Huge v. Colvin
Filing
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MEMORANDUM (Order to follow as separate docket entry) re 1 Complaint filed by Christopher Huge. Signed by Magistrate Judge Martin C. Carlson on 9/22/2017. (sc)
IN THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF PENNSYLVANIA
CHRISTOPHER HUGE,
Plaintiff,
v.
CAROLYN W. COLVIN
Acting Commissioner of Social
Security,
Defendant.
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Civil No. 3:16-CV-641
(Magistrate Judge Carlson)
MEMORANDUM OPINION
I.
Introduction
One unique feature of Social Security litigation is the very deferential
standard of review which applies to Social Security appeals.
On appeal, this
Court’s review is limited to determining whether the findings of the Administrative
Law Judge are supported by substantial evidence in the record. See 42 U.S.C.
§405(g); 42 U.S.C. §1383(c)(3); 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).
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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).
Given this very deferential standard of review, which is satisfied by less than
a preponderance of the evidence but more than a scintilla, we are obliged to affirm
agency determinations denying disability benefits whenever the factual record
reveals the existence of such relevant evidence as a reasonable mind might accept
as adequate to support the agency’s conclusion, even if that evidence may well also
have supported a contrary conclusion had it been construed in a different light.
Mindful of this deferential standard of review, for the reasons set forth below, we
will AFFIRM the decision of the Commissioner in this case because we conclude
that the ALJ’s findings are supported by substantial evidence which was
sufficiently articulated by the agency decision-maker.
II.
Statement of Facts and of the Case
The case of Christopher Huge came to be heard by an ALJ based upon an
extensive, but often equivocal, medical and factual record.
Huge applied for
disability insurance benefits on August 15, 2015, alleging that he had been
disabled since November 30, 2013, due to the combined effects of various cervical
spine ailments, left hand weakness and sensory change, left arm pain, left hip pain,
and depression. (Tr. 155, 172.) Huge was an older worker, in his early 50s, at the
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time of this disability application. He had completed high school, attended vo-tech
school for auto body training, and had a significant past relevant work history as a
general foreman in the tree service industry. (Tr. 60, 73, 95, 200, 353.)
With respect to Huge’s disability application, in rendering a decision on this
application the ALJ was obliged to consider: (1) the credibility of Huge and his
wife, both of whom described the limitations that he was experiencing as a result
of these various impairments; (2) Huge's reported activities of daily living; (3)
contemporaneous medical treatment and examination records documenting the
medical care Huge received during this period of claimed disability; and (4)
various medical opinions regarding the degree to which Huge’s physical and
emotional impairments were wholly disabling. As described below, these various
evidentiary threads lent themselves to competing and contradictory conclusions
concerning the extent to which Huge’s physical and emotional conditions
precluded him from undertaking any gainful employment.
This mixed and
equivocal evidence is discussed separately below.
A. Huge’s Reported Limitations and Self-Described Activities of Daily
Living
In the course of these administrative proceedings, both Huge and his wife
described the combined effects of the plaintiff’s physical and emotional
impairments in terms that were completely disabling. However, other accounts
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given by Huge regarding his activities of daily living indicated a greater capacity
for gainful activity. For example, during a November 2014, examination Huge
reported that he was able to dress, bathe, and groom himself seven times a week,
although he had trouble with buttons and tying shoes. (Tr. 355.) He was also able
to cook and prepare simple meals, clean, do laundry, shop, manage money, and
drive.
(Tr. 355.)
He socialized with family on a regular basis.
(Tr. 355.)
According to Huge his hobbies and interests included fishing, walking in the
woods, and watching television. (Tr. 356.)
Huge also completed an Adult Function Report in September of 2014. In
this report Huge described the impairments caused by pain, discomfort, numbness
and loss of grip and sensation in his left hand, arm and hip. (Tr. 217-222.) Huge
stated that these impairments, and particularly the weakness in his left hand, made
it difficult for him to perform many personal care and grooming activities. (Id.)
However, in this report Huge stated that he did not need special reminders to take
care of personal needs or take medicine. (Tr. 218.) He prepared simple meals and
occasionally did tasks like laundry and touch up painting. (Tr. 218.) Huge also
reported that he drove occasionally, or would walk when he went out. (Tr. 219.)
According to Huge, he was able to shop in stores for fishing tackle and worms, and
would try to go fishing or do artwork a “couple of times” a week. (Tr. 220.) In
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addition, Huge reported that he would frequent to flea markets or yard sales,
attending such events two to three times a week. (Tr. 220.) Huge also was able to
handle an array personal finance activities in a fashion which suggested that his
mental acuity was not severely impairment. Thus, Huge stated that he was able to
pay bills, count change, and handle a savings account. (Tr. 219.) He did not need
to be reminded to go places, and he did not need someone to accompany him when
he went places. (Tr. 220.) Huge also asserted that his ability to pay attention was
unlimited, and he had no problems following written instructions, following
spoken instructions, or getting along with authority figures. (Tr. 221-22.)
B. Huge’s Medical Treatment History
During the relevant period encompassed by this disability application, Huge
sought and received medical care from a variety of treating sources. In fact, it
appears that between 2014 and 2015 as many of nine different treating sources may
have provided clinical encounters, examinations, and treatments to Huge. The
contemporaneous treatment records of these health care providers confirmed that
Huge was suffering from cervical spinal conditions which left him with some
impairment of his left arm, as well as pain in his left hip. Furthermore, these
records confirmed that Huge experienced periodic depressions. However, these
clinical records were also notable in that the examination results that were
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independently obtained from multiple medical sources did not confirm a
completely disabling level of impairment.
For example, during the Spring and Summer of 2014 Huge twice visited a
hospital emergency room complaining of neck and arm pain and numbness. At the
outset, on March 24, 2014, Huge sought emergency room treatment complaining
of intermittent hand and arm numbness. (Tr. 294.) A neurological evaluation,
including MRI and MRA of the head and neck revealed cervical neck disease,
specifically bulging discs and canal stenosis. (Tr. 292.) Huge was treated with
steroids and pain medication, and discharged home the following day in stable
condition. (Tr. 292.) Four months later, on July 19, 2014, Huge again reported to
the emergency room with complaints of neck pain radiating to his left arm. (Tr.
306-07.) Examination of the left army revealed decreased sensation to light touch,
decreased grip strength, normal finger abduction/adduction, normal wrist flexion
and extension, normal proximal strength, and full range of motion in all
extremities. (Tr. 308.) A psychiatric examination of Huge conducted at this time
revealed that his mood and affect were normal. (Tr. 309.)
