WOODSBEY v. COLVIN
Filing
14
MEMORANDUM OPINION AND ORDER OF COURT denying Plaintiff's 8 Motion for Summary Judgment; and granting Defendant's 11 Motion for Summary Judgment. Signed by Judge Terrence F. McVerry on 07/07/15. (mcp)
IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF PENNSYLVANIA
LAURA PEARL WOODSBEY,
Plaintiff,
v.
CAROLYN W. COLVIN,
ACTING COMMISSIONER OF
SOCIAL SECURITY,
Defendant.
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) 1:14-CV-285-TFM
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MEMORANDUM OPINION AND ORDER OF COURT
July 7, 2015
I.
Introduction
Laura Pearl Woodsbey (“Plaintiff”) brought this action pursuant to 42 U.S.C. §§ 405(g)
and 1383(c)(3), for judicial review of the final decision of the Commissioner of Social Security
(“Commissioner”), which denied her application for supplemental security income (“SSI”) under
Title XVI of the Social Security Act (“Act”), 42 U.S.C. §1381-1383(f). Pending before the Court
are the parties’ cross-motions for summary judgment (ECF Nos. 8,10), which have been fully
briefed, and are ripe for disposition. For the reasons that follow, Plaintiff’s motion will be
DENIED, and the Commissioner’s motion will be GRANTED.
II.
Background
A.
Factual Background
Plaintiff was born on December 26, 1969, and was forty-one years old when she filed her
current application for social security benefits. (R. 29). Plaintiff did not complete the ninth grade,
and has a “dysfunctional” family background. (R. 56). At the time of the hearing, Plaintiff lived
with her sister-in law. (R. 52). Plaintiff has also been incarcerated nine times for various charges
and has spent approximately eight years of her life in prison. (R. 607). Her most recent
incarceration lasted twelve months and concluded in September 2011. (R. 53). The
Administrative Law Judge (“ALJ”) noted in his opinion that Plaintiff had received SSI in the
past, but her eligibility for benefits was terminated as a result of her incarceration.1 (R. 15).
B.
Relevant Educational, Medical, and Opinion Evidence
A psychological study of Plaintiff’s cognitive function conducted in 1978, while Plaintiff
was in the first grade, indicated that she displayed “mild mental retardation and inability to
function in normal developmental curriculum.” (R. 213). Plaintiff’s IQ was 66. Id.
Treatment notes from Stairways Behavior Health, where Plaintiff underwent treatment
for her mental impairments from May 2008 to November 2009, albeit inconsistently, showed
that Plaintiff experienced mood swings and anxiety of fluctuating intensity. (See e.g., R. 225,
231, 235). Gail Holland, D.O., a physician at Stairways, assigned Plaintiff a GAF Score of 45-50
in May 2008. (R. 257).
A psychological evaluation conducted by Byron Hillin, Ph.D., in April 2009 reflected
that Plaintiff’s full scale IQ was 72, demonstrating borderline intellectual functioning. (R. 263).
Dr. Hillin noted that Plaintiff’s Weschler Adult Intelligence Scale-III results indicated that she
has below average intelligence in the areas of reasoning, math, spelling, and reading
comprehension. Id. She was also classified as being “marginally literate.” (R. 265). Dr. Hillin
also found that Plaintiff’s ability to maintain full-time employment was “very precarious,” and
he recommended that Plaintiff be limited to food service, cleaning or other “hands-on” work. Id.
The Social Security Administration terminates a recipient’s benefits after twelve consecutive months of
benefit suspension for any reason, 20 C.F.R. § 416.1335, including residence as an inmate in a public
institution. 20 C.F.R. § 415.1325(a) (defining suspension of benefits); 42 U.S.C. § 1382(e)(1)(A)
(defining eligibility for benefits). A new application is needed to reestablish eligibility for the receipt of
benefits following termination for non-disability reasons. DI 280705.020 Reestablishing Title XVI
Eligibility Following Suspension or Termination for Nondisability Reasons, Social Security
Administration, https://secure.ssa.gov/apps10/poms.nsf/lnx/0428075020 (last visited June 29, 2015).
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2
Medical records from the Bureau of Prisons, generated from November 2010, to May
2011, during Plaintiff’s term of incarceration, demonstrated that Plaintiff was generally “pleasant
and cooperative.” (R. 283). A physical and mental status examination conducted by Tiffany
Sanders, M.D., in November 2010 indicated that Plaintiff had asthma, benign essential
hypertension, psychosocial and environmental problems, but that she otherwise had normal
mood and affect. (R. 318). Plaintiff’s healthcare providers from the Bureau of Prisons evaluated
her and assigned her a GAF score range from 51 to 70 on numerous occasions, (R. 274, 278,
294, 306, 318, 347), but on two occasions, she received a specific GAF score of 55. (R. 294,
347).
Cameron McGavin, M.D., evaluated Plaintiff for mental health issues from June to
September, 2011, while she resided at Renewal, a half-way house. (R. 498, 525). Plaintiff
reported that she was depressed and anxious, although Dr. McGavin suspected possible
“malingering” and symptom magnification. (R. 520). During this period, Plaintiff also got a full
time job at McDonald’s, although she claimed the job increased the level of her anxiety and
stress. (R. 504, 509). As a result, Dr. McGavin recommended that Plaintiff be excused from
work for sixty days to address these issues. (R. 503). In September, 2011, Dr. McGavin assessed
Plaintiff’s GAF score at 40-45. (R. 502).
