Harrison v. Commissioner of Social Security
Filing
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MEMORANDUM (Order to follow as separate docket entry) OPINION re: appeal of a final decision of the Acting Commissioner of the Social Security Administration. Signed by Magistrate Judge Martin C. Carlson on September 5, 2017. (kjn)
IN THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF PENNSYLVANIA
CHARLES J. HARRISON,
Plaintiff,
v.
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NANCY A. BERRYHILL
Acting Commissioner of
Social Security
Defendant.
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Civil No. 1:16-CV-1169
(Magistrate Judge Carlson)
MEMORANDUM OPINION
I.
Introduction
The plaintiff, Charles Harrison, (“Mr. Harrison”) is an adult individual who
resides within the Middle District of Pennsylvania.
On November 28, 2012,
Harrison filed a claim for disability insurance benefits, alleging his disability began
on September 21, 2011. This claim was denied in a final decision of the Acting
Commissioner of the Social Security Administration (“Commissioner”). He now
appeals.
This matter has been assigned to the undersigned United States Magistrate
Judge on consent of the parties, pursuant to the provisions of 28 U.S.C. § 636(c)
and Rule 73 of the Federal Rules of Civil Procedure. (Doc. 13; Doc. 14). Upon a
1
Pursuant to Rule 25(d) of the Federal Rules of Civil Procedure and 42 U.S.C. §
405(g), Acting Commissioner Nancy A. Berryhill is automatically substituted as
the named defendant in place of the former Commissioner of Social Security.
careful review of the administrative record, and following consideration of the
arguments of counsel, for the reasons expressed herein, we have found that the
final decision of the Commissioner is supported by substantial evidence.
Accordingly, we will affirm the Commissioner’s decision.
II.
Background and Procedural History
The record of Mr. Harrison’ medical treatment for physical and mental
health issues is extensive. On August 16, 2011, a few weeks prior to his alleged
September 21, 2011, date of onset of disability, Mr. Harrison underwent back
surgery to relieve pressure on his nerve root at L5. About a week after the surgery,
Nicholas Pandelidis, M.D., the orthopedist who performed the procedure, noted
that Mr. Harrison’s leg pain was “much better,” but he would need physical
therapy. (Admin. Tr. 569-70; Doc. 12-15 pp. 4-5). Shortly after his alleged date of
onset of disability, Mr. Harrison conducted a work-conditioning physical therapy
program at the Drayer Physical Therapy Institute. (Admin. Tr. 498, 516; Doc. 1212 pp. 48, 66).
On October 12, 2011, Dr. Pandelidis found Mr. Harrison’s sciatica was
resolving. (Admin. Tr. 471; Doc. 12-12 p. 21). He indicated that Mr. Harrison
“could do light work, but no frequent bending, twisting, or lifting and no lifting
greater than 20 pounds. Ultimately he should be able to get back to moderately
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heavy work. He should not go back to jack hammering.” (Admin. Tr. 571; Doc.
12-15 p. 6). This assessment was upgraded at the next scheduled appointment on
November 23, 2011. Based on the evaluation of physical therapists at Drayer, Dr.
Pandelidis released Mr. Harrison to “medium duty” work. (Admin. Tr. 572, 59396; Doc. 12-15 pp. 7, 28-31). Finally, at the next appointment, on December 27,
2011, Dr. Pandelidis released Mr. Harrison back to work without restrictions but
also stated he should avoid the heaviest work. (Admin. Tr. 573; Doc. 12-15 p. 8).
Dr. Pandelidis reported that although Mr. Harrison’s neck mobility was “somewhat
decreased,” his gait was “good” and he had some tenderness but not spasm. Id.
Dr. Pandelidis referred Mr. Harrison to Ali Yousufuddin, M.D. On March
23, 2012, Dr. Yousufuddin examined Mr. Harrison for his complaint of chronic
low back pain that had continued after surgery. (Admin. Tr. 579; Doc. 12-15 p.
14). Dr. Yousufuddin reported that Mr. Harrison’s straight leg-raising was normal
bilaterally at 90 degrees. (Admin. Tr. 580; Doc 12-15 p. 15). Mr. Harrison’s
motor strength in his legs was 5/5. Id. He had tenderness over the left sacroiliac
joint, but no numbness in his legs or feet. Id. Dr. Yousuffuddin recommended
injections at the left lumbar facet and sacroiliac joint. (Admin. Tr. 581; Doc. 12-15
p. 16). Mr. Harrison stated he had fifty percent less pain from his left-sided lower
back one month after the injections. (Admin. Tr. 582; Doc. 12-15 p. 17). Dr.
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Yousufuddin noted Mr. Harrison had “marked tenderness present over the left
sacroiliac joint” but that his range of motion was “adequate in all directions” and
his straight leg-raising test was again negative. (Admin. Tr. 583; Doc. 12-15 p.
18).
