Hall v. Social Security Administration, No. 4:2017cv00449 - Document 10 (E.D. Ark. 2018)
Court Description: MEMORANDUM OPINION AND ORDER dismissing Hall's complaint and denying all requested relief. Judgment will be entered for the Commissioner. Signed by Magistrate Judge Patricia S. Harris on 2/28/2018. (ljb)
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Hall v. Social Security Administration Doc. 10 IN THE UNITED STATES DISTRICT COURT EASTERN DISTRICT OF ARKANSAS WESTERN DIVISION JEFFREY HALL PLAINTIFF v. NO. 4:17-cv-00449 PSH NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration DEFENDANT MEMORANDUM OPINION AND ORDER Plaint iff Jeffrey Hall (“ Hall” ) began t his case by filing a complaint pursuant t o 42 U.S.C. 405(g). In t he complaint , he challenged t he final decision of t he Act ing Commissioner of t he Social Securit y Administ rat ion (“ Commissioner” ), a decision based upon t he findings of an Administ rat ive Law Judge (“ ALJ” ). Hall maint ains t hat t he ALJ’ s findings are not support ed by subst ant ial evidence on t he record as a whole and offers t wo reasons why. 1 Hall first maint ains t hat his depression and obesit y are severe impairment s, and t he ALJ erred when he failed t o so find. Second, Hall maint ains t hat his residual funct ional capacit y was erroneously assessed for t he following reasons: t here is no opinion from a t reat ing physician addressing Hall’ s residual funct ional capacit y, inadequat e considerat ion was given t o a prior disabilit y rat ing, and inadequat e considerat ion was given t o Hall’ s work hist ory. The question for the Court is whether the ALJ’s findings are supported by substantial evidence on the record as a whole. “Substantial evidence means less than a preponderance but enough that a reasonable person would find it adequate to support the decision.” See Boettcher v. Astrue, 652 F.3d 860, 863 (8th Cir. 2011). 1 Dockets.Justia.com The record reflect s t hat Hall was born on May 13, 1966, and was fort y-t hree years old on August 19, 2009, i.e., t he day he allegedly became disabled. He last met t he insured st at us requirement s of t he Social Securit y Act on December 31, 2013. Thus, t he relevant period in t his case is from August 19, 2009, t o December 31, 2013. He alleged in his applicat ion for disabilit y insurance benefit s t hat he became disabled and unable t o work because of impairment s t hat included degenerat ive disc disease, sleep apnea, carpal t unnel syndrome, and depression. Hall has ably summarized t he evidence in t he record, and t he Commissioner has not challenged t he summary. It will not be reproduced, except t o not e several mat t ers germane t o t he issues raised in t he part ies’ briefs. Hall served in t he Unit ed St at es Navy from Sept ember of 1984 unt il Sept ember of 2004 and has been t reat ed for his impairment s exclusively at medical facilit ies operat ed by t he Depart ment of Vet erans Affairs (“ VA” ). On November 14, 2008, he present ed t o a VA facilit y for complaint s t hat included int ermit t ent back pain, sleep apnea, and carpal t unnel syndrome. See Transcript at 586-590. Dr. St even St rode, M.D., (“ St rode” ) ordered t est ing of Hall’ s back, and t he result s revealed mild loss of space height at L5-S1. See Transcript at 626-627. St rode prescribed cyclobenzaprine and Et odolac for Hall’ s back pain. Wit h regard t o Hall’ s sleep apnea, St rode not ed t hat Hall was using a CPAP machine. The mask did not fit well, t hough, and Hall had difficult y sleeping. St rode ordered a consult at ion wit h a VA sleep sect ion. Wit h regard t o Hall’ s carpal t unnel syndrome, Hall report ed t hat it affect ed bot h his hands and caused int ermit t ent numbness in several of his fingers. The pain was worse in his right hand. St robe prescribed bilat eral wrist splint s t o be worn during sleep. 2 Hall was seen at VA facilit ies for his cont inued complaint s of back pain on several occasions bet ween November 14, 2008, and March 25, 2011. See Transcript at 573-576 (03/ 26/ 2009); 479-483, 621 (06/ 10/ 2010); 475-478 (07/ 07/ 210); 406-409 (09/ 12/ 2010); 401-406 (09/ 27/ 2010); 391-395 (10/ 12/ 2010); 314-315 (10/ 29/ 2010); 373-376 (12/ 14/ 2010); 366-372 (01/ 07/ 2011). 