On-going care and treatment of Huge by a number of independent medical
providers in the Fall of 2014 provided some further confirmation of left side pain
and weakness for Huge, but also documented that Huge retained substantial
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physical capabilities despite these impairments. For example, on September 23,
2014, Steven Gold, M.D., a physician associated with St. Luke’s University Health
Network, saw Huge for an initial visit and transfer of care. (Tr. 323-25.) At that
time Huge denied limb weakness, (Tr. 324.), a physical examination was
essentially normal, and a psychiatric examination revealed that his mood and affect
were also normal. (Tr. 325.)
One month later, on October 13, 2014, Jason Smith, M.D., a neurologist,
saw Huge regarding his complaints of neck and upper back pain. (Tr. 236, 330.)
At that time a physical examination of Huge revealed that his sensation was intact
to light touch in the bilateral upper extremities (Tr. 330.); Huge’s motor strength
was 5/5 in all muscle groups except for 3/5 finger flexors and 3/5 small finger
abduction on his left hand. (Tr. 330.) Dr. Smith diagnosed Huge as suffering from
cervical radiculopathy, cervical spine degeneration, and cervical herniation, and
recommended a conservative course of treatment, cervical epidural steroid
injections. (Tr. 330.)
One month later, on November 11, 2014, a third medical source, Rafay
Ahmed, M.D., performed a consultative physical examination of Huge. (Tr. 33538.) At this time Huge complained of numbness in his left arm, neck pain, tingling
and burning sensations in his left hand, decreased dexterity of the left hand as of
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March 2014, and hip pain as of March 2014. (Tr. 335.) While Huge stated that he
used a cane, medical notes disclosed that he did not present to the examination
with a cane. (Tr. 335.) Upon examination, Dr. Ahmed observed that Huge was
right-handed, and that his gait was normal. (Tr. 336.) He could heel and toe walk
without difficulty, he could fully squat, his stance was normal, he used no assistive
devices, he needed no help changing for the exam or getting on and off the exam
table, and he was able to rise from a chair without difficulty.
(Id.)
A
musculoskeletal examination revealed no scoliosis or abnormality in the thoracic
spine; negative straight leg raising bilaterally; no evident joint deformity; as well
as stable and nontender joints. (Tr. 337.) A neurologic examination disclosed that
deep tendon reflexes were normal and equal in the upper and lower extremities,
decreased sensation to pinprick and soft touch on the ulnar aspect of the left hand,
5/5 strength in the right arm and both legs, and 4/5 strength in the left arm. (Tr.
337.) Dr. Ahmed found no muscle atrophy and examination of the Huge’s hands
revealed that right hand finger dexterity was intact, grip strength was 5/5 on the
right, but left hand dexterity was decreased, and grip strength was 4/5 in the left
hand. (Tr. 337.) Although the ability to button and pick up a coin with the left
hand was decreased and Huge could not make a fist, he was able to cook twice a
week, clean, do laundry twice a week, and shower, bathe and dress himself every
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day. (Tr. 336.) Dr. Ahmed diagnosed Huge as suffering from left hand numbness
and tingling associated with decreased left hand dexterity and grip strength. (Tr.
338.)
Treatment records for Huge documenting care he received throughout 2015
continued to confirm some degree of impairment, but failed to document fully
disabling medical conditions. Thus, Mark Powell, M.D., a physician at St. Luke’s
University Health Network, provided routine medical care for Huge from
November 2014 through August 2015. (Tr. 363-74, 460-67.) During this time, Dr.
Powell confirmed diagnoses of spinal degeneration and herniation, gout,
depression, and anxiety for Huge. (Tr. 363, 366, 369, 372, 460, 464.) However,
despite these diagnoses, in December 2014, Dr. Powell described Huge’s
depression was asymptomatic. (Tr. 369.) In January 2015, Dr. Powell performed
a limited physical examination of Huge which found that his cranial nerves were
intact, reflexes were symmetric, and his mood and affect were normal. (Tr. 36768.)
On February 24, 2015, John Denny, M.D., a neurologist, consulted with
Huge to discuss treatment options for his cervical spinal conditions. (Tr. 473.) At
that time a physical examination of Huge confirmed weakness in his left arm and
some decreased sensation, but disclosed normal coordination, no atrophy, and no
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abnormal movements.
(Tr. 475.)
Huge also demonstrated normal memory,
thought processes, attention span, mood, and affect. (Tr. 475-76.)
Dr. Denny ordered an MRI of the cervical spine, which was conducted on
March 10, 2015. (Tr. 361-62.) This MRI showed degenerative disease resulting in
mild to moderate stenosis of several cervical vertebrae, findings which were
similar to a prior MRI. (Tr. 362.) On March 16, 2015, Dr. Denny reviewed an
EMG study which reflected moderate to severe carpal tunnel syndrome, a
condition which appeared more severe on Huge’s left hand and wrist. (Tr. 385.)
Dr. Denny referred Huge to a neurosurgeon for possible carpel tunnel surgery. (Tr.
385.)
Three weeks later, on April 8, 2015, Doron Rabin, M.D., a neurosurgeon,
saw Huge regarding his complaints of arm and neck pain, and weakness in his left
hand. (Tr. 446.) The reported results of this clinical encounter were largely
unremarkable. Huge denied any difficulties with handwriting or gait. (Tr. 447.)
Further, Dr. Rabin noted that Huge had declined cervical epidural steroid
injections, and had not tried physical therapy. (Tr. 447.) After performing a
physical examination of Huge and reviewing the results of his recent MRI and
EMG tests, Dr. Rabin opined that neck surgery was not necessarily recommended.
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(Tr. 446.) Huge, however, was interested in discussing carpal tunnel release, and
so Dr. Rabin referred him to another neurosurgeon for a second opinion. (Tr. 446.)
That second consultation took place one week later, on April 16, 2015, when
Dang Zhang, M.D., a neurosurgeon, performed a physical examination of Huge.
This examination confirmed some pain and nerve impingement affecting Huge’s
left arm, a moderately limited cervical range of motion, 4/5 left grip strength and
wrist extension, 5/5 muscle strength in all other areas, grossly intact sensation and
deep tendon reflexes, and a normal gait. (Tr. 429.) Based upon these clinical
findings, Dr. Zhang recommended conservative options for Huge, including
physical therapy, epidural steroid injections, and medication before pursuing
surgery. (Tr. 426.)
