Pinson v. Colvin, No. 3:2014cv31165 - Document 13 (S.D.W. Va. 2015)
Court Description: MEMORANDUM OPINION finding that the Commissioner's decision is supported by substantial evidence; affirming the final decision of the Commissioner; dismissing this matter from the docket of this Court. Signed by Magistrate Judge Cheryl A. Eifert on 12/16/2015. (cc: counsel of record) (jsa)
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Pinson v. Colvin Doc. 13 IN TH E U N ITED STATES D ISTRICT COU RT FOR TH E SOU TH ERN D ISTRICT OF W EST VIRGIN IA H U N TIN GTON D IVISION CALVIN F. PIN SON , Plain tiff, v. Cas e N o .: 3 :14 -cv-3 116 5 CAROLYN W . COLVIN , Actin g Co m m is s io n e r o f th e So cial Se cu rity Ad m in is tratio n , D e fe n d an t. MEMORAN D U M OPIN ION This is an action seeking review of the decision of the Com m issioner of the Social Security Adm inistration (hereinafter the “Com m issioner”) denying Plaintiff’s application for disability insurance benefits (“DIB”) and supplem ental security incom e (“SSI”) under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 40 1-433, 1381-1383f. The case is presently before the Court on the parties’ m otions for judgm ent on the pleadings as articulated in their briefs. (ECF Nos. 11, 12). Both parties have consented in writing to a decision by the United States Magistrate J udge. (ECF Nos. 5, 8). The Court has fully considered the evidence and the argum ents of counsel. For the reasons that follow, the Court finds that the decision of the Com m issioner is supported by substantial evidence and should be affirm ed. I. Pro ce d u ral H is to ry Plaintiff, Calvin F. Pinson (“Claim ant”), com pleted applications for DIB and SSI on March 8, 20 12 and March 14, 20 12, respectively, alleging a disability onset date of 1 Dockets.Justia.com October 31, 20 0 7, (Tr. at 230 , 232), which he later am ended at his hearing to February 5, 20 10 ,1 (Tr. at 34), due to “back, leg pain, depression, anxiety, headaches, obesity, [and] knee pain.” (Tr. at 251). The Social Security Adm inistration (“SSA”) denied the applications initially and upon reconsideration. (Tr. at 10 ). Claim ant filed a request for a hearing, which was held on J uly 15, 20 13 before the Honorable Michele M. Kelley, Adm inistrative Law J udge (“ALJ ”). (Tr. at 27-75). By written decision dated August 28, 20 13, the ALJ determ ined that Claim ant was not disabled. (Tr. at 10 -21). The ALJ ’s decision becam e the final decision of the Com m issioner on October 29, 20 14, when the Appeals Council denied Claim ant’s request for review. (Tr. at 1-3). On December 30 , 20 14, Claim ant filed the present civil action seeking judicial review of the adm inistrative decision pursuant to 42 U.S.C. § 40 5(g). (ECF No. 1). The Com m issioner filed an Answer and a Transcript of the Proceedings on March 13, 20 15. (ECF Nos. 9, 10 ). Thereafter, the parties filed their briefs in support of judgm ent on the pleadings. (ECF Nos. 11, 12). Accordingly, this m atter is fully briefed and ready for disposition. II. Claim an t’s Backgro u n d Claim ant was 34 years old at the tim e of his alleged onset of disability and 37 years old at the tim e of the ALJ ’s decision. (Tr. at 34, 75). He com pleted the tenth grade in school, subsequently obtaining a GED, and he com m unicates in English. (Tr. at 34, 250 ). Claim ant’s prior work experience includes jobs as a delivery driver, telem arketer, and stocker. (Tr. at 34, 252). 1 Claim ant previously filed applications for SSI and DIB, which were denied by the February 4, 20 0 0 written decision of an ALJ . The ALJ ’s decision becam e the final decision of the Com m issioner when the Appeals Council refused a request for review. The Com m issioner’s decision was affirm ed by this Court on October 26, 20 11. Consequently, Claim ant am ended his onset date to one day after the ALJ ’s decision. (Tr. at 10 , 34). 2 III. Su m m ary o f ALJ’s Fin d in gs Under 42 U.S.C. § 423(d)(5), a claim ant 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 by reason of any m edically determ inable physical or m ental im pairm ent 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 m onths.” 42 U.S.C. § 423(d)(1)(A). The Social Security Regulations establish a five step sequential evaluation process for the adjudication of disability claim s. 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. §§ 40 4.1520 (a)(4), 416.920 (a)(4). First, the ALJ determ ines whether a claim ant is currently engaged in substantial gainful employm ent. Id. §§ 40 4.1520 (b), 416.920 (b). Second, if the claim ant is not gainfully em ployed, then the inquiry is whether the claim ant suffers from a severe im pairm ent. Id. §§ 40 4.1520 (c), 416.920 (c). Third, if the claim ant suffers from a severe im pairm ent, the ALJ determ ines whether this im pairm ent m eets or equals any of the im pairm ents listed in Appendix 1 to Subpart P of the Adm inistrative Regulations No. 4 (the “Listing”). Id. §§ 40 4.1520 (d), 416.920 (d). If the im pairm ent does m eet or equal a listed im pairm ent, then the claim ant is found disabled and awarded benefits. However, if the im pairm ent does not m eet or equal a listed impairm ent, the adjudicator m ust determ ine the claim ant’s residual functional capacity (“RFC”), which is the m easure of the claim ant’s ability to engage in substantial gainful activity despite the lim itations of his or her im pairm ents. Id. §§ 40 4.1520 (e), 416.920 (e). In the fourth step, the ALJ ascertains whether the claim ant’s im pairm ents prevent the perform ance of past relevant work. Id. §§ 40 4.1520 (f), 416.920 (f). If the im pairm ents do prevent the 3 perform ance of past relevant work, then the claim ant has established a prim a facie case of disability and the burden shifts to the Com m issioner to prove the final step. McLain v. Schw eiker, 715 F.2d 866, 868-69 (4th Cir. 1983). Under the fifth and final inquiry, the Com m issioner m ust dem onstrate that the claim ant is able to perform other form s of substantial gainful activity, while taking into account the claim ant’s rem aining physical and m ental capacities, age, education, and prior work experiences. 