Mr. Harrison presented at Holy Spirit Hospital with a right arm infection on
November 19, 2012. (Admin. Tr. 717; Doc. 12-17 p. 49). Helen Makinde, M.D.
reported that Mr. Harrison’s gait and musculoskeletal examination was normal.
(Admin. Tr. 718; Doc. 12-17 p. 50). His memory was intact, his speech was
normal, his affect was appropriate, and his thought content was normal. Id. Mr.
Harrison denied any hallucinations and suicidal/homicidal ideation. Id.
At the request of the state agency, Thomas McLaughlin, M.D. examined Mr.
Harrison on February 7, 2013.
(Admin. Tr. 780; Doc. 12-18 p. 31).
Dr.
McLaughlin took note of the fact of Mr. Harrison’s 2011 back surgery and also
noted that Mr. Harrison continued to complain of back pain. Id. Mr. Harrison also
complained to Dr. McLaughlin of knee issues dated back to a high school football
injury in 1983 and ACL replacement in both knees. (Admin. Tr. 781; Doc. 12-18
p. 32).
Dr. McLaughlin opined Mr. Harrison could frequently lift two to three
pounds and occasionally ten pounds, and could walk one to two hours a day and sit
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for eight hours a day with a sit/stand option. (Admin. Tr. 787; Doc. 12-18 p. 38).
Dr. McLaughlin further opined that Mr. Harrison could occasionally bend, but
never kneel, stoop, crouch, balance, or climb. (Admin. Tr. 788; Doc. 12-18 p. 39).
X-rays of Mr. Harrison’s knees showed “minor osteoarthritic changes involving
the medial and, to a lesser extent, the lateral joint compartments.” (Admin. Tr.
791; Doc. 12-18 p. 42). The x-rays did not show osseous injury or loose body
though, and there was no visible joint fluid. Id.
On April 25, 2013, Mr. Harrison was treated at Holy Spirit Hospital for back
pain he experienced after falling off his back porch step a few weeks prior.
(Admin. Tr. 872; Doc. 12-19 p. 37). Tamra Helmert, M.D. compared an x-ray of
Mr. Harrison’s back with old x-ray images of Mr. Harrison from May 23, 2011.
(Admin. Tr. 875; Doc. 12-19 p. 40). Dr. Helmert found anatomic alignment of the
lumbar spine, with vertebral body heights maintained, intervertebral disc space
narrowing at L4/5 and L5/S1, no compression fracture, and normal sacroiliac
joints. Id. Dr. Helmert stated that Mr. Harrison showed “[m]ild degenerative
changes with disc space narrowing with facet arthropathy at the level L4/L5 and
L5/S1,” and did not show “acute compression fracture[s] or malalignment.” Id.
At the request of the state agency, Stanley Schneider, Ed.D. performed a
clinical psychological evaluation of Mr. Harrison on May 14, 2013. (Admin. Tr.
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797; Doc. 12-18 p. 48). Mr. Harrison reported to Dr. Schneider that he was not
receiving any outpatient mental health treatment. (Admin. Tr. 800; Doc. 12-18 p.
51). He also reported that he had been on Zoloft “and had a positive response to
the medication.” Id. Dr. Schneider stated that Mr. Harrison was able to perform
serial fives, “slowly, but accurately.” (Admin. Tr. 803; Doc. 12-18 p. 54). He
further stated that Mr. Harrison “was oriented to date and place” although “[h]e
incorrectly name [sic] the day of the week.” Id. Mr. Harrison exhibited no
significant memory impairment.
Dr. Schneider did note that Mr. Harrison’s
attention and concentration were impaired, though only mildly. Id. Mr. Harrison
told Dr. Schneider that he is able to do light cleaning, cook, and pay bills. (Admin.
Tr. 804; Doc. 12-18 p. 55). He also told Dr. Schneider that he has a few friends
and goes to church a couple of times a week. Id.
Dr. Schneider opined that Mr. Harrison had a “mild” restriction on the
ability to understand and remember simple instructions. (Admin. Tr. 806; Doc. 1218 p. 58). He found Mr. Harrison had a “marked” restriction on the ability to carry
out complex or simple instructions, the ability to understand and remember
complex instructions, and the ability to make judgments on complex work-related
decisions. Id. In support of his assessment, Dr. Schneider cited “Chronic pain –
low tolerance for sitting. Poor focus.” Id. In the area of interaction with others,
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Dr. Schneider found Mr. Harrison had “marked” restriction on the ability to
interact appropriately with the public, the ability to interact appropriately with coworkers, and the ability to respond appropriately to usual work situations and
changes in a routine work setting. (Admin. Tr. 807; Doc. 12-18 p. 59). He found
Mr. Harrison had a “moderate” restriction on the ability to interact appropriately
with supervisors. Id. In support of those findings, Dr. Schneider cited the fact that
Mr. Harrison reported a loss of temper at work and stated to Dr. Schneider, “I’ve
been fighting my whole life.” Id.