Treatment notes provided to the agency following the initial ALJ decision
documenting treatment received by Huge from a physician assistant on June 24,
2015, further corroborated that Huge did not regard these cervical and left arm
issues as wholly disabling. In fact, Huge reported that that time that he was not
interested in neck surgery, was having second thoughts about carpal tunnel surgery
on his left wrist, and was able to operate a motorcycle, using wrist splints. (Tr.
478.) Finally, On August 19, 2015, Dr. Powell saw Huge for a cold and discussion
of disability paperwork. (Tr. 460.) At that time Huge stated that his depression
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had improved, (Tr. 460.), and a physical examination of Huge resulted in findings
were largely normal. (Tr. 462.)
C. Opinion Evidence
Finally, consistent with the mixed and equivocal quality of the other
evidence that was before the ALJ, the record in this case was marked by divergent
opinion evidence, which argued in favor of contrary conclusions on this disability
claim.
Turning first to the opinion evidence relating to Huge’s mental state, three
sources have opined on this issue, reaching contrasting conclusions. First, at the
outset of the agency review process, on November 26, 2014, John Rohar, Ph.D., a
state agency psychologist, completed a Psychiatric Review Technique form and a
mental RFC assessment for the plaintiff based on his review of Huge’s medical
records. (Tr. 163-64,168-69.) In these assessments Dr. Rohar found that Huge had
affective and anxiety related disorders that resulted in mild restriction of activities
of daily living, moderate difficulties in maintaining social functioning, and
moderate difficulties in maintaining concentration, persistence, or pace, but had
resulted in no repeated episodes of decompensation, each of extended duration.
(Tr. 163.) Dr. Rohar also concluded that Huge had no limitations in the areas of
understanding and memory; concentration, persistence, and pace; and social
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interaction. (Tr. 168.) In the area of adaptation, Dr. Rohar found no significant
limitations in Huge’s ability to be aware of normal hazards and take appropriate
precautions, travel in unfamiliar places or use public transportation, and set
realistic goals or make plans independently of others; and moderate limitations in
his ability to respond appropriately to changes in the work setting. (Tr. 168.) Dr.
Rohar found that despite the limitations resulting from Huge’s emotional
impairments, he had the mental residual capacity to perform the basic mental
demands of competitive work on a sustained basis. (Tr. 168.)
In November of 2014 Gregory Coleman, Psy.D., performed a consultative
psychiatric evaluation of Huge. (Tr. 353-57.) While Huge reported past episodes
of suicidal ideation, at the time of this examination he was cooperative,
appropriately dressed, well-groomed, and fully oriented to person, place, and time.
(Tr. 354-55.)
His motor behavior was normal; eye contact was appropriate;
thought processes were coherent and goal directed with no evidence of
hallucinations, delusions, or paranoia; his attention and concentration were intact;
and while his recent and remote memory skills were mildly impaired due to
anxiety Huge’s intellectual functioning was in the average range and his insight
and judgment were determined to be good. (Tr. 355.) Huge reported that he was
able to dress, bathe, and groom himself seven times a week, although he had
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trouble with buttons and tying shoes. (Tr. 355.) He was also able to cook and
prepare simple meals, clean, do laundry, shop, manage money, and drive. (Tr.
355.) He socialized with family on a regular basis. (Tr. 355.) His hobbies and
interests included fishing, walking in the woods, and television. (Tr. 356.) Dr.
Coleman opined that “[t]he results of the examination appear to be consistent with
psychiatric problems, but in itself, this does not appear to be significant enough to
interfere with the claimant’s ability to function on a daily basis.” (Tr. 356.) Thus,
Dr. Coleman found that Huge’s ability to understand, remember, and carry out
instructions was not affected by his impairment, concluded that there was no
impairment in Huge’s ability to interact appropriately with the public, supervisors,
and coworkers, and found only moderate limitation in his ability to respond
appropriately to usual work situations and to changes in a routine work setting.
(Tr. 357-59.)
In contrast to these relatively benign mental health findings, Paul Boggia, a
Social Worker who had been counseling Huge in 2014 opined on two occasions
that his emotional impairments were extreme and wholly disabling. (Tr. 389-94.)
Mr. Boggia’s opinions, while internally consistent, rested upon an enigmatic
foundation since Boggia stated that Huge’s emotional impairments stemmed from
March 2014 auto accident, but there is no indication of any such accident in any of
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Huge’s medical records, and Huge specifically denied being in an auto accident in
March of 2014 at the time of his ALJ hearing. (Tr. 82.)
Likewise, opinions regarding the disabling effects of Huge’s physical
impairments were varied and contrasting. For example, on July 24, 2014, an
individual associated with Huge’s primary care provider, St. Luke’s Family
Practice – Huge completed a form for the Pennsylvania Department of Public
Welfare. (Tr. 312-13.) This form indicated that Huge would be “temporarily
disabled” for 12 months or more due to cervical radiculopathy with left arm pain
and numbness, and cervical spine stenosis. (Tr. 313.)
Four months later, on November 19, 2014, at the outset of the agency
administrative process a second medical opinion was issued by a state agency
physician, Elizabeth Kamenar, M.D., performed a physical residual functional
capacity (RFC) assessment based of Huge on her review of his medical records.
(Tr. 164-67.)
Dr. Kamenar found that Huge could lift and carry 20 pounds
occasionally and 10 pounds frequently, stand and walk for a total of about 6 hours
in an 8-hour workday, sit for a total of about 6 hours in an 8-hour workday, but
would need to avoid repetitive pushing or pulling with his left arm. (Tr. 165.) The
doctor also found that Huge could climb ramps and stairs, balance, stoop, kneel,
crouch, and crawl occasionally, but could never climb ladders, ropes or scaffolds,
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and was limited in his ability to reach, handle, finger, and feel with his left arm and
hand. (Tr. 165.) Dr. Kamenar further concluded that Huge would need to avoid
concentrated exposure to extreme cold, humidity, noise, vibration, fumes, odors,
dusts, gases, poor ventilation, and hazards such as machinery and heights. (Tr.
166-67.) In reaching these results the doctor relied both upon Huge’s medical
records and his self-reported physical activities. Dr. Kamenar noted that despite
Huge’s complaints of pain and decreased left hand function, he prepared meals,
walked on a daily basis, did laundry, did paint touchups, drove, shopped, went
fishing with assistance, went to flea markets and yard sales, and could walk “a
couple hundred yards.” (Tr. 167.)
