Reinbolt v. Commissioner of Social Security

Filing 18

Memorandum Opinion: Petitioner's objections to Magistrate Judge Thomas M. Parker's Report and Recommendation are overruled. The decision of the Administrative Law Judge is affirmed, in accordance with the Report and Recommendation. re 15 Judge Jeffrey J. Helmick on 9/27/2017. (S,AL)

UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF OHIO
WESTERN DIVISION

Teresa Schirm Reinbolt,

Case No. 15-cv-813

Plaintiff
v.

MEMORANDUM OPINION

Commissioner of Social Security,
Defendant

I.

INTRODUCTION

Before me are: (1) Magistrate Judge Thomas M. Parker’s Report & Recommendation (Doc.
No. 15); (2) Plaintiff Teresa Schirm Reinbolt’s objections to the R & R (Doc. No. 16); and (3)
Defendant Commissioner of Social Security’s response to Plaintiff’s objections. (Doc. No. 17).
II.

BACKGROUND

On September 19, 2010, Reinbolt first applied for Disability Insurance Benefits and
Supplemental Security Income. After a hearing, the ALJ found that she was not disabled. But the
Appeals Council remanded the decision, stating, among other things, that the ALJ had failed to
adequately evaluate the opinions of treating physicians Hafeez and Rai. (Doc. No. 8 at 144). On
remand, another hearing took place, but the ALJ again denied disability benefits. The Appeals
Council affirmed the ALJ’s decision.
Reinbolt filed this case, contesting the second decision of the ALJ. Magistrate Judge
Thomas M. Parker recommends I affirm the ALJ’s decision. Reinbolt objected and the
Commissioner responded to Reinbolt’s objections. I find Magistrate Judge Parker has accurately

and comprehensively set forth the procedural and factual background of this case, and I adopt those
sections of the R & R in full. (Doc. No. 15 at 1-29).
III.

STANDARD

A district court must conduct a de novo review of “any part of the magistrate judge’s
disposition that has been properly objected to. The district judge may accept, reject or modify the
recommended disposition, receive further evidence, or return the matter to the magistrate judge with
instructions.” Fed. R. Civ. P. 72(b)(3); see also Norman v. Astrue, 694 F.Supp.2d 738, 740 (N.D. Ohio
2010).
The district judge “must affirm the Commissioner’s conclusions absent a determination that
the Commissioner has failed to apply the correct legal standards or has made findings of fact
unsupported by substantial evidence in the record.” Walters v. Comm’r of Soc. Sec., 127 F.3d 525, 528
(6th Cir. 1997); see also 42 U.S.C. § 405(g). “Substantial evidence is defined as ‘such relevant evidence
as a reasonable mind might accept as adequate to support a conclusion.’” Colvin v. Barnhart, 475 F.3d
727, 730 (6th Cir. 2007) (quoting Heston v. Comm’r of Soc. Sec., 245 F.3d 528, 534 (6th Cir. 2001)). If
the Commissioner’s findings of fact are supported by substantial evidence, those findings are
conclusive. McClanahan v. Comm’r of Soc. Sec., 474 F.3d 830, 833 (6th Cir. 2006).
IV.

DISCUSSION

Reinbolt raises two objections to the Magistrate Judge’s affirmation of both the weight given
to the opinion of treating physicians Hafeez and Rai and the ALJ’s credibility assessment.
A.

Treating Source Opinions
When considering an application for supplemental security income, the Social Security

