Pinson v. Commissioner of Social Security

Filing 12

Memorandum Opinion and Order. Following review of the arguments presented, the record, and the applicable law, the undersigned finds the Commissioner's decision denying disability insurance benefits supported by substantial evidence and AFFIRMS that decision. Related document 1 . Magistrate Judge James R. Knepp, II on 2/28/2019. (S,JM)

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

THERESA DENIS PINSON,

Case No. 3:18 CV 12

Plaintiff,
v.

Magistrate Judge James R. Knepp, II

COMMISSIONER OF SOCIAL SECURITY,
Defendant.

MEMORANDUM OPINION AND ORDER 

INTRODUCTION
Plaintiff Theresa Denis Pinson (“Plaintiff”) filed a Complaint against the Commissioner of
Social Security (“Commissioner”) seeking judicial review of the Commissioner’s decision to deny
disability insurance benefits (“DIB”). (Doc. 1). The district court has jurisdiction under 42 U.S.C.
§§ 1383(c) and 405(g). The parties consented to the undersigned’s exercise of jurisdiction in
accordance with 28 U.S.C. § 636(c) and Civil Rule 73. (Doc. 11). For the reasons stated below,
the undersigned affirms the decision of the Commissioner.
PROCEDURAL BACKGROUND
Plaintiff filed for DIB in October 2014, alleging a disability onset date of January 2, 20121.
(Tr. 184-85). She had a date last insured of December 31, 2014. See Tr. 70, 87. Her claims were
denied initially and upon reconsideration. (Tr. 106-08, 110-12). Plaintiff then requested a hearing

1. Plaintiff originally alleged an onset date of July 15, 2009 due to degenerative disc disease, posttraumatic stress disorder (“PTSD”), spinal stenosis, anemia, arthritis of the left shoulder, hernias,
chronic menstrual bleeding, mitral valve prolapse, and hypertension. (Tr. 213, 217). Plaintiff later
amended her alleged onset date to January 2, 2012. (Tr. 34). As an aside, the ALJ’s decision uses
January 12, 2012 as the alleged onset date. (Tr. 10). Neither party raises this as an issue, and it
appears to be a typographical error, as Plaintiff identified January 2, 2012 in her oral motion to
amend. See Tr. 34. Regardless, any such distinction does not make a difference in the outcome
herein. 

before an administrative law judge (“ALJ”). (Tr. 122-24). Plaintiff (represented by counsel), and
a vocational expert (“VE”) testified at a hearing before the ALJ on October 12, 2016. (Tr. 31-69).
On February 21, 2017, the ALJ found Plaintiff not disabled in a written decision. (Tr. 10-25). The
Appeals Council denied Plaintiff’s request for review, making the hearing decision the final
decision of the Commissioner. (Tr. 1-3); see 20 C.F.R. §§ 404.955, 404.981. Plaintiff timely filed
the instant action on January 2, 2018. (Doc. 1).
FACTUAL BACKGROUND
Personal Background and Testimony
Plaintiff was born in January 1962, making her 50 years old on her alleged onset date, and
54 years old on the date of the hearing. See Tr. 34, 213. She alleged disability due to degenerative
disc disease, post-traumatic stress disorder (“PTSD”), spinal stenosis, anemia, arthritis of the left
shoulder, hernias, chronic menstrual bleeding, mitral valve prolapse, and hypertension. (Tr. 213,
217). Plaintiff had past work in retail as an assistant manager and salesperson. (Tr. 218).
When she filed for disability in the fall of 2014, Plaintiff thought she could no longer work
due to neck and back pain. (Tr. 35). Plaintiff testified that it was “hard for [her] to do anything”,
and she was not getting better. Id. She saw Dr. Evanoff, her family physician, twice per year for
pharmacological management of her pain symptoms. (Tr. 35-37, 39).
Plaintiff “sometimes” grocery shopped with her husband. (Tr. 53). She could lift a gallon
of milk on her own but testified that it was sometimes difficult. (Tr. 54). Plaintiff estimated she
could not lift a gallon of milk more than four times per hour. Id. Plaintiff estimated she spent
fifteen minutes at a time, on average, in a grocery store and noted that she would be in pain after
running the errand. (Tr. 54-55). Around the house, she washed dishes, loaded the dishwasher, and
folded “a little” laundry. (Tr. 60-61).