On May 22, 2013, John Gavazzi, Psy.D. reviewed Mr. Harrison’s record,
including Dr. Schneider’s assessment, on behalf of the agency. (Admin. Tr. 13537; Doc. 12-4 pp. 12-14). Dr. Gavazzi opined that Mr. Harrison “can understand,
retain, and follow simple job instructions, i.e., perform one- [sic] and two-step
tasks” and that Mr. Harrison “can perform simple, routine, repetitive work in a
stable environment.” (Admin. Tr. 136; Doc. 12-4 p. 13). Dr. Gavazzi reported that
Mr. Harrison was moderately limited in his ability to do the five following tasks:
(1) understand and remember detailed instructions; (2) carry out detailed
instructions; (3) interact appropriately with the general public; (4) accept
instructions and respond appropriately to criticism from supervisors; and, (5)
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respond appropriately to changes in the work setting. (Admin. Tr. 136-37; Doc.
12-4 pp. 13-14).
Milagros Buenaventura, M.D., of Diakon Family Life Services performed a
psychiatric evaluation on Mr. Harrison on August 13, 2013. (Admin. Tr. 881; Doc.
12-20 p. 2). Dr. Buenaventura reported that Mr. Harrison was cooperative with
good eye contact and that his speech was normal in rate and tone. (Admin. Tr.
882; Doc. 12-20 p. 3). Mr. Harrison appeared appropriately groomed and also
appeared his stated age. Id. Mr. Harrison reported to Dr. Buenaventura that he had
suicidal ideations at times but he did not think he would harm himself. (Admin.
Tr. 882-83; Doc. 12-20 p. 3-4). He said he used to have thoughts about having
fights with people but he no longer had those thoughts. (Admin. Tr. 883; Doc. 1220 p. 4). He had no hallucinations or delusions, though he did think people were
out to get him. Id. Mr. Harrison’s thinking was goal-directed and he was oriented
in three spheres. Id. Dr. Buenaventura found Mr. Harrison’s memory to be fair
and his intellectual functioning to be average.
Id.
However, he found Mr.
Harrison’s judgment to be poor and opined that Mr. Harrison lacked insight. Id.
Dr. Buenaventura recommended Mr. Harrison receive counseling from Rosemarie
Holland, MA, LPC at Diakon Family Life Services. Id.
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On August 24, 2014, George Wiswesser, M.D. authored a progress note that
reported Mr. Harrison had normal energy, was generally cooperative, and had an
unremarkable appearance and psychomotor. (Admin. Tr. 920; Doc. 12-21 p. 5).
Mr. Harrison’s speech rate was normal, his mood was euthymic, and his affect was
congruent. Id. His thought process was linear and goal directed. Id. Mr. Harrison
was not suffering from any hallucinations or delusions, nor did he have
suicidal/homicidal ideations. Id. His cognition was grossly intact. Id.
On September 17, 2013 Dr. Buenaventura authored a psychiatric progress
note. (Admin. Tr. 891; Doc. 12-20 p. 12). Dr. Buenaventura reported that Mr.
Harrison’s appetite had increased while his energy had decreased.
Id.
Mr.
Harrison’s sleep was “not good” and complicated by anxiety. Id. Mr. Harrison’s
mood was depressed.
Id.
However, he was generally cooperative and his
appearance and psychomotor were unremarkable. Id. His speech rate was normal
and his affect was congruent. Id. Dr. Buenaventura observed that Mr. Harrison’s
thought process was linear and goal directed.
Id.
He did not suffer from
hallucinations or delusions. Id. Mr. Harrison had not suicidal/homicidal ideations
and his cognition was grossly intact. Id.
The next psychiatric progress report, dated October 11, 2013, this time by
Dr. Wiswesser again, showed much improvement in Mr. Harrison’s condition.
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(Admin. Tr. 890; Doc. 12-20 p. 11). Specifically, his sleep, energy, and libido
were now normal, and his mood was upgraded from depressed to euthymic. Id.
The rest of the evaluation categories, which had not shown any issues before,
continued to present no issue. Mr. Harrison was still generally cooperative and his
appearance and psychomotor were still unremarkable. Id. His speech rate was still
normal, and his affect was still congruent. Id. Mr. Harrison still had a linear and
goal directed thought process and still did not suffer hallucinations or delusions.
Id. He still had no suicidal/homicidal ideations and his cognition was still grossly
intact. Id.
Mr. Harrison continued to present no issue through the conclusion of his
treatment with Dr. Wiswesser sometime after August 26, 2014, a span of eight
more psychiatric progress reports. (Admin. Tr. 885-89, 920-26; Doc. 12-20 pp. 610, 4-10). Mr. Harrison had normal appetite, energy, sleep, and libido. Id. Mr.