20 C.F.R. §§ 40 4.1520 (g), 416.920 (g); see also Hunter v. Sullivan, 993 F.2d 31, 35 (4th Cir. 1992). The Com m issioner m ust establish two things: (1) that the claim ant, considering his or her age, education, skills, work experience, and physical shortcom ings has the capacity to perform an alternative job, and (2) that this specific job exists in significant num bers in the national econom y. McLam ore v. W einberger, 538 F.2d 572, 574 (4th Cir. 1976). When a claim ant alleges a m ental im pairm ent, the ALJ “m ust follow a special technique” when assessing disability. 20 C.F.R. §§ 40 4.1520 a, 416.920 a. First, the ALJ evaluates the claim ant’s pertinent signs, sym ptom s, and laboratory results to determ ine whether the claim ant has a m edically determ inable m ental im pairm ent. Id. §§ 40 4.1520 a(b), 416.920 a(b). If such im pairm ent exists, the ALJ docum ents the findings. Second, the ALJ rates and docum ents the degree of functional lim itation resulting from the im pairm ent according to criteria specified in the Regulations. Id. §§ 40 4.1520 a(c), 416.920 a(c). Third, after rating the degree of functional lim itation from the claim ant’s im pairm ent(s), the ALJ determ ines the severity of the lim itation. Id. §§ 40 4.1520 a(d), 416.920 a(d). A rating of “none” or “m ild” in the first three functional areas (activities of daily living, social functioning, and concentration, persistence or pace) and “none” in the fourth (episodes of decom pensation) will result in a finding that the im pairm ent is not severe unless the evidence indicates that there is m ore than m inim al lim itation in the 4 claim ant’s ability to do basic work activities. Id. §§ 40 4.1520 a(d)(1), 416.920 a(d)(1). Fourth, if the claim ant’s im pairm ent is deem ed severe, the ALJ com pares the m edical findings about the severe im pairm ent and the degree of functional lim itation against the criteria of the appropriate listed m ental disorder to determ ine if the severe im pairm ent m eets or is equal to a listed m ental disorder. Id. §§ 40 4.1520 a(d)(2), 416.920 a(d)(2). Finally, if the ALJ finds that the claim ant has a severe m ental im pairm ent that neither m eets nor equals a listed m ental disorder, then the ALJ assesses the claim ant’s residual function. 20 C.F.R. §§ 40 4.1520 a(d)(3), 416.920 a(d)(3). In this case, the ALJ determ ined as a prelim inary m atter that Claim ant m et the insured status requirem ents of the Social Security Act through Septem ber 30 , 20 10 . (Tr. at 13, Finding No. 1). The ALJ acknowledged that Claim ant satisfied the first inquiry because he had not engaged in substantial gainful activity since October 31, 20 0 7, the alleged disability onset date.2 (Id., Finding No. 2). Under the second inquiry, the ALJ found that Claim ant suffered from severe im pairm ents of “m orbid obesity, diabetes m ellitus, knee dysfunction, low back pain and hypertension.” (Tr. at 13-15, Finding No. 3). Claim ant also had several non-severe im pairm ents, including hiatal hernia, depression, and anxiety. (Id.). Under the third inquiry, the ALJ concluded that Claim ant’s im pairm ents, either individually or in com bination, did not m eet or m edically equal the severity of one of the listed im pairm ents. (Tr. at 15, Finding No. 4). Therefore, the ALJ determ ined that Claim ant had the RFC to: [P]erform a range of light work as defined in 20 CFR 40 4.1567(b) and 416.967(b) as follows: he can lift, carry, push, and pull 10 pounds m axim um ; sit for six hours out of an eight-hour workday; stand and walk for six hours out of an eight-hour workday; occasionally clim b ram ps or stairs, balance, stoop, or crawl. The claim ant can never kneel, clim b ladders, clim b ropes or 2 This date should be February 5, 20 10 , the am ended disability onset date. 5 scaffolds, and cannot crouch and squat due to knee pain. The claim ant cannot work in concentrated exposure to extrem e cold, extrem e heat, hum idity, vibration, fum es, odors, dust, gas, and poor ventilation; and m ust avoid even m oderate exposure to hazards, such as work at unprotected heights, around inherently dangerous m oving m achinery, or uneven surfaces, and around large bodies of water. (Tr. at 15-19, Finding No. 5). At the fourth step of the analysis, the ALJ determ ined that Claim ant was capable of perform ing past relevant work as a telem arketer. The ALJ found that this occupation did not require the perform ance of work-related activities precluded by Claim ant’s RFC. (Tr. at 19-20 , Finding No. 6). The ALJ also found that in addition to his past relevant work, Claim ant was capable of perform ing other jobs existing in significant num bers in the national economy. (Tr. at 19, Finding No. 6). The ALJ considered that (1) Claim ant was born in 1976 and was defined as a younger individual on the alleged disability onset date; (2) he had at least a high school education and could com m unicate in English; and (3) transferability of job skills was not m aterial, because the Medical-Vocational Rules supported a finding of non-disability regardless of Claim ant’s transferable job skills. (Tr. at 19-20 , Finding No. 6). Taking into account all of these factors and Claim ant’s RFC, and relying upon the opinion testim ony of a vocational expert, the ALJ determ ined that Claim ant could perform the following jobs at the sedentary level: telephone order clerk, clerical worker, and product grader, sorter, or selector. (Tr. at 20 ). Therefore, the ALJ concluded that Claim ant was not disabled under the Social Security Act. (Tr. at 20 , Finding No. 7). IV. Claim an t’s Ch alle n ge to th e Co m m is s io n e r’s D e cis io n Claim ant argues that the Com m issioner’s decision is not supported by substantial evidence, because the ALJ failed to give proper weight to the opinion of Claim ant’s treating physician, Dr. Gregory Holm es, who stated that Claim ant was unable to 6 consistently work eight hours a day, five days a week due to his m orbid obesity, chronic back pain, and social anxiety. (ECF No. 11 at 4-7). Claim ant asserts that Dr. Holm es’s opinion was substantiated by the statem ents of a non-exam ining physician, Dr. Stephen Nutter, who diagnosed Claim ant with chronic lum bar strain and degenerative arthritis, and by the diagnosis of m ajor depressive disorder, recurrent, severe without psychosis, m ade by consultant, Susan Bartram , M.A. (Id. at 5). In view of the supporting diagnoses, Claim ant contends that the ALJ disregarded applicable regulations favoring the opinions of treating physicians, and then exacerbated her error by failing to provide good reasons for the lack of weight she afforded Dr. Holm es’s statem ent. Claim ant m aintains that if the ALJ was unsure about