Cummings v. ColvinCummings v. Colvin
MEMORANDUM OPINION
I. Introduction
Eriс Allen Cummings (“Plaintiff’) has filed this action for judicial review of the decision of the Acting Commissioner of Social Security, which denied his. applications for disability insurance benefits (“DIB”) and supplemental security income (“SSI”) under Titles II and XVI of the Social Security Act (“Act”),
II. Background
Plaintiff is a 47-year-old high school graduate with two years of college education. He worked as an auto mechanic, baker’s' assistant (a job he held for just two weeks), and laborer for Zambelli’s Fireworks, but he stopped working for Zambelli’s in 2009- because he failed a background cheek. He hasn’t worked since. He alleges that he has been disabled since September 10, 2005, due to a myriad of impairments, but his back pain is the focus of this appeal. (R. 210).
Plaintiffs báck pain began in 2003. (R. 241). A few years later, he was diagnosed with a ruptured disc. (R. 344). He underwent a L3-4 discectomy to removе the damaged portion of his spine on April 25, 2006. (R. 312). At a June 2006 follow up, Plaintiff said that he continued to experience pain and spasms in his lower back, but the pain was not as bad as it had been before his surgery. (É. 343). His surgeon, William Welch, M.D., believed that his recovery was going well and that the pain would continue to subside over time. Id. After the initial follow-up, Dr. Welch referred Plaintiff. to physical therapy (“PT”). Id. Plaintiff only attended six PT sessions, however, cancelling four others and failing to show for one because he was either “out golfing” or cоuld not get a ride (Plaintiff has had four DUI convictions, and so he does not have a driver’s license). (R. 236, 358). He was discharged from PT on July 17, 2006, due to his non-compliance and lack of attendance. (R. 356, 358). At his last session on July 5; Plaintiff rated his pain at 3/10, and. an examination showed full, active range of motion of the lumbar spine, with 4/5 strength. (R. 358).
Following Plaintiffs time in PT during the summer of 2006, there is a gap in the record, until March 20, 2008, when he underwent a physical with his primary care physician, Gerald Kahler, M.D., following his release from jail. (R. 350). Plaintiff complained of continuing back pain and claimed that the 2006 surgery failed to provide' him any relief. Id. He had been taking ibuprofen to manage the pain. Id. Dr. Kahler noted-that Plaintiffs “lumbar spinous processes” were tender, and, in
Three years later, Plaintiff returned to Dr. Kahler’s office complaining that his back still bothered him, especially when bending over and sitting. (R. 349). While Ibuprofen helped to alleviate the pain, he hadn’t taken any in four months. Id. According to Dr. Kahler,. Plaintiff had full range of motion and normal muscle strength, though his back was tender in the" area of the incision at L3-4. Id. Straight leg tests were negative. Id. Plaintiff was prescribed Diclofenac Sodium and Cyclobenzaprine and advised to follow up as needed. Id.
Plaintiff returned to Dr. Kahler on September 27, 2011,' for & comprehensive physical examination. (R. 432). He complained that his left leg had been going numb and affecting his ability to stand. Id. He also reported constant pain in his back, which had become more problematic since he quit drinking alcohol. Id. Excedrin, which he was taking eight times a day, seemed to help, though. Id. On examination, Plaintiff displayed normal gait; satisfactory-to-full range of motion in his neck and spine; adequate strength with normal stability in his neck; normal stability, strength, and tone in his spine; and full range of motion with normal stability, strength, and tone In his extremities. (R. 434). Dr. Kahler diagnosed Plaintiff with low back pain and degenerative disc disease with myelopathy and prescribed Flexeril, Excedrin, and Diclofenac Sodium. Id, He was also referred back to PT. Id.
Plaintiff attended nine PT sessions from September 29, 2011, to October 27, 2011. (R. 412). When he was discharged, he displayed 50° of flexion, 18° of extension, 30° of right side bending, .and 25° of left side bending. Id. Straight leg raises tests were positive. Id. In addition, Plaintiff scored a 36 percent on the Oswestiy Disability Index (“ODI”), which, according to his physical therapist, “indicated] an increase in function with his [activities of daily living].” Id. Plaintiff nonetheless denied any change in his symptoms. Id.
When Plaintiff followed up with Dr. Kahler in April 2012, he reported that he continued to suffer lower back pain. (R. 429). He described experiencing stiffness and a decreased range of motiоn, as well. Id. Overall, though, he said the symptoms were “moderate in severity.” Id. Upon examination, Plaintiff showed a full range of motion and straight leg raise tests were negative. Id. Dr. Kahler restarted him on Cyclobenzaprine and also prescribed Tramadol. (R.' 430).
Dr. Kahler saw Plaintiff again a month later, and he still complained of lower back pain and left leg numbness. (R. 426). He said that the pain was exacerbated when he bent “over a fender to work” or when was lying, “under a car.” Id. He also reported that it hurt to sit or walk .for long periods of time. Id. Plaintiff was continued on each of his medications and, once again referred to PT. (R. 426).
