Mills v. Colvin

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 5/2/2014. (cc: attys) (mkw)

IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF WEST VIRGINIA
HUNTINGTON DIVISION
GARRETT D. MILLS,
Plaintiff,
v.

Case No. 3:13-cv-06421

CAROLYN W. COLVIN,
Acting 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 disability insurance benefits (“DIB”) and supplemental security income
(“SSI”) under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 401-433, 13811383f. The case is presently before the Court on the parties’ motions for judgment on the
pleadings. (ECF Nos. 11, 12). Both parties have consented in writing to a decision by the
United States Magistrate Judge. (ECF Nos. 7, 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, Garrett D. Mills (“Claimant”), filed for DIB and SSI on December 18,

2009 and February 19, 2010, respectively. (Tr. at 154, 158). Claimant alleged a disability
-1-

onset date of September 10, 2009, (id.), due to “carpal tunnel spine and back sleep and
social disorders.” (Tr. at 178). The Social Security Administration (“SSA”) denied the
applications initially and upon reconsideration. (Tr. at 67-76, 81-94). Claimant filed a
request for a hearing, (Tr. at 95), which was held on September 22, 2011 before the
Honorable George D. Roscoe, Administrative Law Judge (“ALJ”). (Tr. at 26-59). By
written decision dated October 20, 2011, the ALJ determined that Claimant was not
entitled to benefits. (Tr. at 10-21). The ALJ’s decision became the final decision of the
Commissioner on January 22, 2013, when the Appeals Council denied Claimant’s
request for review. (Tr. at 1-3).
On March 27, 2013, Claimant filed 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 an Answer and a Transcript of the proceedings on June 3, 2013.
(ECF Nos. 9, 10). Thereafter, the parties filed their briefs in support of judgment on the
pleadings. (ECF Nos. 11, 12). Accordingly, this matter is ripe for resolution.
II.

Claimant’s Background
Claimant was 30 years old at the time of his alleged onset of disability and 32

years old on the date of the ALJ’s decision. (Tr. at 20, 30). He attended school through
eleventh grade, subsequently received a GED, and communicates in English. (Tr. at 3132). Claimant has prior work experience performing manual labor and working in retail
sales. (Tr. at 32, 180, 191-96).
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, 775 (4th Cir.
1972). A disability is defined as the “inability to engage in any substantial gainful activity
-2-

by reason of any medically determinable physical or mental impairment which can be
expected to result in death or which has lasted or can be expected to last for a
continuous period of 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(a)(4), 416.920(a)(4). First, the ALJ determines whether a claimant is
currently engaged in substantial gainful employment. Id. §§ 404.1520(b), 416.920(b).
Second, if the claimant is not gainfully employed, then the inquiry is whether the
claimant suffers from a severe impairment. Id. §§ 404.1520(c), 416.920(c). Third, if the
claimant suffers from a severe impairment, the ALJ determines whether this
impairment meets or equals any of the impairments listed in Appendix 1 to Subpart P of
the Administrative Regulations No. 4 (the “Listing”). Id. §§ 404.1520(d), 416.920(d). If
the impairment does meet or equal a listed impairment, then the claimant is found
disabled and awarded benefits.
However, if the impairment does not meet or equal a listed impairment, the
adjudicator must 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). In the fourth
step, the ALJ ascertains 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, then the claimant has established a prima facie case
of disability and the burden shifts to the Commissioner to prove the final step. McLain
v. Schweiker, 715 F.2d 866, 868-69 (4th Cir. 1983). Under the fifth and final inquiry, the
-3-

Commissioner must demonstrate that the claimant is able to perform other forms of
substantial gainful activity, while taking into account the claimant’s remaining physical
and mental capacities, age, education, and prior work experiences. 20 C.F.R. §§
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).
When a claimant alleges a mental impairment, the ALJ “must follow a special
technique” when assessing disability. 20 C.F.R. §§ 404.1520a, 416.920a. First, the ALJ
evaluates the claimant’s pertinent signs, symptoms, and laboratory results to determine
whether the claimant has a medically determinable mental impairment. Id. §§
404.1520a(b), 416.920a(b). If such impairment exists, the ALJ documents the findings.
Second, the ALJ rates and documents the degree of functional limitation resulting from
the impairment according to criteria specified in the Regulations. Id. §§ 404.1520a(c),
416.920a(c). Third, after rating the degree of functional limitation from the claimant’s
impairment(s), the ALJ determines the severity of the limitation. Id. §§ 404.1520a(d),
416.920a(d). A rating of “none” or “mild” in the first three functional areas (activities of
daily living, social functioning, and concentration, persistence or pace) and “none” in
the fourth (episodes of decompensation) will result in a finding that the impairment is
not severe unless the evidence indicates that there is more than minimal limitation in
the claimant’s ability to do basic work activities. Id. §§ 404.1520a(d)(1), 416.920a(d)(1).
Fourth, if the claimant’s impairment is deemed severe, the ALJ compares the medical
findings about the severe impairment and the degree of functional limitation against the
-4-