the basis of Dr. Holm es’s opinion, she should, at a m inim um , have sought clarification or supplem entation from Dr. Holm es. (Id. at 7). The Com m issioner responds by pointing out that the ALJ , not the treating physician, determ ines the Claim ant’s ability to work. The ALJ was not required to give any “special significance” to Dr. Holm es’s opinion, but was required only to consider the opinion and weigh it based upon the record as a whole. (Id. at 9-12). The Com m issioner em phasizes that the opinions of the consulting experts are not as supportive of Dr. Holm es’s statem ent as Claim ant argues in his brief. Indeed, while Dr. Holm es diagnosed Claim ant with social anxiety, Ms. Bartram opined that Claim ant’s social function was within norm al lim its and his m ental status was “generally norm al.” (Id. at 11). The Com m issioner also notes that Dr. Nutter exam ined Claim ant and found that he had lim itations related to obesity, chronic lum bar strain, and degenerative arthritis; however, Dr. Nutter did not provide an opinion that these im pairm ents prevented substantial, gainful activity. Dr. Um a Reddy, who reviewed Dr. Nutter’s findings to assess Claim ant’s RFC, concluded to the contrary that Claim ant could perform light work with additional 7 postural and environm ental lim itations. According to the Com m issioner, the ALJ properly afforded great weight to Dr. Reddy’s conclusions and com m itted no error in her assessm ent of Dr. Holm es’s opinion. V. Re le van t Me d ical Re co rd s The Court has reviewed the transcript of proceedings in its entirety including the m edical records in evidence. The Court has confined its sum m ary of Claim ant’s treatm ent and evaluations to those entries m ost relevant to the issues in dispute. A. Tre atm e n t Re co rd s On March 26, 20 12, Claim ant presented to Gregory A. Holm es, M.D., com plaining of chronic knee pain and expressing a desire to lose weight. (Tr. at 338). At the tim e, Claim ant was m easured at slightly over six feet tall and weighed nearly 430 pounds. (Tr. at 335). Claim ant reported that he took ibuprofen two to three tim es a day for pain, because Flexeril no longer provided m uch benefit. (Tr. at 338). Dr. Holm es exam ined Claim ant, noting that he was in no acute distress. Claim ant’s knees showed no effusion, but Claim ant had joint line tenderness bilaterally. Dr. Holm es assessed Claim ant with m orbid obesity. He discussed diet and exercise with Claim ant and ordered physical therapy in order for Claim ant to becom e m ore active and to alleviate knee pain. Dr. Holm es also decided to send Claim ant to a nutritionist for diet advice. He instructed Claim ant to return in one m onth. (Id.), Claim ant reported to Tri-State Rehab Services of Westm oreland on April 10 , 20 12 per Dr. Holm es’s referral, and was seen by Craig Buell, MSPT. (Tr. at 325-26). Claim ant provided a past m edical history of arthritis, respiratory issues, and psychological problem s. He com plained of chronic bilateral knee pain, which he rated as five on a tenpoint pain scale, when at rest, and as a nine with activity. He stated that his right knee 8 was m ore painful, but the left knee seem ed weaker. Claim ant reported that his knee pain had caused him to becom e less active, which in turn, had resulted in a sixty-pound weight gain. Claim ant also com plained of low back pain and a hernia. (Tr. at 325). Mr. Buell perform ed an objective inspection, finding Claim ant to be m orbidly obese. Claim ant’s range of m otion in the right knee m easured ten degrees to one hundred thirteen degrees while his left knee m easured five degrees to one hundred twenty degrees. The strength of his quadriceps m uscles was m easured at 4-/ 5 on the right and 4+/ 5 on the left. His right ham string was 4/ 5, and the left ham string was 5/ 5. Claim ant’s gait was antalgic, with an external rotation of the right lower extrem ity. Mr. Buell perform ed som e therapeutic exercises and instructed Claim ant on a hom e exercise program . Mr. Buell docum ented that Claim ant’s problem s included pain, decreased range of m otion and strength, and gait abnorm alities, but he still had fair rehabilitation potential. Mr. Buell recom m ended physical therapy two to three tim es per week for six weeks. (Tr. at 325-26). Claim ant attended physical therapy six additional tim es in April, 20 12. (319-24). On April 11, Claim ant reported problem s going up and down stairs and getting out of a chair. He rated his current knee pain as two on a ten-point pain scale, with a 24-hour average of five and the worst at six. (Tr. at 324). Claim ant underwent range of motion and stretching exercises of his knees. At the end of the sessions, he reported no pain and could walk up and down the stairs. On April 13, Claim ant rated his current pain level at seven, adding that he was now having low back pain. (Tr. at 323). Although Claim ant reported im provem ent in overall knee pain, he continued to have difficulty walking and going from a sitting to standing position. On April 18, Claim ant rated the pain in his left knee at three and in his right knee pain at five. (Tr. at 322). He reported overall im provem ent of knee pain, but continued to have trouble with clim bing stairs and getting in and out of a car. 9 On April 20 , his pain level was rated at two, and he continued to report overall im provem ent. (Tr. at 321). Nonetheless, Claim ant still experienced difficulty going up and down stairs and m aking positional transfers. On April 24, Claim ant’s pain level was a three in both knees, and he reported greater strength leading to an im proved ability to walk on level surfaces. Claim ant continued to have problem s with stairs, however. (Tr. at 320 ). On April 26, Claim ant reported that he had no pain in his knees and both his gait and ability to transfer from a sitting to standing position were better. (Tr. at 319). The physical therapist confirm ed that Claim ant showed functional im provem ent in clim bing up stairs, but still had trouble walking down them . On April 30 , 20 12, Claim ant returned to Dr. Holm es, reporting that he was doing “okay,” although he felt his anxiety was returning. (Tr. at 337). He requested a prescription for Wellbutrin. Claim ant also com plained of pain in his right anterior shoulder. He described feeling the shoulder “catching” in certain positions, which occasionally interfered with his sleep. Claim ant stated that