Lee v. Astrue
Filing
13
MEMORANDUM OPINION Affirming the final decision of the Commissioner and Dismissing this matter from the docket of this Court. Signed by Magistrate Judge Cheryl A. Eifert on 12/11/2012. (cc: attys) (mkw)
IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF WEST VIRGINIA
HUNTINGTON DIVISION
BRENDA SUE LEE,
Plaintiff,
v.
Case No.: 3:11-cv-00958
MICHAEL J. ASTRUE,
Commissioner of the Social
Security Administration,
Defendant.
MEMORANDUM OPINION
This is an action seeking review of the decision of the Commissioner of the Social
Security Administration (hereinafter the “Commissioner”) denying plaintiff’s application
for a period of disability and disability insurance benefits (“DIB”) and supplemental
security income (“SSI”) under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 401433, 1381-1383f. The case is presently before the Court on the parties’ Motions for
Judgment on the Pleadings. (ECF Nos. 11 and 12). Both parties have consented in writing
to a decision by the United States Magistrate Judge. (ECF Nos. 5 and 8). The Court has
fully considered the evidence and the arguments of counsel. For the reasons that follow,
the Court finds that the decision of the Commissioner is supported by substantial evidence
and should be affirmed.
I.
Procedural History
Plaintiff, Brenda Sue Lee (hereinafter referred to as “Claimant”), filed for DIB and SSI
on March 24, 2009, (Tr. at 140, 142), alleging disability beginning on June 1, 2005 due to
“back, legs, stomach problems (undiagnosed) bad nerves, high blood pressure.” (Tr. at
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162). The Social Security Administration (“SSA”) denied the application initially and upon
reconsideration. (Tr. at 12). On September 19, 2009, Claimant filed a written request for a
hearing before an Administrative Law Judge (“ALJ”), which was held on July 28, 2010
before the Honorable Charlie Paul Andrus, ALJ. (Tr. at 12, 29-55). By decision dated
August 23, 2010, the ALJ determined that Claimant was not entitled to benefits. (Tr. at 1223).
The ALJ’s decision became the final decision of the Commissioner on September 30,
2011 when the Appeals Council denied Claimant’s request for review. (Tr. at 1-3). On
December 2, 2011, Claimant brought the present civil action seeking judicial review of the
administrative decision pursuant to 42 U.S.C. § 405(g). (ECF No. 2). The Commissioner
filed his Answer and a Transcript of the Proceedings on February 13, 2012. (ECF Nos. 9
and 10). Thereafter, the parties filed their briefs in support of judgment on the pleadings.
(ECF Nos. 11 and 12). Accordingly, this matter is ripe for resolution.
II.
Claimant’s Background
Claimant was 44 years old at the time of her alleged disability onset and was 50
years old at the time of the ALJ’s decision. (Tr. at 21). She grew up in Mason County, West
Virginia where she completed the tenth grade and subsequently obtained a GED. (Tr. at
34). Claimant previously worked as a personal caregiver for elderly clients and as a general
laborer for several different employers. (Tr. at 163). Her past relevant employment was
classified as medium to heavy, unskilled work. (Tr. at 50).
III.
Summary of ALJ’s Findings
Under 42 U.S.C. § 423(d)(5), a claimant seeking disability benefits has the burden of
proving a disability. See Blalock v. Richardson, 483 F.2d 773, 774 (4th Cir. 1972). A
disability is defined as the “inability to engage in any substantial gainful activity by reason
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of any medically determinable impairment which can be expected to last for a continuous
period of not less than 12 months.” 42 U.S.C. 423(d)(1)(A).
The Social Security Regulations establish a five-step sequential evaluation process for
the adjudication of disability claims. If an individual is found “not disabled” at any step of
the process, further inquiry is unnecessary and benefits are denied. 20 C.F.R. §§ 404.1520,
416.920. First, the ALJ determines whether a claimant is currently engaged in substantial
gainful employment. Id. §§ 404.1520(b), 416.920(b). If the claimant is not gainfully
employed, then the second inquiry is whether the claimant suffers from a severe
impairment. Id. §§ 404.1520(c), 416.920(c). If the claimant suffers from a severe
impairment, the ALJ next determines whether the impairment meets or equals any of the
impairments listed in Appendix 1 to Subpart P of the Administrative Regulations No. 4. Id.
§§ 404.1520(d), 416.920(d) (the “Listing”). If the impairment does, then the claimant is
found disabled and awarded benefits.
However, if the impairment does not, the ALJ must then determine the claimant’s
residual functional capacity (“RFC”), which is the measure of the claimant’s ability to
engage in substantial gainful activity despite the limitations of his or her impairments. Id.
§§ 404.1520(e), 416.920(e). Once the RFC is established, the ALJ moves on to the fourth
step, which requires an assessment of whether the claimant’s impairments prevent the
performance of past relevant work. Id. §§ 404.1520(f), 416.920(f). If the impairments do
prevent the performance of past relevant work, the claimant has established a prima facie
case of disability and the burden shifts to the Commissioner to present evidence to rebut a
finding of disability. McLain v. Schweiker, 715 F.2d 866, 868-69 (4th Cir. 1983). Under the
fifth and final inquiry, the Commissioner must demonstrate that the claimant is able to
perform other forms of substantial gainful activity, while taking into account the claimant’s
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remaining physical and mental capacities, age, education, and prior work experiences. Id.
