GONZALES v. COMMISSIONER OF SOCIAL SECURITY

Filing 18

OPINION and ORDER denying 9 Motion for Summary Judgment; granting 11 Motion for Summary Judgment. Signed by Judge Donetta W. Ambrose on 1/12/17. (slh)

IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF PENNSYLVANIA
ANGELITA H. GONZALES,
Plaintiff,
-vsCAROLYN W. COLVIN,
COMMISSIONER OF SOCIAL SECURITY,
Defendant.

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Civil Action No. 15-283

AMBROSE, Senior District Judge

OPINION
Pending before the court are Cross-Motions for Summary Judgment. (ECF Nos. 9 and
11). Both parties have filed Briefs in Support of their Motions. (ECF Nos. 10, 12 and 16). After
careful consideration of the submissions of the parties, and based on my Opinion set forth
below, I am denying Plaintiff’s Motion for Summary Judgment (ECF No. 9) and granting
Defendant’s Motion for Summary Judgment. (ECF No. 11).
I.

BACKGROUND
Plaintiff brought this action for review of the final decision of the Commissioner of Social

Security (ACommissioner@) denying her application for supplemental security income benefits
(“SSI”) pursuant to the Social Security Act (AAct@). Plaintiff filed her application alleging she had
been disabled since November 1, 2008. (ECF No. 7-5, p. 2).

Administrative Law Judge

(“ALJ”), Wayne Stanley, held a hearing on May 1, 2014. (ECF No. 7-2, pp. 24-65). On June 13,
2014, the ALJ found that Plaintiff was not disabled under the Act. (ECF No. 7-2, pp. 15-23).
After exhausting all administrative remedies, Plaintiff filed the instant action with this
court. The parties have filed Cross-Motions for Summary Judgment. (ECF Nos. 9 and 11). The
issues are now ripe for review.

II.

LEGAL ANALYSIS
A.

Standard of Review

The standard of review in social security cases is whether substantial evidence exists in
the record to support the Commissioner=s decision. Allen v. Bowen, 881 F.2d 37, 39 (3d Cir.
1989). Substantial evidence has been defined as Amore than a mere scintilla. It means such
relevant evidence as a reasonable mind might accept as adequate.@ Ventura v. Shalala, 55
F.3d 900, 901 (3d Cir. 1995), quoting Richardson v. Perales, 402 U.S. 389, 401 (1971).
Additionally, the Commissioner=s findings of fact, if supported by substantial evidence, are
conclusive. 42 U.S.C. '405(g); Dobrowolsky v. Califano, 606 F.2d 403, 406 (3d Cir. 1979). A
district court cannot conduct a de novo review of the Commissioner=s decision or re-weigh the
evidence of record. Palmer v. Apfel, 995 F.Supp. 549, 552 (E.D. Pa. 1998). Where the ALJ's
findings of fact are supported by substantial evidence, a court is bound by those findings, even if
the court would have decided the factual inquiry differently. Hartranft v. Apfel, 181 F.3d 358, 360
(3d Cir. 1999). To determine whether a finding is supported by substantial evidence, however,
the district court must review the record as a whole. See, 5 U.S.C. '706.
To be eligible for social security benefits, the plaintiff must demonstrate that he cannot
engage in substantial gainful activity because of a 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 at least 12 months. 42 U.S.C. '423(d)(1)(A); Brewster v. Heckler,
786 F.2d 581, 583 (3d Cir. 1986).
The Commissioner has provided the ALJ with a five-step sequential analysis to use
when evaluating the disabled status of each claimant. 20 C.F.R. '404.1520(a). The ALJ must
determine: (1) whether the claimant is currently engaged in substantial gainful activity; (2) if not,
whether the claimant has a severe impairment; (3) if the claimant has a severe impairment,
whether it meets or equals the criteria listed in 20 C.F.R., pt. 404, subpt. P., appx. 1; (4) if the
impairment does not satisfy one of the impairment listings, whether the claimant=s impairments

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prevent him from performing his past relevant work; and (5) if the claimant is incapable of
performing his past relevant work, whether he can perform any other work which exists in the
national economy, in light of his age, education, work experience and residual functional
capacity. 20 C.F.R. '404.1520. The claimant carries the initial burden of demonstrating by
medical evidence that he is unable to return to his previous employment (steps 1-4).
Dobrowolsky, 606 F.2d at 406. Once the claimant meets this burden, the burden of proof shifts
to the Commissioner to show that the claimant can engage in alternative substantial gainful
activity (step 5). Id.
A district court, after reviewing the entire record may affirm, modify, or reverse the
decision with or without remand to the Commissioner for rehearing. Podedworny v. Harris, 745
F.2d 210, 221 (3d Cir. 1984).
B.