physical therapy was helping his knee pain, although he believed the benefits could be better as “they [were] not working on his knees at all.” (Id.). On physical exam ination, Claim ant appeared to be in no acute distress. His right shoulder revealed tenderness at the AC joint; however, there was no other tenderness anteriorly or laterally. Claim ant dem onstrated a full range of active and passive m otion. Dr. Holm es assessed Claim ant with anxiety and right shoulder pain. He prescribed Wellbutrin for anxiety and ordered x-ray of Claim ant’s AC joint. Claim ant presented for physical therapy three additional tim es in May, 20 12. (Tr. at 316-18). On May 4, Claim ant rated his pain at two, noting im provem ent with getting out of a chair or car, and with walking. (Tr. at 318). The therapist observed functional im provem ent in Claim ant’s increased activity tolerance, but docum ented that he still had 10 trouble descending stairs. On May 8, Claim ant reported that his pain averaged between two and three on the pain scale, and he verified an overall reduction of pain. Claim ant’s function was im proved, as evidenced by his range of m otion and decreased pain. He continued to have trouble rising from a chair. (Tr. at 317). On May 10 , Claim ant was not currently experiencing any pain and rated his average pain level at two. (Tr. at 316). Functional im provem ent was noted in his gait on level surfaces and clim bing up stairs; however, he continued to have problem s descending stairs. Claim ant returned to Dr. Holm es on May 21, 20 12 with a com plaint of acute back pain. (Tr. at 336). Claim ant reported that he com pleted a functional capacity evaluation at physical therapy without issue; however, he was now having significant right-sided low back pain that radiated into the left side. Claim ant told Dr. Holm es that neither tizanidien, nor ibuprofen, was effective at relieving his discom fort. On physical exam ination, Claim ant was in no acute distress, with stable vital signs, although he appeared in “significant” pain. Dr. Holm es docum ented that Claim ant had m uch difficulty rising from a seated position to a standing position. Dr. Holm es assessed Claim ant with m echanical low back pain and prescribed Valium 5 m g to be taken twice daily. Claim ant returned nine days later and reported that his back had im proved and he was m oving around m ore. (Tr. at 367). Claim ant indicated that Valium was helpful. Claim ant was upset that he was denied disability but stated that “physically he [was] doing okay.” (Id.). On physical exam ination, Claim ant appeared in no acute distress with stable vital signs, although Dr. Holm es reported Claim ant’s blood pressure, which had been high the last several visits, continued to be “up.” Dr. Holm es observed that Claim ant had good eye contact and norm al range of affect. He assessed Claim ant with hypertension, m orbid obesity, and depression. Claim ant was advised to continue taking Wellbutrin every day. 11 Hydrochlorothiazide 25 m g daily was prescribed to control Claim ant’s blood pressure. Claim ant returned to Dr. Holm es’s office on Septem ber 4, 20 12 for follow-up. (Tr. at 368-70 ). Claim ant told Dr. Holm es that he currently had no m edical com plaints. He adm itted that he had not taken his m edications for the past m onth, but stated that he was not depressed, “just lazy and didn’t go to the pharm acy.” (Tr. at 368). On further questioning by Dr. Holm es, Claim ant reported having m oderate depression, accom panied by increased appetite, increased sleep, and anhedonia. Claim ant adm itted to sm oking a pack of cigarettes per day, but denied alcohol or illegal drug use. On physical exam ination, Claim ant was 6 feet 3.5 inches tall and weighed 410 pounds. (Tr. at 370 ). He appeared well, alert, and oriented with norm al groom ing, norm al affect, and euthym ic m ood. Dr. Holm es diagnosed Claim ant with benign hypertension and depression. He prescribed Wellbutrin, ibuprofen 80 0 m gs, Tylenol Extra Strength Arthritis pain m edication 50 0 m gs, and Hydrochlorothiazide. Claimant was told to return in three m onths. Claim ant returned in Decem ber as instructed. (Tr. at 371-73). He had no new com plaints, although he reported that he was not taking his m edication for high blood pressure, because he felt it caused lightheadedness and palpitations. Claim ant also stopped taking Wellbutrin because he did not feel it was helping. Regardless, Claim ant reported having no change in m ood or m otivation when off of the m edication. (Tr. at 371). On physical exam ination, Claim ant had an elevated blood pressure at 128/ 87. He weighed 40 7 pounds, but his heart and lungs were norm al. (Tr. at 372). Dr. Holm es noted nonpitting edem a of Claim ant’s ankles, bilaterally, which he attributed to inactivity. He prescribed Furosem ide 20 m gs and told Claim ant to return in one m onth. (Tr. at 373). On J anuary 7, 20 13, Claim ant presented to Dr. Holm es’s office for follow-up. (Tr. 12 at 374-76). He had no new problem s. On exam ination, Dr. Holm es found Claim ant’s blood pressure to be high at 129/ 94. He weighed 398 pounds. Otherwise, the exam ination was unrem arkable. Claim ant was diagnosed with benign hypertension and obesity. (Tr. at 376). He was instructed to return in two m onths. Two m onths later, on March 7, 20 13, Claim ant returned to Dr. Holm es’s office as instructed. (Tr. at 377-79). He com plained of sinus pressure and itchy throat. Claim ant’s blood pressure rem ained high, but he had lost ten pounds. On exam ination, Claim ant had signs of sinusitis and rhinitis. He was given prescriptions for cetirizine and am oxicillin. (Tr. at 379). Claim ant returned five days later to review bloodwork taken by Dr. Holm es on March 7. (Tr. at 380 -82). While Claim ant’s laboratory results suggested diabetes m ellitus, Claim ant reported that he had consum ed large quantities of sweet tea the day prior to the blood draw. Dr. Holm es discussed diabetes m ellitus in detail with Claim ant, advising him of the need to m aintain a proper diet and watch for signs of diabetic com plications. (Tr. at 380 ). On physical exam ination, Claim ant was again noted to have high blood pressure. His weight was down to 385 pounds. He displayed sym ptom s of acute bronchitis and was given an inhaler, as well as diabetes supplies. (Tr. at 382). Dr. Holmes instructed Claim ant to return in two weeks. Claim ant presented on March 