PROTZMAN v. COLVIN

Filing 16

ORDER denying 11 Plaintiff's Motion for Summary Judgment and granting 13 Defendant's Motion for Summary Judgment. Signed by Judge Alan N. Bloch on 3/28/2018. (lwp)

IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF PENNSYLVANIA

RANDALL ALAN PROTZMAN,

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Plaintiff,
v.
CAROLYN W. COLVIN, ACTING
COMMISSIONER OF SOCIAL SECURITY,
Defendant.

Civil Action No. 17-108

ORDER
AND NOW, this 28th day of March, 2018, upon consideration of the parties’ crossmotions for summary judgment, the Court, upon review of the Acting 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 Acting 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

Plaintiff argues that the Administrative Law Judge (“ALJ”) erred by: (1) failing to find
at Step Two of the sequential analysis that Plaintiff did not have the severe impairments of
bilateral carpal tunnel syndrome, arthritis in the neck, knees and thumbs, a mental health disorder,
and emphysema; (2) failing to give proper weight in his analysis to the medical opinions of
Plaintiff’s treating physicians; (3) failing to include in his residual functional capacity (“RFC”)
assessment the limitations from the above-mentioned impairments, which were erroneously
considered to be not severe; (4) improperly evaluating Plaintiff’s subjective complaints of pain;
and (5) improperly disregarding the testimony of the vocational expert (“VE”). 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.
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With regard to Plaintiff’s first argument, the Court notes at the outset that the Step Two
determination as to whether a claimant is suffering from a severe impairment is a threshold
analysis requiring the showing of only one severe impairment. See Bradley v. Barnhart, 175
Fed. Appx. 87, 90 (7th Cir. 2006). In other words, as long as a claim is not denied at Step Two,
it is not generally necessary for the ALJ specifically to have found any additional alleged
impairment to be severe. See Salles v. Comm’r of Soc. Sec., 229 Fed. Appx. 140, 145 n.2 (3d
Cir. 2007); Lee v. Astrue, 2007 WL 1101281, at *3 n.5 (E.D. Pa. Apr. 12, 2007); Lyons v.
Barnhart, 2006 WL 1073076, at *3 (W.D. Pa. March 27, 2006). Since Plaintiff’s claim was not
denied at Step Two, it is irrelevant whether the ALJ correctly or incorrectly found any other of
Plaintiff’s alleged impairments to be non-severe, as long as, as discussed, infra, he properly
accounted for all impairments at Steps Four and Five.
Moreover, the Court finds here that substantial evidence supports the ALJ’s findings,
which do not include bilateral carpal tunnel syndrome, arthritis in the neck, knees and thumbs, a
mental health disorder, and emphysema among Plaintiff’s severe impairments. (R. 15). A
claimant has the burden of demonstrating, at Step Two of the disability determination process,
that he or she has a “severe” impairment or combination of impairments. See 20 C.F.R.
§§ 404.1512(a), 404.1520(c), 416.912(a), 416.920(c); Bowen v. Yuckert, 482 U.S. 137, 140-41
(1987). An impairment is “not severe” if the medical evidence establishes that the condition has
no more than a minimal effect on the claimant’s ability to perform basic work activities. See
SSR 85-28, 1985 WL 56856, at *3 (1985); Newell v. Comm’r of Soc. Sec., 347 F.3d 541, 546
(3d Cir. 2003) (citing SSR 85-28). The severity step of the sequential evaluation process thus
functions as “a de minimis screening device to dispose of groundless claims.” Newell, 347 F.3d
at 546; see also McCrea v. Comm’r of Soc. Sec., 370 F.3d 357, 360 (3d Cir. 2004) (holding that
the “burden placed on an applicant at step two is not an exacting one”).