On August 19, 2015, another medical opinion regarding Huge’s impairment
was prepared by Dr. Powell at St. Luke’s. The doctor prepared this report at
Huge’s request after Huge had made an appointment to see Dr. Powell regarding a
cold and to discuss disability paperwork. (Tr. 460.) During this appointment,
Huge stated that his depression had improved and Dr. Powell’s physical
examination findings were largely normal. (Tr. 462.) Nonetheless, Dr. Powell
completed a Medical Opinion Re: Ability To Do Work-Related Activities
(Physical) form for Huge, (Tr. 395-98.), in which he found that Huge could lift
and carry less than 10 pounds frequently and occasionally, stand and walk for
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about 4 hours during an 8-hour workday, and sit for less than 2 hours in an 8-hour
workday. (Tr. 395.) Dr. Powell also found that Huge could occasionally stoop,
crouch, and climb stairs but could never twist or climb ladders; and would need to
avoid concentrated exposure to extreme cold and heat, wetness, humidity, and
noise, moderate exposure to fumes, odors, dusts, gases, and poor ventilation, and
all exposure to hazards such as machinery and heights. (Tr. 397-98.) Dr. Powell
further concluded that reaching, handling, and pushing or pulling were affected by
Huge’s impairment, but that fingering, fine manipulation and feeling were not
affected by his impairments. (Tr. 397.)
D.
Agency Administrative Proceedings
It was against this medical and factual backdrop marked by contrasting,
competing, and equivocal medical evidence that the ALJ conducted a hearing into
Huge’s disability application on October 22, 2015. (Tr. 67-102.) Huge testified at
this hearing, along with a vocational expert who stated in response to hypothetical
questions posed by the ALJ that there were a number of light exertional work jobs
in the regional economy that a person suffering from conditions similar to those
experienced by the plaintiff could perform. (Id.)
On November 2, 2015, the ALJ issued a decision denying Huge’s claim for
disability benefits. (Tr. 45-62.) In this decision, the ALJ first found at Step 1 of
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the five-step sequential process that applies to disability claims that Huge had met
the insured status requirements of the Social Security Act. (Tr. 50.) At Step 2 of
this sequential analysis process, the ALJ concluded that Huge had the following
severe impairments: cervical disc disease, depressive and anxiety disorders and
carpel tunnel syndrome. (Tr. 50.) At Steps 3 and 4 of this sequential analysis, the
ALJ concluded that none of Huge’s impairments met a listing which would define
him as per se disabled, (Tr. 51.), and determined that Huge could not return to his
past relevant work as a tree surgeon. (Tr. 60.)
The ALJ then concluded that Huge retained the residual functional capacity
to perform a limited range of light work. Specifically, the ALJ found that:
After careful consideration of the entire record, . . . the claimant has
the residual functional capacity to perform a range of light work as
defined in 20 CFR 404.1567(b). He can occasionally push/pull with
the left upper extremity. He can frequently push/pull with the right
upper extremity. He can occasionally balance, stoop, crouch. Crawl,
kneel, and climb, but never on ladders, ropes, or scaffolds. He can
occasionally reach overhead with the left upper extremity and
occasionally engage in fingering. feeling, and fine manipulation. He
can occasionally handle and perform gross manipulation with the left
upper extremity. There are no such limitations with the right, upper.
dominant extremity. He should avoid concentrated exposure to
temperature extremes of cold, wetness, humidity, vibrations, and
hazards, including moving machinery and unprotected heights. He
can do simple, routine tasks, no complex tasks, in a low stress work
environment, defined as occasional decision-milking and occasional
changes in the work setting. He can have occasional interaction with
the public.
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(Tr. 53.)
In reaching this residual functional capacity assessment, the ALJ carefully
detailed Huge’s medical treatment history, describing the contrasting and often
equivocal findings of the nine medical sources that had treated and examined him,
or considered his case. (Tr. 53-60.) As the ALJ observed that these medical
source treatment records confirmed that Huge suffered from some cervical and
emotional impairments, but this objective clinical data collected by these treating
sources seemed to generally confirm that he retained the ability to perform some
light work. (Id.) The ALJ also noted the conservative course of treatment afforded
Huge for these conditions, a level of treatment which was not consistent with
wholly disabling impairments. (Id.)
In addition, the ALJ weighed the claims of disability described by Huge and
his wife against the plaintiff’s self-reported activities of daily living. On this score,
the ALJ concluded that Huge’s description of his limitations and his wife’s reports
were not entirely credible since they conflicted with objective medical date, some
medical opinions, and Huge’s own self-reported activities. (Id.)
Finally, the ALJ examined the conflicting medical opinion evidence in this
case, and determined on balance that those opinions which suggested that Huge
was capable of a limited range of light work were more consistent with the clinical
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data and Huge’s self-described activities.
(Id.)
Finding that these medical
opinions drew greater support from the objective medical record, the ALJ afforded
greater weight to those opinions that found that Huge retained the capacity to
perform some work. Having conducted this analysis, and found that the medical
evidence supported a conclusion that Huge could perform a limited range of light
work, the ALJ concluded that there were a significant numbers of jobs in the
regional economy that Huge could perform. (Tr. 61.) Accordingly, the ALJ found
that Huge was not disabled, and denied his application for disability benefits. (Tr.
62.)
Huge’s appealed this decision to the Appeals Council. In connection with
this agency appeal, Huge tendered additional medical records to the Appeals
Council including treatment notes from a physician assistant on June 24, 2015,
documenting an encounter in which Huge reported that that time that he was not
interested in neck surgery, was having second thoughts about carpal tunnel surgery
on his left wrist, and was able to operate a motorcycle, using wrist splints. (Tr.
478.)
The Appeals Council found this additional evidence unpersuasive, and
affirmed the decision of the ALJ.
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This appeal followed. This matter has been fully briefed by the parties, and
is now ripe for resolution. For the reasons set forth below, we will AFFIRM the
decision of the Commissioner.
A. Substantial Evidence Review – the Role of the Administrative
Law Judge and the Court
Resolution of the instant social security appeal involves an informed
consideration of the respective roles of two adjudicators–the Administrative Law
Judge (ALJ) and this Court. At the outset, it is the responsibility of the ALJ in the
first instance to determine whether a claimant has met the statutory prerequisites
for entitlement to benefits. 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 twelve months.” 42
U.S.C. §1382c(a)(3)(A); see also 20 C.F.R. §416.905(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. §1382c(a)(3)(B); 20 C.F.R.