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In late 2011, Plaintiff and her husband got rid of their farm animals because she was unable
to carry a bucket of feed corn to the cows due to pain. (Tr. 56-57). Plaintiff estimated the feed
bucket was a three- to four-gallon bucket. (Tr. 57).
Plaintiff also had trouble sleeping. (Tr. 59). Plaintiff testified she slept two hours per night
and often woke due to neck pain, nightmares, and racing thoughts. Id.
Relevant Medical History2
In April 2009, Plaintiff saw neurosurgeon Patrick McCormick, M.D., for neck, shoulder,
and lower back pain. (Tr. 286). Plaintiff reported her pain resulted from a recent car accident. Id.
She reported her “baseline” low back and neck pain ranged from 5/10 to 6/10 but increased to 8/10
with activity. Id. On examination, Plaintiff had a limited range of motion in her neck and left
shoulder, but had a full range of motion in her right shoulder without discomfort. (Tr. 287). Dr.
McCormick explained the cervical MRI results showed “significant disk herniation at C5-C6,
effacement of [cerebrospinal fluid], and right paracentral compromise of cord and root.” Id.
Further, a lumbar MRI revealed an L5-S1 broad-based protrusion without loss of disc space height

2. The relevant time period for consideration in this case is January 2, 2012 (alleged onset date)
to December 31, 2014 (date last insured). See Moon v. Sullivan, 923 F.2d 1175, 1182 (6th Cir.
1990) (“In order to establish entitlement to disability insurance benefits, an individual must
establish that he became “disabled” prior to the expiration of his insured status.”). Therefore, the
undersigned summarizes the medical records relevant to Plaintiff’s impairments during that time,
with a brief summary of a relevant visit prior to her alleged onset date. Post-dated evidence is
immaterial unless it relates back to the period under review. See Pickard v. Comm’r, 224 F. Supp.
2d 1161, 1171 (W.D. Tenn. 2002); Strong v. Comm'r of Soc. Sec., 88 F. App’x 841, 845 (6th Cir.
2004) (“Evidence of disability obtained after the expiration of insured status is generally of little
probative value.”). Herein, the undersigned summarizes a later dated neurology appointment with
MRI results, as well as later-dated opinion evidence relevant to Plaintiff’s arguments.
Further, Plaintiff alleged disability based on both physical and mental conditions, see Tr. 217, and
there are both physical and mental health treatment records. However, in her brief, Plaintiff only
challenges the physical limitations in her RFC. Therefore, the undersigned only summarizes the
medical records relevant to Plaintiff's physical impairments. Kennedy v. Comm'r of Soc. Sec., 87
F. App’x 464, 466 (6th Cir. 2003).  
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and no obvious signs of compromised neurologic structures. (Tr. 287-88). Plaintiff wanted to
proceed with surgical intervention. (Tr. 288).
In May 2012, Plaintiff saw her primary care physician, John Evanoff, M.D., for fatigue and
weight gain. (Tr. 312). On examination, Dr. Evanoff found Plaintiff had a normal gait with no
mobility limitations and full upper and lower extremity strength. (Tr. 313). Dr. Evanoff diagnosed
fatigue and hypothyroidism. Id. In June 2012, Plaintiff saw Dr. Evanoff for left shoulder pain. (Tr.
310). Examination revealed “no real tenderness or range of motion limitations in the left shoulder,”
however, he found the pain emanated from Plaintiff’s C6-C7 vertebrae, and traveled into her left
arm down to her left elbow. (Tr. 311). Dr. Evanoff opined this pain was consistent with a cervical
nerve root impingement. Id. He diagnosed a bulging cervical disk and referred Plaintiff to a
neurosurgeon. Id.
Plaintiff saw Dr. Evanoff again in November 2013 for pain “all over” possibly the result
of a car accident which happened “a while back”. (Tr. 305). On examination, Plaintiff had a normal
gait, full strength in her upper and lower extremities, and no mobility limitations. (Tr. 307). Dr.
Evanoff opined Plaintiff’s pain was likely the result of previous cervical disc issues which she had
yet to repair. Id.
In February 2014, Plaintiff saw John Brunner, M.D., for hypothyroidism. (Tr. 397). On
examination, Plaintiff had normal motor strength in her upper and lower extremities. (Tr. 398).
Plaintiff treated with Dr. Evanoff again in June 2014, complaining of pain in her legs and
ankles. (Tr. 303). On examination, Dr. Evanoff found Plaintiff’s cranial nerves were intact, and
she had normal sensation. (Tr. 304). Dr. Evanoff diagnosed Achilles tendonitis and restless leg
syndrome; he prescribed medication. Id. In July, Plaintiff returned to Dr. Evanoff reporting
shooting pains when stretching and when she elevated her legs. (Tr. 299). Medication helped but