On November 18, 2011 Rebecca Billings, Ph.D., conducted a mental residual functional
capacity (“MRFC”) assessment and consultative psychological evaluation of Plaintiff. Dr.
Billings opined that Plaintiff had slight limitations in her ability to interact appropriately with the
public, her supervisors, and her co-workers, while she had marked limitations in her ability to
respond appropriately to work pressures in a usual work setting, and moderate limitations in her
ability to respond appropriately to changes in a routine work setting. (R. 612). Moreover, Dr.
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Billings diagnosed Plaintiff with Bipolar II disorder, major depressive disorder, cocaine and
alcohol dependence in full remission, personality disorder (not otherwise specified), and
borderline intellectual functioning. (R. 611). Dr. Billings assigned Plaintiff a GAF score of 50
and noted a full scale IQ of 72. (R. 609, 611).
In December 2011, Manuella Link, Ph.D., a state agency psychological consultant,
completed an MRFC assessment after review of Plaintiff’s medical records. (R. 85). Dr. Link
found that Plaintiff had the ability to meet the basic mental demands of sustained work. (R. 91).
That same month, James Caramanna, M.D., performed a physical residual functional capacity
assessment, in which he found that Plaintiff was capable of performing medium exertional work.
(R. 88-89).
Plaintiff returned to Stairways Behavioral Health for psychological evaluations and
check-ups from January 2012 to March 2013. (R. 644, 645). While there, Sean Su, M.D., and his
colleagues treated Plaintiff for mood swings and anxiety, along with racing thoughts. In February
2013, Dr. Su assigned Plaintiff a GAF score of 50. (R. 651). He also assessed Plaintiff as “awake
and alert,” while her intelligence appeared around average, her memory was intact, and her affect
was blunted. Id. Plaintiff described her mood as “up and down.” Id.
On May 12, 2013, Dr. Su completed a medical source statement, in which he evaluated
Plaintiff’s mental impairments. (R. 661). Dr. Su opined that Plaintiff had extreme limitations in
her ability to make judgments on simple, work-related decisions, moderate limitations in her
ability to understand, remember, and carry out detailed instructions, and slight limitations in her
ability to understand, remember, and carry out short, simple instructions. Id. Dr. Su also opined
that Plaintiff had extreme limitations in her ability to interact appropriately with the public,
supervisors, and co-workers, and had similarly extreme limitations in her ability to respond to
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work pressures in a usual work setting. (R. 662). Dr. Su found that Plaintiff would likely call off
from work five out of five days in the work week, and would need more than nine breaks during
the workday. (R. 663). Dr. Su based these findings solely on Plaintiff’s “extremely unstable
mood.” Id.
C.
Procedural History and Opinion of the Administrative Law Judge
Plaintiff applied for SSI on September 7, 2011, alleging disability since October 1, 2005,
and claiming that she suffered from major depression, schizophrenia, post-traumatic stress
disorder, and heart disease. (R. 81, 161). The agency denied Plaintiff’s application. (R. 80). She
thereafter requested an administrative hearing, which was held on June 6, 2013. (R. 104). An
ALJ heard testimony from Plaintiff and a vocational expert. (R. 45). Plaintiff’s counsel had the
opportunity to question the vocational expert at the hearing. (R. 76).
The ALJ subsequently issued his opinion, explaining his decision to deny Plaintiff’s
application for social security benefits. At Step One the ALJ found that Plaintiff had not engaged
in substantial gainful activity since her application date. (R. 17). At Step Two of the analysis, the
ALJ concluded that Plaintiff had the following severe impairments:
gastroesophageal reflux disease (GERD), obesity, cervical degenerative disc
disease, lumbar disc bulge and spondylosis, thoracic spondylosis, migraine
headaches, asthma/ chronic obstructive pulmonary disease (COPD), bipolar
disorder, attention deficit hyperactivity disorder (ADHD), major depressive
disorder, generalized anxiety disorder, borderline intellectual functioning,
learning disorder, and a personality disorder.
Id. In so concluding, the ALJ also discounted some of Plaintiff’s alleged impairments, including
schizophrenia, PTSD, and any medically determinable cardiac disorder because these
impairments were not established in any records or medical documentation. (R. 18).
At Step Three of the analysis, the ALJ concluded that none of Plaintiff’s impairments met
or exceeded one of the listed impairments in 20 C.F.R. Part 404, Subpt P, Appendix 1. Id. The
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ALJ referenced Plaintiff’s MRFC assessment conducted by Dr. Rebecca Billings in 2011, and
the psychological evaluation conducted by Dr. Byron Hillin, in 2009, marked as Exhibits 1F and
3F, respectively, in his analysis. (R. 21).
At Step Four, “after considering the entire record,” the ALJ concluded that Plaintiff was
limited to the following residual functional capacity (RFC):
Claimant has the residual functional capacity to perform sedentary work as
defined in 20 C.F.R. 416.967(a) except she can never climb a ladder, rope, or
scaffold; can never crawl; can only occasionally climb ramps or stairs; can only
occasionally balance, stoop, kneel, or crouch; must avoid concentrated exposure
to heights, dangerous machinery, and like workplace hazards; is limited to
understanding, remembering, and carrying out simple instructions and performing
simple, routine tasks; is limited to no work related contact with the public, only
occasional and superficial interaction with co-workers, and no more than
occasional supervision; and is limited to a low stress work environment, which
means no production rate pace work, but, rather, goal oriented work with only
occasional and routine change in work setting.