2 Test ing was performed on June 10, 2010, and t he result s revealed t he following: Very mild spurring is seen along t he lower t horacic and lumbar vert ebrae. Slight post erior disc space narrowing at L5/ S1 is seen. The visualized pedicles and t he sacroiliac j oint s are unremarkable. Findings appear relat ively st able since t he previous of 11/ 14/ 08. Art hrit ic changes are not ed involving t he right -sided facet j oint at L5/ S1 and left -sided facet j oint at L4/ 5. See Transcript at 621. Hall cont inued t o experience back pain and sought emergency room care for his pain on Sept ember 12, 2010. Test ing was performed, and t he result s revealed “ [m]ild disc space narrowing at L5/ S1” and “ very small ant erior ost eophyt es at a few levels” but no “ acut e compression deformit ies.” See Transcript at 409. He was given an inj ect ion of Toradol and cont inued on prescript ion medicat ion. An MRI of his lumbar spine was performed on Oct ober 29, 2010, and t he at t ending physician int erpret ed t he result s as follows: 1. No evidence of spinal canal st enosis t hroughout t he lumbar spine. 2. No evidence for neuroforaminal st enosis t hroughout t he lumbar spine. However, t he hypert rophied superior facet s of S1 cont act t he exist ing L5 nerve root s bilat erally. 3. Degenerat ive disc disease from L3L1 ... Hall rarely sought medical attention for just one impairment during the typical examination; instead, he usually sought medical attention for several impairments during a single examination. There are other instances in which he sought medical attention for his complaints of back pain. The Court has identified the dates above because they appear to be when he primarily complained of back pain. The Court will do likewise with his other impairments, i.e., the Court will only note the dates when the impairment appeared to have been the primary complaint. 2 3 Hall was seen at VA facilit ies for his sleep apnea on a few occasions bet ween November 14, 2008, and March 25, 2011. See Transcript at 582-585 (12/ 09/ 2008), 573576 (03/ 26/ 2009), 511-515 (02/ 01/ 2010). When he was seen on December 9, 2008, he acknowledged t hat he had not been using his CPAP machine as recommended. He was counseled on t he import ance of using t he machine. When he was seen again on March 26, 2009, he report ed t hat he was doing “ ok” wit h t he machine. See Transcript at 575. Hall was seen at VA facilit ies for his carpal t unnel syndrome on several occasions bet ween November 14, 2008, and March 25, 2011. See Transcript at 573-576 (03/ 26/ 2009); 566-567, 624-625 (07/ 22/ 2009); 562-564 (08/ 20/ 2009); 533-534 (12/ 21/ 2009); 552-553 (12/ 28/ 2009); 527-528 (01/ 15/ 2010); 518-522 (01/ 21/ 2010); 516-517 (01/ 25/ 2010); 504-505 (03/ 11/ 2010); 495-496 (03/ 17/ 2010); 488-489 (03/ 29/ 2010); 391-395 (10/ 12/ 2010); 366, 379 (01/ 11/ 2011). He was init ially t reat ed conservat ively for his pain, but he event ually underwent a left carpal t unnel release on January 15, 2010. The physician who performed t he procedure prepared a let t er in which he represent ed t hat Hall was ent it led t o a one hundred percent t emporary disabilit y rat ing but could resume normal act ivit ies of daily living aft er four weeks of recovery. Hall init ially report ed good result s from t he surgery but report ed t hat pain and swelling event ually ret urned t o his left hand. At t he March 17, 2010, present at ion, he was observed t o have decreased grip and pinch st rengt h in his left hand. He was given a TheraBall, a cock-up splint , a st rip of silicone gel and dressing, and a minivibrat or for t he pain. On January 11, 2011, a nerve conduct ion st udy was performed. The result s of t he t est ing revealed normal conduct ion on his left but “ slowing on t he [right ] wrist consist ent wit h carpal t unnel [syndrome].” See Transcript at 379. 4 Hall also occasionally sought t reat ment for depression bet ween November 14, 2008, and March 25, 2011. See Transcript at 511-515 (02/ 01/ 2010), 496-504 (03/ 17/ 2010), 484-487 (05/ 17/ 2010), 391-395 (10/ 12/ 2010), 387-391 (10/ 14/ 2010). His depression appeared t o have been caused primarily by sit uat ional concerns. For inst ance, he expressed concerns about his inabilit y t o work and problems wit h his family and finances. He report ed sleeping a great deal and being inact ive. An adj ust ment disorder wit h mixed anxiet y and depression relat ed t o a general medical condit ion were diagnosed, and he was prescribed medicat ion. During t he period bet ween November 14, 2008, and March 25, 2011, Hall also st ruggled wit h his weight . When he was seen on March 10, 2011, he had a Body Mass Index of 34.1. See Transcript at 351-355. He was encouraged t o lose weight and was prescribed an exercise program. On March 25, 2011, t he VA grant ed Hall a “ t ot al service-connect ed evaluat ion for individual unemployabilit y benefit s ... as a result of [his] service-connect ed disabilit y,” which was evaluat ed at “ ninet y percent disabling.” See Transcript at 299. A t went y percent evaluat ion was assigned for “ degenerat ive disc disease