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did not resolve the pain. Id. Dr. Evanoff diagnosed Achilles tendonitis and recommended a heel
cup. (Tr. 301). In November 2014, Plaintiff saw Dr. Evanoff for bronchitis symptoms with no
mention of leg pain. (Tr. 296).
Plaintiff attended a consultative physical examination by Sushil Sethi, M.D., in February
2015. (Tr. 362-64). Dr. Sethi found mild tenderness in the acromioclavicular joint bilaterally, with
no sign of shoulder impingement. (Tr. 363). Plaintiff had normal: shoulder and elbow range of
motion; grasp, pinch, manipulation, fine coordination; and range of motion in her cervical and
thoracic spine with no swelling, redness, or deformities. (Tr. 363-64).
In September 2016, Plaintiff saw neurologist Stanford Rapp, D.O., for tingling and
numbness in her right arm. (Tr. 417). On examination, Plaintiff had a normal gait with no ataxia
or unsteadiness, and normal strength in both lower extremities (Tr. 419-20). She had weakness in
her right upper extremity, with normal strength in the left. (Tr. 420). Dr. Rapp diagnosed right arm
weakness. Id. Later that month, a cervical MRI revealed moderate disc disease at C5-C6 with some
degenerative change at C1-C2. (Tr. 450). At C3-C4, Plaintiff had left (greater than right)
uncovertebral and “endplate hypertrophic changes with minor disc bulge causing mild to moderate
foraminal narrowing without significant central stenosis”. Id.
Opinion Evidence
In February 2015, Dr. Sethi opined Plaintiff’s hearing, speaking, and ability to travel were
normal, but her ability to sit, stand, walk, lift, carry, and handle objects “may be slightly affected”
by her physical conditions. (Tr. 364).
Later in February 2015, State agency physician Bradley Lewis, M.D., reviewed Plaintiff’s
medical records and offered a physical residual functional capacity assessment. (Tr. 79-81). Dr.
Lewis opined Plaintiff could occasionally lift/carry 50 pounds; frequently lift/carry 25 pounds; and

5 

stand, sit, or walk approximately six hours in an eight-hour workday. (Tr. 79). He found Plaintiff
had an unlimited ability to push and pull, balance, and climb ramps and stairs. (Tr. 80).
Additionally, Plaintiff could occasionally crawl and climb ladders, ropes, and scaffolds; she could
frequently stoop and crouch. Id. Finally, Dr. Lewis opined Plaintiff had a limited ability to reach
overhead bilaterally, but was unlimited in her ability to handle, finger, and feel. Id.
In July 2015, State agency physician Rannie Amiri, M.D., reviewed Plaintiff’s medical
records and opined she could only occasionally lift/carry twenty pounds and frequently lift/carry
ten. (Tr. 96). She found Plaintiff was unlimited in her ability to climb ramps and stairs, balance,
kneel, and crawl; she could frequently climb ladders, ropes, and scaffolds, stoop, and crouch. (Tr.
97). Dr. Amiri opined Plaintiff had no manipulative limitations. Id.
VE Testimony
A VE appeared and testified at the hearing before the ALJ. See Tr. 61-67. The ALJ asked
the VE to consider a person with Plaintiff’s age, education, and vocational background who was
physically and mentally limited in the way in which the ALJ determined Plaintiff to be. (Tr. 63).
The VE opined such an individual could not perform Plaintiff’s past work, but could perform other
jobs such as a laundry worker, janitor, or dish washer. (Tr. 63-64).
ALJ Decision
In a written decision dated February 21, 2017, the ALJ found Plaintiff last met the insured
status requirements for DIB on December 31, 2014 and had not engaged in substantial gainful
activity from her alleged onset date (January 2012), through her date last insured. (Tr. 12). She
concluded Plaintiff had the severe impairments of: cervical disk disease, cervicalgia, anxiety
disorder, and PTSD, but found these impairments (alone or in combination) did not meet or