(R. 21). In his assessment of Plaintiff’s RFC, the ALJ determined that Plaintiff’s impairments
could reasonably be expected to cause her alleged symptoms, but that her testimony and
statements regarding the persistence and limiting effects of those symptoms were not entirely
credible. Id.
In supporting his determination of Plaintiff’s physical limitations, the ALJ cited to
medical records from Plaintiff’s time in prison, records from her trips to the emergency room,
and records from her primary care physicians. (R. 22-23). The ALJ “gave particular
consideration” to Plaintiff’s potential exertional, postural, and respiratory limitations, on the
basis of her physical impairments, including obesity. (R. 24).
The ALJ also took into account medical opinion evidence in making his RFC
determination for Plaintiff’s physical limitations. He gave the December 2011 assessment
conducted by James Caramanna, M.D., a state medical consultant, some weight as it was fairly
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consistent with the record. (R. 24). However, contrary to Dr. Caramanna’s opinion that Plaintiff
had no disabling physical impairment, the ALJ limited Plaintiff to sedentary work because of her
later treatment for back pain and respiratory conditions. Id.
In determining Plaintiff’s mental limitations, the ALJ considered her prison records,
treatment notes from Dr. McGavin, and records from Stairways Behavioral Health, including Dr.
Su’s treatment notes. The ALJ noted that Plaintiff’s prison records indicated that her GAF scores
were “consistently listed as 55 or more generally as 51-70.” (R. 24, 27). The ALJ gave these
scores, and the prison records in general, great weight based on Plaintiff’s consistent treatment in
prison. (R. 27). The treatment records prepared by Dr. McGavin, plaintiff’s treating psychiatrist
at Renewal from June to September 2011, indicated that Plainitff had some problems with stress,
anxiety, and depression, and that her GAF score was 40-45. (R. 24). However, the ALJ also
noted that Dr. McGavin worried about “suspected exaggeration” and “considerable distortion.”
(R. 25). The ALJ noted records from Stairways Behavioral Health, which indicated that Plaintiff
had mood stability issues, but had intact memory and an average intelligence. (R. 25-26).
The ALJ also considered opinion evidence regarding Plaintiff’s mental impairments. The
ALJ gave great weight to an MRFC assessment conducted by Dr. Billings as it was consistent
with the record. The ALJ explained that he gave Plaintiff “quite restrictive mental limitations” in
his assessment of her RFC based on Dr. Billings’ report. (R. 26-27).
The ALJ gave little weight to Dr. Link’s MRFC assessment, which concluded that
Plaintiff could meet the mental demands of sustained work, because she neither examined the
Plaintiff directly nor had access to her recent records. (R. 27).
The ALJ also gave little weight to the medical source statement prepared by Dr. Sean Su,
which indicated Plaintiff had “extreme” limitations. (R. 27). The ALJ explained that Dr. Su’s
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report lacked objective support and was inconsistent with Plaintiff’s medical records and Dr.
Su’s own assignment of a GAF score of 50. The ALJ also noted that Plaintiff’s treatment
relationship with Dr. Su was much shorter than her treatment relationship with her caregivers in
prison. (R. 27-28).
The ALJ concluded his analysis at Step Four with a summation of the manner in which
he included Plaintiff’s impairments into his RFC assessment:
After a careful review of the evidence, I find that the exertional and postural
limitations of the above residual functional capacity assessment address the
claimant’s back disorder, obesity, and breathing disorders, in combination. The
limitations on exposure to respiratory irritants further account for her asthma and
COPD. Limits on exposure to workplace hazards account for pain distraction
from her back, GERD, and migraines, as well as any potential relapse into drug or
alcohol abuse. Limiting the claimant to simple tasks addresses borderline
intellectual function, learning disorder, ADHD, and distraction from depression.
Restrictions on social interaction account for bipolar disorder mood swings and
personality disorder. Restricting her to low stress work further addresses the
claimant’s anxiety disorder, ADHD, and borderline intellectual functioning.
(R. 28).
Because the ALJ concluded that Plaintiff had no past relevant work, he proceeded to Step
Five. The ALJ determined that Plaintiff was a younger individual according to 20 C.F.R. §
416.963 and that she had a limited education according to 20 C.F.R. § 416.964. (R. 29). He also
sought the assistance of a vocational expert in evaluating the existence of suitable work in the
national economy. In response to the ALJ’s hypothetical question containing Plaintiff’s RFC, see
infra 5-6, the vocational expert testified that an individual with Plaintiff’s limitations would be
able to perform at least three jobs in the national economy: assembler, DOT No. 734.687-018;
table worker, DOT No. 739.687-182; and surveillance monitor, DOT No. 379.687-010. (R. 74).
As a result of these findings, the ALJ concluded that Plaintiff was not disabled. (R. 30).
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Plaintiff requested a review of the decision from the Appeals Council, which
subsequently denied her request. (R. 3-6). The ALJ’s decision thus became the final decision of
the Commissioner. Id.
III.
Legal Analysis
A. Standard of Review
To qualify for disability under the Act, a claimant must demonstrate that there is some
“medically determinable basis for an impairment that prevents him or her from engaging in any
substantial gainful activity for a statutory twelve-month period.” Fargnoli v. Massanari, 247
F.3d 34, 38-39 (3d Cir. 2001) (internal citation omitted); 42 U.S.C. §423(d)(1). This evaluation
requires the Commissioner to consider, in sequence, whether a claimant (1) is working, (2) has a
severe impairment, (3) has an impairment that meets or exceeds the requirements of a listed
impairment, (4) has the ability to return to his or her past relevant work, or, (5) if not, whether he
or she can perform other work. See 20 C.F.R. §404.1520; Newell v. Comm’r of Soc. Sec., 347
F.3d 541, 545-46 (3d Cir. 2003) (quoting Burnett v. Comm’r of Soc. Sec., 220 F.3d 112, 118-19
(3d Cir. 2000)).