Residual Functional Capacity (“RFC”) 1
1.

Carpal Tunnel Syndrome

Plaintiff argues that ALJ improperly determined her RFC.

(ECF No. 10, pp. 3-6).

Specifically, Plaintiff suggests that because the ALJ found she had “severe” carpal tunnel
syndrome, he was required to make an accommodation for that impairment in his RFC. Id.
(ECF No. 10, pp. 27-28). “[S]uch a presumption would conflict with the regulatory scheme for
determining whether a claimant is disabled, under which the determination of whether a
claimant is severely impaired precedes a separate determination of whether the claimant,
despite his severe impairment, retains the [residual functional capacity] to perform substantial
gainful activity.” Jones v. Sullivan, 954 F.2d 125, 129 (3d Cir. 1991). Thus, just because an
impairment is found to be severe does not mean necessarily that it erodes a plaintiff’s RFC.
Franklin v. Astrue, No. 10-CV-02532-PAB, Civ No. 10-cv-2532, 2012 WL 1059995, at *3 (D.
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RFC refers to the most a claimant can still do despite his/her limitations. 20 C.F.R. §§ 404.1545(a),
416.945(a). The assessment must be based upon all of the relevant evidence, including the medical
records, medical source opinions, and the individual’s subjective allegations and description of his own
limitations. 20 C.F.R. § 416.945(a).

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Colo. Mar. 28, 2012) (“Simply because plaintiff established a ‘severe impairment’ which only
‘requires a de minimis showing of impairment,’ does not necessarily require that the ALJ
conclude that the impairment materially erodes plaintiff's RFC.”).

In this case, the ALJ

discussed and thoroughly considered Plaintiff’s carpal tunnel syndrome in his discussion of the
RFC. (ECF No. 7-2, pp. 20-21). I find the ALJ properly reviewed the same and that his RFC,
which does not include any limitations as it relates to Plaintiff’s carpal tunnel syndrome, is based
on substantial evidence. Therefore, remand on this basis is not warranted.
2.

Use of a cane

Plaintiff also argues that the ALJ erred in failing to include the use of a cane in the RFC.
(ECF No. 10, pp. 13-15). In support of the same, Plaintiff points to treatment records that noted
Plaintiff arrived at the office with a cane and that she testified that she needed to use the cane
for balance. Id. In his decision, the ALJ acknowledged Plaintiff’s testimony that she used the
cane for balance. (ECF No. 7-2, p. 19). He further noted that medical records indicated that
she was observed with a cane. (ECF No. 7-2, p. 21). There is no evidence, however, that a
cane was ordered by a doctor. Indeed, Plaintiff does not point to any evidence indicating that a
doctor prescribed the use of a cane. See, ECF No. 10, pp. 13-15.
Additionally, “a medical source does not transform the claimant's subjective complaints
into objective findings simply by recording them....” Hatton v. Comm'r, 131 F. App'x 877, 879 (3d
Cir. 2005) (citation omitted).
credible. (ECF No. 7-2, p. 19).

Here, the ALJ found Plaintiff’s statements to be not entirely
Plaintiff does not attack the ALJ’s credibility finding that she

was not entirely credible. See, ECF Nos. 10, 16. Thus, the ALJ was not required to accept
Plaintiff’s use of a cane as imposing a functional limitation. As a result, there was no credible
evidence that a cane was medically warranted and/or the impact of the use of the cane on
Plaintiff’s functional abilities. Therefore, I find no error in failing to include the use of a cane in
formulating Plaintiff’s RFC. Consequently, remand is not warranted on this basis.