Administration (“SSA”) must evaluate every medical opinion it receives. 20 C.F.R. § 404.1527(c); 20
C.F.R. § 416.927(c). The SSA places medical sources into three categories: (1) non-examining
sources; (2) non-treating, but examining, sources; and (3) treating sources. Smith v. Comm’r of Soc.
Sec., 482 F.3d 873, 875 (6th Cir. 2007). Generally, treating sources are given the greatest amount of
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deference and are to be accorded controlling weight if they are “well-supported by medically
acceptable clinical and laboratory diagnostic techniques and [are] not inconsistent with other
substantial evidence in [the] case record.” Rogers v. Comm’r of Soc. Sec., 486 F.3d 234, 242 (6th Cir.
2007) (quoting Wilson v. Comm’r of Soc. Sec., 378 F.3d 541, 544 (6th Cir. 2004)). In deciding the
amount of weight to give to any medical opinion, the SSA considers (1) the examining relationship;
(2) the treatment relationship; (3) the supportability of the opinion in light of “all of the pertinent
evidence”; (4) the consistency of the opinion with the record as a whole; (5) the medical source’s
specialization, if any; and (6) other factors the claimant or others bring to the SSA’s attention which
tend to support or contradict the source’s opinion. 20 C.F.R. § 404.1527(c)(1)-(6); 20 C.F.R. §
416.927(c)(1)-(6).
The SSA “will always give good reasons” for the weight given to a treating source’s opinion.
See 20 C.F.R. § 404.1527(c)(2); Cole v. Astrue, 661 F.3d 931, 937-39 (6th Cir. 2011) (“In addition to
balancing the factors to determine what weight to give a treating source opinion denied controlling
weight, the agency specifically requires the ALJ to give good reasons for the weight actually
assigned.”). The treating-physician rule is designed to provide claimants with an understanding of
the SSA’s disposition of their applications and to permit “meaningful appellate review of the ALJ’s
application of the rule.” Rogers, 486 F.3d at 242-43 (quoting Wilson, 378 F.3d at 544). To provide
good reasons for discounting a treating physician’s opinion, the ALJ must identify the reasons for
discounting the opinion and explain how those reasons affected the weight the ALJ assigned to the
opinion. Rogers, 486 F.3d at 243.
Reinbolt objects specifically to the weight given to the opinion of treating neurologist,
Faizan Hafeez, M.D., signed onto by treating primary care physician, Krishna Rai, M.D. The ALJ
gave the opinion little weight, explaining,
The opinion of Dr. Hafeez, effectively adopted by Dr. Rai, is inconsistent with the
medical record, including Dr. Hafeez's own objective examinations. For instance,
during her initial visit, Dr. Hafeez noted that the claimant had significant social
stressors, with a non-focal neurological examination, and concluded that it was
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possible the claimant's symptoms were part of a "somatization problem, with no
organic etiology," and later recommended that she follow up with a psychiatrist (Ex.
lOF/71, 81). Dr. Hafeez consistently recommended physical therapy and
occupational therapy, along with an aerobics or water aerobics program for the
claimant, along with increased physical activity, which is inconsistent with restrictions
of standing for no more than five minutes per day and lifting less than ten pounds
only occasionally (Ex. lOF/66; 27F/9). Additionally, objective medical testing has
been normal, including the claimant 's most recent visit with Dr. Hafeez, where he
noted that the claimant's neurological examination was normal , as was recently
conducted EMG and nerve conduction testing (Ex. 46F/1). Additionally, a referral
to another neurologist by Dr. Hafeez yielded a normal examination, where the
claimant was noted to have tenderness in her neck, shoulder, low back, and hips, and
was observed to have good extremity strength (Exh.9F/3). She had normal and
symmetrical reflexes, with a steady gait, and was diagnosed with fibromyalgia (Ex.
9F/3). Given these findings, the opinions of Dr. Hafeez, and therefore those of Dr.
Rai, are given little weight, as they are inconsistent with the objective medical
evidence, including Dr. Hafeez's own examinations of the claimant.
(Doc. No. 8 at 32).
In her objections, Reinbolt first argues the difficulty in diagnosing fibromyalgia. But, as
noted by the Magistrate Judge, there is no debate that Reinbolt has fibromyalgia, as evidenced by the
ALJ’s references to fibromyalgia in his thorough description of her extensive medical history. The
question is “what she is able to do even though she has that condition.” (Doc. No. 15 at 39).
Relatedly, Reinbolt also alleges that she was faulted for pursuing physical therapy as opposed to a
more aggressive treatment regimen for her fibromyalgia. This is not true either. The ALJ did not
reference physical therapy to critique the treatment, but to explain the inconsistency between the
opinion given and regimen prescribed. Both of these specific allegations are immaterial to the
objection. The weight given to the opinion will be upheld so long as the ALJ properly applied the
treating-physician rule, weighing the factors and giving good reasons for his decision.
The ALJ evaluated and described all of the medical evidence, including the treatment
relationship with Dr. Hafeez, beginning in May 2003 to the time the decision was made. There is no
debate that the treatment relationship was extensive. It is the inconsistency of the opinion with the
record as a whole, including the medical records from Dr. Hafeez’s office, that the ALJ explains as
his reasoning for assigning little weight. The opinion in question, given in July 2010 and resigned in
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July 2013 as “unchanged,” cites continuous pain so severe that she could not stand more than 5
minutes, sit more than 20, and could only walk one block. (Doc. No. 8 at 1196). These physical
restrictions are inconsistent with Dr. Hafeez’s regular recommendations that she exercise and
perform physical and aqua therapy. Id. at 909 (Feb. 2009), 914 (Aug. 2006), 915 (Dec. 2003), 929
(April 2011), 931 (Oct. 2010). Dr. Hafeez also reported that she had been “exercising regularly” in
June 2012. Id. at 1010.
Not only do Dr. Hafeez’s records fail to support the opinion, but the ALJ also noted records
from other medical professionals that contradict the restrictions. Between September and
November of 2012, Reinbolt performed five physical therapy sessions which resulted in decreased
pain and increased range of mobility. Id. at 30-31, 1085-91. In February 2010, Reinbolt’s examining
rheumatology consultant stated that “her clinical presentation [was] compatible with fibromyalgia,”
noting her normal range of motion and tender points. Id. at 29, 940. The rheumatology consultant
also recommended thirty minutes of exercise three to four times per week. Id. Finally, in July 2008,
another examining neurologist who concurred with the diagnosis of fibromyalgia, but stated she had
good strength and normal tone and bulk in her extremities. Id. at 612. These records span several
years, account for her diagnosis of fibromyalgia, and consistently support the fact that she can
perform physical activity. After reviewing the medical record, I find the ALJ correctly noted the
consistently “normal” findings, citing not only laboratory style tests, but also alternate objective
medical evidence.
The ALJ found Reinbolt’s fibromyalgia did affect her ability to perform work, but based on
the entire record he determined that it did not restrict her abilities to the extent opined by Dr.
Hafeez. His thorough review and consideration of the record is evident not only by his explanation
of the weight given to Dr. Hafeez’s opinion, but also that given to conflicting opinions. The ALJ
also gave little weight to the consultative examiner, finding the opinion “generally inconsistent with
the evidence, which shows that the claimant has impairments that limit her to less than the light
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range of work.” Id. at 33. As much as Dr. Hafeez had underestimated Reinbolt’s abilities, the
consultative examiner had overestimated them. The ALJ instead gave great weight to the state
agency medical consultants which reflected Reinbolt’s ability to perform “light work” with some
limitations. Id. at 33. After reviewing the medical record and the ALJ’s decision, I find the ALJ
properly considered the factors and gave “good reasons” for assigning little weight to Dr. Hafeez’s
opinion. Reinbolt’s first objection is overruled.
B.