criteria of the appropriate listed mental disorder to determine if the severe impairment
meets or is equal to a listed mental disorder. Id. §§ 404.1520a(d)(2), 416.920a(d)(2).
Finally, if the ALJ finds that the claimant has a severe mental impairment that neither
meets nor equals a listed mental disorder, then the ALJ assesses the claimant’s residual
function. 20 C.F.R. §§ 404.1520a(d)(3), 416.920a(d)(3).
In this case, the ALJ determined as a preliminary matter that Claimant met the
insured status requirements of the Social Security Act through December 31, 2009. (Tr.
at 12, Finding No. 1). The ALJ acknowledged that Claimant satisfied the first inquiry
because he had not engaged in substantial gainful activity since September 10, 2009, the
alleged disability onset date. (Id., Finding No. 2). Under the second inquiry, the ALJ
found that Claimant suffered from severe impairments of “degenerative disc disease of
the lumbosacral spine, carpal tunnel syndrome, degenerative joint disease of the knees,
history of seizure disorder, and obesity.” (Tr. at 12-15, Finding No. 3). However, the ALJ
found that Claimant’s alleged depression, difficulty hearing, and sleeping disorder were
all nonsevere. (Tr. at 13-15). Under the third inquiry, the ALJ concluded that Claimant’s
impairments, either individually or in combination, failed to meet or medically equal
any of the listed impairments. (Tr. at 15, Finding No. 4). Consequently, the ALJ
determined that Claimant had the RFC to:
[P]erform light work (20 C.F.R. 404.1567 and 416.967) with the additional
nonexertional limitations: the claimant cannot climb ladders, ropes and
scaffolds; can occasionally climb ramps and stairs and can occasionally
balance, stoop, kneel, crouch and crawl; cannot work at heights or on
steep, narrow, wet or erratically moving surfaces; cannot perform
repetitive or constant fine finger manipulation; and cannot have
concentrated exposure to cold temperatures or vibration, or any exposure
to hazards such as heights and machinery (20 C.F.R. 404.1569a and
416.969a).

-5-

(Tr. at 15-20, Finding No. 5). Based upon the RFC assessment, the ALJ determined at
the fourth step that Claimant was unable to perform any past relevant work. (Tr. at 20,
Finding No. 6). Under the fifth and final inquiry, the ALJ reviewed Claimant’s past work
experience, age, and education in combination with his RFC to determine if he would be
able to engage in substantial gainful activity. (Tr. at 20-21, Finding Nos. 7-10). The ALJ
considered that (1) Claimant was born in 1979 and was defined as a younger individual;
(2) he had at least a high school education and could communicate in English; and (3)
transferability of job skills was not material to the disability determination. (Tr. at 20,
Finding Nos. 7-9). Given these factors, Claimant’s RFC, and the testimony of a
vocational expert, the ALJ determined that Claimant could perform jobs that exist in
significant numbers in the national economy. (Tr. at 20-21, Finding No. 10). At the light
level, Claimant could work as a route aid, school bus monitor, or house sitter; and at the
sedentary level, Claimant could work as a credit card information verifier, surveillance
system monitor, or product inspector. (Tr. at 21). Therefore, the ALJ concluded that
Claimant was not disabled as defined in the Social Security Act, and was not entitled to
benefits. (Id., Finding No. 11).
IV.

Claimant’s Challenge to the Commissioner’s Decision
Claimant alleges that the Commissioner’s decision is not supported by substantial

evidence because the ALJ failed to properly evaluate Claimant’s credibility. (ECF No.
11). Moreover, Claimant contends that the objective evidence clearly substantiates his
allegations of disabling impairments.
V.

Relevant Medical Records
The Court has reviewed the transcript of proceedings in its entirety including the

medical records in evidence. The Court has confined its summary of Claimant’s
-6-

treatment and evaluations to those entries most relevant to the issues in dispute.
A. Treatment Records
1. 2005-2006
On August 22, 2005, Claimant was referred to Glen P. Imlay, M.D. at Holzer
Clinic with complaints of low back pain dating back to age 16, as well as aggravating
hand pain and numbness. (Tr. at 287). Claimant reported that his back pain radiated
down his left leg to his knee and that Percocet helped relieve pain but Lortab did not.
(Id.). Claimant was observed to walk “with an antalgic gait favoring a flexed position.”
(Tr. at 288). Physical examination revealed decreased lumbar range of motion with
somewhat better flexion than extension, and Dr. Imlay noted that “his flexion was
painful and when we tried to examine, extension was more painful, particularly to the
left side.” (Tr. at 288). Claimant was “tight in two-joint muscles and [was] difficult to
move as such because of the pain in the back.” (Id.). Palpation at Claimant’s “SI joint
and L5-S1 area was most tender,” while his gluteal muscle was also “tender to palpation,
which was increased with the hip extension and there were some trigger points noted in
the gluteal region as well.” (Id.). Claimant’s spine MRI showed “disk degeneration as
well as some general narrowing in the spine.” (Id.). At L4-L5, there was a “broad-based
small +2 post central protrusion,” while at L5-S1 there was a “medial anterior thecal sac,
just occurring at the L5-S1, which was a budding S1 nerve root.” (Id.). Claimant’s upper
extremity EMG revealed electrophysiologic evidence of “moderate right median nerve
entrapment of the wrist (CTS) involving sensory and motor fibers” and “mild left
median nerve entrapment of the wrist (CTS) involving sensory fibers only.” (Tr. at 290).
Accordingly, Dr. Imlay assessed Claimant with “suspected bilateral carpel tunnel
syndrome,” “sac into the left leg with MRI showing thecal sac at the L5-S1 more
-7-