26, 20 13 in follow-up. (Tr. at 383-85). He reported having been hospitalized on March 23 for diabetic ketoacidosis, dehydration, and hypokalem ia. He required resuscitation. Dr. Holm es noted that, going forward, Claim ant would be followed by an endocrinologist for his diabetes. (Tr. at 383). Claim ant told Dr. Holm es that he did not feel well. His blood pressure was norm al, and his weight was 388 pounds. He appeared alert and nourished, but was poorly developed. Dr. Holm es decided 13 to refer Claim ant to a podiatrist due to his uncontrolled diabetes, and to a chiropractor for com plaints of low back pain. (Tr. at 385). Claim ant went to the Huntington Foot & Ankle Clinic on April 19, 20 13 and saw Chris Wood, DPM. (Tr. at 394). Claim ant com plained of painful, thick calluses on his left foot that im peded am bulation. He advised Dr. Wood that he was diabetic. Dr. Wood exam ined Claim ant’s feet and observed that while skin coloration was norm al, the skin was thin and shiny. Claim ant’s left foot, third toe had hyperkeratotic tissue plantarly. His dorsalis pedis pulse was nonpalpable, and skin tem perature was decreased. Dr. Wood diagnosed Claim ant with diabetic pre-ulcerative calluses and prescribed diabetic shoes and custom inserts. (Id.). On April 30 , 20 13, Claim ant returned to Dr. Holm es’s office for follow-up. (Tr. at 386-88). He reported feeling “fine.” (Tr. at 386). Claim ant was m onitoring his blood sugar and taking his m edications without noticing any side effects. His blood pressure was elevated, but his blood sugars m et the targeted range. (Tr. at 387). Claim ant was adhering adequately to his recom m ended diet and weighed 379 pounds. Dr. Holm es tweaked Claim ant’s m edications and told him to return in one m onth. (Tr. at 388). Claim ant has his second appointm ent with Dr. Wood on May 13, 20 13. (Tr. at 393). On this visit, he received his special shoes and inserts and was given instructions on how to break-in the shoes. Dr. Wood noted that the shoes fit properly, and Claim ant was satisfied with them . Claim ant saw Dr. Wood again on J une 3, 20 13, with no changes noted. (Tr. at 392). Claim ant appeared at Dr. Holm es’s office for his scheduled follow-up on May 31, 20 13. (Tr. at 389-91). He continued to do well on his m edications, although his blood pressure was still elevated at 126/ 80 . (Tr. at 389-90 ). On exam ination, Claim ant 14 appeared alert and in no acute distress, but also looked “not well hydrated.” (Tr. at 391). Dr. Holm es diagnosed Claim ant with uncontrolled diabetes m ellitus and told him to return in two m onths. B. R FC Ev a lu a t io n s a n d Op in io n s On March 27, 20 12, Claim ant underwent a psychological evaluation by Susan Bartram , M.A., at the request of the SSA. (Tr. at 30 9-14). Ms. Bartram began with a clinical interview, noting that Claim ant was applying for disability benefits due to back pain, knee pain, depression, and anxiety. (Tr. at 30 9). She asked Claim ant how his sym ptom s affected his daily life, and he responded that he could not stand, kneel, or sit for any length of tim e without pain. He added that not being able to work had caused him to becom e depressed. Claim ant indicated that he lived with an uncle, who fully supported him . Claim ant stated that his back and knee pain had started in 20 0 8; however, he continued to work until 20 11. On October 31, 20 11, Claim ant quit his job as a telem arketer because he was going to be fired for poor perform ance. (Tr. at 310 ). He had not attem pted to return to work thereafter. With respect to his depression, Claim ant reported that it started in 20 0 8 and had gotten progressively worse. He described being tired, sleeping too m uch, and feeling worthless. He felt anxious around people and worried about his future. Claim ant had never received counseling for his psychological sym ptom s, but took Wellbutrin for depression. Claim ant provided an educational, vocational and social history. (Tr. at 311). He stated that he was born and raised in Cabell County, West Virginia by both of his parents. He reported having a “fun, norm al” childhood, although his fam ily m oved frequently. Claim ant never m arried. He indicated that he com pleted the 10 th grade in school, and was the victim of bullying. He obtained a GED after leaving school. Claim ant worked as a 15 laborer for a while, doing construction, plum bing, restaurant work, and delivering parts for an auto dealer. Claim ant’s last job was as a telem arketer. Claim ant described his activities of daily living to include personal groom ing and hygiene, lim ited cooking, reading, watching television, and visiting with his uncle. (Id.). On days when he felt depressed, Claim ant stayed in bed and withdrew from others. Ms. Bartram conducted a m ental status exam ination of Claim ant. (Tr. at 312). He was noted to be casually dressed with fair groom ing and hygiene. He sat slightly slum ped forward and walked with a slow gait. He also lim ped and had a cane with him . Claim ant was generally cooperative during the exam ination. His social interaction was norm al; his eye contact was good; his verbal responses were adequate and appropriate. Claim ant was oriented in all four spheres and his speech was relevant and coherent. Claim ant’s m ood was found to be depressed and irritated, and his affect was blunted. However, Claim ant’s thought process and content were norm al; his im m ediate, recent, and rem ote m em ory were norm al; his concentration, persistence, and pace were norm al; and his judgm ent and insight were intact. Ms. Bartram assessed Claim ant with m ajor depressive disorder, recurrent, severe without psychosis. (Tr. at 312). She based her assessm ent on Claim ant’s reported sym ptom s of staying in bed for days at a tim e and feeling worthless and guilty. She felt his prognosis was poor to fair, depending on whether he obtained consistent and appropriate psychotropic and psychological interventions. (Tr. at 313). She believed Claim ant could m anage his own benefits. On May 15, 20 12, Claim ant was exam ined by Stephen Nutter, M.D., of Tri-State Occupational Medicine, at the request of the SSA. (Tr. at 327-34). Claim ant advised Dr. Nutter that he was applying for disability benefits due to his back and knees. (Tr. at 327). 