lumbosacral spine,” a fift y percent evaluat ion was assigned for sleep apnea, a t en percent evaluat ion was assigned for “ right knee pat ellofemoral syndrome,” a t en percent evaluat ion was assigned for “ left knee pat ellofemoral syndrome,” a t went y percent evaluat ion was assigned for carpal t unnel syndrome in his left hand, and a t hirt y percent evaluat ion was assigned for an adj ust ment disorder wit h depressed mood. See Transcript at 299-300. His ent it lement t o benefit s was grant ed effect ive Sept ember 2, 2009, and was considered t o be permanent in nat ure. 5 Hall was seen for his complaint s of back pain bet ween March 25, 2011, and December 31, 2013. See Transcript at 343-347 (10/ 03/ 2011), 759-762 (07/ 06/ 2012), 731-735 (04/ 03/ 2013), 620-621 (09/ 11/ 2013). The progress not es reflect t hat he cont inued t o be diagnosed wit h back pain and prescribed medicat ion t hat included meloxicam and cyclobenzaprine. When he was seen on Oct ober 3, 2011, t o re-est ablish care in Illinois aft er leaving Arkansas, he report ed t hat his back pain was “ mellow,” but he had t o be very careful about how he moved around. See Transcript at 343. He report ed t hat he was not exercising but was nevert heless const ant ly on his feet . At a February 8, 2012, present at ion primarily for wrist pain, he report ed t hat his back pain had improved over t he previous six mont hs and only arose when he felt st ressed. See Transcript at 333. He report ed t hat cyclobenzaprine t ook care of any pain he might experience. On June 10, 2013, Hall was aut horized t o receive approximat ely five weeks of chiropract ic care for t he t reat ment of “ chronic low back pain.” See Transcript at 722. On Sept ember 11, 2013, t est ing of his back was performed, and t he at t ending physician int erpret ed t he result s as follows: Cervical spine -- There is st raight ening of t he cervical spinal lat eral view. Disk spaces are mildly narrowed at C5-6, C6-7, and C7-T1. Ant erior ost eophyt es are not ed from C4 t hrough C7. No compression deformit y. No list hesis. No prevert ebral soft t issue swelling. Thoracic spine -- Alignment of t he t horacic spine is maint ained only AP and lat eral view. Minimal ant erior ost eophyt e format ion is not ed at mult iple levels wit hin t he t horacic spine wit hout evidence of compression deformit y or list hesis. Lumbar spine – Alignment of t he lumbar spine is maint ained on t he AP and lat eral view. Disk space narrowing at L5-S1. Mild ant erior ost eophyt e format ion is seen at L1-2, L3-4, and L5-S1. No compression deformit y or list hesis. 6 See Transcript at 620. “ Mild mult ilevel degenerat ive changes” were diagnosed. See Transcript at 620. Hall appears t o have report ed few difficult ies wit h sleep apnea bet ween March 25, 2011, and December 31, 2013. The only progress not e of any real significance is from November 6, 2012, when he was seen for a CPAP Tit rat ion St udy. See Transcript at 744-746. The at t ending physician opined t hat Hall probably had adequat e CAPAt it rat ion. The physician’ s recommendat ions included use of a CPAP machine at t he appropriat e set t ing and “ [g]radual weight cont rol t owards an ideal weight of 70 Kg [i.e., approximat ely 154 pounds] using appropriat e diet and exercise t hat is wit hin safe limit s of [Hall’ s] current medical condit ion.” See Transcript at 745. Hall cont inued t o be seen for his carpal t unnel syndrome bet ween March 25, 2011, and December 31, 2013. See Transcript at 343-347 (10/ 03/ 2011), 337-340 (10/ 14/ 2011), 333-337 (02/ 08/ 2012). The progress not es reflect t hat he cont inued t o complain of pain in his wrist s and hands, and he cont inued t o be prescribed medicat ion. When he was seen on Oct ober 14, 2011, he report ed t hat t he left carpal t unnel release had relieved some of t he numbness, but his pain had increased. He report ed t hat his pain was “ mainly at t he base of t he middle t hree fingers and affect [ed] t he t humb as well at t imes.” See Transcript at 337. He had wrist splint s but admit t ed t o spending a good deal of t ime on t he comput er. When Hall was seen on February 8, 2012, he again report ed t hat his pain had increased since t he surgery, but t he pain was cont rolled wit h gabapent in. “ He opt ed not t o have his right [carpal t unnel] released and cont inued t o have pain in t he dist ribut ion of his median nerve.” See Transcript at 333. He showed no weakness, t hough, and his grip st rengt h was 5/ 5 t hroughout . 