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3.
Plaintiff

Reasons for discounting opinions
additionally

argues

that

the

ALJ

erred

in

failing

to

provide

“good/specific/supported” reasons for discounting the opinion of the consultative examiner, Dr.
Kalata. (ECF No. 10, pp. 6-13; No. 16, pp. 1-7). The amount of weight accorded to medical
opinions is well-established. Generally, the ALJ will give more weight to the opinion of a source
who has examined the claimant than to a non-examining source. 20 C.F.R. § 416.927(c)(1).
Also, “the more consistent an opinion is with the record as a whole, the more weight [the ALJ
generally] will give to that opinion.” Id. § 416.927(c)(4). Although the ALJ may choose whom to
credit when faced with a conflict, he “cannot reject evidence for no reason or for the wrong
reason.” Diaz v. Comm’r of Soc. Security, 577 F.3d 500, 505 (3d Cir. 2009).
In this case, the ALJ gave Dr. Kalata’s opinion little weight because he was not able to
perform a full examination on the claimant, his opinions are inconsistent with the treatment
records, and the opinion appears to be based primarily on Plaintiff’s subjective complaints,
(which he found to be not credible). (ECF No. 7-2, p. 22). Plaintiff suggests that these reasons
are not borne out in the record. After a review of the record, I disagree.
As to the first reason, the ALJ noted that Dr. Kalata was not able to perform a full
examination. (ECF No. 7-2, p. 22). The record indicates that Plaintiff was unable to lie in a
supine position or go through the range of motion which impacted the test. Id.; see also, ECF
No. 7-10, pp. 5, 7. As a result, according to Dr. Kalata, he performed the parts of the test that
could be done. Id. In fact, because of the abbreviated nature of the examination, Dr. Kalata
went so far as to suggest that “[i]f it is warranted, please reduce the internal medicine disability
examination fee at your pleasure.” Id. at p. 7. By noting the same, there was no implication by
the ALJ that Plaintiff was not cooperating, as Plaintiff suggests. (ECF No. 10, p. 10). Rather, I
find the ALJ was properly indicating limitations as noted specifically by Dr. Kalata. Thus, I find
no error in this regard.

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As to the second and third reasons, the ALJ noted that the opinion of Dr. Kalata is
inconsistent with the record evidence and is based primarily on Plaintiff’s subjective complaint.
These are valid and acceptable reasons for discounting opinion evidence. See, 20 C.F.R.
§§404.1527; 416.927 (Evaluating Opinion Evidence). Again, I note that “a medical source does
not transform the claimant's subjective complaints into objective findings simply by recording
them....” Hatton v. Comm'r, 131 F. App'x 877, 879 (3d Cir. 2005) (citation omitted).

Finally,

based on a review of the record, I find there is substantial evidence of record to support the
ALJ’s weighing of the opinion of Dr. Kalata. (ECF No. 7-2, pp. 15-23). Consequently, I find no
error in this regard.2
An appropriate order shall follow.

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Plaintiff also argues at the very end of this section in her brief that the ALJ should have ordered an
additional consultative examinination or recontacted Dr. Kalata or sent the file back to the state agency
for a review or obtained testimony from a medical expert. (ECF No. 10, pp. 12-13). The decision to order
a consultative examination is within the sound discretion of the ALJ. Thompson v. Halter, 45 Fed.Appx.
146, 149 (3d Cir. 2002); 20 C.F.R. §§ 404.1517, 416.917. An “ALJ's duty to develop the record does not
require a consultative examination unless the claimant establishes that such an examination is necessary
to enable the ALJ to make the disability decision.” Id. Other circumstances necessitating a consultative
examination include situations where a claimant's medical records do not contain needed additional
evidence, or when the ALJ needs to resolve a conflict, inconsistency or ambiguity in the record. See, 20
C.F.R. §§404.1519(a), 416.919(a). Based on the existing medical records in this case, I find the ALJ was
not required to order a consultative examination. Furthermore, I find the record was sufficient such that
the ALJ could make a proper determination. Thus, I find no error in this regard.

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IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF PENNSYLVANIA
ANGELITA H. GONZALES,

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Plaintiff,
-vsCAROLYN W. COLVIN,
COMMISSIONER OF SOCIAL SECURITY,
Defendant.

Civil Action No. 15-283

AMBROSE, Senior District Judge

ORDER OF COURT
THEREFORE, this 12th day of January, 2017, it is ordered that Plaintiff=s Motion for
Summary Judgment (Docket No. 9) is denied and Defendant=s Motion for Summary Judgment
(Docket No. 11) is granted.
BY THE COURT:
s/ Donetta W. Ambrose
Donetta W. Ambrose
United States Senior District Judge

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