16 He stated that his back problem s began in 20 0 7. His pain was constant and radiated down his right leg, causing num bness. According to Claim ant, activities like bending, stooping, sitting, lifting, standing, and riding in a car aggravated his discom fort. He claim ed that his legs would go num b if he sat for too long. Claim ant also com plained of joint pain in his hands, shoulders, hips, and knees, which was constant in his knees. He described his knees popping, and this event triggered pain. Claim ant stated that walking, standing, kneeling, squatting, and going up and down stairs increased his knee pain. (Tr. at 32728). Reaching up, pushing, or pulling increased his shoulder pain. (Tr. at 328). Claim ant provided relevant history, stating that he had never had joint replacem ent or aspiration. He had no chronic m edical illnesses and had never had surgery. Claim ant identified his treating physician as Dr. Holm es. He stated that he last worked in 20 0 7 as a telem arketer. Claim ant reported having problem s with shortness of breath and wheezing. He indicated that he could only walk 20 0 t0 30 0 feet on flat ground before he becam e short of breath and had to stop and rest. Dr. Nutter perform ed a physical exam ination of Claim ant. (Id.). Claim ant stood 6 feet 1 inch tall and weighed 425 pounds. His blood pressure was high at 152/ 90 . Claim ant was observed walking with a norm al gait, and he did not use a handheld device. He was com fortable in both supine and sitting positions. His m em ory appeared norm al, and his intellectual function appeared average. Claim ant’s head, ears, eyes, nose, throat, and neck were unrem arkable. (Tr. at 329). Claim ant’s chest had an increased AP diam eter due to obesity. There were no signs of shortness of breath or abnorm al breath sounds; however, Claim ant showed m ild restrictive pulm onary disease on a ventilatory function study. (Tr. at 329, 333). His cardiovascular exam ination appeared norm al, except for som e edem a. (Tr. at 329). His abdom en was m orbidly obese, but otherwise unrem arkable. Dr. Nutter 17 exam ined Claim ant’s upper extrem ities and found that they were nontender, with no evidence of redness, warm th, swelling, or nodules. His range of m otion of the shoulder was norm al. Claim ant’s grip strength was 5/ 5 bilaterally. He was able to write and pick up coins without difficulty. Dr. Nutter’s exam ination of Claim ant’s legs and cervical spine yielded no worrisom e findings, but Claim ant com plained of pain on range of m otion of his dorsolum bar spine. (Tr. at 330 ). Neurologically, Claim ant showed norm al m uscle strength bilaterally, except for his left hip, which had limited flexion and extension due to pain. His reflexes and sensation were intact. Claim ant was able to walk on heels and toes and do a tandem gait, but squatting caused knee pain. Dr. Nutter diagnosed Claim ant with chronic lum bar strain and degenerative arthritis. He did not find definite evidence of nerve root com pression. Dr. Nutter com m ented that Claim ant had pain and crepitus in his knees, prim arily due to his obesity. There was no evidence of rheum atoid arthritis. (Tr. at 331). On August 8, 20 12, Dr. Um a Reddy com pleted a Physical Residual Functional Capacity Assessm ent at the request of the SSA. (Tr. at 136-38). Dr. Reddy found that Claim ant could occasionally lift and carry 10 pounds, frequently lift and carry 10 pounds, and stand, walk, or sit about six hours each in an eight-hour work day. She felt Claim ant had an unlim ited ability to push and pull. (Tr. at 137). He could occasionally clim b ram ps and stairs, balance, stoop, and crouch, but he could never clim b ladders, ram ps, and scaffolds, kneel, and crawl. She explained that Claim ant’s knee pain precluded him from squatting, and his m orbid obesity prevented him from clim bing ladders, ropes and scaffolds. Dr. Reddy found no m anipulative or comm unicative lim itations, but believed that Claim ant should avoid concentrated exposure to extrem e tem peratures, wetness, hum idity, vibrations, fum es, odors, gases, poor ventilation, and dusts. (Tr. at 137-38). She 18 recom m ended that he avoid even m oderate exposure to hazards. She explained these environm ental lim itations by stating that Claim ant m ight not be able to m ove quickly away from dangerous work situations, and his obesity m ight m ake concentrated exposures to the other environm ental conditions uncom fortable. (Tr. at 138). On J uly 11, 20 13, Dr. Holm es responded to certain focused questions sent by Claim ant’s disability counsel. (Tr. at 395-96). Dr. Holm es indicated that Claim ant had m orbid obesity, chronic back pain, and social anxiety based upon objective findings. He did not feel Claim ant was capable of engaging in em ploym ent 8 hours per day, 5 days per week on a consistent basis due to Claim ant’s m edical problem s. Dr. Holm es did not list any additional im pairm ents that lim ited Claim ant’s ability to work. (Tr. at 396). VI. Sco p e o f Re vie w The issue before this Court is whether the final decision of the Com m issioner denying Claim ant’s application for benefits is supported by substantial evidence. The Fourth Circuit has defined substantial evidence as: evidence which a reasoning m ind would accept as sufficient to support a particular conclusion. It consists of m ore than a m ere scintilla of evidence but m ay be som ewhat 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 Law s v. Celebrezze, 368 F.2d 640 , 642 (4th Cir. 1966)). Additionally, the adm inistrative law judge, not the court, is charged with resolving conflicts in the evidence. Hay s v. Sullivan, 90 7 F.2d 1453, 1456 (4th Cir. 1990 ). The Court will not re-weigh conflicting evidence, m ake credibility determ inations, or substitute its judgm ent for that of the Com m issioner. Id. Instead, the Court’s duty is lim ited in scope; it m ust adhere to its “traditional function” and “scrutinize the record as a whole to determ ine whether the conclusions reached are rational.” Oppenheim v. Finch, 495 F.2d 19 396, 397 (4th Cir. 1974). Thus, the ultim ate question for the Court is not whether the Claim ant is disabled, but whether the decision of the Com m issioner that the Claim ant is not disabled is well-grounded in the evidence, bearing in m ind that “[w]here conflicting evidence allows reasonable m inds to differ as to whether a claim ant is disabled, the responsibility for that decision falls on the [Com m issioner].” W alker v. Bow en, 834 F.2d 635, 640 (7th Cir. 1987). VII. An alys is As previously stated, Claim ant’s sole challenge involves the weight given to the opinion of Dr. Holm es that Claim ant was not capable of consistently working a five-day, eight-hour per day week. When evaluating a claim ant’s application for disability benefits, the ALJ “will always consider the m edical opinions in [the] case record together with the rest of the relevant evidence [he] receives.” 