7 Hall cont inued t o be seen for depression bet ween March 25, 2011, and December 31, 2013. See Transcript at 745-751 (10/ 02/ 2012), 756 (10/ 23/ 2012), 737-740 (04/ 03/ 2013), 717-720 (06/ 20/ 2013), 426-430 (09/ 24/ 2013). He cont inued t o be diagnosed wit h depression and/ or an adj ust ment disorder and prescribed medicat ion. On August 20, 2011, Dr. Kennet h Hobby, Ph.D., (“ Hobby” ) performed a ment al diagnost ic evaluat ion of Hall. See Transcript at 302-313. Hall’ s complaint s were not ed t o be as follows: “ [Hall’ s] depression is because of t he physical problems. He st at es t hat t he sympt oms t hat have had t he most effect on [his] abilit y t o work have been his back pain, carpal t unnel, and wit h t he depression he can’ t remember t hings.” See Transcript at 302. Hall was observed t o be of a normal height but of slight ly above normal weight . His mood was depressed but relaxed, his affect was sit uat ionally appropriat e, and he had no problems wit h his speech, t hought process, or t hought cont ent . Hobby diagnosed an adj ust ment disorder wit h depressed mood but made t he following findings wit h respect t o Hall’ s adapt ive funct ioning: 1. How do ment al impairment s int erfere wit h t his person’ s day t o day adapt ive funct ioning? ... This individual report ed being able t o drive a car on familiar roads. He said he could drive on unfamiliar rout es. He said he can drive alone for dist ances up t o any number of miles from home. He report s t he following problems wit h being able t o shop adequat ely for groceries, clot hing, and personal it ems: None. He report s t he following problems wit h being able t o use a checkbook t o pay bills: None. He report s t he following problems wit h being able t o make change and purchase t hings at t he st ore wit h cash: None. He report s t hat he part icipat es in t he following social groups: Immediat e family. On a t ypical day, he get s up at 10 a.m. During t he day he plays on a comput er, t alks wit h his wife, piddles in t he yard every once in a while, and fixes somet hing t o eat . In regard t o [his act ivit ies of daily living], his report ed MENTAL impairment DOES NOT appear t o significant ly impact an independent level of feeding himself, bat hing, self-care, personal hygiene, and dressing. 8 2. Capacit y t o communicat e and int eract in a socially adequat e manner? ... This individual report s get t ing along well wit h his parent s. He report s get t ing along well wit h his siblings. He report s get t ing along well wit h his neighbors. In school, good relat ionships were report ed wit h his t eachers and all but one here and t here of his schoolmat es. He report ed good relat ionships wit h his childhood playmat es. No significant limit at ions were not ed in his current capacit y t o communicat e and int eract in a socially adequat e manner. There were no discrepancies bet ween alleged inadequacies and t he int erpersonal skill level demonst rat ed during t he int erview. 3. Capacit y t o communicat e in an int elligible and effect ive manner? This person’ s grammar was adequat e for communicat ing informat ion on at least a basic work-like t ask. This individual did not seem t o have any difficult y underst anding inst ruct ions given by t he examiner. There seems t o be a level of underst anding t hat would enable t he person t o respond t o normal inst ruct ions. 4. Capacit y t o cope wit h t ypical ment al/ cognit ive demands of basic work-like t asks? This individual has t he abilit y t o underst and, carry out , and remember basic work-like t asks. This individual would probably respond adequat ely t o work pressure in a work-like set t ing if he could physically do t he work. 5. Abilit y t o at t end and sust ain concent rat ion on basic t asks? No limit at ions were observed in t his individual’ s abilit y t o at t end and sust ain concent rat ion on basic work-like t asks. 6. Capacit y t o sust ain persist ence in complet ing t asks? He was able t o persist at t he t asks during t he int erview. He should be able t o ment ally persist on appropriat e skill level work-like t asks for an 8 hour day if he could physically do t he work. 7. Capacit y t o complet e work-like t asks wit hin an accept able t ime frame? The pace at which t his person worked was normal and st eady and appropriat e for complet ing work-like t asks. 9 See Transcript at 310-311. On June 11, 2012, Dr. Gary Ludwig, Ph.D., (“ Ludwig” ) performed a ment al st at us evaluat ion of Hall. See Transcript at 415-417. Hall’ s affect was flat , and his mood appeared depressed. Hall report ed t hat he spent most of his days playing on t he comput er. He also report ed remodeling his house but not ed t hat he could only work for about t went y minut es at a t ime before he required rest . He report ed t aking cit alopram for his depression. Ludwig