§§ 404.1520(g), 416.920(g); see also Hunter v. Sullivan, 993 F.2d 31, 35 (4th Cir. 1992).
The Commissioner must establish two things: (1) that the claimant, considering his or her
age, education, skills, work experience, and physical shortcomings has the capacity to
perform an alternative job, and (2) that this specific job exists in significant numbers in the
national economy. McLamore v. Weinberger, 538 F.2d. 572, 574 (4th Cir. 1976).
Here, the ALJ determined as a preliminary matter that Claimant met the insured
status requirement of the Social Security Act through December 31, 2008. (Tr. at 14,
Finding No. 1). The ALJ found that Claimant satisfied the first inquiry because she had not
engaged in substantial gainful activity since June 1, 2005, the alleged date of disability
onset. (Id., Finding No. 2). Under the second inquiry, the ALJ found that Claimant suffered
from the severe impairments of: degenerative disc disease, chronic obstructive pulmonary
disease (“COPD”), Depressive Disorder (not otherwise specified), and Generalized Anxiety
Disorder. (Tr. at 14-15, Finding No. 3). The ALJ considered Claimant’s complaints of
hypertensive disease and abdominal distress but found these impairments to be nonsevere. (Tr. at 15).
At the third inquiry, the ALJ concluded that Claimant’s impairments did not meet
or equal the level of severity of any impairment contained in the Listing. (Tr. at 15-17,
Finding No. 4). The ALJ then found that Claimant had the following RFC:
[L]imited to light exertion which involves lifting/carrying of no more than
twenty pounds maximum occasionally and ten pounds maximum frequently;
requires sit/stand option at ½ hour intervals; no work in excessive
dust/fumes; and limited to but capable of simple routine work in a lower
stress setting.
(Tr. at 18-21, Finding No. 5). Under the fourth inquiry, the ALJ found that Claimant was
unable to return to her past relevant employment. (Tr. at 21, Finding No. 6). Claimant was
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44 years old at the time of the alleged onset of disability, which qualified her as a “younger
individual age 18-49,” but her age category had changed to a “person closely approaching
advanced age” by the time of the hearing (Tr. at 21, Finding No. 7). Claimant had at least a
high school education and could communicate in English. (Tr. at 22, Finding No. 8). The
ALJ found that transferability of job skills was not an issue, because Claimant’s past
relevant work was unskilled. (Id., Finding No. 9). Considering these factors and Claimant’s
RFC and relying upon the testimony of a vocational expert, the ALJ determined that
Claimant could perform various jobs that existed in significant numbers in the national
economy. (Tr. at 22-23, Finding No. 10). At the light exertional level, Claimant could
function as a routing clerk, machine tender, and clerical machine operator. At the
sedentary level, Claimant was capable of working as an inspector, security monitor, and
charting clerk. On this basis, the ALJ found that Claimant was not under a disability as
defined by the Social Security Act. (Tr. at 23, Finding No. 11).
IV.
Relevant Medical Records
The Court has reviewed the Transcript of Proceedings in its entirety, including the
medical records, and summarizes Claimant’s treatment and evaluations to the extent they
are relevant to the issues in dispute.
A.
Treatment by or at the request of Dr. Robert Holley, Claimant’s
primary care physician
The first record in evidence documenting care or treatment by Dr. Robert Holley1 is
dated February 11, 2008 and reflects an office visit with Claimant. (Tr. at 373-74). At this
visit, Dr. Holley administered an injection of Depo-Medrol into Claimant’s right shoulder,
1 The record does include two earlier reports of tests performed at the request of Dr. Holley by the
Department of Radiology at Pleasant Valley Hospital. (Tr. at 396-97). On October 3, 2005 an acute
abdominal series was completed to investigate the source of Claimant’s abdominal pain. The series showed
no evidence of any acute condition. (Tr. at 397). The following day, a gallbladder ultrasound was performed
which showed a normal gallbladder without evidence of stones or disease. (Tr. at 396).
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although the reason for the treatment is unclear due to the illegibility of Dr. Holley’s
entries.
On February 20, 2009, Claimant presented to the Emergency Department at
Pleasant Valley Hospital for complaints of sore throat, nasal congestion, sinus pressure and
cough. (Tr. at 260-63). Claimant reported a past medical history of hypertension. Her
examination was essentially negative in all systems with the exception of a mildly inflamed
throat and some costochondral tenderness. She was diagnosed with an upper respiratory
infection, given an antibiotic and cough medicine, and was told to check in with Dr. Holley
in 4-7 days.
A week later, Dr. Holley ordered right hip and lumbar spine x-rays of Claimant for
complaints of right hip pain. (Tr. at 393-94). The films confirmed mild multilevel
spurring/degenerative changes, moderate degenerative changes of the facet joints at L5-S1,
and normal vertebral body and disc space height with no definite evidence of significant
bone abnormality. At a follow-up office visit on March 11, 2009, Dr. Holley confirmed
Claimant’s diagnosis of COPD, among other conditions, and ordered a repeat gallbladder
ultrasound. (Tr. at 365-66) The ultrasound was performed a week later and was
interpreted to be largely unremarkable. (Tr. at 392).