§416.905(a).
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In making this determination at the administrative level, the ALJ follows a
five-step sequential evaluation process.
20 C.F.R. §416.920(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.
§416.920(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
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.
§§416.920(e), 416.945(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.
§416.945(a)(2).
At steps one through four, the claimant bears the initial burden of
demonstrating the existence of a medically determinable impairment that prevents
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him or her in engaging in any of his or her past relevant work.
42 U.S.C.
§1382c(a)(3)(H)(i)(incorporating 42 U.S.C. §423(d)(5) by reference); 20 C.F.R.
§416.912; Mason v. Shalala, 994 F.2d 1058, 1064 (3d Cir. 1993).
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. §416.912(f); Mason, 994 F.2d at
1064.
Once the ALJ has made a disability determination, it is then the
responsibility of this Court to independently review that finding. In undertaking
this task, this Court applies a specific, well-settled and carefully articulated
standard of review. In an action under 42 U.S.C. § 405(g) to review the decision
of the Commissioner of Social Security denying plaintiff’s claim for disability
benefits, Congress has specifically provided that the “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). Thus, 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.
23
§405(g); 42 U.S.C. §1383(c)(3); 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.”
Comm’n, 383 U.S. 607, 620 (1966).
Consolo v. Fed. Maritime
“In determining if 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 a plaintiff is disabled, but
whether the Commissioner’s finding that he is not disabled is supported by
24
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 . . . .”).
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
25
relying on as the basis for his finding.” Schaudeck v. Comm’r of Soc. Sec., 181 F.
3d 429, 433 (3d Cir. 1999). Moreover, in conducting this review we are cautioned
that “an ALJ's findings based on the credibility of the applicant are to be accorded
great weight and deference, particularly since an ALJ is charged with the duty of
observing a witness's demeanor and credibility.’ Walters v. Commissioner of
Social Sec., 127 F.3d 525, 531 (6th Cir.1997); see also Casias v. Secretary of
Health & Human Servs., 933 F.2d 799, 801 (10th Cir.1991) (‘We defer to the ALJ
as trier of fact, the individual optimally positioned to observe and assess witness
credibility.’).” Frazier v. Apfel, No. 99-715, 2000 WL 288246, *9 (E.D. Pa.
March 7, 2000). Furthermore, in determining if the ALJ's decision is supported by
substantial evidence the court may not parse the record but rather must scrutinize
the record as a whole. Smith v. Califano, 637 F.2d 968, 970 (3d Cir. 1981).
B. Legal Benchmarks for the ALJ’s Assessment of Medical Opinion
Evidence
Social Security appeals frequently entail review of an Administrative Law
Judge’s evaluation of competing medical evidence. This evaluation is conducted
pursuant to clearly defined legal benchmarks. The Commissioner’s regulations
define medical opinions as “statements from physicians and psychologists or other
acceptable medical sources that reflect judgments about the nature and severity of
[a claimant’s] impairment(s), including [a claimant’s] symptoms, diagnosis and
26
prognosis, what [a claimant] can still do despite impairments(s), and [a claimant’s]
physical or mental restrictions. 20 C.F.R. §404.1527(a)(2). Regardless of its
source, the ALJ is required to evaluate every medical opinion received. 20 C.F.R.
§404.1527(c).
In deciding what weight to accord to competing medical opinions, the ALJ is
guided by factors outlined in 20 C.F.R. §404.1527(c). “The regulations provide
progressively more rigorous tests for weighing opinions as the ties between the
source of the opinion and the individual become weaker.” SSR 96-6p, 1996 WL
374180 at *2. Treating sources have the closest ties to the claimant, and, therefore,
their opinions may be entitled to significant weight. See 20 C.F.R. §404.1527(c)
(2) (“Generally, we give more weight to opinions from your treating sources...”);
20 C.F.R. §404.1502 (defining treating source). Under some circumstances, the
medical opinion of a treating source may even be entitled to controlling weight. 20
C.F.R. §§04.1527(c)(2); see also SSR 96-2p, 1996 WL 374188 (explaining that
controlling weight may be given to a treating source’s medical opinion only where
it is well-supported by medically acceptable clinical and laboratory diagnostic
techniques, and it is not inconsistent with the other substantial evidence in the case
record). However, it is also clear that treating physician opinions do not control
27
this determination. State agency doctors are also entitled to have their opinions
given careful consideration. As the court of appeals has observed:
“[t]he law is clear ... that the opinion of a treating physician does not
bind the ALJ on the issue of functional capacity,” Brown v. Astrue,
649 F.3d 193, 197 n. 2 (3d Cir.2011). State agent opinions merit
significant consideration as well. See SSR 96–6p (“Because State
agency medical and psychological consultants ... are experts in the
Social Security disability programs ... 20 C.F.R. §§ 404.1527(f) and
416.927(f) require [ALJs] ... to consider their findings of fact about
the nature and severity of an individual's impairment(s)....”).
Chandler v. Comm'r of Soc. Sec., 667 F.3d 356, 361 (3d Cir. 2011).
Where no medical source opinion is entitled to controlling weight, the
Commissioner’s regulations direct the ALJ to consider the following factors, where
applicable, in deciding the weight given to any non-controlling medical opinions:
length of the treatment relationship and frequency of examination; nature and
extent of the treatment relationship; the extent to which the source presented
relevant evidence to support his or her medical opinion, and the extent to which the
basis for the source’s conclusions were explained; the extent to which the source’s
opinion is consistent with the record as a whole; whether the source is a specialist;
and, any other factors brought to the ALJ’s attention. 20 C.F.R. §404.1527(c).
Oftentimes an ALJ must evaluate a number of medical opinions tendered by
both treating and non-treating sources. Judicial review of this aspect of ALJ
decision-making is guided by several settled legal tenets. First, when presented
28
with a disputed factual record, it is well-established that “[t]he ALJ – not treating
or examining physicians or State agency consultants – must make the ultimate
disability and RFC determinations.” Chandler v. Comm’r of Soc. Sec., 667 F.3d
356, 361 (3d Cir. 2011). Thus, “[w]here, . . . , the opinion of a treating physician
conflicts with that of a non-treating, non-examining physician, the ALJ may
choose whom to credit but ‘cannot reject evidence for no reason or for the wrong
reason.’ ”
Morales v. Apfel, 225 F.3d 310, 317 (3d Cir. 2000).