Harrison was generally cooperative and his appearance and psychomotor were
unremarkable. Id. His speech rate was normal, his mood was euthymic, and his
affect was congruent. Id. Mr. Harrison had a linear and goal directed thought
process and did not suffer hallucinations or delusions.
Id.
He had no
suicidal/homicidal ideations and his cognition was grossly intact. Id. However,
the nine reports of repeatedly normal findings were contradicted in nearly every
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category by Rosemarie Holland, MA, LPC in a single report, which was dated
February 12, 2014. (Admin. Tr. 911-16; Doc. 12-20 pp. 32-37).
At the time of the hearing, Mr. Harrison was divorced with one teenage
child. (Admin. Tr. 801; Doc. 12-18 p. 52). He was born in 1964 and is a high
school graduate. (Admin. Tr. 288; Doc. 12-7 p. 18).
Mr. Harrison has past
relevant work as a roll tender and maintenance worker. (Admin. Tr. 50; Doc. 12-2
p. 51).
Mr. Harrison filed an application for disability insurance benefits under
Title II of the Social Security Act on November 28, 2012. After his claim was
denied at the initial level of administrative review, a hearing was held on October
28, 2014 before an Administrative Law Judge (“ALJ”).
That hearing was
continued until January 15, 2015, when the ALJ obtained testimony from a VE
who was present at the first hearing. (Admin. Tr. 49; Doc. 12-2 p. 50). The ALJ
issued an opinion denying Mr. Harrison’s claim on January 26, 2015. (Admin. Tr.
37; Doc. 12-2 p. 38).
In this opinion at Step One of the five-step sequential analysis process that
applies to Social Security disability claims, the ALJ found Mr. Harrison was not
working at a substantial gainful activity. (Admin. Tr. 25; Doc. 12-2 p. 26). At
Step Two, the ALJ found Mr. Harrison had the following eight severe
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impairments: (1) degenerative disc disease of the lumbar spine; (2) degenerative
joint disease of the knees; (3) major depressive disorder; (4) bipolar disorder; (5)
anxiety disorder; (6) substance abuse disorder; (7) ADHD; and, (8) personality
disorder. Id. At Steps Three and Four, the ALJ found that Mr. Harrison’s severe
impairments did not meet or equal a Listing that would cause him to be per se
disabled, (Admin. Tr. 26-29; Doc. 12-2 pp. 27-30), but that his impairments
nonetheless prevented him from performing his past relevant work. (Admin. Tr.
35; Doc. 12-2 p. 36).
The ALJ then determined that Mr. Harrison had the following residual
functional capacity:
[T]o perform less than the full range of light work as defined in 20
CFR 404.1567(b). He can frequently lift thirty pounds and frequently
carry twenty pounds. He can occasionally lift or carry forty pounds.
He is limited to sitting for three hours, standing for three hours, and
walking for three hours. He can push/pull with the upper extremities
a maximum of fifty pounds. He can frequently reach in all directions.
He can occasionally crouch, stoop, and climb ramps and stairs. He is
limited to occasional exposure to cold temperature extremes. He is
limited to jobs that can be learned within one month with repetitive
short cycle tasks, occasional decision making, and occasional
interaction with coworkers, supervisors, and the public.
(Admin. Tr. 29; Doc. 12-2 p. 30). Finally, at Step Five, the ALJ determined that
there were jobs in the national economy that Mr. Harrison could perform and thus
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he was not disabled as defined by the Social Security Act. (Admin. Tr. 36; Doc. 52 p. 37).
The agency Appeals Council denied Mr. Harrison’s request for review of the
ALJ’s decision. The denial by the Appeals Council made the ALJ’s January 26,
2015, decision the final decision of the Acting Commissioner—subject to review
by this Court.
On June 16, 2016, Mr. Harrison filed a complaint in this Court alleging that
the Commissioner’s final decision denying his claim is contrary to the law and
regulations, and that the Commissioner’s findings of fact are not supported by
substantial evidence. (Doc. 1). As relief, Mr. Harrison requests that the Acting
Commissioner’s decision be reversed and set aside, or in the alternative, that this
case be remanded for a new administrative hearing. Id.
On August 23, 2016, the Commissioner filed her answer. (Doc. 11). The
Commissioner maintains that the final decision denying Mr. Harrison’ claim was
made in accordance with the law and regulations, and is supported by substantial
evidence. Together with her answer, the Commissioner filed a certified transcript
of the administrative proceedings in this case. (Doc. 12).
This matter has been fully briefed by the parties and is ripe for decision.
(Doc. 13; Doc. 16).
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III.
Legal Standards
A. Substantial Evidence Review – the Role of This Court
When reviewing the Commissioner’s final decision denying a claimant’s
application for benefits, this Court’s review is limited to the question of whether
the findings of the final decision-maker are supported by substantial evidence in
the record. See 42 U.S.C. §405(g); Johnson v. Comm’r of Soc. Sec., 529 F.3d 198,
200 (3d Cir. 2008); Ficca v. Astrue, 901 F.Supp.2d 533, 536 (M.D.Pa. 2012).
