Lauer v. Berryhill
MEMORANDUM DECISION AND ORDER - The court concludes that the ALJs decision is supported by substantial evidence and is free of harmful legal error. Accordingly, the court hereby AFFIRMS. Signed by Magistrate Judge Dustin B. Pead on 2/8/2018. (las)
IN THE UNITED STATES DISTRICT COURT
DISTRICT OF UTAH
MEMORANDUM DECISION &
CASE No: 1:17-cv-00089-DBP
NANCY A. BERRYHILL,
Acting Commissioner of Social
MAGISTRATE JUDGE DUSTIN B.
Plaintiff Dorinda Lauer (Plaintiff or Ms. Lauer) seeks judicial review of the
decision of the Acting Commissioner of Social Security (the Commissioner) denying her
claims for disability insurance benefits (DIB) and supplemental security income (SSI)
payments under Titles II and XVI of the Social Security Act (Act). See 42 U.S.C.
§405(g). Now, after careful review of the record, the parties’ briefs, and arguments
presented at the January 17, 2018 hearing, the court affirms the Commissioner’s
decision and denies Ms. Lauer’s appeal.
In early 2013, Plaintiff filed applications for DIB and SSI, alleging she became
disabled in November 2012 1 (see ECF No. 8, Certified Administrative Transcript (Tr.)
40, 205-18). Ms. Lauer alleged disability due to a number of conditions including a back
injury, arthritis, and chronic pain (Tr. 245). Following an April 2016 hearing, at which Ms.
Lauer and her attorney appeared and testimony was given by both Plaintiff and a
vocational expert (Tr. 57-76), Administrative Law Judge (ALJ) Jason Crowell denied
Plaintiff’s applications in his June 1, 2016 decision (Tr. 37-56).The ALJ’s decision
followed the familiar five-step sequential evaluation process set forth under the
regulations and determined, while limited by her impairments, Plaintiff could still perform
certain unskilled jobs and was not disabled as defined by the Act (Tr. 42-51). See 20
C.F.R. §§ 404.1520(a)(4), 416.920(a)(4).
The Appeals Council denied Plaintiff’s request for review (Tr. 1-6, 32-36), making
the ALJ’s decision the Commissioner’s final decision for purposes of judicial review. See
20 C.F.R. §§ 404.981, 416.1481, 422.210(a). This appeal followed and Plaintiff filed her
petition for review before this court on June 9, 2017 (ECF No. 3).
Although Plaintiff alleges this earlier onset date, SSI benefits are not actually payable until the
month following the month in which the claimant files an application, which, in this case, was February
2013 (see Tr. 40). See 20 C.F.R. §416.335.
Ms. Lauer stopped working in November 2012 due to exacerbation of her chronic
back pain (Tr. 63, 64, 327). Prior to that time, she was a supervising manager at
PetSmart for 15 years (Tr. 63, 327).
The record reflects that Ms. Lauer saw a chiropractor for neck and back pain in
late 2012 and early 2013 (Tr. 332-411). Plaintiff also saw family practitioner Michael
Woolman, M.D., for regular health needs, maintenance of her hypertension/mild
diabetes mellitus, and for complaints of fibromyalgia, back pain, and joint pain (see,
e.g., Tr. 434, 553-62, 575-604).
The record before the ALJ also contained opinions from:
Dr. Woolman (Tr. 455-58 (May 2012), 539-40 (January 2015), 563
(October 2015), 542-50 (January 2016))
Physical therapist Ernie Chavez (Tr. 435-44 (February 2014))
Consultative examining physician Joseph Nelson, D.O. (Tr. 426-33
Consultative examining psychologist Richard Grow, Ed.D. (Tr. 413
State agency psychologist Melvin Sawyer, Ph.D. (Tr. 80-86 (August
State agency physician
(November 2013)), and
State agency psychologist Charles Raps, Ph.D. (Tr. 109-14
STANDARD OF REVIEW
The Court reviews the Commissioner’s decision to determine whether substantial
evidence in the record as a whole supports the factual findings and whether the correct
legal standards were applied. Lax v. Astrue, 489 F.3d 1080, 1084 (10th Cir. 2007).
“Substantial evidence is such relevant evidence as a reasonable mind might accept as
adequate to support a conclusion.” Id. (internal quotation and citation omitted). Where
the evidence as a whole can support either the agency’s decision or an award of
benefits, the agency’s decision must be affirmed. Ellison v. Sullivan, 929 F.2d 534, 536
(10th Cir. 1990).