prominent on the right with a disk protrusion moderate in size at L4-L5,” “SI joint
pain,” “lumbosacral sprain/strain,” “gluteal enthesitis,” and “suspected carpal tunnel
syndrome.” (Tr. at 288). Dr. Imlay ordered an MRI contrast of Claimant’s back and an
EMG of his lower extremity; ordered a right wrist splint for him to wear; prescribed
Neurontin and Percocet; and instructed Claimant to return in three to four months. (Tr.
at 288-89).
Claimant’s September 8, 2005 lumbar spine MRI with contrast revealed “stable
L3-4, L4-5 and L5-S1 degenerative disc disease.” (Tr. at 296). There was “moderate
canal stenosis with symmetric lateral recess involvement at L4-5” but “no enhancement
associated with the 1cm cystic structure adjacent to the right S1 nerve root.” (Id.).
Claimant’s September 14, 2005 lower extremity EMG revealed no electrophysiologic
evidence of either “left lumbosacral radiculopathy or plexopathy” or of “bilateral
peroneal or sural peripheral neuropathy.” (Tr. at 297).
On October 12, 2005, Claimant attended a follow-up appointment with Dr. Imlay.
(Tr. at 301). Claimant complained of “having the same symptoms” since his last visit,
including stiffness in the morning. (Id.). Claimant reported that his pain medication
helped somewhat, as did his wrist splint, but that he was “still having the back pain and
gets symptoms that seem to go into his left hip area as well as sometimes down the leg.”
(Id.). Physical examination revealed that Claimant’s left gluteal area was particularly
tender to palpation, as “as well as the L5, S1 area on the iliac crest,” and that Claimant’s
“gluteal muscles [were] also tender to palpation.” (Id.). Claimant was assessed with
“right carpal tunnel syndrome improved with wrist splints,” “mild central disc
protrusion at L4, L5 with moderate canal stenosis. Patient with sciatic type symptoms
into the left lower extremity. Nerve root cyst noted ablating the right S1 nerve root,” “SI
-8-

joint pain,” “lumbosacral sprain/strain particularly on the left,” and “left gluteal
antithesis with left gluteal myofascial pain.” (Id.).
On December 1, 2005, Claimant attended a follow-up appointment with Dr.
Imlay. (Tr. at 302). Claimant reported that he had run out of Percocet, and that the
Duragesic patch had been helpful in the past. (Tr. at 302). Physical examination
revealed that Claimant’s “lumbar range of motion [was] decreased because of pain” and
that the “L5/S1 area was the most tender.” (Id.). Claimant was assessed with “right
carpal tunnel syndrome improved with wrist splints,” “mild central disc protrusion at
L4/L5 with moderate canal stenosis,” “patient with radicular type symptoms in the left
lower extremity,” “SI joint pain,” “lumbosacral sprain, strain,” and “left gluteal
myofascial pain, gluteal enthesis.” (Id.).
On January 12, 2006, Claimant attended a follow-up appointment with Dr.
Imlay. (Tr. at 303-04). Claimant reported that he could not afford Duragesic or
Neurontin, but that the Lortab helped although less than Percocet. (Tr. at 303). Physical
examination reflected that “[p]alpation at L5-S1 area was the most tender” and that
Claimant “had limited ability to range his back.” (Id.). Claimant was assessed with “right
carpal tunnel syndrome, improved with wrist splints,” “mild central disk protrusion at
L4-L5 with moderate canal stenosis,” “S1 radicular pains in the left lower extremity”
with “changes affecting the right S1 nerve root,” “SI joint pain,” “lumbosacral
sprain/strain,” and “gluteal myofascial pain and gluteal enthesitis.” (Id.). Dr. Imlay
prescribed Percocet, Sulindac, and Doxepin, and instructed Claimant to follow-up in six
weeks. (Tr. at 304).
On April 5, 2006, Claimant attended a follow-up appointment with Dr. Imlay.
(Tr. at 306). Claimant reported running out of Percocet, and that Ultram had not helped
-9-