On April 1, 2009, Claimant saw Dr. Stephen Rerych at Dr. Holley’s request for
persistent right upper quadrant abdominal pain. (Tr. at 340-41). Claimant stated that she
had experienced the pain for at least ten years, and it was accompanied by occasional
nausea and vomiting. She added that, over the years, she had seen physicians for the
problem but had never been given a diagnosis. Claimant reported a history of cigarette
abuse, arthritis, nervousness, hypertension, and bowel irregularity. Dr. Rerych performed
a thorough physical examination making no abnormal findings except for tenderness in
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Claimant’s mid epigastrium, right upper quadrant, and left upper quadrant. Dr. Rerych
found no evidence of neurological impairment, no signs of an acute abdomen, normal vital
signs, and a full range of motion in all of Claimant’s extremities. (Id.). He felt that
Claimant’s symptoms were atypical and required additional investigation; accordingly, he
suggested an upper gastrointestinal series, followed by a scan to examine the ejection
fraction of the gallbladder. The scan and upper gastrointestinal series were performed and
showed a normal liver, biliary tract, gallbladder, and small bowel, but did suggest the
presence of a duodenal bulb ulcer. (Tr. at 388, 390). For this reason, Dr. Rerych
recommended an esophagogastroduodenoscopy (“EGD”) with biopsy. (Tr. at 342).
Claimant was admitted to Pleasant Valley Hospital on April 27, 2009 for completion
of the EGD. (Tr. at 336-39, 343-47). Dr. Holley took a pre-operative history and performed
a physical examination. He recorded Claimant’s past medical history to include COPD,
hypertensive cardiovascular disease, hyperlipidemia, generalized anxiety disorder,
metabolic syndrome, and irritable bowel syndrome. (Tr. at 336). When conducting the
review of systems, Dr. Holley documented that Claimant complained of chronic lumbar
pain radiating to her right foot, which she rated as a seven in severity on a ten point pain
scale, even with the use of pain medication. She reported only being able to sit, stand, or
walk for a period of five minutes. (Tr. at 337). On physical examination, Dr. Holley found
Claimant to have an increased AP diameter but no rales, wheezes, rhonchi, or rubs; her
cardiovascular system was essentially normal; her mood and affect were normal; and she
was neurologically intact. He determined that Claimant was stable for surgery. (Tr. at 339).
Dr. Rerych performed the EGD later that day. (Tr. at 345-46). In the operative note,
he documented that Claimant had no evidence of a duodenal bulb ulcer and mild “if any”
antral gastritis. The surgical pathology report was equally unimpressive, showing only
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some findings compatible with mild reflux disease. (Tr. at 343).
On July 15, 2009, Claimant presented to the office of Dr. Gerald McKinney of
University Surgeons & Physicians. (Tr. at 330-32). Claimant was referred by Dr. Holley for
a consultation related to Claimant’s continued complaints of abdominal pain and nausea.
Dr. McKinney performed a comprehensive physical examination and made the following
findings: Claimant was alert, oriented, and in no acute distress; her neck, eyes, ears, throat,
lungs, cardiovascular and nervous systems were all normal; her bowel sounds were
normal; there was no swelling of her liver or spleen and no masses found in her abdomen;
she had normal movement of all extremities with no swelling of the legs or deformities of
the arms and legs; and her motor strength was normal. After reviewing the results of
Claimant’s various studies, Dr. McKinney concluded that Claimant had dyspepsia, or in
nonmedical terminology, indigestion. (Id.). He placed her on medication to alleviate the
symptoms.
The record reflects that Claimant had several contacts with Dr. Holley between
November 10, 2009 and April 14, 2010; however, the records are largely illegible. (Tr. at
432-38). On April 30, 2010, Claimant had a CT scan of her chest for symptoms of cough
and congestion. (Tr. at 454). The film was interpreted as stable. Pulmonary function
studies performed on May 5, 2010 confirmed severe restriction likely due to Claimant’s
COPD. (Tr. at 455-56).
On May 17, 2010, an MRI of Claimant’s lumbar spine was performed at the request
of Dr. Holley. (Tr. at 452). The films were read as showing no evidence of disc herniation or
neural impingement, but reflected a mild acquired canal stenosis at the L3/4 and L4/5 due
to broad based annular bulging and facet arthritis.
On July 19, 2010, Dr. Holley completed a questionnaire and Medical Assessment To
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Do Work-Related Activities (Physical) Form at the request of Claimant’s attorney. (Tr. at
462-66). Dr. Holley opined that Claimant’s subjective complaints of pain and fatigue
between 6/2005 and 12/2008 were consistent with his objective findings. He felt that
Claimant was incapable of engaging in full-time employment during that time frame,
although he provided no supportive explanation or medical findings. He indicated that
Claimant had no other impairments that limited her ability to work, but he felt that
degenerative disc disease of her lumbar spine severely restricted her physical capabilities
and effectively prevented her from returning to any form of employment. Dr. Holley
specifically found that Claimant’s condition affected her ability to lift, carry, stand, walk
and sit, but offered scant details except that Claimant could not sit more than 2 hours in an
eight hour workday and could not sit longer than fifteen minutes without interruption; she
could only occasionally climb, stoop, crouch, and kneel, and she should never crawl.
B.