In addition, the federal “harmless error” statute instructs courts to review cases
for errors of law without regard for errors that do not affect the parties’ substantive
rights. See 28 U.S.C. §2111. It is “the party that seeks to have a judgment set aside
because of an erroneous ruling [that] carries the burden of showing that prejudice
resulted.” Shinseki v. Sanders, 556 U.S. 396, 407-409 (2009) (internal quotation marks
and citation omitted).
The ALJ’s June 2016 decision followed the regulatory five-step sequential
evaluation in determining that Ms. Lauer was not disabled (Tr. 40-51). See 20 C.F.R.
§§ 404.1520(a)(4), 416.920(a)(4). As relevant here, the ALJ found, notwithstanding her
severe impairments of lumbar and cervical degenerative disc disease, obesity, major
depressive disorder, and generalized anxiety disorder, Plaintiff retained the residual
functional capacity (RFC) for a limited range of light work that only required simple
decisions and was without fast paced production or work place changes (Tr. 42-49). 2
The ALJ relied on vocational expert testimony to conclude that Ms. Lauer could perform
work existing in significant numbers in the national economy, including the
representational jobs of router, office helper, and marker (Tr. 50). Based thereon, the
ALJ determined that Ms. Lauer was not disabled within the meaning of the Act (Tr. 5051).
Plaintiff challenges the ALJ’s decision and raises two main issues on appeal.
First, Ms. Lauer argues the ALJ erred when he failed to properly evaluate the medical
opinion evidence of Dr. Woolman. Second, Plaintiff claims it was error to not account for
her headaches in the RFC assessment. The court addresses each of Ms. Lauer’s
RFC is the most that a claimant can do notwithstanding functional limitations stemming from her
medically determinable impairments. See 20 C.F.R. §§ 404.1545, 416.945.
The ALJ Did Not Err In Failing To Properly Evaluate The Medical
Plaintiff argues the ALJ erred in failing to explicitly discuss treating source, Dr.
Woolman’s, May 2012 opinion. 3 Dr. Woolman’s May 2012 opinion predated Ms. Lauer’s
onset date. Even so, the evidence is probative and regulations require consideration of
“all evidence in [the] case record.” 20 C.F.R. §404.1520(a)(3). Thus, while it may have
been preferable for the ALJ to explicitly discuss Dr. Woolman’s May 2012 opinion, the
failure to do so was not reversible error.
First, there was no error because the ALJ discussed and weighed three other
subsequent opinions rendered by treating source Dr. Woolman. 4 Notably, these
opinions were rendered during the relevant time period and indicated even greater
limitations than those included in the May 2012 opinion (Ex. 9F (Tr. 450-461), 10F,
Ms. Lauer argues the ALJ also failed to consider the opinions of her physical therapist, Ernie
Chavez. The court rejects Plaintiff’s argument. Chavez concluded Plaintiff could perform full-time work on
a regular and continuing basis and his opinion does not support disability (Tr. 436-436). Moreover, while
the ALJ acknowledged that Chavez’s opinion was issued after the examinations of Drs. Grow and Nelson,
the ALJ concluded that Chavez’s findings were “generally consistent with the medical records and
examination conducted prior to [Chavez’s] opinion.”(Tr. 49). Finally, even though the ALJ raised Ms.
Lauer’s limitations from “sedentary”, as offered by Chavez, to “light level”, the ALJ supported his decision
with medical evidence showing Plaintiff’s limited ability to kneel, crouch, crawl, ride a scooter and perform
other activities of daily living. See 2013 examination findings (Tr. 328), Dr. Nelson’s June 2013 findings
(Tr. 426-433) and Dr. Woolman’s January 2016 findings (Tr. 557).
For purposes of subsequent review, an ALJ’s decision must specifically identify the weight given
to a treating source’s medical opinion and the reasons therefore. Watkins v. Barnhart, 350 F.3d
1297,1300 (10th Cir. 2003). The Tenth Circuit explains “[t]he more comprehensive the ALJ’s explanation,
the easier our task; but we cannot insist on technical perfection.” Id. Therefore, where the court “can
follow the adjudicator’s reasoning in conducting . . . review and can determine that correct legal standards
have been applied, merely technical omissions in the ALJ’s reasoning do not dictate reversal.” Id. Further,
while the ALJ must evaluate all evidence of record, there is no requirement to “discuss every piece of
evidence”. See Wall v. Astrue, 561 F.3d 1048, 1052 (10 Cir. 2009) (citation omitted).