him. (Id.). Physical examination revealed “[p]alpation along the L5-S1 area with some
tenderness” and that Claimant’s “[l]umbar range of motion was limited.” (Id.). Claimant
was assessed with “right carpal tunnel syndrome stable with wrist splints,” “right central
disc protrusion L4-L5 with moderate canal stenosis,” “SI radicular pains in the left lower
extremity with MRI showing some right S1 nerve root involvement,” “sacroiliac joint
pain,” “lumbosacral sprain/strain,” “gluteal myofascial pain enthesis,” and “failed
appointment.” (Id.). Dr. Imlay prescribed Lortab, ordered a drug screen, and instructed
Claimant to return in 6 to 8 weeks. (Id.). Claimant’s drug screen was positive for
cannabinoids, opiates, and oxycodone. (Tr. at 305.).
2. 2010-2011
On September 27, 2010, Claimant attended an initial appointment to establish
care with Dawn McFarland, M.D. (Tr. at 309-12). Claimant complained of migraines
over the past several years; pain, swelling, and stiffness in his hands and elbows;
anxiousness and insomnia; and itchy/watery eyes. (Tr. at 309). Claimant reported
experiencing carpal tunnel syndrome in his right more than left side, numbness when he
sleeps in his left arm, and right hand aches. (Tr. at 312). Claimant reported dropping
things bilaterally, and stated that he wears a wrist brace at times. (Id.). Physical
examination reflected decreased range of motion and crepitance in Claimant’s right
knee. (Tr. at 312). Claimant was diagnosed with “back pain – spinal stenosis,”
“paresthesias – legs,” and “carpal tunnel bilat UE’s.” (Id.).
On October 8, 2010, Claimant attended a follow-up appointment with Dr.
McFarland, in which he requested an increase in Percocet, as well as “something for
sleep.” (Tr. at 316). Claimant complained of his knees bothering him, especially his right
knee. (Id.). Claimant was diagnosed with low back pain, paresthesia, CTS bilateral, and
- 10 -

tobacco use. (Id.). Dr. McFarland ordered an MRI of Claimant’s spine and x-rays of his
knees, increased his Percocet dosage, and prescribed a Trazodone trial. (Id.). Claimant’s
spine x-ray results, dated October 15, 2010, reflected “disc space height loss at L4-5,”
resulting in an impression of “degenerative disc changes at L4-5.” (Tr. at 321).
Claimant’s chest, hands, and knees x-ray results, dated October 20, 2010, revealed no
abnormalities. (Tr. at 320).
On December 14, 2010, Claimant attended a follow-up appointment with Dr.
McFarland. (Tr. at 315). Claimant reported that Trazodone did not help, requested
Xanax for his nerves and insomnia, reported taking 5-6 Percocet per day, and reported
that Neurontin continued to help some. (Id.). Physical examination reflected decreased
range of motion, cyanosis, edema, and crepitance of his right knee. (Id.). Claimant was
diagnosed with carpal tunnel syndrome, low back pain, insomnia, and bilateral knee
pain. (Id.). Dr. McFarland ordered a bilateral knee MRI, prescribed Cymbalta and
Xanax, and increased Claimant’s Neurontin dosage. (Id.).
On April 11, 2011, Claimant was seen by Dr. McFarland “to start urine stream.”
(Tr. at 314). He also reported that “Xanax and Neurontin seem to help with relaxing.”
(Id.). Claimant was assessed with carpal tunnel syndrome, low back pain, and PSA. (Id.).
On August 11, 2011, Claimant attended a follow-up appointment with Dr.
McFarland in which he requested that his Xanax dosage be increased due to insomnia.
(Tr. at 313). A problem list, also dated August 11, 2011, indicates that Claimant
continued to suffer from spinal stenosis, bilateral carpal tunnel in his wrists, bilateral
knee pain, and insomnia. (Tr. at 308).

- 11 -

B. Agency Evaluations and RFC Opinions
1. Mental Evaluations
On May 4, 2010, Penny O. Perdue, M.A. of Associates in Psychology and Therapy,
Inc. completed a mental evaluation of Claimant, consisting of a clinical interview and
mental status examination. (Tr. at 235-38). During the interview, Claimant reported
that he was applying for benefits because of his “back and knees, sleep disorder and
[being] nervous around people,” and provided a brief history of his symptoms. (Tr. at
235). Claimant reported that his “pain difficulties increase his mood difficulties” and
“estimated that about half of his mood related problems are pain related.” (Id.).
Regarding presenting symptoms, Claimant reported experiencing “constant, daily
depressive symptoms,” which began approximately 3-4 years prior but had become
progressively worse over time, as well as “a poor appetite but his weight is stable,
difficulty sleeping (due to pain or anxiety), loss of energy, feelings of worthlessness and
guilt, recurrent thoughts of death, poor concentration, occasional irritability, increased
nervousness and increased worrying.” (Id.). Claimant reported that “due to pain and
anxiety, he has difficulty getting to sleep and wakens through the night due to pain.”
(Id.). Regarding his anxiety, Claimant reported that he had “always been a nervous
person,” but that his anxiety became excessive when he began having chronic pain. (Id.).
Reported symptoms included “excessive anxiety and worry, occurring more days than
not, about his health, his child, financial problems, getting things done, and not being
able to do the things he used to,” as well as “difficulty controlling his worry, restlessness,
feeling on edge, being easily fatigued, difficulty concentrating, muscle tension, and sleep
disturbance.” (Tr. at 235-36). Claimant also reported feeling useless, not “want[ing] to
be around others because he is afraid they will judge him as being useless as well,” and
- 12 -

