § 405(g). The Fourth Circuit
has defined “substantial evidence” as “more than a scintilla and [doing]
more than creat[ing] a suspicion of the existence of a fact to be established.
It means such relevant evidence as a reasonable mind might accept as
adequate to support a conclusion.” Smith v. Heckler, 782 F.2d 1176, 1179
(4th Cir. 1986) (quoting Perales, 402 U.S. at 401).
The Court may not re-weigh the evidence or substitute its own
judgment for that of the Commissioner, even if it disagrees with the
3
Commissioner’s decision, so long as there is substantial evidence in the
record to support the final decision below. See Hays, 907 F.2d at 1456;
see also Lester v. Schweiker, 683 F.2d 838, 841 (4th Cir. 1982).
III.
THE SEQUENTIAL EVALUATION PROCESS
In determining whether or not a claimant is disabled, the ALJ follows
a five-step sequential process. 20 C.F.R. §§ 404.1520, 416.920. If the
claimant’s case fails at any step, the ALJ does not go any further and
benefits are denied. See Pass v. Chater, 65 F.3d 1200, 1203 (4th Cir.
1995).
First, if the claimant is engaged in substantial gainful activity, the
application is denied regardless of the medical condition, age, education, or
work experience of the applicant.
20 C.F.R. §§ 404.1520, 416.920.
Second, the claimant must show a severe impairment. If the claimant does
not show any impairment or combination thereof which significantly limits
the claimant’s physical or mental ability to perform work activities, then no
severe impairment is shown and the claimant is not disabled. Id. Third, if
the impairment meets or equals one of the listed impairments of Appendix
1, Subpart P, Regulation 4, the claimant is disabled regardless of age,
education, or work experience. Id. Fourth, if the impairment does not meet
the criteria above but is still a severe impairment, then the ALJ reviews the
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claimant’s residual functional capacity (RFC) and the physical and mental
demands of work done in the past. If the claimant can still perform that
work, then a finding of not disabled is mandated. Id. Fifth, if the claimant
has a severe impairment but cannot perform past relevant work, then the
ALJ will consider whether the applicant’s residual functional capacity, age,
education, and past work experience enable the performance of other
work. If so, then the claimant is not disabled. Id.
V.
THE ALJ’S DECISION
On August 14, 2012, ALJ Riley issued a decision denying the
Plaintiff’s claim. [T. 529-544]. Proceeding to the sequential evaluation, the
ALJ found that the Plaintiff’s date last insured was March 31, 2008 and that
she had not engaged in substantial gainful activity since June 20, 2007. [T.
529-530]. The ALJ then found that the medical evidence established the
following severe impairments: degenerative disc disease of the lumbar and
cervical spines, back pain with spondylolisthesis at L5-S1 and facet
changes, neck pain with degenerative disc disease and facet changes,
bipolar disorder, personality disorder, substance abuse, and history of
seizures. [T. 531]. The ALJ determined that none of Plaintiff’s impairments
met or equaled a listing. [T. 537].
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The ALJ then assessed the Plaintiff’s residual functional capacity
(RFC), finding that the Plaintiff had the ability to perform light work as
defined in 20 C.F.R. § 404.1567(b) and § 416.967(b) involving simple tasks
with low stress and low demand, except with occasional postural activities,
with no climbing of ladders, no working at unguarded heights, no working
around hazardous equipment or machinery, and no driving. [T. 539]. The
ALJ found that the Plaintiff was unable to perform any past relevant work.
[T. 542]. The ALJ further found that the transferability of job skills was not
material to the determination of disability according to the MedicalVocational Rules framework. [T. 542-43]. Finally, when considering the
Plaintiff’s age, education, work experience, and residual functional
capacity, the ALJ found that there are jobs that exist in significant numbers
in the national economy that the Plaintiff could perform, [T. 543], and he
ruled that the Plaintiff was not disabled [T. 544].
VI.
DISCUSSION1
The Plaintiff asserts the following assignment of error: (1) that ALJ
Riley failed to properly evaluate the opinion of Dr. Motley, the Plaintiff’s
treating physician; (2) and that ALJ Riley failed to follow the August 10,
1
Rather than set forth a separate summary of the facts in this case, the Court has
incorporated the relevant facts into its legal analysis.