Substantial evidence “does not mean a large or considerable amount of evidence,
but rather such relevant evidence as a reasonable mind might accept as adequate to
support a conclusion.”
Pierce v. Underwood, 487 U.S. 552, 565 (1988).
Substantial evidence is less than a preponderance of the evidence but more than a
mere scintilla. Richardson v. Perales, 402 U.S. 389, 401 (1971). A single piece of
evidence is not substantial evidence if the ALJ ignores countervailing evidence or
fails to resolve a conflict created by the evidence. Mason v. Shalala, 994 F.2d
1058, 1064 (3d Cir. 1993).
But in an adequately developed factual record,
substantial evidence may be “something less than the weight of the evidence, and
the possibility of drawing two inconsistent conclusions from the evidence does not
prevent [the ALJ’s decision] from being supported by substantial evidence.”
Consolo v. Fed. Maritime Comm’n, 383 U.S. 607, 620 (1966). “In determining if
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the Commissioner’s decision is supported by substantial evidence the court must
scrutinize the record as a whole.” Leslie v. Barnhart, 304 F.Supp.2d 623, 627
(M.D.Pa. 2003). The question before this Court, therefore, is not whether Mr.
Harrison is disabled, but whether the Commissioner’s finding that he is not
disabled is supported by substantial evidence and was reached based upon a correct
application of the relevant law. See Arnold v. Colvin, No. 3:12-CV-02417, 2014
WL 940205, at *1 (M.D.Pa. Mar. 11, 2014)(“[I]t has been held that an ALJ’s
errors of law denote a lack of substantial evidence.”)(alterations omitted); Burton
v. Schweiker, 512 F.Supp. 913, 914 (W.D.Pa. 1981)(“The Secretary’s
determination as to the status of a claim requires the correct application of the law
to the facts.”); see also Wright v. Sullivan, 900 F.2d 675, 678 (3d Cir. 1990)(noting
that the scope of review on legal matters is plenary); Ficca, 901 F.Supp.2d at 536
(“[T]he court has plenary review of all legal issues . . . .”).
B.
Initial Burdens of Proof, Persuasion, and Articulation for the ALJ
To receive benefits under the Social Security Act by reason of disability, a
claimant must demonstrate an 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);
15
see also 20 C.F.R. §404.1505(a). To satisfy this requirement, a claimant must have
a severe physical or mental impairment that makes it impossible to do his or her
previous work or any other substantial gainful activity that exists in the national
economy. 42 U.S.C. §423(d)(2)(A); 20 C.F.R. §404.1505(a). To receive benefits
under Title II of the Social Security Act, a claimant must show that he or she
contributed to the insurance program, is under retirement age, and became disabled
prior to the date on which he or she was last insured. 42 U.S.C. § 423(a); 20
C.F.R. § 404.131(a).
In making this determination at the administrative level, the ALJ follows a
five-step sequential evaluation process.
20 C.F.R. §404.1520(a).
Under this
process, the ALJ must sequentially determine: (1) whether the claimant is engaged
in substantial gainful activity; (2) whether the claimant has a severe impairment;
(3) whether the claimant’s impairment meets or equals a listed impairment; (4)
whether the claimant is able to do his or her past relevant work; and (5) whether
the claimant is able to do any other work, considering his or her age, education,
work experience and residual functional capacity (“RFC”).
20 C.F.R.
§404.1520(a)(4).
Between Steps Three and Four, the ALJ must also assess a claimant’s RFC.
RFC is defined as “that which an individual is still able to do despite the
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limitations caused by his or her impairment(s).” Burnett v. Comm’r of Soc. Sec.,
220 F.3d 112, 121 (3d Cir. 2000) (citations omitted); see also 20 C.F.R.
§§404.1520(e), 404.1545(a)(1). In making this assessment, the ALJ considers all
of the claimant’s medically determinable impairments, including any non-severe
impairments identified by the ALJ at step two of his or her analysis. 20 C.F.R.
§404.1545(a)(2).
At Steps One through Four, the claimant bears the initial burden of
demonstrating the existence of a medically determinable impairment that prevents
him or her in engaging in any of his or her past relevant work.
42 U.S.C.
§423(d)(5); 20 C.F.R. §404.15122; Mason, 994 F.2d at 1064.
Once this burden has been met by the claimant, it shifts to the Commissioner
at Step Five to show that jobs exist in significant number in the national economy
that the claimant could perform that are consistent with the claimant’s age,
education, work experience and RFC. 20 C.F.R. §404.1512(f); Mason, 994 F.2d at
1064.