avoiding social situations as much as possible. (Tr. at 236). Claimant reported no history
of past counseling or past psychiatric hospitalizations, and was not currently receiving
counseling. (Id.).
In his mental status examination, Claimant’s “mood was depressed and anxious,”
while his “affect was restricted.” (Id.). Regarding psychomotor activity, he “exhibited
slight fidgeting during the evaluation and various pain behaviors,” including “shifting of
weight and having to stand.” (Tr. at 237). Otherwise, Claimant’s attitude/behavior,
social interaction, speech, orientation, thought process, thought content, perception,
insight, judgment, immediate memory, recent memory, remote memory, and
concentration were all within normal limits, and he denied any suicidal/homicidal
ideations. (Tr. at 236-37). Ms. Perdue diagnosed Claimant with “depressive disorder
NOS” along Axis I, based upon his reports of anxiety and depressive symptoms, and
opined that Claimant’s prognosis was “fair” with appropriate treatment. (Tr. at 237).
Claimant reported activities of daily living consisting of watching television,
listening to music, and caring for his child on weekends. (Id.). Claimant reported that he
was able to make microwave and quick stovetop meals, sweep and dust, take quick
shopping trips, complete personal grooming and hygiene tasks independently, handle
his finances, and drive for short trips under 30 minutes, although his license was
expired. (Id.). Claimant reported that he could no longer play cards, play pool, go
bowling, hang out with his friends, or build model cars due to pain, weakness, and
anxiety. (Id.). Although Claimant described himself as socially “withdrawn” and
reported having no social activities, Ms. Perdue observed Claimant’s social functioning,
pace, and persistence to be within normal limits, and opined that Claimant was
competent to manage his own finances. (Tr. at 237-38).
- 13 -

On May 7, 2010, G. David Allen, Ph.D. provided a psychiatric review technique
based upon Ms. Perdue’s evaluation. (Tr. at 240-53). Dr. Allen diagnosed Claimant with
Depressive Disorder NOS, (Tr. at 243), but concluded that Claimant did not meet any of
the mental impairment Listings as he was only mildly limited in his ability to maintain
social functioning; had no restriction on activities of daily living or his ability to
maintain concentration, persistence, or pace; and suffered from no episodes of extended
decompensation. (Tr. at 250-51). Dr. Allen found Claimant to have “partial credibility”
given that the “degree of functional impairment observed at CE [was] somewhat less
than alleged on AFRQ and [Claimant had] no psych treatment.” (Tr. at 252).
On January 25, 2011, James W. Bartee, Ph.D. provided a case analysis, in which
he reviewed the medical evidence on file and affirmed as written Dr. Allen’s opinion that
Claimant has a non-severe mental impairment. (Tr. at 273).
2. Physical Evaluations
On July 26, 2010, W. Roy Stauffer, M.D. conducted an internal medicine
examination of Claimant, and provided an accompanying RFC opinion. (Tr. at 254-59).
Claimant reported a history of carpal tunnel syndrome, back pain, and knee pain. (Tr. at
254). Claimant complained of “problems with pain in his left arm up to his shoulder,”
and difficulty sleeping related to his carpal tunnel, as well as constant pain radiating
down his left leg to his knee and intermittent bilateral foot numbness, and bilateral knee
pain accompanied by a lot of grinding and popping. (Tr. at 255).
Claimant’s physical examination was essentially within normal limits as to his
vital signs, HEENT, neck, skin, chest/lungs, heart, abdomen, and extremities. (Tr. at
255-56). Examination of Claimant’s back reflected “tenderness over the lumbar spine”
while his straight leg raise was “60° on the left associated with low back pain.” (Tr. at
- 14 -

256). Examination of Claimant’s joints reflected that Claimant “cannot fully extend the
right fourth and fifth fingers, but no other deformity, heat, nodes, tenderness or
redness” was observed, although Claimant did have “bilateral knee crepitus.” (Id.).
Claimant also had diminished right knee flexion to 130° (150° standard) due to pain;
diminished left ankle dorsiflexion to 15° (20° standard); and diminished lumbar spine
flexion to 60° (20° standard). (Tr. at 256, 258-59). Otherwise, Claimant had full range of
motion without pain as to his shoulders, elbows, wrists, hips, and cervical spine. (Id.).
Dr. Stauffer further observed that Claimant’s gait was mildly antalgic and that he “tends
to be bent over at the waist and seems to be in pain.” (Tr. at 256). Claimant could
“perform fine manipulation and gross dexterous movements with his hands.” (Id.).
Claimant could “knee squat only about one-half way down” and could “walk on heels
and toes, although it causes low back pain.” (Id.). Claimant’s mental status was normal.
(Id.).
Accordingly, Dr. Stauffer provided a diagnosis of bilateral carpal tunnel
syndrome, “chronic back pain with possible left lower extremity radiculopathy,”
“bilateral knee pain probably secondary to degenerative joint disease,” and a “history of
recent seizures, uncontrolled, untreated.” (Id.). Based upon his examination and
diagnosis, Dr. Stauffer opined that Claimant could occasionally lift 20 lbs; frequently
but not repetitively lift 10 lbs; stand and walk six hours in an eight-hour day with
normal breaks; sit six hours in an eight-hour day with normal breaks; and push or pull
occasionally, but not repetitively with his upper extremities. (Id.). Regarding postural
limitations, Dr. Stauffer opined that Claimant would need to limit climbing ladders,
ropes, and scaffolds; and could occasionally balance, stoop, kneel, crouch, and crawl.
(Tr. at 256-57). Dr. Stauffer further opined that Claimant should not do anything
- 15 -