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medically equal the severity of a listed impairment. (Tr. 12-13). The ALJ then set forth Plaintiff’s
residual functional capacity (“RFC”):
to perform medium work as defined in 20 CFR 404.1567(c) except: no overhead
reaching with the right upper extremity, climbing, ropes, ladders, scaffolds, no
balancing and performing the remaining postural activities on a frequent basis. In
addition, the claimant could perform simple routine tasks that required little or no
judgment and could perform skills that could be learned in no more than thirty days
as stated in the Dictionary of Occupational Titles (DOT) (i.e. SVP of 2), in
environments with no high production quotas as needed on an assembly line, in
environments with no dangerous machinery, no unprotected elevations, and no
commercial driving. In addition, the claimant could have occasional interaction
with the public, co-workers and supervisors.
(Tr. 15-16). The ALJ found Plaintiff was unable to perform past relevant work (Tr. 23); was
defined as “an individual closely approaching advanced age” on the date last insured id.; and had
a limited education (Tr. 24). The ALJ concluded that, considering Plaintiff’s age, education, work
experience, and residual functional capacity, there were jobs that existed in significant numbers in
the national economy that Plaintiff could have performed. Id. Thus, the ALJ found Plaintiff not
disabled “from July 15, 20093 the alleged onset date, through December 31, 2014, the date last
insured.” (Tr. 25).
STANDARD OF REVIEW
In reviewing the denial of Social Security benefits, the Court “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). “Substantial evidence
is more than a scintilla of evidence but less than a preponderance and is such relevant evidence as
a reasonable mind might accept as adequate to support a conclusion.” Besaw v. Sec’y of Health &

3. Here, it appears the ALJ mistakenly used the non-amended onset date. See Tr. 34 (oral motion
to amend).
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Human Servs., 966 F.2d 1028, 1030 (6th Cir. 1992). The Commissioner’s findings “as to any fact
if supported by substantial evidence shall be conclusive.” McClanahan v. Comm’r of Soc. Sec.,
474 F.3d 830, 833 (6th Cir. 2006) (citing 42 U.S.C. § 405(g)). Even if substantial evidence or
indeed a preponderance of the evidence supports a claimant’s position, the court cannot overturn
“so long as substantial evidence also supports the conclusion reached by the ALJ.” Jones v.
Comm’r of Soc. Sec., 336 F.3d 469, 477 (6th Cir. 2003).
STANDARD FOR DISABILITY
Eligibility for benefits is predicated on the existence of a disability. 42 U.S.C. §§ 423(a),
1382(a). “Disability” is defined as 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.” 20 C.F.R. § 404.1505(a); see also 42 U.S.C. § 1382c(a)(3)(A). The
Commissioner follows a five-step evaluation process—found at 20 C.F.R. § 404.1520—to
determine if a claimant is disabled:
1.

Was claimant engaged in a substantial gainful activity?

2.

Did claimant have a medically determinable impairment, or a combination
of impairments, that is “severe,” which is defined as one which substantially
limits an individual’s ability to perform basic work activities?

3.

Does the severe impairment meet one of the listed impairments?

4.

What is claimant’s residual functional capacity and can claimant perform
past relevant work?

5.

Can claimant do any other work considering her residual functional
capacity, age, education, and work experience?