20 C.F.R. §§ 40 4.1527(b), 416.927(b). Medical opinions are defined as “statem ents from physicians and psychologists or other acceptable m edical sources that reflect judgm ents about the nature and severity of [a claim ant’s] im pairm ent(s), including [his] sym ptom s, diagnosis and prognosis, what [he] can still do despite [his] im pairm ent(s), and [his] physical or m ental restrictions.” Id. §§ 40 4.1527(a)(2), 416.927(a)(2). Title 20 C.F.R. § 40 4.1527(c) and 20 C.F.R. § 416.927(c) outline how the opinions of accepted m edical sources will be weighed in determ ining whether a claim ant qualifies for disability benefits. In general, an ALJ should allocate m ore weight to the opinion of an exam ining m edical source than to the opinion of a nonexam ining source. Id. '§ 40 4.1527(c)(1), 416.927(c)(1). Even greater weight should be given to the opinion of a treating physician, because that physician is usually m ost able to provide Aa detailed, longitudinal picture@ of a claim ant=s alleged disability. Id. §§ 40 4.1527(c)(2), 416.927(c)(2). Indeed, a treating physician’s opinion should be given 20 co n t r o llin g weight when the opinion is supported by clinical and laboratory diagnostic techniques and is not inconsistent with other substantial evidence. Id. If the ALJ determ ines that a treating physician=s opinion is not entitled to controlling weight, the ALJ m ust then analyze and weigh all the m edical opinions of record, taking into account certain factors listed in 20 C.F.R. § 40 4.1527(c)(2)-(6) and 20 C.F.R. § 416.927(c)(2)-(6),3 and m ust explain the reasons for the weight given to the opinions.4 “Adjudicators m ust rem em ber that a finding that a treating source m edical opinion is not well-supported by m edically acceptable clinical and laboratory diagnostic techniques or is inconsistent with other substantial evidence in the case record m eans only that the opinion is not entitled to ‘controlling weight,’ not that the opinion should be rejected ... In m any cases, a treating source’s opinion will be entitled to the greatest weight and should be adopted, even if it does not m eet the test for controlling weight.” Social Security Ruling (“SSR”) 96-2p, 1996 WL 374188, at *4 (S.S.A. 1996). Nevertheless, a treating physician’s opinion m ay be rejected in whole or in part when there is persuasive contrary evidence in the record. Coffm an v. Bow en, 829 F.2d 514, 517 (4th Cir. 1987). 3 The factors include: (1) length of the treatment relationship and frequency of evaluation, (2) nature and extent of the treatment relationship, (3) supportability, (4) consistency, (5) specialization, and (6) other factors bearing on the weight of the opinion. 4 Although 20 C.F.R. § 40 4.1527(c) and 20 C.F.R. § 416.927(c) provide that in the absence of a controlling opinion by a treating physician, all of the m edical opinions m ust be evaluated and weighed based upon various factors, the regulations do not explicitly require the ALJ to recount the details of that analysis in the written opinion. Instead, the regulations m andate only that the ALJ give “good reasons” in the decision for the weight ultim ately allocated to m edical source opinions. Id. §§ 40 4.1527(c)(2), 416.927(c)(2); see also SSR 96-2p, 1996 WL 374188, at *5 (“the notice of the determ ination or decision m ust contain specific reasons for the weight given to the treating source's medical opinion, supported by the evidence in the case record, and m ust be sufficiently specific to m ake clear to any subsequent reviewers the weight the adjudicator gave to the treating source's m edical opinion and the reasons for that weight.”). “[W]hile the ALJ also has a duty to ‘consider’ each of the ... factors listed above, that does not m ean that the ALJ has a duty to discuss them when giving ‘good reasons.’ Stated differently, the regulations require the ALJ to consider the ... factors, but do not dem and that the ALJ explicitly discuss each of the factors.” Hardy v. Colvin, No. 2:13– cv– 20 749, 20 14 WL 4929464, at *2 (S.D.W.Va. Sept. 30 , 20 14). 21 Ultim ately, it is the responsibility of the ALJ , not the court, to evaluate the case, m ake findings of fact, weigh opinions, and resolve conflicts of evidence. Hay s, 90 7 F.2d at 1456. Medical source statem ents on issues reserved to the Com m issioner are treated differently than other m edical source opinions. SSR 96-5p, 1996 WL 374183 (S.S.A. 1996). In both the regulations and SSR 96-5p, the SSA explains that “som e issues are not m edical issues regarding the nature and severity of an individual's im pairm ent(s) but are adm inistrative findings that are dispositive of a case; i.e., that would direct the determ ination or decision of disability,” including the following: 1. Whether an individual's im pairm ent(s) m eets or is equivalent in severity to the requirem ents of any im pairm ent(s) in the listings; 2. What an individual's RFC is; 3. Whether an individual's RFC prevents him or her from doing past relevant work; 4. How the vocational factors of age, education, and work experience apply; and 5. Whether an individual is “disabled” under the Act. Id. at *2. “The regulations provide that the final responsibility for deciding issues such as these is reserved to the Com m issioner.” Id. Consequently, a m edical source statem ent on an issue reserved to the Com m issioner is never entitled to controlling weight or special significance, because “giving controlling weight to such opinions would, in effect, confer upon the [m edical] source the authority to m ake the determ ination or decision about whether an individual is under a disability, and thus would be an abdication of the Com m issioner’s statutory responsibility to determ ine when an individual is disabled.” Id. at *2. Still, these opinions m ust always be carefully considered, “m ust never be ignored,” and should be assessed for their supportability and consistency with the record as a whole. 