repetitively with his hands, but that he had no other manipulative limitations. (Tr. at
257). Regarding environmental limitations, Dr. Stauffer recommended that Claimant
avoid heights, hazards, and commercial driving, and reiterated that Claimant should not
climb ladders, ropes, or scaffolds at all due to his history of probable seizures. (T Id.).
On July 31, 2010, consultative physician Atiya M. Lateef, M.D. provided a
Physical RFC opinion of Claimant based upon Dr. Stauffer’s examination, (Tr. at 26168), in which she opined that Claimant could occasionally lift or carry 20 pounds,
frequently lift or carry 10 pounds, stand and/or walk (with normal breaks) for a total of
6 hours in an 8-hour workday, sit (with normal breaks) for a total of 6 hours in an 8hour workday, and had unlimited ability to push/pull. (Tr. at 262). Claimant could
never climb ladders, ropes or scaffolds, but could occasionally climb ramps and stairs,
balance, stoop, kneel, crouch, and crawl. (Tr. at 263). Claimant was limited in his
fingering (fine manipulation), but was otherwise unlimited in his ability to reach all
directions (including overheard), handling (gross manipulation), and feeling (skin
receptors). (Tr. at 264). Dr. Lateef elaborated that Claimant had “minor limitation with
fine manipulation” and recommended that Claimant “avoid repetitive or constant fine
manipulation with hands.” (Id.). Claimant had no visual or communicative limitations,
(Tr. at 264-65). Dr. Lateef opined that Claimant should avoid all exposure to hazards
such as machinery and heights, and avoid concentrated exposure to extreme cold and
vibration, but that he could withstand unlimited exposure to extreme heat, wetness,
humidity, noise, and fumes. (Tr. at 265). Dr. Lateef noted that “review of MER and
ADL’s supports partial credibility,” (Tr. at 266), and therefore reiterated that Claimant’s
“physical RFC [was] reduced to light with postural, manipulative and environmental
limitations as mentioned.” (Tr. at 268).
- 16 -

On February 1, 2011, Narendra Parikshak, M.D. provided a case analysis in which
she reviewed the medical evidence on file and affirmed Dr. Lateef’s RFC opinion on the
ground that there was “no new medical evidence on record since [Claimant’s] last RFC
to suggest increased functional impairment.” (Tr. at 274).
VI.

Scope of Review
The issue before this Court is whether the final decision of the Commissioner

denying Claimant’s application for benefits 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.”
Blalock, 483 F.2d at 776 (quoting Laws v. Celebrezze, 368 F.2d 640, 642 (4th Cir.
1966)). Additionally, the administrative law judge, not the court, is charged with
resolving conflicts in the evidence. Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir.
1990).

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). Thus, 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).
- 17 -

The Court has considered Claimant’s challenges and finds them unpersuasive. To
the contrary, having analyzed the record as a whole, the Court concludes that the finding
of the Commissioner that Claimant is not disabled is supported by substantial evidence.
VII.

Analysis
Claimant argues that the Commissioner’s decision is not supported by substantial

evidence, and insists that his physical and mental impairments in combination prevent
him from engaging in substantial gainful activity. (ECF No. 11 at 4-6). In support of his
position, Claimant argues that the ALJ improperly assessed his credibility by failing to
apply the correct legal standard for assessing credibility and by failing to adequately
articulate the reasons for discounting Claimant’s credibility. (Id. at 6-8). Having
carefully reviewed the ALJ’s decision, the Court affirms the ALJ’s credibility
determination.
Pursuant to the Regulations, the ALJ evaluates a claimant’s report of symptoms
using a two-step method. 20 C.F.R. §§ 404.1529, 416.929. First, the ALJ must determine
whether the claimant’s medically determinable medical and psychological conditions
could reasonably be expected to produce the claimant’s symptoms, including pain. Id. §§
404.1529(a), 416.929(a). That is, a claimant’s “statements about his or her symptoms is
not enough in itself to establish the existence of a physical or mental impairment or that
the individual is disabled.” SSR 96-7p, 1996 WL 374186, at *2. Instead, there must exist
some objective “[m]edical signs and laboratory findings, established by medically
acceptable clinical or laboratory diagnostic techniques” which demonstrate “the
existence of a medical impairment(s) which results from anatomical, physiological, or
psychological abnormalities and which could reasonably be expected to produce the
pain or other symptoms alleged.” 20 C.F.R. §§ 404.1529(b), 416.929(b).
- 18 -