11F). The ALJ determined that the three subsequent opinions were only entitled to
partial weight because they were inconsistent with the medical evidence of record and
vague (Tr. 49). See 20 C.F.R. §§ 404.1527(c)(4), 404.927(c)(4) (ALJ considers whether
an opinion is consistent with the record as a whole); 20 C.F.R. §§ 404.1527(c)(3),
416.927(c)(3) (“The better an explanation a source provides for an opinion, the more
weight [the ALJ] will give that opinion.”); see also Tarpley v. Colvin, 601 F. App’x. 641,
643 (10th Cir. 2015) (unpublished) (affirming the ALJ’s decision to discount treating
physicians’ opinions due to the fact that medical evidence did not support them). Here,
the ALJ’s conclusion that the three subsequent opinions were inconsistent with the
medical evidence supports a similar rejection of Dr. Woolman’s May 2012 opinion. See
Lately v. Colvin, No. 560 F. App’x. 751, 754 (10th Cir. 2014) (unpublished) (finding that
the error in failing to discuss and explicitly weigh an examining physician’s opinion was
harmless: “we can tell from the ALJ’s rejection of [the treating physician’s] nearly
identical opinion that the ALJ gave no weight to [the examining physician’s] opinion”).
Second, there is no error because the ALJ sufficiently weighed the opinions of
Drs. Nelson, Peterson and Terry and found they were supported by the record as a
whole (Tr. 48). See Davis v. Erdmann, 607 F.2d 917, 919 n.1 (10th Cir. 1979) (“we will
uphold a decision of less than ideal clarity if the agency’s path may reasonably be
discerned”) (citations omitted). Specifically, the ALJ determined that although the
physical examinations showed some negative symptoms, the exams did not show
significant limitations overall (Tr. 48, citing Tr. 328, 426-33, 557). See 20 C.F.R.
§ 404.1527(c)(4) (ALJ considers whether an opinion is consistent with the record as a
whole), 20 C.F.R. § 404.1527(c)(3) (“The more a medical source presents relevant
evidence to support an opinion, particularly medical signs and laboratory findings, the
more weight we will give that opinion.”). Further, having set forth a detailed summary of
the medical records in the paragraphs preceding his discussion of the doctors’ opinions
(see Tr. 47-49)—the ALJ was not required to repetitively recite the same evidence in
giving weight to those opinions. See Endriss v. Astrue, 506 F. App’x 772, 777 (10th Cir.
2012) (unpublished) (“The ALJ set forth a summary of the relevant objective medical
evidence earlier in his decision and he is not required to continue to recite the same
evidence again in rejecting [the doctor’s] opinion.”).
Overall, the ALJ’s decision supports his consideration and weighing of the
opinion evidence. The decision is amply supported by the longitudinal record, and any
imprecision in his articulation regarding Dr. Woolman’s May 2012 opinion does not
warrant remand. Indeed the decision, read as a whole, is sufficiently specific to follow
and medical evidence of record clearly supports the reasoning provided. See KeyesZachary, 695 F.3d at 1167 (in reviewing an ALJ’s reasoning, “common sense, not
technical perfection, is our guide”).
The ALJ Did Not Err In Failing To Include Limitations For Lauer’s
Headaches In The RFC Assessment.
Next, Ms. Lauer argues the ALJ erred in failing to include her alleged headaches
when making the RFC assessment. Here too, the Court finds no reversible error.
At the April 2016 administrative hearing, Plaintiff testified she had “severe
migraines” three to four days a week such that she could only sleep or lay on the couch
(Tr. 65-66). In assessing Ms. Lauer’s RFC, the ALJ noted her testimony but did not
explain how he accounted for Plaintiff’s alleged migraine symptoms (see Tr. 45-49).
Again, while it may have been preferable for the ALJ to have provided an explanation,
the Court finds no error as there is substantial evidence in the record to support the
conclusion. See, e.g., Payton v. Astrue, 480 F. App’x 465, 469 (10th Cir. 2012)
(unpublished) (while “an explicit statement” that the ALJ had discounted evidence
“would be preferable,” the court took the ALJ at her word when she stated she
considered the medical evidence in accordance with the applicable standards).