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Thus, the ALJ noted that Plaintiff had had surgery for carpal tunnel syndrome, and that
the treating surgeon reported that Plaintiff was doing very well after the surgeries and that his
symptoms had improved and/or resolved. (R. 16). As there was no indication that Plaintiff
needed additional treatment for the condition, or that it persisted for a continuous period of
twelve months or resulted in more than minimal functional limitations, the ALJ found them to be
non-severe per the regulations. (R. 16).
Regarding Plaintiff’s allegations of arthritis in his neck, knees and thumbs, the ALJ found
that the record lacked recurrent subjective complaints, abnormal physical examinations, or
objective diagnoses regarding the cervical spine and knees, and he noted that Plaintiff admitted to
not pursuing treatment for neck and knee allegations. (R. 17). The ALJ explained that
although an examining physician reported left thumb arthritis at one point, Plaintiff was
asymptomatic and reported that he was not interested in any treatment at that time. (R. 17).
Moreover, since the record thereafter lacked similar complaints, substantiating radiographic
studies, or objective diagnoses in support of an arthritic condition in his hands, the ALJ found
that the record did not support a finding that the left thumb resulted in more than minimal
functioning limitation or that Plaintiff had any impairment of the cervical spine or knees. (R.
17).
Regarding Plaintiff’s claim of a medically determinable mental impairment of adjustment
disorder, the ALJ also found that it did not cause more than minimal limitation in Plaintiff’s
ability to perform basic mental work activities and was thus non-severe. (R. 17). The ALJ
included appropriate discussions and found that Plaintiff had only mild limitation in activities of
daily living, social functioning, and concentration, persistence or pace, and no episodes of
decompensation. (R. 18). The ALJ also noted that Plaintiff’s treatment consisted primarily of
prescribed medication through his primary care provider, and that he had had only a single
psychiatric examination with no need for follow-up. (R. 17). The ALJ further explained that
Plaintiff’s exams reported him largely doing well, and his most recent examination reported that
Plaintiff denied depression, anxiety, sadness, and suicidal ideation. (R. 17).
Finally, with regard to emphysema, the ALJ noted that Plaintiff’s pulmonary function
testing found only mild obstruction with normal lung capacity and FVC and FEV1 values.
(R. 16). The ALJ explained that Plaintiff also denied symptoms of shortness of breath, physical
examinations were unremarkable, and no medical source indicated a diagnosis of emphysema.
(R. 16). Thus the ALJ found that the record failed to substantiate the existence of a medically
determinable impairment of emphysema. (R. 16).
Upon consideration of the evidence presented in this case, the Court therefore finds that
the ALJ’s decision, which included ample discussion of the above-referenced conditions but did
not include them as severe impairments, is indeed supported by substantial evidence. (R. 1519).