Under this five-step sequential analysis, the claimant has the burden of proof in Steps One
through Four. Walters, 127 F.3d at 529. The burden shifts to the Commissioner at Step Five to

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establish whether the claimant has the residual functional capacity to perform available work in
the national economy. Id. The ALJ considers the claimant’s residual functional capacity, age,
education, and past work experience to determine if the claimant could perform other work. Id.
Only if a claimant satisfies each element of the analysis, including inability to do other work, and
meets the duration requirements, is she determined to be disabled. 20 C.F.R. §§ 404.1520(b)-(f);
see also Walters, 127 F.3d at 529.
DISCUSSION
Plaintiff raises a single challenge to the ALJ’s decision – the RFC is without evidentiary
support. (Doc. 9, at 7-9). Specifically, Plaintiff argues the ALJ erred in finding she could work at
a medium exertional level. Id. The Commissioner responds that substantial evidence supports the
RFC. (Doc. 10, at 8-19). For the reasons stated below, the undersigned agrees with the
Commissioner and affirms the decision.
A claimant’s RFC is an assessment of “the most [she] can still do despite [her] limitations.”
20 C.F.R. § 404.1545(a)(1). An ALJ must consider all symptoms and the extent to which those
symptoms are consistent with the objective medical evidence Id. § 404.1529. While an ALJ must
consider and weigh medical opinions, the RFC determination is expressly reserved to the
Commissioner. Ford v. Comm’r of Soc. Sec., 114 F. App’x 194, 198 (6th Cir. 2004); 20 C.F.R. §§
404.1527(e)(2), 404.1546. The Court must affirm “so long as substantial evidence also supports
the conclusion reached by the ALJ” even if substantial evidence or indeed a preponderance of the
evidence also supports a claimant’s position. Jones, 336 F.3d at 477.
To support her argument that she is more physically limited than determined by the ALJ,
Plaintiff relies on three pieces of evidence. See Doc. 9, at 6-9. These are: first, Plaintiff’s testimony
that she could not carry a feed bucket Id. at 7-8 (citing Tr. 56-57); second, an MRI from 2009

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(prior to her alleged onset date) which, Plaintiff argues, showed “compromise of cord and root”,
id. (citing Tr. 287-88); and third, Dr. Sethi’s opinion, which Plaintiff argues is inappropriately
vague, id. (citing Tr. 364). The undersigned addresses Plaintiff’s arguments in this order.
Testimony Regarding Lifting Abilities
First, Plaintiff argues that nothing in the record supports the ALJ’s finding that she is
capable of the lifting requirements of “medium work”. (Doc. 9, at 7). Under the regulations,
“[m]edium work involves lifting no more than 50 pounds at a time with frequent lifting or carrying
of objects weighing up to 25 pounds.” 20 C.F.R. § 404.1567(c). As evidence she cannot perform
the requirements of “medium work”, Plaintiff points to testimony where she detailed her inability
to carry a three to four-gallon feed bucket filled with corn. (Doc. 9, at 8) (citing Tr. 57). With her
brief, Plaintiff attached a volume to weight conversion chart showing the weight of one gallon of
shelled corn. See Doc. 9, at 10-11. Using the conversion chart, Plaintiff argues that a four-gallon
bucket of feed corn weighs 24.08 pounds, and a three-gallon bucket weighs 18.06 pounds. Id. at
8. Thus, her testimony that she was no longer able to carry her feed bucket – which presumably
weighed between 18.06 and 24.08 pounds – demonstrates that she is unable to work at the medium
exertional level which requires “frequent lifting or carrying of objects weighing up to 25 pounds.”
20 C.F.R. § 404.1567(c).
While the ALJ did not specifically reference the feed bucket, she did address the credibility
of Plaintiff’s testimony.4 See Tr. 17, 20. Under the regulations, an ALJ is required to consider a