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2011 remand Order to re-evaluate the severity of the Plaintiff’s cervical and
lumbar degenerative disc disease by improperly applying the rules of 20
C.F.R. § 404.1527(c).
A. The ALJ’s Evaluation of Dr. Motley’s Opinion
The Plaintiff specifically argues that the ALJ erred by not giving
controlling weight to Dr. Motley’s opinion, misapplying the 20 C.F.R. §
404.1527 factors, and not discussing Dr. Motley’s treatment of the Plaintiff
after June 2009. [Doc. 5-1 at 18-24].
An ALJ must give controlling weight to the opinion of a claimant's
treating physician when the opinion concerns the nature and severity of an
impairment, 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). Thus,
an opinion of a treating physician is not entitled to controlling weight if it is
unsupported by medically acceptable clinical and laboratory diagnostic
techniques and/or inconsistent with other substantial evidence of record.
Id.; see also Rogers v. Barnhart, 204 F. Supp. 2d 885, 893 (W.D.N.C.
2002) (“Even the opinion of a treating physician may be disregarded where
it is inconsistent with clearly established, contemporaneous medical
records”).
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Further, an ALJ must evaluate every medical opinion received in the
record, regardless of its source. 20 C.F.R. § 404.1527(c). A “medical
opinion” is a “judgment [ ] about the nature and severity of [the claimant's]
impairment(s), including [the claimant's] symptoms, diagnosis and
prognosis, what [the claimant] can still do despite impairment(s), and [the
claimant's] physical or mental restrictions.” 20 C.F.R. §§ 404.1527(a)(2),
416.927(a)(2). In evaluating the weight of a medical source, the ALJ must
consider certain factors including: the examining relationship, the length of
the treatment relationship, the frequency of examination, the nature and
extent of the treatment relationship, the supportability of the medical
source, the consistency of the medical source, the specialization of the
provider, and any other factors which tend to support or contradict the
opinion. 20 C.F.R. § 404.1527(c)(1–6). The ALJ is not required, however,
to specifically discuss each of the 20 C.F.R. § 404.1527(c) factors in
determining how much weight to give to medical opinions. See Clontz v.
Astrue, No. 2:12-CV-00013-FDW, 2013 WL 3899507 at *7 (W.D.N.C. July
29, 2013).
The Plaintiff argues that the ALJ erred by not giving Dr. Motley’s
opinion controlling weight and not evaluating his opinions according to the
factors set forth in 20 C.F.R. § 404.1527(c)(1)-(6). [Doc. 5-1 at 22]. The
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ALJ did not err in these respects, however. The ALJ provided adequate
explanation for why he did not adopt Dr. Motley’s assessments of the
Plaintiff’s restrictions, as follows:
He stated the claimant has a medical condition that
affects the claimant’s ability to work, but did not give
clinical findings, laboratory results, and test results
[to] support this statement . . . [H]e [Dr. Motley]
apparently relied quite heavily on the subjective
report of symptoms and limitations provided by the
claimant, and seemed to uncritically accept as true
most, if not all, of what the claimant reported. Yet,
his objective findings are not consistent with the
limitations he imposed on the claimant. Moreover,
good reasons exist for questioning the reliability of
the claimant’s subjective complaints. Dr. Motley
indicated that he feels the claimant is medically
disabled and opined she has been disabled since
2000. However, the undersigned notes that Dr.
Motley began treating the claimant in March 2008.
The undersigned rejects Dr. Motley’s opinion that
the claimant is unable to engage in gainful
employment on a regular reliable basis over eight
hours and forty hours per week as it appears
inconsistent with the medical signs and findings of
record. Furthermore, it is inconsistent with other
evidence of record including findings of consultative
exams by Dr. Seagle. In addition, it contrasts
sharply with the other evidence of record including
the opinion of medical expert Dr. Bland, who had
the opportunity to review the medical evidence of
record.
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[T. 541].
The ALJ noted many of Dr. Motley’s opinions and findings
throughout his treatment and care of the Plaintiff.
[T. 533-35].2
He
discussed the Plaintiff’s complaints, medications, injections, and therapy at
Southeastern Sports Medicine, and noted specific visits for which the
Plaintiff’s records reflected some improvement with medication.