2
The version of 20 C.F.R. § 404.1512 effective on the date the ALJ issued his
decision in his case has been amended during the pendency of this action. Section
(a) of this regulation was not substantively changed, and section (f) was
redesignated as section (b)(3) in the new version of 20 C.F.R. § 404.1512. We cite
to the version of this regulation that was effective on the date of the ALJ’s
decision, see 20 C.F.R. § 404.1512(effective Apr. 20, 2015 to Mar. 26, 2017),
however, the outcome in this case would be the same under the new version of this
regulation.
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The ALJ’s disability determination must also meet certain basic substantive
requisites. Most significant among these legal benchmarks is a requirement that
the ALJ adequately explain the legal and factual basis for this disability
determination.
Thus, in order to facilitate review of the decision under the
substantial evidence standard, the ALJ's decision must be accompanied by "a clear
and satisfactory explication of the basis on which it rests." Cotter v. Harris, 642
F.2d 700, 704 (3d Cir. 1981). Conflicts in the evidence must be resolved and the
ALJ must indicate which evidence was accepted, which evidence was rejected, and
the reasons for rejecting certain evidence. Id. at 706-707. In addition, “[t]he ALJ
must indicate in his decision which evidence he has rejected and which he is
relying on as the basis for his finding.” Schaudeck v. Comm’r of Soc. Sec., 181 F.
3d 429, 433 (3d Cir. 1999).
IV.
Discussion
On appeal Harrison raises two interrelated issues before this Court:
(1) Did the ALJ erroneously weigh the medical opinions of record?
(2) Is the ALJ’s “mental RFC” assessment facially deficient?
These two issues are interrelated because Harrison’s RFC argument is based
upon what he alleges was the erroneous weighing of the medical evidence. Yet,
under the deferential standard of review that applies to Social Security appeals, we
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find for the Acting Commissioner on Mr. Harrison’s first issue. Because Mr.
Harrison’s second issue relies on the logic of his first issue, his second issue also
fails.
A. The ALJ weighed the medical opinions in accordance with 20
C.F.R. § 404.1527(c) and Properly Determined Harrison’s
Residual Functional Capacity Based Upon this Medical
Evidence
The version of the Commissioner’s regulations governing how an ALJ must
evaluate medical opinions in effect on the date the ALJ issued her decision
provide, in pertinent part:
(c) How we weigh medical opinions. Regardless of its source, we will
evaluate every medical opinion we receive. Unless we give a treating
source's opinion controlling weight under paragraph (c)(2) of this
section, we consider all of the following factors in deciding the weight
we give to any medical opinion.
(1) Examining relationship. Generally, we give more weight to
the opinion of a source who has examined you than to the
opinion of a source who has not examined you.
(2) Treatment relationship. Generally, we give more weight to
opinions from your treating sources, since these sources are
likely to be the medical professionals most able to provide a
detailed, longitudinal picture of your medical impairment(s)
and may bring a unique perspective to the medical evidence that
cannot be obtained from the objective medical findings alone or
from reports of individual examinations, such as consultative
examinations or brief hospitalizations. If we find that a treating
source's opinion on the issue(s) of the nature and severity of
your impairment(s) is well-supported by medically acceptable
clinical and laboratory diagnostic techniques and is not
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inconsistent with the other substantial evidence in your case
record, we will give it controlling weight. When we do not
give the treating source's opinion controlling weight, we apply
the factors listed in paragraphs (c)(2)(i) and (c)(2)(ii) of this
section, as well as the factors in paragraphs (c)(3) through
(c)(6) of this section in determining the weight to give the
opinion. We will always give good reasons in our notice of
determination or decision for the weight we give your treating
source's opinion.
(i) Length of the treatment relationship and the frequency
of examination. Generally, the longer a treating source
has treated you and the more times you have been seen
by a treating source, the more weight we will give to the
source's medical opinion. When the treating source has
seen you a number of times and long enough to have
obtained a longitudinal picture of your impairment, we
will give the source's opinion more weight than we
would give it if it were from a nontreating source.
(ii) Nature and extent of the treatment relationship.
Generally, the more knowledge a treating source has
about your impairment(s) the more weight we will give
to the source's medical opinion. We will look at the
treatment the source has provided and at the kinds and
extent of examinations and testing the source has
performed or ordered from specialists and independent
laboratories. For example, if your ophthalmologist
notices that you have complained of neck pain during
your eye examinations, we will consider his or her
opinion with respect to your neck pain, but we will give
it less weight than that of another physician who has
treated you for the neck pain. When the treating source
has reasonable knowledge of your impairment(s), we will
give the source's opinion more weight than we would
give it if it were from a nontreating source.
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(3) Supportability. The more a medical source presents relevant
evidence to support an opinion, particularly medical signs and
laboratory findings, the more weight we will give that opinion.