diagnosed maj or depression. During t he period bet ween March 25, 2011, and December 31, 2013, Hall cont inued t o st ruggle wit h his weight . When he was seen on April 3, 2013, he had a BMI of 35.6. See Transcript at 733. Hall and t he at t ending physician discussed “ weight loss t hrough increasing physical act ivit y.” See Transcript at 734. Hall’ s medical records were reviewed by st at e agency medical professionals. See Transcript at 75-84, 86-96, 65-72. Their findings were inconsist ent . It appears t hat t wo of t he professionals opined t hat Hall was capable of performing medium work wit h a limit at ion for right hand fingering. Anot her professional opined, t hough, t hat Hall was limit ed t o light work wit h post ural but no manipulat ive limit at ions. A series of document s were complet ed by Hall and ot hers in connect ion wit h his applicat ion. See Transcript at 206-212, 218-223, 242-249, 250-260, 263-267, 268-273. In t he document s, he represent ed t hat he is five feet , six inches t all and weighs approximat ely t wo hundred pounds. He has a hard t ime st anding, shopping, or doing t asks around t he house. He represent ed t hat he has difficult y walking and has t o spend all of his t ime at home. He can cook and wash dishes but must sit in a chair t o do so. He requires a CPAP machine t o sleep at night . He cont inues t o t ake prescript ion medicat ion for pain and depression. 10 The record cont ains a summary of Hall’ s earnings. See Transcript at 169-170. The summary reflect s t hat he had earnings for t hree of t he four years bet ween his discharge from t he Unit ed St at es Navy and his alleged onset dat e. Hall t est ified during t he administ rat ive hearing. See Transcript at 29-57. He was one mont h shy of his fift iet h birt hday. His last j ob was doing j anit orial work at WalMart , but he st opped working because of problems caused by his back pain and carpal t unnel syndrome. During t he relevant period, Hall occasionally hunt ed and fished but primarily devot ed his t ime t o playing comput er games. He helped out around t he house, doing various j obs in and around t he house. He did not exercise. He est imat ed t hat he could st and in place for only about five minut es at one t ime and could not be on his feet for more t han about one t o t wo hours a day. He remained seat ed most of t he day. Hall’ s depression caused him t o “ get agit at ed a lit t le bit easier t han most ,” see Transcript at 50, and affect ed his abilit y t o concent rat e. When asked t o rank his impairment s in t erms of t heir impact on his abilit y t o work, he list ed his back, t hen t he following: his hands, his knees, his depression, and his sleep apnea. The ALJ found t hat Hall had severe impairment s in t he form of spine disorders and carpal t unnel syndrome during t he relevant period. The ALJ considered Hall’ s sleep apnea, obesit y, and depression but found t hat t hey were not severe impairment s. The ALJ assessed Hall’ s residual funct ional capacit y and found t hat he was capable of performing medium work but wit h t he following addit ional limit at ions: ... he was limit ed t o lift ing and carrying 50 pounds occasionally and 25 pounds frequent ly. He could sit for at least 6 hours in an 8-hour workday. He could st and and/ or walk at least 6 hours in an 8-hour workday. He could push and pull t he same amount s he could lift and carry. His fingering on t he right side was limit ed t o frequent . 11 See Transcript at 14. In so finding, t he ALJ gave lit t le weight t o t he VA disabilit y rat ing because it was inconsist ent wit h t he record as a whole and was made on t he basis of VA policies and definit ions, not t he policies and definit ions applied by t he Commissioner. The ALJ gave lit t le weight t o Hobby and Ludwig’ s evaluat ions of Hall’ s ment al impairment because Hobby and Ludwig appeared t o have based t heir diagnoses solely on Hall’ s self-report s. The ALJ also gave lit t le weight t o t he opinion of t he st at e agency medical professional who opined t hat Hall was limit ed t o light work wit h post ural but no manipulat ive limit at ions. The ALJ gave great weight , t hough, t o t he opinions of t he st at e agency medical professionals who opined t hat Hall was capable of performing medium work wit h a limit at ion for right hand fingering. The ALJ found t hat Hall was capable of performing his past relevant work during t he relevant period and t herefore was not disabled for purposes of t he Social Securit y Act . The ALJ alt ernat ively found t hat if Hall could not perform his past relevant work, t here was ot her work he could have performed during t he relevant