[Id.].
Thus, the ALJ properly considered the factors within 20 C.F.R. §
404.1527(c)(1)-(6) when not giving controlling weight to Dr. Motley’s
opinions, as he found them to be based primarily on subjective complaints,
not adequately supported by objective findings, and inconsistent with other
evidence of record. [T. 541].
An ALJ ‘s “failure to discuss every specific piece of evidence ‘does
not establish that [the ALJ] failed to consider it.’” Mitchell v. Astrue, No.
2:11-cv-00056-MR, 2013 WL 678068 (W.D.N.C. Feb. 25, 2013) (quoting
Elias v. Astrue, No. 3:07-cv-43, 2008 WL 191662, at *21 (N.D. W.Va. Jan.
22, 2008)).
Although the ALJ did not discuss the Plaintiff’s visits to
Southeastern Sports Medicine after June 2009, any error by the ALJ in this
respect was not prejudicial, because his decision was based upon
substantial record evidence.
2
In this regard, the ALJ also made note of the opinions of Dr. Motley’s partner, Dr.
Maxwell, who also treated the Plaintiff at Southeastern Sports Medicine. [T. 534, 536].
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Therefore, the Plaintiff’s arguments regarding the ALJ’s evaluation of
Dr. Motley’s opinion are without merit.
B. The ALJ’s Compliance with the Order of Remand
The Plaintiff further argues that the ALJ erred by failing to evaluate
the severity of the Plaintiff’s cervical and lumbar degenerative disc disease,
according to the Order of Remand from this Court. [Doc. 5-1 at 19].
Here, this Court remanded the Plaintiff’s case for the ALJ to perform
the following:
evaluate the severity of Plaintiff’s cervical and
lumbar degenerative disc disease, and reassess
Plaintiff’s physical residual functional capacity in
light of all of the medical evidence of record,
obtaining input from the medical staff or a State
Agency medical consultant, [and] if necessary, hold
a new hearing at which Plaintiff will be able to testify
and present evidence.
[T. 620-22]. The Court finds that ALJ Riley properly followed the Order of
Remand from this Court with regard to the evaluation of the Plaintiff’s
cervical and lumbar degenerative disc disease.
The ALJ acknowledged that “the record reveals degenerative disc
disease of the cervical and lumbar spine as well as spondylolisthesis and
facet changes.
These are well documented and supported by medical
signs and findings and are consistent throughout the medical evidence of
record. This is also consistent with credible testimony by medical expert,
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Dr. Bland.”
[T. 539-40].
The ALJ discussed many of the findings of
consultative examiner Dr. Seagle [T. 532, 535, 540], Dr. Maxy of Carolina
Orthopaedic Specialists [T. 533], and consultative examiner Dr. Caviness
[T. 536, 540], in addition to the findings at Southeastern Sports Medicine
[T. 533-35, 541] with regard to the Plaintiff’s back and neck conditions.
Further, according to the direction of the Order of Remand from this
Court, [T. 620-22], the ALJ obtained testimony from a medical expert, Dr.
Susan Bland. [T. 575-80]. In his decision, the ALJ noted that Dr. Bland
testified:
that a review of the evidence regarding back pain
reveals spondylolisthesis with pars defect at L5-S1
level documented on x-ray of February 2007. An
MRI of June 2007 showed this plus foraminal
narrowing at the L5-S1 level. She had some facet
joint changes at that level. The combination of facet
changes and ligamentum changes caused a mild
spinal canal stenosis. In regard to her neck pain,
imaging studies and x-rays showed some
degenerative disc disease and some facet changes.
There were pain management, evaluations, epidural
steroid injections, and pain medication, the claimant
has continued to complain of pain. Dr. Bland stated
she looked at all the physical exams and there is no
evidence of full-blown radiculopathy, objectively
speaking.