The better an explanation a source provides for an opinion, the
more weight we will give that opinion. Furthermore, because
nonexamining sources have no examining or treating
relationship with you, the weight we will give their opinions
will depend on the degree to which they provide supporting
explanations for their opinions. We will evaluate the degree to
which these opinions consider all of the pertinent evidence in
your claim, including opinions of treating and other examining
sources.
(4) Consistency. Generally, the more consistent an opinion is
with the record as a whole, the more weight we will give to that
opinion.
(5) Specialization. We generally give more weight to the
opinion of a specialist about medical issues related to his or her
area of specialty than to the opinion of a source who is not a
specialist.
(6) Other factors. When we consider how much weight to give
to a medical opinion, we will also consider any factors you or
others bring to our attention, or of which we are aware, which
tend to support or contradict the opinion. For example, the
amount of understanding of our disability programs and their
evidentiary requirements that an acceptable medical source has,
regardless of the source of that understanding, and the extent to
which an acceptable medical source is familiar with the other
information in your case record are relevant factors that we will
consider in deciding the weight to give to a medical opinion.
20 C.F.R. § 404.1527(c) (effective August 24, 2012 through March 26, 2017).
“[T]he ALJ has no obligation to explicitly enumerate each of the six factors
described in the Social Security regulations.” Grant v. Astrue, 857 F. Supp. 2d
21
146, 155 (D.D.C. 2012). “The regulations require only that ‘good reasons’ be
provided for the weight given a treating physician's opinion.”
citations omitted).
Id.
(internal
The regulations further provide that the Commissioner is
required to evaluate all evidence in the case record that has a bearing on the
determination of disability. See 20 C.F.R. §§ 404.1520(a)(3), 404.1520b (effective
Mar. 26, 2012 through Mar. 26, 2017).
Mr. Harrison argues that the ALJ erroneously accorded limited weight to the
medical opinions of the agency’s examining physician, Dr. McLaughlin; the
agency’s examining psychologist, Dr. Schneider; the agency’s non-examining
psychiatrist, John Gavazzi, Psy.D.; and, Mr. Harrison’s treating psychiatrist, Ms.
Holland. (Plaint. Br. 3-7; Doc. 13 pp. 3-7). He further contends the alleged error
harms him because those sources documented limitations greater than the RFC that
the VE used to determine there are jobs in the national economy that he can
perform. (Plaint. Br. 7; Doc. 13 p. 7).
The ALJ afforded the opinion of Dr. McLaughlin limited weight because she
found it was “not consistent with the plethora of normal clinical examination
findings. (Admin. Tr. 34; Doc. 12-2 p. 35). She also afforded the opinion of Dr.
Schneider limited weight because she found it was “not consistent with the
repeated normal mental status examination findings noted in the claimant’s
22
medical records.” Id. As for Mr. Gavazzi, the ALJ afforded his opinion, which
found no more than moderate issues, generally significant weight. Id. However,
the ALJ gave “limited weight to that aspect of the opinion indicating that the
claimant has experienced episodes of decompensation of extended duration
because it is not consistent with the entirety of the record.” Id. Finally, the ALJ
afforded the opinion of Ms. Holland limited weight because it was “not consistent
with the entirety of the claimant’s medical records, including the persistently
documented normal mental status examination findings.” Id.
Mr. Harrison denies that the record contains persistent normal findings,
physical or mental, in the record. He further contends that even if there were
records of such findings, the ALJ failed to cite them. However, there are persistent
normal findings, both physical and mental, in the record; and, the ALJ did cite
them.
The ALJ explained her assessment of Mr. Harrison’s physical capacity as
follows:
The undersigned notes that the claimant's medical records
also document that the claimant was assessed with a negative
bilateral straight leg raising test, normal strength in his lower
extremities, no tenderness, redness, warmth, swelling, effusion,
laxity, crepitus, or clicks of the knees, and a gait within normal
limits (Exhibits 4F, 7F, 8F). He was observed to able to ascend
and descend stairs using an alternative pattern and without the use
of handrails (Exhibit 4F). He was also observed to be able to walk
23
on the heels, walk on the toes, walk heel to toe, squat without
difficulty, stand unassisted and be able to rise from the seated
position, step up and down from an examination table without
difficulty or assistive devices, stand on one leg at one time and
appeared comfortable both in the seated and supine position
(Exhibit SF).
Additionally, the claimant's medical records
indicate that he was able to complete all physical therapy
exercises during a physical therapy treatment session despite a
reported pain level of 8/10 at the time and was able to perform the
whole physical therapy "program" very fast (Exhibit 3F). Such
clinical examination findings and observations are not
consistent with the claimant experiencing symptomatology and
limitations associated with his back and knee impairments to
the extent he has suggested and undermines his credibility
regarding his allegations pertaining to same.
The undersigned acknowledges that the claimant's treatment
measures have included physical therapy treatment, injections for
pain, the use of prescribed pain medication, the use of a TENS
unit, lumbar spine surgery, and a remote history of reconstructive
surgery on both knees (Exhibits IF, 3F, 4F, SF, 13F, 14F, 20F).