Second, after establishing that the claimant’s conditions could be expected to
produce the alleged symptoms, the ALJ must evaluate the intensity, persistence, and
severity of the symptoms to determine the extent to which they prevent the claimant
from performing basic work activities. Id. §§ 404.1529(a), 416.929(a). If the intensity,
persistence or severity of the symptoms cannot be established by objective medical
evidence, the ALJ must assess the credibility of any statements made by the claimant to
support the alleged disabling effects. SSR 96-7P, 1996 WL 374186, at *2. In evaluating a
claimant’s credibility regarding his or her symptoms, the ALJ will consider “all of the
relevant evidence,” including (1) the claimant’s medical history, signs and laboratory
findings, and statements from the claimant, treating sources, and non-treating sources,
20 C.F.R. §§ 404.1529(c)(1), 416.929(c)(1); (2) objective medical evidence, which is
obtained from the application of medically acceptable clinical and laboratory diagnostic
techniques, id. §§ 404.1529(c)(2), 416.929(c)(2); and (3) any other evidence relevant to
the claimant’s symptoms, such as evidence of the claimant's daily activities, specific
descriptions of symptoms (location, duration, frequency and intensity), precipitating
and aggravating factors, medication or medical treatment and resulting side effects
received to alleviate symptoms, and any other factors relating to functional limitations
and restrictions due to the claimant’s symptoms. Id. §§ 404.1529(c)(3), 416.929(c)(3);
see also Craig v. Chater, 76 F.3d 585, 595 (4th Cir. 1996); SSA 96-7P, 1996 WL 374186,
at *4-5. In Hines v. Barnhart, the Fourth Circuit Court of Appeals stated that:
Although 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 he suffers.

- 19 -

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. SSR 96-7P, 1996 WL 374186, at *6.
Social Security Ruling 96-7p provides further guidance on how to evaluate a
claimant’s credibility. For example, “[o]ne strong indication of the credibility of an
individual’s statements is their consistency, both internally and with other information
in the case record.” Id. at *5. Likewise, a longitudinal medical record “can be extremely
valuable in the adjudicator’s evaluation of an individual’s statements about pain or other
symptoms,” as “[v]ery often, this information will have been obtained by the medical
source from the individual and may be compared with the individual’s other statements
in the case record.” Id. at *6-7. A longitudinal medical record demonstrating the
claimant’s attempts to seek and follow treatment for symptoms also “lends support to an
individual’s allegations. . . for the purposes of judging the credibility of the individual’s
statements.” Id. at *7. On the other hand, “the individual’s statements may be less
credible if the level or frequency of treatment is inconsistent with the level of
complaints.” Id. Ultimately, the ALJ “must consider the entire case record and give
specific reasons for the weight given to the individual’s statements.” Id. at *4. Moreover,
the reasons given for the ALJ’s credibility assessment “must be grounded in the
evidence and articulated in the determination or decision.” SSR 96-7p, 1996 WL 374186,
at *4.
When considering whether an ALJ’s credibility determinations are supported by
substantial evidence, the Court does not replace its own credibility assessments for
those of the ALJ; rather, the Court scrutinizes the evidence to determine if it is sufficient
- 20 -

to support the ALJ’s conclusions. In reviewing the record for substantial evidence, the
Court does not re-weigh conflicting evidence, reach independent determinations as to
credibility, or substitute its own judgment for that of the Commissioner. Hays, 907 F.2d
at 1456. 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 (4th Cir.
1984).
Here, the ALJ provided an overview of Claimant’s testimony, (Tr. at 16), which he
then compared to the relevant medical evidence and consultative evaluations in order
to assess Claimant’s credibility. (Tr. at 17-20). The ALJ found that Claimant’s
impairments could reasonably be expected to cause the symptoms he alleged, but that
Claimant’s statements concerning the intensity, persistence and limiting effects of these
symptoms were only partially credible. (Tr. at 19). The ALJ observed that Claimant’s
claims of disabling symptoms were inconsistent with his continued activities of daily
living, which included caring for his ten-year-old son, taking care of personal needs and
household chores, driving and shopping, and managing his finances. (Id.). Furthermore,
the ALJ observed that “there is very little medical evidence in the file” as well as a “fouryear gap between treatments,” noting that “the fact that the claimant has had little
treatment for his conditions calls his credibility into question.” (Id.). The ALJ added that
Claimant “alleged he has no money for treatment” but testified to smoking a pack of
cigarettes per day, the costs of which amounted to over $1,800 per year. (Id.).
In Claimant’s view, it is “difficult to understand how the [ALJ] concluded that
Plaintiff can perform light and sedentary work” in view of objective medical evidence of
Claimant’s chronic pain. (ECF No. 11 at 7-8). Claimant argues that Dr. Stauffer’s
- 21 -

physical examination, Ms. Perdue’s mental evaluation, and his 2005 and 2006 medical
records all constitute objective evidence substantiating Claimant’s allegations of
disabling impairments. (Id. at 5). Looking first at Ms. Perdue’s mental evaluation, the
undersigned notes that Ms. Perdue did not evaluate the effect of Claimant’s
impairments on his ability to work. She merely assessed Claimant with Depressive
Disorder NOS and observed that he exhibited slight fidgeting and certain pain
behaviors. (Tr. at 237). However, Claimant reported no history of past mental health
treatment, and Ms. Perdue described his prognosis as fair with appropriate treatment.
(Tr. at 236-37). Ms. Perdue’s observations regarding Claimant’s fidgeting and pain
behaviors hardly demonstrate that Claimant was unable to perform light and sedentary
work, particularly given the extensive activities of daily living that he reported during
the evaluation. (Tr. at 237). Similarly, while Dr. Stauffer’s physical evaluation reflects
medically determinable impairments relating to Claimant’s back, hands, and knee, it
does not support Claimant’s testimony of disabling symptoms of impairments. (Tr. at
254-59). Indeed, Dr. Stauffer himself provided a physical RFC opinion, which included
limitations corresponding with “light” level work, (Tr. at 256), and was subsequently
affirmed by a second consultative physician. (Tr. at 274). Finally, Claimant’s 2005 and
2006 MRI’s are entirely insufficient to demonstrate that Claimant was incapable of
substantial gainful activity, as they predate his alleged onset of disability by at least 3
years. In fact, the record reflects that despite radiographic evidence of disc
degeneration, Claimant continued to work throughout this period and beyond. (Tr. at
180, 191, 306). In short, it is clear that the ALJ conducted a thorough analysis of the
relevant evidence, appropriately weighed the medical source opinions, and provided a
logical reason for discounting the credibility of Claimant’s statements regarding the
- 22 -