Therefore,
provided that the decision is accompanied by an adequate, articulated rationale, it
is the province and the duty of the ALJ to choose which medical opinions deserve
greater weight.
In making this assessment of medical opinion evidence:
An ALJ is [also] entitled generally to credit parts of an opinion
without crediting the entire opinion. See Thackara v. Colvin, No.
1:14–CV–00158–GBC, 2015 WL 1295956, at *5 (M.D.Pa. Mar. 23,
2015); Turner v. Colvin, 964 F.Supp.2d 21, 29 (D.D.C.2013)
(agreeing that “SSR 96–2p does not prohibit the ALJ from crediting
some parts of a treating source's opinion and rejecting other
portions”); Connors v. Astrue, No. 10–CV–197–PB, 2011 WL
2359055, at *9 (D.N.H. June 10, 2011). It follows that an ALJ can
give partial credit to all medical opinions and can formulate an RFC
based on different parts from the different medical opinions. See e.g.,
Thackara v. Colvin, No. 1:14–CV–00158–GBC, 2015 WL 1295956,
at *5 (M.D.Pa. Mar. 23, 2015).
Durden v. Colvin, 191 F. Supp. 3d 429, 455 (M.D. Pa. 2016).
29
Moreover, in determining the weight to be given to a medical source
opinion, it is also well-settled that an ALJ may discount such an opinion when it
conflicts with other objective tests or examination results. Johnson v. Comm'r of
Soc. Sec., 529 F.3d 198, 202–03 (3d Cir. 2008). Likewise, an ALJ may conclude
that discrepancies between the source’s medical opinion, and the doctor’s actual
treatment notes, justifies giving a medical source opinion little weight in a
disability analysis. Torres v. Barnhart, 139 F. App'x 411, 415 (3d Cir. 2005).
Additionally, “an opinion from a [medical] source about what a claimant can still
do which would seem to be well-supported by the objective findings would not be
entitled to controlling weight if there was other substantial evidence that the
claimant engaged in activities that were inconsistent with the opinion.” Tilton v.
Colvin, 184 F. Supp. 3d 135, 145 (M.D. Pa. 2016).
Finally, it is important to note that the regulations in existence at the time of
this ALJ hearing drew a distinction between opinions from acceptable medical
sources, and other opinion evidence, and afforded greater weight to acceptable
medical source opinions. In this case:
The distinction between “acceptable medical sources” and “other
sources” is important because only acceptable medical sources can be
considered treating sources and accorded great or controlling weight.
See 20 C.F.R. § 416.927(c). Acceptable medical sources include
licensed physicians, licensed psychologists, licensed optometrists,
licensed podiatrists, and qualified speech-language pathologists. See
30
20 C.F.R. §§ 416.913(a), 416.913(a). Medical sources not listed as an
acceptable medical source are considered “other sources.” 20 C.F.R.
§ 416.913(d)(1). Licensed clinical social workers, therapists, public
and private social welfare agency personnel, and rehabilitation
counselors are not acceptable medical sources. SSR 06–03p; see also
20 C.F.R. § 416.913(d).
Mack v. Astrue, 918 F. Supp. 2d 975, 982 (N.D. Cal. 2013).
C. Claimant Credibility Analysis
Social Security appeals also often entail review of an Administrative Law
Judge’s assessment of both claimant and witness credibility. On this score, it is
well-settled that, “an ALJ's findings based on the credibility of the applicant are to
be accorded great weight and deference, particularly since an ALJ is charged with
the duty of observing a witness's demeanor and credibility.’
Walters v.
Commissioner of Social Sec., 127 F.3d 525, 531 (6th Cir.1997); see also Casias v.
Secretary of Health & Human Servs., 933 F.2d 799, 801 (10th Cir.1991) (‘We
defer to the ALJ as trier of fact, the individual optimally positioned to observe and
assess witness credibility.’).” Frazier v. Apfel, No. 99-715, 2000 WL 288246, *9
(E.D. Pa. March 7, 2000). In order to aid ALJs in this task of assessing claimant
credibility Social Security Rulings and Regulations provide a framework under
which a claimant's subjective complaints are to be considered.
20 C.F.R. §
404.1529; SSR 96–7p. First, symptoms, such as pain or fatigue, will only be
considered to affect a claimant's ability to perform work activities if such
31
symptoms result from an underlying physical or mental impairment that has been
demonstrated to exist by medical signs or laboratory findings.
404.1529(b); SSR 96–7p.
20 C.F.R. §
During this credibility assessment, the ALJ must
determine whether the claimant's statements about the intensity, persistence or
functionally limiting effects of his or her symptoms are substantiated based on the
ALJ's evaluation of the entire case record. 20 C.F.R. § 404.1529(c); SSR 96–7p.
This includes, but is not limited to: medical signs and laboratory findings,
diagnosis and other medical opinions provided by treating or examining sources,
and other medical sources, as well as information concerning the claimant's
symptoms and how they affect his or her ability to work. Id. Thus, to assist in the
evaluation of a claimant's subjective symptoms, the Social Security Regulations
identify seven factors which may be relevant to the assessment of the severity or
limiting effects of a claimant's impairment based on a claimant's symptoms. 20
C.F.R. § § 404.1529(c)(3). These factors include: activities of daily living; the
location, duration, frequency, and intensity of the claimant's symptoms;
precipitating and aggravating factors; the type dosage, effectiveness, and side
effects of any medication the claimant takes or has taken to alleviate his or her
symptoms; treatment, other than medication that a claimant has received for relief;
any measures the claimant has used to relieve his or her symptoms; and, any other
32
factors concerning the claimant's functional limitations and restrictions. Id. See
George v. Colvin, No. 4:13–CV–2803, 2014 WL 5449706, at *4 (M.D.Pa. Oct. 24,
2014); Martinez v. Colvin, No. 3:14-CV-1090, 2015 WL 5781202, at *8–9 (M.D.
Pa. Sept. 30, 2015). In making these credibility determinations, an ALJ should
also consider a claimant’s prior work history, particularly when that work history
confirms a strong commitment to work in the past. However, past work history,
standing alone, is not determinative of a claimant’s credibility. Rather, “[p]ast
work history is but one factor that may be used in analyzing a plaintiff's
credibility.” Bermudez v. Colvin, No. 3:13-CV-0156, 2014 WL 4716510, at *10
(M.D. Pa. Sept. 22, 2014).
