MCCONNELL v. COMMISSIONER OF SOCIAL SECURITY
Filing
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ORDER denying 10 Plaintiff's Motion for Summary Judgment and granting 12 Defendant's Motion for Summary Judgment. Signed by Judge Alan N. Bloch on 11/30/2016. (lwp)
IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF PENNSYLVANIA
LISA ANN MCCONNELL,
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) Civil Action No. 15-1336
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Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY,
Defendant.
ORDER
AND NOW, this 30th day of November, 2016, upon consideration of the parties=
cross-motions for summary judgment, the Court, upon review of the Commissioner of Social
Security=s final decision, denying Plaintiff=s claim for disability insurance benefits under
Subchapter II of the Social Security Act, 42 U.S.C. ' 401, et seq., and denying Plaintiff=s claim
for supplemental security income benefits under Subchapter XVI of the Social Security Act, 42
U.S.C. ' 1381, et seq., finds that the Commissioner=s findings are supported by substantial
evidence and, accordingly, affirms.
See 42 U.S.C. ' 405(g); Jesurum v. Secretary of U.S. Dep’t
of Health & Human Servs., 48 F.3d 114, 117 (3d Cir. 1995); Williams v. Sullivan, 970 F.2d
1178, 1182 (3d Cir. 1992), cert. denied sub nom., 507 U.S. 924 (1993); Brown v. Bowen, 845
F.2d 1211, 1213 (3d Cir. 1988); see also Berry v. Sullivan, 738 F. Supp. 942, 944 (W.D. Pa.
1990) (if supported by substantial evidence, the Commissioner=s decision must be affirmed, as a
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federal court may neither reweigh the evidence, nor reverse, merely because it would have
decided the claim differently) (citing Cotter v. Harris, 642 F.2d 700, 705 (3d Cir. 1981)).1
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Plaintiff argues, in essence, that the Administrative Law Judge (“ALJ”) erred by:
(1) improperly assessing the medical opinions of Plaintiff’s treating physicians in formulating
her residual functional capacity assessment (“RFC”); and (2) failing to consider Plaintiff’s work
history when evaluating her credibility. The Court disagrees and finds that substantial evidence
supports the ALJ’s findings as well as his ultimate determination, based on all the evidence
presented, of Plaintiff’s non-disability.
First, 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) (citing 20 C.F.R. §§ 404.1527(e)(1),
404.1546(c)). Moreover, “[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). In fact, a treating physician’s opinion is only entitled to controlling weight if it is
“well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not
inconsistent with the other substantial evidence in [the claimant’s] case record.” Fargnoli v.
Massanari, 247 F.3d 34, 43 (3d Cir. 2001) (quoting 20 C.F.R. § 404.1527(c)(2)). “If, however,
the treating physician's opinion conflicts with other medical evidence, then the ALJ is free to
give that opinion less than controlling weight or even reject it, so long as the ALJ clearly
explains [his or] her reasons and makes a clear record.” Salles v. Comm’r of Soc. Sec., 229
Fed. Appx. 140, 148 (3d Cir. 2007). Thus, a treating physician’s opinion on the ultimate issue
of disability is not entitled to any “special significance,” and an ALJ is not required to accept it
since the determination of whether an individual is disabled “is an ultimate issue reserved to the
Commissioner.” Smith v. Comm’r of Social Sec., 178 Fed. Appx. 106, 112 (3d Cir. 2006).
In the present case, the Court finds no merit in Plaintiff’s contention that, in formulating
Plaintiff’s RFC, the ALJ improperly decided against giving controlling weight to certain
opinions in the record, including those of Jeffrey P. Hein, M.D., John Carey, M.D., and Elizabeth
DeCicco, C.R.N.P. Instead, the Court finds that the ALJ fulfilled his duty as fact-finder to
evaluate the opinions expressed by the various health care providers, considering a number of
factors, and in light of all the evidence presented in the record. See 20 C.F.R. §§ 404.1527,
416.927. Further, the Court notes that the ALJ extensively reviewed Plaintiff’s medical
records—including those related to the doctors’ treatment relationships with Plaintiff—and
stated that he was giving those opinions little weight for reasons that were clearly and
specifically explained in his decision.