intensity, persistence, and limiting effects of his symptoms, in accordance with the
applicable Regulations.
Other errors Claimant assigns to the ALJ’s credibility determination are likewise
meritless. Claimant argues that under the “mutually supportive test” recognized in
Coffman v. Bowen, 829 F.2d 514 (4th Cir. 1987), he satisfies the requirements of 42
U.S.C. § 423(d)(5)(A) because his testimony is supported by objective medical evidence.
(ECF No. 11 at 7). Claimant misinterprets the holding in Coffman. There, the issue was
not whether the ALJ erred in assessing the claimant’s credibility, but whether the ALJ
applied the appropriate legal standard in weighing the treating physician’s opinion that
the claimant was disabled from gainful employment. Coffman, 829 F.2d at 517-18. The
Fourth Circuit found that the ALJ had misapplied the relevant standard by discounting
the physician’s opinion due to the alleged lack of corroborating evidence, when the
correct standard was to give the opinion great weight unless persuasive contradictory
evidence was present in the record. Id. at 518. The Fourth Circuit then pointed out that
evidence supporting the physician’s opinion, in fact, existed in the record, noting
“[b]ecause Coffman’s complaints and his attending physician’s findings were mutually
supportive, they would satisfy even the more exacting standards of. . . 42 U.S.C. §
423(d)(5)(A).” Id. Coffman offers no applicable “test” for assessing a claimant’s
credibility and, consequently, is inapposite. As the written decision in the present case
plainly reflects, the ALJ applied the correct two-step process in determining Claimant’s
credibility.
Claimant also contends that the ALJ’s use of “boilerplate” credibility language
warrants remand on the ground that such language “provides no basis to determine
what weight the [ALJ] gave the Plaintiff’s testimony.” (ECF No. 11 at 8). It is well
- 23 -

established that “ALJ’s have a duty to explain the basis of their credibility
determinations, particularly where pain and other nonexertional disabilities are
involved.” Long v. United States Dep’t of Health and Human Servs., No. 88-3651, 1990
WL 64793, at *2 n.5 (4th Cir. May 1, 1990). Social Security Ruling 96-7p instructs that
“[w]hen evaluating the credibility of an individual’s statements, the adjudicator must
consider the entire case record and give specific reasons for the weight given to the
individuals statements.” SSR 96-7p, 1996 WL 374186, at *4. Moreover, the ALJ’s
credibility finding “cannot be based on an intangible or intuitive notion about an
individual’s credibility.” Id. Rather, the reasons given for the ALJ’s credibility
assessment “must be grounded in the evidence and articulated in the determination or
decision.” Id. Thus, a “bare conclusion that [a claimant’s] statements lack credibility
because they are inconsistent with ‘the above residual functional capacity assessment’
does not discharge the duty to explain.” Kotofski v. Astrue, Civil No. SKG-09-981, 2010
WL 3655541, at *9 (D. Md. Sept. 14, 2010); see also Stewart v. Astrue, Action No. 2:11cv-597, 2012 WL 6799723, at *15 n.15 (E.D.Va. Dec. 20, 2012). To the contrary, the
decision “must contain specific reasons for the finding on credibility, supported by the
evidence in the case record, and must be sufficiently specific to make clear to the
individual and to any subsequent reviewers the weight the adjudicator gave to the
individual’s statements and the reasons for that weight.” SSR 96-7p, 1996 WL 374186, at
*4.
The ALJ admittedly used “boilerplate” language in finding that “the claimant’s
statements concerning the intensity, persistence and limiting effects of these symptoms
are not credible to the extent they are inconsistent with the residual functional capacity
assessment.” (Tr. at 19). However, the ALJ did not stop his analysis with only that bare
- 24 -

conclusion. As discussed above, the ALJ went on to explain that Claimant’s ongoing
activities of daily living, his lack of treatment history, and his claims of financial
difficulty despite his costly smoking habit all tended to undermine his credibility. (Tr.
19). The ALJ’s credibility finding was sufficiently articulated, as he explained his
rationale with references to the specific evidence that informed his decision.
Consequently, the Court finds that the ALJ followed the proper agency
procedures in assessing Claimant’s credibility and weighing medical source opinions.
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
matter is DISMISSED from the docket of this Court.
The Clerk of this Court is directed to transmit copies of this Order to all counsel
of record.
ENTERED: May 2, 2014

- 25 -