Agency Evaluations
On May 21, 2009, Dr. A. Rafael Gomez completed a Physical Residual Function
Capacity Evaluation based upon a review of the records. (Tr. at 271-78). He specifically
assessed Claimant’s condition as it existed prior to her date last insured for DIB; that being
December 31, 2008. Based upon the dearth of available information, Dr. Gomez concluded
that there was insufficient evidence to find disability prior to that date. Dr. Gomez then
separately analyzed the remaining records for the period after December 31, 2008 and
determined that Claimant’s impairments from that date to the present were non-severe.
(Tr. at 279-86). On September 9, 2009, Dr. Rabah Boukhemis completed a second review
of the evidence and affirmed Dr. Gomez’s conclusions.
On June 17, 2009, Claimant was evaluated by William C. Steinhoff, a Masters level
psychologist, to determine the extent of her mental impairments. (Tr. at 287-93). Mr.
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Steinhoff started with a clinical interview. He noted that Claimant had adequate grooming
and was cooperative, although her processing was slow and she was restless. She reported
that her chief complaints were pain in the right side of her chest, severe back pain, and a
painful catching in her right knee, making it difficult to walk or bend. She described her
mood as being mostly “bad,” indicating that she slept very little, cried a lot, worried
constantly, and was easy to upset. Claimant stated that she was last employed providing
home care to an elderly woman and, prior to that, she had worked for twenty years as a
housekeeper at a local motel. She had never been fired from any job, never supervised
other employees, and never had any problems working with others. Claimant reported no
mental health treatment in the past.
After completing the interview, Mr. Steinhoff performed a mental status
examination and made the following findings: Claimant’s eye contact was fair; her speech
was clear, relevant, and coherent; she was oriented in all spheres; her mood was mildly
depressed with some irritability; her judgment, immediate memory, and remote memory
were normal; her recent memory, concentration, and persistence were moderately
deficient; her pace and social functioning were mildly deficient; and her insight was poor.
Claimant described her daily activities as minimal, indicating that her husband did most of
the work around the house, although she performed her own grooming, did some laundry,
watched television, and occasionally drove. Mr. Steinhoff diagnosed Claimant with
depressive disorder, not otherwise specified, and generalized anxiety disorder. He felt her
prognosis was guarded, although he believed she was capable of managing her own
finances.
On July 11, 2009, Holly Cloonan, Ph.D. completed two Psychiatric Review
Techniques and a Mental Residual Functional Capacity Assessment at the request of the
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SSA. (Tr. at 294-325). Dr. Cloonan first considered Claimant’s psychiatric state prior to
the date last insured for DIB, noting that there was insufficient evidence to evaluate
Claimant’s condition. (Tr. at 324). Turning next to Claimant’s condition after December 31,
2008, Dr. Cloonan diagnosed Claimant with an affective disorder (depressive disorder)
and an anxiety-related disorder (generalized anxiety disorder). (Tr. at 297, 299). Dr.
Cloonan found evidence that Claimant was mildly restricted in her activities of daily living
and social functioning, was moderately restricted in her ability to maintain concentration,
persistence, and pace, and had no episodes of decompensation of extended duration. (Tr.
at 304). Dr. Cloonan found no evidence of paragraph C criteria. (Tr. at 305). Performing a
detailed function-by-function assessment, Dr. Cloonan opined that Claimant was not
significantly limited in: her ability to understand and remember short, simple instructions,
locations, and work-like procedures; her ability to carry out short, simple instructions;
perform on schedule with regular and punctual attendance; make simple decisions; work
with others; work an ordinary routine without special supervision; interact appropriately
with the general public, coworkers, peers, and supervisors; ask simple questions; maintain
socially appropriate behavior; appreciate hazards and take precautions; set realistic goals
and make plans independently; and travel to unfamiliar places and use public
transportation. Dr. Cloonan felt Claimant was moderately limited in her ability to
understand, remember, and carry out detailed instructions, maintain her concentration for
long periods of time, perform at a consistent pace without interruptions from psychological
symptoms, and respond appropriately to changes in the work setting. (Tr. at 308-09). In
summary, Dr. Cloonan believed that Claimant was able to perform uncomplicated worklike activities in a low pressure setting and with few distractions. (Tr. at 310). Dr. Cloonan’s
observations and opinions were reviewed on August 29, 2009 by Dr. Debra Lilly, who
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agreed with Dr. Cloonan’s assessment.
V.
Claimant’s Challenges to the Commissioner’s Decision
Claimant raises two challenges to the Commissioner’s decision. First, she argues
that the ALJ failed to afford sufficient weight to the opinions of Dr. Holley given that he
was Claimant’s primary treating physician. (ECF No. 11 at 5-7). Second, Claimant contends
that the ALJ failed to properly assess her credibility. According to Claimant, the ALJ
arbitrarily disregarded her subjective complaints although the record plainly supported her
contention that her symptoms were disabling. (Id. at 7).
In response, the Commissioner emphasizes that Claimant carries the burden of
establishing disability, yet fails to provide sufficient evidence to sustain her claim. In the
Commissioner’s view, the ALJ properly disregarded Dr. Holley’s opinion because the
objective medical records contradicted his conclusions regarding the severity of Claimant’s
impairments. In addition, the Commissioner asserts that Dr. Holley relied heavily upon the
Claimant’s subjective complaints despite the fact that these complaints were often
inconsistent with the medical evidence of record. (ECF No. 12 at 10-17).