For example, Plaintiff first points to a medical statement form filled out by treating
physician Dr. Hein on October 8, 2013. (R. 600-03). On that date, Dr. Hein indicated that
Plaintiff had no work capacity and was essentially limited to less than sedentary work with
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marked limitations in functioning. (R. 44). In his decision, the ALJ explained that he gave
this form very little weight because Plaintiff’s next appointment, only three weeks later, was
unremarkable, she reported doing well, had no complaints, and was described as alert and
oriented, pleasant and cooperative, and without distress. (R. 44). The ALJ also explained
that, a few weeks after that, Plaintiff reported during another appointment with Dr. Hein that her
headaches were well-controlled and that she was otherwise stable. (R. 44). The ALJ further
noted that, at about that same time, records from Staunton Clinic indicate that Plaintiff reported
that she was dating, that she was going out 2-3 times a week in 2014, and that she was having a
good time. (R. 44). Thus, after considering the opinion expressed by Dr. Hein in conjunction
with the other evidence from the same time period, the ALJ concluded that “[s]uch
inconsistencies cannot be ignored, and they significantly undermine the persuasiveness that can
be afforded to [Dr. Hein’s] statements in reflecting the most that can be sustained on a regular
and continuous basis.” (R. 44).
Additionally, the Court notes that the form from October, 2013, consists merely of
options to circle or check and blanks to be filled in by hand. (R. 601-03). The Court of
Appeals for the Third Circuit has stated that “[f]orm reports in which a physician’s obligation is
only to check a box or fill in a blank are weak evidence at best.” Mason v. Shalala, 994 F.2d
1058, 1065 (3d Cir. 1993). Thus, Dr. Hein’s opinion lacks significant discussion, explanation
or details to justify his statements contained therein. Likewise, the Court notes that another
simple form which Plaintiff mentions in a footnote, a state employability assessment form filled
out by Dr. Hein in March, 2014, was also appropriately given little weight by the ALJ. (R. 44,
613-15). This document is, likewise, merely a form report which lacks details or discussion to
justify Dr. Hein’s decision to check the box indicating that Plaintiff is permanently disabled.
See Smith, 178 Fed. Appx. at 112 (explaining that an ALJ is not required to give special
significance to a treating physician’s opinion on the ultimate issue of disability). Accordingly,
the ALJ did not err in declining to give such forms controlling weight.
Next, the ALJ explained in his decision that he also gave little weight to a second medical
statement form filled out by Dr. Hein in September, 2014, because that form is also inconsistent
with Plaintiff’s treatment records from that time. (R. 44, 672-75, 680). That statement
includes findings of marked restrictions of activities of daily living and marked difficulty in
maintaining social functioning, and findings that Plaintiff could never climb, balance, stoop,
kneel, crouch or crawl. (R. 674-75). The ALJ pointed out that the records from that date
actually show that Plaintiff presented with no distress and as breathing easily, that she had lost
weight, and that her hypertension was stable. (R. 44, 680). The ALJ also explained that the
records further show that, although Plaintiff reported neck pain, Dr. Hein specifically noted that
Plaintiff’s imaging showed merely mild narrowing of her cervical spine, and that, although she
subjectively reported ear pain, he stated that her examination was completely normal. (R. 44,
680). Additionally, the ALJ explained that, although Dr. Hein indicated that Plaintiff had
depression with trouble sleeping, he did nothing more than prescribe her medication. (R. 44,
680). The ALJ also noted that Plaintiff’s treatment records at Staunton Clinic during this time
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indicate that Plaintiff had GAF scores above 50 and relatively unremarkable mental status
exams. Thus, the ALJ concluded that “[w]hen considered in light of the claimant’s treatment
records as a whole, the limitations reflected in Dr. Hein’s opinion statements are not reasonably
supported, and his statements cannot be found to be an accurate reflection of the most that could
be sustained on a regular and continuous basis.” (R. 44). Moreover, the Court further notes
that the ALJ did not completely reject Dr. Hein’s opinions, but instead restricted her to light
work with considerable postural limitations. (R. 33). Accordingly, the Court finds that the
ALJ thoroughly explained his reasons for giving Dr. Hein’s opinions less than controlling
weight.