4.  Social Security Regulations previously used the term “credibility” for evaluating a Plaintiff’s
subjective report of symptoms. See SSR 96-7p, 1996 WL 374186. In March 2016, the Social
Security Administration issued new Social Security Ruling 16-3p, which eliminated “‘the use of
the word ‘credibility’ . . . to ‘clarify that the subjective symptoms evaluation is not an examination
of an individual’s character.’” Dooley v. Comm’r of Soc. Sec., 656 F. App’x 113, 119 n.1 (6th Cir.
2016) (quoting SSR 16-3p, 2016 WL 1119029, at *1). Both SSR 96-7p and SSR 16-3p direct the
ALJ to evaluate an individual’s subjective report of symptoms with the factors listed in 20 C.F.R.
10 

claimant’s statements about their symptoms, however, “there must be objective medical evidence
from an acceptable medical source that shows. . . a medical impairment(s) which could reasonably
be expected to produce the pain or other symptoms alleged[.]” 20 C.F.R. § 404.1529. In
determining whether a claimant has disabling symptoms, the regulations also require an ALJ to
consider certain factors including: 1) daily activities; 2) location, duration, frequency, and intensity
of pain or symptoms; 3) precipitating and aggravating factors; 4) the type, dosage, effectiveness,
and side effects of any medication; 5) treatment, other than medication, to relieve pain, 6) any
measures used to relieve pain, and 7) other factors concerning functional limitations and
restrictions due to pain or other symptoms. Id.; SSR 16-3p, 2017 WL 5180304, at *7 (“In addition
to using all of the evidence to evaluate the intensity, persistence, and limiting effects of an
individual’s symptoms, we will also use the factors set forth in 20 CFR 404.1529(c)(3)[.]”).
Although the ALJ must “consider” the listed factors, there is no requirement that the ALJ discuss
every factor. White v. Comm’r of Soc. Sec., 572 F.3d 272, 287 (6th Cir. 2009).
As to Plaintiff’s credibility, the ALJ explained:
After careful consideration of the evidence, I find that the claimant’s medically
determinable impairments could reasonably be expected to cause some of the
alleged symptoms; however, the claimant’s statements concerning the intensity,
persistence and limiting effects of these symptoms are not entirely consistent with
the medical evidence and other evidence in the record for the reasons explained in
this decision.
***
[W]hile the claimant had medically determinable physical impairments that could
reasonably cause some symptoms and limitations, I find the allegations are broader