VI.
Scope of Review
The issue before this Court is whether the final decision of the Commissioner
denying Claimant’s application for benefits was reached by proper application of the law
and is supported by substantial evidence. The Fourth Circuit has defined substantial
evidence as:
Evidence which a reasoning mind would accept as sufficient to support a
particular conclusion. It consists of more than a mere scintilla of evidence but
may be somewhat less than a preponderance. If there is evidence to justify a
refusal to direct a verdict were the case before a jury, then there is
“substantial evidence.”
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Blalock, 483 F.2d at 776 (quoting Laws v. Celebrezze, 368 F.2d 640, 642 (4th Cir. 1966)).
The Commissioner, not the court, is charged with resolving conflicts in the evidence. Hays
v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990). Thus, the court will not re-weigh
conflicting evidence, make credibility determinations, or substitute its judgment for that of
the Commissioner. Id. Instead, the court’s duty is limited in scope; it must adhere to its
“traditional function” and “scrutinize the record as a whole to determine whether the
conclusions reached are rational.” Oppenheim v. Finch, 495 F.2d 396, 397 (4th Cir. 1974).
The ultimate question for the court is not whether the Claimant is disabled, but whether
the decision of the Commissioner that the Claimant is not disabled is well-grounded in the
evidence, bearing in mind that “[w]here conflicting evidence allows reasonable minds to
differ as to whether a claimant is disabled, the responsibility for that decision falls on the
[Commissioner].” Walker v. Bowen, 834 F.2d 635, 640 (7th Cir. 1987).
This Court has considered both of Claimant’s challenges in turn and finds them
unpersuasive. To the contrary, having examined the record as a whole, the Court concludes
that the decision of the Commissioner finding Claimant not disabled was properly reached
and is supported by substantial evidence.
VII.
Analysis
A.
ALJ’s Consideration of Dr. Holley’s Opinions
Claimant contends that the Social Security regulations and rulings require the ALJ
to give great deference to the opinions of a treating physician. Notwithstanding that
mandate, the ALJ in this case afforded Dr. Holley’s opinions little weight. Moreover,
Claimant argues that the ALJ failed in his duty to provide good reasons for the limited
weight given to Dr. Holley’s opinions. Claimant asserts that the “lack of meaningful
analysis of the medical evidence is unacceptable and should justify a reversal or remand.”
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(ECF No. 11 at 5).
When evaluating a claimant’s application for disability benefits, the ALJ “will always
consider the medical opinions in [the] case record together with the rest of the relevant
evidence [he] receives.” 20 C.F.R. §§ 404.1527(b), 416.927(b). Medical opinions are
defined as “statements from physicians and psychologists or other acceptable medical
sources that reflect judgments about the nature and severity of [a claimant’s]
impairment(s), including [his] symptoms, diagnosis and prognosis, what [he] can still do
despite [his] impairment(s), and [his] physical or mental restrictions.” Id. §§
404.1527(a)(2), 416.927(a)(2). 20 C.F.R. §§ 404.1527(c), 416.927(c) outline how the
opinions of accepted medical sources will be weighed in determining whether a claimant
qualifies for disability benefits. In general, the ALJ should give more weight to the opinion
of an examining medical source than to the opinion of a non-examining source. See 20
C.F.R. § § 404.1527(c)(1), 416.927(c)(1). Even greater weight should be allocated to the
opinion of a treating physician, because that physician is usually most able to provide Aa
detailed, longitudinal picture@ of a claimant=s alleged disability. See 20 C.F.R. §§
404.1527(c)(2), 416.927(c)(2). Nevertheless, a treating physician’s opinion on the nature
and severity of an impairment is afforded controlling weight only if two conditions are
met: (1) the opinion is well-supported by clinical and laboratory diagnostic techniques and
(2) the opinion is not inconsistent with other substantial evidence. Id. A treating
physician’s opinion must be weighed against the record as a whole when determining a
claimant’s eligibility for benefits.
If the ALJ determines that a treating physician=s opinion should not be afforded
controlling weight, the ALJ must analyze and weigh all the medical opinions of record,
taking into account the factors listed in 20 C.F.R. §§ 404.1527(c)(2)-(6), 416.927(c)(2)-(6).
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These factors include: (1) length of the treatment relationship and frequency of evaluation,
(2) nature and extent of the treatment relationship, (3) supportability, (4) consistency, (5)
specialization, and (6) various other factors. “A finding that a treating source’s medical
opinion is not entitled to controlling weight does not mean that the opinion is rejected. It
may still be entitled to deference and be adopted by the adjudicator.” SSR 96-2p.
Generally, the more consistent a physician’s opinion is with the record as a whole, the
greater the weight that will be given to it. 20 C.F.R. §§ 404.1527(c)(4), 416.927(c)(4).