These same principles apply to an ALJ’s credibility determinations as they
relate to statements made by a claimant’s family and friends, like the spouse report
made in this case. When evaluating such evidence “ALJs should consider ‘such
factors as the nature and extent of the relationship, whether the evidence is
consistent with other evidence, and any other factors that tend to support or refute
the evidence’ when evaluating evidence from non-medical sources such as family
or friends.” Zirnsak v. Colvin, 777 F.3d 607, 612 (3d Cir. 2014). Moreover:
To properly evaluate these factors, the ALJ must necessarily make
certain credibility determinations, and this Court defers to the ALJ's
assessment of credibility. See Diaz v. Comm'r, 577 F.3d 500, 506 (3d
33
Cir.2009) (“In determining whether there is substantial evidence to
support an administrative law judge's decision, we owe deference to
his evaluation of the evidence [and] assessment of the credibility of
witnesses....”). However, the ALJ must specifically identify and
explain what evidence he found not credible and why he found it not
credible. Adorno v. Shalala, 40 F.3d 43, 48 (3d Cir.1994) (citing
Stewart v. Sec'y of Health, Education and Welfare, 714 F.2d 287, 290
(3d Cir.1983)); see also Stout v. Comm'r, 454 F.3d 1050, 1054 (9th
Cir.2006) (stating that an ALJ is required to provide “specific reasons
for rejecting lay testimony”).
Zirnsak v. Colvin, 777 F.3d 607, 612 (3d Cir. 2014). Applying these benchmarks,
it has been held that when an ALJ discounts a family member’s disability report
because it is inconsistent with clinical data, and may reflect a biased family
perspective, substantial evidence supports that credibility determination and it may
not be disturbed on appeal. Id.
D. Newly Discovered Evidence
Finally, in a case such as this where additional evidence is submitted by a
plaintiff to the Appeals Council after the ALJ’s decision, we must assess the
relevance and import of that evidence under clearly defined rules. These rules
provide that we cannot consider Appeals Council evidence in performing its
substantial evidence review, since that review must be limited to the evidence
presented to, and considered by, the ALJ. See Matthews v. Apfel, 239 F.3d 589,
593-95 (3d Cir. 2001). However, where the record reveals the existence of new
evidence following the ALJ hearing, 42 U.S.C. § 405(g) provides that: “The court
34
may, . . . at any time order additional evidence to be taken before the
Commissioner of Social Security, but only upon a showing that there is new
evidence which is material and that there is good cause for the failure to
incorporate such evidence into the record in a prior proceeding.” In exercising this
authority, the United States Court of Appeals for the Third Circuit has emphasized
that a claimant seeking remand on the basis of new evidence must demonstrate that
the additional evidence is both new and material, and that the claimant had good
cause for not submitting the evidence to the ALJ for his initial review. Szubak v.
Sec’y of Health and Human Servs., 745 F.2d 831, 833 (3d Cir. 1984). Where such
criteria are met, the district court may enter what is colloquially referred to as a
“sentence six” remand pursuant to the sixth sentence of 42 U.S.C. § 405(g).
In order for a claimant to prevail on a request for a sentence six remand, the
evidence to be considered must first truly be “new evidence” and “not merely
cumulative of what is already in the record.” Szubak, 745 F.2d at 833. In this
regard, “in order to be new, evidence must not be merely cumulative of what is
already in the record. Szubak, 745 F.2d at 833. However, . . . the Third Circuit
has allowed ‘corroborating’ evidence to constitute new evidence, id. at 834.”
Shuter v. Astrue, 537 F. Supp. 2d 752, 757 (E.D. Pa. 2008).
35
Second, the evidence must be “material”, meaning that it must be “relevant
and probative.” Id. In making this determination, “the materiality standard of §
405(g) requires ‘that there be a reasonable possibility that the new evidence would
have changed the outcome of the Secretary's determination.’ Id. See also Booz v.
Secretary of Health and Human Services, 734 F.2d 1378, 1381 (9th Cir.1984);
Dorsey v. Heckler, 702 F.2d 597, 604–05 (5th Cir.1983); Chaney v. Schweiker,
659 F.2d 676, 679 (5th Cir.1981). Thus, to secure remand, a claimant must show
that new evidence raises a ‘reasonable possibility’ of reversal sufficient to
undermine confidence in the prior decision. The burden of such a showing is not
great. A ‘reasonable possibility,’ while requiring more than a minimal showing,
need not meet a preponderance test. Instead, it is adequate if the new evidence is
material and there is a reasonable possibility that it is sufficient to warrant a
different outcome.” Newhouse v. Heckler, 753 F.2d 283, 287 (3d Cir. 1985).
Further, “[a]n implicit materiality requirement is that the new evidence relate to the
time period for which benefits were denied, and that it not concern evidence of a
later-acquired disability or of the subsequent deterioration of the previously nondisabling condition. See Ward v. Schweiker, 686 F.2d 762, 765 (9th Cir.1982).”
Szubak v. Sec'y of Health & Human Servs., 745 F.2d 831, 833 (3d Cir. 1984).
36
In practice, “[f]our factors must be considered pursuant to this requirement.
See, e.g., Newhouse v. Heckler, 753 F.2d 283, 287 (3d Cir.1985). First, the
evidence must be new and not merely cumulative of what is already in the record.
Id. at 287. Second, the evidence must be material, relevant and probative. Id.
Third, there must exist a reasonable probability that the new evidence would have
caused the Commissioner to reach a different conclusion. Id. Fourth, the claimant
must show good cause as to why the evidence was not incorporated into the earlier
administrative record. Id.” Scatorchia v. Comm'r of Soc. Sec., 137 F. App'x 468,
472 (3d Cir. 2005).
E. Substantial Evidence Supports the ALJ’s Determinations and
Assessments in this Case
Judged against these legal benchmarks, we conclude that substantial evidence
supports the finding made by the ALJ in this case. With respect to these findings,
our review of the ALJ’s decision is limited to determining whether the findings of
the ALJ are supported by substantial evidence in the record.
See 42 U.S.C.
§405(g); 42 U.S.C. §1383(c)(3); 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). In
this context, 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
37
(1988), and 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).