22 Id. at *3. Here, the ALJ specifically considered the opinion offered by Dr. Holm es. (Tr. at 18). The ALJ acknowledged that Dr. Holm es was Claim ant’s treating physician, and that Dr. Holm es believed that Claim ant was unable to work due to m orbid obesity, chronic back pain, and social anxiety. Nonetheless, the ALJ rejected Dr. Holm es’s opinion for two reasons. First, the ALJ pointed out that the opinion was on an issue reserved to the Com m issioner. Pursuant to SSR 96-5p, this type of statem ent is an adm inistrative finding, not a m edical opinion, and, therefore, is not entitled to any special weight. Second, the ALJ did not feel that Dr. Holm es’s opinion was supported by the m edical records. The ALJ noted that Claim ant had com plained of interm ittent health problem s for years, but had been able to work even when his sym ptom s were at their worst. (Id.). She em phasized that in the five years that Claim ant had treated with Dr. Holm es, Claim ant had lost weight and his blood pressure had decreased to the point where he stopped taking antihypertensive m edication. Although Claim ant still com plained about his knees, the records from Dr. Holm es’s office dem onstrated that Claim ant was treated only with nonsteroidal anti-inflam m atory m edications. Moreover, his condition was described as stable. Claim ant com plained of depression, but unilaterally stopped taking anti-depressant m edication, confirm ing that he had no real m ood change after stopping the m edication. The ALJ further com m ented on the significant overall im provem ent in Claim ant’s condition leading up to the adm inistrative hearing. Accordingly, contrary to Claim ant’s contention, the ALJ fully considered Dr. Holm es’s opinion, weighed it in light of the evidence, and explained why she found it lacking in support. It is im portant to note that before the ALJ weighed Dr. Holm es’s opinion, the ALJ thoroughly reviewed and discussed Claim ant’s testim ony and 23 statem ents, the treatm ent records, the findings m ade on consultative exam inations, and the m edical source statem ents. The ALJ ’s rationale for discounting the opinion was clear. She was not confused about the basis of Dr. Holm es’s statem ent, she sim ply disagreed with it, finding the opinion to be inconsistent with other substantial evidence in the record, not the least of which was Dr. Holm es’s own office record. In addition, as the ALJ stated, the opinion offered by Dr. Holm es was not entitled to special weight or significance, because under the pertinent regulations and ruling, opinions on whether or not a claim ant is capable of working invade the province of the Com m issioner. Although the ALJ was bound to consider Dr. Holm es’s statem ent, she was not obligated to give it controlling weight or even special significance. 20 C.F.R. §§ 40 4.1527(d), 416.927(d); see also Morgan v. Barnhart, 142 F. App'x 716, 722 (4th Cir. 20 0 5). Having carefully reviewed the record, the Court finds that the ALJ ’s decision is supported by substantial evidence. While the m edical evidence established that Claim ant was m orbidly obese and had discom fort in various joints and in his low back, nothing in the record (other than Dr. Holm es’s unfounded statem ent) suggested that these im pairm ents prevented Claim ant from perform ing less than a full range of light exertional work. The ALJ adopted Dr. Reddy’s opinions and included a series of lim itations in the RFC finding designed to address the functional deficits related to Claim ant’s weight, m edical conditions, low back pain, and inability to squat. The lim itations selected by the ALJ were adequate given the objective findings. At Claim ant’s evaluation by Dr. Nutter, Claim ant was able to walk with a norm al gait, heel and toe walk, and tandem walk. (Tr. at 328-30 ). He was com fortable in both the supine and sitting positions, and his straight leg-raising test was negative. Claim ant’s grip strength was equal and norm al at 5/ 5. He could write and pick up coins without difficulty. Claim ant’s m uscle strength in the 24 extrem ities was norm al except for som e reduction of flexion and extension of the left hip, but there were no signs of m uscle atrophy. His reflexes were norm al bilaterally and his sensation was intact. Dr. Nutter found som e range of m otion lim itations in Claim ant’s knees that were related to his weight, which at that tim e was 425 pounds. However, Claim ant steadily lost weight after his consultative exam ination, and within one year, Claim ant was nearly fifty pounds lighter. (Tr. at 387). When Claim ant consistently perform ed physical therapy exercises, his knee pain decreased substantially, his knee strength increased, and his overall tolerance for activity increased. His treatm ent was largely conservative. He did not require surgical intervention, wear braces, receive injections, or undergo joint aspirations. He occasionally used a cane, but never had an assistive device prescribed for him . By the tim e of the adm inistrative hearing, Claim ant had even stopped taking som e of his m edications because he did not feel that he needed them . In addition to the m edical evidence, Claim ant’s self-reported activities, as described in his Adult Function Reports and in reports to treating and exam ining m edical sources, were consistent with the ALJ ’s RFC finding. Claim ant described a norm al day as watching television, preparing and eating his m eals, logging on to Facebook, watching television, reading, and perform ing light housework and laundry. Claim ant also liked to play online gam es and interacted with his parents and uncle frequently. (Tr. at 285-88). At the adm inistrative hearing, Claim ant testified that he walked a couple of blocks every day and watched his diet, resulting in substantial weight loss. Dr. Holm es docum ented that Claim ant was m eeting his target blood sugars. Thus, taking the record as a whole, the ALJ ’s determ ination that Claim ant could do som e light and sedentary jobs was factually sound and corroborated by the expert opinions. 25 VIII. Co n clu s io n After a careful consideration of the evidence of record, the Court finds that the Com m issioner’s decision IS supported by substantial evidence. Therefore, by J udgm ent Order entered this day, the final decision of the Com m issioner is AFFIRMED and this m atter is D ISMISSED from the docket of this Court. The Clerk of this Court is directed to transm it copies of this Order to counsel of record. EN TERED : December 16, 20 15 26
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