§ 404.1529. SSR 16-3p, 2017 WL 5180304, at *7; 1996 WL 374186, at *2. Thus, while the term
“credibility” was eliminated, prior case law is still applicable as both regulations refer to the twostep process in 20 C.F.R. § 404.1529. See Pettigrew v. Berryhill, 2018 WL 3104229, at *14 n.14
(N.D. Ohio) (“While the court applies the new SSR, it declines to engage in verbal gymnastics to
avoid the term credibility where usage of the term is most logical. Furthermore, there is no
indication that the voluminous case law discussing and applying the credibility or symptom
analysis governed by SSR 96–7p has been invalidated by SSR 16–3p.”), report and
recommendation adopted by 2018 WL 3093696. 
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and more restricted than was established by the medical evidence. This is not to say
that the claimant was symptom free or did not experience difficulty performing
some tasks. However, the objective evidence did not demonstrate the existence of
limitations of such severity as to have precluded the claimant from performing all
work on a regular and continuing basis at any time from the onset date of disability
through her date last insured.
(Tr. 17, 20).
Turning to the objective evidence, the ALJ cited (among other things) a lack of a consistent
treatment history. (Tr. 17-18). The ALJ first noted a lack of treatment from the alleged onset date
in January 2012 until May 2012 where Plaintiff saw her primary care provider only for fatigue and
weight gain. (Tr. 17) (citing Tr. 312). The ALJ pointed to another significant break in treatment
from June 2012 where she reported shoulder pain to Dr. Evanoff (Tr. 310), through November
2013 where she saw Dr. Evanoff for back tenderness (Tr. 305). (Tr. 18). Plaintiff next saw a thyroid
specialist for an unrelated condition in February 2014 (Tr. 397), and again did not seek medical
care until a June 2014 appointment with Dr. Evanoff where she complained of leg pain (Tr. 303).
Plaintiff saw Dr. Evanoff for bronchitis symptoms, with no mention of leg pain in November 2014
(Tr. 296), and did not seek further treatment for her cervical disc disease until September 2016 –
over one year past her date last insured (Tr. 417). (Tr. 18). A lack of treatment is a legitimate
reason on which the Commissioner may rely to discount credibility. See Rudd v. Comm’r of Soc.
Sec., 531 F. App’x, 719, 727 (6th Cir. 2013) (minimal treatment or lack of treatment is valid reason
to discount severity and credibility); see also SSR 16-3p, 2017 WL 5180304, at *8 (“[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 . . . we may find the alleged intensity and persistence of an
individual’s symptoms inconsistent with the overall evidence of record.”).
Later in her opinion, the ALJ noted that – when Plaintiff did receive treatment – it was
rather conservative. (Tr. 19). For example, Plaintiff saw Dr. Evanoff for left shoulder pain in June
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2012 where, on examination, he found Plaintiff may have a cervical nerve root impingement that
would need to be surgically corrected. (Tr. 311). Plaintiff did not have surgery and did not see a
physician again for pain until two years later when, in June 2014, she saw Dr. Evanoff for leg
tenderness and restless leg syndrome. (Tr. 303). On examination, Dr. Evanoff found Plaintiff had
mild tenderness in her Achilles tendon, and prescribed medication for restless leg syndrome. (Tr.
304). At a follow-up visit with Dr. Evanoff the following month, Plaintiff still had mild tenderness
in the Achilles tendon. (Tr. 301). Dr. Evanoff prescribed a heel-cup and advised her to “return
when necessary”. Id. The record does not reflect that Plaintiff returned to Dr. Evanoff for pain
following this visit. As noted above, an ALJ does not err when she considers such a conservative
treatment history when assessing Plaintiff’s credibility. Rudd, 531 F. App’x at 727; Walters, 127
F.3d at 531 (“Discounting credibility to a certain degree is appropriate where an ALJ finds
contradictions among the medical reports, claimant’s testimony, and other evidence.”); McKenzie
v Comm’r of Soc. Sec., 2000 WL 687680, at *13 (6th Cir.) (Plaintiff’s non-aggressive treatment
undermined his complaints of disabling pain); Howell v. Comm’r of Soc. Sec., 2018 WL 1224513,
at *7 (S.D. Ohio) (holding that an ALJ did not err in formulating RFC when he considered
“Plaintiff’s relatively conservative treatment – namely that he did not require surgical intervention,
consistent use of a TENs unit, epidural steroid injections, the use of an assistive device or any other
treatment modality commonly seen with disabling impairments [.]”).
For the reasons discussed above, the undersigned finds no error with the ALJ’s credibility
assessment.
2009 MRI
As further evidence she is unable to work at a medium exertional level, Plaintiff points to
the April 2009 MRI reviewed by Dr. McCormick. (Tr. 286). Plaintiff notes the MRI revealed a

13 

“compromise of cord root” and she opines “that means the herniation was pushing against the
spinal cord and the root nerves at the C5-C6 . . . it is not surprising that Plaintiff experienced severe
pain when she tried to lift any weight . . . certainly she could not have lifted and carried 25 pounds
for 5 hours in an 8-hour workday.” (Doc. 9, at 8). Of note, this evidence pre-dates the relevant time
period by almost three years and Plaintiff points to no other objective evidence of record.
Even so, the ALJ considered the MRI, finding it:
[s]howed evidence of mild degenerative disc disease; however, there was no further
testing or treatment after this remote imaging study and nothing reflects greater
than mild findings. (1F). The above stated conditions have been managed medically
and conservatively and should be amenable to proper control by adherence to
recommended medical management and medication compliance. No aggressive
treatment was recommended or anticipated.
(Tr. 13). Thus, the ALJ acknowledged the MRI showed evidence of disc disease, however, the
ALJ also (again) considered Plaintiff’s minimal and conservative treatment history following this
diagnosis. Id. For example, at her 2009 appointment with Dr. McCormick, Plaintiff expressed a
desire to proceed with surgical intervention (Tr. 288), but never followed through, and there is no
indication in the record she ever returned to Dr. McCormick. Again, as discussed above, a minimal
and conservative treatment history may be considered by the ALJ when arriving at her RFC. See
McKenzie, 2000 WL 687680, at *13 (Plaintiff’s non-aggressive treatment undermined his
complaints of disabling pain); Howell, 2018 WL 1224513, at *7 (holding that an ALJ did not err
in formulating RFC when he considered “Plaintiff’s relatively conservative treatment – namely
that he did not require surgical intervention, consistent use of a TENs unit, epidural steroid
injections, the use of an assistive device or any other treatment modality commonly seen with
disabling impairments [.]”). And importantly, “the mere diagnosis of [an impairment], of course,
says nothing about the severity of the condition.” Higgs v. Bowen, 880 F.2d 860, 863 (6th Cir.