Ultimately, it is the responsibility of the Commissioner, not the court, to evaluate the case,
make findings of fact, and resolve conflicts of evidence. Hays v. Sullivan, 907 F.2d 1453,
1456 (4th Cir. 1990). When a treating physician’s opinion is not supported by clinical
findings or is inconsistent with other substantial evidence, the ALJ may give the
physician’s opinion less weight, Mastro v. Apfel, 270 F.3d 171, 178 (4th Cir. 2001), but
must explain the reasons for discounting the opinion. 20 C.F.R. '§ 404.1527, 416.927. The
regulations do not state with specificity the extent to which the ALJ must explain the
weight given to a treating source’s opinion; however Social Security Ruling 96-2p provides
that the ALJ’s decision “must be sufficiently specific to make clear to any subsequent
reviewers the weight the adjudicator gave to the treating source’s medical opinion and the
reasons for that weight.” 1996 WL 374188 *5. A minimal level of articulation is “essential
for meaningful appellate review,” given that “when the ALJ fails to mention rejected
evidence, ‘the reviewing court cannot tell if significant probative evidence was not credited
or simply ignored.’” Zblewski v. Schweiker, 732 F.2d 75, 79 (7th Cir. 1984) (citing Cotter v.
Harris, 642 F.2d. 700, 705 (3rd Cir. 1981)).
Medical source opinions on issues reserved to the Commissioner are treated
differently than other medical source opinions; they are never entitled to controlling
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weight or special significance, because “giving controlling weight to such opinions would,
in effect, confer upon the [medical] source the authority to make the determination or
decision about whether an individual is under a disability, and thus would be an abdication
of the Commissioner’s statutory responsibility to determine when an individual is
disabled.”2 SSR 96-5p, 1996 WL 374183 *2. However, these opinions must always be
carefully considered, “must never be ignored,” and should be assessed for their
supportability and consistency with the record as a whole. Id.
The adjudicator is required to evaluate all evidence in the case record that
may have a bearing on the determination or decision of disability, including
opinions from medical sources about issues reserved to the Commissioner. If
the case record contains an opinion from a medical source on an issue
reserved to the Commissioner, the adjudicator must evaluate all the evidence
in the case record to determine the extent to which the opinion is supported
by the record. In evaluating the opinions of medical sources on issues
reserved to the Commissioner, the adjudicator must apply the applicable
factors in 20 CFR 404.1527(d) and 416.927(d).3
Id. at *3. Although the ALJ is required to consider all of the evidence submitted on behalf
of a claimant, “[t]he ALJ is not required to discuss all evidence in the record.” Aytch v.
Astrue, 686 F.Supp.2d 590, 602 (E.D.N.C. 2010) (emphasis added); see also Dyer v.
Barnhart, 395 F.3d 1206, 1211 (11th Cir. 2005) (explaining there “is no rigid requirement
that the ALJ specifically refer to every piece of evidence in his decision”). Indeed, “[t]o
require an ALJ to refer to every physical observation recorded regarding a Social Security
claimant in evaluating that claimant's ... alleged condition[s] would create an impracticable
standard for agency review, and one out of keeping with the law of this circuit.” White v.
Examples of issues reserved to the Commissioner include “whether an individual’s impairment(s) meets or
is equivalent in severity to the requirements of any impairment(s) in the listings ... what an individual’s RFC
is ... whether an individual’s RFC prevents him or her from doing past relevant work ... and whether an
individual [is unable to work or] is ‘disabled’ under the Social Security Act. . .” SSR 96-5p, 1996 WL 374183
*2.
2
3The
applicable factors are now found at 20 C.F.R. §§ 404.1527(c), 416.927(c).
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Astrue, 2009 WL 2135081, at *4 (E.D.N.C. July 15, 2009).
In the present case, the ALJ clearly complied with the Social Security regulations
and rulings in his treatment of Dr. Holley’s opinions. Contrary to Claimant’s contention,
the ALJ did not reject all of Dr. Holley’s statements regarding the nature and severity of
Claimant’s impairments. Instead, the ALJ accepted a significant portion of Dr. Holley’s
findings and disagreed only with Dr. Holley’s conclusion that Claimant was unable to
engage in any gainful employment due to extreme physical restrictions. For example, at
step two of the sequential analysis, the ALJ relied largely upon Dr. Holley’s notations and
findings to establish Claimant’s severe impairments of COPD and degenerative disc
disease. (Tr. at 15). Accordingly, the ALJ reviewed and accepted Dr. Holly’s opinions on
these issues. Likewise, at step four, the ALJ thoroughly discussed Dr. Holley’s records, first
noting that Claimant’s medically determinable impairments, as diagnosed by Dr. Holley,
could be expected to cause the symptoms alleged by Claimant. (Tr. at 19). Once again, the
ALJ accepted Dr. Holley’s findings as documented in his treatment records.
Although the ALJ expressly rejected Dr. Holley’s opinions pertaining to the
disabling effects of Claimant’s impairments, the ALJ provided a reasoned explanation for
the discounted weight he gave to that assessment. The ALJ explained that the limitations
described by Dr. Holley simply were not consistent with the medical records, including Dr.
Holley’s own notations. The ALJ emphasized that Dr. Holley appeared to base his RFC
opinions upon Claimant’s subjective reports rather than the objective records, which
demonstrated no more than “modest findings and observations.” (Tr. at 20). Looking at
the treatment course prescribed by Dr. Holley for Claimant’s musculoskeletal complaints,
the ALJ noted that Claimant received only conservative care. Dr. Holley had not
recommended more aggressive treatments, such as physical therapy, surgical intervention,
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pain management, or assistive devices. The ALJ observed that, indeed, Claimant’s
objective findings did not support the need for more intensive treatment. Pointing to
Claimant’s medical imaging and physical examinations, which consistently confirmed
“intact neurological status and good range of motion of all extremities,” the ALJ fully
discussed the medical evidence that contradicted the severity findings of Dr. Holley. The
ALJ indicated that Claimant had no evidence of a gross musculoskeletal abnormality on
any physical examination, as well as no evidence of focal disc herniation or significant
neural
impingement
on
medical
imaging.