Plaintiff attended five physical therapy sessions between May 22, 2012, and June 5, 2012. (R. 406). By the time of his discharge, his range of motion and strength had improved and his perception of pain had fluctuated. Id. However, although his pain decreased following therapy, it returned when he tried to do other activities. Id. As. a result, his physical therapist - determined that he had only
On the same date he was discharged from PT, Plaintiff followed up with Dr. Kahler. (R. 425). He described experiencing a “severe dull aching” pain in his lower back, which radiated down his left leg. Id. He said the pain was aggravated by bending, twisting, and standing. ' Id. Upon examination, Plaintiff showed 20° of trunk extension, 90° of lumbar spine flex-ion, 45° right rotation, and 45° left rotation. Id. Straight leg raises were positive at 45° on the left side and 90° on the right side. Id.
On June 16, 2012, Plaintiff underwent an x-ray of his lumbar spine. (R. 411). The x-rays showed that the disc height at L4-5 was “borderline but unchanged from the prior study” in July 2005. Id. Otherwise, the examination was normal. Id.
Three days later, Plaintiff returned to Dr. Kahler’s office for their last recorded visit.- (R. 424). Plaintiff complained that his lоwer back pain continued and asked to try a TENS unit. Id. His range of motion was-the same as it had been two weeks earlier, but bilateral straight leg raise testing was negative. Id. Dr. Kahler ordered an MRI of Plaintiffs spine and referred him to a pain management clinic. Id. The results of the MRI showed mild diffuse disc bulging at L3-4, mild hypertrophic change, and minimal foraminal narrowing. (R. 438). Meanwhile, at L4-5, there was minimal disc bulging and mid facet degerenative change, leading to mild bilateral foraminal narrowing. Id.
A. Procedural History
Plaintiff protectively filed applications for DIB and SSI on August 15, 2011. His аpplications were denied at the administrative level. On February 28, 2013, Plaintiff had a hearing before Administrative Law Judge (“ALJ”) Brian W. Wood. He was represented by counsel and testified at the hearing, as did an impartial vocational expert (“VE”). On April 16, 2013, the ALJ issued a decision that denied Plaintiffs applications for benefits. The ALJ’s decision became the final decision of the Acting Commissioner on August 7, 2014, when the Appeals Council denied Plaintiffs request for review. Plaintiff then filed this action for judicial review of the ALJ’s decision. The parties’ crоss-motions for summary judgment followed.
III. Legal Analysis
A. Standard of Review
The Act strictly limits the Court’s ability to review the Commissioner’s final decision. ’
B. Sequential Evaluation Process
To qualify for disability benefits under the Act, a claimant must demonstrate that there is some “medically determinablе basis for an impairment that prevents him or her from engaging in any substantial gainful activity for a statutory twelve-month period,” Fargnoli v. Massanari,
C. Discussion
Following the five-step sequential evaluation process, the ALJ- first found that Plaintiff had. not engaged in substantial gainful activity since September 10, 2005. At step two, the ALJ found that Plaintiffs degenerative disc disease with radiculopathy, gastroesophageal reflux disease, depression, PTSD, anxiety, borderline personality disorder, and alcohol abuse are severe impairments. At step three, however, the ALJ concluded that none of these impairments rose to the level of any of the Listed Impairments. So prior to proceeding to the next step of the sequential evaluation process, the ALJ assessed Plaintiffs residual functional capacity (“RFC”) and found that he retained the ability to perform light work, with various additional physical and mental limitations. The ALJ proceeded to find that Plaintiff is not disabled at the fifth step of the sequential evaluation process based on the VE’s testimony that there are jobs existing in significant numbers in the national economy that someone of Plaintiffs age,, education, experience, and RFC could perform: bench assembler; sorter; and inspector/hand packer. The ALJ also identified three sedentary jobs that Plaintiff could perform: ticket counter; final assembler; and addressor clerk.
Plaintiff raises two arguments in support of his motion for summary judgment. These arguments .will be addressed seriatim.
1. Substantial evidence supported the ALJ’s RFC finding.
Plaintiff first takes issue with the ALJ’s RFC finding, arguing.that it is not supported by substantial evidence because there was no medical opinion in the record regarding Plaintiffs physical impairments. In Plaintiffs view, an ALJ can never review and interрret medical records and arrive at his own RFC finding unaided by an opinion from a physician as to a claimant’s functional capacity. Plaintiff says that this rule is grounded in the Court of Appeals’ decision in Doak v. Heckler,
Plaintiff is correct that the record is devoid of any medical opinions as to his physical impairments. However, his reliance on Doak and the other cases cited in his brief for the proposition that an ALJ must always, bаse his RFC on a medical
The erroneous reading of Doak adopted by various courts throughout this Circuit seems to have originated in the' district court’s decision in Chandler v. Astrue,
Nevertheless, courts . in subsequent cases, predominantly in the Middle District but also in-this District, have continued to trot out the very same reasoning in many cases, word-for-word — that the district coiirt employed and the "Court'of Appeals rejected in Chandler. See, e.g., Kester v. Colvin, No. 3:13-CV-02331,
Having determined what the ALJ was not required to do — base his RFC on an' opinion from a medical source — the Court now must address what was required of the ALJ. RFC refers to the most a claimant can still do despite his limitations.