In assessing a claimant’s RFC, the ALJ must account for all limitations stemming
from medically determinable impairments. See 20 C.F.R. §§ 404.1545(a)(2),
416.945(a)(2). A claimant’s “symptoms . . . will not be found to affect [her] ability to do
basic work activities unless medical signs or laboratory findings show that a medically
determinable impairment(s) is present.” See 20 C.F.R. §§ 404.1529(b), 416.929(b).
Therefore, a claimant must produce objective evidence—i.e., medical signs and/or
laboratory findings—showing the existence of a medically determinable impairment that
could reasonably be expected to produce the symptoms alleged. See 20 C.F.R.
§§ 404.1529(b), 416.929(b). Without doing so, a claimant cannot establish disability.
20 C.F.R. §§ 404.1529(a), 416.929(a); see also Social Security Ruling (SSR) 96-4p,
1996 WL 374187, at *1 (“A ‘symptom’ is not a ‘medically determinable physical or
mental impairment’ and no symptom by itself can establish the existence of such an
Ms. Lauer first complained to Dr. Woolman of headaches in July 2014. When she
reported continued headaches in October of 2014, Dr. Woolman ordered cervical x-rays
which showed degenerative changes that were “[c]ertainly enough to cause her
symptoms” (Tr. 581,Tr. 585). Dr. Woolman prescribed hydrocodone and refilled the
prescription in November 2014 when Plaintiff complained of headaches (Tr. 585, 589).
Ms. Lauer made no mention of headaches in 2015 (r. 593-98). However, in January
2016 when she saw Dr. Woolman for a disability examination, Ms. Lauer reported “full
blown migraines” daily with visual changes and flashing lights (Tr. 557). While
Dr. Woolman included “Headache” in his assessments, he did not render any related
treatment and Ms. Lauer did not mention any headaches or migraines at any of her
other visits to Dr. Woolman during 2016 (Tr. 554-56, 558, 599-600).
Ms. Lauer alleges symptoms of “full blown migraines” in 2016 (Tr. 65-66, 557),
but the record does not contain any objective evidence of migraine headaches. Plaintiff
complained of headaches in late 2014, yet the record does not document migraine
symptomology (i.e., visual changes or flashing lights) or otherwise suggest migraines.
Instead, the record evidence indicates Ms. Lauer’s headaches were related to cervical
degenerative disc disease and resolved with medication (Tr. 585). Dr. Woolman
prescribed hydrocodone twice in late 2014 and, even though Ms. Lauer reported
“various aches and pains with most of her pain centered in her upper and lower back,”
the record does not show any report of headaches by Plaintiff throughout all of 2015 (Tr.
585, 589, 591, 593-98, Tr. 597 (“unable to exercise due to her pain especially in her
back”), 554 (“[s]he is trying to do a little walking for exercise but is limited by her back
and neck pain”).
In this case, Ms. Lauer has not met her burden to show that her migraines were
a medically determinable impairment. As a result, it would not be proper for the ALJ to
account for her migraine symptoms in the RFC assessment. See 20 C.F.R.
§§ 404.1529(b), 416.929(b).The Court finds the RFC assessment is supported by
substantial evidence in the record as a whole. Further, Ms. Lauer has not shown that
she was prejudiced by the ALJ’s failure to discuss migraines in assessing the RFC. See
Bernal v. Bowen, 851 F.2d 297, 302 (10th Cir. 1988) (“Since the ALJ’s decision is amply
supported by the medical reports and the record, [claimant] was not prejudiced by the
ALJ’s actions.”), see also Sanders, 556 U.S. at 409-10 (the party that seeks to have a
judgment set aside because of an erroneous ruling carries the burden of showing that
prejudice resulted). Accordingly, the Court finds any no error. Alternatively, even
assuming error, Ms. Lauer has not shown any prejudice and therefore her claim is
For the reasons set forth above, the court concludes that the ALJ’s decision is
supported by substantial evidence and is free of harmful legal error. Accordingly, the
court hereby AFFIRMS. Judgment shall be entered in accordance with federal rule 58,
consistent with the U.S. Supreme Court’s decision in Shalala v. Schaefer, 509 U.S. 292,
296-304 (1993). Fed. R. Civ. P. 58.
DATED this 8th day of February, 2018.
DUSTIN B. PEAD
United States Magistrate Judge
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