Plaintiff also contends that the ALJ did not properly weigh the opinion of her treating
neurologist, Dr. Carey, in formulating her RFC. In particular, Plaintiff argues that the ALJ
never specified in his analysis how much weight he gave to Dr. Carey’s opinion. The Court
notes, first, that Plaintiff is mistaken, and that the ALJ did in fact state that he gave Dr. Carey’s
opinion “little” weight. (R. 36). The Court further finds that the ALJ thoroughly discussed his
decision to do so. (R. 36). For example, the ALJ stated that Dr. Carey had opined that
Plaintiff has migraine headaches with blurry vision occurring approximately once a week, and
that she cannot work when she has such a headache. (R. 36, 577). The ALJ explained that he
gave such assessment little weight because it is largely inconsistent with the doctor’s own
treatment record, which described her headaches as “ameliorated” with medication, and the
records of Dr. Hein, which describe her headaches as “well controlled.” (R. 36, 504, 606).
Additionally, the ALJ noted the fact that Plaintiff has sought no subsequent treatment for her
headaches. Also, the ALJ stated that even when Plaintiff reported having tension headaches to
her providers at Staunton Clinic—and when she initially went to see Dr. Carey—her presentation
was relatively unremarkable. (R. 38, 507, 639). In fact, other than noting some anxiety issues
(which were no more than moderate), Plaintiff was alert, cooperative, and had normal gait and
she showed unremarkable orientation, affect, mood, and thought organization. Thus, the ALJ
found that he could not find that Dr. Carey’s statement that Plaintiff’s “headaches would
preclude all work entirely supported by her objective presentation on examination.” (R. 36).
Moreover, the ALJ noted that he took Plaintiff’s headaches into consideration when he
formulated her RFC, limiting her to no more than unskilled work that avoids workplace hazards,
but he simply found that “a more restrictive limitation is not reasonably supported by the medical
evidence of record as a whole.” (R. 36). Therefore, the Court finds that the ALJ provided
adequate reasons for giving Dr. Carey’s assessment less than controlling weight when
formulating Plaintiff’s RFC.
Finally, Plaintiff contends that the ALJ was not clear about the weight that he assigned to
Nurse DeCicco’s statement in formulating Plaintiff’s RFC, and Plaintiff appears to suggest that
the ALJ should have given greater weight to the opinion of Nurse DeCicco in reaching his
decision. First, the Court notes that the ALJ was not required to consider the opinion of Nurse
DeCicco because, as a nurse practitioner, she is not an “acceptable medical source” for purposes
of determining Social Security disability benefits. 20 C.F.R. § 404.1513(a); Chandler v.
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Comm’r of Soc. Sec., 667 F.3d 356, 361-62 (3d Cir. 2011). Nevertheless, the ALJ discussed
Nurse DeCicco’s statement in his decision, and explained that he gave the statement some
weight to the extent that it indicated moderate mental limitations. (R. 44-45, 667-68). To the
extent that Nurse DeCicco’s opinion listed marked limitations in maintaining attention and
concentration, however, the ALJ found that the treatment records did not establish that such a
restrictive limitation is warranted in Plaintiff’s case. (R. 45). The ALJ also noted that Nurse
DeCicco suggested that Plaintiff has moderate to marked limitations in behaving in an
emotionally stable manner and in relating predictably in social situations, and he explained that
such statements are a significant factor in his inclusion of restrictions of no production rate pace
work or more than occasional and routine changes in a work setting and limited interaction with
others. (R. 45). The ALJ concluded, however, that, given Plaintiff’s consistent and
conservative treatment, her GAF scores, and the fact that she generally presents as alert,
cooperative, and with normal orientation, he could not find that the record supports more
significant limitations than those which he included in his RFC. (R. 45). The Court therefore
finds that the ALJ adequately considered Nurse DeCicco’s opinion, and that he did not err in
declining to give that opinion controlling weight.