If the claimant is unable to resume previous employment, the burden shifts to the
Commissioner to prove that, given the claimant’s mental or physical limitations, age, education,
and work experience, she can still perform substantial gainful activity in jobs available in the
national economy. Doak v. Heckler, 790 F. 2d 26, 28 (3d Cir. 1986); see also Burns v. Barnhart,
312 F.3d 113, 119 (3d Cir. 2002). “The Commissioner uses the RFC assessment, [20 C.F.R.] §
404.1520(e), and the testimony of vocational experts and specialists, Id. § 404.1566(e);
416.966(e), to make this determination.” Zirnsak v. Colvin, 777 F.3d 607, 612 (3d Cir. 2014).
“‘Ultimately, entitlement to benefits is dependent upon finding the claimant is incapable of
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performing work in the national economy.’” Id. (quoting Provenzano v. Comm’r, Civil No. 10–
4460(JBS), 2011 WL 3859917, at *1 (D.N.J. Aug. 31, 2011)).
Judicial review of the Commissioner’s final decisions on disability claims is provided by
statute, and is plenary as to all legal issues. 42 U.S.C. §§ 405(g), 1383(c)(3); Sweeney v. Comm’r
of Soc. Sec., 847 F. Supp. 2d 797, 800 (W.D. Pa. 2012) (citing Schaudeck v. Comm’r of Soc.
Sec., 181 F. 3d 429, 431 (3d Cir. 1999)). Section 405(g) permits a district court to review the
transcripts and records upon which a determination of the Commissioner is based; the court will
review the record as a whole. See 5 U.S.C. §706. The district court must then determine whether
substantial evidence existed in the record to support the Commissioner’s findings of fact.
Gaddis v. Comm’r of Soc. Sec., 417 F. App’x 106, 107 n. 3 (3d Cir. 2011) (citing Burns v.
Barnhart, 312 F. 3d 113, 118 (3d Cir. 2002)).
Substantial evidence is defined as “‘more than a mere scintilla’; it means ‘such relevant
evidence as a reasonable mind might accept as adequate’” to support a conclusion. Hagans v.
Comm’r of Soc. Sec., 694 F. 3d 287, 292 (3d Cir. 2012) (quoting Plummer v. Apfel, 186 F. 3d
422, 427 (3d Cir. 1999)). If the Commissioner’s findings of fact are supported by substantial
evidence, they are conclusive. Id. (citing Fargnoli, 247 F. 3d at 38); 42 U.S.C. § 405(g). When
considering a case, a district court cannot conduct a de novo review of the Commissioner’s
decision nor re-weigh the evidence of record; the court can only judge the propriety of the
decision in reference to the grounds invoked by the Commissioner when the decision was
rendered. Gamret v. Colvin, 2014 WL 109089 at *1 (W.D. Pa. Jan. 10, 2014) (citing Palmer v.
Apfel, 995 F. Supp. 549, 552 (E.D. Pa. 1998); S.E.C. v. Chenery Corp., 332 U.S. 194, 196-97
(1947)). The court will not affirm a determination by substituting what it considers to be a proper
basis. Chenery, 332 U.S. at 196-97. Further, even where this court acting de novo might have
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reached a different conclusion, “so long as the agency’s fact-finding is supported by substantial
evidence, reviewing courts lack power to reverse either those findings or the reasonable
regulatory interpretations that an agency manifests in the course of making such findings.” Albert
Einstein Med. CnR. v. Sebelius, 566 F. 3d 368, 373 (3d Cir. 2009) (quoting Monsour Med. CnR.
v. Heckler, 806 F. 2d 1185, 1191 (3d Cir. 1986)).
B.
Discussion
Plaintiff challenges the ALJ’s determination that she is not disabled on three grounds: (1)
the ALJ ignored Social Security Regulations in evaluating the evidence contained in the record,
specifically Dr. Billings’ mental status examination; (2) the ALJ improperly discounted the
opinion of Dr. Su; and (3) the ALJ failed to discuss significant, probative evidence that supports
a finding of disability.2 For her part, the Commissioner claims that the Administrative Law Judge
(ALJ) considered and assigned appropriate weight to all of the evidence in the record, including
treating source opinions and Plaintiff’s own testimony regarding her limitations.
For the reasons that follow, the Court concludes that the ALJ properly considered and
evaluated the evidence in the record and that his disability determination was supported by
substantial evidence. The Court will therefore affirm the ALJ’s decision.
1.
The Application of Social Security Ruling 85-15 to the Evaluation of
Dr. Billings’ Report
Plaintiff claims that the ALJ was obligated to find that she was disabled based on his
acceptance of Dr. Billings’ restrictive assessment of her mental functions as “well-reasoned.” (R.
13). In making this argument, Plaintiff relies heavily on Social Security Ruling (SSR) 85-15, as
cited, in part:
2
The Court notes that counsel for Plaintiff nominally divided her argument into two claims.
However, the first of these encompassed two distinct arguments. Therefore, the Court has
divided Plaintiff’s first claim into its two logical components, as stated above.