period. Hall maint ains t hat t he ALJ’ s findings are not support ed by subst ant ial evidence on t he record as a whole. Hall first maint ains his depression and obesit y are severe impairment s, and t he ALJ erred at st ep t wo of t he sequent ial evaluat ion process when he failed t o so find. Wit h respect t o Hall’ s depression, Hall maint ains t hat t he ALJ gave inadequat e reasons for discount ing t he diagnoses of four ment al healt h professionals, all of whom diagnosed Hall wit h a ment al impairment . Wit h respect t o Hall’ s obesit y, Hall maint ains t hat t he reason t he ALJ gave for discount ing t he obesit y, i.e., Hall consist ent ly denied short ness of breat h upon exert ion, is an inadequat e basis for discount ing t he severit y of his excess weight . 12 At st ep t wo, t he ALJ is obligat ed t o ident ify t he claimant ’ s impairment s and det ermine if t hey are severe. An impairment is severe if it has “ more t han a minimal effect on t he claimant ’ s abilit y t o work.” See Henderson v. Sullivan, 930 F.2d 19, 21 (8t h Cir. 1992) [int ernal quot at ions omit t ed]. Subst ant ial evidence on t he record as a whole support s t he ALJ’ s finding t hat Hall’ s depression and obesit y were not severe impairment s. The Court so finds for t hree reasons. First , t he det erminat ion at st ep t wo is a medical det erminat ion, see Bowen v. Yuckert , 482 U.S. 137 (1987), and t here is lit t le medical evidence t hat Hall’ s depression and obesit y had more t han a minimal effect on his abilit y t o work. Alt hough he was diagnosed wit h depression and/ or an adj ust ment disorder wit h depressed mood, t he evidence underlying t he diagnoses consist s primarily of his self-report s. It is t rue t hat he st ruggled wit h his weight , but t here is lit t le evidence t hat his excessive weight impact ed his ot her impairment s in any significant way. Second, t o t he ext ent t here is medical evidence relevant t o t he severit y of Hall’ s depression and obesit y, it is unremarkable. His depression appeared t o have been caused by sit uat ional concerns, i.e., it was brought about by an inabilit y t o work and problems arising from his family and finances. Moreover, t he impairment did not give rise t o any funct ional limit at ions as Hobby and Ludwig ident ified few, if any, rest rict ions in Hall’ s adapt ive funct ioning. Moreover, Hall was asked t o rank his impairment s in t erms of t heir impact on his abilit y t o work, he list ed his back, hands, and knees before making any ment ion of his depression. Wit h respect t o Hall’ s obesit y, t he record reflect s t hat his BMI was well above t hirt y on a number of occasions, but he was repeat edly encouraged t o lose weight by increasing his physical act ivit y and exercising. 13 Third, t he ALJ’ s failure t o ident ify Hall’ s depression and/ or obesit y as severe impairment s at st ep t wo is ult imat ely of lit t le legal significance. Once t he ALJ proceeds past st ep t wo, as he did here, t he labeling of an impairment as “ severe” or “ nonsevere” has lit t le legal significance because t he ALJ must consider all of t he claimant ’ s impairment s in craft ing t he residual f unct ional capacit y. See 20 C.F.R. 416.945(e). Hall offers a second reason why t he ALJ’ s findings are not support ed by subst ant ial evidence on t he record as a whole. It is Hall’ s cont ent ion t hat his residual funct ional capacit y was erroneously assessed, and he offers t hree reasons why. The ALJ is required t o assess t he claimant ’ s residual funct ional capacit y, which is a det erminat ion of t he most a person can do despit e his limit at ions. See Brown v. Barnhart , 390 F.3d 535 (8t h Cir. 2004). The assessment is made using all of t he relevant evidence in t he record, but t he assessment must be support ed by some medical evidence. See Wildman v. Ast rue, 596 F.3d 959 (8t h Cir. 2010). As a part of making t he assessment , t he ALJ is required t o evaluat e t he claimant ’ s subj ect ive complaint s and do so in accordance wit h t he fact ors ident ified in Polaski v. Heckler, 739 F.2d 1320 (8t h Cir. 1984). Hall first maint ains t hat t he record was not adequat ely developed because t here is no opinion from a t reat ing physician. It is Hall’ s cont ent ion t hat t he ALJ should have obt ained an opinion from a t reat ing physician, or ordered a consult at ive examinat ion, rat her t han rely solely upon t he opinions of non-examining physicians and t he ALJ’ s own inferences. Alt ernat ively, Hall maint ains t hat “ t he ALJ’ s residual [funct ional] capacit y finding is not support ed by what evidence t here is in t he record.” See Docket Ent ry 8 at CM/ ECF 34. 