Claimant
repeatedly
denied
having
musculoskeletal pain on the occasions that she was seen for other medical ailments. (Id).
In addition, films of Claimant’s lumbar spine showed normal disc space heights and no
bony abnormalities, spondylolisthesis, or spondylosis. Her right hip series revealed the
absence of fractures, subluxation, lytic or sclerotic lesions, tendonitis, or joint space
narrowing. (Id.).
In regard to Claimant’s severe COPD, the ALJ acknowledged Dr. Holley’s diagnosis,
but also observed that Dr. Holley did not place any environmental restrictions on
Claimant, nor did he indicate any specific lifting and carrying restrictions. (Tr. at 20). The
ALJ remarked that Claimant had never required hospitalization to stabilize acute
exacerbations of her chronic lung disease and her chest CT scans were stable. Pulmonary
function studies confirmed respiratory obstruction, but also indicated that Claimant’s lung
function would improve if she ceased smoking.
The ALJ meticulously reviewed Dr. Holley’s clinical records, his disability opinions,
and his RFC assessment, identifying conflicts within them. Concluding that Dr. Holley’s
finding of disability, as well as the extreme restrictions he included in the RFC assessment
form, were incompatible with Claimant’s relatively benign and unimpressive clinical
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findings, diagnostic testing results, and treatment course, the ALJ exercised his right to
give little deference to these opinions. As previously stated, under SSR 96-5p, 1996 WL
374183 *2, opinions on issues reserved to the Commissioner, such as whether a claimant is
unable to work, are not entitled to controlling weight. Similarly, opinions of treating
physicians that are not well-supported by diagnostic and clinical findings or are
inconsistent with other substantial evidence are not entitled to controlling weight. Instead,
these opinions are assessed in relation to the record as a whole to determine their
consistency and supportability. When there are inconsistencies in the record, the ALJ is
charged with the duty of resolving the conflicts. If the ALJ completes this task in
accordance with the applicable rules and regulations, and the ultimate finding is supported
by evidence which a reasoning mind would accept as sufficient, the Court may not
substitute its judgment for that of the ALJ.
Here, substantial evidence supports the ALJ’s decision to discredit Dr. Holley’s
disability determination and RFC assessment. The medical records simply do not support
the level of disability described by Dr. Holley. Moreover, the record suggests, as the ALJ
found, that Dr. Holley’s assessment was based almost exclusively on Claimant’s subjective
reports rather than on an impartial review of the medical evidence. The ALJ provided a
detailed explanation for his decision. Therefore, the Court FINDS that the ALJ afforded
appropriate weight to Dr. Holley’s various findings and assessments and provided a
sufficient explanation for the reduced evidentiary value he placed on Dr. Holley’s disability
and RFC opinions.
B.
Credibility Assessment
Claimant also takes issue with the ALJ’s credibility finding. She argues that her
subjective complaints of pain and fatigue were fully supported by the RFC assessment of
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Dr. Holley; therefore, she is entitled to disability benefits. In Claimant’s view, the ALJ’s
statement that Claimant’s allegations were “vague, exaggerated and inconsistent with the
documented objective findings and treatment history” is entirely unwarranted in light of
the “mutually supportive” statements of Claimant’s “long-time primary care physician.”
(ECF No. 11 at 7).
In Hines v. Barnhart, the Fourth Circuit restated the well-established role of
subjective evidence in proving the intensity, persistence, and disabling effects of pain,
stating “[b]ecause pain is not readily susceptible of objective proof, however, the absence of
objective medical evidence of the intensity, degree or functional effect of pain is not
determinative.” 453 F.3d at 564–565 (emphasis in original). Once an underlying condition
capable of eliciting pain is established by objective medical evidence, disabling pain can be
proven by subjective evidence alone. Of course, the extent to which an individual’s
statements can be relied upon as probative of the degree or functional effect of chronic
pain depends upon the individual’s credibility. “In basic terms, the credibility of an
individual’s statements about pain or other symptoms and their functional effects is the
degree to which the statements can be believed and accepted as true.” SSR 96-7p, 1996 WL
374186 *4. For that reason, the ALJ must assess and consider the credibility of the
claimant when determining the weight to give to her statements regarding the intensity,
degree, or functional impact of pain.
Social Security Ruling 96-7p provides practical guidance on how an ALJ should
evaluate a claimant’s allegation of pain and fatigue in order to determine their limiting
effects on her ability to work. First, the ALJ must establish whether the claimant’s
medically determinable medical and psychological conditions could reasonably be
expected to produce these symptoms. SSR 96-7P. Once the ALJ finds that the conditions
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can be expected to produce the symptoms, the ALJ must consider whether the intensity,
persistence, and severity of the pain can be established by objective medical evidence. Id.