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Where a person's only impairment is mental, is not of listing severity, but does
prevent the person from meeting the mental demands of past relevant work and
prevents the transferability of acquired work skills, the final consideration is
whether the person can be expected to perform unskilled work. The basic mental
demands of competitive, remunerative, unskilled work include the abilities (on a
sustained basis) to understand, carry out, and remember simple instructions; to
respond appropriately to supervision, coworkers, and usual work situations; and to
deal with changes in a routine work setting. A substantial loss of ability to meet
any of these basic work-related activities would severely limit the potential
occupational base. This, in turn, would justify a finding of disability because even
favorable age, education, or work experience will not offset such a severely
limited occupational base [. . .]. The reaction to the demands of work (stress) is
highly individualized.
Pl.’s Br., ECF No. 9 at 11-12 (quoting SSR 85-15) (emphasis added by Plaintiff). The Court
finds no merit in this argument.
Social Security Ruling 85-15 “clarifies policies applicable in cases involving the
evaluation of solely non-exertional impairments,” when the medical-vocational guidelines would
otherwise fail to direct a conclusion of disabled or not disabled.3 SSR 85-15 at 1-2 (emphasis
added).
Non-exertional impairments are “restrictions imposed by [a claimant’s] impairments and
related symptoms, such as pain, [which] affect only [a claimant’s] ability to meet the demands of
3
The Secretary of Health and Human Services promulgated medical-vocational guidelines—also
known as “grids”—in order to improve the consistency and uniformity of disability
determinations. Heckler v. Campbell, 461 U.S. 458, 462 (1983). “[The medical-vocational
guidelines] consist of a matrix of the four factors identified by Congress—physical ability, age,
education, and work experience—and set forth rules that identify whether jobs requiring specific
combinations of these factors exist in significant numbers in the national economy.” Id. These
guidelines do not apply, however, “if one of the findings of fact about the person’s vocational
factors and residual functional capacity is not the same as the corresponding criterion of a rule.”
20 C.F.R. § 404.1569; Sykes v. Apfel, 228 F.3d, 259, 270 (3d Cir. 2000) (“the [medicalvocational guidelines] apply only to ‘an issue that is not unique to each claimant.’”). Where the
guidelines do not apply, the Commissioner may choose how best to make the disability
determination. See 20 C.F.R. § 404.1566(e) (“[The Commissioner] will decide whether to use a
vocational expert or other specialist” if presented with a “complex issue” in disability
determination).
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jobs other than strength demands. 20 C.F. R. § 404.1569a(c)(1). Exertional impairments are
those affecting a claimant’s “ability to meet the strength demands of jobs.” 20 C.F.R. §
404.1569a(b); see Sykes, 228 F.3d at 263. Mental impairments are typically categorized as nonexertional impairments. SSR 85-15 at 2. In complex cases—those involving a combination of
exertional and non-exertional impairments, for example—SSR 85-15 directs the Commissioner
to enlist the support of “vocational resources,” including vocational experts in making their
disability determination, but does not necessarily dictate a particular finding. Id. at 3.
This case involves a claimant with more than non-exertional impairments. Indeed, the
ALJ concluded at Step Two that Plaintiff suffered multiple impairments, some exertional and
others non-exertional, some mental and others physical. (R. 17). Plaintiff’s impairments are thus
beyond the scope of SSR 85-15, rendering it inapplicable to this case.
Assuming, arguendo, that SSR 85-15 governed this case, the ALJ would still not be
bound to find Plaintiff disabled based on Dr. Billings’ report, who generally assessed Plaintiff’s
mental limitations as “slight” or “moderate.” (R. 612). Dr. Billings also found that Plaintiff had
“marked” limitations in her ability to respond appropriately to work pressures in a usual work
setting. Id. Yet, none of these findings are serious enough to direct a finding of disability.4
Moreover, given the complex and individualized nature of Plaintiff’s non-exertional limitations,
SSR 85-15 would have directed the ALJ to seek the assistance of a vocational expert before
making his determination. See SSR 85-15 at 3. The ALJ’s reliance on a vocational expert would
Dr. Billing’s conclusions were based on a scale commonly used to measure the severity of a
claimant’s limitations. This scale ranges from “none” to “slight” or “mild” to “moderate” to
“marked” to “extreme.” 20 C.F.R. § 416.920a(c)(4). The “extreme” notation represents “a degree
of limitation that is incompatible with the ability to do any gainful activity” and would thus,
strongly support a finding of disability. Id. “Marked” and “moderate” limitations generally
support the conclusion that a claimant has a severe impairment, see 20 C.F.R. § 416.920a(d)(1),
but this conclusion does not direct a finding of disability, see id at § 416.920a(d)(2)-(3). It does,
however, warrant further assessment of claimant’s limitations. Id.
4
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have comported with the policy recommended by the SSR 85-15 had it applied and is therefore
proper.
Thus, the Court finds that the ALJ was not bound by SSR 85-15 to conclude that Plaintiff
was disabled based on Dr. Billings’ report.
2.
The Consideration of Dr. Su’s Medical Source Statement and
Plaintiff’s GAF Scores
Plaintiff next claims that the ALJ improperly discounted the opinions of Dr. Sean Su, one
of Plaintiff’s treating physicians. In particular, she claims that the ALJ wrongly discounted Dr.
Su’s findings based solely on Plaintiff’s inconsistent treatment, and an apparent inconsistency
between Dr. Su’s conclusion that Plaintiff had “extreme” limitations and his assertion that her
GAF score was 50. In any event, Plaintiff claims that her GAF scores support a finding of
disability. The Commissioner responds that the ALJ appropriately discounted Dr. Su’s opinion.