14 The Court is sat isfied t hat t he ALJ adequat ely developed t he record, and t here is sufficient informat ion for her t o have made an informed decision. 3 It is t rue t hat t here is no opinion from a t reat ing physician addressing Hall’ s abilit y t o perform workrelat ed act ivit ies. Alt hough such an opinion would have been helpful, one was not required. 4 The ALJ could and did rely upon t he medical records prepared by Hall’ s t reat ing physicians. Their records reflect t hat alt hough Hall suffered from degenerat ive disc disease, it was charact erized as mild. His back pain responded favorably t o medicat ion, and he was encouraged t o lose weight by, int er alia, exercising consist ent wit h his abilit ies. When he did receive ot her t reat ment for his back pain, t he t reat ment was conservat ive. For inst ance, in June of 2013, he was aut horized t o receive approximat ely five weeks of chiropract ic care for his “ chronic low back pain.” Hall report ed difficult ies sleeping, but t he medical records prepared by his t reat ing physicians reflect t hat he had not been using his CPAP machine properly. Aft er being counseled on t he import ance of using t he machine properly, and undergoing a CPAP Tit rat ion St udy, he made few complaint s about difficult ies sleeping. The ALJ has an obligation to fully develop the record. See Battles v. Shalala, 36 F.3d 43 (8th Cir. 1994). There is no bright line test for determining whether the ALJ fully developed the record; the determination is made on a case by case basis. See Id. It involves examining whether the record contains sufficient information for the ALJ to have made an informed decision. See Pratt v. Asture, 372 Fed.Appx. 681 (8th Cir. 2010). 4 In Hensley v. Colvin, 829 F.3d 926, 932 (8th Cir. 2016), the Court of Appeals observed the following: ... “Because a claimant’s [residual functional capacity] is a medical question, an ALJ’s assessment of it must be supported by some medical evidence of the claimant’s ability to function in the workplace.” Cox, 495 F.3d at 619. However, there is no requirement that an [residual functional capacity] finding be supported by a specific medical opinion. See Myers, 721 F.3d at 526 27 (affirming RFC without medical opinion); Perks v. Astrue, 687 F.3d 1086, 1092 93 (8th Cir. 2012) (same). ... In the absence of medical opinion evidence, “medical records prepared by the most relevant treating physicians [can] provide affirmative medical evidence supporting the ALJ’s residual functional capacity findings.” Johnson v. Astrue, 628 F.3d 991, 995 (8th Cir. 2011). ... 3 15 Hall’ s carpal t unnel syndrome appeared t o have been his primary impairment , part icularly t he carpal t unnel syndrome in his right hand. The medical records prepared by his t reat ing physicians reflect t hat t he impairment responded t o medicat ion. For inst ance, when he was seen on February 8, 2012, he report ed t hat his pain was cont rolled wit h gabapent in. A left carpal t unnel release helped relieve some of t he numbness in t hat hand, alt hough t he pain in t he hand event ually ret urned. Despit e t he pain in his hands, he acknowledged spending a good deal of t ime on his comput er. Moreover, his grip st rengt h was observed t o be 5/ 5 t hroughout . In any event , t he ALJ account ed for Hall’ s carpal t unnel syndrome in assessing his residual funct ional capacit y by limit ing his abilit y t o finger on t he right side. Hall experienced bout s of depression and sought medical at t ent ion for his condit ion on a number of occasions. The medical records prepared by his t reat ing physicians reflect , t hough, t hat his depression sprang from sit uat ional concerns involving an inabilit y t o work, his finances, and his family. His depression was not chronic. There is no evidence t he impairment gave rise t o any meaningful rest rict ions in his adapt ive funct ioning. The record reflect s t hat Hall was five feet , six inches t all and weighed, at t imes, as much as t wo hundred pounds. His BMI was consist ent ly above t hirt y-five, which placed him in t he obese range. Despit e carrying excessive weight , t here is no evidence t hat Hall’ s weight impact ed his residual funct ional capacit y. The medical records prepared by his t reat ing physicians reflect t hat he was encouraged t o lose weight by exercising consist ent wit h his abilit ies, and he was capable of performing many rout ine act ivit ies of daily living. 