Plaintiff argues, additionally, that the ALJ erred in evaluating her credibility, particularly
in failing to consider her work history. The Court disagrees and finds that the ALJ properly
considered in his decision all the relevant evidence, that he included an extremely detailed
discussion of the medical evidence in the record, and that he explained the ways in which that
evidence contradicted Plaintiff’s subjective complaints regarding her many alleged impairments.
(R. 34-43). For example, the ALJ noted that Plaintiff has had only routine office visits with her
primary care physician, and that when she sought specialized care, her symptoms were
ameliorated with conservative treatment and only minimal objective findings were made.
(R. 39-40). Additionally, the ALJ stated that while Plaintiff was alleging significant limitations
in her daily activities due to pain, she was reporting a wide range of activities to her mental
health providers. (R. 40). Thus, the ALJ concluded that “[w]hen considered as a whole, the
record does not reasonably reflect the intensity, persistence or functionally limiting effects
resulting from the claimant’s pain complaints as would support a more restrictive finding than
adopted herein.” (R. 40).
Moreover, while the ALJ was not required to afford Plaintiff heightened credibility based
solely on her work history, see Schreibeis v. Comm’r of Soc. Sec., No. 10-1025, 2012 WL
11101, at *1, n.1 (W.D. Pa. Jan. 3, 2012), the ALJ did state in his decision the fact that Plaintiff
has a strong work history up until 2008. (R. 46). However, the Court notes that Plaintiff has
not worked since 2008, which is approximately four years before the alleged onset date of
disability. Additionally, although the ALJ pointed out that Plaintiff does have a strong work
history, he also specified that her past work included skilled work at a medium exertional level,
and that—while Plaintiff is clearly now limited in a manner that precludes her returning to her
past work—the evidence does not reasonably establish that she would be precluded at the present
time from sustaining a limited range of unskilled, light exertion work, as set forth in the RFC.
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Therefore, IT IS HEREBY ORDERED that Plaintiff=s Motion for Summary
Judgment (Doc. No. 10) is DENIED and Defendant=s Motion for Summary Judgment (Doc.
No. 12) is GRANTED.
s/ Alan N. Bloch
United States District Judge
ecf: Counsel of record
(R. 46). Therefore, the Court finds that the ALJ adequately evaluated Plaintiff’s credibility, and
that substantial evidence supports the ALJ’s conclusion that, “after careful consideration of the
evidence . . . the claimant’s medically determinable impairments could reasonably be expected to
cause the alleged symptoms; but, the claimant’s statements concerning the intensity, persistence
and limiting effects of these symptoms are not entirely credible for the reasons explained” in his
decision. (R. 34).
Thus, upon review, the Court finds that the ALJ properly discharged his duty to consider
Dr. Hein’s opinion, Dr. Carey’s opinion, Nurse DeCicco’s opinion and the other relevant
evidence presented in the record. Throughout his decision, the ALJ clearly considered all the
evidence, provided discussion of the evidence to support his evaluation, and ultimately
concluded that certain opinions of record were not supported by the evidence as a whole. The
Court therefore finds that substantial evidence supports the ALJ’s evaluation of the opinions
presented and his decisions as to the weight he gave to those opinions in making his ultimate
determinations regarding Plaintiff’s RFC. The Court further finds that the ALJ did not err in
assessing Plaintiff’s credibility. Accordingly, the Court affirms.
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