Reinbolt’s Credibility
Reinbolt also objects to the ALJ’s finding that “her allegations of the limiting effects of [her]

impairments [were] not entirely credible.” Reinbolt first asserts that the ALJ erred in using
boilerplate language. But usage of some boilerplate language by the ALJ with respect to credibility is
permissible so long as “the ALJ provide[s] an adequate explanation of the adverse credibility
finding.” Sorrell v. Comm’r of Soc. Sec., 656 F. App’x 162, 174 (6th Cir. 2016). Here, the ALJ satisfied
this requirement by supplanting the boilerplate language with a thorough explanation of his
credibility finding with citations to evidence in the record. (Doc. No. 8 at 33-34).
The ALJ’s credibility assessments are accorded “great weight and deference, particularly
since an ALJ is charged with the duty of observing a witness's demeanor and credibility.” Walters v.
Comm’r of Soc. Sec., 127 F.3d 525, 531 (6th Cir. 1997). The reviewing court is “limited to evaluating
whether or not the ALJ's explanations [of credibility] are reasonable and supported by substantial
evidence in the record.” Jones v. Comm’r of Soc. Sec., 336 F.3d 469, 476 (6th Cir. 2003). In addition to
the objective medical evidence, “an ALJ may consider household and social activities in evaluating
complaints of disabling pain.” Blancha v. Sec’y of Health and Human Servs., 927 F.2d 228, 231 (6th Cir.
1990).
As noted above, the ALJ thoroughly reviewed the entire record and analyzed the consistency
of the evidence. In his credibility assessment, the ALJ cited not one, but many statements in the
medical records inconsistent with Reinbolt’s alleged debilitating pain. Specifically, he noted activities
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such as going out dancing, baking “all day,” several trips to Jamaica, shoveling horse stalls, and
exercising to lose weight. (Doc. No. 8 at 33). Reinbolt does not point to any evidence to support
her alleged severe pain, but instead says the statements cited by the ALJ were taken out of context or
mischaracterized. After reviewing the record, I do not find that to be true. These statements
regarding her household and social activities supply a sufficient basis for the ALJ’s finding that her
statements made to the SSA about the severity of her pain were not entirely credible. I find the ALJ
had a reasonable basis for his credibility assessment and overrule Reinbolt’s second objection.
V.

CONCLUSION

For the foregoing reasons, both of Reinbolt’s objections are overruled. (Doc. No. 16). In
accordance with Magistrate Judge Parker’s R &R, I affirm the ALJ’s decision.
So Ordered.
s/ Jeffrey J. Helmick
United States District Judge

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