Upon reviewing the .evidence, the ALJ in this case found that Plaintiff can perform light work, so long as he could alternate between sitting and standing every thirty minutes. (R. 24). He also found, as relevant to this appeal, that Plaintiff could never climb ladders, ropes, and scaffolds; occasionally climb ramps and stairs; occasionally engage in postural activities;, and occasionally push and pull with his left leg. (R. 24). This finding was. supported by substantial evidence. In fact, the ALJ’s RFC assessment generously accounted for the limitаtions credibly established by the evidence of record. “Light work involves lifting no more than 20 pounds at a time with frequent lifting or carrying of objects, weighing up to 10 pounds.”
Even assuming, arguendo, that there was not support for the finding that Plaintiff could perform light work, it ultimately would not matter. - The VE also identified several positions at the sedentary level that. Plaintiff could perform. While it might be arguable .that he cannot, perform the demands of light-work, there is clearly substantial evidence to support a finding that he can perform sedentary work with a sit/stand option. Plaintiff himself indicated in a disability report, dated August 24, 2011, that he could lift .up to 25 pounds, sit for two hours, and stand for one hour. At the hearing, he clarified that he could not sit for long than 45 minutes before he had to get up and move around. (R. 41). Either way, by his own account, he could meet the requirements of. sedentary work with a sif/stand option. See
2. The Acting Commissioner did pot improperly remove records from the certified copy of the transcript, and remand is not required to аddress whether the ALJ relied on records . of another claimant in deciding Plaintiffs case.
Plaintiff’s second contention is that the Acting Commissioner’s decision to “unilaterally .., remove records” relating to another claimant from the certified copy of the transcript without leave of Court was improper. Pl.’s Br. at 11. While Plaintiff does not dispute that the redacted records do in fact relate to another claimant, he nonetheless argues that the Acting Commissioner should be ordered to file the complete administrаtive record, including the documents related to the other claimant. Failing that, Plaintiff submits that the matter should be remanded because otherwise this Court' cannot- determine whether the ALJ’s decision' is actually based on substantial evidence. This argument fails. Plaintiff has not cited' any authority to support the suggestion that the Acting Commissioner was required to seek leave of Court before redacting portions of the administrative record pertaining to someone other than Plaintiff. Perhaps that is not surprising, considering the Acting Commissionеr adhered to the Social Security Administration’s internal guidance when it redacted the aforesaid documents prior to filing the certified record. Hearing, Appeals and Litigation Law Manual (“HALLEX”) 1-4-1-54 (S.S.A.),
Plaintiff makes one final argument. He contends that there is no indication that the ALJ was aware that certain documents in the record related to another claimant, let alone how much the ALJ may have relied on these documents in reaching his decision. Thus, relying on an unpublished summary order from the Second Circuit Court of Appeals, Yenik v. Commissioner of Social Security,
This is akin to the situation in Melle v. Barnhart, where the Court of Appeals held that to the extent the ALJ may have relied on the records of another person in rendering his decision, the error was harmless.
[t]he ALJ’s determination was Supported by substantial evidence divorced from any discrepancy between the report relating to the [other person] and the numerous other records pertaining to the Appellant. The [other person’s] report was just one of a number of the records reviewed and possibly relied upon by the ALJ in making his determinations.
Id. So too in this case — although there is even less of a basis for remanding here because the Court can discern that the ALJ did not rely on any of the documents related to the-other clаimant in his decision, It is also worth noting that, as in Melle, Plaintiffs counsel did not object to the accuracy of the record at the administrative hearing, (R. 36), so “the ALJ was entitled to rely on [Plaintiffs] counsel’s assertion as to the accuracy of the record.” Id. Thus, there is no need to remand the matter to allow.the ALJ to undertake a new evaluation of Plaintiffs eligibility for benefits. Cf., e.g., Smith-Chonko v. Colvin, No. CIV.A. 12-1301,
IV. Conclusion
It is undeniable that Plаintiff has a number of impairments, and this Court is sympathetic and aware of, the challenges that he faces in seeking gainful employment. However, under- the applicable standard of review and- the current state of the record, the Court must -defer to the reasonable findings of the ALJ and his conclusion that Plaintiff is not disabled within the. meaning of the Social Security Act. Accordingly, the Court will GRANT the motion for summary judgment filed by the Acting Commissioner and DENY the motion for summary judgment filed by Plaintiff. An appropriate Order follows.
ORDER
AND NOW, this 7th day of July 2015, in accordance with the foregoing Memorandum Opinion, it is hereby ORDERED, ADJUDGED, and DECREED that the Acting Commissioner’s MOTION FOR SUMMARY JUDGMENT (EOF No. 9) is GRANTED, and Plaintiffs MOTION FOR SUMMARY JUDGMENT (ECF No. 13) is DENIED. The Clerk shall docket this case CLOSED.
Notes
. In addition to Doak, the district court in Chandler purported to find support for its reasoning in a practice treatise and two cases from the Southern District of New York. Chandler,
. The record before - the ALJ" in Doak was quite limited, consisting only of the "claimant’s testimony, three physicians’ reports, ’and a vocational expert’s testimony,” Doak,