14 

1988). For these reasons, the undersigned finds no error in the ALJ’s consideration of the April
2009 MRI results.
Dr. Sethi
Lastly, Plaintiff argues Dr. Sethi’s opinion that her “ability to do work-related physical
activities such as sitting, standing, walking, lifting, carrying and handling objects may be slightly
affected” is significant. (Doc. 9, at 8-9) (quoting Tr. 364). Plaintiff does not offer a specific
argument as to why the opinion is significant, however. Here, she quotes the only “opinion”
proffered by Dr. Sethi and even acknowledges “[the] opinion is highly vague”. Id.
The ALJ addressed Dr. Sethi’s opinion and gave several reasons for assigning the opinion
“only some weight”. (Tr. 19). The ALJ found:
This assessment is consistent with his objective findings, noting only mild to
moderate tenderness on exam, but otherwise reflecting normal strength, normal
gait, normal sensation, and an ability to perform exertional motion (walking) and
postural movements (squatting). Yet, his general statement noted that the claimant
would be “slightly limited” and this is vague in nature, as it does not provide
specific functional limitations.
Id. (internal citations omitted).
Substantial evidence supports the ALJ’s finding regarding Dr. Sethi’s opinion. As a
consultative examiner, Dr. Sethi’s opinion is not entitled to controlling weight, however, the ALJ
must weigh the opinion under the same factors as a treating physician, including the supportability
and consistency of the opinion. See 20 C.F.R. § 404.1527(c)(3)-(4). The ALJ is not required to
provide “good reasons” as she must for a treating physician’s opinion, but her decision must still
be supported by substantial evidence. Stacey v. Comm’r of Soc. Sec., 451 F. App’x 517, 519 (6th
Cir. 2011). The ALJ’s decision “must say enough ‘to allow the appellate court to trace the path of
his reasoning’”. Id. (quoting Diaz v. Chater, 55 F.3d 300, 307 (7th Cir. 1995).

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In support of her decision, the ALJ pointed out that Dr. Sethi failed to provide any specific
functional limitations, only proffering a very broad opinion that Plaintiff was “slightly limited” in
her ability to perform some work-related functions. (Tr. 19) (citing Tr. 364). As she did here, an
ALJ may reject a consultative examiner’s opinion (or portions of it) because it is vague or unclear.
See Coldiron v. Comm’r of Soc. Sec., 391 F. App’x 435, 440 (6th Cir. 2010) (an ALJ gave “good
reasons” when he did not assign controlling weight to a treating physician’s opinion he found “too
inconsistent and unclear to be helpful”); see also Gaskin v. Comm’r of Soc. Sec., 280 F. App’x
472, 476 (6th Cir. 2008) (an ALJ properly rejected portions of a non-treating physician’s opinion
he found “vague and not defined”). Here, the ALJ properly accorded Dr. Sethi’s opinion “some
weight” due to the vague nature of the opinion statement. (Tr. 19). Further, Dr. Sethi did not offer
any functional limitations which could be incorporated into an RFC by the ALJ. Moreover,
Plaintiff does not explain how, even if the ALJ adopted Dr. Sethi’s opinion, it would change the
RFC. Thus, the undersigned finds no error in the ALJ’s assessment here.
In sum, for the reasons discussed above, the undersigned finds the ALJ properly assessed
Plaintiff’s credibility, and properly discussed the 2009 MRI, and properly discounted Dr. Sethi’s
opinion. Thus, the ALJ’s determination that Plaintiff is capable of “medium work” supported by
substantial evidence.
CONCLUSION
Following review of the arguments presented, the record, and the applicable law, the
undersigned finds the Commissioner’s decision denying DIB supported by substantial evidence
and affirms that decision.

s/James R. Knepp II
United States Magistrate Judge
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