The Commissioner generally gives more weight to medical evidence generated by a
claimant’s treating or examining physician. See 20 C.F.R. § 404.1527(c)(1)-(2); see also
Brownawell v. Comm’r of Soc. Sec., 554 F.3d 352, 355 (3d Cir. 2008) (“An ALJ should give
treating physicians’ reports great weight” especially when based on “continuing observation”
over a “prolonged period of time.”) (quoting Morales v. Apfel, 255 F.3d 310, 317 (3d Cir.
2000)). Indeed, a treating physician’s opinion is entitled to “controlling weight,” when it is
founded upon “medically acceptable, clinical, and laboratory diagnostic techniques” and is not
contradicted by other evidence in the record. 20 C.F.R. § 404.1527 (c)(2); Fargnoli v.
Massanari, 247 F.3d 34, 43 (3d Cir. 2001). However, an ALJ is entitled to reject a treating
source’s opinion, but cannot do so “for no reason or the wrong reason.” Plummer, 186 F.3d at
429 (citing Mason v. Shalala, 994 F.2d 1058, 1066 (3d Cir. 1993)).
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In this regard, the United States Court of Appeals for the Third Circuit has found that an
ALJ is prohibited from discounting treating source opinions based solely on her “credibility
judgments, speculation or lay opinion.” Morales, 225 F.3d at 317 (citing Plummer, 186 F.3d at
429); see Kent v. Schweiker, 710 F.2d 110, 115 (3d Cir. 1983) (holding that ALJ erred in relying
on “amorphous impressions, gleaned from the record and from his evaluations of [claimant’s]
credibility”). This rule is especially acute in cases involving a medically substantiated disability.
Morales, 225 F.3d at 319. Rather, an ALJ must take into consideration several factors when
discounting a treating source opinion, including the nature and length of the treatment
relationship, the opinion’s objective support, its consistency with the record, the specialization of
the treating source, and other factors that the parties bring to the ALJ’s attention. 20 C.F.R. §
404.1527(c)(2)-(6); see also Jones v. Sullivan, 954 F.2d 125, 129 (3d Cir. 1991) (finding treating
source opinion was properly discounted where opinion was “conclusory and unsupported by the
medical evidence,” and was plagued by “internally contradictory evidence”).
Here, the ALJ followed the regulations and applicable case law when he discounted Dr.
Su’s opinion. The ALJ found that Dr. Su’s opinion deserved little weight for several cogent and
well-supported reasons after review of the entire medical record. The ALJ noted that Dr. Su’s
conclusion that Plaintiff had “extreme” limitations, along with his conclusion that she would
need to call off five out of five days in the work week, was inconsistent with his assigned GAF
scores of 50 and the narrative entries in his treatment notes. (R. 27); see 20 C.F.R.
§404.1527(c)(3); Jones, 954 F.2d at 129. The ALJ further explained that Dr. Su’s opinion rested
on his observation of Plaintiff’s “wild mood swings,” an ailment that was not documented in her
prison records. (R. 27); see 20 C.F.R. § 404.1527(c)(4). The ALJ also found that Dr. Su’s
treatment relationship with Plaintiff was shorter than her relationship with her healthcare
15
providers in prison, due to her consistent treatment while incarcerated. (R. 27); see 20 C.F.R. §
404.1527(c)(2)(i). Moreover, the ALJ determined that Dr. Su’s opinion was inconsistent with
both Dr. Billings’ report and Plaintiff’s treatment records from the Bureau of Prisons, both of
which documented more moderate limitations, but contained similar GAF scores. (Compare R.
651 with R. 611 and R. 294, 347).
“GAF scores ‘are used by mental health clinicians and doctors to rate the social,
occupational, and psychological functioning of adults.”5 Sweeney v. Commissioner of Social
Sec., 847 F. Supp. 2d 797, 802 (W.D. Pa. 2012) (quoting Irizarry v. Barnhart, 233 Fed. App’x.
189, 190 n.1 (3d Cir. 2007). GAF scores constitute “medical evidence accepted and relied upon
by a medical source” and must be taken into consideration in an ALJ’s decision. Wiggers v.
Astrue, 2010 WL 1904015, at *8 (W.D. Pa. May 10, 2010). However, though indicative of a
claimant’s limitations, a GAF score does not establish disability. Chanbunmy v. Astrue, 560 F.
Supp. 2d 371, 383 (E.D. Pa. 2008) (citing Camp v. Barnhart, 103 Fed. App’x. 352, 354 (10th
Cir. 2004) (“The [GAF] score, without evidence that it impaired [claimant’s] ability to work,
does not establish an impairment.”); see also 65 Fed Reg. 5074601, 50764 (Aug. 21, 2000)
(noting Commissioner does not “endorse” use of GAF scale in social security disability
determinations, but that GAF scores can “provide valuable additional functional information”).
A GAF score of 41 to 50 indicates “serious symptoms (e.g. suicidal ideation, severe obsessional
rituals, frequent shoplifting) OR any serious impairment in social, occupation, or school
functioning (e.g. no friends, unable to keep a job).” American Psychiatric Association,
Diagnostic and Statistical Manual of Mental Disorders, at 34 (4th ed, 2000). A GAF of 51- 60
indicates “moderate symptoms, e.g., flat affect and circumstantial speech, occasional panic
attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends,
conflicts with peers or co-workers).” Id. A GAF score of 61-70 indicates “[s]ome mild symptoms
(e.g., depressed mood and insomnia) OR some difficulty in social, occupational, or school
functioning (e.g., occasional truancy, or theft within the household), but generally functioning
pretty well, has some meaningful relationships.” Id.