Whenever the intensity, persistence or severity of the symptoms cannot be established by
objective medical evidence, the ALJ must closely examine the claimant’s statements about
the disabling effects of pain and assess their reliability. The Ruling sets forth the factors
that the ALJ should consider in assessing the claimant’s credibility, emphasizing the
importance of explaining the reasons supporting the credibility determination. In
performing this evaluation, the ALJ must take into consideration “all the available
evidence,” including: the claimant’s subjective complaints; claimant's medical history,
medical signs, and laboratory findings;4 any objective medical evidence of pain5 (such as
evidence of reduced joint motion, muscle spasms, deteriorating tissues, redness, etc.); and
any other evidence relevant to the severity of the impairment, such as evidence of the
claimant's daily activities, specific descriptions of the pain, the location, duration,
frequency and intensity of symptoms; precipitating and aggravating factors; any medical
treatment taken to alleviate it; and other factors relating to functional limitations and
restrictions.6 Craig v. Cather, 76 F.3d 585, 595 (4th Cir. 1996). In Hines, the Fourth Circuit
Court of Appeals stated,
[a]lthough a claimant’s allegations about her pain may not be discredited
solely because they are not substantiated by objective evidence of the pain
itself or its severity, they need not be accepted to the extent they are
inconsistent with the available evidence, including objective evidence of the
underlying impairment, and the extent to which that impairment can
reasonably be expected to cause the pain the claimant alleges she suffers.
4
See 20 C.F.R. §§ 416.929(c)(1) & 404.1529(c)(1).
5
See 20 C.F.R. §§ 416.929(c)(2) & 404.1529(c)(2).
6
See 20 C.F.R. §§ 416.929(c)(3) & 404.1529(c)(3).
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453 F.3d at 565 n.3 (citing Craig, 76 F.3d at 595). The ALJ may not reject a claimant’s
allegations of intensity and persistence solely because the available objective medical
evidence does not substantiate the allegations; however, the lack of objective medical
evidence may be one factor considered by the ALJ.
When reviewing an ALJ’s credibility determinations, the court does not replace its
own assessments for those of the ALJ; rather, the court reviews the evidence to determine
if it is sufficient to support the ALJ’s conclusions. “In reviewing the record for substantial
evidence, the Court does not re-weigh conflicting evidence ... or substitute its own
judgment for that of the Commissioner.” Hays v. Sullivan, 907 F.2d. 1453, 1456 (4th Cir.
1990). Because the ALJ had the “opportunity to observe the demeanor and to determine
the credibility of the claimant, the ALJ’s observations concerning these questions are to be
given great weight.” Shively v. Heckler, 739 F.2d 987, 989–990 (4th Cir. 1984) (citing
Tyler v. Weinberger, 409 F. Supp. 776 (E.D.Va. 1976)).
In this case, the ALJ correctly followed the two-step process in evaluating
Claimant’s credibility. First, the ALJ conducted a comprehensive review of Claimant’s
statements, including those written in a Disability Report and Pain Questionnaire; those
shared with Dr. Holley and documented in other medical records; and those made during
Claimant’s testimony at the administrative hearing. Considering Claimant’s allegations, the
ALJ accepted that Claimant’s medically determinable impairments could reasonably be
expected to cause her pain and fatigue; thus, completing the first step. The ALJ next
evaluated the intensity, persistence, and limiting effects of Claimant’s symptoms to
determine the extent to which they prevented her from working. The ALJ compared and
contrasted Claimant’s allegations with the remaining evidence and concluded that her
statements concerning the intensity, persistence, and severity of her symptoms were
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exaggerated and inconsistent with the record as a whole. The ALJ stressed the complete
absence of objective clinical findings and diagnostic results buttressing Claimant’s
descriptions of extreme and disabling pain and fatigue. Moreover, the ALJ observed that
Claimant “had been rather inconsistent in her symptom and function descriptions.” (Tr. at
19). He found Claimant’s testimony to be embellished, indicating that she had to be
prompted before she could remember some of her allegedly severe symptoms. He noted
the lack of aggressive treatment recommendations from her primary and consulting
physicians, as well as her unimpressive treatment history. Finally, the ALJ found
Claimant’s activities somewhat at odds with her complaints, pointing out that Claimant
complained of debilitating COPD, yet continued to smoke against medical advice. (Tr. at
19-20). The ALJ conducted a comprehensive analysis of the relevant evidence and
provided a logical basis for discrediting Claimant’s overstatements. Having reviewed the
Transcript of Proceedings, including the ALJ’s written decision, the Court finds that the
ALJ's credibility assessment of Claimant was consistent with the applicable regulations,
case law, and Social Security Rulings. 20 C.F.R. §§ 404.1529 and 416.929; SSR 96-7p, 1996
WL 374186 (July 2, 1996); Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996). The Court
further finds that substantial evidence exists in the record to support the ALJ’s credibility
finding. Claimant’s complaints of pain simply do not correlate well with the objective
findings in the record, her history of treatment, her current treatment course, and her
documented activities.
VIII. Conclusion
After a careful consideration of the evidence of record, the Court finds that the
Commissioner’s decision IS supported by substantial evidence. Therefore, by Judgment
Order entered this day, the final decision of the Commissioner is AFFIRMED and this
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matter is DISMISSED from the docket of this Court.
The Clerk of this Court is directed to transmit copies of this Order to counsel of
record.
ENTERED: December 11, 2012.
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