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Second, the Court finds no merit in Plaintiff’s contention that the ALJ failed to give
proper weight in his RFC analysis to the medical opinions of Plaintiff’s treating physicians. The
Court notes that a claimant’s RFC is the most that a claimant can do despite his limitations, and
the determination of a claimant’s RFC is solely within the province of the ALJ. See 20 C.F.R.
§§ 404.1527(d)(2), 404.1545(a), 404.1546(c), 416.927(d)(2), 416.945(a), 416.946(c). In
formulating a claimant’s RFC, the ALJ must weigh the evidence as a whole, including medical
records, medical source opinions, a claimant’s subjective complaints, and descriptions of his or
her own limitations. See 20 C.F.R. §§ 404.1527, 404.1529, 404.1545, 416.927, 416.929,
416.945.
Moreover, 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)). “The 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). 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). 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).
The Court emphasizes, first, that the opinions of John R. Belasco, D.O. and Srikant
Rangaraju, M.D. at issue here appear to consist of short administrative forms from the
Pennsylvania Department of Public Welfare that were simply filled out by the doctors. (R. 48186). The forms largely contain options to check and blanks to be filled in by hand. 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, the Court notes that these opinions lack significant
discussion, explanation, or details to justify the statements contained therein. Nevertheless, the
Court finds that the ALJ sufficiently explained his reasons for giving these opinions less than
controlling weight.
The Court finds that the ALJ did not fail to provide sufficient reasons for discounting the
opinions of Dr. Belasco, nor did he substitute his own lay analysis for the judgment of Dr.
Belasco in formulating Plaintiff’s RFC. Rather, the ALJ fulfilled his duty as fact-finder to
evaluate Dr. Belasco’s opinions, considering a number of factors, and in light of all the evidence
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presented in the record. See 20 C.F.R. §§ 404.1527, 416.927. In fact, the ALJ specified that
he was giving Dr. Belasco’s opinions “little weight” only after engaging in discussion of
Plaintiff’s treatment records with the doctor. (R. 21-22). The ALJ explained that he afforded
“little weight to Dr. Belasco’s opinion that [Plaintiff] was permanently disabled due to left eye
blindness, a colostomy, and severe depression because the depression is not a severe impairment,
the colostomy was removed, and [Plaintiff] demonstrated normal visual acuity in the right eye.”
(R. 22). The ALJ further noted that since “Dr. Belasco’s opinions were based on a brief course
of treatment that consisted of only three preceding office visits . . . his opinions are not
representative of [Plaintiff’s longitudinal functional capacity.” (R. 22).
The Court also finds that the ALJ provided sufficient reasons for discounting the opinion
of Dr. Rangaraju in formulating Plaintiff’s RFC. (R. 23). The ALJ explained that he was
giving “little weight” to Dr. Rangaraju’s opinion that Plaintiff was temporarily disabled because
that opinion was based only on “a brief encounter in the hospital setting and not a longitudinal
treating relationship.” (R. 23). The ALJ further noted that Dr. Rangaraju’s opinion was not
consistent with Plaintiff’s self-reported ability to perform activities after he was seen by the
doctor, including snow shoveling, climbing ladders and lifting hay bales. (R. 23).
Moreover, in determining Plaintiff’s RFC, the ALJ also addressed the opinion of the state
agency medical consultant, Dilip S. Kar, M.D., who reviewed Plaintiff’s records and assessed
him as being capable of performing light work with further postural and environmental
limitations. (R. 22, 89-104). The ALJ noted that Dr. Kar’s opinions were generally supported
by Plaintiff’s course of treatment, associated objective findings at the time of review, and
Plaintiff’s progressive improvement following bowel surgery. (R. 22). However, the ALJ
explained that Dr. Kar’s opinion failed to account for any eye restriction and that Plaintiff
experienced several gastrointestinal complications after Dr. Kar’s review of the record. (R. 22).
Therefore, the ALJ’s opinion by Dr. Kar was given “some weight,” and the ALJ noted that he
accounted for Dr. Kar’s opinions but further limited Plaintiff “to account for any reasonable
limitation stemming from his loss of visual acuity and gastrointestinal impairments.” (R. 22).
Accordingly, the Court finds that the ALJ properly discharged his duty to discuss the
opinion evidence presented in the record. The Court finds that substantial evidence supports
the ALJ’s evaluation of that opinion evidence and his decisions as to the weight he gave to those
opinions in making his ultimate determination.
Third, Plaintiff argues that the ALJ failed to include in his RFC assessment the limitations
from the above-mentioned impairments that Plaintiff alleges were erroneously found to be not
severe. The Court notes that even if an impairment is non-severe, it may still affect a claimant’s
RFC. Additionally, in assessing a claimant’s RFC, the ALJ “must consider limitations and
restrictions imposed by all of an individual’s impairments, even those that are not ‘severe.’” SSR
96-8p, 1996 WL 374184, at *5 (July 2, 1996); see also 20 C.F.R. §§ 404.1545(a)(2),
416.945(a)(2). “While a ‘not severe’ impairment(s) standing alone may not significantly limit
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an individual’s ability to do basic work activities, it may—when considered with limitations or
restrictions due to other impairments—be critical to the outcome of a claim.” SSR 96-8p at *5.
Accordingly, just because the ALJ did not find the above-referenced conditions to be severe does
not mean that such condition could not still have affected his RFC.
However, the Court finds here that substantial evidence supports the ALJ’s findings as to
Plaintiff’s functional limitations, and the evidence does not establish that any issues that Plaintiff
may have had with regard to the above-referenced conditions that were found to be non-severe
impacted his work-related functional ability. In fact, in his decision, the ALJ discussed at length
Plaintiff’s various alleged mental and physical health issues, examined the treatment Plaintiff