5
16
Contrary to Plaintiff’s claims, the GAF scores assigned by Dr. Su, Dr. Billings, or
Plaintiff’s caregivers from the Bureau of Prisons are not sufficient to compel the ALJ to
determine that Plaintiff was disabled. See Chanbunmy 560 F. Supp. 2d at 383; see also 65 Fed.
Reg. 5074601 at 50764. In this case, the Court instead finds that the ALJ appropriately factored
Plaintiff’s GAF scores into his decision. Specifically, the ALJ gave great weight to Dr. Billings’
assigned GAF score of 50 and the GAF scores assigned to Plaintiff in prison, which generally
ranged from 51-70, (R. 27), and included “quite restrictive mental limitations” in Plaintiff’s
RFC. (R. 26-27).
For these reasons, the Court finds that the ALJ followed the applicable regulations and
the law in discounting Dr. Su’s medical source opinion and in considering Plaintiff’s assigned
GAF scores.
3.
The Alleged Failure to Discuss Significant, Probative Evidence
Plaintiff lastly claims that the ALJ erred by failing to discuss exhibits 1F, 2F, and 3F and
explain the weight each of these sources deserve. According to Plaintiff, these exhibits contain
evidence probative of the extent of claimant’s underlying conditions, and the ALJ’s failure to
discuss them warrants remand. This argument is not persuasive.
The Court of Appeals for the Third Circuit has long held that, in making her decision, an
ALJ must provide a “clear and satisfactory explication of the basis upon which it rests,” which is
“as comprehensive and as analytical as possible.” Cotter v. Harris, 642 F.2d 704, 704-05 (3d Cir.
1981); see Burnett v. Comm’r of Soc. Sec. Admin., 220 F.3d 112, 119-120 (3d. Cir. 2000)
(remanding where ALJ did not provide explanation of evidence considered, rendering Step Three
analysis “hopelessly inadequate”). As the Cotter Court explained:
We interpret our [. . .] holding in light of our statutory function of judicial review.
In this regard we need from the ALJ not only an expression of the evidence s/he
17
considered which supports the result, but some indication of the evidence which
was rejected. In the absence of such an indication, the reviewing court cannot tell
if significant probative evidence was not credited or simply ignored.
642 F.2d at 705. This requirement is especially pertinent where the record contains significant,
probative, or contradictory evidence. Farngoli, 247 F.3d at 41-42; Cotter, 642 F.2d at 706; see
Reefer v. Barnhart, 326 F.3d 376, 382 (3d Cir. 2003) (remanding where ALJ did not discuss
choice to credit some reports over others where reports were contradictory). This rule extends to
the ALJ’s consideration of the weight given to opinion evidence illustrating the extent of a
claimant’s physical and mental limitations. 20 C.F.R. § 404.1527(e)(2)(ii)(explaining evaluation
of opinion evidence); § 416. 927(e)(2)(ii) (same). There is no requirement, however, that an ALJ
must reference all of the evidence a claimant presents. Johnson v. Comm’r of Soc. Sec., 549 F.3d
198, 204 (3d Cir. 2008); see Fargnoli, 247 F.3d at 42 (“[W]e do not expect the ALJ to make
reference to every relevant treatment note in a case where the claimant [as here] has voluminous
medical records”).
Moreover, though many district courts in the Third Circuit have found that the failure to
discuss GAF scores may warrant remand, Rivera v. Astrue, 9 F. Supp.3d 495, 504-05 (E.D. Pa
2014) (collecting cases), remand is not appropriate when the Court finds that the ALJ did not
“cherry-pick evidence or ignore medical assessments that ran counter to her finding” in the
evaluation of a claimant’s GAF scores. Rios v. Commissioner of Social Sec., 444 Fed. App’x.
532, 535 (3d Cir. 2011).
Additionally, the Court of Appeals for the Third Circuit has held that an error does not
necessarily warrant remand where the error was harmless. Rutherford v. Barnhart, 399 F.3d 546,
552-53 (3d Cir. 2005) (finding ALJ’s failure to consider claimant’s obesity was harmless where
it “would not affect the outcome of the case”). In this regard, an ALJ’s failure to explicitly
18
discuss evidence may be harmless when the evidence is duplicative or is consistent with the
ALJ’s RFC analysis. Mays v. Colvin, 739 F.3d 569, 579 (10th Cir. 2014); see McGraw v.
Comm’r of Soc. Sec., 2015 WL 1951892 at *2 (3d Cir. 2015) (holding ALJ’s failure to discuss
medical examination report was not error where report “added nothing that the ALJ had not
already taken into account”).
Here, Plaintiff challenges the ALJ’s failure to discuss three exhibits: 1F, which Plaintiff
alleges contains evidence of her “marked limitations”; 2F, which Plaintiff identifies as
containing a GAF score of 45-50; and 3F, which contains Dr. Hillin’s 2009 psychological
evaluation of Plainitff. Each exhibit will be addressed in turn.
Exhibit 1F contains two separate documents. (R. 211, 213). The first document is the
hand-written attachment to the mental residual functional capacity (MRFC) assessment
conducted by Dr. Billings (R. 212). Although it is a separate report and was, curiously, separated
from Dr. Billings’ full assessment contained in Exhibit 7F, (R. 604), this hand-written
attachment was created on the same date as the full MRFC assessment, bears the signature of Dr.