However, the entirety of the claimant's medical records
indicates that the claimant has not sought treatment for his
purported symptomatology associated with his hack and knee
impairments on a persistent basis throughout the relevant
period of time for this matter and include a notable gap
between May, 2012 and May, 2013 (Exhibits 4E 14F). The
lack of persistent treatment for his . . . symptomatology and
limitations associated with his lumbar spine and knee
impairments during the relevant period of time for this matter is
not consistent with the claimant's allegations regarding his
symptomatology and limitations and undermines his credibility
regarding his allegations pertaining to same. Additionally,
although the claimant has alleged that he uses a prescribed cane at
times (Testimony of Charles Jeffrey Harrison) the claimant's medical
records do not indicate that the cane was prescribed by a health care
provider.
24
(Admin. Tr. 31-32; Doc. 12-2 pp. 33-34) (emphasis added). This analysis cites to
the normal findings of Dr. Pandelidis, Dr. Makinde, Dr. McLaughlin himself, and
records from Mr. Harrison’s physical therapy program.
The ALJ then explained her assessment of Mr. Harrison’s mental health as
follows:
The undersigned notes, however, that the claimant's mental
health therapy treatment records also indicate repeated normal
mental status examination findings characterized by a normal
appetite, normal energy level, normal sleep, normal libido,
unremarkable appearance, unremarkable psychomotor, normal
speech, euthymic mood, congruent affect, linear and goal directed
thought process, normal thought content, no suicidal ideation, no
homicidal ideation, and grossly intact cognition (Exhibits 15F,
18F). He was also noted to have an affect appropriate to the
situation and be able to engage in appropriate conversation, no
significant memory impairment, and answer questions appropriately
and follow directions (Exhibits SF, 1OF). The presence of such
repeated normal mental status examination findings is not consistent
with the claimant experiencing symptoms and limitations to the
ex1ent he has suggested and undermines his credibility regarding his
allegations pertaining to same.
(Admin. Tr. 32; Doc. 12-2 p. 33) (emphasis added). This analysis cites to the
records of Diakon Family Life Services, specifically the numerous and continuous
normal mental health findings by Dr. Buenaventura and Dr. Wiswesser.
The ALJ’s review of the evidence discloses that the plaintiff’s physical and
mental limitations found in the record were not unanimously agreed upon, as Mr.
Harrison claims.
Quite the contrary, the administrative record is marked by
25
competing and contrasting evidence.
Accordingly, the ALJ did follow the
regulations on weighing of medical opinions. She looked to the consistency of the
opinions with the record as a whole, which is one of the enumerated techniques
found at 20 C.F.R. § 404.1527(c). Furthermore, it is clear from the ALJ’s decision
that this medical evidence received individualized consideration.
Thus, in its
decision ALJ accepted some of this opinion evidence, assigned limited weight to
other aspects of the consulting physician opinion when that opinion was
undermined by objective evidence, and fashioned a residual functional capacity for
Harrison based upon the record as a whole. All of these assessments reflected a
careful and measured approach to this issue, and in each instance we conclude that
substantial, albeit disputed, evidence supported these findings by the ALJ.
Therefore, the ALJ’s decision to weigh these opinions as she did is supported by
substantial evidence.
This is all that the law requires in this setting, where we are called upon to
review an administrative law judge’s determination of a disability claim. Mindful
of the fact that substantial evidence “does not mean a large or considerable amount
of evidence, but rather such relevant evidence as a reasonable mind might accept
as adequate to support a conclusion,” Pierce v. Underwood, 487 U.S. 552, 565
(1988), and substantial evidence is less than a preponderance of the evidence but
26
more than a mere scintilla, Richardson v. Perales, 402 U.S. 389, 401 (1971), we
find that substantial evidence supported the ALJ’s assessment of these medical
opinions, and the RFC determination which flowed from this medical opinion
review.
In sum, the ALJ’s decision that Harrison could perform a limited range of
light work was supported by substantial evidence in the medical record, and the
decision to deny benefits to Harrison was thoroughly explained by the ALJ in the
decision denying this application for benefits.
Therefore, we will affirm the
decision of the ALJ, direct that judgment be entered in favor of the defendant, and
instruct the clerk to close this case.
V.
Conclusion
Accordingly, because we find that the ALJ’s decision is supported by
substantial evidence, IT IS ORDERED that the Mr. Harrison’s request for a new
administrative hearing is DENIED, the final decision of the Commissioner denying
this claim IS AFFIRMED. IT IS FURTHER ORDERED that final judgment
should be entered in favor of the Acting Commissioner and against Mr. Harrison.
An appropriate form of order follows.
27
So ordered this 5th day of September, 2017.
s/Martin C. Carlson
Martin C. Carlson
United States Magistrate Judge
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