Guided by this deferential standard of review, we also recognize that, “the ALJ
may choose whom to credit but ‘cannot reject evidence for no reason or for the
wrong reason.’ ” Morales v. Apfel, 225 F.3d 310, 317 (3d Cir. 2000). Therefore,
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 the instant case, we submit that the thorough opinion of the ALJ meets all
of these benchmarks prescribed by law.
The ALJ’s decision carefully and
comprehensively documented Huge’s injuries, his reported activities of daily
living, his medical treatment history, and the contrasting medical opinion evidence.
(Tr. 53-60.)
While the plaintiff has argued that much of the ALJ’s opinion
consisted of little more than a boilerplate recital, we disagree. Quite the contrary,
we find that this opinion provided a factually specific and legally sufficient
analysis of all of the factors that are relevant to a disability determination.
38
For example, to the extent that Huge argues on appeal that the ALJ erred in
giving his subjective complaints and the reports submitted by his spouse only
limited weight and credibility, we note “an ALJ's findings based on the credibility
of the applicant are to be accorded great weight and deference, particularly since an
ALJ is charged with the duty of observing a witness's demeanor and credibility.’
Walters v. Commissioner of Social Sec., 127 F.3d 525, 531 (6th Cir.1997); see also
Casias v. Secretary of Health & Human Servs., 933 F.2d 799, 801 (10th Cir.1991)
(‘We defer to the ALJ as trier of fact, the individual optimally positioned to
observe and assess witness credibility.’).” Frazier v. Apfel, No. 99-715, 2000 WL
288246, *9 (E.D. Pa. March 7, 2000). In this case, the ALJ discounted Huge’s
subjective complaints for multiple reasons, noting that: (1) they were inconsistent
with emergency room records (Tr. 54-55, 292-94, 298, 308-09.); (2) they were
inconsistent with Dr. Gold’s clinical findings (Tr. 55, 323-25.); (3) they were not
supported by the results of the March 2015 MRI of the cervical spine (Tr. 55, 36162.); (4) they were inconsistent with Dr. Ahmed’s clinical findings (Tr. 55-56, 33538.); (5) they were not supported by the results of a November 2014 left hip x-ray
(Tr. 59, 339.); (6) they were inconsistent with Dr. Coleman’s psychological
examination (Tr. 56, 353-57.); (7) they were inconsistent with Dr. Rabin’s clinical
findings (Tr. 56, 449.); (8) they were inconsistent with Dr. Zhang’s clinical
39
findings (Tr. 57, 429.); (9) they were inconsistent with essentially normal primary
care provider physical examination findings in June 2015 and August 2015, and a
notation in August 2015 documenting improved depression (Tr. 57, 462, 466.);
(10) they were inconsistent with Huge’s activities of daily living (Tr. 51-52, 57.)
(see above discussion); (11) they were inconsistent with Dr. Rohar’s opinion (Tr.
57, 163-64, 168-69.); (12) they were inconsistent with Dr. Kamenar’s opinion (Tr.
58, 164-67.); and (13) they were inconsistent with the fact that neither Dr. Rabin
nor Dr. Zhang, examining neurosurgeons, recommended neck surgery. (Tr. 56-57.)
This close and careful factual assessment provides substantial evidence to support
this credibility determination, and it may not now be disturbed on appeal.
Similarly, the ALJ’s decision to afford limited weight to the reports provided
by Huge’s spouse was based upon a finding that the reports were inconsistent with
clinical data, and may reflect a biased family perspective, factors which the courts
have found to be legitimate grounds for discounting such opinions. Zirnsak v.
Colvin, 777 F.3d 607, 612 (3d Cir. 2014). Therefore, there was no error by the
ALJ in the consideration of this evidence.
Huge also errs when he suggests that the ALJ ignored his past work history.
Quite the contrary, the ALJ’s decision acknowledged that work history while
observing that Huge had not sought work outside his prior field of endeavor, arbor
40
work, following the alleged onset of his impairments. In doing so, the ALJ acted
in accordance with settled law which recognizes that, “[p]ast work history is but
one factor that may be used in analyzing a plaintiff's credibility.” Bermudez v.
Colvin, No. 3:13-CV-0156, 2014 WL 4716510, at *10 (M.D. Pa. Sept. 22, 2014).
The ALJ’s assessment of the medical treatment and opinion evidence was
also thorough, and balanced, and the conclusions reached by the ALJ drew support
from substantial evidence in the record. Thus, the ALJ separately reviewed the
treatment records of as many as nine treating sources, finding that these
contemporaneous treatment records confirmed the existence of various
impairments for Huge, but the treatment records, objective tests, and conservative
course of treatment provided to Huge undermined his claim of total disability.
Given this equivocal medical history, and the objective evidence which
contradicted Huge’s claim of total disability, the ALJ was justified in concluding
that the opinions expressed by state agency physicians who found that Huge could
perform some work were entitled to greater weight than other treating source
opinions. In particular, with respect to the mental health professionals who opined
regarding Huge’s conditions, the ALJ was well-justified in giving greater weight to
the acceptable medical source opinions of the consulting and examining doctors,
over the opinion tendered by Mr. Boggia, who was not an acceptable medical
41
source, and whose opinions rested in part upon a factual error, the claim that Huge
had experienced emotional trauma following a March 2014 auto accident. See
Mack v. Astrue, 918 F. Supp. 2d 975, 982 (N.D. Cal. 2013).
Finally, to the extent that we are invited to remand this case based upon the
evidence submitted to the Appeals Council following the ALJ’s decision, we will
decline this invitation. That evidence—which included treatment notes which
stated that Huge was reconsidering any surgery for his carpel tunnel and cervical
conditions and was operating a motorcycle—does not meet the criteria for a new
evidence remand for at least three reasons. First, this evidence is not new but is
merely cumulative of what is already in the record. Second, this evidence is not
material, relevant and probative. Third, this evidence does not create a reasonable
probability that the new evidence would have caused the Commissioner to reach a
different conclusion. See Scatorchia v. Comm'r of Soc. Sec., 137 F. App'x 468,
472 (3d Cir. 2005).
III.
Conclusion
In sum, the ALJ’s decision that Huge could perform a limited range of light
work was supported by substantial evidence in the medical record, and the decision
to deny benefits to Huge was thoroughly explained by the ALJ in the decision
denying this second application for benefits.
42
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.
An appropriate order follows.
So ordered this 22d day of September 2017.
s/Martin C. Carlson
Martin C. Carlson
United States Magistrate Judge
43
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