Billings, and sets forth conclusions identical to those in the full assessment. (Compare R. 211212 with R. 612). That the ALJ devoted considerable effort to explaining the great weight he
afforded Dr. Billings’ assessment convinces the Court that, contrary to Plaintiff’s claims, the
ALJ more-than-adequately considered the information contained in the first document. The
second document is a school psychologist’s report from the School District of the City of Erie
from 1978, when Plaintiff was in first-grade. Id. This report indicates the results of intelligence
and grade-equivalency tests Plaintiff took in elementary school. The ALJ also specifically
considered and appropriately addressed this report in his opinion at Step Three. (R. 21). Thus,
the ALJ properly discussed and considered Exhibit 1F.
19
Exhibit 2F contains several treatment notes from 2008 to 2010 from Stairways
Behavioral Health, where Drs. Gail Holland and Sean Su, among others, evaluated Plaintiff on a
somewhat regular basis. Plaintiff specifically directs the Court’s attention to the GAF score range
of 45-50, which Dr. Holland assigned to her in 2008 (R. 257). The Court is not convinced that
the ALJ committed error in failing to discuss this specific GAF score, however. The ALJ was not
obligated to discuss every GAF score or treatment note, see Fargnoli, 247 F.3d at 41; Johnson,
549 F.3d at 204, especially one which, as here, does not conflict with other evidence in the
record. Indeed, Dr. Holland’s score is very similar to Dr. Billings’ and the Bureau of Prisons’
more recently assigned GAF scores of 50 and 55, respectively. (Compare R. 257 with R. 294,
347 and R. 611). Moreover, there is no indication that the ALJ “cherry picked” GAF scores in
his evaluation of the record. See Rios, 444 Fed. App’x. at 535. The Court therefore finds that the
ALJ did not commit error by excluding discussion of a single GAF score range from 2008 in his
evaluation of Plaintiff’s limitations.
Exhibit 3F contains Dr. Hillin’s consultative psychological evaluation of Plaintiff from
2009. Though Plaintiff is correct that courts in the Third Circuit generally require ALJs to
discuss medical sources such as Dr. Hillin’s report, the purpose for that requirement is to enable
the Court to exercise its statutory function of reviewing the Commissioner’s decision for
substantial evidence. See 20 C.F.R. § 404.1527(e)(2)(ii); 20 C.F.R. § 416.927(e)(2)(ii); Cotter,
642 F.2d at 705. That the ALJ specifically referenced the battery of tests that Dr. Hillin
performed in evaluating Plaintiff’s impairments at Step Three of the analysis, (R. 21), convinces
the Court that the ALJ considered the report as part of his disability determination. Moreover,
Dr. Hillin’s assigned GAF score of 55 was higher than that assigned by Dr. Billings and
consistent with those in Plaintiff’s prison records. (Compare R. 264 with R. 294, 347 and R.
20
611). Moreover, Dr. Hillin, did not conclude that Plaintiff was disabled. Rather, Dr. Hillin
opined that Plaintiff was limited to “hands-on” work, a recommendation that was similar in
substance to the limitations the ALJ included in the hypothetical question posed to the vocational
expert. (R. 28, 265). Thus, any error the ALJ committed in failing to discuss Exhibit 3F was
harmless because it would not affect the outcome of the case. See Rutherford, 399 F.3d at 552553.
For these reasons, the Court concludes that the ALJ appropriately considered all of the
evidence of record and that any failure to specifically discuss exhibits 1F, 2F, or 3F, was at most
harmless error.
IV.
Conclusion
Under the Social Security regulations, a district court has three options upon review of a
decision of the Commissioner that has denied a claimant’s request for benefits. The Court can
affirm the decision, reverse the decision and award benefits directly to a claimant, or remand the
matter to the Commissioner for further consideration. 42 U.S.C. § 405(g) (sentence four). In light
of this Court’s objective review of all of the evidence in the record and for the reasons stated in
this memorandum opinion, the Court finds that the ALJ supported his determination that Plaintiff
was not disabled with substantial evidence.
The Court understands that Plaintiff faces many challenges as a result of her impairments
and is sympathetic to the effect these challenges have on her search for gainful employment.
Under the applicable standard of review and the current state of the record, however, the Court
must defer to the reasonable findings of the ALJ and his conclusion that Plaintiff is not disabled
within the meaning of the Social Security Act, and that she is able to perform a limited range of
21
sedentary work. Accordingly, the Court will grant Defendant’s motion for summary judgment.
An appropriate Order and Judgment follows.
McVerry, S.J.
22
IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF PENNSYLVANIA
LAURA PEARL WOODSBEY,
Plaintiff,
v.
CAROLYN W. COLVIN,
ACTING COMMISSIONER OF
SOCIAL SECURITY,
Defendant.
)
)
)
) 1:14-CV-285-TFM
)
)
)
)
)
)
ORDER OF COURT
AND NOW, this 7th day of July, 2015, in accordance with the foregoing Memorandum
Opinion, it is hereby ORDERED, ADJUDGED, and DECREED that the Motion for Summary
Judgment (ECF No. 8) filed by Carolyn W. Colvin, Acting Commissioner of Social Security, is
GRANTED, and the Motion for Summary Judgment (ECF No. 10) filed by Plaintiff Laura Pearl
Woodsbey is DENIED.
IT IS FURTHER ORDERED that the Decision of the Commissioner of the Social
Security Administration is hereby AFFIRMED. The Clerk shall docket this case CLOSED.
BY THE COURT:
s/Terrence F. McVerry
Senior United States District Judge
cc:
R. Christopher Brode
Email: brodelaw@gmail.com
Marshall J. Piccinini
Email: marshall.piccinini@usdoj.gov
(via CM/ECF)
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