16 The ALJ did not rely solely upon t he medical records prepared by Hall’ s t reat ing physicians, t hough. The ALJ also considered Hall’ s t est imony, his represent at ions as t o his daily act ivit ies, and t he opinions offered by t he st at e agency medical professionals. For inst ance, t he ALJ could and did find t hat Hall’ s daily act ivit ies included t aking care of his mot her’ s propert ies, playing comput er games, wat ching t elevision, camping, fishing, cooking, and caring for his children. Hall was also capable of sit t ing in an aut omobile while he drove long dist ances and was capable of walking long dist ances. Hall fault s t he ALJ for relying t oo heavily upon t he opinions of t he st at e agency medical professionals. The Court cannot agree. The record reflect s t hat t heir opinions were but one of t he fact ors t he ALJ relied upon in assessing Hall’ s residual funct ional capacit y. Moreover, as t he ALJ could properly find, t heir opinions were “ consist ent wit h t he record as a whole ...” See Transcript at 16. Hall next maint ains t hat inadequat e considerat ion was given t o t he VA disabilit y rat ing. Alt hough t he VA assigned him a t ot al and permanent disabilit y rat ing, Hall maint ains t hat “ [t ]he ALJ ... gave t he VA’ s decision lit t le weight on t he ground t hat it was not based on t he Social Securit y Administ rat ion’ s policy or definit ion of disabilit y.” See Docket Ent ry 8 at CM/ ECF 35. Hall charact erizes t he reason as arbit rary. “ [A] disabilit y det erminat ion by t he VA is not binding on an ALJ considering a Social Securit y applicant ’ s claim for disabilit y benefit s.” See Morrison v. Apfel, 146 F.3d 625, 628 (8t h Cir. 1988). The rat ing is nevert heless ent it led t o some weight and must be considered in t he ALJ’ s decision. See Id. If t he ALJ does not give explicit at t ent ion t o t he rat ing, it is adequat e if she addresses and discredit s t he medical records support ing t he VA’ s det erminat ion. See Baker v. Colvin, 620 Fed.Appx. 550 (8t h Cir. 2015). 17 Here, t he ALJ gave adequat e and explicit considerat ion t o t he VA disabilit y rat ing. It is t rue t hat at one point in her opinion, she not ed t hat t he rat ing was given lit t le weight because it was “ not based on t his Agency’ s policy or definit ions of disabilit y.” See Transcript at 17. Had t hat reason been t he only reason for discount ing t he rat ing, t he Court would agree wit h Hall t hat t he reason was arbit rary and t herefore improper. That reason was not , t hough, t he only reason provided by t he ALJ. At anot her point in t he opinion, she not ed t hat t he rat ing was discount ed because it was inconsist ent wit h t he record as a whole. That reason is not arbit rary and not improper because it is support ed by subst ant ial evidence on t he record as a whole. Hall last maint ains t hat adequat e considerat ion was not given t o his work hist ory. He not es t hat he served for t went y years in t he Unit ed St at es Navy, and his milit ary service “ great ly enhances his credibilit y.” See Docket Ent ry 8 at CM/ ECF 36. Alt hough t he ALJ’ s opinion does not cont ain an ext ensive discussion of Hall’ s work hist ory in general or his milit ary service in part icular, subst ant ial evidence on t he record as a whole support s t he ALJ’ s limit ed considerat ion of Hall’ s work hist ory. Hall t est ified about his milit ary service and t he work he performed while in t he service. Specifically, he t est ified t hat he was t rained as an aut omobile mechanic/ heavy equipment mechanic. The ALJ represent ed t hat she considered Hall’ s work hist ory at st ep four, see Transcript at 17, and t he Court presumes t hat t he ALJ did as she represent ed. In any event , a claimant ’ s work hist ory is but one fact or t he ALJ should consider in craft ing a claimant ’ s residual funct ional capacit y. It is not clear how a more ext ensive analysis of Hall’ s work hist ory would have led t o a different assessment of his residual funct ional capacit y. 18 The governing st andard in t his case, i.e., subst ant ial evidence on t he record as a whole, allows for t he possibilit y of drawing t wo inconsist ent conclusions. See Culbert son v. Shalala, 30 F.3d 934 (8t h Cir. 1994). The ALJ craft ed an assessment of Hall’ s residual funct ional capacit y t hat limit ed him t o medium work, and Hall has not shown why t he ALJ erred in doing so. In short , t he ALJ could find as she did. On t he basis of t he foregoing, t he Court finds t hat t here is subst ant ial evidence on t he record as a whole t o support t he ALJ’ s findings. Hall’ s complaint is dismissed, all request ed relief is denied, and j udgment will be ent ered for t he Commissioner. IT IS SO ORDERED t his 28t h day of February, 2018. ________________________________________ UNITED STATES MAGISTRATE JUDGE 19
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