Although there is a suggestion of
symptoms in the lower extremities, from an
examination standpoint, she had normal strength,
normal reflexes, and no atrophy. Straight leg tests
were for the most part negative. The claimant has
had some reduced range of motion in the lumbar
spine. . . Dr. Bland stated that the claimant’s
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limitations would be mostly for her back problem—
spondylolisthesis, which justifies a light level of
physical exertion with no more than light activity,
which is lifting and/or carrying 20 pounds
occasionally and 10 pounds frequently. She stated
occasional postural activities are supported by the
evidence with no climbing of ladders, no working at
unguarded heights, no working around hazardous
equipment or machinery, and no driving (because of
the medication she is taking).
[T. 536-37]. The ALJ’s findings regarding the Plaintiff’s residual functional
capacity reflect Dr. Bland’s observations with regard to the Plaintiff’s ability
to perform light work and her restrictions on physical activities. [T. 539].
Finally, the ALJ properly considered the credibility of the Plaintiff’s
own testimony. In the Fourth Circuit, a two-step process is used to analyze
subjective allegations. Hines v. Barnhart, 453 F.3d 559, 564 (4th Cir. 2006);
Craig v. Chater, 76 F.3d 585, 594-95 (4th Cir. 1996); 20 C.F.R. §
404.1529(b)-(c).
First, the ALJ must determine whether a medical
impairment is present which can reasonably be expected to cause the
symptoms alleged. Craig, 76 F.3d at 594-95; 20 C.F.R. § 404.1529(b). If
this question is answered affirmatively, the ALJ then must evaluate the
intensity and persistence of the symptoms. Craig, 76 F.3d at 594-95; 20
C.F.R. § 404.1529(c). Factors relevant to this determination include the
claimant’s daily activities; the claimant’s statements regarding the location,
duration, and frequency of the symptoms; precipitating and aggravating
13
factors; and the effectiveness of medicine and other treatment. Craig, 76
F.3d at 594-95; 20 C.F.R. §§ 404.1529(c)(3)(i)-(vii). Moreover, although a
claimant’s allegations cannot be disregarded at step two because of a lack
of objective evidence, an ALJ may still take the objective medical evidence
into consideration and is free to reject the allegations to the extent they are
inconsistent with the available evidence, including the objective medical
evidence. Hines, 453 F.3d at 565 n.3; 20 C.F.R. § 404.1529(c)(2). Here,
the ALJ undertook the proper analysis in rejecting the Plaintiff’s allegations
of completely disabling symptoms.
Here, the ALJ found the following regarding the Plaintiff’s testimony:
it was “not credible in regard to her described
limitations, as it is not supported by the objective
medical signs and findings of record. The claimant
has described daily activities that are not limited to
the extent one would expect, given the complaints
of disabling symptoms and limitations. . . . The
claimant’s report of actual activities including
cleaning her house, reading, feeding chickens,
cooking, washings [sic] dishes, mopping floors,
carrying water, driving, and caring for her own
personal needs indicates that she is able to get
about in a manner which is not significantly
restricted. The record does not indicate pain of
such severity as to interfere with her ability to
perform light work-related tasks. Moreover, the
claimant lacks credibility due to drug use,
inconsistent statements, and a prior incarceration.”
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[T. 542]. The ALJ did not err in his consideration of the Plaintiff’s credibility
in light of her daily activities, according to Craig, 76 F.3d at 594 and 20
C.F.R. § 404.1529(c)(3).
As noted previously, this Court will not substitute its own judgment for
that of the Commissioner where substantial evidence exists in the record to
support the final decision below. See Hays, 907 F.2d at 1456; see also
Lester v. Schweiker, 683 F.2d at 841.
Here, the ALJ followed the
instruction from the Order of Remand in this case, [T. 620-22], and properly
evaluated the Plaintiff’s medical record evidence. The ALJ acknowledged
and evaluated the Plaintiff’s cervical and lumbar degenerative disc disease,
and his findings were properly supported by substantial evidence.
Thus, the Plaintiff’s assignment of error regarding the Order of
Remand in this case is without merit.
ORDER
Accordingly, IT IS ORDERED that the Plaintiff’s Motion for Summary
Judgment [Doc. 5] is DENIED; the Defendant’s Motion for Summary
Judgment [Doc. 8] is GRANTED; the decision of the Commissioner is
AFFIRMED; and this case is DISMISSED.
A judgment shall be entered simultaneously herewith.
IT IS SO ORDERED.
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