received, and reviewed Plaintiff’s testimony, activities of daily living, and the medical opinion
evidence. (R. 15-23). Thus, as discussed, supra, the Court finds that the ALJ did not err in his
evaluation of Plaintiff’s severe impairments at Step Two of the sequential analysis, and that
substantial evidence supports the ALJ’s ultimate RFC assessment.
Fourth, Plaintiff asserts that the ALJ erred in improperly evaluating his subjective
complaints of pain. In support of this contention, Plaintiff contends that the ALJ did not show
any rational basis for discounting Plaintiff’s testimony about pain and limitations caused by
problems with his low back, thumb, hands, knees and neck, and his balance problems and
inability to judge distances due to left eye blindness. The Court finds, however, that the ALJ
did in fact properly address the relevant evidence of record, including adequate consideration of
Plaintiff’s subjective complaints—and ultimately appropriately accounted for the limitations
resulting from his impairments—in forming Plaintiff’s RFC.
In determining whether a claimant is disabled, the ALJ must consider all of a claimant’s
symptoms and the extent to which the symptoms can reasonably be accepted as consistent with
the objective medical evidence. See 20 C.F.R. §§ 404.1529(a), 416.929(a). A claimant’s
subjective complaints of symptoms alone are not sufficient to establish disability. See id. In
evaluating a claimant’s subjective complaints, the ALJ must consider, first, whether the claimant
has a medically determinable impairment that could reasonably be expected to produce the
symptoms he alleges. See 20 C.F.R. §§ 404.1529(b), 416.929(b). Once an impairment is
found, the ALJ then must evaluate the intensity and persistence of the claimant’s symptoms to
determine the extent to which those symptoms limit his ability to work. See 20 C.F.R.
§§ 404.1529(c)(3)(i)-(vii), 416.929(c)(3)(i)-(vii) (factors relevant to symptoms can include daily
activities, medications and medical treatment). In the ALJ’s decision here, after examining
Plaintiff’s medical treatment and subjective complaints in connection with his alleged
impairments, the ALJ ultimately found that such evidence simply did not fully support the
limitations he alleges.
Here, the ALJ considered Plaintiff’s testimony, as well as that of his roommate, but he
found that his subjective complaints were simply less than fully credible. (R. 20, 23). The
ALJ found that Plaintiff’s various complaints, which included requiring use of a cane and having
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extensive bathroom needs, were simply not supported by the medical record. The ALJ also
properly considered activities in which the record indicated Plaintiff had engaged, including
climbing ladders, shoveling snow and lifting hay bales, and found that such significant activities
also did not lend support to his testimony. Moreover, the ALJ did in fact find that Plaintiff has
a number of severe impairments, and he did not find Plaintiff to be lacking in pain and
limitations altogether. (R. 15, 19). However, upon substantial review of all the evidence of
record, the ALJ simply found that the evidence as a whole did not support the extreme
limitations that Plaintiff alleges.
Thus, the ALJ found, after careful consideration of all the evidence, that Plaintiff’s
“medically determinable impairments could reasonably be expected to cause the alleged
symptoms; however, [Plaintiff’s] statements concerning the intensity, persistence and limiting
effects of these symptoms are not entirely credible” for the reasons he provided in his decision.
(R. 20). The Court finds that the ALJ did not err in evaluating Plaintiff’s subjective allegations
because he thoroughly reviewed them in accordance with the regulations, and he provided
sufficient explanation as to why he found those allegations to be not entirely credible.
Lastly, Plaintiff argues that the ALJ erred in improperly disregarding the testimony of the
VE. While the hypothetical question to the VE must accurately portray the claimant’s
impairments, such question needs only to reflect those impairments that are adequately supported
by the record. See Podedworny v. Harris, 745 F.2d 210, 218 (3d Cir. 1984); Chrupcala v.
Heckler, 829 F.2d 1269, 1276 (3d Cir. 1987). In this case, the Court finds that the ALJ’s
hypothetical question to the VE fully accommodated the limitations that were supported by the
record, which were also properly included in the RFC, as discussed, supra. The ALJ accounted
for the limitations supported by the record when he asked the VE to assume an individual with
Plaintiff’s age, education, work experience and RFC, and whether jobs exist for such an
individual. Considering these limitations, the VE testified that such an individual would be able
to perform the requirements of representative light work occupations such as ticket taker, mail
clerk and information clerk, and the ALJ properly relied on these findings in concluding that
Plaintiff is not disabled. (R. 24-26, 66-67). The Court notes that while the ALJ posed a
number of additional hypothetical questions to the VE, those additional questions did not include
limitations that the ALJ ultimately included in Plaintiff’s RFC, and therefore the VE’s responses
to all of these additional questions did not have to be included in his analysis.
As to any additional arguments mentioned summarily by Plaintiff in his brief, the Court
finds that he has failed to establish how the ALJ’s failure to consider properly any additional
evidence of record constitutes reversible error.
In sum, the Court finds that the ALJ did not err in his findings regarding Plaintiff’s severe
impairments at Step Two of his analysis. The Court further finds that the ALJ gave proper
weight in his decision to the medical opinion evidence, and he included appropriate limitations in
his RFC finding. Additionally, the Court finds that the ALJ did not err in evaluating Plaintiff’s
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Therefore, IT IS HEREBY ORDERED that Plaintiff’s Motion for Summary Judgment
(Doc. No. 11) is DENIED, and Defendant’s Motion for Summary Judgment (Doc. No. 13) is
GRANTED.

s/ Alan N. Bloch
United States District Judge
ecf:

Counsel of record

subjective complaints, and he properly considered the testimony of the VE in reaching his
conclusions. Accordingly, the Court affirms.
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